Cal State Northridge Nursing Theory and Clinical Courses Reflection Paper

? Hi I need help writing a 1 page paper that reflects on my course this term! I will post the instructions below along with the class book for any reference The Nursing Evolution:This is a one-page reflection paper you must complete before taking the final due week 10;this must be submitted to be eligible for your final exam.? It is a portfolio paper you will need to save in your computer files for your final portfoliorequired at the end of your program.? All theory classes have this assignment towards the end. These are the guidelines:o 1 double-spaced paper, 12-point font, Times New Roman or 11-point fontCalibri.o If you use a source, then credit it using the APA formato If it is your own reflection only, then APA is not needed Path: Nursing Evolution (Must be Answered):1. How your theory and clinical courses support each other, i.e., what you learn intheory should inform your performance in clinical.2. Effective communication style development (describe communicating withpatients and/or other healthcare team members.3. Leadership – describe an applicable event (an example).Questions (These questions too will need to be answered to receive credit for theassignment):1. What challenges did you face in this spring term core nursing class and skillslab?2. How did you overcome those challenges?3. What will you take with you that will prepare you to endure the challenges whenyou start working as a Registered Nurse? Mary A. Miller, RN, PhD
Dean Emeritus
School of Nursing, Aurora University
Aurora, Illinois
Associate Dean Emeritus
School of Professional Studies
Metropolitan State College of Denver
Denver, Colorado
Pamella Rae Stoeckel, RN, PhD, CNE
Professor
Loretto Heights School of Nursing
Regis University
Denver, Colorado
Client
Education
Theory and
Practice
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Library of Congress Cataloging-in-Publication Data
Names: Miller, Mary A. (Mary Alice), author. | Stoeckel, Pamella Rae, author.
Title: Client education : theory and practice / by Mary A. Miller, Pamella
Rae Stoeckel.
Description: Third edition. | Burlington, MA : Jones & Bartlett Learning,
[2019] | Includes bibliographical references and index.
Identifiers: LCCN 2017036562 | ISBN 9781284161304 (pbk. : alk. paper)
Subjects: | MESH: Patient Education as Topic | Nurse-Patient Relations |
Models, Educational | Nurses’ Instruction
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DEDICATION
To Nurse Educators
and to
Our students,
Our clients,
Our colleagues:
Our teachers
iii
© MirageC/Moment Open/Getty
CONTENTS
Preface
xi
Part I A Framework for Health Education
1
1
Overview of the Miller–Stoeckel Client Education Model
3
Introduction
Purposes and Goals of Health Education
The Miller–Stoeckel Client Education Model
Nurse as Educator
Client as Learner
Nurse–Client Relationship
Client Education Outcomes
Definitions
Context for Health Education
Summary
4
4
4
7
8
8
15
17
20
22
Part II The Learning Process
27
2 Thinking and Learning
29
Introduction
Domains of Learning
Thinking
Ways of Thinking
Reflecting on Your Thinking
Promoting Thinking in Clients
Styles of Thinking and Learning
Summary
30
31
33
33
37
38
39
46
v
vi ■ Contents
3 Theories and Principles of Learning
Introduction
Value of Theory
Theories of Learning
Behavioral Views of Learning
Cognitive Views of Learning
Social Cognitive View of Learning
Principles of Learning
Summary
53
54
54
55
56
60
65
68
72
Part III Assessment for Health Education
77
4 Learner and Setting Assessment
79
Introduction
Psychological Factors
Biological Factors
Social Factors
Intellectual Factors
Environmental Factors
Summary
5 Child Learner
Introduction
Biologic Characteristics, Psychosocial Stages, and Developmental Tasks
Implications for Health Education
Orientation to Learning
Pedagogy
Educating Clients with Disabilities
Educating Families
Educating Groups and Communities
Educating Health Team Members
Summary
6 Adult Learner
Introduction
Biologic Characteristics, Psychosocial Stages, and Developmental Tasks
Implications for Health Education
Orientation to Learning
Andragogy
80
81
87
91
97
102
107
113
114
114
125
126
136
139
141
141
142
143
147
148
148
150
152
154
Contents ■ vii
Experiential Learning
Educating Clients with Disabilities
Educating Families
Educating Groups and Communities
Educating Health Team Members
Summary
7 Older Learner
Introduction
Ageism
Psychosocial Stages, Developmental Tasks, and Physiologic Changes
of Late Adulthood
Implications for Health Education
Ethnic Elderly
Educating Clients with Disabilities
Educating Families
Educating Groups and Communities
Educating Health Team Members
Summary
8 Culturally Diverse Learner
Introduction
Characteristics of Culturally Diverse Learners
Cultural Competence and Cultural Humility
Culturally Congruent Client Education
Culturally Specific Client Assessments and Concerns
Cross-Cultural Communication
Linguistically and Culturally Appropriate Teaching Strategies
and Instructional Materials
Summary
9 Nurse Educator as Learner
Introduction
Overview of the Continuum of Learning
Role of the Nurse as Educator
Advanced Role of Nurse as Educator
Nurse Educators in the Academic Environment
Nurse Educators in the Practice Environment
Becoming an Effective Nurse Educator
161
162
163
163
164
164
167
168
168
169
177
181
183
188
189
189
190
195
196
197
198
202
204
215
219
220
225
226
226
227
229
230
233
234
viii ■ Contents
Lifelong Learning
Summary
238
239
Part IV Planning and Implementing Client Education
243
10 Client Education Plan
245
Introduction
Client Education Plan
Mission
Goals
Learning Outcomes
Learning Objectives
Selection of Content
Selection of Evaluation Methods
Case Example: Mrs. Rosa Lopez
Summary
11 Teaching Strategies
Introduction
Types of Teaching Strategies
Teacher-Directed Strategies
Teacher-Facilitated Strategies
Learner-Directed Strategies
Selecting the Right Teaching Strategy
Case Example: Mrs. Rosa Lopez
Summary
12 Instructional Materials
Introduction
Health Literacy
Types of Instructional Materials
Printed Materials
Multimedia
Internet and World Wide Web
Selecting Instructional Materials
Clients with Disabilities
Evaluating Effectiveness of Instructional Materials
Copyright Issues in Using Instructional Materials
Summary
246
246
246
247
247
248
256
256
256
260
263
264
264
264
273
276
278
284
287
291
292
292
294
294
301
308
312
315
315
315
316
Contents ■ ix
Part V Client Education Outcomes
321
13 Formative Evaluation
323
Introduction
Evaluation
Formative Evaluation: Evaluation of the Client Education Plan
Formative Evaluation: Evaluation of the Learning Environment
Formative Evaluation: Evaluation of the Nurse–Client Interaction
Case Example: Mrs. Rosa Lopez
Summary
14 Summative Evaluation
Introduction
Summative Evaluation: Evaluation of Client Learning
Summative Evaluation: Evaluation of Educational Effectiveness
Summative Evaluation: Evaluation of Integration of Learning into Daily Living
Case Example: Mrs. Rosa Lopez
Summary
15 Application of the Miller–Stoeckel Client Education Model
Introduction
Overview of the Miller–Stoeckel Client Education Model
Conceptual and Theoretical Support
Definition of Major and Embedded Concepts in the Model
Propositions of the Model
Assumptions of the Model
Application of the Model
Summary
Appendix: Physical Changes Associated with Aging by System
Index
324
324
325
328
329
330
332
335
336
337
349
352
359
361
367
367
368
368
369
370
370
370
372
373
377
© MirageC/Moment Open/Getty
PREFACE
We are pleased to present the third edition of our book Client Education: Theory and Practice, ­written for
practicing nurses, nurse educators, and baccalaureate and master’s degree nursing students. The Miller–
Stoeckel Client Education Model continues to be the organizing framework for the text, with the
Nurse–Client Relationship as central to the model. We believe this relationship to be paramount
to the success of client education. The model is our unique contribution to the nursing profession.
The text has been carefully reviewed and augmented with updated statistics and information
on current practices. Many additions were made based on information from our readers. Overall
additions to each chapter include evidence-based nursing practice exercises and test questions for
ease of use by instructors. PowerPoint presentations with audio are provided to enhance the text.
Specific changes to the text include the following changes by chapter. We strengthened the
conceptual and theoretical underpinning of the Miller–Stoeckel Model in Chapter 1. Four embedded concepts were added that further enhance the model. These concepts are cultural caring,
communication, negotiation, and collaboration.
Chapter 2: Thinking and Learning adds information on critical thinking. Chapter 3: ­Theories
and Principles of Learning was rewritten for ease of understanding the theories. Chapter 4: Learner
and Setting Assessment was reorganized around a more comprehensive approach using learner
assessment factors.
Chapter 5: Child Learner, Chapter 6: Adult Learner, and Chapter 7: Older Learner all have
new sections on educating clients with disabilities. Chapter 8: Culturally Diverse Learner includes
information on cultural humility and social determinants of health that impact client education.
We are pleased to present a new chapter, Chapter 9: Nurse Educator as Learner. The need
for this chapter became clear as we realized the importance of focusing on the nurse as learner.
We describe the continuum of learning on the journey to becoming a nurse educator. Chapter 10:
Client Education Plan was extensively revised to reflect current practice and changing terminology.
Chapter 11: Teaching Strategies includes an expanded sample of the client educational plan.
Chapter 14: Summative Evaluation includes additional information on cost effectiveness supporting client education.
We conclude the text with a new chapter, Chapter 15: Application of the Miller–Stoeckel
­Client Education Model. This chapter summarizes the model and serves as a ready resource for
those aspiring to apply the model.
