A model for facilitation in nursing education

Tel/Fax (051)401-2407 E-mail: gnvkem.MD@mail.uovs.ac.za Abstract: Curationis 28(2): 22-29 A key step in the development of a model for learning is to identify the needs of both the facilitators and the learners. The purpose of this study was to develop a model for facilitation in nursing education based on the identified needs of facilitators and learners and a confirmation by the literature. A qualitative research design was used and the population of the study was the facilitators and the learners o f departments/ schools of nursing in four universities in South Africa. Focus group interviews were conducted with facilitators and learners. The sample was purposively selected. The results underline the needs as well as the perceptions of both facilitators and learners with regard to facilitation. Concepts were identified and analyzed from the identified needs which led to the development of the model for facilitation. The complete visual model was described and presented to experts for evaluation. Feedback from the evaluators was used to adapt and finalize the model, after which the model was again presented to evaluators who approved and accepted it. The model is a unique contribution to nursing education as it sets guidelines for a new field of learning in nursing education.


Introduction
learning cannot be limited to the delivery o f in fo rm a tio n b u t th a t th e a c tiv e participation o f the learner is essential.
The starting point would be the revision of the traditional teaching role of the lecturer which, according to Creedy and Hand (1994:696-702) is characterized by the dominance and control o f learning by the teacher.Changing this role to that of a facilitator of learning means that the fa c ilita to r lic e n se s th e stu d e n ts to assum e control and direct their own learning (Andrews & Jones, 1996:357-365).Effective learning is possible when the role of the teacher is not that o f a controller and provider of information but that of a facilitator and manager o f the learning process (Erasmus & van Dyk, 19 9 6 :6 7 ).T h is n e c e s s ita te s th e developm ent of a model for facilitation because in the past lecturers were trained to lecture and not to facilitate learning.

Problem statement
The study evolves from the introduction of a non-traditional teaching/learning method, problem-based learning (PBL) and the m ove from curative care to community-based learning (CBE) in the undergraduate programme of the School of Nursing of the University of the Free S ta te (U F S ).T he p la n n in g o f the curriculum for PBL and CBE in the School of Nursing of the University o f the Free State was extensive.The focus was on the process of PBL and CBE and not much on facilitation.All lecturers were trained to lecture and not to facilitate learning.L ecturers attended several workshops and conferences, locally and internationally, but this seem ed to be inadequate in preparing facilitators for T he stu d e n ts w ho r e g is te r fo r the undergraduate nursing course come from school backgrounds where self-directed learning until recently has not been e n c o u ra g e d (B ec k er, 1999:4).The students were unfamiliar with learning by using facilitation, they struggled to adapt to this mode of learning and their needs regarding the method were not known.It w as th erefo re im portant to make an assessm ent o f both the facilitator and learners needs in order to develop a model to meet those needs.

Aim of the study
The aim of the study was to develop a model for the process o f facilitation in nursing education

Objectives
• To identify the needs of the facilitators in different schools of nursing.

•
To identify the needs of the students with regard to facilitation.

•
To construct a model for facilitation according to the determined needs.

Reseach design
In this explorative and descriptive study a qualitative design was used and the research was contextual in nature.The combined methods o f theory generation of Chinn and Kramer (1999) and Duldt and Giffin (1985) as well as the steps of L a n c a ste r and L an caster (1992) for building a model were used for designing the model.

Sample
The sample was purposively selected and included the facilitators and learners in the schools and departments of nursing o f four South African universities using facilitation as a teaching-learning method and who were willing to take part in the research.A total of 12 focus groups were conducted.Two (one with facilitators and the others with learners) of the twelve were pilot studies to test the research question and to practise the technique.T he data o f the pilot study w as not included in the study.O f the ten (10), fo u r fo c u s g ro u p s w ere h eld w ith facilitators and six (6) with students.At each university one focus group was held w ith the fa c ilita to rs.R eg ard in g the students, two focus groups each were conducted in two universities and one focus group each was held w ith the remaining two universities

Ethical considerations
Inform ed consent was sought prior to conducting the focus group discussions.
A ll p a rtic ip a n ts w ere a ssu re d th at confidentiality and anonymity would be maintained.Participants were informed that participation was voluntary and they had the rig h t to d is c o n tin u e th e ir participation if they felt uncomfortable or did not wish to continue.Informants a g re e d to be p art o f fo c u s g ro u p discussions and none of them left before discussions were completed

Data collection
The  1994:44).Only one open-ended question was asked to enable the facilitators and the learners to share personal thoughts, p e rc e p tio n s and fe e lin g s in an unstructured manner.
T h e q u e stio n w as " H ow d o y o u experience facilitation as a teaching/ le a rn in g m e th o d ? .An expert in the f a c ilita tio n o f fo c u s g ro u p s w as a p p ro a c h e d to act as fo c u s g ro u p fa c ilita to r or m o d erato r in d ifferen t sessions.

