Innovative Teaching Strategies Within A Nursing Education Model

INNOVATIVE TEACHING STRATEGIES
WITHIN A NURSING EDUCATION MODEL
by
EUGENE POTGIETER
submitted in accordance with the requirements

for the degree of
DOCTOR OF LITERATURE AND PHILOSOPHY
in the
DEPARTMENT OF NURSING SCIENCE
at the
UNIVERSITY OF SOUTH AFRICA
PROMOTER: PROF HIL BRINK
JOINT PROMOTER: PROF PJN STEYN
JUNE 1996
To Freddie and Ferdinand
with love
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ACKNOWLEDGEMENTS
I would like to express my sincere appreciation to the following persons for their
respective contributions to this thesis:
• My promoters, Professor HIL Brink and Professor PJN Steyn, for their guidance,
support, precious time, constructive criticism and encouragement during the
course of this study.
• Professor Roy Tustin, for the many hours spent in the thorough editing of the
manuscript and his careful scrutinising of the text.
• Mrs Rina Coetzer, for the high standard 'of typing and the excellent technical
presentation of the manuscript. Her very special contribution in this regard is
highly appreciated.
• My friend, Viviene Pretorius, for helping with the first proof reading of this
thesis.
• My colleagues in the Department of Nursing Science, Unisa, for their assistance

with the final proof reading.
• My husband and son, F~e and F~d, for their love, moral support,
forbearance and patience during the course of the study and the writing of this
thesis.
• My Creator, for granting me the strength and courage to complete this study.
. .,.. .,.....
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SUMMARY
Recent nursing literature has repeatedly proclaimed the need for creativity in nursing.
The complexity of contemporary nursing practice as a result of the explosion of
knowledge and technology, changing human values and diverse health care systems,
requires an innovative and creative nurse who can adapt to change and provide holistic,
individualised, context-specific patient care. Higher levels of cognitive thought, creative
thinking and problem-solving skills have been stressed as desirable qualities of student
nurses. It is suggested in the literature that the evolution of innovative strategies and the
ways to implement them into nursing curricula be explored in order to assist and
encourage students to develop these higher cognitive skills.
From an analytical study of the literature which was undertaken with the aim of exploring
the nature of creativity and the processes involved in creative thinking and learning, and
of identifying innovative strategies particularly relevant to the teaching of nursing, it
became apparent that the most significant determinants in teaching for creativity, are the
learning enviromnent, the educator-student relationship, and the provision of a variety
of teaching strategies, which are student-centred with a problem-solving focus. It was
established that stimulation of both the left and right hemispheres of the brain is essential
for the development of creative thinking skills.
Based on the insights and knowledge gained in the study, a nursing education model for
the fostering of creativity was developed. This model encompasses a wide variety of
didactic considerations and is designed to stimulate whole brain learning. It is hoped that
its use will be of value in the production of innovative and courageous nurse practitioners
who will be better equipped to cope with the changes and challenges of their working
environment and be able to provide context-specific nursing care.
Key terms:
creativity; innovative teaching strategies; problem-solving; student-centred learning;
creative learning environ,ment; nursing education model; creative thinking skills; whole
,,.,.
brain learning; productive learning; science-art of nursing.

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TABLE OF CONTENTS PAGE
CHAPTERl
Orientation to the study
1.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 EXPOSITION OF THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . 3
1.3 STATEMENT OF THE RESEARCH PROBLEM . . . . . . . . . . . 4
1.4 ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5 AIMS OF THE STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6 SIGNIFICANCE OF THE STUDY . . . . . . . . . . . . . . . . . . . . . . . 9
1.7 RESEARCH METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . 10
1.8 THEORETICAL FRAMEWORK . . . . . . . . . . . . . . . . . . . . . . . 11
1.9 DEFINITIONS AND DESCRIPTIONS OF TERMI-
NOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.9.1 Creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.9.2 Creative thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.9.3 Divergent thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.9.4 Convergent thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.9.5 Creative problem-solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.9.6 Teaching strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.9. 7 Innovative teaching strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.9.8 Model .............................................. 13
1.10 OUTLINE OF THE RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . 14
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CHAPTER2
The nature of creativity
2.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2 MODERN CONCEPTIONS OF CREATIVITY . . . . . . . . . . . . 17
2.3 CRITERIA FOR DEFINITIONS OF CREATIVITY . . . . . . . . 17
2.3.1 Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.3.2 Product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.3.3 Process ............................................. 19
2.3.4 Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.4 DEFINITIONS OF CREATIVITY . . . . . . . . . . . . . . . . . . . . . . . 21
2.5 THEORIES OF CREATIVITY . . . . . . . . . . . . . . . . . .. . . . . . . 26
2.5.1 Cognitive, rational and semantic theories . . . . . . . . . . . . . . . . . 26
2.5.1.1 Cognitive abilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.5.1.2 Creative problem-solving .............................. 33
2.5.1.3 Associative theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.5.1.4 Gestalt theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.5.2 Personality and environmental theories . . . . . . . . . . . . . . . . . . . 41
2.5.2.1 Personality theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.5.2.2 Environmental theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.5.2.2.1 Social and cultural influences . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.5.2.2.2 Learning environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.5.2.2.3 Teacher attitudes - the open teacher . . . . . . . . . . . . . . . . . . . . . . 45
2.5.2.2.4 Rewards and motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.5.3 Humanistic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.5.4 Psychoanalytic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.5.5 Psychedelic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.6 SYNTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
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CHAPTER3
Whole brain creativity
3.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.2 THE SPLIT BRAIN STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.3 LEFT AND RIGHT HEMISPHERIC SPECIALISATION 62
3.4 TWO DIFFERENT THEORIES OF HOW THE BRAIN
IS ORGANISED PHYSIOLOGICALLY . . . . . . . . . . . . . . . . . . 64
3.4.1 The triune brain theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.4.2 The left brain/right brain theory . . . . . . . . . . . . . . . . . . . . . . . . 65
3.5 THE WHOLE BRAIN CREATIVITY MODEL . . . . . . . . . . . . 68
3.5.1 From the split brain theory to the four quadrant model ..... 69
3.5.2 The whole brain model in relation to creativity . . . . . . . . . . . . . 73
3.5.3 The whole brain teaching and learning model . . . . . . . . . . . . . . 77
3.6 SYNTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
3. 7 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
CHAPTER4
The nature of creative learning
4.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.2 COGNITIVE STYLES (LEARNING STYLES) . . . . . . . . . . . . 86
4.2.1 The field-dependent/independent cognitive styles . . . . . . . . . . . 87
4.2.1.1 Field-dependency/independency in relation to whole brain
learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.2.1.2 Educational implications of the field-dependent/independent
cognitive styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
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4.2.2 Kolb's experiential learning model . . . . . . . . . . . . . . . . . . . . . . . 94

4.2.2.1 The modes of the learning process . . . . . . . . . . . . . . . . . . . . . . . 95
4.2.2.2 Kolb's four learning styles ............................. 98
4.2.2.3 Educational implications for whole brain learning and
creativity ........................................... 100
4.2.2.4 Synthesis ........................................... 105
4.2.3 Cognitive style, brain dominance and professional occupa-
tion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.3 INSTRUCTIONAL OBJECTIVES .................... . 109
4.3.1 Bloom's taxonomy .................................. . 109
4.3.1.1 Cognitive domain .................................... 110
4.3.1.2 Affective domain .................................... 112
4.3.2 De Corte's classification ............................. . 117
4.3.2.1 Receptive-reproductive operations ..................... . 118
4.3.2.2 Productive operations ............................... . 118
4.4 THEORIES OF LEARNING 121
4.4.1 Cognitive theories of learning ......................... . 123
4.4.1.1 Problem-solving and creative thinking .................. . 123
4.4.1.2 Metacognition and creative thinking ................... . 124
4.4.1.3 Piaget: formal operational thought ..................... . 126
4.4.1.4 Bruner: Discovery learning ........................... . 128
4.4.2 Humanistic theories of learning ....................... . 131
4.4.2.1 Humanistic psychology .............................. . 131
4.4.2.2 Rogers: Student-centred learning ...................... . 134
4.4.2.3 Maslow: Self-actualisation ........................... . 135
4.5 CONCLUSION ..................................... . 137
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CHAPTERS
Educational models and creativity
5.1 INTRODUCTION .................................. . 138

5.2 ADULT LEARNING ................................ . 139
5.2.1 Nature of adult education ............................ . 139
5.2.2 Assumptions of adult learning ........................ . 141
5.2.2.1 The need to know ................................... . 141
5.2.2.2 The learner's self-concept ............................ . 141
5.2.2.3 The role of the learner's experience .................... . 142
5.2.2.4 Readiness to learn .................................. . 143
5.2.2.5 Orientation to learning .............................. . 144
5.2.2.6 Motivation to learn ................................. . 144
5.2.3 v Learning environment and teaching strategies ........... . 145
5.2.4 Significance of adult learning to nursing education ....... . 146
5.3 MASTERY OF LEARNING .......................... . 150
5.3.1 Nature of mastery learning ........................... . 150
5.3.2 Assumptions of mastery learning ...................... . 151
5.3.3 v" Learning environment and teaching strategies ........... . 153
5.3.4 Significance of mastery learning to nursing education ..... . 154
5.4 EXPERIENTIAL LEARNING ......................... 157
5.4.1 Nature of experiential learning ......................... . 157
5.4.2 Assumptions of experiential learning ................... . 159
5.4.2.1 Learning is conceived as a process ..................... . 159
5.4.2.2 Learning is a continuous process ...................... . 159
5.4.2.3 Learning requires the resolution of conflicts between dialecti-
cally opposed modes of adaptation to the world .......... . 160
5.4.2.4 Learning is a holistic process of adaptation to the world ... . 161
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5.4.2.5 J Learning involves transactions between the person and the

environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
5.4.2.6 Learning is the process of creating knowledge . . . . . . . . . . . . 162
5.4.2.7 The experiential taxonomy: experiential learning involves
five stages, initially proposed by Steinaker and Bell (1979) 164
5.4.3 v Learning environment and teaching strategies . . . . . . . . . . . . 165
5.4.4 Significance of experiential learning to nursing education . . . 166
5.5 OPEN LEARNING .................................. 170
5.5.1 Nature of open learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
5.5.2 Assumptions of open learning . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.5.3 Learning environment and teaching strategies . . . . . . . . . . . . 174
5.5.4 Significance of open learning to nursing education . . . . . . . . . 175
5.6 THE RELATION BETWEEN THE FOUR EDUCATIONAL
MODELS AND CREATIVITY . . . . . . . . . . . . . . . . . . . . . . . . . 178
5.6.1 The relation between the four educational models and
creativity ............................. ~ . . . . . . . . . . . . . 178
5.6.2 The relation between the learning environments of the four
educational models and creativity . . . . . . . . . . . . . . . . . . . . . . . 186
5. 7 SYNTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
CHAPTER6
The practice of nursing
6.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

6.2 DEFINITIONS OF NURSING . . . . . . . . . . . . . . . . . . . . . . . . . 193
6.3 PHILOSOPHICAL FOUNDATIONS OF NURSING ...... 197
6.4 PROFESSIONAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . 199
6.4.1 Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
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6.4.2 Code for Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

6.4.3 Scope of practice .................................... 210
6.5 THE SCIENCE-ART OF NURSING PRACTICE . . . . . . . . . 224
6.5.1 Psychomotor skills .................................. . 228
6.5.2 Affective skills 232
6.5.3 Cognitive skills 237
6.5.3.1 Concept learning ................................... . 237
6.5.3.2 Problem-solving .................................... . 238
6.5.3.3 Intuition .......................................... . 240
6.5.3.4 Decision-making 241
6.5.3.5 Critical thinking 242
6.5.3.6 Clinical judgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
6.5.4 The expert nurse practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . 245
6.5.5 Creativity and the science-art of nursing practice ......... 247
6.6 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
CHAPTER 7
Innovative teaching strategies
7.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

7.2 BRAINSTORMING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
7.2.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
7.2.2 Advantages and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
7.2.3 Application to nursing education . . . . . . . . . . . . . . . . . . . . . . . 255
7.2.4 Relation to creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
7.3 CREATIVE PROBLEM-SOLVING . . . . . . . . . . . . . . . . . . . . 256
7.3.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
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7.4 TEACHING BY METAPHOR . . . . . . . . . . . . . . . . . . . . . . . . . 264
7.4.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
7.4.3 Application to nursing education ...................... . 269
7.4.4 Relation to creativity ................................ . 270
7.5 SYNECTICS ....................................... . 271
7.5.1 Description ........................................ . 271
7.5.1.1 Making the strange familiar ........................... 272
7.5.1.2 Making the familiar strange ........................... 273
7.5.1.3 Synectics procedure ................................. . 277
7.5.2 Advantages and limitations ........................... . 279
7.5.3 Application to nursing education ...................... . 280
7.6 VISUALISATION: IMAGERY AND FANTASY . . . . . . . . . . 282
7.6.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
7.6.1.1 Visualisation techniques .............................. 284
7.6.1.1.1 Relaxation exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
7.6.1.1.2 Observer fantasy .................................... 286
7.6.1.1.3 Identification fantasy (personal analogy) . . . . . . . . . . . . . . . . . 287
7. 7 HUMOUR AS A TEACHING STRATEGY . . . . . . . . . . . . . . 293
7. 7.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
7. 7.2 Advantages and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
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7. 7.3 Application to nursing education . . . . . . . . . . . . . . . . . . . . . . . 296

7. 7.4 Relation to creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
7.8 WRITING AS AN INNOVATIVE TEACHING STRATEGY 299
7.8.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
7.9 ROLE PLAY ....................................... 306
7.9.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
7.10 SOCIODRAMA (PSYCHODRAMA) ................... 310
7.10.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
7.11 SIMULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
7.11.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
7.11.4 Relation to creativity . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . 322
7.12 THE CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
7.12.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
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7.13 VALUES CLARIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . 331

7.13.1 Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
7.14 SYNTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
CHAPTERS
A nursing education model for the fostering of creativity

8.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
8.2 BACKGROUND OF THE MODEL . . . . . . . . . . . . . . . . . . . . . 341
8.2.1 Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
8.2.2 Rationale of the model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
8.2.3 A prescriptive instructional model . . . . . . . . . . . . . . . . . . . . . . 343
8.3 ASSUMPTIONS WHEREUPON THE MODEL IS
BASED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
8.4 DESCRIPTION OF THE MODEL . . . . . . . . . . . . . . . . . . . . . 345
8.4.1 The context of the model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
8.4.2 The structure of the model ............................ 345
8.4.2.1 Visual presentation .................................. 346
8.4.2.2 Description of the concepts and interrelationships . . . . . . . . . 348
8.5 EVALUATION OF THE MODEL . . . . . . . . . . . . . . . . . . . . . . 364
8.6 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
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CHAPTER9
Summary, conclusions and recommendations
9.1 SUMMARY ........................................ 368

