Learning Theories PDF

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Chapter 3
Applying Learning
Theories to Margaret M.
Braungart
Healthcare Richard G.
Braungart
Practice
CHAPTER HIGHLIGHTS
Applying Learning Theories Common Principles of Learning
Behaviorist Learning Theory How Does Learning Occur?
Cognitive Learning Theory What Kinds of Experiences Facilitate or
Social Learning Theory Hinder the Learning Process?
Psychodynamic Learning Theory What Helps Ensure That Learning Becomes
Humanistic Learning Theory Relatively Permanent?
Neuropsychology and Learning State of the Evidence
Comparison of Learning Theories
KEY TERMS
learning information processing
learning theory cognitive development
respondent conditioning social constructivism
systematic desensitization social cognition
stimulus generalization cognitive-emotional perspective
discrimination learning role modeling
spontaneous recovery vicarious reinforcement
operant conditioning defense mechanisms
escape conditioning resistance
avoidance conditioning transference
metacognition hierarchy of needs
gestalt perspective therapeutic relationship
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52 Chapter 3: Applying Learning Theories to Healthcare Practice
OBJECTIVES
After completing this chapter, the reader will be able to
1. Differentiate among the basic approaches to learning for each of the five learning theories.
2. Define the principal constructs of each learning theory.
3. Give an example applying each theory to changing the attitudes and behaviors of learners in
a specific situation.
4. Discuss how neuroscience research has contributed to a better understanding of learning and
learning theories.
5. Outline alternative strategies for learning in a given situation using at least two different
learning theories.
6. Identify the differences and similarities in the learning theories specific to (a) the basic pro-
cedures of learning, (b) the assumptions made about the learning, (c) the task of the educa-
tor, (d) the sources of motivation, and (e) the way in which the transfer of learning is
facilitated.
Learning is defined in this chapter as a relatively ing occurs, what kinds of experiences facilitate
permanent change in mental processing, emo- or hinder the learning process, and what ensures
tional functioning, and/or behavior as a result of that learning becomes relatively permanent.
experience. It is the lifelong, dynamic process by Until the late 19th century, most of the dis-
which individuals acquire new knowledge or cussions and debates about learning were
skills and alter their thoughts, feelings, atti- grounded in philosophy, school administration,
tudes, and actions. and conventional wisdom (Hilgard, 1996).
Learning enables individuals to adapt to Around the dawn of the 20th century, the new
demands and changing circumstances and is field of educational psychology emerged and
crucial in health carewhether for patients and became a defining force for the scientific study
families grappling with ways to improve their of learning, teaching, and assessment (Woolfolk,
health and adjust to their medical conditions, 2001). As a science, educational psychology rests
for students acquiring the information and skills on the systematic gathering of evidence or data
necessary to become a nurse, or for nurses and to test theories and hypotheses about learning.
other healthcare staff devising and learning A learning theory is a coherent framework of
more effective approaches to educating and integrated constructs and principles that
treating patients and each other in partnership. describe, explain, or predict how people learn.
Despite the significance of learning to each indi- Rather than offering a single theory of learning,
viduals development, functioning, health and educational psychology provides alternative the-
well-being, debate continues about how learn- ories and perspectives on how learning occurs
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Applying Learning Theories 53
and what motivates people to learn and change solve problems, change unhealthy habits, build
(Hilgard & Bower, 1966; Ormrod, 2004; constructive relationships, manage emotions,
Snowman & Biehler, 2006). and develop effective behavior.
The construction and testing of learning the- This chapter reviews the principal psycho-
ories over the past century have contributed logical learning theories that are useful to health
much to our understanding of how individuals education and clinical practice. Behaviorist, cog-
acquire knowledge and change their ways of nitive, and social learning theories are most often
thinking, feeling, and behaving. Reflecting an applied to patient education as an aspect of pro-
evidence-based approach to learning, the accu- fessional nursing practice. It is argued in this
mulated body of research information can be used chapter that emotions and feelings also need
to guide the educational process and has chal- explicit focus in relation to learning in general
lenged a number of popular notions and myths (Goleman, 1995) and to health care in particular
about learning (e.g., Spare the rod and spoil the (Halpern, 2001). Why? Emotional reactions are
child, Males are more intelligent than females, often learned as a result of experience, they play
You cant teach an old dog new tricks.). In addi- a significant role in the learning process, and
tion, the major learning theories have wide appli- they are a vital consideration when dealing with
cability and form the foundation of not only the health, disease, prevention, wellness, medical
field of education but also psychological counsel- treatment, recovery, healing, and relapse preven-
ing, workplace organization and human resource tion. To address this concern, psychodynamic
management, and marketing and advertising. and humanistic perspectives are treated as learn-
Whether used singly or in combination, ing theories in this review because they encour-
learning theories have much to offer the practice age a patient-centered approach to care and add
of health care. Increasingly, health profession- much to our understanding of human motiva-
als must demonstrate that they regularly tion and emotions in the learning process.
employ sound methods and a clear rationale in The chapter is organized as follows. First,
their education efforts, patient and client inter- the basic principles of learning advocated by
actions, staff management and training, and behaviorist, cognitive, social learning, psycho-
continuing education and health promotion dynamic, and humanistic theories are sum-
programs (Ferguson & Day, 2005). marized and illustrated with examples from
Given the current structure of health care in psychology and nursing research. With the
the United States, nurses, in particular, are often current upsurge and interest in neuroscience
responsible for designing and implementing research, brief mention is made of the contri-
plans and procedures for improving health edu- butions of neuropsychology to understanding
cation and encouraging wellness. Beyond ones the dynamics of learning and sorting out the
profession, however, knowledge of the learning claims of learning theories. Next, the learning
process relates to nearly every aspect of daily life. theories are compared with regard to:
Learning theories can be applied at the individ-
ual, group, and community levels not only to Their fundamental procedures for
comprehend and teach new material, but also to changing behavior
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The assumptions made about the learner each theory, readers are asked to consider the fol-
The role of the educator in encouraging lowing questions:
learning
How do the environment and the inter-
The sources of motivation for learning
nal dynamics of the individual influence
The ways in which learning is trans-
learning?
ferred to new situations and problems
Is the learner viewed as relatively pas-
Finally, the theories are compared and then syn- sive or more active?
thesized by identifying their common features and What is the educators task in the learn-
addressing three questions: (1) How does learning ing process?
occur? (2) What kinds of experiences facilitate or What motivates individuals to learn?
hinder the learning process? (3) What helps ensure What encourages the transfer of learn-
that learning becomes relatively permanent? ing to new situations?
While surveying this chapter, readers are encour- What are the contributions and criti-
aged to think of ways to apply the learning theo- cisms of each learning theory?
ries to both their professional and personal lives.
The goals of this chapter are to provide a con-
ceptual framework for subsequent chapters in
Behaviorist Learning Theory
this book and to offer a toolbox of approaches Focusing mainly on what is directly observable,
that can be used to enhance learning and change behaviorists view learning as the product of the
in patients, students, staff, and oneself. Although stimulus conditions (S) and the responses (R)
there is a trend toward integrating learning the- that followsometimes termed the S-R model
ories in education, it is argued that knowledge of of learning. Whether dealing with animals or
each theorys basic principles, advantages, and people, the learning process is relatively simple.
shortcomings allows nurses and other health pro- Generally ignoring what goes on inside the
fessionals to select, combine, and apply the most individualwhich, of course, is always difficult
useful components of learning theories to specific to ascertainbehaviorists closely observe
patients and situations in health care. After com- responses and then manipulate the environment
pleting the chapter, readers should be able to to bring about the intended change. Currently
identify the essential principles of learning, in education and clinical psychology, behavior-
describe various ways in which the learning ist theories are more likely to be used in com-
process can be approached, and develop alterna- bination with other learning theories, especially
tive strategies to change attitudes and behaviors cognitive theory (Bush, 2006; Dai & Sternberg,
in different settings. 2004). Behaviorist theory continues to be con-
sidered useful in nursing and health care.
Learning Theories To modify peoples attitudes and responses,
behaviorists either alter the stimulus conditions
This section summarizes the basic principles in the environment or change what happens
and related concepts of the behaviorist, cogni- after a response occurs. Motivation is explained
tive, social learning, psychodynamic, and hu- as the desire to reduce some drive (drive reduc-
manistic learning theories. While reviewing tion); hence, satisfied, complacent, or satiated
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Learning Theories 55
individuals have little motivation to learn and ulus (NS)a stimulus that has no particular
change. Getting behavior to transfer from the value or meaning to the learneris paired with
initial learning situation to other settings is a naturally occurring unconditioned or unlearned
largely a matter of practice (strengthening stimulus (UCS) and unconditioned response
habits). Transfer is aided by a similarity in the (UCR) (Figure 31). After a few such pairings,
stimuli and responses in the learning situation the neutral stimulus alone, without the uncondi-
relative to future situations where the response tioned stimulus, elicits the same unconditioned
is to be performed. Much of behaviorist learn- response. Thus, learning takes place when the
ing is based on respondent conditioning and newly conditioned stimulus (CS) becomes associ-
operant conditioning procedures. ated with the conditioned response (CR)a
Respondent conditioning (also termed classical or process that may well occur without conscious
Pavlovian conditioning) emphasizes the impor- thought or awareness.
tance of stimulus conditions and the associations Consider an example from health care.
formed in the learning process (Ormrod, 2004). Someone without much experience with hospi-
In this basic model of learning, a neutral stim- tals (NS) may visit a sick relative. While in the
Figure 31 Respondent conditioning model of learning.
BASIC MODEL OF LEARNING
UCS UCR
NS + UCS UCR
(Several pairings)
NS UCR
or
CS CR
where: NS = Neutral stimulus
UCS = Unconditioned stimulus
UCR = Unconditioned response
CS = Conditioned stimulus
CR = Conditioned response
EXAMPLE
Offensive odors Queasy feeling