Field notes
The researcher took field notes.Moloto (1999:57) states that the tasks o f the research er are to develop questions, facilitate the sessions, docum ent data during the session, analyze the data and interpret the results.

Data analysis
D ata w as a n a ly z e d by m ean s o f a combination of Tesch (1990)

Phases of model development
The model was developed according to the d iag ram m a tic re p re se n ta tio n in Figure 1.The model was designed in two phases, namely the reconnaissance or scouting and the empirical phases (see Figure 1).(1999) and Duldt and Giffin (1985) as well as the steps of Lancaster and Lancaster (1992) for building the model were used for designing the model The purpose of the model The model has four purposes: • The main purpose is that learning must take place through the process of facilitation. • The model should give guidelines to prepare facilitators for their new role of facilitation.
• It is also designed to enable facilitators of learning to make the learners the focus of the learning event.
• The model will assist facilitators to understand their roles in the learning process during facilitation and to understand the learners.

Constructivism
It is the philosophy of constructivism to view knowledge as something that the learners must construct by themselves th ro u g h th e ir in te ra c tio n w ith the environment (Chalmers & Fuller, 1996:18;Duffy & Cunningham, undated: 171;von Glaserfeld, 1995:3-16).Constructivism builds on the knowledge known by the learner (Dougiamas, 1998).This model is b ased on th e p h ilo s o p h y o f constructivism.

Assumptions
T he m odel is based on a num ber of assumptions, some of which have been taken from the paradigm guiding the research and some of which have been derived from the identified concepts.The main assumptions are from adult learning theory.O ther assum ptions relevant to this model, namely those from symbolic interaction theory (Pearson, Vaughan & Fitzgerald, 1997:45)

Facilitation
Facilitation is the central concept in this model.It is both a method and a strategy for learning (B rockbank and M cGill (1998:145) Salmon (1980:5) Holtzhausen (1998:33-37) Rooth (1995:95).As a central concept facilitation takes place in the classroom and in the clinical setting in a small group format according to the data co llected from both fa c ilita to rs and learners.It is based on the principles of a d u lt le a rn in g and it re q u ire s the involvem ent o f both the learners and their facilitator through the process of interaction.Real-life situations are the b asis and these en co u rag e life-long le a rn in g as le a rn in g is c o n te x tu a l.Facilitation promotes critical thinking in the learners and both become reflective learners.Their problem-solving ability as w ell as th e ir c lin ic a l re a so n in g is developed.
Learning L earn ing focuses on the process of discovery in which the learner seeks to understand issues and the issues that guide the discovery process must be p e rso n a lly re le v a n t (D u ffy & Cunningham , undated ) A ccording to constructivism learning is contextual and should occur or be situated in a realistic setting.It also occurs within a social c o n te x t (D a lg a rn o :O n lin e) and is culturally constructed (Boud and Felleti, 1993:7-8).Learning should lead to the cognitive, affective and psychom otor development of the learner.

Adult learning
Nursing learners are regarded as adults (Klopper, 1999:2) The reason is that most consum ers o f nursing care are adults (N unnery, 1997:199) and nurses are expected to be more responsible for the liv es o f p eo p le.A dult lea rn in g is characterized by the following principles:

•
An adult self-concept includes being treated as being capable of self-direction.
• Adults need to recognize the purpose of learning • They will build on their own life experience • Adults will learn best if the learning is task-, problem-or inquiry-centred.
• Adults will learn when they are ready.

Facilitator
The facilitator is the person responsible for helping the learners to construct knowledge.According to the data the facilitator must posses the follow ing qualities: • Self-awareness

Learner
Nursing learners are regarded as adults (Klopper, 1999:2).).This is because most consumers of nursing care are adults (N unnery, 1997:199) and nurses are expected to be more responsible for the lives o f people.Learners must acquire three main components, namely nursing knowledge, nursing com petencies and professional values.
Core competencies expected to be learned through facilitation include: • Critical thinking

Classroom setting
Facilitation in the classroom occurs in sm all groups.T hese groups provide expertise from the rest of the group which is not available to the solitary individual (Gregory & Thomley, 1994:20).The group members plan activities together as well as reflect on how their activities could be more effective.The size o f the group should be betw een fo u r and fifteen members, it should be small enough to • encourage diversity o f viewpoints and ideas and not too large so that it interferes # with face-to-face interactions.M embers receive feedback from one another to im prove group activ ities.T hey also m anage the group by setting ground rules and by agreeing to com m itm ent th ro u g h a lea rn in g c o n tra c t (D an a, 1997:41-43).All group activities are assessed.

