Nursing+Education+&+Motivation

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The best way to inspire people to a superior performance is to convince them by everything you do and by your everyday attitude that you are wholeheartedly supporting them. ~ Harold H. Geneen

__Catherine Cantrell, MSN-Ed, OCN, RN __ = **Learning to be a nurse.** = Nursing students tend to exhibit intrinsic motivation, due in part to the nature of nursing. It is a caring profession, therefore, nursing students want to learn well so that they can care for others with the necessary level of expertise to avoid harming a patient. This study by Nilsson and Stomberg sought by use of survey to assess students self-assessment of motivation throughout their BSN (Bachelor's of Science in Nursing) program.

Eight main motivators were identified and measured in this study.
 * 1) The degree of difficulty/demand of the studies
 * 2) The teacher's engagement
 * 3) The organization of the program
 * 4) Contents in the studies associated to the profession
 * 5) The attitude towards the studies
 * 6) The study result achieved (did studying achieve desired results)
 * 7) The life situation surrounding the studies
 * 8) Friendship surrounding the studies

Nursing school is not like any other training at the Associate's or Bachelor's level. Students are in lecture two days a week, on average, and are in a clinical setting from 12-24 hours each week caring for patients. This is time spent learning about pathophysiology of body systems and diseases and learning technical skills that are supportive of that knowledge. Additionally, on the job training means that skills are usually being attempted for the first time in front of an instructor and a vulnerable patient. The stress level is tremendous. Paperwork is due regarding patient care after each clinical day. This includes new knowledge about medications, synthesizing knowledge regarding medications, laboratory results, medical imaging studies, and the patient's actual minute to minute needs.

I recall vividly learning about an entire body system's disease processes in the same amount of class time as my friend who was getting her Bachelor's in social work watched a video in class. A video?!? I have 10 pages of notes and 3 chapters of highlighted material I have to know or I might kill someone, and you watched a video?! Hmmm...

But it is interesting, fun, meaningful, and has a deep purpose in the world around us. There is never a dull moment in a nurse's day! Though we might occasionally wish for one.

"The outstanding statement for a high motivation score was the students' [|wish] to become a nurse and obtain their degree as registered nurse. At the same time several students found the organization of the program stimulating and they had a positive attitude to the studies" (p. 4). While it is true that the external motivation of earning a degree and having gainful employment is a motivator, personal experience tells me this is not enough to spur someone through the rigors of nursing school.

One of the factors listed in this study is that of engagement. Nursing classes can be quite large, and there is a great degree of content that must be covered. This is often to the detriment of the synthesis and depth we would like to explore and foster. Engagement is very difficult to attain in a nursing classroom... unless the student possess that intrinsic motivation fed by the greater purpose.

This study found that the latter semesters students showed the highest motivation, and they hypothesize that this is due to the increased application and [|relevance] of studies in that semester. I would add that the increased competence felt as skills and knowledge meld (mastery performance) into a usable and more comfortable form is also highly motivating to the senior nursing student.

An unsurprising finding was that those with high motivation scores were found to have higher self-efficacy as well. Higher self-efficacy combined with higher motivation (and the reciprocal nature of the two) results in higher levels of achievement (study skills are effective enough to produce better clinical and exam results).

 [] Nilsson, K.E.L. & Stomberg, M.I.W. (2008). Nursing students motivation toward their studies-a survey study. BMC Nursing, 7(6), 1-7. doi:10.1186/1472-6955-7-6.