(UCS) (UCR)
Hospital + Offensive odors Queasy feeling
(NS) (UCS) (UCR)
(Several pairings of Hospitals + Offensive odors Queasy feeling)
Hospital Queasy feeling
(CS) (CR)
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relatives room, the visitor may smell offensive vidual learns that no harm will come to him or
odors (UCS) and feel queasy and light-headed her from the once fear-inducing stimulus.
(UCR). After this initial visit and later repeated Finally, the client is able to confront the stimu-
visits, hospitals (now the CS) may become asso- lus without being anxious and afraid.
ciated with feeling anxious and nauseated (CR), As examples from healthcare research, re-
especially if the visitor smells odors similar to spondent conditioning has been used to extin-
those encountered during the first experience guish chemotherapy patients anticipatory
(see Figure 31). Respondent conditioning high- nausea and vomiting (Stockhurst, Steingrueber,
lights the importance of the atmosphere and its Enck, & Klosterhalfen, 2006), while systematic
effects on staff morale in health care. Often with- desensitization has been used to treat drug
out thinking or reflection, patients and visitors addiction (Piane, 2000), phobias (McCullough
formulate these associations as a result of their & Andrews, 2001), tension headaches (Deyl &
hospital experiences, providing the basis for Kaliappan, 1997), and to teach children with
long-lasting attitudes toward medicine, health- ADHD or autism to swallow pills (Beck,
care facilities, and health professionals. Cataldo, Slifer, Pulbrook, & Guhman, 2005). As
Besides influencing the acquisition of new another illustration, prescription drug advertis-
responses to environmental stimuli, principles ers regularly employ conditioning principles to
of respondent conditioning may be used to encourage consumers to associate a brand name
extinguish a previously learned response. Re- medication with happy and improved lifestyles;
sponses decrease if the presentation of the con- once conditioned, consumers will likely favor
ditioned stimulus is not accompanied by the the advertised drug over the competitors med-
unconditioned stimulus over time. Thus, if the ications and the much less expensive generic
visitor who became dizzy in one hospital sub- form. As a third example, taking the time to
sequently goes to other hospitals to see relatives help patients relax and reduce their stress when
or friends without smelling offensive odors, then applying some medical interventioneven a
her discomfort and anxiety about hospitals may painful procedurelessens the likelihood that
lessen after several such experiences. patients will build up negative and anxious
Systematic desensitization is a technique based associations about medicine and health care.
on respondent conditioning that is used by psy- Certain respondent conditioning concepts are
chologists to reduce fear and anxiety in their especially useful in the healthcare setting.
clients (Wolpe, 1982). The assumption is that Stimulus generalization is the tendency of initial
fear of a particular stimulus or situation is learning experiences to be easily applied to other
learned, so it can, therefore, be unlearned or similar stimuli. For example, when listening to
extinguished. Fearful individuals are first taught friends and relatives describe a hospital experi-
relaxation techniques. While they are in a state ence, it becomes apparent that a highly positive
of relaxation, the fear-producing stimulus is or negative personal encounter may color
gradually introduced at a nonthreatening level patients evaluations of their hospital stays as
so that anxiety and emotions are not aroused. well as their subsequent feelings about having
After repeated pairings of the stimulus under to be hospitalized again. With more and varied
relaxed, nonfrightening conditions, the indi- experiences, individuals learn to differentiate
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among similar stimuli, and we say that discrim- and identifying ways to change individuals
ination learning has occurred. As an illustration, behaviors in the healthcare setting. The key is to
patients who have been hospitalized a number carefully observe individuals responses to spe-
of times often have learned a lot about hospital- cific stimuli and then decide the best reinforce-
ization. As a result of their experiences, they ment procedures to use to change a behavior.
make sophisticated distinctions and can dis- Two methods to increase the probability of a
criminate among stimuli (e.g., what the various response are to apply positive or negative rein-
noises mean and what the various health profes- forcement after a response occurs. According to
sionals do) that novice patients cannot. Much of Skinner (1974), giving positive reinforcement
professional education and clinical practice (i.e., reward) greatly enhances the likelihood
involves moving from being able to make gen- that a response will be repeated in similar cir-
eralizations to discrimination learning. cumstances. As an illustration, although a
Spontaneous recovery is a useful respondent con- patient moans and groans as he attempts to get
ditioning concept that needs to be given careful up and walk for the first time after an operation,
consideration in relapse prevention programs. praise and encouragement (reward) for his
The principle of the concept operates as follows: efforts at walking (response) will improve the
Although a response may appear to be extin- chances that he will continue struggling toward
guished, it may recover and reappear at any time independence.
(even years later), especially when stimulus con- A second way to increase a behavior is by
ditions are similar to those in the initial learn- applying negative reinforcement after a response
ing experience. Spontaneous recovery helps us is made. This form of reinforcement involves the
understand why it is so difficult to completely removal of an unpleasant stimulus through
eliminate unhealthy habits and addictive behav- either escape conditioning or avoidance condi-
iors such as smoking, alcoholism, or drug abuse. tioning. The difference between the two types
Another widely recognized approach to of negative reinforcement relates to timing.
learning is operant conditioning, which was devel- In escape conditioning, as an unpleasant stimulus
oped largely by B. F. Skinner (1974, 1989). is being applied, the individual responds in some
Operant conditioning focuses on the behavior of way that causes the uncomfortable stimulation to
the organism and the reinforcement that occurs cease. Suppose, for example, that when a member
after the response. A reinforcer is a stimulus or of the healthcare team is being chastised in front
event applied after a response that strengthens of the group for being late and missing meetings,
the probability that the response will be per- she says something humorous. The head of the
formed again. When specific responses are rein- team stops criticizing her and laughs. Because the
forced on the proper schedule, behaviors can be use of humor has allowed the team member to
either increased or decreased. escape an unpleasant situation, chances are that
Table 31 summarizes the principal ways she will employ humor again to alleviate a stress-
to increase and decrease responses by applying ful encounter and thereby deflect attention from
the contingencies of operant conditioning. her problem behavior.
Understanding the dynamics of learning pre- In avoidance conditioning, the unpleasant stim-
sented in this table can prove useful in assessing ulus is anticipated rather than being applied
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Table 31 Operant Conditioning Model: Contingencies to Increase

and Decrease the Probability of an Organisms Response
I. To increase the probability of a response: II. To decrease or extinguish the probability of a
A. Positive reinforcement: application of a response:
pleasant stimulus A. Nonreinforcement: an organisms con-
Reward conditioning: a pleasant stimulus is ditioned response is not followed by
applied following an organisms response any kind of reinforcement (positive,
negative, or punishment)
B. Negative reinforcement: removal of an aver-
sive or unpleasant stimulus B. Punishment: following a response, an
aversive stimulus that the organism
Escape conditioning: as an aversive stimu-
cannot escape or avoid is applied
lus is applied, the organism makes a
response that causes the unpleasant
stimulus to cease
Avoidance conditioning: an aversive stimu-
lus is anticipated by the organism, which
makes a response to avoid the unpleasant
event
directly. Avoidance conditioning has been used riences, the joke teller, who more than likely
to explain some peoples tendency to become ill wants attentionand negative attention is pre-
so as to avoid doing something they do not want ferable to no attentionmay curtail his or her
to do. For example, a child fearing a teacher or use of offensive humor. Keep in mind, too, that
test may tell his mother that he has a stom- desirable behavior that is ignored may lessen as
achache. If allowed to stay home from school, well.
the child increasingly may complain of sickness If nonreinforcement proves ineffective, then
to avoid unpleasant situations. Thus, when fear- punishment may be employed as a way to
ful events are anticipated, sickness, in this case, decrease responses, although there are risks in
is the behavior that has been increased through using this approach. Under punishment condi-
negative reinforcement. tions, the individual cannot escape or avoid an
According to operant conditioning princi- unpleasant stimulus. Suppose, for example, the
ples, behaviors also may be decreased through healthcare team members attempt at humor is
either nonreinforcement or punishment. Skinner met by the leaders curt remark, You are con-
(1974) maintained that the simplest way to tinually a source of difficulty in this group, and
extinguish a response is not to provide any kind if this continues, your job is in jeopardy,
of reinforcement for some action. For example, embarrassing her in front of her peers. The prob-
offensive jokes in the workplace may be handled lem with using punishment as a technique for
by showing no reaction; after several such expe- teaching is that the learner may become highly
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emotional and may well divert attention away reinforcement. Initial learning requires a con-
from the behavior that needs to be changed. tinuous schedule, reinforcing the behavior
Some people who are being punished become so quickly every time it occurs. If the desired
emotional (sad or angry) that they do not behavior does not occur, then responses that
remember the behavior for which they are being approximate or resemble it can be reinforced,
punished. One of the cardinal rules of operant gradually shaping behavior in the direction of
conditioning is to punish the behavior, not the the goal for learning. As an illustration, for geri-
person. atric patients who appear lethargic and unre-
If punishment is employed, it should be sponsive, nurses or physicians might begin by
administered immediately after the response rewarding small gestures such as eye contact or
with no distractions or means of escape. Pun- a hand that reaches out, then build on these
ishment must also be consistent and at the high- friendly behaviors toward greater human con-
est reasonable level (e.g., health professionals tact and connection with reality. Once a
who apologize and smile as they admonish the response is well established, however, it becomes
behavior of a staff member or client are sending ineffective and inefficient to continually rein-
out mixed messages and are not likely to be force the behavior; reinforcement then can be
taken seriously or to decrease the behavior they administered on a fixed (predictable) or variable
intend). Moreover, punishment should not be (unpredictable) schedule after a given number
prolonged (bringing up old grievances or com- of responses have been emitted or after the pas-
plaining about a misbehavior at every opportu- sage of time.
nity), but there should be a time-out following Operant conditioning techniques provide rel-
punishment to eliminate the opportunity for atively quick and effective ways to change
positive reinforcement. The purpose of punish- behavior. Carefully planned programs using
ment is not to do harm or to serve as a release for behavior modification procedures can readily be
anger; rather, the goal is to decrease a specific applied to health care. For example, computer-
behavior and to instill self-discipline. ized instruction and tutorials for patients and
The use of reinforcement is central to the suc- staff rely heavily on operant conditioning prin-
cess of operant conditioning procedures. For ciples in structuring learning programs. In the
operant conditioning to be effective, it is nec- clinical setting, the families of chronic back pain
essary to assess what kinds of reinforcement are patients have been taught to minimize their
likely to increase or decrease behaviors for each attention to the patients whenever they com-
individual. Not every client, for example, finds plain and behave in dependent, helpless ways,
health practitioners terms of endearment but to pay a lot of attention when the patients
rewarding. Comments such as Very nice job, attempt to function independently, express a
dear, may be presumptuous or offensive to positive attitude, and try to live as normal a life
some clients. A second issue involves the timing as possible. Some patients respond so well to
of reinforcement. Through experimentation operant conditioning that they report experi-
with animals and humans, it has been demon- encing less pain as they become more active and
strated that the success of operant conditioning involved. Operant conditioning and behavior
procedures partially depends on the schedule of modification techniques also have been found to
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work well with some nursing home and long- to be comprised of a number of subtheories and
term care residents, especially those who are los- is widely used in education and counseling. The
ing their cognitive skills (Proctor, Burns, key to learning and changing is the individuals
Powell, & Tarrier, 1999). cognition (perception, thought, memory, and
The behaviorist theory is simple and easy to ways of processing and structuring information).
use, and it encourages clear, objective analysis of Cognitive learning, a highly active process
observable environmental stimulus conditions, largely directed by the individual, involves per-
learner responses, and the effects of reinforce- ceiving the information, interpreting it based on
ments on peoples actions. There are, however, what is already known, and then reorganizing
some criticisms and cautions to consider. First, the information into new insights or under-
this is a teacher-centered model in which learn- standing (Bandura, 2001; Hunt, Ellis, & Ellis,
ers are assumed to be relatively passive and eas- 2004).
ily manipulated, which raises a crucial ethical Cognitive theorists, unlike behaviorists,
question: who is to decide what the desirable maintain that reward is not necessary for learn-
behavior should be? Too often the desired ing. More important are learners goals and
response is conformity and cooperation to make expectations, which create disequilibrium,
someones job easier or more profitable. Second, imbalance, and tension that motivate them to
the theorys emphasis on extrinsic rewards and act. Educators trying to influence the learning
external incentives reinforces and promotes process must recognize the variety of past expe-
materialism rather than self-initiative, a love of riences, perceptions, ways of incorporating and
learning, and intrinsic satisfaction. Third, thinking about information, and diverse aspira-
research evidence supporting behaviorist theory tions, expectations, and social influences that
is often based on animal studies, the results of affect any learning situation. A learners metacog-
which may not be applicable to human behav- nition, or understanding of her way of learning,
ior. A fourth shortcoming of behavior modifica- influences the process as well. To promote trans-
tion programs is that clients changed behavior fer of learning, the learner must mediate or act
may deteriorate over time, especially once they on the information in some way. Similar pat-
are back in their former environmentan envi- terns in the initial learning situation and subse-
ronment with a system of rewards and punish- quent situations facilitate this transfer.
ments that may have fostered their problems in Cognitive learning theory includes several
the first place. well-known perspectives, such as gestalt, infor-
We now move from focusing on responses mation processing, human development, social
and behavior to the role of mental processes in constructivism, and social cognition theory.
learning. More recently, attempts have been made to
incorporate considerations related to emotions
Cognitive Learning Theory within cognitive theory. Each of these perspec-
While behaviorists generally ignore the internal tives emphasizes a particular feature of cognition,
dynamics of learning, cognitive learning theo- which, when pieced together, indicates much
rists stress the importance of what goes on about what goes on inside the learner. As the var-
inside the learner. Cognitive theory is assumed ious cognitive perspectives are briefly summa-
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rized here, readers are encouraged to think of tors: past experiences, needs, personal motives
their potential applications in the healthcare set- and attitudes, reference groups, and the partic-
ting. In keeping with cognitive principles of ular structure of the stimulus or situation (Sherif
learning, being mentally active with information & Sherif, 1969). Assessing these internal and
encourages memory and retention. external dynamics has a direct bearing on how a
One of the oldest psychological theories is health educator approaches any learning situa-
the gestalt perspective, which emphasizes the tion with an individual or group. Moreover,
importance of perception in learning and laid because individuals vary widely with regard to
the groundwork for the various other cognitive these and other characteristics, they will per-
perspectives that followed (Kohler, 1947, 1969; ceive, interpret, and respond to the same event
Murray, 1995). Rather than focusing on discrete in different ways, perhaps distorting reality to
stimuli, gestalt refers to the configuration or fit their goals and expectations. This tendency
patterned organization of cognitive elements, helps explain why an approach that is effective
reflecting the maxim that the whole is greater with one client may not work with another
than the sum of the parts. A principal assump- client. People with chronic illnesseseven dif-
tion is that each person perceives, interprets, and ferent people with the same illnessare not
responds to any situation in his or her own way. alike, and helping any patient with disease or
While there are many gestalt principles worth disability includes recognizing each persons
knowing (Hilgard & Bower, 1966), several will unique perceptions and subjective experience
be discussed here as they relate to health care. (Imes, Clance, Gailis, & Atkeson, 2002).
A basic gestalt principle is that psychologi- Information processing is a cognitive perspective
cal organization is directed toward simplicity, that emphasizes thinking processes: thought,
equilibrium, and regularity. For example, study reasoning, the way information is encountered
the bewildered faces of some patients listening and stored, and memory functioning (Gagn,
to a complex, detailed explanation about their 1985; Sternberg, 2006). How information is
disease, when what they desire most is a simple, incorporated and retrieved is useful for health
clear explanation that settles their uncertainty professionals to know, especially in relation to
and relates directly to them and their familiar older peoples learning (Hooyman & Kiyak,
experiences. 2005; Kessels, 2003).
Another central gestalt principle is that per- An information-processing model of memory
ception is selective, which has several ramifica- functioning is illustrated in Figure 32. Track-
tions. First, because no one can attend to all the ing learning through the various stages is help-
surrounding stimuli at any given time, individ- ful in assessing what happens to information as
uals orient themselves to certain features of an it is perceived, interpreted, and remembered by
experience while screening out or ignoring other each learner, which, in turn, may suggest ways
features. Patients in severe pain or worried about of improving the structure of the learning situ-
their hospital bills may not attend to well- ation as well as how to correct misconceptions,
intentioned patient education information. distortions, and errors in learning.
Second, what individuals pay attention to and The first stage in the memory process
what they ignore are influenced by a host of fac- involves paying attention to environmental
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Figure 32 Information-processing model of memory.
EXTERNAL INTERNAL EXTERNAL