Clinical setting
Facilitation also occurs in the clinical setting.T he literatu re d escrib es the clinical setting as more than just a place # to apply theory to practice.It is where the lea rn er learn s p ro b le m -so lv in g , decision-making and divergent thinking skills necessary for dealing w ith the uncertainties of clinical practice.(Reilly and Oermann 1985, in Dana & Gwele, 1998:58-64, Mashaba 1994:44, Chabeli (1998:39-44).The clinical setting may be the hospital, clinic, patient's home or an old age home.(Neuman, 1997:43).Chinn and Kramer (1991:116) suggest that concepts should be given a structural form so as to clarify their relationship by m eans o f a sym bolic representation.

Assessment
Based on the definitions provided in the • p re c e d in g se c tio n , th e fo llo w in g relationships are proposed: • Facilitation takes place in the context of nursing education.
The focus o f nursing education is the learner, the facilitator, the process o f facilitation, as well as the learning environment, which may be the classroom or the clinical setting.
Learning takes place through the process o f facilitation.
Facilitation is based on the philosophy of constructivism and the principles of adult learning are applied.
The principles o f adult learning indicate that certain aspects of learning need to be taken into consideration when dealing with adult learners, for example facilitation requires understan ding of how learners experience learning otherwise the purpose of facilitation may be defeated.
Learning is facilitated when learners participate in the learning process.
The main role players in learning through facilitation are the facilitator and the adult learners.
The facilitator must have skills, certain qualities, develop a relationship, with the learners and have roles to fulfil in helping the learners to develop core competencies, the nursing role and professional values.
The facilitator interacts with the learners in facilitation through the process of dialogue, negotiation and discourse.
The learners interact with the learning environment by being active participants in the learning process.
In facilitation learning takes place in the classroom through group work and in the clinical setting.
The goal of facilitated learning in nursing education is to produce a competent theoretical nurse at the same time as a practical nurse is produced because nursing is a practice-based profession; hence facilitation occurs in the classroom and the clinical setting.
The relationship between the facilitator and the learner and between the learners is a much more complex interaction and process than in the traditional form of teaching. • The facilitator supports the learners by means of scaffolding and mentoring.
• It is important for the process of facilitation to be assessed

•
The group members assess one another as well as the facilitator, and then they all assess the facilitation process and the group dynamics

•
First each learner should reflect on his or her own work and interactions with the group.Second, each learner should reflect on the contributions of other members, considering both their methods and efforts.Finally, members should share their thoughts about how the group operated as a whole.
It should be a form alized structure of schools.
• Different strategies should be used such as designing standardized assessment tools.
• Assessment should be carried out frequently, for example at the end of every session or completion of a module.
• Formative and summative assessment should be used.

Evaluation of the model
A tentative model was constructed and sent to 10 evaluators to be evaluated.
Overall feedback indicates that the model was accepted but that som e changes were needed to be implemented for a final model.The researcher adapted the model as valuable input was received from the evaluators

Conclusion
The data collected indicates that the fa c ilita to rs as w ell as the le a rn e rs experienced problems with facilitation as a teaching/learning method.The data and the lite ra tu re re v ie w g u id e d the researcher in developing the model.The main purpose of the model is that learning must take place through the process of fa c ilita tio n and th at it sh o u ld give guidelines to the facilitators as well as the learners.Facilitation was the central concept in the model.Other important role players are the learner and the facilitator.The research indicated the need for the development of a model.

Acceptability and usability of the model
This model provides nursing educators with aspects that must be considered in train in g nurse ed u cato rs to becom e fa c ilita to rs.The trad itio n al training methods must include facilitation as a teaching-learning method.Models are not intended as rigid structures that must at all tim es be adhered to (Pearson, Vaughan & Fitzgerald, 1997:70).This model may be used in the early stage of facilitation to provide structure or a framework to give learners direction.As facilitators' expertise develops the model may be used as a guideline or aidememoire.

Recommendations for facilitators
• Facilitators should be thoroughly prepared for their facilitation role and should commit themselves to a paradigm shift o f relinquishing classroom control and adapt to a student-centred approach.
• They should use appropriate skills to encourage learning.
• They must have facilitative personalities characterized by, for example, openness, warmth, patience and flexibility to enable learning to take place.

Recommendation for nursing education
• Nurse educators should continuously revise the method of learning and shift from traditional methods of learning to self-directed learning.
• Nursing education should make it mandatory for the skills required of the nursing student to be built into the nursing curriculum.Development and support should be contained in the curriculum.