9.2 CONCLUSIONS .................................... 370
9.2.1 Modern conceptions of creativity . . . . . . . . . . . . . . . . . . . . . . . 370
9.2.2 Definitions of creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
9.2.3 Theories of creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
9.2.3.1 Cognitive, rational and semantic theories . . . . . . . . . . . . . . . . 371
9.2.3.1.1 Cognitive abilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
9.2.3.1.2 Creative problem-solving ............................. 372
9.2.3.1.3 Associative theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
9.2.3.2 Personality and environmental theories . . . . . . . . . . . . . . . . . . 373
9.2.3.3 Humanistic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
9.2.3.4 Psychoanalytic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
9.2.4 The whole brain theory of creativity . . . . . . . . . . . . . . . . . . . . 376
9.2.4.1 Left and right hemispheric specialisation ................ 376
9.2.4.2 The four quadrant model ............................. 377
9.2.4.3 The whole brain model in relation to creativity . . . . . . . . . . . . 378
9.2.4.4 The whole brain teaching and learning model • . . . . . . . . . . . . 379
9.2.5 Cognitive styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
9.2.5.1 The field-dependent/independent cognitive styles in relation
to whole brain learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
9.2.5.1.1 Field-dependency . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 380
9.2.5.1.2 Field-independency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
9.2.5.1.3 Educational implications for whole brain learning . . . . . . . . . 381
9.2.5.2 Kolb's experiential learning model . . . . . . . . . . . . . . . . . . . . . . 382
xv
9.2.5.2.1 Modes of the learning process in relation to the whole brain

model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
9.2.5.2.2 Kolb's four cognitive styles in relation to the whole brain model
and the educational implications for whole brain creativity . 383
9.2.5.2.3 The relation between cognitive style, brain dominance and
professional occupation ............................... 385
9.2.6 Instructional objectives ............................... 385
9.2.6.1 Bloom's taxonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
9.2.6.2 De Corte's classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
9.2.7 Theories of learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
9.2.7.1 Cognitive theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
9.2.7.2 Humanistic theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
9.2.8 Educational models and creativity . . . . . . . . . . . . . . . . . . . . . . 391
9.2.8.1 Adult learning ...................................... 391
9.2.8.1.1 Assumptions of adult learning ......................... 391
9.2.8.1.2 Significance of adult learning to nursing education . . . . . . . . 392
9.2.8.2 Mastery learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
9.2.8.2.1 Assumptions of mastery learning . . . . . . . . . . . . . . . . . . . . . . . 393
9.2.8.2.2 Significance of mastery learning to nursing education . . . . . . 394
9.2.8.3 Experiential learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
9.2.8.3.1 Assumptions of experiential learning . . . . . . . . . . . . . . . . . . . . 394
9.2.8.3.2 The experiential taxonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
9.2.8.3.3 Significance of experiential learning to nursing education . . . 396
9.2.8.4 Open learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
9.2.8.4.1 Assumptions of open learning . . . . . . . . . . . . . . . . . . . . . . . . . . 396
9.2.8.4.2 Significance of open learning to nursing education . . . . . . . . . 397
9.2.8.5 The relation between the four educational models and
creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
XVl
9.2.8.6 Relation between the learning environments of the four

9.2.9 The practice of nursing .............................. . 399
9.2.9.1 Definitions of nursing ................................ . 400
9.2.9.2 Philosophical foundations of nursing ................... . 400
9.2.9.3 Professional practice ................................ . 400
9.2.9.3.1 Professionalism ..................................... . 400
9.2.9.3.2 Code for nurses .................................... . 401
9.2.9.3.3 Scope of practice ................................... . 401
9.2.9.4 The science-art of nursing practice ..................... . 403
9.2.9.4.1 Psychomotor skills .................................. . 404
9.2.9.4.2 Affective skills ...................................... 404
9.2.9.4.3 Cognitive skills ...................................... 405
9.2.9.5 The expert nurse practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . 408
9.2.9.6 Creativity and the science-art of nursing . . . . . . . . . . . . . . . . . 408
9.2.10 Innovative teaching strategies . . . . . . . . • . . . . . . . . . . . . . . . . . 409
9.2.10.1 Brainstorming ...................................... 409
9.2.10.2 Creative problem-solving . . . . . • . . . . . . . . . . • . . . . . . . . . . . . 409
9.2.10.3 Teaching by metaphor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
9.2.10.4 Synectics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
9.2.10.5 Visualisation: imagery and fantasy . . . . . . . . . . . . . . . . . . . . . . 411
9.2.10.6 Humour as a teaching strategy . . . . . . . . . . . . . . . . . . . . . . . . . 412
9.2.10.7 Writing as an innovative teaching strategy . . . . . . . . . . . . . . . 413
9.2.10.8 Role play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
9.2.10.9 Sociodrama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
9.2.10.10 Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
9.2.10.11 The case study ...................................... 415
9.2.10.12 Values clarification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •. 416
xvn
9.2.10.13 Relation between innovative teaching strategies and

creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
9.2.11 General conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
9.3 IMPLICATIONS FOR NURSE EDUCATORS ........... 419
9.4 RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
9.4.1 Methods that stimulate creative thinking skills . . . . . . . . . . . . 421
9.4.2 Theories of learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
9.4.3 General educational models ........................... 422
9.4.4 The nursing education model for the fostering of creativity . . 422
9.5 LIMITATIONS OF THE STUDY . . . . . . . . . . . . . . . • . . . . . . 422
9.6 POST SCRIPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
XVlll
LIST OF FIGURES PAGE
CHAPTER2
Figure 2.1: The structure-of-intellect model . . . . . . . . . . . . . . . . . . . . . . . . . 28

Figure 2.2: Pattern identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
CHAPTER3
Figure 3.1: The four quadrant concept: a synthesis of the Triune- and
left brain/right brain theories . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Figure 3.2: The whole brain model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Figure 3.3: The whole brain creativity model . . . . . . . . . . . . . . . . . . . . . . . . 76
Figure 3.4: Whole brain teaching and learning model . . . . . . . . . . . . . . . . . 78
Figure 3.5: Teaching strategies for whole brain teaching and learning . . . 80
CHAPTER4
Figure 4.1: Kolb's experiential learning model indicating the basic

knowledge forms, the cycle of learning modes and the
learning styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Figure 4.2: Kolb's learning cycle and learning styles in relation to the
four quadrants of the whole brain model . . . . . . . . . . . . . . . . . 102
Figure 4.3: Scores of various professional groups ................... 107
Figure 4.4: Occupational patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Figure 4.5: Creative learning model .............................. 113
Figure 4.6: The relationship between De Corte's classification and
Guilford's structure-of-intellect model .................. 122
XIX
LIST OF FIGURES PAGE
CHAPTERS
Figure 5.1: Example: Adult learning versus whole brain learning . . . . . . 148
Figure 5.2: Example: Mastery learning versus whole brain learning . . . . 156
Figure 5.3: The relationship between learning as a process of creating
knowledge and the four quadrants of the whole brain
model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Figure 5.4: Example: Experiential learning versus whole brain learning 169
Figure 5.5: Example: Open learning versus whole brain learning . . . . . . 177
Figure 5.6: Synthesis: the four educational models and creativity 191
CHAPTER 7
Figure 7.1: Creative problem-solving process ...................... . 257

Figure 7.2: Evaluation model ................................... . 261
Figure 7.3: Abbreviated formative evaluation form for expressive
•t• 303
wr1 1ng ........................ · · · · · · · · · · · · · · · · · · · · ·
Figure 7.4: The relation between innovative teaching strategies and
creativity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Figure 7.5: Grouping of innovative teaching strategies within the whole
brain model, according to primary focus . . . . . . . . . . . . . . . . . 339
CHAPTERS
Figure 8.1: A nursing education model for the fostering of creativity . . . 347
xx
LIST OF TABLES PAGE
CHAPTER3
Table 3.1: Functions of the left and right cerebral hemispheres of the
brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
CHAPTERS
Table 5.1: Relation between the four educational models and creativity 179
Table 5.2: Relation between the learning environments of the four
CHAPTER 7
Table 7.1: Relation of creative problem-solving to the creative process,

key-abilities of creativity and whole brain creativity . . . . . . . 265
Table 7.2: Questions for stimulating creative thinking . . . . . . . . . . . . . . . 326
1
CHAPTERl
Orientation to the study
1.1 INTRODUCTION
The need for creativity in nursing has been the subject of active debate in recent years.
Many nurse educators have expressed increasing concern regarding the development and
expression of creativity in student nurses and proclaim that nurse practitioners need a
variety of thinking, learning and behavioural skills which are not sufficiently emphasised
in current nursing education courses. This quest for creativity must be viewed against
a complex modem world marked by turbulence and change because of the explosion in
knowledge and technology.
Contemporary health care delivery is confronted by diversity, uncertainty, conflict and

instability as a result of changing human values, escalating health care costs, the
shrinking half-life of knowledge and technology, and changing health problems. The
contribution of the nursing profession is subject to change as society has become more
2
knowledgeable and more differentiated relative to the services it demands. The essence
of nursing is only relevant to the society in which it exists; social change and
concomitant changes in science and medicine have lead to a fundamental shift in the
perception of the nurse's role. Nurses have to fimction effectively in technically complex
environments and humanise their environments with caring and concern (Bevis &
Watson 1989:18; Soothill, Henry & Kendrick 1992:201).
The present debate on the worth of creativity for nursing education and practice must be
viewed against this expanding role of the nurse and the need for more effective ways to
cope with contextually based patient problems in a diverse health care system. The
maintenance-adaptation type learning which refers to acquisition of fixed outlooks,
methods and rules, does not prepare the learner to reconcile value-conflicts under crisis
conditions - it is regarded as ineffective during times of change and discontinuity. An
alternative approach of anticipatory-innovative learning is suggested which encourages
participation, dialogue, cooperation, imagination, open communication and the testing
of operating rules and values. The needs of modem health care demand a well-educated
and not just a well-trained nurse, and creative thinking is perceived to be the mark of the
educated individual (Bevis & Watson 1989:5, 40-41).
The kind of nurse to be educated for the new age in nursing and health care must be one
who can accept the ambiguities of the modem medical and health care world where no
certainties or clear solutions prevail (Chaska 1990: 101 ). The nurse no longer depends
upon routinised behaviour, traditions or procedural manuals to guide clinical judgement
and decision-making. The ability to make high level decisions based on a strong
knowledge base and effective problem-solving strategies have become indispensable
assets. The need for greater flexibility, sensitivity and expertise on the part of the nurse
is clearly indicated (Chaska 1990:101; Klaassens 1992:28; Malek 1986:20; Soothill,
Henry & Kendrick 1992:161).
The essential survival skills for successful adaptation in the 21st century appear to be
3
flexibility, innovative thinking and intellectual efficiency upheld through life-long

learning. Nursing education courses should be adjusted to synthesise knowledge,
technology and human values and to prepare students to solve the complex problems
they face (Holbert & Thomas 1988:30).
1.2 EXPOSITION OF THE PROBLEM
The results of the following research studies support nurse educators' concern about the
need for the development of creativity in student nurses.
Sullivan (1987: 12-13, 15) conducted a study to determine if critical thinking, creativity
and clinical performance improved during nursing programme enrolment. The sample
consisted of 46 registered nurses enrolled in a four-year Bachelor of Science in Nursing
degree at the University of Missouri - St Louis, from 1981to1985. The Torrance Tests
of Creative Thinking, Verbal forms A and B, were used to determine scores of creative
thinking ability. Entry and exit scores of the students were compared and the findings
were that overall creativity decreased during the period under review.
Thomas (1979: 117-118) studied the effect of a newly instituted process curriculum on
the creative abilities of 152 students enrolled in a baccalaureate nursing programme. She
wanted to determine whether there were any differences in creative thinking between
those beginning the course and those graduating from it. She assessed the pretest -
posttest differences between the two categories of students by using the t-test and found
that beginning students scored significantly higher for originality, elaboration, and total
creative thinking.
From these studies, therefore, it seems that nursing education today faces a great
challenge if the outcomes of traditional education are reviewed. If creative thinking skills
need to be developed in students, nurse educators will have to move away from unilateral
teaching, such as lecturing, which promotes dependency and passivity (Pond, Bradshaw
4
& Turner 1991:22). The empiricist, behaviouristic curriculum paradigm which

prescribed nursing education for the last forty years has cast nursing into a training
modality which ignores all aspects of education not covered by observable behaviour.
It is anti-thetical to the graduation of the kind of nurse needed in the present health care
system. Nursing has emerged as a specialised clinical field with much of its practice
independent of physicians. The present nursing model is humanistic-existentialistic,
holistic, subjective, phenomenological and human experience oriented. The nurse of
today must be a well-educated, creative and critical thinker capable of independent
judgement and action, and a morally astute and courageous person (Bevis & Watson
1989:2, 17, 32, 155; Zerwekh & Claborn 1994:7).
Nursing's body of knowledge has to be learned convergently in a rational, logical and

analytical manner as practice in any profession requires the processing of technical and
scientific knowledge. The application of this knowledge, however, takes place in a
context that is rapidly changing and uncertain, and this necessitates divergent thinking
skills (Ferguson 1992: 17; Saylor 1990: 11 ). For example, cardiac resuscitation
necessitates convergent thinking whereas the nursing care of the patient convalescing
from a coronary thrombosis requires divergent thinking and innovative approaches
because of the uniqueness of the patient-situation. It is thus essential for student nurses
to develop divergent thinking processes which would equip them to deal with the
ambiguities of the complex health problems they are continuously confronted with in
practice. A study conducted by Davies (1993:627) has revealed the traits of creativity
and flexibility posessed by experienced nurses who exhibit the ability to provide context-
specific nursing care.
The tendency to overemphasise the convergent left brain modalities including logical,
analytical, verbal and linear skills, while neglecting the important divergent processes of
the right brain such as intuitive, holistic, synthesising, creative and artistic skills, has been
found to produce an imbalance in education as it fails to develop both hemispheres of
the brain (Holbert & Thomas 1988:30; Parfitt 1989:666). This has happened, and
5
continues to happen, in nursing education because of the inflexible adherence to the