PROCESSES PROCESSES PROCESSES
Stage 1 Stage 2 Stage 3 Stage 4

Attention Processing Memory Storage Action
Short- Long-
Orienting Sensory encoding Term storage Term
Response
stimuli Memory Memory strategy Memory
Physical and (Fleeting (Brief (Enduring:

emotional less than less than but
properties 1 second) 30 seconds) retrieval
arouse problems)
interest.
stimuli; attention, then, is the key to learning. The last stage involves the action or response
Thus, if a client is not attending to what a nurse that the individual makes on the basis of how
educator is saying, perhaps because the client is information was processed and stored. Education
weary or distracted, it would be prudent to try involves assessing how a learner attends to,
the explanation at another time when he is more processes, and stores the information that is pre-
receptive and attentive. sented as well as finding ways to encourage the
In the second stage, the information is retention and retrieval processes. Errors are cor-
processed by the senses. Here it becomes impor- rected by helping learners reprocess what needs
tant to consider the clients preferred mode of to be learned (Kessels, 2003).
sensory processing (visual, auditory, or motor In general, cognitive psychologists note that
manipulation) and to ascertain whether there are memory processing and the retrieval of informa-
sensory deficits. tion are enhanced by organizing information and
In the third stage, the information is trans- making it meaningful. A widely used descriptive
formed and incorporated (encoded) briefly into model has been provided by Robert Gagn
short-term memory, after which it is either disre- (1985). Subsequently, Gagn and his colleagues
garded and forgotten or stored in long-term mem- outlined nine events and their corresponding
ory. Long-term memory involves the organization cognitive processes that activate effective learn-
of information by using a preferred strategy for ing (Gagn, Briggs, & Wagner, 1992):
storage (e.g., imagery, association, rehearsal, or
breaking the information into units). While long- Gain the learners attention (reception)
term memories are enduring, a central problem is Inform the learner of the objectives and
retrieving the stored information at a later time. expectations (expectancy)
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Stimulate the learners recall of prior and styles of learning unlike their own, which
learning (retrieval) may promote maturity, creativity, and a greater
Present information (selective percep- tolerance for differences. Since nurses are expected
tion) to instruct a variety of people with diverse styles
Provide guidance to facilitate the of learning, Tennants suggestion has interesting
learners understanding (semantic implications for nursing education programs.
encoding) The information-processing perspective is
Have the learner demonstrate the infor- particularly helpful for assessing problems in
mation or skill (responding) acquiring, remembering, and recalling infor-
Give feedback to the learner (reinforce- mation. Some strategies include the following:
ment) (1) have learners indicate how they believe they
Assess the learners performance learn (metacognition); (2) ask them to describe
(retrieval) what they are thinking as they are learning;
Work to enhance retention and transfer (3) evaluate learners mistakes; and (4) give close
through application and varied practice attention to their inability to remember or
(generalization) demonstrate information. For example, forget-
ting or having difficulty in retrieving informa-
In employing this model, instructors must care- tion from long-term memory is a major
fully analyze the requirements of the activity, stumbling block in learning. This problem may
design and sequence the instructional events, and occur because the information has faded from
select appropriate media to achieve the outcomes. lack of use, other information interferes with its
Within the information-processing perspec- retrieval (what comes before or after a learning
tive, Sternberg (1996) reminds us to consider session may well confound storage and re-
styles of thinking, which he defined as a prefer- trieval), or individuals are motivated to forget
ence for using abilities in certain ways (p. 347). for a variety of conscious and unconscious rea-
Thinking styles concern differences, he noted, sons. This material on memory processing and
and not judgments of better or worse. In educa- functioning is highly pertinent to healthcare
tion, the instructors task is to get in touch with practicewhether in developing health educa-
the learners way of processing information and tion brochures, engaging in one-to-one patient
thinking. Some implications for health care are education, delivering a staff development work-
the need to carefully match jobs with styles of shop, preparing community health lectures, or
thinking, to recognize that people may shift from studying for ones courses and examinations.
preferring one style of thinking to another, and, Focusing on attention, storage, and memory is
most important, to appreciate and respect the dif- essential in the patient education of older adults,
ferent styles of thinking reflected among the including the identification of fatigue, medica-
many players in the healthcare setting (see tions, and anxieties that may interfere with
Chapter 4 on learning styles). Yet striving for a learning and remembering (Kessels, 2003).
match in styles is not always necessary or desir- Heavily influenced by gestalt psychology, cog-
able. Tennant (2006) notes that adult learners nitive development is a third perspective on learning
may actually benefit from grappling with views that focuses on qualitative changes in perceiving,
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thinking, and reasoning as individuals grow and Health professionals and family members need
mature (Santrock, 2006; Vander Zanden, Crandell, to determine what children are perceiving and
& Crandell, 2007). Cognitions are based on how thinking in a given situation. As an illustration,
external events are conceptualized, organized, and young children usually do not comprehend fully
represented within each persons mental frame- that death is final. They respond to the death of
work or schema, which is partially dependent on a loved one in their own way, perhaps asking
the individuals stage of development in percep- God to give back the dead person or believing
tion, reasoning, and readiness to learn. that if they act like a good person, the deceased
Much of the theory and research in this area loved one will return to them (Gardner, 1978).
has been concerned with identifying the charac- Within the cognitive development perspective
teristics and advances in the thought processes are some differences worth considering. For exam-
of children and adolescents. A principal assump- ple, while Piaget stressed the importance of per-
tion is that learning is a developmental, sequen- ception in learning and viewed children as little
tial, and active process that transpires as the scientists exploring, interacting, and discovering
child interacts with the environment, makes the world in a relative solitary manner, Russian
discoveries about how the world operates, and psychologist Lev Vygotsky (1986) emphasized the
interprets these discoveries in keeping with significance of language, social interaction, and
what s/he knows (schema). adult guidance in the learning process. When
Jean Piaget is the best-known of the cogni- teaching children, Vygotsky says the job of adults
tive developmental theorists. His observations is to interpret, respond, and give meaning to chil-
of childrens perceptions and thought processes drens actions. Rather than the discovery method
at different ages have contributed much to our favored by Piaget, Vygotsky advocated clear, well-
recognition of the unique, changing abilities of designed instruction that is carefully structured to
youngsters to reason, conceptualize, communi- advance each persons thinking and learning.
cate, and perform (Piaget & Inhelder, 1969). By In practice, some children may learn more
watching, asking questions, and listening to effectively by discovering and putting pieces
children, Piaget identified and described four together on their own, whereas other children
sequential stages of cognitive development (sen- benefit from a more social and directive
sorimotor, preoperational, concrete operations, approach. It is the health educators responsi-
and formal operations). These stages become bility to identify the childs or teenagers stage
evident over the course of infancy, early child- of thinking, to provide experiences at an appro-
hood, middle childhood, and adolescence, priate level for children to actively discover and
respectively (see Chapter 5 on developmental participate in the learning process, and to deter-
stages). According to Piagets theory of cogni- mine whether a child learns best through lan-
tive learning, children take in information as guage and social interaction or through
they interact with people and the environment. perceiving and experimenting in his or her own
They either make their experiences fit with way. Research suggests that young childrens
what they already know (assimilation) or change learning is often more solitary, whereas older
their perceptions and interpretations in keeping children may learn more readily through social
with the new information (accommodation). interaction (Palincsar, 1998).
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What do cognitive developmental theorists assumptions of the information-processing view