=__A lesson plan in action__ = __Immunology for Nurses based on Self-Determination Theory__  [] Nursing is a difficult discipline to learn due to its complexity and sheer volume of required knowledge. Here, I will explore intrinsic motivation, self-determination theory, and ways to enhance competence, autonomy, and relatedness within a six-hour nursing lecture on the topic of immunology. **Self-Determination Theory** Self-determination theory stems from the idea of intrinsic motivation, which describes ways that people become motivated to complete a task or assignment (Schunk & Zimmerman, 2008). Similarly, attribution theory also emphasizes this sense of control and empowerment as essential to the intellectual progress of the student (Schunk, Pintrich, & Meece, 2008). In either theory, motivation is derived from within the student’s own personal toolbox of abilities and perceptions. This requires the student to be self-aware of needs, limitations, and strengths (Schunk et al., 2008). People that learn via self-determination look internally for solutions to problems, reasons for failure, and ways to succeed in the future.

Self-determination theory (SDT) informs teachers how best to illicit creativity, performance, and persistence from students by describing what motivates students to learn and strive to reach that outcome (http://www.selfdeterminationtheory.org/theory). Learning, under this theory, is thought to occur when the student exhibits self-awareness, and when the teacher is able to provide and encourage opportunities for competence, autonomy, and relatedness (Schunk et al., 2008). Competence is another way of saying that a person has mastered content or accomplished a task successfully. Similar to the attribution theory of learning, mastery is assumed to be a need that people have (Schunk et al., 2008). Through the use of SDT, teachers help students to meet this need via challenging yet achievable assignments (Schunk et al., 2008). This means that the assignment is reasonable considering the student’s previous experiences and knowledge, but will push thinking a little farther and deeper. This requires the assignment to be neither too hard or too simple. So, a balance between achievability and difficulty is essential to the overall degree of competence the student will retain as a result. Autonomy is another need identified within the SDT. As demonstrated also in attribution theory, this sense of control and empowerment is considered essential to the intellectual growth of the student (Schunk et al., 2008). Autonomy speaks to the desire to have choices or options. This could be accomplished several ways in the classroom including allowing flexible time frames for assignments, choice of assignments that meets the same requirements, or a choice of topic within an assignment. Students are robbed of autonomy when they have a lack, or perceived lack, of choice and flexibility. So, inflexible deadlines for assignments and assignments that are uniform for all students is detrimental to the student’s ability to gain autonomy. A certain amount of firmness is warranted at certain grade levels, with specific assignments and objectives, and under particular circumstances. However, it is important to allow for autonomy, and the subsequent self-directedness, whenever it is possible. Increased autonomy breeds increased competence and motivation to learn more broadly and deeply (Schunk & Zimmerman, 2008). In its broadest terms, relatedness indicates a sense of belonging (Schunk et al. 2008). In the case of learning, relatedness also refers to the relevance and usefulness of the material being taught. This also refers to whether the information is connected to previous information and real world experiences that might call this new learning into play. One way this can be achieved is by giving real world examples, or war stories, that demonstrate use of the material. **Why Self-Determination Theory?** Nursing students tend to exhibit intrinsic motivation, due in part to the nature of nursing. It is a caring profession; therefore, nursing students want to learn well so that they can care for others with the necessary level of expertise to avoid harming a patient. Time is spent learning about pathophysiology of body systems and diseases and learning technical skills that are supportive of that knowledge. The stress level is tremendous. Paperwork is due regarding patient care after each clinical day (6-12 hours spent caring for a patient in a healthcare facility). This includes new knowledge about medications, synthesizing knowledge regarding medications, laboratory results, and medical imaging studies, in addition to caring for the patient's actual minute-to-minute needs. Suffice it to say, extrinsic motivation is not usually adequate to motivate a student to be successful in nursing school. A study by Nilsson and Stomberg sought, by use of survey, to evaluate students’ self-assessment of motivation throughout their BSN (Bachelors of Science in Nursing) program. This study found that the latter semesters’ students showed the highest motivation, and they hypothesize that this is due to the increased