We find joy in writing and bringing to our readers practical information and guidance in
teaching clients. We encourage you to explore the chapters and find application to your practice.
xi
I
A Framework for Health
Education
© MirageC/Moment Open/Getty
1
Overview of the Miller–Stoeckel
Client Education Model
OBJECTIVES
Upon completion of this chapter, you will be able to do the following:
■■
■■
■■
■■
■■
Introduce the Miller–Stoeckel Client Education Model.
Describe the purposes and goals of health education.
Define the concepts, propositions, and assumptions of the Miller–Stoeckel Client
Education Model.
Elaborate on the major concepts and embedded concepts of the model.
Explain the Wellness Illness Functional Continuum.
CHAPTER OUTLINE
Introduction
Purposes and Goals of Health Education
The Miller–Stoeckel Client Education Model
Nurse as Educator
• Nurses’ Roles in Health Education
Client as Learner
Nurse–Client Relationship
• Nursing Process
— Assessment
— Analysis
— Planning
— Implementation
— Evaluation
• Teaching and Learning Process
• Clinical Judgment
• Evidence-Based Nursing Practice
• Interrelatedness of the Components in
the Nurse–Client Relationship
Client Education Outcomes
Definitions
• Health Education
• Health
• Illness
• Stoeckel Wellness-Illness Functional
Continuum
• Health Belief and Health Promotion
Models
Context for Health Education
• National Importance of Health
Education
3
4 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
• Living in an Interactive and
Interdependent Global Community
• Future Challenges and Trends Facing
Nurses as Educators
Summary
Exercises
References
INTRODUCTION
This chapter introduces the Miller–Stoeckel Client Education Model as the conceptual framework
around which this text is written. The use of the model is a unique contribution to understanding
the delivery of health education and nursing science. The chapter begins by giving the purposes
and goals of health education and then defines the concepts, propositions, and assumptions of
the Miller–Stoeckel Client Education Model. Concepts are elaborated on, and the Stoeckel
Wellness–Illness Functional Continuum is explained. There is a review of health belief and health
promotion models, and then the chapter concludes by reviewing the context for health education.
PURPOSES AND GOALS OF HEALTH EDUCATION
We view purpose and goal as having essentially the same meaning (Webster’s, 2013) and believe the
overall purpose and goal of health education is to promote, retain, and restore health, which is a
phrase you will see throughout this text. It involves the prevention, treatment, and management
of illness and the preservation of clients’ mental and physical well-being. Comprehensive client
education includes maintenance and promotion of health, illness prevention, restoration of health,
and coping with impaired function. This view of health care can be achieved only by shifting the
emphasis away from illness and cure and integrating client education into a comprehensive approach
to health maintenance, prevention, and promotion (Davidhizar & Cramer, 2002).
Health education promotes positive, informed changes in lifestyle and involves encouraging
behaviors that prevent acute and chronic disease, decrease disability, and enhance wellness. Nurses
as educators empower clients to strive for optimal health and well-being. Individuals learn to
make informed decisions about personal and family health practices and use health services in the
community. From a public health perspective, health education is intended not only to enhance
individuals’ abilities to make positive lifestyle changes but also to support social and political actions
that promote health and quality of life in communities. Hall (2001) notes that effective community education is essential as individuals, communities, and the nation shift focus to wellness and
illness prevention. The concept of community empowerment is designed to help individuals and
organizations use their abilities and resources in collective efforts to address their health priorities
and needs. The ultimate goal of health education is for nurses as educators to help clients make
changes in behavior that support healthy living.
THE MILLER–STOECKEL CLIENT EDUCATION MODEL
The Miller–Stoeckel Client Education Model provides the conceptual framework for understanding the essential, interrelated concepts of health education. The terms conceptual framework and
conceptual model are used interchangeably. Fawcett (2005) defined a conceptual model as:
The Miller–Stoeckel Client Education Model ■ 5
A set of relatively abstract and general concepts that address the phenomena
of central interest to a discipline, the propositions that broadly describe these
concepts, and the propositions that state relatively abstract and general relations
between two or more of the concepts. (p. 16)
Conceptual models assist us in identifying concept links that we believe exist and then communicating those concepts to others. Models include concepts, propositions, and assumptions.
Concepts are words or phrases that summarize the essential characteristics or properties of a phenomenon. Propositions are statements about a concept or a statement of the relationship between
two or more concepts. Assumptions are “I believe” statements believed to be true. Models have
practical value because they guide practice and research. Conceptual models give direction to the
search for relevant questions about the phenomena of interest to nursing as a discipline and also
suggest solutions to practical problems.
The theoretical basis for the Miller–Stoeckel Client Education Model is drawn from theories of nursing and education: Hildegard Peplau’s interpersonal relations theory (1952); Ida Jean
Orlando’s nursing process discipline theory (1972); Nola Pender’s health promotion model (2011);
Josepha Campinha-Bacote’s model of cultural competence in the delivery of healthcare services
model (1998); Christine Tanner’s model of clinical judgment in nursing (2006); Bernadette Melnyk
and Ellen Fineout-Overholt’s process of evidence-based practices (2011); and Malcolm Knowles’s
adult learning theory—andragogy (1990). These theories provide the theoretical support for the
model and are applied throughout the text.
The four major concepts of the Miller–Stoeckel Client Education Model follow:
■■
■■
■■
■■
Nurse as Educator: Nurses are professionals who plan, organize, teach, and direct health
education to promote, retain, and restore health in a variety of settings.
Client as Learner: Clients are consumers of health education and include individuals, families,
groups and communities, and health team members.
Nurse–Client Relationship: the Nurse–Client Relationship creates the environment for the
interaction that focuses on the achievement of health education goals.
Client Education Outcomes: Client Education Outcomes are the results of health education efforts.
The four embedded concepts of the Miller–Stoeckel Client Education Model follow:
■■
■■
■■
■■
Cultural Caring: Behaviors and attitudes exhibited by the nurse that respects and values diversity.
Communication: The exchange of information in spoken, written, and nonverbal forms that
is the foundation for clients to understand and act on health information.
Negotiation: The give and take within the relationship that acknowledges the client as a partner
with the nurse in achieving mutually acceptable goals.
Collaboration: Sharing, planning, setting goals, solving problems, and working cooperatively
together to achieve the goals of health education.
The propositions for the model are as follows:
■■
■■
The Nurse as Educator and Client as Learner come together in the Nurse–Client Relationship
to achieve Client Education Outcomes of promoting, retaining, and restoring health.
The environment created by the Nurse–Client Relationship is influenced by the embedded
concepts of Cultural Caring, Communication, Negotiation, and Collaboration.
6 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
The major assumptions of the model are as follows:
■■
■■
■■
■■
■■
Health status can be improved for most clients through health education.
Health status is affected by a variety of factors, including lifestyle, heredity, environment,
culture, and availability of health care.
Clients can learn positive health behaviors.
Clients are responsible for choices under their control that affect their health.
Nurses are primary providers of health education in a variety of settings (Figure 1-1).
The remainder of the chapter will now further elaborate on the concepts of the model.
FIGURE 1-1
Overview of the Miller–Stoeckel Client Education Model
Miller–Stoeckel Client Education Model
Cultural Caring
Nurse–Client Relationship
• Nursing process
• Teaching/learning
process
Nurse as Educator
Health Care Institutions
Public Health
Health Education Programs
• Clinical judgment
• Evidence-based
nursing practice
Client as Learner
Individuals
Families
Groups/Communities
Health Team Members
Collaboration
Communication
Client Education Outcomes
Formative Evaluation
Summative Evaluation
• Evaluation of the
client education plan
• Evaluation of the
learning environment
• Evaluation of the
nurse–client interaction
• Evaluation of client
learning
• Evaluation of educational
effectiveness
• Evaluation of integration
of learning into daily living
Negotiation
Nurse as Educator ■ 7
NURSE AS EDUCATOR
Nurses are professionals who plan, organize, teach, and direct health education to promote, retain,
and restore health in a variety of settings. The Nurse as Educator implements health education
through the client education plan or teaching plan. The model shows that nurses work in public
health, healthcare institutions, and health education programs. The model is not meant to limit
nurses to those settings but to identify the most common places in which nurses are employed.
Nurses as Educators are employed in many areas beyond what we have identified; we list these
only as examples.
Nurses work with other healthcare professionals, civic groups, and community officials to
identify health needs, develop desirable health education goals, and evaluate the availability of
healthcare services. Nurses as Educators focus on promoting optimal health and preventing illness,
but they also deal with social, cultural, behavioral, legal, and economic issues as they affect health.
Nurses’ Role in Health Education
The teaching role of nurses has long been recognized as a function of nursing practice. It has been
within the scope of nursing practice since the days of Florence Nightingale. In 1918 the National
League of Nursing Education (NLNE), precursor to the present-day National League for Nursing (NLN), defined nursing as the prevention of illness and the promotion of health especially in
public health, child welfare, schools, home visiting, industries, hospitals, and social services. Nurses
were expected to be responsible for health teaching. Two decades later, in 1937, the NLNE stated
that a nurse was essentially a teacher and an agent of health in whatever field nursing practice
occurred. In 1998 the American Nurses Association (ANA) stated in the Standards of Clinical
Nursing Practice that educating clients is a primary responsibility of nurses. The ANA continues
its long-standing support for patient teaching as a primary component of nursing care. Today all
state nurse practice acts in the United States include client teaching within the scope of nursing
practice. Further support for the role of Nurse as Educator is found in the Patient’s Bill of Rights,
which was first adopted by the American Hospital Association (AHA) in 1973. The current bill was
approved by the AHA board of trustees in 1992 and states that patients have the right to “relevant,
current, and understandable information concerning diagnosis, treatment, and prognosis” (AHA,
1992, Right #2). The Joint Commission, the organization that accredits hospitals, revised its patient
education standards to include follow-up treatment and services in 2009 (The Joint Commission,
2009). Many practicing nurses and nurse educators support client education as an essential role
for nurses (Bastable & Alt, 2014; Pender, 2011; Redman, 2006).
