Reflections on service to nurse education: Dr Betty Andersen AM

Dr Betty Andersen was awarded an Honorary doctorate from the University of Newcastle and in 1986 she was awarded an Order of Australia (AM) for her service to nursing education. Betty Andersen, now retired, was a registered nurse and midwife who trained in the 1950s and devoted her working life to nurse education and practice in numerous Australian and international settings. Her missionary work in Bangladesh caused her to explore the manner in which nurses needed to continuously deal with novel situations. On her return to Australia she pursued Masters level studies in Education. Following her Masters studies she persued research that led her to the conclusion that Problem-based learning was an educational philosophy and methodology which could accommodate continuous reappraisal of both practice itself and appropriate learning strategies to equip nurses for competent practice.

In Newcastle she worked on the first Graduate Diploma for Nurse teachers and incorporated her models and frameworks into that curriculum. She later developed a curriculum for entry level nurses. This was adopted by the Hunter Institute of Higher Education at the time of the transfer of nurse education to the tertiary sector in 1984. The same curriculum document was used by the Macarthur Institute of Higher Education in Sydney. Both Institutes later became part of Universities in 1989 and nurse education programs were revised to Bachelor level awards. Subsequent developments in graduate studies were underpinned by her models and frameworks.

Dr Andersen's models and frameworks have informed numerous national projects on the scope of nursing practice in Australia. Many doctoral studies have utilized her theoretical frameworks. Recently she was asked to reflect on her journey. Her colleagues asked her the following questions.

What stimulated your involvement in PBL as philosophy and methodology?

In professional life nothing is quite as rewarding as the freedom to explore a vision, especially if a radical one and respond to the challenges involved implementing it. This account records briefly, both the processes and outcomes driving the vision along with its origins. It was to result in a radical change of approach to curriculum development, based on research, which in turn closely reflected theory linked to clinical practice.

What led you to this view of learning?

Though the process journey was destined ultimately to be centred in the academic arena, the foundations of such enquiry and action taking were laid in childhood. Then, the young child listening to everyday family discussions at the dinner table was influenced by the comments and judgements of older siblings and parents. Later, much is due to 'quality infants' and primary school education which fostered confidence, a love of enquiry and learning.

How did the vision unfold in the way that it did?

In looking back, an ongoing series of opportunities, experiences and learning discoveries built one on the other. Armed with three different registered nursing certificates, plus graduate practice experience, and a desire to teach, I settled to work in rural village India and later East Pakistan (now Bangladesh). Here the need to train local girls to staff the new hospital we built meant developing a three year curriculum in the Bengali language. Simply adapting the courses given in my training to the tropical context and culture, seemed not quite appropriate. To achieve relevance demanded a new approach involving contextual analysis in search of relevance.

How did you set about achieving your goals?

The way to gain these skills and insights initially required my undertaking a Nurse Education Diploma followed by a Bachelor of Arts degree studies and employment as a Nurse Educator back in Australia. Combining both degree studies and work as a nurse educator provided many meaningful transfer of learning experiences. What I was to discover through study of different disciplines, including those from an education major, could be applied to and tested out in the practice setting.

The opportunity to do this came about through my designated teaching role in a joint pilot nurse training programme involving Prince Henry Hospital, Nursing Education Centre and the University of NSW. The programme was known as the Combined Degree General Nurse Training Course. The opportunity to develop and coordinate the course provided freedom to design, implement and sharpen my skills in innovative course development work.

Coinciding with this teaching role one education course, focussing on curriculum development. Provided appropriate principles for development guidelines. A key message encouraged the planner to not jut make changes 'around the edges' but to start planning from 'scratch'. This approach involved asking questions, in the right sequence about the discipline in order to analyse thoroughly the given field. A framework would emerge from the systematic organisation of the data t guide development. Such a framework, it was claimed, should "bring new vitality to course implementation".