Behavioural Model.
The need for the development of the higher cognitive skills which include problem-
solving, formal operational, reflective and divergent thought as well as creativity, is
stressed by various nurse authors. Reilly and Oermann (1992:8, 29, 33, 241) focused
attention on the need for the development of higher cognitive skills especially divergent
thinking, to enable nurses to deal with ambiguities and risk-taking and to problem-solve,
more effectively. They explained that complex practice problems demand a reflection-
in-action experience and that reflective thought fosters divergent thinking. Heliker
(1994:45) advocated the need for the development of a critically thinking reflective
practitioner. Demetriulias and Shaw (1985:13) emphasised the importance ofproblem-
solving abilities in clinical practice but expressed concern because practical guidelines
for encouraging divergent thinking in students are minimal.
Jones (1990:405) viewed problem-solving abilities as desirable attributes of nurses as

they enable them to recognise and react to unique elements in an otherwise well-known
and seemingly ordinary setting. Holbert and Abraham (1988:23) regarded problem-
solving as central to the practice of nursing but question nurse educators' efficiency to
teach problem-solving skills. It appears as though the concern expressed in the literature
is justified as a study reported by Klaassens (1992:28, 30) showed that student nurses are
not functioning at a level consistent with formal reasoning-abilities. She states that it
should present a challenge to nurse educators to implement innovative teaching strategies
to stimulate the higher levels of thought. A study done by Fredericson and Mayer as
cited by Reilly and Oermann (1985:150) found that associate degree and baccalaureate
student nurses lack skills in problem-solving especially during the evaluation stage of the
proposed solutions.
The need for the implementation of more creative teaching strategies is explicitly
indicated in the literature. Ferguson (1992:16) stated that nurse educators need to
6
examine methods which would enhance creative development as innovative and creative
nurses are highly valued in the health care system. The need for more creative strategies
to enable nurses to develop their critical skills is advocated by Parfitt ( 1989:666, 673).
She refers to the results of an experiment showing that creative teaching strategies
improved nurses' ability to identify patient problems and to suggest suitable interven-
tions.
Pond, Bradshaw and Turner (1991:22) have revealed the need for educators to examine
and implement strategies that will provide participatory, stimulating and meaningful
learning for students. They encourage nurses to exercise their creative abilities and to use
a variety of teaching-learning strategies. Stepp-Gilbert and Wong (1985:32) have
suggested that divergent thinking can be promoted by offering students the freedom to
explore, experiment, question and try out a variety of approaches to the same situation.
Bevis and Watson ( 1989: 164) advocated that education must be creative, imaginative,
supportive of learner maturity and independence - it should be liberating, active and
thought provoking.
A recent study by Freitas, Lantz and Reed (1991:6-7) reported that a total of 425
questionnaires were mailed to 425 National League for Nursing (NLN) accredited
schools of nursing to be completed by identified creative educators within the schools.
The completed questionnaires ( 180) were divided into three groups and each group was
independently rated by three researchers. Several similar descriptions of creative
teaching were identified in the data and from these factors common to creative teaching
were grouped into seven categories. The results showed creative teaching to be more
student-centred and less inhibited than the traditional methods.
According to the NLN, research on existing methods on how to develop and teach
creative problem-solving skills in nursing is relatively limited. Emphasis in teaching
practice and research has been on convergent thinking processes and less attention had
7
been given to the divergent thinking processes necessary for the creative solving of
problems. The NLN emphasises the need for nursing to focus on creative problem-
solving in education and practice, and to discover and implement innovative patterns of
practice in order to improve the delivery of nursing and health care (NLN 1990:79, 95).
The necessity for the development of creativity in nursing is recognised by the South
African Nursing Council (SANC) in their policy statement with regard to professional
nursing education. This body stipulates that the aim of the learning process in nursing
education is to direct education towards the development of analytical, critical and
creative thinking, and it continues to emphasise the concept of creativity in its
programme objectives for the four-year course in nursing in which it states that student
nurses should develop an enquiring and scientific approach to problems in nursing
practice and be prepared to initiate and accept change (SANC 1993:2; South Africa
1985:3).
A study that was conducted by Makhathini (1992:90-91) on South African nurses

enrolled for the diploma course in nursing, revealed that during the four years of the
course no improvement had occurred in the problem-solving abilities of some of the
students. There appeared to be a deficiency in the teaching of problem-solving skills.
It was recommended that more attention should be given to it in order to challenge the
students' critical and creative thinking abilities and that tutors should be given assistance
in developing skills in the teaching of problem-solving.
1.3 STATEMENT OF THE RESEARCH PROBLEM
Although many nurse educators and authors do proclaim creativity to be a valued

attribute of the nursing student, nursing education courses in general do not stimulate
creative approaches to nursing in students. The literature indicates the educational
paradigm over the past few decades as being teacher-centred with the student as a passive
recipient. The lecture method still seems to be the predominantly used strategy to deliver
8
content in the highly formalised and time controlled curricula characteristic of nursing
programmes. The result is that the newly graduate nurse in many cases fails to exhibit
patient-oriented, critically thinking, problem-solving and creative qualities and in practice
lacks adequate decision-making skills (Ferguson 1992:16; Heliker 1994:45; Jones
1983 :402; Klaassens 1992 :28).
It is evident that while research studies have shown a decline in creativity with advanced
nursing education, there is an increasing demand for creativity in contemporary nursing
practice and education. The need to teach student nurses creative thinking skills and to
implement innovative teaching strategies has been emphasised repeatedly in recent
nursing literature. This study is an attempt to address this problem. The following
questions serve as a departure point:
• What does the concept creativity encompass?

• How can creative thinking skills be stimulated and developed in student nurses?
• What teaching strategies would foster creativity in student nurses?
1.4 ASSUMPTIONS
Assumptions are basic principles that are assumed to be true without proof or
verification, and research studies necessarily build on a series of assumptions (Polit &
Hungler 1993:13, 88).
The following assumptions serve as a departure point for this study:
• There is a pressing need for creativity in nursing education and practice.

• Creativity is essential to effective functioning in the contemporary diverse and
complex health care setting.
• The current basic nursing education programmes do not develop creative
thinking and problem-solving skills in student nurses.
9
1.5 AIMS OF THE STUDY
Deriving from the exposition and statement of the problem, and the assumptions, the
aims of the study are to
• explore the concept creativity by analysing the existing definitions and theories
of creativity
• analyse the whole brain theory of creativity
• establish the relationship between cognitive styles and teaching for creativity
• indicate the role of learning objectives in the development of creative thinking

skills
• determine the relation between theories of learning and creativity
• identify educational models of specific relevance to nursing education which

facilitate creative learning
• analyse the practice of nursing in order to indicate whether creativity is required
• identify and describe innovative teaching strategies applicable to nursing

education
• develop a nursing education model which would foster creativity in student

nurses
10
1.6 SIGNIFICANCE OF THE STUDY
According to Chaska (1990:406), contemporary nursing practice requires the extreme

in adaptation, flexibility, innovation and creativity in addition to upholding the basis and
foundation of nursing practice. Bevis and Watson ( 1989: 15) pleaded for a curriculum
that promotes education - critical thinking, creativity and engagement of students' minds
in issues and questions that will educate, rather than train. These two viewpoints appear
to indicate a need for achieving the outcomes of significant learning as advocated by
Rogers (1967). This is a process which is more than an accumulation of facts, a deeply
social process which makes a difference fundamentally to the actions, behaviour and
personal growth of the learner. This type ofleaming is believed to result in an improved
capacity to accept self and others more fully, and in becoming more flexible and less
rigid in perceptions and more open to evidence.
The ability to make high level decisions based on effective problem-solving strategies
is an expected behaviour of the professional nurse. The modem nurse practitioner has
to respond to the patient as a unique individual, assist him/her towards maximum
functioning and fully explore, experience and resolve his/her problems. According to
Klaassens (1982:28), any nurse regardless of role who cannot solve problems, is a costly
and risky practitioner who delivers a lesser quality of patient care.
It is believed that this study will provide knowledge that will lead towards a deeper
understanding of what teaching for creativity entails. It is trusted that the implementa-
tion of innovative teaching strategies will assist in facilitating the fostering of creativity
in student nurses and will produce professional nurses who will be capable of delivering
context - specific care, nurses who will be self-actualised, mature, effective, independ-
ent, flexible and innovative practitioners.
11
1.7 RESEARCH METHODOLOGY
The methodology will comprise a descriptive analytical study of the relevant literature
on creativity, the nature of the practice of nursing, and specific educational-related
aspects.
1.8 THEORETICAL FRAMEWORK
The different theories on creativity as classified by Gowan (1972) and the whole brain
theory proposed by Herrmann (1989), will be used as the theoretical framework for this
study. The framework is presented in chapters 2 and 3.
1.9 DEFINITIONS AND DESCRIPTIONS OF TERMINOLOGY
The following definitions and descriptions are given to clarify the terms which will be
used throughout this thesis:
1.9.1 Creativity
The word create originates from the Latin creane which means to bring into being.
Creativity is a concept which has been defined and described by numerous authors and
researchers which has resulted in a variety of perspectives on its meaning. It is therefore
not plausible to give only one definition to explain its full meaning. Most definitions,
however, describe creativity as bringing into being something original (new, unusual)
and valuable (useful, appropriate) (Ochse 1990:2).
In order to clarify the meaning of creativity at this stage, Paul Torrance's definition is
given since the principle components of his conception of it explains it explicitly.
Several other definitions and theories of creativity are discussed in chapter 2 of this
thesis.
12
Torrance defines creativity as
the process of becoming sensitive to problems, deficiencies, gaps in

knowledge, missing elements, disharmonies; identifying the difficulty;
searching for solutions, making guesses, or formulating hypotheses about
the deficiencies, testing and retesting these hypotheses and possibly
modifying and retesting them; and finally communicating the results
(Ferguson 1992:16).
The principal components of Torrance's conception of creativity are sensitivity, fluency,

flexibility, originality, elaboration, penetration, psychological openness, synergy,
internal visualisation, synthesis and redefinition (Treffinger, Isaksen & Firestien 1982:6-
9; Torrance 1979:46, 103, 116-117). These are explained in 2.5.1.1
Creativity requires both right brain and left brain processes (intuitive and rational types
of thinking), it includes open-mindedness, tolerance of ambiguity, in-depth judgement,
and openness to the ideas of others and to new experiences (Ferguson 1992:16-17).
Creativity is a function of knowledge, imagination and evaluation (Parnes 1972:6).
1.9.2 Creative thinking
Creative thinking is defined by Demetrulias and Shaw (1985:12) as a divergent process

marked by flexibility, fluency, originality, exploration, intentional ambiguity and
problem-solving. Torrance (1979:73, 116) adds that creative thinking encompasses
analysis and synthesis. The NLN (1990:79, 81) views creative thinking as an intensely
subjective act of problem-solving, associating the commonplace with the unusual to
produce an innovative and novel perspective product.
13
1.9.3 Divergent thinking
It is a mode of thinking which uses new directions, searching and seeking a variety of
approaches to the same situation and reconstructuring new combinations of both old and
new knowledge into complete new thought structures (Parnes 1972:35-36).
Guilford (1968) identified the factors of which divergent thinking consists as fluency,
flexibility, originality, elaboration, sensitivity and redefinition (Olivier 1978:57).
1.9.4 Convergent thinking
It includes logical, linear, critical, analytical and sequential thinking with the goal of
precision, exactness and correctness. Factual detail, process and procedure are
emphasised (Demetrulias & Shaw 1985:12; Herrmann 1989:17, 121).
1.9.5 Creative problem-solving
It involves new ways of thinking, the use of divergent thinking processes, considering
multiple alternatives, and nonroutine, unique approaches for solutions to problems
(NLN 1990:80).
1.9.6 Teaching strategy
A teaching strategy comprises a set of teaching actions which are intended to attain
specific desired outcomes. It implies that teachers must carefully plan and organise
instruction in order to attain their goals and that there is an art and skill involved in the
implementation of these strategies (International Encyclopedia of Education 1985 :5148).
14
1.9.7 Innovative teaching strategies
Teaching strategies which use new and unique methods to motivate students, and
facilitate and enhance learning, are referred to as innovative teaching strategies for the
purposes of this thesis.
1.9.8 Model
A model is a standardised version which offers a description of a concept, structure or

process. It is a representation against which something else can be compared or
measured (Herrmann 1989:219).
According to Good (1973:371), a model aids in the understanding of a structure or a

process and should describe phenomena in order to become comprehensible. Page and
Thomas (1979:223) described a model as being a representation of a concept or system
in a two- or three-dimensional diagram or mathematical or other analogous form.
The essential characteristic of a model is the proposed structure of the model which is
used to investigate the interrelationship between the variables (International Encyclopedia
of Education 1985:3382).
For the purpose of this study a model is presented in a two-dimensional diagram, with
an accompanying description and explanation of the concepts and relationships within
the structure of the model.
1.10 OUTLINE OF THE RESEARCH
Chapter 1 presents an introduction to the study, exposition and statement of the problem,
assumptions and aims of the research, the significance of the study, and the definitions
and a description of the terms used in this thesis.
15
Chapter 2 reviews different approaches, and various definitions and theories of

creativity.
Chapter 3 offers an analysis of the whole brain theory of creativity.
Chapter 4 covers a discussion of the cognitive and affective domains of objectives,

cognitive styles and, theories of learning relevant to the development of creativity.
Chapter 5 presents an analysis of the adult, mastery, experiential and open learning
models depicting their congruency to the principles of creative learning.
Chapter 6 explores the nature of the practice of nursing to establish whether creativity
is essential to practice.
Chapter 7 discusses various innovative teaching strategies which stimulate creative

thinking skills and are of particular application to nursing education.
Chapter 8 presents a model for the fostering of creativity in student nurses.
Chapter 9 presents a summary, the conclusions and implications, recommendations and

limitations of the study.
16
CHAPTER2
The nature of creativity
2.1 INTRODUCTION
The word creativity has been both misused and overused, and the concept it stands for
is vague, indefinite and confusing. Creativity means different things to different people.
It refers to a very complex aspect of human behaviour which has been linked to
intelligence, heredity and even psychopathology.
When we consider the concept of creativity we open ourselves to misunderstanding

unless we define it and explain what our viewpoint of it is as there is no universally
acceptable definition available. In fact, the vast variety of hypothetical ideas about its
nature has lead to a diversity of definitions and theories concerning it. Various defini-
tions and some of the more prominent theories of creativity are discussed in this chapter
with the aim to explore and analyse common elements and interpretations in an attempt
to arrive at a more thorough understanding of the subject.
17
2.2 MODERN CONCEPTIONS OF CREATIVITY
The literature on creativity generally discloses two opposing approaches. In the

traditional view creativity is regarded as a special talent belonging to a few superior
individuals, often referred to as creative geniuses. According to this view, the creative
ability is unchangeable and exists only in individuals who have inherited it genetically.
It is believed that this kind of creativeness cannot be fostered, nor can it be fully
comprehended because of the eccentricity of the creative genius. The only way to
partially understand it is through the results of the creativeness, the creative product, as
exemplified by people such as Darwin, Einstein, Da Vinci and Poincare.
A more recent approach towards creativity has resulted from contemporary research. In
it creativity is viewed as an authentic human ability which manifests itself in different
human activities. It is not the prerogative of a few selected human beings, but exists in
all human beings and can be encouraged by education fostered in a suitable environment
(Prinsloo 1973:44-45; Ochse 1990:3).
Whereas the traditional approach focuses on the creative product, the more recent
approach emphasises the creative process. For the purposes of this study, the more
recent approach towards creativity will be explored, since the aim of this research is not
to investigate the creative genius or the creative product, but to explore the educational
possibilities which would enhance creative behaviour. The focus will thus be on the
creative process and the creative environment.
2.3 CRITERIA FOR DEFINITIONS OF CREATIVITY
Research, criteria and definitions of creativity can be classified into the following
categories as distinguished by Rhodes (1961); person, product, process and environment
(Treffinger, Isakson & Firestien 1982: 5).
18
2.3.1 Person
Numerous research studies have been conducted on the creative personality. Definitions
of creativity referring to the person emphasise personality characteristics which
distinguish highly creative people from less creative people. Some of the specific
personality traits attributed to the creative personality, are humour, non-conformity,
self-confidence, independence, openness and flexibility. The question is, however,
whether the same traits cannot be present (but not overtly manifested) in the (apparently)
less creative person?
Complicating this issue are the results of recent research studies which refer to the
concept of the unity of opposites which postulates that highly creative people are at the
same time more dependent and more independent and more conforming and more non-
conforming (Torrance 1979:7).
Ochse (1988) reports in her study of highly creative people that they tend to be extremely
rigid, very independent and highly motivated in their ways. This is contradictory to the
findings of others such as Guilford and Torrance who have found that the ability to be
flexible is indeed a characteristic of the creative person. It must be taken into
consideration, however, that Ochse focused on the traditional approach towards creativity
and studied only highly creative people (ie individuals recognised by expert opinion as
having contributed something of original value to our culture). She refers to these people
as creative geniuses (Ochse 1990:4).
2.3.2 Product
The majority of definitions refer to creativity as the production of something new or