Just as important as educating clients, nurses also have a professional responsibility to educate
colleagues and health team members. The health care environment changes rapidly and requires
colleagues and team members to stay current in their knowledge and skills. Nursing team members
have differing levels of education and training and may require additional education. The Nurse as
Educator is often the primary educator and resource for the team (Donner, Levonian, & Slutsky,
2005). Lifelong learning is essential for those in the healthcare professions and requires all providers to stay current with their knowledge and skills.
Nurses coordinate client health education because they are the healthcare providers who have
the most continuous contact with clients. Nurses are with clients at teachable moments and do much
of the health education. As a nurse, your educational background in anatomy, physiology, nutrition,
psychology, sociology, anthropology, and other social and physical sciences enhances your role as
8 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
an educator. Your education has taught you how the body can and should function and about the
interplay among mind, body, and spirit. Your understanding of the importance of using current
research helps you assist clients in choosing and maintaining healthy behaviors.
Nurses have earned the public’s trust, and by modeling healthy habits, they are more believable
when they teach. Clients are entering the healthcare system better informed about health issues.
This means they will be demanding more knowledgeable caregivers, and they expect to be provided with current, sound information. Many clients have done considerable reading about their
particular health problem and consequently ask informed, sophisticated questions. Your credibility
will be established by your answers and ability to access information.
CLIENT AS LEARNER
We chose the word client to describe the learner in this text because the client is the consumer of
health education and is the focus of our teaching efforts. We define clients as individuals, families,
groups and communities, and health team members, which covers the scope of humanity. Clients
are everywhere and include everyone in need of health information. The word client connotes
someone who is free to come and go from your presence; someone who is free to accept or refuse
the services, counsel, and teaching that nurses offer. We view clients as responsible, thinking individuals who have the right to make choices about their health.
Contrast the view of the client with the view of the individual as a patient. When examined from
this perspective, we think of individuals who must depend on nurses for their care and sometimes
for their very survival. The term patient conjures up an image of someone who is dependent and
in need of physical or psychological assistance related to health. A patient is in your presence—on
your nursing unit or in your service area—and needs the health education that nurses can deliver.
Clients bring their individual and collective perceptions of what optimal health is to the Nurse–
Client Relationship. Perceptions are influenced by their expectations, emotions, and needs. Perceptions about health are determined individually, culturally, environmentally, and socially. Clients’
perceptions may not always be the same as nurses’ perceptions. In the client education context, we
perceive clients as active participants in health education to the extent of their ability and choice.
NURSE–CLIENT RELATIONSHIP
Between the Nurse as Educator and Client as Learner is the Nurse–Client Relationship. This is the
participants’ point of contact where the environment between them is created. The Nurse–Client
Relationship is built upon the embedded concepts of Cultural Caring, Communication, Negotiation, and Collaboration. These concepts more fully describe the context in which interactions
occur within the model. We call them embedded because they permeate the environment in which
health education occurs. The concepts are readily understandable and essential to the process of
teaching clients.
The Nurse as Educator uses skills in Cultural Caring to be sensitive to clients’ needs in all
aspects of the model. Cultural Caring is manifest in all verbal and nonverbal Communication in
teaching clients. Through Communication we get an understanding of what clients need to learn and
how best to structure the teaching, which in itself is a process of Negotiation. To achieve successful
Nurse–Client Relationship ■ 9
outcomes, it is often necessary to Collaborate with others, including the client’s family and other
health professionals. The embedded concepts are part of the process of creating an environment
that supports successful client outcomes.
The Nurse–Client Relationship is therapeutic, promoting a psychological environment that
facilitates positive change and growth. This aspect of the model is drawn from Hildegard Peplau’s
interpersonal nursing theory (1952) that stressed the importance of the therapeutic interpersonal
process. Therapeutic communication between the Nurse as Educator and the Client as Learner
is collaborative and focuses on the achievement of health education goals. It focuses on the client
achieving optimal personal growth and the highest level of wellness possible given the client’s
situation. An explicit time frame, a goal-directed approach, and the expectation of confidentiality
are important to the relationship. The nurse establishes, directs, and takes responsibility for the
interaction where the clients’ needs take priority over nurses’ needs.
Four goal-directed phases characterize the Nurse–Client Relationship. The preinteraction
phase occurs before meeting the client and involves gathering all available client information. This
gives the nurse time to anticipate health concerns and plan for the initial interaction. The orientation phase occurs when the Nurse as Educator meets the Client as Learner and they get to know
one another. The working phase occurs when the Nurse as Educator engages in health teaching
and works with the client to solve problems and accomplish goals. Last is the termination phase,
which is the process of ending the relationship (Potter & Perry, 2009).
The components that shape the environment of the Nurse–Client Relationship are the Nursing
Process, the Teaching and Learning Process, Clinical Judgment, and Evidence-Based Nursing
Practice (EBNP). We describe each in order (Figure 1-2).
Nursing Process
The Nursing Process is a variation of the scientific reasoning process that allows you to organize
your thoughts and systematize nursing practice. Its focus is to address client problems in professional
practice in a variety of clinical settings. Steps in the nursing process include assessment, analysis,
planning, implementation, and evaluation. Applied to health education, the steps of the nursing
FIGURE 1-2
Nurse–Client Relationship in the Miller–Stoeckel Client Education Model
• Nursing process
• Teaching/learning
process
Nurse as Educator
• Clinical judgment
Client as Learner
Healthcare Institutions
Public Health
Health Education Programs
• Evidence-based
nursing practice
Individuals
Families
Groups/Communities
Health Team Members
10 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
process relate directly to the learning needs of clients that are designed to improve clients’ health
knowledge and promote, retain, and restore health.
The steps of the Nursing Process are iterative because they may overlap or occur simultaneously. Reassessment, reordering of priorities, new goal setting, and revising the client education
plan continue as part of the process toward attainment of the health education goals. A discussion
of the steps of the nursing process as they apply to health education follows.
Assessment
Assessment is gathering the essential information about the client to identify health education needs.
As you assess the physiologic, psychological, sociocultural, developmental, and spiritual influences
on each client, it helps to determine each individual’s learning style and learning capacity. Assessment includes collecting subjective and objective client data, recording the data, and noting the
data that affect learning. Subjective data include clients’ perceptions of their condition and health
status. How does the client view his or her situation? How does the client view his or her health?
Is the client’s situation conducive or obstructive to learning? Does the client show a readiness to
learn? Do you have the requisite knowledge, skills, and attitudes to facilitate each client’s learning
in the situation at hand?
Analysis
The second step, analysis, is a careful examination and validation of the facts to identify the client’s
specific health education needs. When possible, you will collaborate with clients to diagnose their
learning needs. A clear understanding of these needs becomes the basis for planning, implementing, and evaluating the client education plan. This step includes analyzing both your perceptions
and your clients’ perceptions of the learning needs to validate them. Assessing and analyzing needs
also includes determining the kind of learning clients want. For instance, in which domain are your
clients deficient? Do they lack information? What do they want to know? Do they lack necessary
skills? Is their developmental level a barrier to learning? Do they display attitudes that impair their
optimum functioning?
When your client is a specific population, your assessment becomes complex. You may need
to conduct a survey as part of the assessment. Another option is to form a focus group composed
of individuals who are representative of the large group you are teaching. For smaller groups,
interviewing selected members of the group may serve your purpose just as well. In all instances,
it is important to avoid making assumptions about what clients need to learn. Ask them and be as
thorough in your assessment and analysis as possible.
Another way to approach clients is from the perspective of potential growth. What information
do they desire? What new skills do they wish to learn? What opportunities for growth are inherent
in their developmental stages? What attitudes are they ready to exhibit? What attitudes do they
already possess that could motivate further growth? What strengths of mind, body, and spirit do
they manifest that can help them in the inevitable transitions of life?
A nursing diagnosis identifies the human response to the disease process. Standard classifications of nursing diagnosis used to identify dysfunctional patterns include North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classification (NIC), and Nursing
Outcomes Classification (NOC) (McFarland & McFarland, 1997). These diagnoses are applicable
to health education.
Nurse–Client Relationship ■ 11
Planning
Planning, the third step of the Nursing Process, is the development of the client education plan.
In this step you will outline the learning objectives based on the assessment and analysis of the
findings. It involves identifying specific learning objectives and educational outcomes, establishing
priorities, and selecting teaching strategies to achieve the outcomes. Planning is deciding what
needs to be learned and what strategies and materials will most likely facilitate achievement of the
learning objectives. Once these are selected, a written client education plan is devised.
The planning step should involve clients and their families when appropriate. For example, if
your client has Alzheimer’s disease, then significant others, such as caregivers, a spouse, or family
members, must be included in the formation of plans. It is important to get feedback during the
planning process about what is to be learned and how this is to be accomplished to discover if you
and the client are in accord.
Implementation
Implementing the plan involves acting to accomplish the learning objectives and educational outcomes. You and your clients will carry out the actions that are most likely to facilitate the desired
learning. During this step you will need to elicit periodic feedback and stay attuned to behavioral
clues that indicate clients’ feelings of success or failure. You will use a variety of teaching strategies and instructional materials to facilitate client learning. Ongoing reassessment and continued
analysis are part of implementation and involve adapting to feedback as you enact the plan. Note
the client’s responses to your teaching and modify your approach as needed. Last, it is important
to document the health education that you provide.