say about adult learning? First, although the and build on the works of John Dewey, Jean
cognitive stages develop sequentially, some Piaget, and Lev Vygotsky (Palincsar, 1998).
adults never reach the formal operations stage. Social constructivists posit that individuals for-
These adults may learn better from explicitly mulate or construct their own versions of reality
concrete approaches to health education. Second, and that learning and human development are
adult developmental psychologists and geron- richly colored by the social and cultural context
tologists have proposed advanced stages of rea- in which people find themselves. A central tenet
soning in adulthood beyond formal operations. of this approach is that ethnicity, social class,
For example, it is not until the adult years that gender, family life, past history, self-concept,
people become better able to deal with con- and the learning situation itself all influence an
tradictions, synthesize information, and more individuals perceptions, thoughts, emotions,
effectively integrate what they have learned interpretations, and responses to information
characteristics that differentiate adult thought and experiences. A second principle is that effec-
from adolescent thinking (Kramer, 1983). Third, tive learning occurs through social interaction,
older adults may demonstrate an advanced level collaboration, and negotiation (Shapiro, 2002).
of reasoning derived from their wisdom and life According to this view, the players in any
experiences, or they may reflect lower stages of healthcare setting may have differing percep-
thinking due to lack of education, disease, tions of external reality, including distorted per-
depression, extraordinary stress, or medications ceptions and interpretations. Every person
(Hooyman & Kiyak, 2005). operates on the basis of her or his unique repre-
Research indicates that adults generally do sentations and interpretations of a situation, all
better with self-directed learning (emphasiz- of which have been heavily influenced by that
ing learner control, autonomy, and initiative), individuals social and cultural experiences. The
an explicit rationale for learning, a problem- impact of culture cannot be ignored, and learn-
oriented rather than subject-oriented approach, ing is facilitated by sharing beliefs, by acknowl-
and the opportunity to use their experiences and edging and challenging differing conceptions,
skills to help others (Tennant, 2006). Also, keep and by negotiating new levels of conceptual
in mind that anxiety, the demands of adult life, understanding (Marshall, 1998). Cooperative
and childhood experiences may interfere with learning and self-help groups are examples of
learning in adulthood. social constructivism in action. With Americas
Because cognitive theory was criticized for rapidly changing age and ethnic composition,
neglecting the social context, the effects of social the social constructivist perspective has much to
factors on perception, thought, and motivation contribute to health education and health pro-
are receiving increased attention. Social construc- motion efforts.
tivism and social cognition are two increasingly Rooted in social psychology, the social cog-
popular perspectives within cognitive theory. nition perspective reflects a constructivist ori-
Drawing heavily from gestalt psychology and entation and highlights the influence of social
developmental psychology, social constructivists factors on perception, thought, and motivation.
take issue with some of the highly rational A host of scattered explanations can be found
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under the rubric of social cognition (Fiske & childrens moral development and in
Taylor, 1991; Moskowitz, 2005), which, when motivating peoples prosocial behavior
applied to learning, emphasize the need for and ethical responses (Hoffman, 2000).
instructors to consider the dynamics of the social Memory storage and retrieval, as well as
environment and groups on both interpersonal moral decision making, involve both
and intrapersonal behavior. As an illustration, cognitive and emotional brain process-
attribution theory concerns the cause-and-effect ing, especially in response to situations
relationships and explanations that individuals that directly involve the self and are
formulate to account for their own and others stressful (Greene, Sommerville,
behavior and the way in which the world operates. Nystrom, Darley, & Cohen, 2001).
Many of these explanations are unique to the indi- Emotional intelligence (EI) entails man-
vidual and tend to be strongly colored by cultural aging ones emotions, self-motivation,
values and beliefs. For example, patients with cer- reading the emotions of others, and
tain religious views or a particular parental working effectively in interpersonal
upbringing may believe that their disease is a relationships, which some argue is more
punishment for their sins (internalizing blame); important to leadership, social judg-
other patients may attribute their disease to the ment, and moral behavior than cogni-
actions of others (externalizing blame). From this tive intelligence (Goleman, 1995).
perspective, patients attributions may or may not Self-regulation includes monitoring
promote wellness and well-being. The route to cognitive processes, emotions, and ones
changing health behaviors is to change distorted surroundings to achieve goals, which is
attributions. The medical staffs prejudices, biases considered a key factor to successful liv-
(positive and negative), and attributions need to ing and effective social behavior (Eccles
be considered as well in the healing process. & Wigfield, 2002).
Cognitive theory has been criticized for
neglecting emotions, and recent efforts have The implications are that nursing and other
been made to incorporate considerations related health professional education programs would do
to emotions within a cognitive framework, well to exhibit and encourage empathy and emo-
known as the cognitive-emotional perspective. As tional intelligence in working with patients,
Eccles and Wigfield (2002) commented, cold family, and staff and to attend to the dynamics of
cognitive models cannot adequately capture self-regulation as a way to promote positive per-
conceptual change; there is a need to consider sonal growth and effective leadership. Research
affect as well (p. 127). indicates that the development of these attri-
Several slightly different cognitive orienta- butes in self and patients is associated with a
tions to emotions have been proposed and are greater likelihood of healthy behavior, psycho-
briefly summarized in the following list: logical well-being, optimism, and meaningful
social interactions (Brackett, Lopes, Ivcevic,
Empathy and the moral emotions (e.g., Mayer, & Salovey, 2004).
guilt, shame, distress, moral outrage) A significant benefit of the cognitive theory to
play a significant role in influencing health care is its encouragement of recognizing
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and appreciating individuality and diversity in nitive considerations, such as the attributes of
how people learn and process experiences.When the self and the internal processing of the
applied to health care, cognitive theory has been learner. More recently, his attention turned to
useful in formulating exercise programs for breast the impact of social factors and the social con-
cancer patients (Rogers, Matevey, Hopkins-Price, text within which learning and behavior occur.
Shah, Dunnington, & Courneya, 2004), under- As the model has evolved, the learner has
standing individual differences in bereavement become viewed as central (what Bandura calls a
(Stroebe, Folkman, Hansson, & Schut, 2006), and human agency), which suggests the need to
dealing with adolescent depression in girls identify what learners are perceiving and how
(Papadakis, Prince, Jones, & Strauman, 2006). they are interpreting and responding to social
Cognitive theory highlights the wide variation in situations. As such, careful consideration needs
how learners actively structure their perceptions; to be given to the healthcare environment as a
confront a learning situation; encode, process, social situation.
store, and retrieve information; and manage their One of Banduras early observations was that
emotions, all of which are affected by social and individuals need not have direct experiences to
cultural influences. The challenge to educators is learn; considerable learning occurs by taking
to identify each learners level of cognitive de- note of other peoples behavior and what hap-
velopment and the social influences that affect pens to them. Thus, learning is often a social
learning, and then find ways to foster insight, cre- process, and other individuals, especially signif-
ativity, and problem solving. Difficulties lie in icant others, provide compelling examples or
ascertaining exactly what is transpiring inside the role models for how to think, feel, and act. Role
mind of each individual and in designing learn- modeling is a central concept of the theory. As an
ing activities that encourage people to restructure example, a more experienced nurse who demon-
their perceptions, reorganize their thinking, reg- strates desirable professional attitudes and be-
ulate their emotions, change their attributions haviors sometimes is used as a mentor for a less
and behavior, and create solutions. experienced nurse. Research indicates that nurse
The next learning theory to be discussed managers attitudes and actionsensuring
combines principles from both the behaviorist safety, integrating knowledge with practice,
and cognitive theories. sharing feelings, challenging staff nurses and
students, and their competence and willingness
Social Learning Theory to provide guidance to othersinfluence the
Social learning theory is largely the work of outcomes of the clinical supervision process
Albert Bandura (1977; 2001), who mapped out (Berggren & Severinsson, 2006). How nurse
a perspective on learning that includes consid- mentors perceive their role is an important con-
eration of the personal characteristics of the sideration in the leadership selection process
learner, behavior patterns, and the environment. (Neary, 2000).
The theory has gone through several paradigm Vicarious reinforcement is another concept from
shifts (2001, p. 2). In early formulations, he the social learning theory and involves deter-
emphasized behaviorist features and the imita- mining whether role models are perceived as
tion of role models; next the focus was on cog- rewarded or punished for their behavior. Reward
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is not always necessary, however, and the behav- lined a four-step, largely internal process that
ior of a role model may be imitated even when directs social learning, as can be seen in Figure
no reward is involved for either the role model or 33. Although some components are similar to
the learner. In many cases, however, whether the the information processing model described pre-
model is viewed by the observer as rewarded or viously, a principal difference is the inclusion of
punished may have a direct influence on learn- a motivational component in the social learning
ing. This relationship may be one reason why it theory model.
is difficult to attract health professionals to geri- First is the attentional phase, a necessary con-
atric care. Although some highly impressive role dition for any learning to occur. Research indi-
models work in the field, geriatric health care is cates that role models with high status and
often accorded lower status with less pay in com- competence are more likely to be observed,
parison to other specialty areas. although the learners own characteristics (needs,
While social learning theory is based partially self-esteem, competence) may be the more sig-
on behaviorist principles, the self-regulation and nificant determiner of attention. Second is the
control that the individual exerts in the process retention phase, which involves the storage and
of acquiring knowledge and changing behavior retrieval of what was observed. Third is the
are considered more critical and are more reflec- reproduction phase, where the learner copies the
tive of cognitive principles. Bandura (1977) out- observed behavior. Mental rehearsal, immediate
Figure 33 Social learning theory.
EXTERNAL INTERNAL PROCESSES EXTERNAL

PROCESSES PROCESSES
Self-Regulation and Control
Role model Attentional Retention Reproduction Motivational Performance

demonstrates Phase Phase Phase Phase
behavior,
which is Observation Processing Memory Influenced by
perceived of role and repre- guides vicarious rein-
by the learner model sentation performance forcement and
to be in memory of model's punishment
reinforced actions
(vicarious Covert cogni-
reinforcement); tive activity,
model consequences
may facilitate of behavior,
or inhibit and self-
learning reinforcement
a behavior. and
punishment
Source: Based on Bandura (1977).

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enactment, and corrective feedback strengthen tive role models and engage in unhealthy and
the reproduction of behavior. Fourth is the moti- destructive behaviors. Healthcare professionals
vational phase, which focuses on whether the need to find ways to encourage patients feelings
learner is motivated to perform a certain type of of competency and to promote wellness rather
behavior. Reinforcement or punishment for a than fostering dependency, helplessness, and
role models behavior, the learning situation, and feelings of low self-worth.
the appropriateness of subsequent situations The social learning theory extends the learn-
where the behavior is to be displayed all affect a ing process beyond the educatorlearner rela-
learners performance (Bandura, 1977; Gage & tionship to the larger social world. The theory
Berliner, 1998). Well suited to conducting helps explain the socialization process as well as
health education and staff development training, the breakdown of behavior in society. Respon-
this organized approach to learning requires sibility is placed on the educator or leader to act
attention to the social environment, the behav- as an exemplary role model and to choose socially
ior to be performed, and the individual learner healthy experiences for individuals to observe
(Bahn, 2001). and repeat (requiring the careful evaluation of
Reflecting a constructivist orientation, learning materials for stereotypes, mixed or hid-
Bandura (2001) shifted his focus to sociocultural den messages, and negative effects). Yet simple
influences, viewing the learner as the agent exposure to role models correctly performing a
through which learning experiences are filtered. behavior that is rewarded (or performing some
As he argues, the human mind is not just re- undesirable behavior that is punished) does not
active; it is generative, creative, and reflective. ensure learning. Attention to the learners self-
Essentially, the individual engages in a transac- system and the dynamics of self-regulation may
tional relationship between the social environ- help sort out the varying effects of the social
ment and the self, where sociocultural factors are learning experience.
mediated by psychological mechanisms of the In health care, social learning theory has been
self-system to produce behavioral effects (p. 4). applied to nursing education, to addressing psy-
In his model, Bandura stressed the internal chosocial problems, and to maximizing the use
dynamics of personal selection, intentionality, of support groups. For example, research indi-
self-regulation, self-efficacy, and self-evaluation cates that those managers who are aware of their
in the learning process. Culture and self-efficacy roles and responsibilities in promoting a positive
play a key role, with Bandura noting that indi- work environment enhance learning, compe-
vidualistic cultures interpret self-efficacy differ- tence, and satisfaction; dissatisfaction, of course,
ently than group-oriented cultures. However has a detrimental effect and is a significant cause
defined, a low sense of self-efficacy in either of staff turnover (Kane-Urrabazo, 2006). Nurses
kind of culture produces stress. This perspective have applied social learning principles success-
applies particularly well to the acquisition of fully when working with teenage mothers
health behaviors and partially explains why (Stiles, 2005) and in addressing alcoholism
some people select positive role models and among older adults (Akers, 1989). A major dif-
effectively regulate their attitudes, emotions, ficulty is that this theory is complex and not eas-
and actions, whereas other people choose nega- ily operationalized, measured, and assessed.
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The final two theories to be reviewed in this avoid pain. For example, dry, dull lectures given
chapter focus on the importance of emotions and by nurse educators who go through the motions
feelings in the learning process. of the presentation without much enthusiasm or
emotion inspire few people (patients, staff, or
students) to listen to the information or heed
Psychodynamic Learning the advice being given. This does not mean,
Theory however, that only pleasurable presentations
Although not typically treated as a learning will be acceptable.
theory, some of the constructs from the psy- The id (primitive drives) and superego (inter-
chodynamic theory (based on the work of nalized societal values and standards, or the con-
Sigmund Freud and his followers) have signif- science) are mediated by the ego, which operates
icant implications for learning and changing on the basis of the reality principlerather than
behavior (Hilgard & Bower, 1966; Slipp, insisting on immediate gratification, people learn
2000). Largely a theory of motivation stressing to take the long road to pleasure and to weigh the
emotions rather than cognition or responses, choices or dilemmas in the conflict between the id
the psychodynamic perspective emphasizes the and superego. Healthy ego (self) development, as
importance of conscious and unconscious forces emphasized by Freuds followers, is an important
in guiding behavior, personality conflicts, and consideration in the health fields. For example,
the enduring effects of childhood experiences. patients with ego strength can cope with painful
As Pullen (2002) pointed out, negative emo- medical treatments because they recognize the
tions are important to recognize and assess in long-term value of enduring discomfort and pain
nursepatientdoctorfamily interactions, and to achieve a positive outcome. Patients with weak
the psychodynamic theory can be helpful in this ego development, in contrast, may miss their
regard. appointments and treatments or engage in short-
A central principle of the theory is that term pleasurable activities that work against their
behavior may be conscious or unconsciousthat healing and recovery. Helping patients develop
is, individuals may or may not be aware of their ego strength and adjust realistically to a changed
motivations and why they feel, think, and act as body image or lifestyle brought about by disease
they do. According to the psychodynamic view, and medical interventions is a significant aspect
the most primitive source of motivation comes of the learning and healing process. Nurses and
from the id and is based on libidinal energy (the other health professionals, too, require personal
basic instincts, impulses, and desires we are ego strength to cope with the numerous predica-
born with), which includes eros (the desire for ments in the everyday practice of delivering care
pleasure and sex, sometimes called the life as they face conflicting values, ethics, and de-
force) and thanatos (aggressive and destructive mands. Professional burnout, for example, is
impulses, or death wish). Patients who survive rooted in an overly idealized concept of the
or die despite all predictions to the contrary pro- healthcare role and unrealistic expectations for
vide illustrations of such primitive motivations. the self in performing the role. Malach-Pines
The id, according to Freud, operates on the basis (2000) notes that burnout may stem from nurses
of the pleasure principleto seek pleasure and childhood experiences with lack of control.
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When the ego is threatened, as can easily to being told they have a serious threat to their
occur in the healthcare setting, defense mechanisms health and well-being is to employ the defense
may be employed to protect the self. The short- mechanism of denial. It is too overwhelming for
term use of defense mechanisms is a way of com- patients to process the information that they are
ing to grips with reality. The danger comes in likely to die. While most patients gradually
the overuse or long-term reliance on defense accept the reality of their illness, the dangers are
mechanisms, which allows individuals to avoid that if they remain in a state of denial, they may
reality and may act as a barrier to learning and not seek treatment and care, and if their illness
transfer. Table 32 describes some of the more is contagious, they may not protect others
commonly used defense mechanisms. Because of against infection. In turn, a common defense
the stresses involved in health care, knowledge mechanism employed by healthcare staff is to
of defense mechanisms is useful, whether nurs- intellectualize rather than deal realistically at an
ing students are grappling with the challenges emotional level with the significance of disease
of nursing education, staff nurses are dealing and death. For example, one study reported that
with the strains of working in hospitals and nurses may strive too quickly to classify termi-
long-term care facilities, or patients and their nally ill patients within a denial-acceptance
families are learning to cope with illness. framework and, as a result, may not listen to
As an example of defense mechanisms in patients attempting to tell their stories and
health care, Kbler-Ross (1969) pointed out interpret their illness experiences (Telford,
that many terminally ill patients initial reaction Kralik, & Koch, 2006). Protecting the self (ego)
Table 32 Ego Defense Mechanisms: Ways of Protecting the Self

