Lifelong Learning In Nursing A Delphi Study

Published Date: 02 Nov 2017

Abstract: In order to foster a culture of lifelong learning in nursing,

it is important to identify what the concept means in the nursing

profession as well as the characteristics of a lifelong learner. The

purpose of this Delphi study was to conceptualize lifelong learning from

the perspective of nursing, and to identify characteristics and essential

elements of lifelong learning. Phase 1 of the study included the

distribution of the first questionnaire that consisted of three, openended

statements/ questions. In phase two of the study, participants

were asked to rate their agreement with the characteristics and

attributes identified through phase one using a four-point, Likert-type

scale. In phase three of the study, the rankings were distributed to

participants. Using the results, a definition, to include characteristics

of a lifelong learner in nursing, was developed. It is hoped that a

clearer understanding of lifelong learning in nursing will foster more

discussion and research about intentional, active inclusion of lifelong

learning behaviors in nursing curricula.

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Abstract

In order to foster a culture of lifelong learning in nursing, it is important to identify what the

concept means in the nursing profession as well as the characteristics of a lifelong learner. The purpose

of this Delphi study was to conceptualize lifelong learning from the perspective of nursing, and to identify

characteristics and essential elements of lifelong learning. Phase 1 of the study included the distribution

of the first questionnaire that consisted of three, open-ended statements/ questions. In phase two of the

study, participants were asked to rate their agreement with the characteristics and attributes identified

through phase one using a four-point, Likert-type scale. In phase three of the study, the rankings were

distributed to participants. Using the results, a definition, to include characteristics of a lifelong learner in

nursing, was developed. It is hoped that a clearer understanding of lifelong learning in nursing will foster

more discussion and research about intentional, active inclusion of lifelong learning behaviors in nursing

curricula.

*Manuscript (without Title Page)

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Lifelong Learning in Nursing: A Delphi Study

Lifelong learning has been clearly identified as an imperative for professional nursing. The

Institute of Medicine ([IOM], 2011) recommends that nurses engage in lifelong learning, and further, that

healthcare organizations and schools of nursing create a culture of lifelong learning. The American

Association of Colleges of Nursing and the National League for Nursing identify lifelong learning as an

expectation for professional nursing practice ([NLN,2011). Advocates for radical transformation in

nursing education acknowledge the importance of lifelong learning to nursing education and practice

(Benner, Sutphen, Leonard and Day, 2010). However, no curricular elements to foster this culture have

been identified. Furthermore, no assessment criteria for determining the achievement of lifelong learning

outcomes have been established. Before this culture can be fostered, it is important to identify what the

concept of lifelong learning means in the nursing profession as well as the characteristics of a lifelong

learner.

Lifelong learning is defined in education as the "development of human potential through

a continuously supportive process which stimulates and empowers individuals to acquire all the

knowledge, values, skills, and understanding they will require throughout their lifetimes and to apply

them with confidence, creativity and enjoyment in all roles, circumstances and environments"

(Longworth and Davies cited in Guthrie [2003], p. 22). The purpose of this Delphi study was to

conceptualize lifelong learning from the perspective of nursing, and to identify characteristics and

essential elements of lifelong learning.

Review of Literature

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Although lifelong learning is discussed at length in educational and philosophical literature, there

is no clear understanding of how to promote lifelong learning nor are specific characteristics of the

lifelong learner articulated. Lifelong learning is identified as necessary, but rather vaguely in nursing

literature. Eason (2010) states lifelong learning allows for development of critical thinking and supports

introspection and detail in client care. A requisite to lifelong learning is not a cognitive capacity to learn,

but the ability to recognize and understand information (Winch, 2008). Beyond this ability, the desire to

learn, based on confidence in being able to conceptually infer, evaluate and appreciate what is learned is

required. Independence (self-direction) as a learner is an attribute of successful lifelong learning (Winch,

2008; O’Shea, 2003; Ponton, Derrick & Carr, 2005). This independence is built on confidence, patience,

persistence, diligence, and attention to detail. Janssen, van der Berg, Tattersall, Hummel and Koper

(2007) concur with the need for independent thought and add that lifelong learning also includes actively

seeking a variety of sources in order for the learner to make informed choices.