Evaluation
The evaluation phase is the final step of the Nursing Process. This is where you and your clients
evaluate teaching effectiveness. Did the clients learn what was expected? Is their behavior more
conducive to good health? Has the client’s level of wellness improved? Are the problems with which
clients needed help diminished, or are they coping with their problems more effectively? Two-way
communication with clients helps you to summarize and interpret results.
Although evaluation is presented as the final step of the Nursing Process, evaluation takes
place throughout the Teaching and Learning Process. During the assessment phase, for instance, while identifying how clients perceive their problems, you will evaluate how well you
communicated. Did you understand what the clients conveyed? To find out, repeat back your
interpretation of what they said. Did clients indicate that they were understood correctly? Did
clients indicate that your words and actions made sense to them? Such transactions are ongoing throughout each step of the Nursing Process. Evaluation involves determining the overall
quality of health education.
Some suggest that the Nursing Process contributes to linear thinking. Chitty and Black
state that “the nursing process can be taught, learned, and used in a rigid, mechanistic and linear manner” (2007, p. 194). However, we believe it can be used as a creative approach to health
education by attending to feedback throughout the process. The Nursing Process used in health
education is ongoing, with constant evaluation and reassessment to meet the ongoing learning
needs of clients.
12 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
Teaching and Learning Process
The Teaching and Learning Process is the next component of the Nurse–Client Relationship. The
process of teaching and learning means to engage with others to acquire new knowledge, behaviors, and skills. Nurses as Educators use “planned learning experiences based on sound theories
that provide individuals, groups and communities the opportunity to acquire the information they
need to make quality health decisions” (Wurzbach, 2004, p. 6). Learning is a process by which
behavior changes as a result of experiences (Ormrod, 2012). In teaching, the Nurse as Educator
chooses teaching strategies and selects instructional materials to assist the Client as Learner to
make behavioral changes that promote, retain, and restore health.
Learning theories guide teaching practices. They are the foundation of the Teaching and
Learning Process. Some learning theories are more applicable than others, depending on the
teacher, the client, and the learning context. You will be introduced to behavioral, cognitive, and
social theories of learning as they apply to learners at all ages. Learning theories are important and
provide the foundation that guides you as educator. Together the Teaching and Learning Process
and the Nursing Process provide a holistic approach to address clients’ health education needs.
Clinical Judgment
The third component in the Nurse–Client Relationship is the exercise of sound Clinical Judgment
during teaching and learning. Clinical Judgment in nursing is the outcome of clinical reasoning,
often referred to as clinical decision making. It is a characteristic way of thinking in the nursing
discipline. You exercise Clinical Judgment as you assess clients, develop client education plans,
select teaching strategies and instructional materials, and evaluate the success of your efforts. Your
judgments and decisions impact the outcome of health education.
Some nursing educators believe that critical thinking is “the brain’s tool for developing the
expert nursing judgment needed to improve patient outcomes” (Scheffer & Rubenfeld, 2006,
p. 195). Others believe that forming clinical judgments in the delivery of nursing care is distinct
from general critical thinking skills (Tanner, 2005). Regardless, it is essential for nurses to exercise
sound Clinical Judgment in the Teaching and Learning Process.
The Teaching and Learning and Nursing Processes provide the structural framework through
which Clinical Judgment and clinical reasoning occur. Nurses engage in a variety of thinking patterns because no single pattern characterizes all situations. Tanner (2006) proposed a model with
four aspects describing how nurses reason in the clinical area that is applicable to health education
situations. The first aspect is noticing, whereby the nurse grasps the situation at hand. The second is
interpreting, whereby the nurse develops an understanding of the situation. The third is responding,
whereby the nurse decides on an appropriate course of action. The fourth is reflecting, whereby
the nurse evaluates the effectiveness of the outcomes. These thinking and reasoning patterns occur
within each step of the Teaching and Learning Process and Nursing Process to guide the nurse in
the formation of Clinical Judgments related to health education.
Clinical Judgment in nursing develops as nurses gain experience and expertise in a practice
area and expand their knowledge, moving from being a novice to being an expert. To become an
expert in nursing, a beginning nurse passes through five levels of proficiency: novice, advanced
beginner, competent, proficient, and expert (Benner, 1984). The novice has no experience in a
situation, relies on rules, and is inflexible. The advanced beginner has more experience and has
marginally acceptable performance. The competent nurse has 2 to 3 years of experience in similar
Nurse–Client Relationship ■ 13
situations and brings perspective, abstract, and analytic thinking to problem solving. The proficient
nurse sees situations as wholes rather than specific aspects and has learned from past experience
what to expect in situations and what to do when things do not go as expected. The expert nurse
has a deep understanding and intuitive grasp of situations and no longer needs rules or guidelines.
This nurse sees the totality of situations and quickly identifies the nature of the problem and how
to solve it. These skill levels apply not only to the delivery of nursing care but also to the delivery
of health education.
Evidence-Based Nursing Practice
The last component of the Nurse–Client Relationship is EBNP as it relates to health education. EBNP is the use of current best practices in making decisions about patient care by using a
problem-solving approach. This approach incorporates a systematic search for evidence, clinical
expertise, and patient preferences and values (Melnyk & Fineout-Overholt, 2004). It is the act of
applying current research findings to clinical practice. Applying research to health education is an
integral part of the Miller–Stoeckel Client Education Model. It means using the best available and
most pertinent research to make health education decisions.
The history of evidence-based research goes back to Dr. Archie Cochrane, an English physician who, in 1972, confronted healthcare professionals about the lack of randomized control studies to support medical practice decisions. Because of his influence, the first electronic database of
clinical trials was established in 1988. First called the Oxford Database of Prenatal Trials, it later
became The Cochrane Collaboration (Bliss-Holtz, 2007). The Cochrane Collaboration is now an
international database that disseminates research worldwide.
The concept of evidence-based practice was embraced by nursing and other healthcare professions in the 1990s. The motivation behind this decision was the realization that many healthcare
practices were based on intuition, experience, clinical skills, and guesswork rather than science.
EBNP uses a research-based decision-making process to guide the delivery of holistic clientcentered nursing care and health education. The specific steps involved in carrying out EBNP
include defining the problem and searching for evidence, critically appraising the evidence, applying the findings to practice, taking into account the client–learner’s values and preferences, and
then evaluating outcomes.
Although EBNP is accepted as a means of promoting best practices, differences of opinion exist
among nurses regarding what types of studies constitute the strongest evidence and what weight
to give them. The terms levels of evidence and strength of evidence refer to systems for classifying the
evidence in a body of literature through a hierarchy of scientific rigor and quality. Several dozen
of these hierarchies exist (Agency for Healthcare Research and Quality, 2002). The reviewers must
select the most relevant levels of evidence to meet their needs. The following concise definitions
of terms are used in describing the levels of evidence.
■■
■■
■■
■■
Meta-analysis is a statistical analysis of a collection of quantitative studies.
Systematic review is a research summary that searches the literature and critically appraises
individual quantitative studies to identify valid, applicable evidence.
Randomized controlled trial is a study in which subjects are randomly assigned to groups; one
receives the intervention, and the other is a control group.
Quasi-experimental design is a modification of an experimental design in which there may not
be manipulation of the independent variable, random assignment, or control group.
14 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
■■
■■
■■
■■
■■
■■
■■
Observational study is a study in which researchers have no control; instead, they observe what
happens to groups of people.
Case study (case report, single case report) is an uncontrolled observational study involving an
intervention and outcome in a single situation.
Descriptive study is a statistical study to identify patterns or trends in a situation, but not cause
and effect.
Cohort study is a study that involves the selection of a large population of people who have
the same condition, who receive a specific intervention, and who are followed over time and
compared with a group that is not affected by the condition.
Case-controlled study is a study that compares two groups of people: those with the condition,
and a similar group without the condition. It is also called a retrospective study.
Expert opinion is a judgment by people who have experience with a particular subject.
Qualitative study is a study focused on subjective experiences in naturalistic settings rather than
under experimental conditions. There are different types of qualitative studies.
A diagram of the hierarchy of research evidence is included in Figure 1-3. It illustrates a research hierarchy in which the lowest tier includes the descriptive studies, case studies, case series,
FIGURE 1-3
Levels of Evidence in Research
Meta-Analyses and
Systematic Reviews
Randomized Controlled Clinical Trials
and Quasi-Experimental Studies
Observational Studies:
Cohort and Case-Controlled Studies
Descriptive Studies, Case Studies, Case Series, Qualitative
Studies, and Expert Opinion
Client Education Outcomes ■ 15
qualitative studies, and expert opinion. The highest tier includes meta-analyses and systematic
reviews. Research at this tier has a greater chance of being generalized to a group of clients.
Nurses as Educators should rely on substantiated, critically critiqued research to ensure that the
most current health education practices and teaching strategies are provided to clients. Nurses as
Educators need a core foundation of health information that reflects quality care and best teaching
practices supported by current research. More research is needed on the effectiveness of various
teaching strategies and instructional materials for different populations. In addition to using the
best available evidence, nurses are called on to exercise their best judgment in clinical and health
education situations.
Interrelatedness of the Components in the Nurse–Client Relationship
The components in the Nurse–Client Relationship (Nursing Process, Teaching and Learning Process,
Clinical Judgment, and EBNP) are interacting and interdependent. The components complement
one another. During assessment and analysis, the client’s learning needs are assessed and analyzed
to determine the extent of the client’s need for health education. In this step, the nurse grasps the
client’s situation. It may involve looking for applicable literature specific to the client’s situation or
a group’s health education needs.