original. Creative products may be, amongst others, artistic, theoretical, or literary in
nature. Some researchers regard a product as creative when it is new for the person who
created it. On the other hand, others differ and contend that a creative product must be
19
new and must contribute towards the culture within which the person functions. Parnes
is of the opinion that the criteria of uniqueness and usefulness are required in a product
before it can be considered creative (Klein 1973:22; Prinsloo 1973:51).
2.3.3 Process
Some definitions of creativity describe the stages of the creative process while others
analyse and assess the abilities which influence creativity. Torrance describes the process
occurring during creative thought while Guilford analyses various abilities such as
spontaneous flexibility, elaboration and expressional fluency which are essential to the
creative process. A more detailed description of creativity as a process is given below
in this chapter in the discussion of the theories on creativity.
2.3.4 Environment
Various researchers focus on the influence of the environment on creativity. Social and
cultural factors as well as the home and school environments are believed to play a role
in the initiation and development of creativity.
There are two conceptions concerning the creative environment. The first is the
assumption that a person's creativeness increases in a creativity-inducing environment as
has been found by Parnes, Torrance and several others (Parnes 1972: 14). While this may
be true concerning creative production and creative problem-solving, the other concept
is that the truly creative person is believed to be able to create his own environment by
maximising his interactions with it through perceiving it more openly while purposefully
eliminating his previous perceptions. Schachtel states:
... perception is a selective and potentially creative act in which the

individual consciously and unconsciously chooses those phenomena
judged relevant from the standpoint of his unique personality (Klein
20
1973:27).
A very common stand taken among contemporary creativity experts is that a person
should be able to move outside his usual paradigms (ie personal frames of reference or
preconceived perceptions) in order to see issues or problems from a different perspective,
thereby facilitating creative thought.
Another point of view regarding the role played by the environment on creativity was
raised by Golovin who theorised that creativity may be biologically determined through
genetics, but enhanced through environmental conditioning. He discussed the possible
involvement of built-in ability for novelty or creativeness found in the capacity of the
variability that allows the neural pathway pattern in the human brain to be varied.
Golovin refers to the more original person as follows:
. .. in response to any particular stimulus, his stores of experience will

produce a greater range of new engrams than will be forthcoming from
the memory ofthe individual having more rigidly determined characteris-
tic parameter values (Klein 1973 :28).
Golovin stated that although he believes that this may be genetically determined he still
considers that variability in parameter values can be enhanced through environmental
conditioning. This viewpoint is clearly illustrated in the following quotation by Boden
(1992:215):
Mozart was different from the rest of us in that his mind contained more
richly - detailed maps ofmusical structures, and more ways ofnegotiating
them fruitfully, than other people's.
Golovin's view corresponds with Jung's theory of creativity as both acknowledge the role
of hereditary and environmental influences on creativity.
21
Jung believed that creativity originated from the collective unconscious, the storehouse
of primordial experiences and social memories, which are passed on from one generation
to another (Yau 1991: 157). He viewed the creative process to occur in two modes when
pertaining to art. The psychological mode draws from the realm of human consciousness
which includes the lessons of life, whereas the visionary mode which does not derive
from the reality of life, comes from the collective unconscious (Arieti 1976:26).
In Jung's theory, the psychological mode involves environmental influences as lessons

of life refer to the interaction between man and his environment. His visionary mode,
however, refers to genetic inheritance because it stems from the collective unconscious.
It is my own opinion that creativity can be stimulated by a creativity- inducing environ-

ment but that exceptionally creative people such as Einstein, Mozart and Da Vinci may
have genetically inherited their creativeness. Some people are rigid in their ways of
thinking throughout their lives, others become more open to different perceptions with
experience and advanced education and still others seem to be born with open minds and
use their minds and abilities to maximum capacity to make valuable contributions
towards society. Golovin and Jung's viewpoints become very acceptable when one
endeavours to explain this phenomenon.
2.4 DEFINITIONS OF CREATIVITY
One should not attempt to define creativity with the aim of describing the phenomenon
but should only give some clarification of one's own stream of thought on it. A variety
of definitions of creativity is given to illustrate its diversity:
(1) Fromm: creativity is the ability to see (or to be aware) and to

respond
(2) Anderson: creativity is affection for an idea, absorption, con-

22
centration, intensity of encounter, peak experience,
delight, ecstasy
(Prinsloo 1973 :49)
(3) Barron: the creative individual is one who has learned to

prefer irregularities and apparent disorder and to
trust himself to make a new order simply because in
his own experience he has been confronted with
interpersonal situations which made prediction on
the basis of repetition extremely difficult
(Klein 1973:3)
The above definitions focus on the person and although the definitions of Fromm and
Anderson do not refer directly to personality characteristics they emphasise certain
human abilities. In Fromm's definition the ability to see or become aware means much
more than observing the obvious. In a creative sense, to see is to be open to all incoming
sensory impulses, to free oneself from previous perceptions and to use all six senses.
Responding creatively will not be possible before that which has been seen, has been
analysed, evaluated and synthesised in order to provide a unique or new response.
Anderson's definition emphasises the subtle blending of the affective aspect of creativity
as apparent in the words affection, intensity, delight and ecstasy, as well as the cognitive
aspect of the concept which is expressed in idea, concentration, encounter and
experience. When he refers to the peak experience and to ecstasy, he also mentions the
aha-experience, that sudden illumination which has been described by so many people
during the emergence of a creative idea.
In Barron's definition there appears to be a combination of personality characteristics and

abilities. The creative person is characterised by self trust and preference for
irregularities and disorder which may imply flexibility and tolerance for ambiguity. The
ability to synthesise is implied by having to make a new order.
23
(4) Plato: bring into birth some new reality

(Klein 1973 :2)
(5) Bruner: it's an act that produces surprise - this I shall take as
the hallmark of creative enterprise
(6) Murray: the occurrence of a composition which is both new

and valuable
(7) Taylor: creativity is that thinking which results in the

production of ideas (or other products) that are both
novel and worthwhile
(Prinsloo 1973:47, 48)
Definitions numbers 4 to 7 refer to creativity as a product. A common factor in them is

that creativity generates something (whether it be an idea, a composition, a product, a
reality) but its nature is not specified and thus leaves the hint that it can be anything.
Novelty and usefulness of the product are implied in all four above definitions. Even
though Plato does not expressly mention usefulness it is implied in the phrase new reality
since before a phenomenon can be called a reality it has to be experienced by more than
one person and realities do have some degree of value. Bruner mentions surprise. This
is generally experienced during the emergence of something new and different as people
are not surprised by the familiar.
(8) May: creativity is the encounter of the intensively con-

scious human being with his world
(9) Allen: creativity is the production of meaning by synthesis

(Klein 1973:3-4)
24
(10) Getzels and Jackson: conjoining elements that are customarily thought of
as independent and dissimilar
(11) Mednick and Mednick: forming new combinations of associative elements

which either meet specified requirements, or are in
some way useful
(Olivier 1978:50)
(12) Henle: the creative solution, the creative idea, is one which
the individual achieves by freeing himselffrom his
own conceptual system, and by which he sees in a
deeper or more comprehensive or clearer way the
structure of the situation he is trying to understand
(13) Maslow: self-actualising creativeness - these people can see

the fresh, the raw, the concrete, the idiographic, as
well as the generic, the abstract, the rubricised, the
categorised and the classified. Consequently they
live far more in the real world of nature than in the
verbalised world of concepts, abstractions, expecta-
tions, beliefs and stereotypes that most people
confuse with the real world
(Prinsloo 1973:47, 49)
All the definitions from numbers 8 to 13 focus on creativity as a process. A common

factor which refers to the individual as being in intensive encounter with his world is
contained in the definitions of May, Henle and Maslow. Henle expresses the necessity
for the individual to free himself from his own conceptual systems in order to enable
himself to see deeper. This concept is reaffirmed by Maslow who considers that creative
people can see the raw, the fresh, the real world while May refers to the intense
25
consciousness of the individual with his world. These definitions indicate a difference
between an ordinary encounter with one's world and an encounter in which the individual
is freed from any biases and previous perceptions, the latter being conditional to
creativity. The definitions also imply that there is a process involved in creativity -
certain steps are to be followed, and that creativity does not happen instantly.
The definitions of Allen, Getzels and Jackson, and Mednick and Mednick focus on
another aspect of the creative process. They all refer directly to the ability to synthesise
and indirectly to the ability to be flexible. Dissimilar elements can only be joined in the
presence of flexibility proceeded by synthesis. The same applies in the formation of
useful new combinations of associative elements.
It becomes obvious that these definitions focus on different aspects of creativity as a

process.
(14) Nash: the thesis to be proposed here is that genuine

scientific creativity is ultimately a function of moral
synthesis, a harmonious balance of the factors of
freedom and discipline
(15) Stein: creativity is the resultant process that occurs within

the individual ... (because of environmental in-
fluences and personal events) ... creativity is the
resultant process of social interaction
(Prinsloo 1973:50)
(16) De Bono: creativity involves breaking out of established

patterns in order to look at things in a different way
(Herrmann 1989:193)
26
Definitions numbers 14 to 16 focus on the environment in relation to creativity. Both

Stein and Nash mention the influence of the social and personal environments on
creativity. Stein refers to the influence of social interaction and personal events. Nash
refers to the delicate balance between freedom and discipline which means to be free,
while at the same time adhering to authority. Freedom is always accompanied by
responsibility as one has to live with fellow man.
In the use of the term established patterns De Bono may be implying those that are
enstowed on us by education and cultural practices.
In all these definitions, however diverse, certain concepts associated with creativity
emerge repeatedly. These include flexibility, freedom, openness, intensive involvement,
analysis, evaluation, synthesis, originality, newness and usefulness.
2.5 THEORIES OF CREATIVITY
Several classifications on the theories of creativity are available. All show a remarkable
comparability and for the purpose of this study, Gowan's (1972) classification is used as
it offers a very comprehensive review of them. The categories include: cognitive,
rational and semantic theories; personality and environmental theories; humanistic
theories; psycho-analytic theories; and psychedelic theories.
2.5.1 Cognitive, rational and semantic theories
The theories in this group view creativity as being rational and largely set in the cognitive
domain, and emphasise its verbal or semantic concepts or associations. They seek to
define the stages of the creative process and many stress the products of creative thinking
and problem-solving (Treffinger et al 1982:6).
27
2.5.1.1 Cognitive abilities
A major group within this first category is concerned with certain of the cognitive
abilities involved in creativity. These are demonstrated in the work of JP Guilford and
Paul Torrance.
Guilford made a major contribution to the study of the nature and assessment of
intelligence and creativity with his structure-of-intellect model. In it human intelligence
is classified into three dimensions, namely, operations, contents and products, and each
of a total of 120 unique abilities, is represented in one of the 120 cubes of the model.
An ability in any cube is unique by virtue of its particular combination of one kind of
operation, one kind of content and one kind of product. Two examples of such abilities
are the memory for semantic relations, and the evaluation of behavioural systems (see
figure 2.1) (Guilford & Hoepfner 1971: 19).
Operations: major kinds of intellectual activities or processes; things that the

organism does in the processing of ieformation, information being
defined as that which the organism discriminates
Contents: broad, substantive, basic kinds or areas of information
Products: basic forms that information takes in the organism's processing of

it
According to Guilford, an individual has to use many of the abilities in the model to be
able to carry out effective problem-solving. It is, however, mainly the operations (see
figure 2.1) involving divergent production and the products concerning transformations
which are linked to creativity (Treffinger et al 1982:9).
Figure 2.1
The structure-of-intellect model
Units
Classes
Relations Products
Systems N
CXl
Transformations
Implications
Figural Convergent production

Symbolic Divergent production
~
Memory
Contents Operations
'
(Guilford & Hoepfner 1971:19)

29
Divergent thinking comprises the following abilities: word fluency, concept fluency,
associational fluency, ideational fluency, expressional fluency, figural spontaneous
flexibility, semantic spontaneous flexibility, originality, elaboration, symbolic
redefinition, and semantic redefinition (Klein 1973:14-16).
Transformation includes changes of various kinds (redefinitions, shifts, transitions or

modifications) in existing information (Guilford & Hoepfner 1971 :21 ).
Guilford's structure-of-the-intellect model has delivered a valuable contribution towards

the testing for creative ability. Abilities such as flexibility, fluency, elaboration and
originality are evaluated in creativity tests and in addition, various methods which aim
to stimulate creativity also focus on these factors. Guilford emphasises the cognitive
abilities which come into being during the creative process.
Torrance, a well-known educational psychologist, has conducted an exceptionally large

amount of research on creativity and its nurturance since 1958. He developed the
Torrance Tests of Creative Thinking (previously known as the Minnesota Tests of
Creativity) which measure creative talent, and test for several of Guilford's abilities.
Torrance considers that the major reason for developing these tests was his belief that
they provide a useful basis for adjusting teaching methods to individual learning styles.
According to him, knowledge about creative thinking abilities provides clues about
different preferences for ways of learning.
The process definition of creativity by Torrance (see 1. 9 .1) was formufated for research
purposes. According to him, this definition describes a natural human process involving
strong human needs during each stage. In his own words:
... ifwe sense some incompleteness or disharmony, tension is aroused. We

are uncomfortable and want to relieve the tension. Since habitual ways
of behaving are inadequate, we begin trying to avoid the commonplace
30
and obvious (but incorrect) solutions by investigating, diagnosing,

manipulating and making guesses or estimates. Until the guesses or
hypotheses have been tested, modified, and retested, we are still
uncomfortable. The tension is unrelieved, however, until we tell somebody
of our discovery (Rothenberg & Hausman 1976:217-218).
The above quotation illuminates not only Torrance's definition, but also his view of the
creative process and thoughts behind the creative thinking abilities which he has
identified. In addition, it has a message for the educator as it indicates the manner in
which students should be approached which will give them the opportunity to be free to
use their minds to discover for themselves the truths of reality.
Throughout his research on creativity, Torrance has emphasised the teacher's role in
organising the classroom environment in order to encourage and allow creativity.
According to him, the key-creative abilities are:
sensitivity: the ability to see defects, needs and deficiencies or to see

what needs to be done.
ideational fluency: the ability to produce a variety of ideas or hypotheses

concerning possible solution to problems.
flexibility: the ability to adapt to changing instructions, to be free from

inertia of thought, and to use a variety of approaches.
originality: the ability to produce uncommon responses, unusual or

unconventional associations.
elaboration: it involves imagination and exposition of detail, it is a

function of creative detail.
31
penetration: the ability to go beyond the obvious in seeking a solution.
analysis: the ability to analyse problem situations or to determine

meanings.
synergy: the ability to put things into context, arriving at whole

systems unpredicted by knowledge ofits parts or subsystems.
synthesis: the ability to organise meanings by bringing together

previously unrelated items in a meaningful order.
redefinition: the ability that makes thinking more productive than

reproductive - to redefine or reorganise what we see, to shift
the function of a familiar object, or to see something well
known in a new context.
internal visualisation: to visualise beyond exteriors, to pay attention to the

internal, dynamic workings of things.
psychological openness: to take time to understand a problem to consider a variety

offactors and alternative solutions.
(Klein 1973: 17; Marriner 1977:58; Torrance 1979:64, 66, 73, 103, 116, 168)
When contemplating these creative thinking abilities it becomes clear that creativity can
never be mere reproduction - these abilities lead to productive thinking. To reaffirm this
statement Torrance's artistic and survival definitions are given.
His artistic definition of creativity is ...