While studying undergraduate college students’ use of computers, Tan and Morris (2005)

concluded that lifelong learning involves both formal and informal learning. This learning must include

both content (knowledge) and the process of learning (acquisition of knowledge) over time. Tuijnman

(2003) proposes that that process of acquisition of knowledge is the more important of the two and Bosier

and Huang (2008) add it is a basic human developmental activity. Indeed, lifelong learning is central to

the concept of professionalism (Frost, 2001; Raidal &Volet, 2009).

Critical thinking and problem-based learning have been associated with lifelong learning.

Currently nursing education programs believe they are working toward problem-based learning and

critical thinking exercises but entry level coursework is still primarily lecture-based learning leading to

knowledge acquisition and application (AAMC & AACN, 2010). Unfortunately, understanding of what

constitutes a problem-based or critical thinking approach to learning is not universally understood. In

addition, the term lifelong learning is often used synonymously with continuing education (AAMC &

AACN, 2010), and while continuing education can certainly be integral to life-long learning, it does not

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define it. Bolhuis (2003) discussed self-directed lifelong learning in terms of education, economics and

society and concluded that the concept is so complex that a multi-dimensional approach to determining

how to foster lifelong learning is warranted. Defining lifelong learning and determining the characteristics

of a lifelong learner are necessary to determine how to foster this attribute which is deemed so important

to the profession of nursing.

Methodology

This study was conducted using the Delphi method. The Delphi method is appropriate to develop

a range of possible responses, to explore underlying assumptions that would lead to different judgments,

to seek information which may generate a consensus, and to correlate informed judgments (Delbecq,

Gusfafson and Van de Ven, 1975). After approval from the Institutional Review Board, the researchers

identified thirty potential participants through a review of the literature. Recognized experts were

selected to participate because of their contributions to nursing education, administration, clinical practice

and public policy.

Participants in this study were identified and invited using a list of prominent educators,

clinicians and nursing administrators in the United States, Canada, and United Kingdom. Introductory

letters were sent to the selected participants to inform them of their selection to participate and the

expectations if they decided to participate. Participants were also provided the opportunity to decline to

participate by contacting the researchers and request that no further correspondence be sent. No such

requests were received. Participants were asked to identify others who might have expertise or interest in

participating in the study. Three additional contacts were made based on this request. Participants were

informed that participation was voluntary and that responses would be treated confidentially. If a

participant wanted their name associated with their comments in any publication of the work, they had the

option to consent to being identified in the first phase of the study.

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Survey Monkeyâ„¢ was used as the vehicle for distribution of the questionnaires. Participants

were provided the link to the questionnaires through e-mail correspondence. The study had three distinct

phases. Phase 1 of the study included the distribution of the first questionnaire that consisted of three,

open-ended statements/ questions. These prompted responses about general conceptualizations of the

meaning of lifelong learning and the characteristic behaviors of lifelong learners. These prompts were,

"Describe your conceptualization of lifelong learning"; "What are the characteristics and/or behaviors of

lifelong learners?" and, "What is essential for lifelong learning?" The researchers gleaned the responses

for those that were mentioned frequently and those that were similar. In those cases, the researchers

analyzed the responses for the essential qualities and collapsed them into statements that retained their

collective conceptual meaning. Unique responses were also identified, analyzed and statements were

developed that captured their meaning.

In phase two of the study, participants were asked to rate their agreement with the characteristics

and attributes identified through phase one using a four-point, Likert-type scale. Descriptive statistics

were used to rank the responses to the second questionnaire. In phase three of the study, the rankings

were distributed to participants. Participants were asked to respond to the results by adding what they

believed was missing or reconsidering the second round responses by commenting. The third round of

responses were analyzed to determine areas of consensus among the expert participants.