Planning involves developing individualized care plans drawn from EBNP and setting
priorities and learning objectives based on client health education needs. The nurse develops
sufficient understanding of the situation and responds by involving the client in designing the
client education plan.
Implementation is carrying out the client education plan. The nurse takes action and responds
based on EBNP where it exists but also reflects on client responses. Using judgment, the nurse is
prepared to alter the client education plan if necessary. The nurse uses judgment in selecting teaching
strategies and instructional materials to meet the client’s health education needs and preferences.
Evaluation reviews the successes and failures in meeting the learning objectives of the client
education plan. Teaching strategies may need to be modified to achieve the objectives. The nurse
continually reviews the literature to update the client education plan using current EBNP where
available. The client’s achievement of the learning objectives is measured and reinforced to help
ensure continued success.
The Nurse–Client Relationship is at the heart of the Miller–Stoeckel Client Education Model.
To initiate the process, the Nurse as Educator should ask specific questions that guide the process.
For example, how am I using the nursing process to initiate and follow through with teaching
­clients? What are the teaching and learning principles I am using? How am I using clinical judgment in assessing clients and designing and implementing client education? And what research
that is evidence-based supports my decisions?
The interrelatedness of the Nursing Process, Teaching and Learning Process, Clinical Judgment,
and EBNP components is illustrated in Table 1-1.
CLIENT EDUCATION OUTCOMES
Client Education Outcomes are achieved when health-promoting changes in knowledge, attitudes,
and skills occur in clients. The last portion of the Miller–Stoeckel Client Education Model focuses
on evaluation. To determine if health education efforts are successful, nurses must evaluate the
16 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
TABLE 1-1
Interrelatedness of the Nurse–Client Relationship Components
Nursing Process
Teaching–Learning Process
Clinical
Judgment
EBNP Process
Assessment and
analysis
Determine learning needs
Noticing
Define problem and search literature
Planning
Develop client education plan
Interpreting
Appraise research findings
Implementation
Use teaching strategies
Responding
Apply to clinical situation
Evaluation
Determine behavior change
Reflecting
Assess the outcomes
TABLE 1-2
Client Education Outcomes
Formative Evaluation
Summative Evaluation
Evaluation of the client education plan
Evaluation of client learning
Evaluation of the learning environment
Evaluation of educational effectiveness
Evaluation of the nurse–client interaction
Evaluation of learning into daily living
results. Evaluation of client education outcomes is measuring the degree to which the learning
objectives are met.
Evaluation is important to clients and educators because it informs them about their progress
and the effectiveness of the Teaching and Learning Process. The Miller–Stoeckel Client Education
Model addresses both Formative Evaluation and Summative Evaluation. Both are essential aspects
of evaluation that provide a holistic picture of what was achieved (Table 1-2).
Formative Evaluation is ongoing during teaching and learning activities. It is important to know
if the learning activities are meeting the learning objectives as teaching is progressing. If weaknesses are identified, they can be changed right away. Formative Evaluation addresses three areas:
evaluation of the client education plan, evaluation of the learning environment, and evaluation of
the nurse–client interaction. The involvement of the Client as Learner and Nurse as Educator is
essential to the process.
In Formative Evaluation, evaluation of the client education plan is done by considering concept comprehension and client motivation. The learning environment is evaluated by assessing
the effectiveness of the delivery format and the use of technology. The nurse–client interaction is
evaluated by determining the level of client engagement and communication. These components
of Formative Evaluation seek to answer the question, how are we doing?
Summative Evaluation occurs at the conclusion of the Teaching and Learning Process. It is
directed toward measuring the degree to which the learning objectives and overall outcomes are
Definitions ■ 17
met at the conclusion of the learning activity or program. It addresses three areas: evaluation of
client learning, evaluation of educational effectiveness, and evaluation of integration of learning
into daily living.
Measurement of learning occurs not only at the conclusion of individual learning activities
and programs, but it also involves long-term follow-up of client learning. Results of systematically
conducted long-term evaluations are important from an EBNP perspective. Findings from EBNP
can serve to guide future health education practices. Summative Evaluation is directed toward outcomes that determine whether clients have learned and if the activities and programs are feasible
to continue in the future. Determining feasibility includes examining the effectiveness of learning
materials, the costs, the time requirements, the degree of client satisfaction, and the long-term
benefits of programs. Basically, Summative Evaluation asks the question, how did we do?
DEFINITIONS
The following definitions support the Miller–Stoeckel Client Education Model and will broaden
your understanding of health education. The most important terms to understand are health education, health, illness, Stoeckel Wellness–Illness Functional Continuum, and Health Belief and
Health Promotion Models.
Health Education
Health education enhances the quality of life for people worldwide. It is defined broadly by Green
and Kreuter (1991) as any combination of learning experiences designed to encourage voluntary
actions that are beneficial to health. Health education is achieved through the use of learning
theories combined with teaching strategies to help individuals, families, groups and communities,
and health team members to promote, retain, and restore health. It not only involves providing
relevant health information, but it also helps clients make appropriate health-related behavioral
changes. The term health education also refers to the process of educating health team members to
become more effective in their roles and responsibilities.
Health
Health, as defined by the World Health Organization in 1948, is “a state of complete physical,
mental, and social well-being, not merely the absence of disease or infirmity” (2004). Health is
a dynamic state in which individuals adapt to changes in the internal and external environments
to maintain a state of well-being in all life dimensions. This is the most popular and comprehensive definition of health worldwide, and it is applicable to individuals, families, groups, and
communities. Clients bring their own definitions and perceptions of health to clinical situations.
Their perceptions of what is and is not normal health influence their willingness to accept health
education teaching.
Illness
Illness is a subjective perception of not being well. It is a mismatch between an individual’s needs
and his or her ability to meet those needs. It signals that the present balance to maintain health is
not working. During illness, changes may occur in the structure and function of a person’s body and
18 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
mind. Illness has a classifiable set of signs and symptoms resulting from disturbed body functioning.
These are associated with characteristic preclinical findings, course, and etiology.
Stoeckel Wellness–Illness Functional Continuum
An individual’s level of health is a constantly changing state that moves along a continuum from
optimal functioning to a state of total disability. The basic premise of the Stoeckel Wellness–Illness
Functional Continuum is that wellness and illness involve a variety of factors: social, physiologic,
environmental, emotional, activities of daily living, and health access. The factors in the model can
either enhance or distract from the client’s health. Disease and illness are a failure of an individual’s
adaptive mechanisms to adequately counteract changes in functional and structural disturbances.
Factors are displayed along a continuum showing incremental increases or decreases in health functioning. Each factor is plotted on the continuum moving from the center (score of 5 is neutral) toward
the right (highest score of 10 indicates highest level of wellness) or left (lowest score of 0 indicates
lowest level of wellness) and shows changes in the state of health. High-level functioning or wellness
involves increased ability to perform the activities of daily living. Low-level functioning is brought
on by illness or disability, resulting in the decreased ability to perform activities of daily living.
This continuum is useful when working with clients to get a holistic picture of their functioning.
Clients can place themselves on each factor’s continuum to identify their strengths and weaknesses.
Each person is unique, with different degrees of wellness and illness. Plotting the continuum for
each factor helps the Nurse as Educator determine clients’ health perceptions and needs. By using
the Stoeckel Wellness–Illness Functional Continuum as an assessment tool when working with
clients, you gain a more accurate picture of how the client perceives his or her state of health. The
continuum can also be used to compare a client’s previous level of health with the present level,
but because of its subjective nature, it cannot be used to compare one client with another. The
continuum illustrates the dynamic, ever changing state of health (Figure 1-4).
Health Belief and Health Promotion Models
The Health Belief Model (Rosenstock, 1974) was developed in the 1950s to explain why people
did not use preventive health services such as immunizations. The model examines the relationship between a client’s beliefs and behaviors, and it helps nurses understand these factors to plan
teaching that effectively assists clients in promoting, retaining, and restoring health. An important
assumption of this model is that the nurse collaborates with the client to reach mutually agreed-upon
goals by understanding the factors that influence health beliefs. The Health Belief Model identifies
the following factors that influence health beliefs:
■■
■■
■■
■■
Personal expectations regarding health and illness
Perception of the seriousness of the illness
Likelihood of following prescribed healthcare measures
Perceived barriers related to such factors as cost, inconvenience, or pain
A criticism of the Health Belief Model is that it is based on the Western cultural health belief
system and does not allow for other influences or for the fact that clients do not always act on their
belief system. Our approach, shown in Table 1-3, uses the basic format of the model, but it includes
questions that address the cultural aspects of client teaching. Our approach is a starting point for
examining client decision making concerning health education and can be used to develop client
10
Increased ability to perform ADLs
Health access factors
Emotional factors
Decreased ability to perform ADLs
0
Environmental factors
Physiological factors
Social factors
High-Level Functioning
Wellness
Factors That Affect Health Status: (plot status on each continuum)
• Social factors include support system, family, friends, work associates
• Physiological factors include genetic issues, disease, developmental issues
• Environmental factors include lifestyle, community, housing, pollution, safety
• Emotional factors include spiritual, adaption to changes, mental status, attitude
• Health access factors include insurance availability, financial, physical access
Low-Level Functioning
Illness/Disability
Stoeckel Wellness–Illness Functional Continuum
FIGURE 1-4
Definitions ■ 19
20 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
TABLE 1-3
Health Belief Model: Perceptions
Client Perceptions
Nursing Application
Need for care
• Clarifies client concerns and reasons for seeking treatment
• Explores client experiences with health issues, past and present
• Asks about family and cultural factors affecting client perceptions
Seriousness and
consequences
of condition
• Clarifies client perceptions of harm that the condition can cause
• Clarifies client perceptions of consequences without treatment
• Answers questions and clarifies prognosis; describes experiences with similar
problems
• Explores common and different beliefs and values
Value of health
intervention
• Discusses treatment client is seeking
• Describes treatment: medical treatment, behavior change (lifestyle), medication
(side effects), costs, answers questions, and so forth
• Clarifies client perceptions of treatment
Effectiveness, cost,
and barriers of
treatment
• Prepares goals and timeline for client and nurse responsibilities
• Sets ground rules and boundaries for nurse–client relationship
• Outlines knowledge and skills for client and nurse
• Suggests and provides resources for knowledge and skill development
• Clarifies client understanding of proposed plan
Data from Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
education plans. It is important for the nurse to understand client perceptions about health and
the likelihood of adhering to health recommendations. This involves examining beliefs through a
cultural lens. Communication is targeted at clarifying the nurse’s and the client’s perceptions and
beliefs. Based on this information, nurses use those strategies that are most effective to meet client
health education needs.