application and relevance, or relatedness of studies in that semester. I would add that the increased sense of competence as skills and knowledge meld (mastery) into a usable and more comfortable form is also highly motivating to the senior nursing student. **The Lesson** Immunology, the study of our body’s defense against invading organisms, is an incredibly complex body system to teach and learn. Immunology deals largely with cells and functions we cannot see, processes we can scarcely measure, and complications that are often only discoverable via patient report of symptoms. Additionally, it includes failures of the body’s immunologic defenses. Traditionally, lecture is used to explain the different aspects of immunology and the associated nursing interventions. Quizzes and tests are a standard way to measure the degree of integrated knowledge the student has achieved. While this can be a very effective method to distribute and assess such a large volume of information for large classes, it is scarcely motivating or engaging. Working within the theory of self-determination, a lesson plan is derivable for teaching immunology. An in-class activity requires the students to write down their “muddiest point” (an unclear idea) and one thing they think they understand quite well. This is done at 30 minute to 1-hour intervals throughout the lecture to increase knowledge by forcing immediate review of material. Then, the students are required to turn to a partner to discuss these two points (muddy and clear). The idea being that they can learn from each other, both by gaining another student’s perspective and by helping each other understand unclear ideas. Explaining a topic to another student solidifies learning and fosters a feeling of mastery about the material. A class wiki is designed where the students are required to share information by topic, and other students are required to respond to the shared information. The topic that the student posts on the wiki is entirely their own choice. The time frame extends from the first lecture until almost a week after the second lecture. Additionally, students were given a choice of ahead of time about how they would like the wiki to be used. The overwhelming choice was for fill-in-the-blank questions, and, so, the assignment is to create one question and to answer one question. This should foster competence also because it is challenging to create a good question, but it is certainly an achievable task. Relatedness is demonstrated by sharing actual patient stories during lecture. A video of a patient with [|lupus] is shared along with her story to further increase the sense of relevance that immunology has in the clinical setting. We discuss scenarios that the students have already been a part of as well. **Conclusion** Although I have briefly mentioned other learning and motivation theories such as attribution theory as having similarities to self-determination theory, SDT is more suitable to nursing practice. Long after graduation, nurses need to have a deep-seated sense of competence in their work and autonomy in seeking answers and providing care. Additionally, connections and relationships continue to be formed between what is known and what is new throughout a nurse’s career. Fostering these intrinsic motivators assists the student now and for years to come. **References** Nilsson, K.E.L. & Stomberg, M.I.W. (2008). Nursing students motivation toward their studies-a survey study. BMC Nursing, 7(6), 1-7. doi:10.1186/1472-6955-7-6. //arch, and Applications// (3rd ed.). Upper Sadle River, New Jersey: Pearson Education. Schunk, D.H. & Zimmerman, B. J. (2008). //Motivation and Self-Regulated Learning: Theory, Research, and Applications//. New York, New York: Lawrence Erlbaum Associates. Self-Determination Theory: An Approach to Human Motivation and Personality. Retrieved from http://www.selfdeterminationtheory.org/theory
 * Competence**
 * Autonomy**
 * Relatedness**
 * Competence**
 * Autonomy**
 * Relatedness**

**Appendix A: Complete Lesson Plan**
 * **Teaching method** || **Purpose** ||
 * Pre-lecture quiz || Allows for recognition of prior knowledge and forces students to perform some pre-lecture reading. ||
 * You-tube video links of complicated processes || For visual learners, reinforces content, breaks up the monotony ||
 * In-class activities || writing down “most important” points and swapping with someone else to see other’s viewpoint ||
 * Videos of real people with these diseases || Again, for visual learners. However, this adds interest by demonstrating the relevance and relatedness of content. ||
 * Wiki fill in the blank exercise || Allowed for student autonomy by taking votes for choices of wiki activity. Will serve as a study guide. ||
 * [|Blog] || Links to information, resources, more videos, and fill in the blank questions I created. ||
 * 1 week post lecture/pre-test open forum content review || Decreases attribution to rushed lecture. Increases feelings of a positive emotional state by demonstrating a caring attitude by orchestrating and unrequired activity. ||

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