wanting to know
digging deeper
32
looking twice
listening for smells
listening to a cat
getting in
getting out
having a ball
cutting holes to see through
cutting corners
plugging into the sun
building sandcastles
singing in your own key
shaking hands with tomorrow
(Sternberg 1988:49-55)
Torrance is of the opinion that the above definition has aided him in generating
hypotheses, suggesting ideas, theorising, organising his thinking, and communicating the
nature of creativity.
His survival definition of creativity is:
The truly creative is always that which cannot be taught. Yet creativity
cannot come from the untaught. ... The elements of a creative solution
can be taught, but the creativity itself must be self-discovered and
self-disciplined (Sternberg 1988:58).
This definition implies that knowledge is necessary before creativity can appear, and that
creative elements become visible once the act of creativity has emerged and can thus be
taught from examples. Creativity itself, however, cannot be taught because it is a unique
experience which has to be self-discovered and self-disciplined.
33
For Torrance, the Japanese concept of satori is synonymous with that of creativity.
According to the Japanese, the highest point attainable in expertness is satori which
means a sudden flash of enlightment. It requires persistence, intense devotion, hard
work, self-discipline, diligence, energy, effort and expertise. Torrance firmly believes
that qualities such as persistence, creative thinking and problem-solving can be taught
(Torrance 1979:ix, 9).
Although Torrance agrees with Guilford on many of the aspects involved in the creative
process and has included many of Guilford's factors in the Torrance Tests of Creative
Thinking, he elaborates on a greater variety of factors which he regards as essential to the
creative process. He not only identifies certain cognitive abilities but also stresses the
need for affective abilities and the urgent message that we receive from him is that
creativity requires hard work, effort, persistence, devotion, self-discipline and
self-discovery - qualities which are mentioned repeatedly by several people who are
considered to be experts on creativity and which are discussed below in the sections
dealing with the theories of creativity.
2.5.1.2 Creative problem-solving
Some theorists have approached creativity through the medium of experimental research
involving complex reasoning and problem-solving processes. The Creative Problem-
solving Approach which was pioneered by Wallas in 1926 but was further developed by
Rossman in 1931 and Alex Osborn in 1963, and advanced by Sydney Parnes and his
associates in 1977, is widely known. In his approach Wallas originally identified four
stages of creative thinking, namely, preparation, incubation, illumination and verification
and although he arrived at this conception through his own observations and
introspection and not through systematic empirical observation, his view has been widely
accepted by other theorists. Wallas made use of the experiences of Helmholtz (a great
German physicist) and Poincare (a reknown French mathematician) in order to clarify
and augment his interpretation of the four stages.
34
Helmholtz described the way in which his most important new thoughts have come to
him. He recorded that after thorough investigation of a problem in all directions ...
happy ideas come unexpectedly without effort, like an inspiration. So far as I am
concerned, they have never come to me when my mind was fatigued, or when I was at
my working table ... They came particularly readily during the slow ascent of wooded
hills on a sunny day (Rothenberg & Hausman 1976:69-70).
According to Wallas, Helmholtz actually describes three stages in the formation of a new
thought. The stage during which the problem was investigated in all directions Wallas
called preparation. The second stage during which Helmholtz was not consciously
thinking about the problem, Wallas referred to as incubation, and the third stage, marked
by the appearance of the happy idea together with the psychologic events preceding and
accompanying that appearance, was called illumination. Wallas added a fourth stage,
verification, not mentioned by Helmholtz, but derived from a description by Henri
Poincare.
Po incare detailed the stages during which two of his great mathematical discoveries were
made. Both discoveries came after a period of incubation during which no conscious
mathematical thinking was done but, as he believed, much unconscious mental explora-
tion took place. Incubation was preceded by a preparation stage of hard, conscious,
systematic and fruitless analysis of the problem. The final ideas came to him with the
same characteristics of conciseness, suddenness and immediate certainty, and in each
case, their advent was followed by a period of verification in which their validity was
tested, and the idea itself reduced to an exact form.
Poincare wrote of the verification stage:
It never happens that unconscious work supplies ready-made the result of

a lengthy calculation in which we have only to apply fixed rules ... All
that we can hope from these inspirations, which are the fruit of un-
35
conscious work, is to obtain points of departure for such calculations.
According to Poincare, the calculations must be made in the second period of conscious
work which follows the inspiration, and in which the results of the inspiration are
verified. He also stresses that the calculations are complicated and that they demand
discipline, attention, will, and consciousness (Rothenberg & Hausman 1976:70).
The manner in which Helmholtz and Poincare arrived at their discoveries has been born
out by many highly creative people who have themselves made exceptional contributions
to society. Ochse (1988) in her study of the determinants of creativity has mentioned that
the phenomenon of the sudden illumination does not only appear to the highly talented
but that it is experienced by all people from time to time. The point to be made here is
that those moments of sudden illumination appear when the mind is at rest or, in other
words, during unconscious thought. It does not appear, however, without much previous
conscious thought on the issue; and if not reconsidered again afterwards during conscious
thought, usually nothing results from the sudden illumination.
The conclusion can thus be drawn that creativeness necessitates in-depth knowledge of
an aspect, dedication, hard work and motivation in addition to unconscious and
conscious thought processes.
After Rossman (1931) had examined the creative processes of 710 inventors, he
extended Wallas's four stages to seven. These were reiterated by Osborn (1953) who
although using slightly different terminology, described the creative problem-solving
process as:
( 1) orientation point out the problem

(2) preparation gather relevant data
(3) analysis break down relevant material
(4) ideation pile up alternatives through ideas
36
(5) incubation letting up to invite illumination

(6) synthesis put the pieces together
(7) evaluation judge the resulting ideas
(Arieti 1976:15-16)
Sydney Parnes and his associates in tum, expanded the scope of Osborn's seven stage
approach to creative problem-solving to one concerned with the practical problems of
daily living. Unlike the theories of Wallas, Osborn and Rossman, application of Parnes'
approach is not primarily restricted to the fields of art, science or writing. According to
Parnes, creative problem-solving is comprised of five stages:
(1) fact finding

(2) problem finding
(3) idea finding
(4) solution finding
(5) acceptance finding
In the above discussion on theories of creative problem-solving both the creative process
and the creative product are emphasised. In it the creative process is illuminated by the
citations of conscious and unconscious thoughts which represent the entire creative
problem-solving process while the creative product is realised through the verification
stage (Wallas), the synthesis and evaluation stages (Osborn) and the solution finding and
acceptance finding stages (Parnes).
2.5.1.3 Associative theories
Associative theories are related to psychological theories of associationism. Thoughts

are believed to be the association of ideas, new ideas being deduced from old ideas.
Creative thought is seen as the activation of mental associations and the conclusion is
made that more associations imply more ideas which leads to increased creativity
37
(Olivier 1978:53).
Mednick ( 1962) defines creative thinking as forming ... associative elements into new
combinations which either meet specific requirements or are in some way useful. The
more mutually remote the elements of the new combination, the more creative the
process or solution. According to Mednick, highly creative people initially give
. conventional responses to verbal stimuli but, unlike most people, they continue to
respond, probing deeper into the associative hierarchy until they find more remote
associations which form the basis for creative ideas or solutions (Treffinger et al
1982:10).
Koestler ( 1964) has introduced the concept of bisociation, which according to him,
underlies every creative process. Bisociation is the connecting of previously unrelated
levels of experience; it is any mental occurrence which is simultaneously associated with
two habitually incompatible frames of reference in the physical, psychological or social
world. When two independent frames of reference interact, the result is a new
intellectual synthesis (Arieti 1976:16; Klein 1973:6; Treffinger et al 1982:10).
Koestler distinguishes between associative and bisociative thought as follows. The

association within the confines of a given frame of reference is viewed as a habit whereas
bisociation of independent frames of reference is seen as originality (Rothenberg &
Hausman 1976:113).
The associative theories reflect many of the principles expressed by the cognitive and
problem-solving theories. Fluency and flexibility are implied by increasing mental
associations and the association of old and new ideas (as cited by Mednick). Originality
is characterised by the remoteness of the elements in a new combination and penetration
is applicable when probing deeper into the associative hierarchy. Synthesis comes into
being during the merging of two independent frames of reference. Originality, synthesis,
flexibility and elaboration are essential during bisociation. The possession of previous
38
knowledge and the ability for dedication and hard work are among those attributes which
are highlighted as being extremely important during problem-solving and are
prerequisites to the design of new combinations and the synthesis of previously unrelated
frames of reference.
Koestler mentioned a very important aspect when he referred to the association of two
habitually incompatible frames of reference. This is supported by many contemporary
creativity experts who emphasise the essentiality of moving out of well known frames
of reference or perceptions, to new and different ones to enable creative thinking to take
place. It has also been restated by many theorists that creative genius stems from hard
work and a deep knowledge of one's subject.
2.5.1.4 Gestalt theories
The Gestalt psychologists believe that creative thinking begins in problematic situations.
The thinker's aim is to reconstruct the gestalt or pattern which appears incomplete in
order to restore the equilibrium of the whole. According to the Gestalt, this focus on
pattern identification is closely related to the negative role of habit, mental set, fixation
and rigidity (Treffinger et al 1982: 10-11 ).
Pattern identification, as related to habits, mental sets and rigidity, refers to the tendency
that people display in focusing on certain elements of the whole, forming their own
personal perceptions and thinking within certain frames of reference. People find it
extremely difficult to change their perceptions or to change from one frame of reference
to another. This phenomenon is illustrated in figure 2.2.
Whether an old lady or a young lady has been recognised in the top picture of the figure
and whether the word fly could be read on the bottom picture all depend on the
individual's own perception.
39
Figure 2.2
Pattern identification
40
The Gestalt's reference to the negative role of habits, mental sets, fixations and rigidity
is an important issue when dealing with creativity. It is this tendency to look at problems
from a certain mental set and to search for solutions among those which proved
satisfactory in the past (although they were not necessarily the most effective solutions)
which hinders creative thought. If the individual can loosen himself from previous
perceptions and habits to look at a problem with an open mind, to view it from an
unfamiliar perspective, and to allow his mind to wander and search for uncommon
solutions amongst a great many possibilities, the chances for more effective solutions
increase. This kind of situation asks for openness, freedom, penetration, fluency,
flexibility and originality - the very qualities essential to creative thinking. These
attributes are directly opposed to fixed mental sets, habits and rigidity.
Wertheimer (1945) focuses on slightly different aspects during pattern identification and
problem-solving. He regards the problem-solving process as a consistent line of thinking
because throughout the process, the thinker attempts to satisfy what he calls an inborn
urge to grasp the whole pattern and to restore it. He describes creative thinking as
follows: The entire process is one consistent line of thinking ... each step is taken
surveying the whole situation (Olivier 1973:54). Wertheimer also relates productive
thinking to creative thinking. He describes the creative process as moving from a
structurally unsatisfactory situation to one which offers a solution. During this process,
grouping, organisation and structuralisation take place to form a better Gestalt, and these
cognitive operations are inherent in all productive thinking (Arieti 1976: 17).
Whereas the Gestalt emphasises the reconstruction of a problem situation and the ability
to focus on pattern identification freed from previous perceptions, Wertheimer elaborates
on this principle by linking creative thinking with productive thinking. To him, the
problem-solving process is marked by grouping, organisation and structuralisation which
actually encompass cognitive abilities such as analysis, evaluation and synthesis -
abilities already identified as crucial to creative thinking by other theorists. His linkage
of productive thinking to creative thinking is a very acceptable one since the creative
41
process is not compatible with reproductive thinking but specifically requires those
cognitive abilities (evaluation and synthesis) which are marked by productive thinking.
From the above discussion it is obvious that the Gestalt theorists focus on the creative
process.
2.5.2 Personality and environmental theories
Within this group of theories of creativity the focus is on the nature of the creative person
and not on the processes or products of creative thinking. This is a shift from the
cognitive abilities emphasised in the first group of theories to the affective nature of
creative talent.
2.5.2.1 Personality theories
Crutchfield's (1955) research on conformity and character revealed some interesting

information on non-conforming and conforming behaviour. He identified the following
characteristics in individuals who exhibit extreme non-conforming behaviour:
intellectual effectiveness, leadership ability, rigid and excessive self-control,
self-reliance, independency, maturity of social relations, authoritarianism, the ability to
think for themselves, ego strength and an absence of inferiority feelings. In sharp
contrast to this group, is the characterisation of those who exhibit highly conforming
behaviour: a narrow range of interests, lack of insight into their own motives,
submissiveness, compliance, conformity, inhibitedness, inability to adapt under stress,
and overly responsive to other people's evaluations. According to Gowan, Demos and
Torrance (1967: 131) conformity and creativity are essentially antithetical because
conformity is believed to restrict freedom, expression and experimentation. The creative
person is thus one who encompasses the characteristics of the non-conforming individual.
Anderson's ( 1959) perception of creativity and personality development is that creative

42
growth stems from confronting differences, differentiating the self from others and
integrating many complex factors into a self-concept. He sees the development of the
creative personality as positive, open and constructive, rather than negative, closed and
defensive (Treffinger et al 1982: 11).
Barron and MacKinnon ( 1961) found that creative people tended to be self-accepting,
flexible, independent, intuitive and perceptive (Rothenberg & Hausman 1976: 197, 198).
Subsequent studies by MacKinnon (1978) and Barron (1969) and their associates showed
that highly creative individuals are more successful than their less creative counterparts
in reconciling the opposites of their nature. The concept of unity of opposites was
demonstrated in their research. Highly creative persons are at the same time more
masculine and more feminine, more independent and more dependent, more conforming
and more non-conforming and are more self-acting, receptive and open. According to
Torrance (1979:7), less creative people are puzzled by these conflicting characteristics
because they do not fit logically, and they are therefore unable to grasp the synthesis of
these opposing characteristics.
During a 32-year longitudinal study Torrance identified eight qualities of creative -