Nola Pender’s health promotion model (2011) assists nurses in understanding the major determinants of health behaviors as a basis for behavioral counseling to promote healthy lifestyles.
Her theory encourages health educators to look at variables that have been shown to impact
health behavior. The model uses research findings from nursing, psychology, and public health to
understand client health behaviors. This model can be used as a foundation to structure nursing
protocols and interventions. This will be further discussed later in the text.
CONTEXT FOR HEALTH EDUCATION
Nurses play a vital role in improving health on a local, national, and global scale. Nurses, in partnership with other healthcare professionals, facilitate delivery of health education in different venues
to achieve positive client education outcomes. In this section we address the importance of the
wider scope of health education. Nurses should be aware that individual health affects the larger
community and eventually affects global health.
Context for Health Education ■ 21
National Importance of Health Education
The 1979 surgeon general’s report, Healthy People, laid the foundation for a national prevention
agenda. Every 10 years since that time, the U.S. Department of Health and Human Services has
provided science-based, 10-year national objectives for promoting health and preventing disease.
Healthy People 2000 and 2010 established national health objectives that serve as the basis for
the development of state and community health initiatives. Currently, Healthy People 2020
(U.S. Department of Health and Human Services, 2012) continues the tradition of improving the
health of Americans by establishing benchmarks and monitoring progress over time to encourage
collaboration across communities and sectors, empowering individuals toward making informed
health decisions, and measuring the impact of prevention activities. Healthy People 2020 contains
about 1,200 objectives in 42 topic areas designed to serve as this decade’s framework for improving the health of all people in the United States (Box 1-1). This information is available at http:///
www.healthypeople.gov/2020/about/default.aspx on a U.S. government website. Core objectives
will remain centered on the prevention of illness and disease as the foundation of health.
Living in an Interactive and Interdependent Global Community
Maintaining health is a global concern. Health issues have global consequences that not only affect
the people of developing nations but also the world community. Healthy, productive citizens are
essential for global economic growth and security. Stable populations reduce pressures on global
economies and the environment. Stable populations also reduce the number and risk of humanitarian crises. Programs to control the spread of infectious diseases reduce the threat of epidemics.
With healthcare services placing ever-greater pressures on state and federal health budgets, the
economic burden of disease, and the burden to individuals and families, is a cause of great concern for governments and healthcare systems. Health education not only affects the immediate
recipients but also future generations that will benefit from improved health habits and efforts to
prevent illness. Eventually improved health behavior will be ingrained when health education is
widely available and an accepted part of health care. The prevention of illness and the promotion
of health through the delivery of efficient and effective health education lie at the core of society’s
ability to affect health worldwide.
Future Challenges and Trends Facing Nurses as Educators
Future challenges in health care are difficult to predict, but current demographic and societal trends
point to the increased need for Nurses as Educators. Demographic trends point to an increasing
older population and a greater percentage of minority groups living in the United States that have
BOX 1-1
Healthy People 2020 Overarching Goals
■■
■■
■■
■■
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
Achieve health equality, eliminate disparities, and improve the health of all groups.
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across all life stages.
22 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
unique health challenges. Societal trends show changes in social practices, such as cohabitation,
acceptance of gay relationships, and more single-parent families. Other trends point to greater
access to reliable information using technology, more reliance on alternative medicine, and more
questioning of medical advice. Nurses as Educators must be aware of demographic and societal
trends. They must adjust to these trends and incorporate the challenges they present into their
health education practices.
It is important for nurses to expand their knowledge of health education, their leadership
abilities, and their involvement in health policy development. More collaborative networks with
other healthcare providers are needed that foster accountability. This collaboration should occur
not only on the local level but also within the global community. Basing health education practices
on research, demanding adherence to ethical standards, and promoting social justice are escalating
challenges and trends. Doing it more, doing it better, and doing it with less are the future challenges
(Breckon, Harvey, & Lancaster, 1998).
SUMMARY
This chapter introduces the Miller–Stoeckel Client Education Model. The model serves as the
conceptual framework around which this text is organized and written. The four major concepts of
Nurse as Educator, Client as Learner, Nurse–Client Relationship, and Client Education Outcomes
were defined and explained, as were the four embedded concepts of Cultural Caring, Communication, Negotiation, and Collaboration.
The nature of the Nurse–Client Relationship involves the Nursing Process, the Teaching and
Learning Process, Clinical Judgment, and EBNP. The model concludes with an examination of
­Client Education Outcomes that encompass Formative and Summative Evaluation. Finally, the
future challenges and trends facing Nurses as Educators were discussed. In this section we examined how health education can impact health, illness, and wellness in the local, national, and global
health arenas. In the subsequent chapters of this book, we delve into greater depth about all aspects
of providing health education.
EXERCISES
Exercise I: Philosophy of Health Education
Purpose: Develop a philosophy of health education.
Directions: Working with a small group of colleagues, write your philosophy of health education.
This will take time, thought, and discussion. Your philosophy statement should be about two to
three pages in length. Include your beliefs about the following:
1. The value of health education as an aspect of comprehensive health care
2. Teaching and what it means
3. Learning and its place in the human experience
4. The role of the Nurse as Educator
5. The role of the Client as Learner
6. The relationship that should exist between the educator and the learner
7. The value of Client Education Outcomes
References ■ 23
Exercise II: Apply the Miller–Stoeckel Client Education Model
Purpose: Gain experience using the model.
Directions: Select a client with whom you have worked who needs health education. Visualize how
you could use the model to build a positive Nurse–Client Relationship and achieve the educational
outcomes.
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How do you see your role as a nurse educator?
How do you see your client as a learner?
How can you use the nursing process to initiate and follow up with teaching your client?
What teaching and learning principles can you use?
How can you use clinical judgment to assess clients and design and implement client education?
What research that is evidence-based supports your decisions?
Exercise III: Using the Stoeckel Wellness–Illness Continuum
Purpose: Self-analysis of wellness–illness state.
Directions: Chart and analyze your progress on the Stoeckel Wellness–Illness Continuum. Print
a copy from the book to plot your score on, or write out your answers.
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Score each factor from 1–10: social, physiological, environmental, emotional, and health access.
Make a summative statement about your overall health.
Discuss in paragraph form how your personal beliefs, culture, and background affect your
views of health, illness, and wellness.
Exercise IV: Ways to Promote Client Education
Purposes:
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■■
Promote creative thinking.
Raise consciousness regarding client education.
Directions: Form small groups and discuss the following situation. Take notes and prepare a report
to be shared with the rest of your peers.
While carrying heavy patient care assignments and responsibilities, some nurses are managing to teach their clients in mutually satisfactory ways. What client teaching have you observed by
your clinical instructors, supervisors, primary nurses, or other nursing personnel? What are you
doing to promote client teaching? If you are not yet in the clinical area, seek out nurses in your
school, hospital, or neighborhood and ask them what they are doing to promote health teaching.
Draw on your experiences as a patient, client, relative, or observer. Upon reflection, summarize
the nurses’ role in client education.
REFERENCES
Agency for Healthcare Research and Quality. (2002). Systems to rate the strength of scientific evidence. Summary, evidence report/technology assessment (No. 47, AHRQ Publication No. 02-E015). Rockville,
MD: Author. Retrieved from http://www.thecre.com/pdf/ahrq-system-strength.pdf http://www.ahrq
.gov/clinic/epcsums/strengthsum.htm
24 ■ Chapter 1: Overview of the Miller–Stoeckel Client Education Model
American Hospital Association. (1992). A patient’s bill of rights. Retrieved from http://www.elcamino.edu
/faculty/dcharman/RT%20106%20AHA%20%20Patient%20Bill%20of%20Rights.pdf
American Nurses Association. (1998). Standards of clinical nursing practice (2nd ed.). Washington, DC:
Author.
Bastable, S. B., & Alt, M. F. (2014). Overview of education in health care. In S. B. Bastable (Ed.), Nurse as
educator: Principles of teaching and learning for nursing practice (4th ed., pp. 3–30). Burlington, MA: Jones &
Bartlett Learning.
Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley.
Bliss-Holtz, J. (2007). Evidence-based practice: A primer for action. Issues in Comprehensive Pediatric Nursing,
30(4), 165–182.
Breckon, D., Harvey, J., & Lancaster, R. (1998). Community health education: Settings, roles, and skills for the
21st century. Sudbury, MA: Jones and Bartlett.
Campinha-Bacote, J. (1998). The process of cultural competence in the delivery of healthcare services
(3rd ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates.
Chitty, K. K., & Black, B. P. (2007). Professional nursing: Concepts and challenges (5th ed.). St. Louis, MO:
Elsevier.