•
The model as indicated in Figure 2 may be used as a guideline or aide-memoire for facilitators and learners.

Summary
The

Figure
Figure 1 Diagrammatic representation of the origin of the model on a sse ssin g the perceptions o f facilitators o f problembased learning and com m unity-based education in the School of Nursing of the Free State University.There was no ro le m odel o r e x p e rt w ho c o u ld demonstrate good facilitation.Most of the facilitation was learned by trial and error.Facilitators struggled to adapt to this mode of teaching because there were no guidelines for facilitation.
was carried out to examine and verify trends and similarities in the data obtained.The results of the a n a ly zed data from the tran sc rib e d material o f the focus group discussions w ere used to id en tify , c la ssify and c a te g o riz e im p o rta n t th e m e s and statements concerning the study.Validity and reliabilityT ru stw o rth in ess w as m aintained by u sin g s tra te g ie s o f c re d ib ility , tra n s fe ra b ilty , d e p e n d a b ility and c o n fo rm a b ility (L in c o ln & G u b a, 1985:290-327).Credibility was achieved by c ro s s -e x a m in a tio n o f d a ta and literature control.D ependability was ensured by dense description of data and the use of the co coder.Presenting the model to different evaluators whose input can be used by facilitators to improve their facilitation skills ensured transferability.B eing c lo se to re sp o n d e n ts w hen c o n d u c tin g fo cu s g ro u p in te rv ie w s ensured conformability.