I
individuals which he refers to as the beyonders. His research subjects were followed
from their primary school years to adulthood. He found these beyonders were all
leamable and teachable, and identified in them the following common qualities or
abilities: vision, knowledgeable, inquisitiveness, rediscovery, creativity, persistence, ·
passion (includes drive, enthusiasm, high energy level) and utilisation of both the left and
right hemispheres oftheit brains (Torrance 1993:132-134).
In the literature theories on personality attempt to identify personality characteristics,

qualities and abilities, attitudes and behaviour patterns in order fo characterise the
creative person. There are obvious similarities with regard to the characteristics of
creative persons. These include an openness to experience, ego strength, independence,
a positive attitude, flexibility, sensitivity and intellectual effectiveness. The abilities of
43
openness to experience, sensitivity, intuitiveness and freedom of perception belong

together and are emphasised by both the cognitive and the Gestalt theorists. Anderson's
reference to the ability of the creative personality to integrate many complex factors into
a self-concept corresponds with the concept of the unity of opposites found in creative
persons, as reported by Barron and MacKinnon and Torrance. This leaves the
impression that the creative personality is a strange synthesis of dichotomies.
2.5.2.2 Environmental theories
The investigations which focus on the influence of environment on creativity are

addressed to specific problems and issues and the conclusions reached do not include
comprehensive theories postulations on the nature and origin of creativity. The influence
of aspects, such as social and cultural expectations, classroom environments, teacher
attitudes, rewards and motivation, are reported in the results of various research studies.
2.5.2.2.1 Social and cultural influences
Research conducted by Sydney Parnes during creative problem-solving courses offered

at the University of Buffalo, New York, show that cultural and emotional blocks hamper
creativity. Emotional blocks interfere with clear thinking and may even freeze it.
Emotions which may play a role are anger, fear, anxiety, hate, love, fear of failure, fear
of being different, fear of ridicule, fear of rejection, and poor self-concept. The
exaggerated emphasis being placed on conformity, competition, perfectionism, logical
thinking; a servile dependency on authority; and a fear of making mistakes, are also
detrimental to creativity. The latter has been reaffirmed by Torrance who, in addition,
claims that social pressures encountered at home and in the community also interfere
with the creative process. He refers to the excessive emphasis being placed on the
attainment of success and the exaggerated fear of making mistakes. There is a tendency
to emphasise the finished product and to give credit only to verbal skills. Not recognised
are the struggles through which achievements come into being, and the amount of
44
thinking which takes place that cannot be expressed in verbal form. Great emphasis is
being placed on what a person knows but not on what the person can do with what he
knows (Davis 1986:9-10; Prinsloo 1973:129; Torrance 1967:54-55).
According to Tumin in Parnes (1992), the individual will strive towards creativity, self-
expression and individual uniqueness in an amount proportional to that of the safety
status he brings with him. Safety prevails when the individual has reassurance regarding
his worth as measured by others - viewing him as desirable and significant and a worthy
member of society. The obstacles to creativity lie in the very nature of society itself.
If a society is competitively-oriented, the individual will not feel status secure if others
are judged more worthy than he and the fate of the majority would be status-insecurity.
The competitive grading system of traditional secondary education systems is a barrier
to the nurturing of creativity. Children are socialised with greater concern about their
whatness as marked by external criteria, and lesser concern about their whoness as
marked by the subjective sense of integrity and individuality. Tumin also refers to the
reliance on habit as a basic instrument for social control - to habituate to the norms of
conformity which yield social safety (Parnes 1992:108-110).
2.5.2.2.2 Learning environment
A psychologically secure and free environment is essential for the nurturance of

creativity. The nature of such an environment is explained in greater detail in the
discussion of Carl Roger's theory of creativity in this chapter. A classroom environment
which promotes the fostering of creativity must, amongst other things, be free from
external evaluation, quick judgement and criticism, and must be organised to allow for
the experience of both cognitive and affective processes.
According to Parnes, the principles of deferred judgement and extended effort are crucial
to the creativity inducing environment. Deferred judgement means to postpone
judgement and is seen to be conducive to the release of creative behaviour. Students
45
should not be restricted but should be allowed to voice their ideas. Extended effort
implies that obvious solutions to problems should not be accepted immediately but that
the opportunity to search for a variety of solutions must be granted in order to increase
the likelihood of considering more alternatives. Twelve out of fourteen studies found
that more ideas, many of which were of good quality, were produced by students when
deferred judgement was applied (Parnes 1972:16-20).
Carl Rogers (Torrance 1979:74-75) has stressed the hazards of external evaluation, a
process which often produces defensiveness, and emphasised that a person should
maintain his own locus of evaluation. The negative influence of expected evaluation on
creative production has been reaffirmed by Amabile. Individuals generate significantly
more creative products when they know they will not be evaluated on their quality than
those who know beforehand that whey will be evaluated (Sternberg 1988:25).
The need for the integration of both cognitive and affective aspects of creativity in the
classroom was indicated by Williams (1970, 1982) who developed a three dimensional
model which emphasises this. While planning and applying learning and instruction
processes, allowance should be made for the facilitation of the cognitive aspects (fluency,
flexibility, originality and elaboration) as well as the affective aspects (curiosity,
intuition, imagination and risk-taking) of the creative process in order to create a
creativity-inducing learning environment (Treffinger et al 1982:12).
2.5.2.2.3 Teacher attitudes - the open teacher
An open relationship between teacher and student is regarded as essential to a creative

relationship. Parnes (1972: 17) views open teachers as those who are idea seeking
persons and closed teachers as those who give all the ideas and information. Studies
show that the environment created by the open teacher is more conducive to growth in
student creative behaviour, and that a caring and trusting teacher is important for
nurturing creativity (Ellison 1993: 12-13 ).
46
According to Goodale (1970:94-95), teachers who are rigid and compulsive cannot
tolerate deviations from their lesson plans and do not allow students to explore and
experiment on their own. Hallman (1967:325-327) lists the obstacles to creativity which
are cited in the literature and which might well typify the attitudes of the closed teacher.
Teacher-chosen goals and activities, standardised routines and authoritarian attitudes,
repress the creative potential of students as they inhibit self-directive and self-responsible
learning. Ridicule and domination of students, hostility towards the divergent personality
(curious, individualistic, non-conforming), and threats, freeze any latent creative
potential. Rigidity of personality which may manifest itself in inflexible defense
mechanisms and compulsive fears which tend to shield teachers' ego-centred interests,
dampen the exploratory and risky ventures which characterise creative activities. The
over-emphasis of rewards such as grading systems, external evaluation and excessive
quest for certainty instilled by teachers who demand only correct answers, suppress the
creative urge. Teachers who over-emphasise success cause student energies to switch
from the creative process to focus upon outcomes. Teachers who do not tolerate a play
attitude in the classroom, stifle creativeness, as innovation requires freedom to toy with
ideas and materials, and permission to indulge in fantasy.
In contrast to the fore-going negative aspects of creativity inducement, research has

provided the principles by which a creativity inducing environment can be organised and
these have a direct bearing on the way the open teacher creates a learning environment.
The open teacher is one who provides opportunities for self-initiated learning while
encouraging self-activity, exploration, experimentation, and hypothesising. This helps
to keep alive the motivational forces for learning within the individual learner. The
creative teacher organises a non-authoritarian learning environment which provides
psychological freedom (established by accepting each student as being unconditionally
worthy, by understanding emphatically and by withholding external evaluation). This
allows students the freedom to express themselves spontaneously and symbolically in
order to promote creativeness. It also fosters responsibility because they are entrusted
to make decisions. They are encouraged to over-learn so that the materials become
47
subject to restructuring. The teacher encourages creative thought processes by
stimulating students to seek new relationships between concepts, and to associate,
imagine, think up tentative solutions for problems, make wild guesses, build on the ideas
of others, and combine materials into new patterns. A very important attribute of the
creative teacher is that of deferred judgement. Outcomes and solutions are not provided;
errors are expected and accepted; and the finalising of solutions is postponed. The result
is that risk taking, exploration and flexibility are encouraged. Open-ended and
operational questions which cannot be answered merely by the recitation of facts, are
asked in order to foster curiosity, encourage exploration and stimulate connotative
tendencies. Self-evaluation is encouraged while group norms and standardised tests are
rejected because of their inappropriateness to, and detrimental effect on creative learning.
Practice in self-evaluation increases self-activity, responsibility, and feelings of self-
worth, because the individual's own powers of judgement serve as the final standard in
determining the worth of newly created products. Students are provided with
opportunities to manipulate materials, ideas, concepts and structures, as craftsmanship
is an essential ingredient in the creative personality. The creative teacher assists the
student to cope with frustration and failure since the creative personality never quits.
Students are also assisted to become more sensitive as a person - to become sensitive not
only to the moods and feelings of others, but also to external stimuli, social and personal
problems, academic problems, public issues, and the commonplace and the unknown.
The creative teacher encourages students to consider problems as wholes, perceiving total
structures rather than additive elements as the greatest insight occurs when priority is
given to structural patterns and principles (Hallman 1967:327-330).
2.5.2.2.4 Rewards and motivation
Research studies indicate that the promise of rewards decreases students' motivation.
Non-rewarded students show a stronger preference for more complex and challenging
tasks and deliver products of much higher quality, than those confronted with rewards
(Sternberg 1988:19-20).
48
Hennessey and Amabile have found a strong positive link between an individual's state
of motivation and the creativity of his performance. They emphasise the important role
that the principle of intrinsic motivation plays during creative performance, because of
interest, enjoyment, satisfaction and the challenge derived from of the task itself.
According to them, people will be most creative when intrinsically motivated (Sternberg
1988:11).
According to Crutchfield (1961, 1962), task-involved intrinsic motivation will lead to

higher levels of creativity than ego-involved extrinsic motivation. He found that high
levels of intrinsic motivation are present while notably, creative persons are working.
Deci and Ryan (1985) viewed intrinsically-motivated persons as those who would seek
situations which interest them and which thus require the utilisation of their resourceful-
ness and creativity. Another view which emphasises this point is that of Lepper and
Greene (1978) who suggested that the intrinsically-motivated person, as apposed to the
extrinsically-motivated one, feels more free to take risks because risks carry no liability
when self-imposed. Other studies have shown that aspects such as rewards, direct
surveillance, deadlines for tasks, external evaluation, and a task being presented as the
means, all tend to decrease intrinsic motivation and are, as a result, detrimental to
creativity (Sternberg 1988: 13-19).
The role of intrinsic motivation in creative performance is apparent in most studies about
creative persons. Their intense involvement and unrivalled love for their work must be
brought about by a deep interest and enjoyment. On the other hand, it appears that
extrinsic motivation will lead a person towards the gaining of knowledge and completion
of tasks, but it will not in itself stimulate creativeness.
2.5.3 Humanistic theories
The humanistic approaches to creativity emphasise self-realisation, personal growth and

fulfilment. The humanists base their theories on the premise that man can create his own
49
life, and view this as the ultimate in creativity. This is illustrated rather clearly by Groch
(1969) as quoted by Klein (1973:7-8):
What is required is the disposition and courage to encounter the world

directly, rather than through the shop-worn thoughts and stereotyped
emotions of others, to originate one's own acts rather than to perform by
rote and habit, and to feel rather than think one's own feelings.
Rollo May distinguished between pseudo creativity which he sees as a superficial

artificial creativity (an aestheticism) and actual creativity which brings something new
into birth, enlarges human consciousness and fulfils man's own being in the world (Klein
1973:8).
Actual creativity is defined by May as the encounter ofthe intensively conscious human
being with his world. Encounter means to absorb something actual or something ideal
and this refers to creativity whereas the escape from the idea by art, is viewed as talent.
The difference between talent and creativity is that talent can be used or not, while
creativity can only be seen in the act. Intensively means a heightened awareness
(consciousness) leading to a feeling of joy. This heightened consciousness refers to
absorption and abandon, but not to self-consciousness. According to May, human beings
cannot will insight or creativity, but can will encounter with intensity and commitment.
The intensity of encounter with the world is explained by May in terms of the Greek
prototypes of passion and vitality (Dionysius) and form and order (Appollo ). May
considers that the combination of these prototypes produces a total person with the
conscious and unconscious forming a unity, the conscious state being supra-rational
rather than irrational. This bringing together of the volitional, emotional, and intellectual
forces produces an ecstasy - this is creativity according to May (Klein 1973:8-9).
May is referring to creativity as a process and his use of the words encounter and
intensively conscious concur with the Gestalt theorists' idea of viewing the real world
50
freed from perceptions. He also implies that creativeness can be developed to the
ultimate if a person is willing to encounter his world with intensity and commitment - this
signifies a passion to live a full and productive life.
Abraham Maslow distinguished between what he calls special talent creativeness

(creative genius) and self-actualising creativeness which originates more directly from
the personality. He viewed self-actualising creativeness as a special kind of perceptive-
ness, an openness to experience. People endowed with the latter can see the fresh, the
raw, the concrete, the idiographic as well as the generic, the abstract, the rubrisized, the
categorised and the classified. According to Maslow, they live in the real world of
nature rather than the verbalised world of concepts, expectations, beliefs and stereotypes
(Rothenberg & Hausman 1976:87-88).
Before formulating his two concepts of creativeness Maslow deviated from his
stereotyped notion that health, genius, talent and productivity are synonymous, when he
realised that some of the greatest geniuses of mankind such as Van Gogh, Wagner and
Byron were not psychologically sound. Health and special talent are separate variables
and on this basis he made the distinction between the two kinds of creativeness. Maslow
focused on self-actualising creativeness and views the individuals possessing this form
as being unfrightened of, and attracted to the unknown, the mysterious and the puzzling.
He describes a resolution of dichotomies in self-actualising people. They can be very
selfish in one way and very unselfish in another; most mature in some sense and yet
strongly childlike in another; they can merge work with play, duty with pleasure. These
opposites, however, are not incompatible, but fuse together in a dynamic unity or
synthesis. Maslow views these self-actualising people as integrators because they bring
separates and opposites together into unity (Ochse 1990 :21; Rothenberg & Hausman
1976:86-87).
Maslow identifies certain personality traits in self-actualising people and proposes that
while creativeness is constructive, synthesising, unifying and integrative, its manifestation
51
depends on the inner integration of the person. Such people are more self-accepting than
the average person, and are less controlled and inhibited. The self-acceptance implies
greater wholeness and integration. Maslow referred to self-actualising creative people
as follows: More of themselves is available for use, for enjoyment, and for creative
purposes. They waste less of their time and energy protecting themselves from
themselves (Klein 1973: 10). Self-actualising people demonstrate an openness to
expenence; an increased spontaneity, expressiveness, courage, freedom, integration and
perspicuity - these characteristics compose the self-actualising creativeness which is
expressed in the creative life, creative attitude or creative person (Rothenberg &
Hausman 1976:89-91).
Maslow's theory of self-actualising creativeness is supported by the work of others

including Buckmaster and Davis (1985) and Craig (1966) who reported that people who
score high in self-actualisation also score high in creativity (Davis 1986 :6).
There appear to be certain commonalities between Maslow's theory and some of the
views already mentioned. Special talent creativeness can be linked to the traditional view
that creativity is inherited. This type of creativity is evident in the lives of creative
geniuses. Self-actualising creativeness includes the Gestalt and Cognitive theorists'
references to a special kind of perceptiveness and an openness to experience. Maslow
affirms the personality theorists' description of the phenomenon of a resolution of
dichotomies, which he identifies in self-actualising people.
Carl Rogers, a noted clinical and research psychologist, stresses the uniqueness of the
individual in his theory of creativity when he states that man's tendency to actualise
himself and to achieve his potentialities, as illustrated in the urge to expand, extend,
develop and mature, is evident in all organic and human life. He sees this not only as the
curative force in psychotherapy but also as the primary motivation for creativity.
According to him, the capability to develop one's fullest potential, exists in every human
being, but in many cases becomes deeply buried under layers ofencrusted psychological
52
defenses (Rothenberg & Hausman 1976:296, 198).
Rogers specifies three internal conditions for constructive creativity:
(1) Openness to experience - this is the opposite of psychological defensiveness. It

signifies a lack of rigidity and a permeability of boundaries in concepts, beliefs,
perceptions and hypotheses, as well as tolerance of ambiguity where it exists. The
ability to receive much conflicting information without forcing closure upon the
situation (which means not to perceive in predetermined categories) is empha-
sised. The complete openness of awareness to what exists at any specific
moment, is an important condition of constructive creativity and is present in all
creativity. Openness to experience, includes a receptiveness to new ideas and an
attraction to new experiences and interests in the real world.
(2) Internal locus of evaluation - this means that the basis of evaluation lies within the
individual. The value of his product is established by the creative individual
himself and not by the praise or criticism of others. He regards this as the most
fundamental condition of creativity.
(3) The ability to toy with elements and concepts - this is the ability to play spontan-
eously with ideas and relationships, to explore, to formulate a variety of
hypotheses and to make a given situation problematic. From this, he believes, one
or two evolutionary forms with more permanent values will emerge (Davis
1986:29-30; Rothenberg & Hausman 1976:300-301).
Rogers considers that an external climate of psychological safety and freedom is

a prequisite for the fostering of the internal climate for constructive creativity.
This can be attained by the three associated processes of:
• accepting the individual as being unconditionally worthy - the in-