from Perceived Threat
Denial: ignoring or refusing to acknowledge Intellectualization: minimizing anxiety by
the reality of a threat responding to a threat in a detached, abstract
manner without feeling or emotion
Rationalization: excusing or explaining away a
threat Projection: seeing ones own unacceptable
characteristics or desires in other people
Displacement: taking out hostility and aggres-
sion on other individuals rather than directing Reaction formation: expressing or behaving the
anger at the source of the threat opposite of what is really felt
Depression: keeping unacceptable thoughts, Sublimation: converting repressed feelings into
feelings, or actions from conscious awareness socially acceptable action
Regression: returning to an earlier (less mature, Compensation: making up for weaknesses by
more primitive) stage of behavior as a way of excelling in other areas
coping with a threat
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by dehumanizing patients and treating them as For example, some staff members and patients feel
diseases and body parts rather than as whole an inordinate need to control the self, other peo-
individuals (with spiritual, emotional, and ple, and certain social situations. This behavior
physical needs) are occupational hazards for may be rooted in their inability to resolve the cri-
nurses and other health professionals. sis of trust versus mistrust at the earliest stage of
Another central assumption of the psychody- life. In working with these individuals, it is essen-
namic theory is that personality development tial to build a trusting relationship and to encour-
occurs in stages, with much of adult behavior age them gradually to relinquish some control.
derived from earlier childhood experiences and Past conflicts, especially during childhood,
conflicts. One of the most widely used models of may interfere with the ability to learn or to
personality development is Eriksons (1968) eight transfer learning. What people resist talking
stages of life, organized around a psychosocial cri- about or learning, termed resistance, is an indi-
sis to be resolved at each stage (see Chapter 5). cator of underlying emotional difficulties, which
Treatment regimens, communication, and health must be dealt with for them to move ahead
education need to include considerations of the emotionally and behaviorally. For instance, a
patients stage of personality development. For young, pregnant teenager who refuses to engage
example, in working with 4- and 5-year-old in a serious conversation about sexuality (e.g.,
patients, where the crisis is initiative versus guilt, changes the subject, giggles, looks out into
health professionals should encourage the chil- space, expresses anger) indicates underlying
dren to offer their ideas and to make and do emotional conflicts that need to be addressed.
things themselves. Staff also must be careful not One study explored psychodynamic sources of
to make these children feel guilty for their illness resistance among nursing students and how they
or misfortune. As a second example, the adoles- engaged with or resisted the learning process. A
cents psychosocial developmental needs to have number of factors requiring consideration sur-
friends and to find an identity require special faced, including childhood struggles, a history
attention in health care. Adolescent patients may of overadaptation, self-image, and learning cli-
benefit from help and support in adjusting to a mate (Gilmartin, 2000).
changed body image and in addressing their fears Serious problems in miscommunication can
of weakness, lack of activity, and social isolation. occur in health care as a result of childhood
One danger is that young people may treat their learning experiences. For example, some physi-
illness or impairment as a significant dimension cians and nurses may have had the childhood
of their identity and self-conceptwell described experience of standing helplessly by watching
in poet Lucy Grealys personal account in Anatomy someone they loved and once depended on
of a Face (1994). endure disease, suffering, and death. Although
According to the psychodynamic view, per- they could do little as children to improve the
sonal difficulties arise and learning is limited situation, they may be compensating for their
when individuals become fixated or stuck at an childhood feelings of helplessness and depen-
earlier stage of personality development. They dency as adults by devoting their careers to fend-
then must work through their previously unre- ing off and fighting disease and death. These
solved crises to develop and mature emotionally. motivations, however, may not serve them well
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 73
as they attempt to cope, communicate, and edu- growth and development of all those involved in
cate dying patients and their families. health care and learning. Health care rests on
Emotional conflicts are not always due to inter- both interpersonal and intrapersonal processes
nal forces; society exerts pressures on individuals involved in the therapeutic use of the self in car-
that promote emotional difficulties as well. The rying out patient care (Gallop & OBrien,
reluctance of health professionals to be open and 2003). Psychodynamic theory is well suited to
honest with a terminally ill patient partially may understanding patient and family noncompli-
be derived from American culture, which encour- ance (Menahern & Halasz, 2000), trauma and
ages medical personnel to fix their patients and loss (Duberstein & Masling, 2000), palliative
extend life. Staff members may or may not be con- care and the deeply emotional issues of terminal
scious of these pressures, but either way they are illness (Chochinov & Breitbart, 2000), and the
likely to feel guilty and that they are failures when anxieties of working with long-term psychiatric
dealing with a dying patient. residents (Goodwin & Gore, 2000). From a pro-
The concept of transfer has special meaning fessional perspective, when examining the prob-
to psychodynamic theorists. Transference occurs lems of bullying nurse managers or the failure
when individuals project their feelings, con- of nurses to formally report incidents of violence
flicts, and reactionsespecially those developed and aggression, results indicated the need to
during childhood with significant others such consider childhood and adult experiences with
as parentsonto authority figures and other abuse and violence, as well as guilt, low self-
individuals in their lives. The danger is that the image, and cultural expectations about nurses
relationship between the health professional and (Ferns, 2006).
the patient may become distorted and unrealis- The psychodynamic approach has been criti-
tic because of the biases inherent in the trans- cized because much of the analysis is speculative
ference reaction. For example, because patients and subjective, and the theory is difficult to
are sick, they may feel helpless and dependent operationalize and measure. Psychodynamic
and then regress to an earlier stage in life when theory also can be used inappropriately; it is not
they relied on their parents for help and support. the job of health professionals with little clini-
Their childhood feelings and relationship with cal psychology or psychiatric training to probe
a parentfor better or worsemay be trans- into the private lives and feelings of patients so
ferred to a nurse or physician taking care of as to uncover deep, unconscious conflicts.
them. While sometimes flattering, the love and Another danger is that health professionals may
dependency that patients feel may operate depend on the many psychodynamic constructs
against the autonomy and independence needed as a way of intellectualizing or explaining away,
to get back on their feet. A particular patient rather than dealing with, people as individuals
may also remind a staff member of someone who need emotional care.
from her or his past, creating a situation of
countertransference. Humanistic Learning Theory
The psychodynamic approach reminds health Underlying the humanistic perspective on
professionals to pay attention to emotions, learning is the assumption that each individual
unconscious motivations, and the psychological is unique and that all individuals have a desire
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to grow in a positive way. Unfortunately, posi- the hierarchy are self-actualization needs (max-
tive psychological growth may be damaged by imizing ones potential). Additional considera-
some of societys values and expectations (e.g., tions include cognitive needs (to know and
males are less emotional than females, some eth- understand) and, for some individuals, aesthetic
nic groups are inferior to others, making money needs (the desire for beauty). An assumption is
is more important than caring for people) and that basic-level needs must be met before indi-
by adults mistreatment of their children and viduals can be concerned with learning and self-
each other (e.g., inconsistent or harsh discipline, actualizing. Thus, clients who are hungry, tired,
humiliation and belittling, abuse and neglect). and in pain will be motivated to get these bio-
Spontaneity, the importance of emotions and logical needs met before being interested in
feelings, the right of individuals to make their learning about their medications, rules for self-
own choices, and human creativity are the cor- care, and health education. While intuitively
nerstones of a humanistic approach to learning appealing, research has not been able to support
(Rogers, 1994; Snowman & Biehler, 2006). Maslows hierarchy of needs with much consis-
Humanistic theory is especially compatible with tency. For example, although some peoples
nursings focus on caring and patient centered- basic needs may not be met, they may nonethe-
nessan orientation that is increasingly chal- less engage in creative activities, extend them-
lenged by the emphasis in medicine and health selves to other people, and enjoy learning
care on science, technology, cost efficiency, for- (Pfeffer, 1985).
profit medicine, bureaucratic organization, and Besides personal needs, humanists contend
time pressures. that self-concept and self-esteem are necessary
Like the psychodynamic theory, the human- considerations in any learning situation. The
istic perspective is largely a motivational theory. therapist Carl Rogers (1961, 1994) argued that
From a humanistic perspective, motivation is what people want is unconditional positive self-
derived from each persons needs, subjective regard (the feeling of being loved without
feelings about the self, and the desire to grow. strings attached). Experiences that are threaten-
The transfer of learning is facilitated by curios- ing, coercive, and judgmental undermine the
ity, a positive self-concept, and open situations ability and enthusiasm of individuals to learn.
in which people respect individuality and pro- It is essential that those in positions of author-
mote freedom of choice. Under such conditions, ity convey a fundamental respect for the people
transfer is likely to be widespread, enhancing with whom they work. If a health professional
flexibility and creativity. is prejudiced against AIDS patients, then little
Maslow (1954, 1987), a major contributor to will be healing or therapeutic in her relationship
humanistic theory, is perhaps best known for with them until she is genuinely able to feel
identifying the hierarchy of needs (Figure 34), respect for the patient as an individual.
which he says plays an important role in human Rather than acting as an authority, say
motivation. At the bottom of the hierarchy are humanists, the role of any educator or leader is
physiological needs (food, warmth, sleep); then to be a facilitator (Rogers, 1994). Listening
come safety needs; then the need for belonging rather than talkingis the skill needed.
and love; followed by self-esteem. At the top of Because the uniqueness of the individual is fun-
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Figure 3 4 Maslows hierarchy of needs.
Self-Actualization
need to fulfill ones potential
Esteem
need to be perceived as competent,
have confidence and independence,
and have status, recognition,
and appreciation
Belonging and Love
need to give and receive affection
Safety
need for security, stability, structure, and protection
as well as freedom from fear
Physiological
to have basic survival needs met
(food, water, warmth, sleep)
Source: Adapted from Maslow (1987).
damental to the humanistic perspective, much tion is referred to as a learner-directed approach