Davidhizar, R., & Cramer, C. (2002). The best thing about the hospitalization was that the nurses kept
me well informed: Issues and strategies of client education. Accident and Emergency Nursing, 10,
149–154.
Donner, C. L., Levonian, C., & Slutsky, P. (2005). Move to the head of the class: Developing staff nurses as
teachers. Journal for Nurses in Staff Development, 21(6), 277–283.
Fawcett, J. (2005). The structure of contemporary nursing knowledge. In Contemporary nursing knowledge:
Analysis and evaluation of nursing models and theories (2nd ed., pp. 1–48). Philadelphia, PA: F. A. Davis.
Green, L. W., & Kreuter, M. (1991). Health promotion planning: An educational and environmental approach. Mountain View, CA: Mayfield.
Hall, A. (2001). Client education. In P. Potter & A. Perry (Eds.), Fundamentals of nursing (7th ed.,
pp. 328–347). St. Louis, MO: Mosby.
Knowles, M. S. (1990). The adult learner: A neglected species (4th ed.). Houston, TX: Gulf.
McFarland, G. K., & McFarland, E. A. (1997). Nursing diagnoses and intervention, planning for patient care
(3rd ed.). St. Louis, MO: Mosby.
Melnyk, B. M., & Fineout-Overholt, E. (2004). Evidence-based practice in nursing and healthcare: A guide to best
practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best
practice (2nd ed). Philadelphia, PA: Wolters Kluwer.
National League of Nursing Education. (1918). Standard curriculum for schools of nursing. Baltimore, MD:
Waverly Press.
National League of Nursing Education. (1937). A curriculum guide for schools of nursing. New York, NY: Author.
Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study. New York, NY: G. P.
­Putman’s Sons.
Ormrod, J. E. (2012). Human learning (6th ed.). Boston, MA: Pearson.
Pender, N. (2011). The health promotion manual. Retrieved from http://research2vrpractice.org/wp-content
/uploads/2013/02/HEALTH_PROMOTION_MANUAL_Rev_5-2011.pdf
Peplau, H. E. (1952). Interpersonal relations in nursing. New York, NY: G. P. Putnam’s Sons.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby.
Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
Redman, B. (2006). The practice of patient education: A case study approach (10th ed.). St. Louis, MO: Mosby Elsevier.
Rosenstock, I. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4),
336–353.
References ■ 25
Scheffer, B. K., & Rubenfeld, M. G. (2006). Critical thinking: A tool in search of a job. Journal of Nursing
E­ducation, 45(6), 195–196.
Tanner, C. (2005). What have we learned about critical thinking in nursing? Journal of Nursing Education,
44(2), 47–48.
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of
Nursing Education, 45(6), 204–211.
The Joint Commission. (2009). The Joint Commission 2009 requirements related to the provision of culturally competent patient-centered care critical access hospitals (CAH). Retrieved from http://www.jointcommission.org
/assets/1/6/2009_CLASRelatedStandardsCAH.pdf
U.S. Department of Health and Human Services. (2012). Healthy People 2020. Washington, DC: Author.
Retrieved from http://www.healthypeople.gov/2020/default.aspx
Webster’s All-In-One Dictionary and Thesaurus (2nd ed.). (2013). Springfield, MA: Federal Street Press.
World Health Organization. (1948). Constitution of the World Health Organization. Retrieved from http://www
.who.int/governance/eb/who_constitution_en.pdf
World Health Organization. (2004). About the World Health Organization. Retrieved from http://www
.who.int/suggestions/faq/en/index.html
Wurzbach, M. E. (2004). Community health education and promotion: A guide to program design and evaluation
(2nd ed.). Sudbury, MA: Jones and Bartlett Publishers.
II
The Learning Process
Chapter 2 Thinking and Learning
Chapter 3 Theories and Principles of Learning
© MirageC/Moment Open/Getty
2
Thinking and Learning
OBJECTIVES
Upon completion of this chapter, you will be able to do the following:
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■■
■■
■■
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■■
■■
Apply the concepts of thinking and learning to the Miller–Stoeckel Client Education
Model.
Analyze definitions of thinking and learning and formulate your own definition.
Differentiate among cognitive, affective, and psychomotor domains of learning by giving
an example of each.
Give examples of how you have engaged in the following ways of thinking in the context of health education: problem solving, critical thinking, creative thinking, intuition,
reflection, fantasy, and reverie.
Identify at least two ways to help clients as learners (individuals, families, groups and
communities, and health team members) develop their thinking abilities.
Describe the following styles and models of thinking and learning: Sternberg’s thinking styles, Witkin and Goodenough’s Cognitive-Style Dimensions, Kolb’s Experiential
Learning Model: Learning Cycle and Styles, and Gardner’s Multiple Intelligences.
Describe how to apply the thinking and learning styles to client education.
CHAPTER OUTLINE
Introduction
Domains of Learning
• Cognitive Domain
• Affective Domain
• Psychomotor Domain
Thinking
• Definitions of thinking
Ways of Thinking
• Problem Solving
• Critical Thinking
• Creative Thinking
• Intuition
• Reflection
• Other Ways of Thinking
Reflecting on your Thinking
Promoting Thinking in Clients
Styles of Thinking and Learning
• Sternberg’s Thinking Styles
• Witkin and Goodenough’s
Cognitive-Style Dimensions
29
30 ■ Chapter 2: Thinking and Learning
• Kolb’s Experiential Learning Model:
Learning Cycle and Styles
• Gardner’s Multiple Intelligences
— Linguistic Intelligence
— Logical Mathematical Intelligence
— Spatial Intelligence
— Musical Intelligence
— Bodily Kinesthetic Intelligence
— Personal Intelligence
• Sensory-Based Learning Styles
• Implications for Health Education
Summary
Exercises
References
INTRODUCTION
Thinking and learning form the basis for the teaching and learning process, which undergirds
the nurse–client relationship in the Miller–Stoeckel Client Education Model. This chapter makes
the connection between thinking and learning and how they impact your approach to teaching
clients. Thinking and learning are purposeful activities with the goal of bringing about a necessary change. The teaching and learning process encourages clients to engage in activities that are
necessary to acquire new knowledge and new skills, and to incorporate new attitudes. Clients as
learners do this by modifying and reorganizing knowledge that is already in place or by acquiring
new knowledge. Clients as learners need specific, new information or assistance in learning how
to use known information to their best advantage. Nurses also need to engage in self-assessment
of their individual thinking and learning styles (Figure 2-1).
This chapter introduces the broad domains of learning: cognitive, psychomotor, and
­affective. Next we examine thinking and the many ways thinking is categorized. The nursing
process and clinical judgment were discussed in the previous chapter; now we discuss problem
solving, critical thinking, creative thinking, intuition, and reflection. The chapter concludes by
examining how thinking translates into various styles of learning and the implications this has
for health education.
FIGURE 2-1
Nurse–Client Relationship in the Miller–Stoeckel Client Education Model
• Nursing process
• Teaching/learning
process
Nurse as Educator
• Clinical judgment
Client as Learner
Healthcare Institutions
Public Health
Health Education Programs
• Evidence-based
nursing practice
Individuals
Families
Groups/Communities
Health Team Members
Domains of Learning ■ 31
DOMAINS OF LEARNING
Clients learn as total beings, with all their senses. When they learn, they have thoughts about learning, and they experience feelings about what they are doing, thinking, and learning. The d
­ oing,
thinking, and feeling aspects of learning are clearly related, but they are not the same. When nurses
help clients learn something, they select one or more domains in which clients need to focus most
of their energy. The three domains that have received the most attention in educational literature are the cognitive, affective, and psychomotor domains (Bloom, Engelhart, Furst, Hill, &
Krathwohl, 1956).
The learning domains have been separated for research and study purposes, but that separation is arbitrary. Human behavior includes components of each domain (Kretchmar, 2008). When
you are providing health education to clients, the domains provide an organizational framework
that is useful as you contemplate what clients need to learn and what should be taught. Figure 2-2
­illustrates the interactive, interdependent relationship among the three domains. The most effective learning occurs when all three domains are engaged in the learning process, as illustrated by
the center triangle (Goulet & Owen-Smith, 2005).
Cognitive Domain
Cognitive learning is concerned with intellectual activities such as thinking, remembering, reasoning,
and using language (The Merriam-Webster Dictionary, 2016). It involves judging, considering, believing,
FIGURE 2-2
The Interacting Domains of Learning: Cognitive (Think), Affective (Feel),
and Psychomotor (Do) Maximize Learning
Feel
Think
Do
32 ■ Chapter 2: Thinking and Learning
reflecting, and recalling. It also means using the mind to exercise judgment, draw inferences, arrive at
conclusions, and make decisions (Miller & Babcock, 1996). The cognitive domain was the first domain
developed by Bloom and colleagues in 1956. It has received the most attention in educational circles
and enjoys the widest application to learning, in part because of the emphasis of Western cultures on
reason over emotions (Kretchmar, 2008). Cognitive learning objectives are concrete and reflect this
emphasis on reason. They are relatively easy to conceptualize, write, and measure.
Affective Domain
The affective domain deals with personal issues: attitudes, beliefs, behaviors, and emotions (­ Krathwohl,
Bloom, & Masia, 1964). In the past, educators believed that the affective domain was an area of
learning that was too complex and fraught with conflicts. Research in this area, however, is changing
that perception, and educators are realizing the importance of integrating the affective domain into
their teaching. Because the affective domain deals with personal issues such as attitudes, beliefs,
behaviors, and emotions, it is increasingly integral to the provision of a comprehensive program
of health education. Educational research indicates that there is a relationship between emotional
intelligence and general intelligence in academic achievement. This research has implications
for health education. Learning objectives in the affective domain focus on influencing attitudes,
­motivating learners, developing respect, and clarifying values.