53
dividual will experience a climate of safety when he senses that his

potentialities are recognised and that he is thus accepted and appreciated,
regardless of his present state.
• providing a climate in which external evaluation is absent - evaluation

is always seen as a threat and this creates defensiveness. In the absence
of external judgement, a person opens up to his experience and senses his
own likes and dislikes. Rogers views exposure to evaluation and the
setting of standards, as the most dangerous enemies of the development
of creativity (Ochse 1990:25).
• understanding emphatically - to understand what another person is

seeing and feeling from his point of view, and still to accept him, provides
complete safety.
Psychological freedom means to permit an individual complete freedom of symbolic

expression (to think and feel and to be what is most inward within the individual
himself). It is, however, a freedom with responsibility since behaviour may be limited
by societal constraints, and this is why only symbolic freedom (for example to destroy
a symbol of a hated object and not the object itself) is allowed (Klein 1973:9;
Rothenberg & Hausman 1976:303-304).
Rogers views creativity as an ability existing in all human beings and describes it as an
urge not only to develop but to excel in life. He emphasises openness to experience and
one can conclude from his writings that the opposite of openness is brought about by
defensiveness and inhibitions, which not only hamper man's development towards his
fullest potential, but also his creativeness. Roger's internal conditions for constructive
creativity and his external conditions which foster it have very important implications
for the educator, particularly with regard to the organisation of the learning
environment.
54
The most prominent similarities in the humanistic theories of creativity are the concepts
of full encounter with the real world through an unlimited openness devoid of inhibitions
and preconceived ideas and attitudes, and the passion to develop one's capabilities to the
ultimate. This, to the humanists, is creativeness. It is evident that the humanists regard
creativity as a process since they describe the prominent elements inherent during the
developing of creativeness. The fact that both May and Maslow distinguish between an
artificial or special talent creativeness and an actual or self-actualising creativeness,
confirms their view of creativity as process.
2.5.4 Psychoanalytic theories
The psychoanalytic theories of creativity originated from the work and influence of Freud
and established the foundation for contemporary research on creativity.
In his analysis of the personality structure, Freud distinguishes between the id (which
stems from the unconscious and is comprised of emotional and sexual drives), the ego
(which refers to the conscious mind and is influenced by the norms of the social
environment), and the super ego (which is the ethical, spiritual and religious dimension
of man). To Freud, creativity develops from conflict which arises as a result of tension
between the unconscious power of the id and the controlling power of the conscious (ego
and super ego). When the unconscious presents a solution which is not acceptable to the
conscious, it is suppressed and neurosis results. If, however, a solution from the
unconscious is approved by the ego, it is released and gives rise to a creative idea which
can lead to a creative product. The creative person is thus able to slacken ego control
over the id with the result that creative impulses generated by the unconscious, surface
without conflict (Klein 1973 :6; Prinsloo 1973: 187-189). Freud also relates the first
traces of creative behaviour as an extension of childhood play and fantasies. Whereas
children display creativity in games and fantasy, adults display creativity in the arts of
writing and painting. According to Freud, these are an outlet of daydreams and fantasies
of which the individual is ashamed (because of social norms or pressures), but, by
55
presenting it in an aesthetically artistic form, he makes it acceptable and enjoyable to

himself as well as to other people (Davis 1986:22; Rothenberg & Hausman 1976:49, 54).
The significance of Freud's theory today is that he directed attention to the fact that
creative thought is linked, not only to the conscious mind but also to the unconscious.
His reference to the unconscious laid the foundation for further research on that basis.
It was Freud who described primary-process thinking as the expression of emotional
urges generated by the id. He also indicated that there is structure, meaning and purpose
in this type of thinking process. Primary-process thinking is usually experienced when
on the verges of sleep or when in a febrile state. It can be described as drifting,
fragmented images, ideas and concepts, which may become fused or may be displaced
from their usual contexts to fuse with formerly unrelated ideas or concepts. Emotional
attitudes and desires may become displaced from one object only to be added to another,
and objects may become symbolised by others. Primary-process thinking involves
specific mental processes such as divergent thinking, analogical thinking and remote
associations. The experience of unconsciously generated creative inspirations occur
under these conditions. Secondary-process thinking on the other hand, is a conscious,
logical, purposeful and realistic process (Davis 1986:22; Ochse 1990:220-221 ).
Freud did not elaborate extensively on the creative process as such, but focused on the
creative writer and childhood play and fantasies, in order to explain the creative process.
His view that creativity already manifests during childhood, corresponds with the general
view amongst many creativity experts that all children are creative. According to
Torrance, children's creativity is illustrated in their open and inquiring attitudes towards
the real world and their spontaneous and imaginative responses to their environment.
Torrance regards the contemporary westernised educational system as detrimental to the
development of creativity.
The neo-psychoanalysts or neo-Freudians which include Schachtel, Rank, Kris and

Kubie, have departed from the traditional Freudian view to place the locus of creativity
56
in the preconscious, rather than the unconscious (Treffinger et al 1982: 15). The
preconscious differs from the unconscious in being open to recall when the ego is
relaxed. The relaxed attitude of the ego is regarded as extremely important. According
to the neo-psychoanalysts, creative thought is only possible when the ego can draw ideas
from the preconscious. The preconscious is more free to form new associations and can
even replace wrong associations with new ones. The preconscious can also make
comparisons and produce new ideas. The creative person can thus derive thoughts from
the preconscious more freely than the non-creative person and can use these thoughts in
the conscious mind to complete a product or to find a solution to a problem. Kubie
(1958) emphasises the importance of the preconscious (material which can become
conscious very easily and under conditions which frequently arise) in the creative process
and ignores ids, egos, libidos and super egos. To him, creativity requires a temporary
release of the preconscious from both the conscious and the unconscious. He views both
the conscious and the unconscious as rigid and not flexible or creative at all. Since
conscious processes are anchored in reality, flexibility and imaginative free play are not
likely to occur. The unconscious processes are even more fixed and rigid and can only
be brought to consciousness by special techniques such as drugs, hypnosis or
psychoanalysis (Davis 1986:24; Olivier 1978:56; Prinsloo 1973:191-192).
Kris (1952) emphasises regression in the service of the ego by which he refers to
regression to primary-process thought which unlike the regression in dreams or
pathological cases, is controlled by, and in service of, the ego. This regression to
primary-process thought (which permits the discharge of the repressed impulses
mentioned by Freud) takes place in fantastic free-wandering thought processes (under a
condition of ego weakness) and in creative processes (in the service of the ego).
However, according to Rothenberg and Hausman (1976) regression to primary process
thought is not typical of the creative process. Although the early stages of the creative
process have the free wandering of thought (without being bound by rules and the
conventional every day world) in common with daydreams and reveries (characterised
by primary-process thought), the creative process is marked by the focusing of these free-
57
wandering thoughts on a specific object, idea or problem. Thus, what distinguishes

regression to primary-process thought, from the creative process, is not a drive discharge
function, but the openness in the encounter with the object (Rothenberg & Hausman
1976:159-160).
The above explanation of the creative process is clearly illustrated in Helmholtz and
Poincare's descriptions of their experiences of the sudden illumination as discussed in
2.5.1.2.
The neo-psychoanalysts contributed towards a better understanding of the creative

process and Freud's approach, by elaborating on the functions of the preconscious. Their
descriptions of the role of the preconscious in the creative process are confirmed by the
reports of many creative people as well as ordinary people about original ideas or sudden
inspirations being experienced when they have been on the brink of wakefulness during
a time that their minds were totally relaxed. The neo-psychoanalysts, however, do not
explain all the facets of the creative process, since a lot of conscious, cognitive and
affective thinking takes place after sudden impirations.
2.5.5 Psychedelic theories
The word p~ychedelic derives from the Greek and means mind-manifesting. The
psychedelic theories on creativity focus on the importance of expanding the conscious-
ness of one's mind - and help a person to be more creative through opening new horizons
of untapped experiences. The assumption underlying these theories is that most people
never reach the most creative dimensions of their minds since they learn from childhood
to restrict their experiences. There is, however, much controversy on how altered states
of consciousness could and should be attained because of the ethical considerations, legal
aspects, and safety of some of the various methods used to induce them. Theorists who
have investigated psychedelic approaches have employed methods such as those
incorporating the use of hallucinogenic drugs, meditation, biofeedback (brain wave
58
training), and imagery training through music (Treffinger et al 1982: 16-17).
As these theories are subject to much controversy and the methods used only accessible
to experts in the field, they will not be discussed in detail for the purposes of this study.
2.6 SYNTHESIS
The various definitions and theories of creativity discussed in this chapter give an
indication of the diversity of ideas and explanations of this phenomenon. Not-
withstanding this divergence, certain similarities can be traced throughout. It is apparent
that most of the,more recent theories focus on the creative process, and although it is
approached from several different viewpoints there are marked resemblances in ideas and
concepts. There is consensus that while certain personality types tend to be more capable
of expressing creative behaviour, creativeness can be developed or enhanced in a
creativity inducing environment.
The theories of creativity should not be viewed as being contradictory with each other,
but rather that they are complementary. Abilities such as flexibility, openness,
penetration, originality and fluency which are described as essential to creativity by the
cognitive theorists, are emphasised by the Gestalt and the humanists. The Gestalt
proponents give much attention to the ability of openness to experience (of being able
to look at things freed from previous perceptions), and the humanists stress both
openness to experience and intensive encounter with the real world. Even the personality
theorists confirm that abilities or characteristics, such as openness, independence,
tolerance of ambiguity, drive, enthusiasm, perceptiveness and self-acting are identified
in creative people. These characteristics bear a great resemblance to those mentioned by
the cognitive theorists. The psychoanalysts' contribution towards creativity is found in
their description of the role of the unconscious or preconscious during the creative
process - an explanation of the sudden illumination experienced when a creative idea
emerges. In contrast with this, many theories focus on the conscious processes necessary
59
during the creative process which eventually lead to the finished creative product.
What emerges from all the definitions and theories discussed is that creative behaviour
needs certain cognitive and affective abilities and that, within the right environment,
creativeness can be fostered and developed.
60
CHAPTER3
Whole brain creativity
3.1 INTRODUCTION
The split brain studies which commenced during the 1960s demonstrated significant
differences between the functions of the left and right hemispheres of the brain. These
studies, together with the vast amount of research studies initiated since, have led to the
psychophysiological approach, the analysis of mental functioning which has subse-
quently gained great impetus. The new knowledge generated through this approach,
which includes the concept of cerebral dominance and implies that in each individual one
hemisphere tends to play a more important role than the other, has resulted in a new
understanding of the nature and process of learning. This has had far-reaching
implications in the field of education.
Originating from the split brain theory is the myth that the right hemisphere is the only
one responsible for holistic, intuitive and creative imaginative operations, while the left
is the seat of logical, linear and verbal operations. Recent research studies have,
61
however, found this not to be valid. The contemporary view on the nature of creative-
ness is summarised in the following quotation by Williams (1983 :4 ):
... the differences between the hemispheres should not obscure the fact that
it is their complementaryfunctioning that gives the mind its power and
flexibility.
The whole brain creativity model which was derived from a synthesis of the triune brain
and left brain/right brain theories, will be described and discussed in this chapter, and its
relationship to creativity learning, explored.
3.2 THE SPLIT BRAIN STUDIES
Speculation about the cerebral asymmetry of the human brain took on new dimensions
during the 1960s as a result of the brain operations carried out on patients suffering from
intractable epileptic seizures. During these operations the corpus callosum (a mass of
nerve fibres connecting the cerebral hemispheres) was split in order to reduce the severity
of the seizures. The first operation, performed by Roger Sperry (Nobel Prize Winner for
Physiology and Medicine, 1981 ), Joseph Bogan and Michael Gazzaniga, proved
successful and the patient responded to medication afterwards. This initiated research
into the split brain phenomenon in human subjects at the California Institute of
Technology, which comprised the same surgical procedure on similar patients, followed
by various brain function tests (Corballis 1980:286; Zdenek 1985:10).
These split brain studies revealed that after the corpus callosum was bisected one cerebral
hemisphere could not communicate with the other. Each functioned separately in
isolation. Thus the separate functions of the left and right hemispheres of the brain could
be studied through sophisticated testing procedures. Results showed that the left and
right hemispheres had their own areas of specialisation and subsequent tests showed that,
in a normal brain, the corpus callosum enables the cerebral hemispheres to work together
62
although one hemisphere predominates for a specific task (Zdenek 1985:11-12).
The results of the early investigators, who based their conclusions about hemispheric
specialisation on studies of brain-damaged subjects, were queried by others who doubted
that these findings could be generalised for the entire population. The answer came
during the 1970s when Robert Ornstein was one of the first to demonstrate that
hemispheric specialisation was not limited to abnormal people but could be measured in
all people. Data gathered through electro-encephalographic techniques showed that when
subjects were engaged in specific tasks, brain waves indicated that only one hemisphere
was engaged while the other was idling (Herrmann 1989:13).
3.3 LEFT AND RIGHT HEMISPHERIC SPECIALISATION
The research on split brain patients and, more recently, on normal subjects, reinforces the
conclusion that the two hemispheres of the brain are indeed specialised for two different
modes of thinking. The left one has been attributed with linear (Efron 1963 ), verbal
(Gazzaniga 1970 ), and analytic (Milner 1971 ), thinking processes, whereas the right has
been described as the one responsible for the exhibition of non-verbal (Kimara 1967),
synthetic (Levy-Aggresti and Sperry 1968), and holistic (Nebes 1974) processes (Harpaz
1990: 161). Table 3.1 is a synopsis of several researchers' findings on brain specialisa-
tion (Kolb 1984:49; Sisk 1987:291; Williams 1983;26; Zdenek 1985:13-14).
Current consensus of opinion on brain asymmetry and creativity is characterised by the

assumption that the source of creative behaviour resides in the right hemisphere (Bogen
& Bogen 1969; Olson 1977; Ornstein 1977; Torrance & Reynolds 1978; Gowan
1979), there is, however, agreement that creativity can originate in both hemispheres but
that it does require interaction between the two hemispheres (West 1975; Brandwein &
Ornstein 1977; McCallum & Glyn 1979) in Harpaz (1990:161).
63
Table 3.1
Functions of the left and right cerebral

hemispheres of the brain
• Verbal: encoding and decoding • Non-verbal: knowledge is achieved

through images
speech, reading, writing, spelling,
mathematics, musical notation
• Analytic: things are figured out part-

b - art
• Synthesis: things are put together to
form wholes
• Linear: think in terms of linked ideas,

process information sequentially, often
• Holistic: perceive the overall patterns
and structures, can process many
leads to a convergent conclusion kinds of information simultaneously,
often leads to diver ent conclusions
• Conver ent thinkin • Diver ent thinkin
• Logical: draw conclusions based on • Intuitive: make leaps of insight, often

logic, one thing follow another in based on incomplete patterns,
lo ical order feelin s, hunches or visual ima es
• Conscious reasoning • Subconscious or preconscious rea-

sonm
• Symbolic: use symbols to indicate • Analogic: understand metaphoric

something relationships and imagery, see like-
nesses between thin s
• Abstract: take out a small bit of • Concrete: relate to things as they are
information and use it to represent the at the present moment
whole thin
• Rational: draw conclusions based on • Non-rational: do not require a basis

reason and facts of reason or facts, willing to suspend
·udgement
• Digital: use numbers as in counting • Visio-spatial: see the relationship be-

tween things and how the parts go to-
ether to form a whole
• Controlled • Emotional: a product of the limbic

system, but the right hemisphere is
more in touch with these feelin s
64
According to Zdenek (1985:15, 17), most creative work requires the combined abilities
of intuitive awareness and logical thinking - a scientist needs his logical left hemisphere
for analytical reasoning but it is his intuitive right hemisphere which provides that leap
of insight that solves a complex problem. This concept is confirmed by Rubenzer in the
following quote:
... the most productive and creative intellectual functioning is theorised to

occur when there is cooperation between hemispheres (Gowan, Khatena
& Torrance 1981 :280).
3.4 TWO DIFFERENT THEORIES OF HOW THE BRAIN IS ORGANISED