of the learning experience requires a direct rela- (Snowman & Biehler, 2006).
tionship between the educator and the learner, Mastering information and facts is not the cen-
with instruction tailored to the needs, self- tral purpose of the humanistic model of learning.
esteem, and positive growth of each learner. Instead, fostering curiosity, enthusiasm, initia-
Learners, not educators, choose what is to be tive, and responsibility is much more important
learned, and within this framework educators and enduring and should be the primary goal of
serve as resource persons whose job is to encour- any educator. Rather than inserting health edu-
age learners to make wise choices. Because the cation videos into television sets for hospital
central focus is on learners perceptions, desires, patients to view or routinely distributing lots of
and decision making, the humanistic orienta- pamphlets and pages of small-print instructions,
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the humanist perspective would suggest estab- The humanistic learning theory has modified
lishing rapport and becoming emotionally at- the approach to education and changing behav-
tuned to patients and their family members. In ior by giving primary focus to the subjective
professional education, the goal is to provide needs and feelings of the learner and by redefining
psychologically safe classrooms and clinical the role of the educator. Humanistic principles have
environments, where humanistic principles can been a cornerstone of self-help groups, wellness pro-
be taught through caring, role modeling, small- grams, and palliative care. Humanistic theory has
group discussion, case discussions, attention to also been found to be well suited to working with
self-awareness and feelings, role playing, and children and young patients undergoing separation
videotaping students in the clinical setting fol- anxiety due to illness, surgery, and recovery (Holy-
lowed by feedback and reflection (Biderman, oake, 1998) and for working in the areas of mental
2003). Providing time for student reflection is health and palliative care (Barnard, Hollingum, &
essential, and instructor feedback must be given Hartfiel, 2006). Similar to psychodynamic theory,
sensitively and thoughtfully (Fryer-Edwards, a principal emphasis is on the healing nature of the
Arnold, Baile, Tulsky, Petracca, & Back, 2006). therapeutic relationship (Pearson, 2006) and the need
Humanistic psychology contends that feel- for nursing students and health professionals to
ings and emotions are the keys to learning, com- grow emotionally from their healthcare experiences
munication, and understanding. Humanists (Block & Billings, 1998).
worry that in todays stressful society, people can The humanistic theory has its weaknesses as
easily lose touch with their feelings, which sets well. Research has not been able to substanti-
the stage for emotional problems and difficulties ate some of its strongest claims, and the theory
in learning (Rogers, 1961). To humanists, tell has been criticized for promoting self-centered
me how you feel is a much more important learners who cannot take criticism or compro-
instruction than tell me what you think, as mise their deeply felt positions. Charged with
thoughts and admonitions (the latter of which being more of a philosophyor a cultthan a
Rogers calls the shoulds) may be at odds with science, the touchy-feely approach of humanists
true feelings. Consider the implications of the makes some learners and educators feel truly
following statements: (1) a young person who uncomfortable. Moreover, information, facts,
says, I know I should go to medical school and memorization, drill, practice, and the tedious
become a doctor because I am smart and that is work sometimes required to master knowledge,
what my parents want, but I dont feel comfort- which humanists minimize and sometimes dis-
able with sick peopleI dont even like them! dain, have been found to contribute to signifi-
or (2) the dying patient who says, I realize that cant learning, knowledge building, and skill
I am going to die and should be brave, but I feel development (Gage & Berliner, 1992).
so sad that I am losing my family, my friends,
and my self; frankly, I am afraid of dyingall Neuropsychology and
the pain and suffering, being a burdenIm Learning
scared! In both cases, humanists would argue,
the overriding factor that will affect the behav- One of the newest and most rapidly growing
ior of the young person and the dying patient is areas of psychology research involves investiga-
their feelings, not their cognitions. tions into the physiological and neurological
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Neuropsychology and Learning 77
bases of thinking, learning, and behavior. Neu- interact with cognitive factors in any
roscience research has implications for learning learning situation, suggesting that they
in several ways: (1) by documenting the dynam- cannot be ignored when teaching, learn-
ics of brain and central nervous system processing, reasoning, or making decisions.
ing of information; (2) by understanding and Neuropsychology studies of learning
working with children and adults who have neu- have confirmed a number of learning
rological conditions, face mental health issues, or theories and constructs, including gestalt
have learning disabilities; (3) by answering ques- principles, constructivism, Piagets
tions about the relationship between stress and notions of assimilation and accommoda-
learning; and (4) by providing evidence to sup- tion, and Freuds conceptualization of
port the assumptions of various learning theories conscious and unconscious processes.
or the integration of these theories. Neurological studies also have docu-
Much of the information in these areas has mented physiological arousal and tracked
been gained through advances in neuroimaging attention, perception, and the organiza-
techniques such as functional magnetic reso- tion of experience while learning.
nance imaging (fMRI) and positron emission Learning is a function of physiological
tomography (PET). Other methodologies in- and neurological developmental changes
clude animal studies based on surgery, electrical that are ongoing and dynamic; the brain
recordings (EEG and ERP), and case studies of is less fixed than once thought, and it
children and adults with head trauma, brain changes with learning and experience
lesions, and neurological abnormalities (Byrnes, (called plasticity).
2001). While the research findings highlight Brain processing is different for each
some of the underlying biological mechanisms learner; thus, gaining the learners
of learning and provide evidence to support some attention, controlling the pace of learn-
of the principal constructs and dynamics of existing, and identifying the specific mecha-
ing learning theories, there is as yet no coherent nisms for enhancing learning are unique
physiological or neuropsychological theory of for each person.
learning. Learning is an active, multifaceted,
In synthesizing neuropsychology research, complex process that involves preferred
some generalizations about learning can be made and interacting sensory modes, is col-
(Anderson, 1997; Gazzaniga, 2000; Page, 2006; ored by the past and present social con-
Phelps, 2006; Shors, 2006; Silverstein & Uhlhaas, text, and is regulated largely by the
2004). Each generalization, listed below, has learner on the basis of his or her devel-
implications for health education in the clinical opment, experiences, and sense of self.
setting, and readers are encouraged to formulate Meaningful practice strengthens learn-
applications to nursing and health care. ing connections, which may fade from
lack of use; thus, one-shot patient edu-
Emotions have been found to play a key cation efforts are not likely to be effec-
role in Pavlovian conditioning, informa- tive in changing behavior.
tion processing, memory, and motiva- Stress can interfere with or stimulate
tion. Emotions are considered to learning, although the responses to
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stress may change with age and differ of the learner as more passive or active, the task
for males and females, or for those who of the educator, the explanation of motivation,
have experienced traumatic events. and the way in which the transfer of learning
is accomplished.
Neurophysiological aspects of learning
A logical question is which of these five the-
become all the more germane for children and
ories best describes or explains learningwhich
adults with physiological disorders; for those
theory, in other words, would be the most help-
with mental, emotional, and behavioral prob-
ful to health professionals interested in increas-
lems; and for those facing the stresses of trauma,
ing knowledge or changing the behavior of
disease, disability, and socioeconomic hardship.
patients, staff, or themselves? The answer to this
Despite numerous neuroscientific studies re-
question is that each theory contributes to
lated to learning, the research is in its early
understanding various aspects of the learning
stages and remains fragmented, scattered, and
process and can be used singly or in combina-
lacking in integration. In addition, neuropsy-
tion to help practitioners acquire new informa-
chological studies are often based on animal
tion and alter existing thoughts, feelings, and
research or on highly specialized and restricted
behavior.
human samples, so few generalizations can be
Each theory gives focus to important consid-
made about most people. Although addressing
erations in any learning situation, involving the
the various biological connections to learning is
consideration of external social factors and inter-
currently a popular and relatively well-funded
nal psychological processing. For example,
area of research, there is a risk of reducing
behaviorists urge us to pay attention to and
human behavior to mere biology while ignoring
change stimulus conditions and to provide rein-
the individual as a person as well as the signifi-
forcement to alter behavior. While criticized for
cance and complexity of psychological and social
being reductionistic, behaviorists emphasis on
processes in any learning situation.
manipulating the environment and reinforce-
ments is admittedly simpler and easier than try-
Comparison of ing to undertake a massive overhaul of an
Learning Theories individuals internal dynamics (perceptions, cog-
nition, memory, feelings, and personality history
Table 33 provides a comparative summary of and conflicts). Moreover, getting someone first
the five learning theories outlined in this chap- to behave in a more appropriate way (abstaining
ter. Generalizations can be made about both from bad habits and engaging in healthy behav-
the differences and the similarities in what the ior) may not be as threatening or daunting to the
theories say about acquiring knowledge and learner as it would be to suggest the need for
changing feelings, attitudes, and behavior. internal personality changes. Desired responses
With regard to some of the differences among are modified and strengthened through practice;
the theories, each theory has its own assump- the new learned responses, in turn, may lead to
tions, vocabulary, and way of conceptualizing more fundamental changes in attitudes and emo-
the learning process. The theories differ in tions. The social learning perspective is another
their emphasis on the relative influence of ex- relatively simple theory to use, stressing the
ternal or internal factors in learning, the view importance of effective role models, who, by
Table 33 Summary of Learning Theories
Learning Assumptions About Educators Sources of Transfer of
Procedures the Learner Task Motivation Learning
46436_CH03_051_090.qxd
Behaviorist
Environmental stimulus Passive, reactive Active educator manipu- Drive reduction. Practice; similarity in
conditions and reinforce- learner responds lates stimuli and rein- stimulus conditions
ment promote changes to environmental forcement to direct and responses between
11/19/07
in responses. conditions (stimuli learning and change. learning and new

and reinforcement). situations.
To change behavior,
change the environment.
9:37 AM
Cognitive
Internal perception and Active learner deter- Active educator struc- Goals. Mental and physical
Page 79
thought processing within mines patterning tures experiences activity.

Expectations.
context of human devel- of experiences; is (through organization
Common patterns.
opment promote learning strongly influenced and meaningfulness) to Disequilibrium.
and change. by attributions. encourage the reorgani- Understanding.
zation of cognitions.
To change behavior, change Learning to learn.
cognitions.
Social Learning
External role models and Active learner Active educator models Socialization experiences, Similarity of setting
their perceived reinforce- observes others and behavior, encourages role models, and self- and role models
ment along with learners regulates decision to perception of reinforce- reactive influences behavior.
internal influences. reproduce behavior. ment, carefully evaluates (observe self, set goals,
learning materials for and reinforce
To change behavior, change
social messages, and performance).
role models, perceived
Comparison of Learning Theories
attempts to influence
reinforcement, and the
learners self-regulation.
learners self-regulating
79
mechanisms. continues
80
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Table 33 Summary of Learning Theories (continued)

Learning Assumptions About Educators Sources of Transfer of
Procedures the Learner Task Motivation Learning
11/19/07
Psychodynamic
Internal forces such as Active learners lifestyle, Educator as a reflective Pleasure principle and Personality conflict,
developmental stage, past experiences, and interpreter makes sense reality principle. resistance, and transfer-
9:37 AM
childhood experiences, current emotional con- of learners personality ence associated with
Imbalance.
emotional conflicts, and flicts influence what is and motivation by listen- learning situations may
ego strength influence learned and how it is ing and posing questions Conscious and uncon- act as barrier.
learning and change. remembered and to stimulate conscious scious influence of con-
Page 80
performed. awareness, insight, and flict, development, and

To change behavior,
ego strength. defense mechanisms.
change interpretations
and make unconscious
motivations conscious.
Humanistic
Internal feelings about Active learner attempts to Facilitative educator Needs, desire for positive Positive or negative feel-
self, ability to make wise actualize potential for encourages positive self- self-growth, and confir- ings about self and
choices, and needs affect positive self-growth and growth, listens empath- mation of self-concept. freedom to learn pro-
learning and change. confirm self-concept; is etically, allows freedom mote
spontaneous, creative, of choice, and respects or inhibit transfer.
To change behavior, change
Chapter 3: Applying Learning Theories to Healthcare Practice
and playful. learner.