Attitudes are acquired by associating with others and participating in satisfying experiences.
Clients are influenced by nurses’ attitudes. Role modeling, for example, occurs when nurses work
with clients. Nurses are constantly observed by clients, who are influenced by their behavior. Characteristics of kindness, fairness, compassion, honesty, punctuality, dependability, and competence are
evident to clients as they observe nurses working. These characteristics help clients determine their
perception of the quality of care they receive. Some examples of the way that nurses display their
values are by treating clients with respect, such as providing privacy, adapting nursing interventions
to their expressed concerns, and giving them undivided attention. It is important to include learning
objectives in the affective domain as you provide health education for clients. Affective learning can
also be facilitated by persuasion from other trusted authorities, such as parents, teachers, scientists,
spiritual leaders, and valued colleagues with special expertise. Participating in group discussions
and role playing also helps promote affective learning.
Psychomotor Domain
Psychomotor learning encompasses many physical procedures that individuals use in their activities
of daily living and the complex physical activities required for work and recreation. It also includes
learning physical skills and procedures applicable to healthcare delivery. Psychomotor learning
requires that individuals acquire information and store it in memory. During the initial practice
of a procedure, skills are shaped and learned until they become automatic (Marzano & Kendall,
2007). This type of learning is the most concrete, and it is the easiest to teach, observe, and measure. Clients form a mental image of how a skill is performed and then translate that image into
external behavior. An example of psychomotor learning is performing an insulin injection. This
type of learning is usually done best in a step-by-step fashion, from the simple to the complex.
Nurses show clients how to perform the skill; then they guide them through return demonstrations.
Nurses correct errors and reinforce correct responses. Practice is encouraged until both clients
and nurses are satisfied with the clients’ skills.
Ways of Thinking ■ 33
THINKING
Thinking is categorized in different ways. In this section we look at definitions of thinking and ways
of thinking engaged in by clients and nurses: problem solving, critical thinking, creative thinking,
intuition, reflection, and other ways of thinking. The nursing process and clinical judgment, also
ways of thinking, were discussed in the previous chapter. Each type of thinking has a distinct focus
because they overlap, are complex, and cannot be confined to distinct categories. They are described
separately for purposes of this discussion to highlight the particular focus of each type of thinking.
Definitions of Thinking
To think is an activity of the mind that is essential to living. It involves a myriad of processes
such as observing, recalling, remembering, reasoning, drawing inferences, calculating likelihoods,
­reflecting, and deciding. It encompasses our knowledge, beliefs, opinions, and judgments. Thinking
has a subjective quality in that all past experiences influence how we see the world. It includes our
personal knowledge, our interpersonal relationships, and our role as nurses.
Ruggiero defined thinking as “any mental activity that helps formulate or solve a problem, make
a decision, or fulfill a desire to understand. It is a searching for answers, a reaching for meaning”
(2012, p. 4). It also involves such mental activities as wondering, imagining, inquiring, interpreting,
evaluating, and judging. Thinking can be concrete, referring to physical materials or objects (What
instructional materials do I need to teach this information?), or abstract, referring to a quality of
something (What value do instructional materials have in learning?). Thoughts can be about the
past (What worked best yesterday in teaching Ms. Jones about diabetes?), the present (How shall
I best present this material on smoking cessation?), or the future (How shall I use client feedback
to improve my teaching?).
Thinking is complex, multifaceted, dynamic, and it involves the creation of images (Halpern,
2014). For example, when you wonder if the intravenous solution is about to run out, you picture
what the fluid level in the bottle looked like the last time you were in the room, and you think
about the amount of time that has passed. In this sense, thinking is imagery accompanied by silent,
internal speech.
Thinking is described as directed and nondirected or automatic (Halpern, 2014). Directed
thinking is a conscious mental focus on a problem or issue with a desired outcome. It is purposeful
and goal directed. Directed thinking has an evaluation component that considers the effectiveness
of thinking outcomes; that is, if the decisions were effective. For example, you might ask yourself,
Did I make a good decision in this situation? In contrast, nondirected or automatic thinking ­occurs
as a result of routine habits, such as getting up in the morning, going to work or school, and so
forth. Many aspects of life involve nondirected, automatic thinking.
WAYS OF THINKING
Problem Solving
The most common type of thinking is problem solving. Problem solving is a process of developing, testing, and evaluating a method for overcoming an obstacle by identifying a problem
and finding the best alternative to solve it. Problem solving consists of these steps: identifying
34 ■ Chapter 2: Thinking and Learning
the problem, analyzing aspects of the problem, collecting pertinent information, hypothesizing
about its cause or causes, generating possible solutions, trying out one of the hypotheses, and
evaluating the results.
In the process of problem solving, individuals use critical thinking skills to understand and
solve a problem. Sometimes a situation requires considerable thought and contemplation (Should
I attend school full or part time?), and at other times it is relatively simple (What shall I do this
weekend?). Problem solving is conscious, focused thinking over which individuals exert control.
Problem solving requires being open to new ways of thinking, reflection, and clinical judgment. Nurses use problem solving most effectively in working with clients, assisting them to think
through their health problems, and finding workable, realistic, and appropriate solutions.
Critical Thinking
Critical thinking is a specific type of thinking that emphasizes rational cognitive processes and
certain attitudes and values. The word critical often connotes negativity, whereas the intended
meaning of the word is analytic. Ideas about critical thinking that are applicable to all disciplines
come from educators in the fields of philosophy and education (Brookfield, 2012; Browne & Keeley,
2012; Halpern, 2014; McPeck, 1990; Paul, 1995; Ruggiero, 2012; Watson & Glaser, 1980). Their
interest was in defining and identifying critical thinking processes applicable to everyday living.
Common themes in these definitions include conscious awareness of one’s thinking processes, including a­ cquiring knowledge and understanding. It involves examining assumptions and validating
inferences, examining evidence, and searching for meaning and solutions through rational thinking
processes. It is purposeful, directed toward solving problems and resolving issues. The definitions
also address attitudes, values, and dispositions, for example, intellectual honesty, fl
­ exibility, and
willingness to listen to other points of view. To be a critical thinker is to be analytic, reflect constructively, and evaluate fairly.
Nursing recognizes the importance of critical thinking in preparing practitioners (Kaddoura,
2013; Wallace & Moughrabi, 2016; Whiffin & Hasselder, 2013) and accepts critical thinking as an
essential component of nursing practice and nursing education programs (Chan, 2013; Holland &
Ulrich, 2016). However, the nursing profession continues to lack a widely accepted definition of
critical thinking (Chan, 2013; Kaddoura, 2013; Victor-Chmil, 2013). Nurse educators accept ­rational,
logical thinking as central features of critical thinking and recognize that critical thinking is different from clinical reasoning and clinical judgment. We agree with Victor-Chmil that these are
distinct but interrelated concepts.
The most widely accepted definition of critical thinking comes from the research of Scheffer
and Rubenfeld (2000). They conducted a study to define critical thinking in nursing with input
from an international panel of nurse experts on critical thinking. They identified both cognitive
and affective dimensions of critical thinking in nursing. Their consensus definition is as follows:
Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of
the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness,
intellectual integrity, intuition, open-mindedness, perseverance, and reflection.
Critical thinkers in nursing practice the cognitive skills of analyzing, applying
standards, discriminating, information seeking, logical reasoning, predicting and
transforming knowledge. (p. 357)
Ways of Thinking ■ 35
Because of the research supporting this definition, we believe it best represents the meaning
of critical thinking in nursing.
Creative Thinking
To create is to bring into being—to cause to exist (The Merriam-Webster Dictionary, 2016). It is
the ability to go beyond current knowledge and think in a new way. Creative thinking has both a
creative and a judgmental phase (Ruggiero, 2012). Individuals have creative thoughts and ideas and
then proceed to judge them as they look for solutions to problems and answers to questions. This
thinking moves back and forth between creating ideas and then judging them, the former being
creative thinking and the latter being critical thinking. Halpern (2014) sees creativity as producing an
unusual outcome while also being appropriate and useful to the situation. Thus creative thinking
and critical thinking are intertwined.
Creative thinkers are curious, adventurous, resourceful, undaunted by the prospect of failure,
and independent in the sense that they are willing to speak freely and do not need a lot of approval
from others (Ruggiero, 2012). Creative thinkers tolerate ambiguity and uncertainty, adjust easily
to new and changing situations, and freely abandon old assumptions when confronted with new
evidence. Creative thinkers are willing to be different, to think outside the box. In problem solving,
creative thinkers propose multiple options to consider that are appropriate to the context rather
than immediately focusing on one option.
Santrock (2014) described the creative process as a five-step sequence, the first of which is
preparation. In this step, a problem or issue arouses interest and curiosity. The next step is incubation, whereby individuals think about the problem and mull over ideas. The third step is insight,
that moment when the pieces of the puzzle seem to fit together. The fourth step is evaluation, when
individuals bring their judgment to bear on a tentative solution to determine if it is workable and
realistic. The final step is elaboration, the most difficult step requiring the most time. These steps
move back and forth and do not follow a linear, sequential path. For example, insight and incubation can occur throughout each step, and evaluation is ongoing.
Intuition
Intuition is quick and ready insight, knowing things without conscious reasoning (The MerriamWebster Dictionary, 2016). It is information that is not acquired by rational, analytic processes; rather,
it occurs outside of conscious thought. Its source is from within the person and is based on life
experiences and accumulated knowled…

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