Results

A total of 38 introductory letters were sent.. Of those, respondents (N=12) to the lifelong learning Delphi

study self-identified as having multiple areas of expertise: nursing education (n=12), administration

(n=7), research (n=3), clinical practice (n=4), theory (n=4), policy (n=5) and health futures (n=1). These

experts described their conceptualization of lifelong learning in terms of both a personal and professional

commitment. While the responses varied, several responses appeared to have common components.

Table 1 provides a full list of concepts gleaned from the responses to conceptualization of lifelong

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learning along with mean ratings on a Likert-type scale of 1-5 with 1 indicating strong disagreement and

5 indicating strong agreement.

[Insert Table 1 here]

Respondents were then asked to rate level of agreement with characteristics or behaviors of

lifelong learning (1=strong disagreement and 5= strong agreement) which were identified from their

responses in round 1. These characteristics and behaviors are listed in Table 2.

[Insert Table 2 here]

Finally, the respondents were asked to indicate their level of agreement (1= strongly disagree and

5 = strongly agree) with a list of statements derived from the first round as important to lifelong learning.

These statements, along with level of agreement with these statements are presented in Table 3.

[Insert Table 3 here]

The concepts, characteristics and behaviors rate in round 2 of the study were analyzed, using the

rating of 5.0 as being most essential to life-long learning. These data were then presented to the

respondents again, in round 3 of the study for ranking the most essential concepts, characteristics and

behaviors of lifelong learning. Concepts ranked as most essential for defining lifelong learning, with 1

being ranked highest are presented in Table 4. Characteristics and behaviors of a person engaged in

lifelong learning were ranked, with 1 being most important, and are presented in Table 5.

[Insert Table 4 here]

In the third round, respondents were also asked to comment on the statements which were

identified as important to the experience and development of lifelong learning. The comments all alluded

to the importance of reflection to lifelong learning as well as the importance of both practice and

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scholarly communities to foster lifelong learning, with the goal of best serving the community within

nurses’ care.

[Insert Table 5 here]

Two exemplars of these ideas eloquently sum up the importance of lifelong learning to nursing:

Lifelong learners find learning in all they do. If faced with a tradition, values, or mores, they

contemplate how what they are facing fits within their own framework…then they are able to

integrate other’s points of view in their community and understand perceptions, concepts and

behaviors that may be different from their own because of the learning they acquired.

And,

Lifelong learners must challenge conventional wisdom; otherwise, they and their thoughts,

beliefs, or values stagnate. Although reflection is often considered a solitary enterprise, i.e. the

contemplative life of a philosopher, lifelong learners in any discipline, but particularly in nursing,

are members of both practice and scholarly communities, with intimate ties to the needs,

concerns, and issues of client communities.

Discussion

A varied response was provided by the experts regarding conceptualization of lifelong learning.

The AACN (2010) report on lifelong learning in medicine and nursing is congruent, in part, with the

competencies of the lifelong learner identified in this study. It identified key competencies as including

acquiring evidence-based healthcare knowledge through literature search and retrieval strategies, practicebased

learning and self-reflection. The educational definitions of lifelong learning (Longworth & Davies,

cited in Guthrie, 2003; Winch, 2008; Ponton, Derrick & Carr, 2005) are all consistent with the

characteristics identified in this study. The most common responses centered around keeping the mind

active, curiosity, seeking new knowledge, and engaging in both scholarly and practical endeavors. It was

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also identified as impacting capacity to deliver high quality nursing care (Baron, Field, and Schuller.

2000, cited in Gopee, 2002). In addition to acquiring new knowledge, the ability to translate that

knowledge was considered key to lifelong learning. Learning and knowing are a dynamic process, which

allows the learner to gain new perspectives. In addition, growth in personal and professional contexts was

considered a result of lifelong learning. Moreover, lifelong learning is considered an obligation for

professional nurses.

When asked to rate level of agreement with characteristics of behaviors of a lifelong learner,

enjoyment of learning, availing self to learning, engaging, understanding that knowledge expands and

changes were strongly identified. Not surprisingly, self-motivation, intentionality and reflection in

learning were identified. Interestingly, courage and optimism were associated with life-long learning.