feelings, self-concept, and
needs.
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Common Principles of Learning 81
their example, demonstrate exactly what behaviorist techniques, whereas curious, highly active,
ior is expected. and self-directed persons may do better with
Cognitive, social learning, psychodynamic, cognitive and humanistic approaches. Also,
and humanistic theories remind us to consider keep in mind that some learners require exter-
internal factorsperceptions, thoughts, ways of nal reinforcement and incentives, whereas other
processing information, feelings, and emotions. learners do not seem to needand may even
These factors cannot be ignored because, ulti- resentattempts to manipulate and reinforce
mately, it is the learner who controls and regu- them.
lates learning: how information is perceived, Individuals who are well educated, verbal,
interpreted, and remembered, and whether the and reflective may be better candidates for cog-
new knowledge is expressed or performed. nitive and psychodynamic approaches, whereas
In practice, learning theories should not be behaviorist approaches may be more suitable for
considered to be mutually exclusive but rather persons whose cognitive processes are impaired
to operate together to change attitudes and or who are uncomfortable dealing with abstrac-
behavior. For example, patients undergoing tions or scrutinizing and communicating their
painful procedures are first taught systematic thoughts and emotions.
desensitization (behaviorist) and while experi- In addition, each individuals preferred modes
encing pain or discomfort are encouraged to of learning and processing may help determine
employ imagery, such as thinking about a the selection of suitable theoretical approaches.
favorite, beautiful place or imagining the That is, while some individuals learn by acting
healthy cells gobbling up the unhealthy cells and responding (behaviorist), the route to learn-
(cognitive). Staff members are highly respectful, ing for others may be through perceptions and
upbeat, and emotionally supportive of each thoughts (cognitive) or through feelings and
patient (humanistic) and create the time and emotions (humanistic and psychodynamic).
opportunity to listen to patients discuss some of Most people appear to benefit from demonstra-
their deepest fears and concerns (psychody- tion and example (social learning).
namic). Waiting rooms and lounge areas for
patients and their families are designed to be
comfortable, friendly, and pleasant to facilitate Common Principles of
conversation and interaction, while support Learning
groups may help patients and family members
learn from each other about how to cope with Taken together, the theories discussed in this
illness or disability and how to regulate their chapter indicate that learning is a more compli-
emotions so that their health is not further com- cated process than any one theory implies.
promised (social learning). Besides the distinct considerations for learning
Another generalization from this discussion suggested by each theory, the similarities among
is that some learning theories are better suited the perspectives point to some core features of
to certain kinds of individuals than to others. learning. The issues raised at the beginning of
While theoretical assumptions about the learner the chapter can be addressed by synthesizing the
range from passive to highly active, passive indi- learning theories and identifying their common
viduals may learn more effectively from behav- principles.
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1. How Does Learning Occur? which, in turn, arouses the learner by creating
tension (drives to be reduced, disequilibrium,
Learning is an active process that takes place as and imbalance) and the propensity to act or
individuals interact with their environment and change behavior.
incorporate new information or experiences with The relative success or failure of the learners
what they already know or have learned. Factors performance may affect subsequent learning
in the environment that affect learning include experiences. In some cases, an inappropriate,
the society and culture, the structure or pattern maladaptive, or harmful previously learned
of stimuli, the effectiveness of role models and behavior may need to be extinguished and then
reinforcements, feedback for correct and incor- replaced with a more positive response. It is, of
rect responses, and opportunities to process and course, easier to instill new learning than to cor-
apply learning to new situations. rect faulty learning.
Furthermore, the individual exerts significant
control over learning, often involving consider-
ations of his or her developmental stage, past his-
2. What Kinds of Experiences
tory (habits, cultural conditioning, socialization, Facilitate or Hinder the
childhood experiences, and conflicts), cognitive Learning Process?
style, dynamics of self-regulation, conscious and The educator exerts a critical influence on learn-
unconscious motivations, personality (stage, con- ing through role modeling, the selection of
flicts, and self-concept), and emotions. Also, learning theories, and how the learning experi-
learners often have a preferred mode for taking ence is structured for each learner. To be effec-
in information (visual, motor, auditory, or sym- tive, educators must have knowledge (of the
bolic), and, while some individuals may learn material to be learned, the learner, the social
best on their own, others will benefit from ex- context, and educational psychology), and they
pert guidance, social interaction, and cooperative must be competent (be imaginative, flexible,
learning. and able to employ teaching methods; display
Learning is an individual matter. Neuro- solid communication skills; and have the abil-
psychology research is beginning to document ity to motivate others).
the uniqueness of each persons way of actively All the learning theories discussed in this
perceiving and processing information, his or chapter acknowledge the need to recognize and
her flexibility and reactions to stress, and the relate the new information to the learners past
impact of culture and emotions on how and experiences (old habits, culture, familiar pat-
what is learned. terns, childhood memories, feelings about the
A critical influence on whether learning self, and what is valued, normative, and per-
occurs is motivation (see Chapter 6 on motiva- ceived as successful or rewarded in society). The
tion). The learning theories reviewed here sug- ultimate control over learning rests with the
gest that to learn, the individual must want to learner, but effective educators influence and
gain something (receive rewards and pleasure, guide the process so that learners advance in
meet goals and needs, confirm expectations, their knowledge, perceptions, thoughts, emo-
grow in positive ways, or resolve conflicts), tional maturity, and behavior.
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State of the Evidence 83
Ignoring these considerations, of course, may the willingness and resources to engage in edu-
hinder learning. Other impediments to learning cational assessment are now considered essential
may involve a lack of clarity and meaningfulness responsibilities of the educator in carrying out
in what is to be learned, neglect or harsh pun- the teaching/learning process. Evaluation feed-
ishment, fear, or negative or ineffective role back can then be used by the nurse educator to
models. Providing inappropriate materials for revamp and revitalize learning experiences.
the individuals ability, readiness to learn, or
stage of life-cycle development is another obsta- State of the Evidence
cle to learning. Moreover, individuals are
unlikely to want to learn if they have had detri- The study of learning in educational psychology
mental socialization experiences, are deprived of is based on evidence from research similar to
stimulating environments, and are without that advocated in nursing, medicine, and health
goals and realistic expectations for themselves. care. Rather than assuming the instructor
knows best, we gather evidence and test learn-
3. What Helps Ensure That ing theories, teaching methods, and what is
believed to be true about learners, teachers, and
Learning Becomes Relatively the environment. The research results are then
Permanent? evaluated for the purpose of modifying the the-
Four considerations assist learning in becoming ories, methods, and assumptions about learning.
permanent. First, the likelihood of learning is Ideally in health education, existing research
enhanced by organizing the learning experience, in psychology, nursing, and medicine is used to
making it meaningful and pleasurable, recogniz- design learning experiences for patients, families,
ing the role of emotions in learning, and by pac- and communities. The same is true for develop-
ing the presentation in keeping with the learners ing, implementing and evaluating teaching and
ability to process information. Second, practicing learning experiences for nursing students and
(mentally and physically) new knowledge or staff. On the basis of the research findings, what
skills under varied conditions strengthens learn- does not work is eliminated, modifications are
ing. The third issue concerns reinforcement. made grounded in additional research, and new
Although reinforcement may or may not be nec- programs are attempted and assessed. Educa-
essary, some theorists have argued that it may be tional accountability is stressed, and decisions
helpful because it serves as a signal to the indi- about how to educate must be justified on the
vidual that learning has occurred. basis of data and research.
A fourth consideration involves whether The applications of the learning theories and
learning transfers beyond the initial educational principles discussed in this chapter are illus-
setting. Learning cannot be assumed to be rela- trated by a number of research studies in nurs-
tively lasting or permanent; it must be assessed ing, psychology, education, and health care. It is
and evaluated by the educator soon after the the research that has allowed us to gain some
learning experience has occurred as well as by confidence about choosing the most appropriate
follow-up measurements at later times. Research theories and principles for each educational expe-
skills, knowledge of evaluation procedures, and rience, and it is the research that has helped us
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 84
hone our approach to teaching and learning in learning in any attempt to measure and evalu-
the healthcare setting. Educational research has ate it. The challenges of measurement are
confirmed many of the constructs and principles immense and require a highly sophisticated
from the various learning perspectives. It also has knowledge of research methods and their
provided evidence to dispute some of the con- weaknesses. Another problem is the lack of
ventional wisdom and myths about learning resources, support, and well-trained personnel
helping us realize that punishment is not needed to truly implement and sustain a
generally effective and may inhibit learning; research-based approach to teaching and learn-
males are not necessarily more intelligent than ing (Ferguson & Day, 2005).
females; and when teaching people, there are a
number of strongly held realities that may or Summary
may not be rational, which strongly influence
each learners processing of the educational expe- This chapter demonstrates that learning is com-
rience. The research on learning in general and plex. Readers may feel overwhelmed by the
health care in particular clearly demonstrates diverse theories, sets of learning principles, and
there is no one-size-fits-all approach to educat- cautions associated with employing the various
ing patients, nursing students, or nursing staff. approaches. Yet, like the blind men exploring
To be effective, educational experiences need to the elephant, each theory highlights an impor-
be refined and tailored to each individual learner. tant dimension that affects the overall learning
Though many advancements have been made process, and together the theories provide a
in understanding the learning process over the wealth of complementary strategies and alter-
past century, much remains unknown and re- native options. There is, of course, no single best
quires careful research, such as why some pa- way to approach learning, although all the the-
tients and nursing students are so much more ories indicate the need to be sensitive to the
eager to learn than others, what can be done to unique characteristics and motivations of each
encourage reluctant learners to change their learner. For additional sources of information
attitudes or behavior, how the various learning about psychological theories of learning and
theories and principles can work together for health care, see Table 34.
every learner, and how the healthcare setting Educators in the health professions cannot be
changes the teaching/learning situation. In the expected to know everything about the teaching
future, more interdisciplinary efforts between and learning process. More importantly, perhaps,
psychologists and nurses are needed to move us is that they can determine what needs to be
toward a more sophisticated level of research known, where to find the necessary information,
and understanding that can be applied to the and how to help individuals, groups, and them-
healthcare setting. selves benefit directly from a learning situation.
Research is not a panacea, however. Critics Psychology and nursing work well together.
charge that the widely promoted research- Psychology has much to contribute to health-
based evidence approach to education and care practice, and nursing is in a strategic posi-
health care is jargonistic, places the emphasis tion to apply and test psychological principles,
on outcomes rather than on the process of constructs, and theories in both the educational
learning, and oversimplifies the complexity of and clinical settings.
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Summary 85
Table 34 Psychological Theories of Learning and Healthcare:

Links
Internet Educational Psychology resources (ERIC):