Complementing this study, and essential to its successful implementation, was an introduction to a theory about the structure of disciplines along with the processes involved in their analysis. This knowledge and skill was to play a pivotal part in the next challenge about to emerge. With the Arts degree completed, an invitation was extended to take up a research scholar's position for two years. This was to provide evidence in support of the transfer of nursing to the tertiary sector of education. The way forward was clear with this new challenge coming at such an opportune time, having just been inspired by what had been presented and tentatively tested in the workplace.

To what extent was 'theory' a part of nurse education in the 60's

The need for Australian theory of nursing was evident so that nurse educators would not have to work from assumptions alone about what should be different about tertiary trained nurses and how education for such nurses could evolve. A review of numerous, current overseas theories at that time was followed by a detailed analysis of the structure of nursing in Australia. This analysis resulted in a significant, interactive theoretical framework against which practice decisions and curriculum planning could be evaluated. The results of concurrent testing of final year hospital based students' ability to make informed judgements in clinical cases, was reviewed in light of the level of cognitive demand made of the students in all examination papers.

Once again an invitation to move in a new direction would allow knowledge of the discoveries made and new nursing theory to spread. A teaching Diploma for registered nurses was to be introduced in Newcastle CAE in 1977. The opportunity to become Head of the Department, to design and implement the course was to prove, not only a wonderful time of sharing and learning, but also more. It was to advance further the vision of a practice inspired theory which in turn would inform education for that practice.

The students were mainly clinical nurse educators from all branches of nursing, including many of its sub- disciplines as well. Exposure to such a variety of clinical settings during supervision of practice teaching allowed the validation and transferability of theory to be tested. The importance of abstract relationships among and between information acquisition, the processing involved in its use and thus judgement affecting action taking and outcomes, could be clearly demonstrated. As the teacher supervisor, holding the belief that who does the work, does the learning, my intention was to raise the issues and relationships thereby 'opening the door' of understanding, encouraging the students to develop and clarify their own way forward. Thus key elements of innovative course development were emerging. The methodology was to include practice-based stimulus to learning; self directed identification of needs. And integration of all relevant knowledge and skills to allow judgement about informed action taking; the need for outcome evaluation and reflection; facilitator role.

Were there other factors influencing the direction you took?

In the meantime, the new Medical Faculty at the nearby University was working on its first curriculum and intake of students. Coincidentally their approach was based on learning principles consistent with those I was advocating. Problem based learning as being adopted by a number of international medical faculties. Interaction with the faculty gave added confidence to continue with the innovative approach in nursing. By the end of 1983 the decision had been made in NSW to transfer Nurse Education to the Tertiary Education Sector. Course development became a pressing necessity once knowledge of the transfer was made public. By this time there were considerable numbers of Newcastle graduates able to join the working group to write the first course submission given approval by the necessary NSW boards. Needless to say it was based on an early version Problem Based Learning (PBL). My preference was a title which substituted Practice for Problem. This option became possible following my transfer back to Sydney on my appointment as Dean of the new Nursing Department at Macarthur Institute of Higher Learning (later University of Western Sydney, Macarthur).

Macarthur, with Newcastle, ran joint staff training programmes, for the implementation of the first course. Ongoing programme development, including stimulus package production, group facilitation sessions, criterion referenced assessment, use of the reflective process and further understanding of the scope and implications of the methodology followed. Committed and dedicated staff added depth to the early initiatives and provided staff workshops as well. Of particular significance was the establishment of the Problem Based Learning, Assessment and Research Centre (PROBLARC) which evolved from the need for faculties to plan the introduction of professional centres. Ours gained wide recognition for its quality work programmes among a wide audience of action-based professions. Senior staff members were frequently involved in sharing their expertise, the theoretical based and principles of our version of Practice- Based Learning and how to adapt and apply it. Not only in Australia but in a number of overseas learning centres. My own PBL consulting continued for a few years in Indonesia after retirement under the auspices of the World Health Organisation.