A
model for facilitation in nursing education T he c o m b in e d m e th o d s o f th e o ry generation of Chinn and Kramer are included.Definition of concepts in the model C o p i's (1968:115-118) principles for d e fin in g c o n c e p ts w ere a p p lie d in defining the concepts in the model The follow ing concepts together create a m odel fo r f a c ilita tio n in n u rsin g education.
L a d y sh e w sk y (1 9 9 1 :2 4 ) d e s c rib e s assessment as an essential and necessary component o f professional competency measurement.It is imperative that the process of facilitation be assessed.From the data and the literature the following * are c o n clu d e d ab o u t a sse ssm e n t in facilitation: Relationship statements of the model According to Breakwell, Hammond and Fife-Schaw (1998:7) theories are basically • sets o f relational rules.They contain m any c o n c e p ts and s p e c ify how concepts relate to one another study was undertaken to construct a m odel fo r fa c ilita tio n in n u rsin g education.The needs of the facilitators and learners regarding facilitation were identified, based on their experiences of this mode o f teaching and learning.A qualitative research design was used.Purposive sampling from all universities u sin g n o n -tra d itio n a l m eth o d s o f teaching was im plem ented.Findings in d ic ate th at both the lea rn ers and facilitators experienced problems with facilitation.A model was constructed with the aim o f p ro v id in g g u id e lin e s .Recommendations are proposed for the facilitator, learner, and nursing education.
K E R , S 1999: E v a lu a tio n o f p ro b le m -b a se d le a rn in g in an u n d e rg ra d u a te n u rsin g e d u c a tio n programme.Bloemfontein: University of the Free State (M.Soc.Sc. in Nursing).B O U D , D & F E L E T T I , G 1991: Introduction.(In: Boud, D. & Feletti, G. (Eds.)The challenge of problem-based learning.London: Kogan Page).B RO CK BA N K , A & M cG IL L , 1 1998: Facilitating reflective learning in higher I : MODEL FOR FA C ILITA TIO N education.Philadelphia: Open University Press.C O P I, IM 1968: Introduction to logic.3rd ed.London: M acM illan Co. ERA SM U S, B J & VAN DYK, PS 1999: Training management in South Africa.2nd ed.J o h a n n e s b u rg : In te rn a tio n a l Thompson Publishing (Pty.)Ltd.BREA K W ELL, G M ; HAM M OND, S & F IV E -S C H A W , C 1 9 9 8 : R e se a rc h methods in psychology.London: Sage Publications C H A B E L I, M 1998: Professional nurses as reflective clinical learning facilitators.Curationis.21 (2):39-44.C H A L M E R S , D & F U L L E R , R 1996: T each in g fo r learn in g at u n iv ersity : Theory and practice.London: Kogan Page.C H IN N , P L & K R A M E R , M K 1991: T h e o ry an d n u rs in g : A sy s te m a tic approach.3rd ed.St. Louis C.V. M osby Co. C H IN N , P L & K R A M E R , M K 1999: T h e o ry an d n u rsin g in te g ra te d knowledge development.5th ed.St. Louis: C.V. M osby Co. C R EE D Y , D & H A N D , B 1994: The im p le m e n ta tio n o f p ro b le m -b a s e d learning: C hanging pedagogy in nurse education.Journal of Advanced Nursing.20( l):696-702.C R E S W E L L , J W 1994: R esearch design.Qualitative and quantitative D A L G A R N O , B C o n s tru c tiv is t com puter assisted learning: Theory and techniques, http://w w w .ascilite.org.au/conference/adelaide96/papers/ 21 .html.D A N A , H & G W E L E , N S 1 9 9 8 : Perceptions o f student nurses o f their person al and academ ic dev elo p m en t during placem ent in the com m unity as a D O U G IA M A S, M 1998.A journey into constructivism , http://dougiam as.com / w riting/constructivism , html.DU lO i r, G ; KHABANJANE, E; KORF, W ; K O T Z E , G ; M A S E H E L A , K ; MOSTERT, S & VAN TONDER, F 2000: Assessment in OBE.A project sponsored by th e M in is try o f th e F le m ish Government, Department of Education.Final report.D U FF, T M & C U N N IN G H A M , D J Undated.Constructivism: Implications for the design and delivery o f instruction.D U L D T , B W & G IF F IN , K 1985: T heoretical perspectives for nursing.Boston: Little, Brown & Co. FK H ARDT, AE & DU RAND, P P 2000: F a c ilita to r's perceptions o f problembased learning and com m unity-based education.Health SA G esondheid.G R E G O R Y , R & T H O R L E Y , L 1994: Present challenges.Qn: Thorley, L. & G regory R. (Eds.)Using group-based learning in higher education: Teaching and le a rn in g in h ig h e r e d u c a tio n .London: Kogan Page).H E A L T H S C IE N C E AND S O C IA L SER V ICES D O C U M EN T PA CK FO R 2 3 rd P L E N A R Y M E E T IN G 2002: February.H O L T Z H A U S E N , S W 1 9 9 8 : T he d e v e lo p m e n t o f f a c ilita to rs and a p re re q u is ite to the su c c e ssfu l transform ation o f educational change.S o u th A fric a n J o u rn a l o f H ig h e r Education.12(3):33-36 K L O P P E R , H 1999: Nursing education: A reflection. 2nd ed.Lynwood Ridge: Amabhuku Publications L A D Y S H E W S K Y , R 1995: Clinical teaching.Gold guide no. 1. Australia: HERDSA.L A N C A ST E R , W & L A N C A ST E R , J 1992: M odels and m odel building in n u rsin g .(In.: N ic o ll, L .H .(E d .)Perspectives o f nursing theory.2nd ed.New York: J.B. Lippincott Co).L IN C O L N , Y & G U B A , E 1985: Naturalistic enquiry.California: sage.M A JU M D A R , B 1996: Self-directed learning in the co n tex t o f a nursing curriculum: Development of a learning plan.Curationis.19(2):43-46.MASHABA, T G 1994: The philosophical b a sis o f n u rsin g e d u c a tio n .(In: M ashaba, T.G. & B rink, H .I. (E ds.) N ursing ed u catio n .An in ternational perspective.Kenwyn: Juta & Co).29 Curationis May 2005 MAYKUT, P & M O REH O U SE, R 1994: B e g in n in g q u a lita tiv e re se a rc h .A philosophic and practical guide.London: The Falmer Press.M O L O T O , J C 1999: A model for the reintegration of marginalized adolescents into the com m unity to facilitate the restoration, prom otion and maintenance o f their m ental health.Johannesburg: Rand Afrikaans N EU M A N , W L 1997: Social research methods.Q ualitative and quantitative approaches.3rd ed.B oston: A llyn & Bacon.NUNNERY, R K 199: Advancing your career: Concepts of professional nursing.Philadelphia: F.A. Davis Co. O M ERY , A 1983: Phenomenology: A method for nursing research.Advances in Nursing Science.5(2):49-63.R O O T H , E 1995: Life skills: A resource book for facilitators.Menzini: MacMillan P E A R S O N , A ; V A U G H A N , B & FITZG ERA LD , M 1997: Nursing models for practice.2nd ed.Oxford: Butterworth-Heinemann.REPUBLIC O F SOUTH AFRICA 1995: W ays o f se e in g the N a tio n a l Q u alifications Fram ew ork.P retoria: Human sciences research Council.SA LM O N , P 1980: Coming to know.London: Routledge.VON GLASSERFELD, E 1987: Learning as a constructive activity.In: Janvier, C. (Ed.) Problems o f representation in the teaching and learning of mathematics.N ew Je rse y : L a w re n c e E rlb au m Associates.Inc.