http://www.lib.muohio.edu/edpsych/internetresources.html
McMaster University: Evidence-based medicine links:
http://www.mlanet.org/education/telecon/ebhc/resource.html
U.S. Department of Education: Evidence-Based Education help desk:
http://www.whatworkshelpdesk.ed.gov
American Psychological Association (search for learning topics):
http://www.apa.org
National Institutes of Health (search for patient education topics):
http://www.nih.gov
Learning Theory Resources (Nova Southeastern University):
http://www.nova.edu/~burmeist/learning_theory.html
Learning Theory links (emTech.net):
http://www.emtech.net/learning_theories.htm
Nursing Patient Education resources (about.com):
http://nursing.about.com/od/patienteducation/Patient_Education_Tools_and_Information_for_Nurses.htm
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 86
REVIEW QUESTIONS
1. What are the five major learning theories discussed in this chapter?
2. What are the principal constructs and contributions of each of the five learning theories?
3. According to the concept of operant conditioning, what are three techniques to increase
the probability of a response, and what are two techniques to decrease or extinguish the
probability of a response?
4. What are some ways the behaviorist theory (which focuses on the environment and
responses to it) and the cognitive perspective (which emphasizes the individuals inter-
nal processing) could be combined to facilitate knowledge acquisition or change a health
behavior?
5. What is meant by the term gestalt, and to which major learning theory is it associated?
6. Which learning theory is a combination of the principles from both the behaviorist and
cognitive perspectives?
7. Which perspective is based primarily on the theory of motivation and stresses emotions
rather than cognition and stimulus-response connections?
8. How do the major learning theories compare to one another with regard to their sim-
ilarities and differences?
9. How does motivation serve as the critical influence on whether learning occurs or not?
10. What types of experiences may facilitate or hinder the learning process?
11. What factors help ensure that learning becomes relatively permanent?
12. What are some ways that emotions might be given more explicit consideration in
nurses education and in patient education?
13. How has neuroscience research contributed to our understanding of learning and learn-
ing theories?
References
Akers, R. L. (1989). Social learning theory and alcohol Bandura, A. (2001). Social cognitive theory: An agentic
behavior among the elderly. Sociological Quarterly, perspective. Annual Review of Psychology, 52, 126.
30, 625638. Barnard, A., Hollingum, C., & Hartfiel, B. (2006).
Anderson, O. R. (1997). A neurocognitive perspective on Going on a journey: Understanding palliative care
current learning theory and science instructional nursing. International Journal of Palliative Nursing,
strategies. Science Education, 81, 6789. 12, 612.
Bahn, D. (2001). Social learning theory: Its application Beck, M. H., Cataldo, M., Slifer, K. J., Pulbrook, V., &
to the context of nurse education. Nurse Education Guhman, J. K. (2005). Teaching children with
Today, 21, 110117. attention deficit hyperactivity disorder (ADHD)
Bandura, A. (1977). Social learning theory. Englewood and autistic disorder (AD) how to swallow pills.
Cliffs, NJ: Prentice-Hall. Clinical Pediatrics, 44, 515526.
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 87
References 87
Berggren, I., & Severinsson, E. (2006). The significance Fiske, S. T., & Taylor, S. E. (1991). Social cognition.
of nurse supervisors different ethical decision- New York: McGraw-Hill.
making styles. Journal of Nursing Management, 14, Fryer-Edwards, K., Arnold, R. M., Baile, W., Tulsky,
637643. J. A., Petracca, F., & Back, A. (2006). Reflective
Biderman, A. (2003). Family medicine as a frame for teaching practices: An approach to teaching
humanized medicine in education and clinical communication skills in a small-group setting.
practice. Public Health Review, 31, 2326. Academic Medicine, 81, 638644.
Block, S., & Billings, J. A. (1998). Nurturing humanism Gage, N. L., & Berliner, D. C. (1992). Educational
through teaching palliative care. Academic psychology (5th ed.). Boston: Houghton Mifflin.
Medicine, 73, 763765. Gage, N. L., & Berliner, D. C. (1998). Educational
Brackett, M. A., Lopes, P. N., Ivcevic, Z., Mayer, J. D., psychology (6th ed.). Boston: Houghton Mifflin.
& Salovey, P. (2004). Integrating emotion and Gagn, R. M. (1985). The conditions of learning (4th ed.).
cognition: The role of emotional intelligence. In New York: Holt, Rinehart & Winston.
D. Y. Dai & R. J. Sternberg (Eds.), Motivation, Gagn, R. M., Briggs, L. J., & Wagner, W. W. (1992).
emotion, and cognition: Integrative perspectives on intel- Principles of instructional design (4th ed.). Fort
lectual functioning and development (pp. 175194). Worth, TX: HBJ College Publishers.
Mahwah, NJ: Lawrence Erlbaum. Gallop, R., & OBrien, L. (2003). Re-establishing psy-
Bush, G. (2006). Learning about learning: From theories chodynamic theory as foundational knowledge for
to trends. Teacher Librarian, 34, 1418. psychiatric/mental health nursing. Issues in Mental
Byrnes, J. P. (2001). Minds, brains, and learning: Health Nursing, 24, 213227.
Understanding the psychological and educational rele- Gardner, H. (1978). Developmental psychology: An introduc-
vance of neuroscientific research. New York: Guilford. tion. Boston: Little, Brown.
Chochinov, H. M., & Breitbart, W. (Eds.). (2000). Gazzaniga, M. S. (Ed.). (2000). The new cognitive neuro-
Handbook of psychiatry in palliative medicine. New sciences (2nd ed.). Cambridge, MA: MIT Press.
York: Oxford University Press. Gilmartin, J. (2000). Psychodynamic sources of resis-
Dai, D. Y., & Sternberg, R. J. (Eds.). (2004). Motivation, tance among student nurses: Some observations in
emotion, and cognition: Integrative perspectives on intel- a human relations context. Journal of Advanced
lectual functioning and development. Mahwah, NJ: Nursing, 32, 15331541.
Lawrence Erlbaum. Goleman, D. (1995). Emotional intelligence. New York:
Deyl, S. G., & Kaliappan, K. V. (1997). Improvement of Bantam Books.
psychosomatic disorders among tension headache Goodwin, A. M., & Gore, V. (2000). Managing the
subjects using behaviour therapy and somatic stresses of nursing people with severe and endur-
inkblot series. Journal of Projective Psychology and ing mental illness: A psychodynamic observation
Mental Health, 4, 113120. study of a long-stay psychiatric ward. British
Duberstein, P. R., & Masling, J. M. (Eds.). (2000). Journal of Medical Psychology, 73, 311325.
Psychodynamic perspectives on sickness and health. Grealy, L. (1994). Anatomy of a face. Boston: Houghton
Washington, DC: American Psychological Mifflin.
Association. Greene, J. D., Sommerville, R. B., Nystrom, L. E.,
Eccles, J. S., & Wigfield, A. (2002). Motivational beliefs, Darley, J. M., & Cohen, J. D. (2001). An fMRI
values, and goals. Annual Review of Psychology, 53, investigation of emotional engagement in moral
109132. judgment. Science, 293, 21052108.
Erikson, E. (1968). Identity: Youth and crisis. New York: Halpern, J. (2001). From detached concern to empathy:
Norton. Humanizing medical practice. New York: Oxford
Ferguson, L., & Day, R. A. (2005). Evidence-based nurs- University Press.
ing education: Myth or reality? Journal of Nursing Hilgard, E. R. (1996). History of educational psychol-
Education, 44, 107115. ogy. In D. C. Berliner & R. C. Calfee (Eds.),
Ferns, T. (2006). Under-reporting of violent incidents Handbook of educational psychology (pp. 9901004).
against nursing staff. Nursing Standard, 20, 4145. New York: Simon & Schuster Macmillan.
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 88
Hilgard, E. R., & Bower, G. H. (1966). Theories of learning for treating affect phobias. Clinical Psychology
(3rd ed.). New York: Appleton-Century-Crofts. Science and Practice, 8, 8297.
Hoffman, M. L. (2000). Empathy and moral development: Menahern, S., & Halasz, G. (2000). Parental noncompli-
Implications for caring and justice. New York: ancea paediatric dilemma: A medical and
Cambridge University Press. psychodynamic perspective. Child Care, Health
Holyoake, D. D. (1998). A little lady called Pandora: An and Development, 26, 6172.
exploration of philosophical traditions of human- Moskowitz, G. B. (2005). Social cognition: Understanding
ism and existentialism in nursing ill children. self and others. New York: Guilford.
Child Care, Health and Development, 24, 325336. Murray, D. J. (1995). Gestalt psychology and the cognitive
Hooyman, N., & Kiyak, H. A. (2005). Social gerontology revolution. New York: Harvester Wheatsheaf.
(7th ed.). Boston: Allyn & Bacon. Neary, M. (2000). Supporting students learning and
Hunt, R. R., Ellis, H. C., & Ellis, H. (2004). professional development through the process of
Fundamentals of cognitive psychology (7th ed.). New continuous assessment and mentorship. Nurse
York: McGraw-Hill. Education Today, 20, 463474.
Imes, S. A., Clance, P. R., Gailis, A. T., & Atkeson, E. Ormrod, J. E. (2004). Human learning (4th ed.). Upper
(2002). Minds response to the bodys betrayal: Saddle River, NJ: Prentice-Hall.
Gestalt/existential therapy for clients with chronic Page, M. P. A. (2006). What cant functional neuroimag-
or life-threatening illnesses. Journal of Clinical ing tell the cognitive psychologist? Cortex, 42,
Psychology, 58, 13611373. 428443.
Kane-Urrabazo, C. (2006). Managements role in shaping Palincsar, A. S. (1998). Social constructivist perspectives
organizational culture. Journal of Nursing on teaching and learning. Annual Review of
Management, 14, 188194. Psychology, 49, 345375.
Kessels, R. P. C. (2003). Patients memory of medical Papadakis, A. A., Prince, R. P. O., Jones, N. P., &
information. Journal of the Royal Society of Medicine, Strauman, T. J. (2006). Self-regulation, rumina-
96, 219222. tion, and vulnerability to depression in adolescent
Kohler, W. (1947). Gestalt psychology. New York: Mentor girls. Developmental Psychopathology, 18, 815829.
Books. Pearson, A. (2006). Powerful caring. Nursing Standard,
Kohler, W. (1969). The task of gestalt psychology. 20(48), 2022.
Princeton, NJ: Princeton University Press. Pfeffer, J. (1985). Organizations and organizational
Kramer, D. A. (1983). Post-formal operations? A need theory. In G. Lindzey & E. Aronson (Eds.), Hand-
for further conceptualization. Human Development, book of social psychology: Vol. 1. Theory and method (3rd
26, 91105. ed., pp. 379440). New York: Random House.
Kbler-Ross, E. (1969). On death and dying. New York: Phelps, E. Z. (2006). Emotion and cognition: Insights
Macmillan. from studies of the human amygdala. Annual
Malach-Pines, A. (2000). Nurses burnout: An existential Review of Psychology, 57, 2753.
psychodynamic perspective. Journal of Psychosocial Piaget, J., & Inhelder, B. (1969). The psychology of the child
Nursing and Mental Health Services, 38, 2331. (H. Weaver, Trans.). New York: Basic Books.
Marshall, H. H. (1998). Teaching educational psychol- Piane, G. (2000). Contingency contracting and system-
ogy: Learner-centered constructivist perspectives. atic desensitization for heroin addicts in
In N. M. Lambert & B. L. McCombs (Eds.), How methadone maintenance programs. Journal of
students learn: Reforming schools through learner- Psychoactive Drugs, 32, 311319.
centered education (pp. 449473). Washington, DC: Proctor, R., Burns, A., Powell, H. S., & Tarrier, N.
American Psychological Association. (1999). Behavioural management in nursing and
Maslow, A. (1954). Motivation and personality. New York: residential homes: A randomized controlled trial.
Harper & Row. Lancet, 354, 2629.
Maslow, A. (1987). Motivation and personality (3rd ed.). Pullen, M. L. (2002). Joes story: Reflection on a difficult
New York: Harper & Row. interaction between a nurse and a patients wife.
McCullough, L., & Andrews, S. (2001). Assimilative International Journal of Palliative Nursing, 8,
integration: Short-term dynamic psychotherapy 481488.
46436_CH03_051_090.qxd 11/19/07 9:37 AM Page 89
References 89
Rogers, C. (1961). On becoming a person. Boston: Sternberg, R. J. (1996). Styles of thinking. In P. B.

Houghton Mifflin. Baltes & U. M. Staudinger (Eds.), Interactive minds:
Rogers, C. (1994). Freedom to learn (3rd ed.). New York: Life-span perspectives on the social foundation of
Merrill. cognition (pp. 347365). New York: Cambridge
Rogers, L. Q., Matevey, C., Hopkins-Price, P., Shah, P., University Press.
Dunnington, G., & Courneya, K. S. (2004). Sternberg, R. J. (2006). Cognitive psychology (4th ed.).
Exploring social cognitive theory constructs for Belmont, CA: Thomson/Wadsworth.
promoting exercise among breast cancer patients. Stiles, A. S. (2005). Parenting needs, goals, & strategies
Cancer Nursing, 27, 462473. of adolescent mothers. MCN American Journal of
Santrock, J. W. (2006). Life-span development (10th ed.). Maternal/Child Nursing, 30, 327333.
Boston: McGraw-Hill. Stockhurst, U., Steingrueber, H. J., Enck, P., &
Shapiro, A. (2002). The latest dope on research (about Klosterhalfen, S. (2006). Pavlovian conditioning
constructivism): Part I: Different approaches to of nausea and vomiting. Autonomic Neuroscience,
constructivismWhat its all about. International 129, 5057.
Journal of Education Reform, 12, 6277. Stroebe, M. S., Folkman, S., Hansson, R. O., & Schut, H.
Sherif, M., & Sherif, C. W. (1969). Social psychology. (2006). The prediction of bereavement outcome:
New York: Harper & Row. Development of an integrative risk factor frame-
Shors, T. J. (2006). Stressful experience and learning work. Social Science and Medicine, 63, 24402451.
across the lifespan. Annual Review of Psychology, 57, Telford, K., Kralik, D., & Koch, T. (2006). Acceptance
5585. and denial: Implications for people adapting to
Silverstein, S. M., & Uhlhaas, P. J. (2004). Gestalt chronic illness. Literature review. Journal of
psychology: The forgotten paradigm in abnormal Advanced Nursing, 55, 457464.
psychology. American Journal of Psychology, 117, Tennant, M. (2006). Psychology and adult learning (3rd
259277. ed.). New York: Routledge.
Skinner, B. F. (1974). About behaviorism. New York: Vander Zanden, J. W., Crandell, T. L., & Crandell, C. H.
Vintage Books. (2007). Human development (8th ed.). Boston:
Skinner, B. F. (1989). Recent issues in the analysis of McGraw-Hill.
behavior. Columbus, OH: Merrill. Vygotsky, L. S. (1986). Thought and language. Cambridge,
Slipp, S. (2000). Subliminal stimulation research and MA: MIT Press.
its implications for psychoanalytic theory and Wolpe, J. (1982). The practice of behavior therapy (3rd ed.).
treatment. Journal of the American Academy of New York: Pergamon.
Psychoanalysis, 28, 305320. Woolfolk, A. E. (2001). Educational psychology. Boston:
Snowman, J., & Biehler, R. (2006). Psychology applied to Allyn & Bacon.
teaching (11th ed.). Boston: Houghton Mifflin.
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What are the five learning theories discussed in the chapter?

What are the five learning theories discussed in the chapter?

What are the objectives of this chapter?

What are the objectives of this chapter?

46436_CH03_051_090.

qxd 11/19/07 9:37 AM Page 51

52 Chapter 3: Applying Learning Theories to Healthcare Practice

Applying Learning Theories 53

54 Chapter 3: Applying Learning Theories to Healthcare Practice

Figure 31 Respondent conditioning model of learning.

BASIC MODEL OF LEARNING

Offensive odors Queasy feeling

56 Chapter 3: Applying Learning Theories to Healthcare Practice

58 Chapter 3: Applying Learning Theories to Healthcare Practice

Table 31 Operant Conditioning Model: Contingencies to Increase

60 Chapter 3: Applying Learning Theories to Healthcare Practice

62 Chapter 3: Applying Learning Theories to Healthcare Practice

Figure 32 Information-processing model of memory.

EXTERNAL INTERNAL EXTERNAL

Stage 1 Stage 2 Stage 3 Stage 4

Physical and (Fleeting (Brief (Enduring:

64 Chapter 3: Applying Learning Theories to Healthcare Practice

What do cognitive developmental theorists assumptions of the information-processing view

66 Chapter 3: Applying Learning Theories to Healthcare Practice

68 Chapter 3: Applying Learning Theories to Healthcare Practice

Figure 33 Social learning theory.

EXTERNAL INTERNAL PROCESSES EXTERNAL

Role model Attentional Retention Reproduction Motivational Performance

Source: Based on Bandura (1977).

70 Chapter 3: Applying Learning Theories to Healthcare Practice

Table 32 Ego Defense Mechanisms: Ways of Protecting the Self

72 Chapter 3: Applying Learning Theories to Healthcare Practice

74 Chapter 3: Applying Learning Theories to Healthcare Practice

Figure 3 4 Maslows hierarchy of needs.

Source: Adapted from Maslow (1987).

damental to the humanistic perspective, much tion is referred to as a learner-directed approach

76 Chapter 3: Applying Learning Theories to Healthcare Practice

Neuropsychology and Learning 77

78 Chapter 3: Applying Learning Theories to Healthcare Practice

in responses. conditions (stimuli learning and change. learning and new

thought processing within mines patterning tures experiences activity.

Table 33 Summary of Learning Theories (continued)

performed. awareness, insight, and flict, development, and

and playful. learner.

Common Principles of Learning 81

82 Chapter 3: Applying Learning Theories to Healthcare Practice

State of the Evidence 83

84 Chapter 3: Applying Learning Theories to Healthcare Practice

Table 34 Psychological Theories of Learning and Healthcare:

Internet Educational Psychology resources (ERIC):

86 Chapter 3: Applying Learning Theories to Healthcare Practice

88 Chapter 3: Applying Learning Theories to Healthcare Practice

Rogers, C. (1961). On becoming a person. Boston: Sternberg, R. J. (1996). Styles of thinking. In P. B.

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