When asked to identify level of agreement with statements derived from the first round of the

Delphi study, lifelong learning is an integral part of communities of practice with time and expectation for

reflection was ranked highest. Questioning tradition, challenging values and being open to new ways also

garnered a high level of agreement. Finally, it was clear from the responses that lifelong learning does

make a difference in nursing education and practice.

The extent to which these characteristics and behaviors, as identified by the experts, are fostered

and practiced in existing learning environments is unknown. In an era when producing a practicing nurse

is pushed to include a shorter, more compressed curriculum, fostering such behaviors and characteristics

may be viewed as untenable. The challenge for nursing is to insure these elements drive the curriculum

rather than be subordinated by the need to present "content". Program evaluation, course evaluation, and

faculty evaluations should address the extent to which these characteristics and behaviors are included

and achieved. Likewise, nurse administrators should expect and reward these characteristics and

behaviors in practice environments and employee evaluations. Developing valid assessment methods

toward this end will be the challenge for nursing faculty and for nurse administrators.

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Round three of the Delphi study identified the most essential concepts to lifelong learning and

characteristics of the lifelong learner. With these data, the following definition for lifelong learning in

nursing is offered:

Lifelong learning in nursing is a dynamic process, which encompasses both personal and

professional life. This learning process is also both formal and informal. Lifelong learning

involves seeking and appreciating new worlds or ideas in order to gain a new perspective as well

as questioning one’s environment, knowledge, skills and interactions. The most essential

characteristics of a lifelong learner are reflection, questioning, enjoying learning, understanding

the dynamic nature of knowledge, and engaging in learning by actively seeking learning

opportunities. Keeping the mind active is essential to both lifelong learning and being able to

translate knowledge into the capacity to deliver high quality nursing care.

The responses in this study add to the body of knowledge about lifelong learning in that nursing experts

considered both personal and professional lifelong learning as important for the practicing nurse. In a

discipline that prides itself in recognizing patients as whole persons, this implies that the whole nurse, not

just a knowledgeable and skilled person, provides care. This whole nurse develops over time as a person

and as a care provider via lifelong learning. Another unique element of lifelong learning identified in this

study is the clear direction to move beyond information literacy, content, and continuing education to

questioning, reflecting and being open to new perspectives. We are called to create spaces for learning

that inspire questioning and reflection, and that also inspire teachers and students to be open to mutual

discovery. Nursing practice is predicated by successful achievement on an objective licensing or

certification examinations of nursing knowledge. Because of this, nursing educators are understandably

focused on presenting nursing content. The characteristics for lifelong learning, upon which competent,

safe, and enduring nursing practice is based, cannot be assessed in objective examinations. Indeed,

objectivism has long been recognized as a limited educational approach and counterproductive to

developing critical thinking. Palmer (2007, pp. 121-122) cautions against pure objectivism, stating,

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"objectivism is so obsessed with protecting the purity of knowledge that students are forbidden direct

access to the object of study, lest their subjectivity defile it. Whatever they know…must be mediated

through the teacher". In order to foster lifelong learning, subjectivity, which would include reflecting,

questioning, and being open to new perspectives should be just as much a part of the learning and practice

culture as objective knowledge.

It is common for students view the end of their compulsory education as the end of their

obligation to learn the concepts of their discipline. Students often value more highly their freedom from

obligation to studies than continuation of their learning (Titmus, 1999, cited in Gopee, 2002). For this

reason, and because of the increasing volume and accessibility to information, it is imperative for nurse

educators to focus on, and model, the development of the skills and attitudes for lifelong learning.

Furthermore, nursing practice organizations need to enable practicing nurses to initiate and continue

personal and professional learning and to benefit patients (Gopee, 2002; 2005).

It is hoped that a clearer understanding of lifelong learning in nursing will foster more discussion

about intentional, active inclusion of lifelong learning behaviors in nursing curricula, and that teaching

and learning practices provide ample opportunities for students to develop the skills and attitudes

necessary for lifelong learning. All learning should be approached from the perspective that learning is a

continuous and infinite process. .