PHYSIOLOGICALLY
In order to understand the theory of whole brain creativity it is necessary to investigate

two current theories of brain organisation - the triune brain theory and the left brain/right
brain theory.
3.4.1 The triune brain theory
The triune brain is an evolutionary model of the brain in which it is envisaged as a three
layered structure. It is proposed that it developed over a period of time from three
separate brains, with each successive entity being superimposed over the earlier one or
ones. This theory of how the brain is organised physiologically has been developed by
Paul MacLean, Head of the Laboratory for Brain Evolution and Behaviour, at the
National Institute for Mental Health, Maryland, United States of America.
The first or oldest brain is the primitive reptilian brain (found in prehistoric as well as
present-day reptiles such as alligators and lizards) comprising the brain stem, mid-brain,
basal ganglia and reticular activating system. It is driven by instinct and governs vital
body functions.
65
The second oldest is the limbic part of the mammalian brain which encircles the reptilian
brain. The limbic brain is the centre for instinct and feeling and is responsible for
maintaining the body's internal equilibrium.
The third brain (newest part of the brain), lies over the limbic brain and is known as the
cerebrum or neocortex. The neocortex (which, in a human being, makes up
approximately five-sixths of the total) consists of a convoluted mass of grey matter
(nerve cells) and is responsible for the higher thought processes which enables the human
to think, perceive and speak (De Meneses 1980:442; Herrmann 1989:31, 435) (see
figure 3 .1 ).
3.4.2 The left brain/right brain theory
The key-aspects of the left brain/right brain theory comprise the organisation of the left
and right cerebral hemispheres, the left and right halves of the limbic system, the
interconnecting fibres and two patterns of brain functioning: situational and iterative.
The brain is divided anatomically into two halves, referred to as the left and right
hemispheres. The greater portion of the left and right hemispheres consists of the left
and right cerebral hemispheres which are responsible for the higher thinking processes:
vision, hearing, intentional motor control, purposeful behaviour, language and non-verbal
ideation.
The left and right halves of the limbic system, located between the cerebral hemispheres
and the brain stem, are much smaller than the cerebral hemispheres (neocortex).
66
Figure 3.1
The four quadrant concept: a synthesis of the Triune- and
left brain/right brain theories
/
/
/
/
/ _ _ _ _ _ _.__Right cerebral
hemisphere
/ Corpus
---~-callosum
Left r----...--Hippocampal
cerebral commissure
hemisphere ~-&.-._ _ Right half
Left half
of the limbic
system
I of the limbic
system
I
m I
Paleomammalian
----(Limbic system)
The Triune brain ----Reptilian
(Adopted from Herrmann 1989:40>

67
The limbic system comprises, inter alia, the thalamus and hypothalamus, and is believed
to control the inner being of the person. Apart from regulating emotions, metabolic
functions, involuntary aspects of behaviour and the autonomic nervous system; it is also
actively involved with the sensory, short-term and long-term memories (Herrmann 1989:
32-33; Marieb 1989:389-390).
The interconnecting nervous fibres in the brain, which connect the different parts of the
brain, provide the physiological basis for wholeness in mental functioning. The corpus
callosum connects the two cerebral hemispheres, providing a channel for hemispheric
communication. Sperry and Gazzaniga's famous split-brain studies during the 1960s
demonstrated that without this connection the left or right cerebral hemisphere has no
way of integrating one specialised mode of knowing with that of its complement; the
brain cannot, for example, develop a concept from a visual experience and then translate
it into spoken words.
The left and right halves of the limbic system are connected by the hippocampal
commissure which facilitates inter-limbic communication, whereas the cerebral
hemispheres are connected to the limbic system through the projection fibres (Herrmann
1989:36-37; Marieb 1989:386) (see figure 3.1).
• Situational functioning
Situational functioning of the brain refers to the phenomenon that occurs if a region of
the brain, specialised to perform a task called for in a particular situation, is activated,
then the regions not required for the task go into a resting state. Research has demonstra-
ted that the activated region of the brain sends out beta waves (high frequency waves
indicating working mode) while the regions of the brain that are relaxed exhibit alpha
(lower in frequency than beta) or theta (low frequency) waves. The intensity of brain
waves is measured by electro-encephalogram (EEG). When a person is painting, for
example, his language centre idles in alpha waves while his visual and spacial processing
68
centres emit beta waves. The ability of the human brain to function situationally is
crucial to a person's effectiveness. The region of the brain needed to function in a
particular situation must be able to do so without competition or interference from other
regions (Gowan, Khatena & Torrance 1981:275-276; Herrmann 1989:37).
• Iterative functioning
Iteration refers to the back-and-forth movement of signals among the brain's specialised
regions when performing a task. It can occur within or between hemispheres. The
following is an example of iteration through the corpus callosum. A film conveying a
complex idea in visual metaphors is shown to a group of people who are expected to
write down their interpretations of its meaning. Signals are sent from the non-verbal
region in the brain to the language region, where the pictures are translated into words.
During this process iteration occurs between the right and left cerebral hemispheres.
When rational thought is overwhelmed by emotional energy, iteration has taken place
between the left cerebral hemisphere and the right half of the limbic system (Herrmann
1989:38-39).
Edward de Bono (a British physician) also refers to the brain's iterative behaviour and
adds that it is biased and self-maximising (Parnes 1992:247). This explains why
individuals viewing the film in the above-mentioned example will have different
interpretations whose nature is dependent on perceptual differences (which include the
involvement of emotions residing in the limbic system).
3.5 THE WHOLE BRAIN CREATIVITY MODEL
The whole brain creativity model as developed by Herrmann (1989) explains how the
brain functions while engaged in the creative process. Wallas' four stages of the creative
process (preparation, incubation, illumination and verification) plus the addition of
interest and application, are related to the four brain quadrants which Herrmann derived
69
by integrating the triune and the left brain/right brain theories (see figure 3 .1) (Parnes
1992:237).
3.5.1 From the split brain theory to the four quadrant model
The research that has been done on brain functioning and specialisation has clarified why
certain people tend to approach problems logically, analytically and factually (left brain
mode); whereas others tend to approach problems intuitively using images, concepts and
patterns (right brain mode). This dominance in brain functioning determines people's
cognitive styles (preferred modes of knowing). According to Herrmann (1989: 17), a
person's preferred mode of knowing correlates strongly with what he prefers to learn and
how he prefers to learn it. This has crucial implications for human learning and thus for
the organisation of teaching programmes and methods. Information which is presented
in pictures, will get through to a student whose preferred mode of knowing is visual,
whereas information presented in a lecture or book with text only, will not appeal to
him/her.
During his search for a brain dominance - measuring technique, Herrmann started with
one day seminars, Brain Update Workshops, in which he shared the results of the split-
brain research of the 1970s with others. He designed a simple questionnaire containing
questions on educational background, job focus, preferred academic subjects and
hobbies, and choices between adjectives describing different functions of the specialised
brain in which the subjects had to select those pertaining to themselves. The Herrmann
Brain Dominance Instrument (HBDI) was developed from the data he gathered through
the questionnaires (Herrmann 1989:50-53).
The early version of the instrument revealed a linear profile which reflected the basic
dichotomy between left brain related modes of mental processing and those of the right
brain. However, as more people completed the questionnaire, the data base grew to show
four distinct clusters. Two clusters appeared at the ends of the continuum while the other
70
two centred between the extremes - the latter two being referred to as left centre and right
centre. This phenomenon of the four clusters finally came together for Herrmann after
much contemplation, when he merged the triune brain theory and the left brain/right
brain theory. The limbic system of the triune brain theory was the link he was looking
for. The four quadrants concept included the left and right cerebral hemispheres and the
left and right halves of the limbic system (the two centre clusters) (see figure 3.1). The
validity of both the design of the instrument and the data it produces has since been
tested repeatedly and confirmed (Herrmann 1989:63).
Herrmann (1989) presented the four quadrant model of preferred modes of knowing and
brain dominance as a whole brain creativity model. The brain is depicted by a circular
diagram, divided into four conscious modes of knowing and behaviours. Although
Herrmann originally thought of the whole brain model as a physiological map, he moved
away from this interpretation to present the model as a metaphor. He ceased to use the
terms cerebral hemispheres and limbic system in order to soften the relationship between
the physiology of the brain and the metaphoric model, and renamed the four quadrants,
A, B, C and D (see figure 3.2) (Herrmann 1989: 63-65). In the figure the similarities
between the whole brain model and the classification of the left and right hemispheric
functions as mentioned in table 3 .1 are brought into perspective. Herrmann attributed
a specific colour to each quadrant. These colours are illustrated in some of the figures
representing the whole brain model in this thesis.
The metaphoric model is regarded as being more appropriate since determining precisely
which part of the brain is doing what has become more difficult and less important -
researchers have discovered that brain laterisation is not clear cut, but much more subtle,
complex and versatile than they thought, as is indicated by the following research
findings:
71
Figure 3.2
The whole brain model
Cerebral mode thinking processes
Intuitive (upper right)

Holistic
Synthesising
Integrating
Left Right
Hemisphere Hemisphere
Planned Emotional
Organised Interpersonal
Detailed Feeling based
B C
(lower left) (lower right)
Lim hie mode thinking processes
(Adopted and adjusted from Herrmann 1989:411)

72
Studies conducted during the 1970s indicated that verbal processing is not exclusively
the function of the left hemisphere but that the right hemisphere is also capable of
processing language if the discriminations are uncomplicated (Nebes & Sperry 1971;
Gazzaniga & Hillyard 1971 ), although it takes twice as long to process the same
information (Moscovitch, Scullion & Christie 1976) in Gowan Khatena and Torrance
( 1981 :273 ). Similar findings have been reported concerning the brain's ability to respond
to music - previously believed to be exclusively a right hemispheric function. Garrett
(1976:241) cites research findings which indicate that non-musically trained individuals
hear music better with the left ear (right brain) whereas musicians hear music better with
the right ear (left brain) because they have learned to perceive music both analytically
and as a total impression. Edwards refers to research conducted by Benton (1980) who
has found that the left hemisphere governs the ability to read music, whereas the right
hemisphere with its holistic pattern, controls the ability to recognise, appreciate and
remember melodies (Kolb 1984:48).
The metaphoric model (figure 3.2) has been proved a reliable replica of human brain
specialisation when considering the results of the implementation of the HBDI. More
than 500 000 people have completed the questionnaire and the study of the profiles
indicates the distribution of brain dominance as follows:
Single dominant 7%
Double dominant = 60%
Triple dominant = 30%
Quadruple dominant = 3% (Herrmann 1989:85)
According to Herrmann, the HBDI measures preference for a mental activity but this
does not necessarily mean competence in performing it. Competence comes through
training and experience, but world class competence can only be achieved in an area of
preference. Herrmann also says that profiles tend to remain constant, but that they can,
and do, change (Herrmann 1989:76).
73
3.5.2 The whole brain model in relation to creativity
The four quadrants of the whole brain model represent the four phases of the creative
process as described by Wallas (see 2.5.1.2). The preparation and verification phases are
represented by the A- and B-quadrant (left brain). These are the phases during which
information is gathered, the problem is defined, and the results are measured and
verified. The incubation and illumination phases are represented by the C- and D-
quadrant (right brain). During these phases subconscious idea generation takes place and
imagination is allowed to take over. The creative process is delicate and the correct
quadrant should thus be activated during each phase. Excessive dominance in any one
of the four quadrants is believed to upset the inherent balance which, according to
Herrmann, makes whole brain applied creativity so powerful (Herrmann 1989: 192, 276).
Herrmann views people who are creative as having a primary preference for the D-
quadrant, but says that they are supported by strong secondary preferences in other
quadrants which enable them to function situationally in order to complete a creative
task. Supporting capabilities, when strengthened, often enhance the original preference
(Herrmann 1989:197). This concept is affirmed by Wenger who states that in order to
improve any area of the brain, an individual should first work in the language of that part
of the brain, and then combine the behaviour with the language of another part of the
brain (Parnes 1992:254).
The premise that creativeness is a product of whole brain functioning has been expressed
by many authors and researchers. Rubenzer quotes several, including Chiselin (1952),
Gilchrist (1970), Kraft (1976) and Norman (1977), as having suggested that creative
geniuses are most adroit at utilising both the left and the right hemispheric processing
modes (Gowan, Khatena & Torrance 1981 :280). Herrmann expresses his view on this
matter as follows:
74
What becomes clear when one studies the lives and writings of scientific
and artistic geniuses is that what made many of them extraordinary was
their use and trust of modes that are non-dominant in their particular
fields (Herrmann 1989: 196).
The distinction between artistic and scientific creativity is made on the basis of the
difference in primary processing modes. The artistic creative process is regarded as
stronger right mode (C- and D-quadrant) oriented, relying on non-verbal, visual,
imaginative and spatial abilities, whereas scientific creativity relies on the left mode (A-
and B-quadrant) processes which include logic, analytical, verbal and mathematical
skills.
The relation between the four quadrant model and creativity can be illustrated by the
examples of creative geniuses such as Da Vinci, Einstein and Kekule. Leonardo da Vinci
has been regarded as a multiple dominant scientific and artistic giant as a result of his art
works and scientific designs. Albert Einstein and August Kekule are perceived to have
been double dominant in the A- and D-quadrant with the ability to move back and forth
between these two specialised modes through iteration. This enabled them to bring two
different mental processes into a synergistic whole (Herrmann 1989: 196-197). Einstein
conceived his theory of relativity after he had a dream of himself riding on a light beam.
He regarded his gift for fantasy as much more important than his gift for logic and
analysis. Kekule, a Dutch chemist, discovered the molecular structure of benzene, the
benzene-ring, through a dream after struggling with this problem over a very long period.
Koestler (1964) cites Kekule's experience during his effort to synthesise benzene:
I turned my chair to the fire and dozed Again the atoms were gambolling
before my eyes. The smaller groups kept modestly in the background My
mental eye, rendered more acute by visions of this kind, could now
distinguish larger structures, of manifold conformations, long rows
sometimes more closely fitted together, all twining and twisting in snake-
75
like motion. But look! What was that? One of the snakes had seized hold
of its own tail and the form whirled mockingly before my eyes. As if by a
flash of lightning I awoke (Gowan, Khatena & Torrance 1981 :250).
The above examples correspond with the descriptions of the creative process as cited by
the two creative geniuses, Helmholtz and Poincare (see 2.5.1.2). The preparation phase
in these examples had taken a long period of intense study, comprising the gathering of
information in order to define the problem, critical and logical thought, analysis, and
verbalisation of the problem, all of which are A-quadrant processes. The organisation
and sequential planning of steps, and the detail needed during this phase, refer to B-
quadrant processes. During the incubation phase when the person is in a relaxed state
and not consciously thinking about the problem, the right mode processes take over. The
D-quadrant processes are evident in imagery, idea generation and visualisation of the
problem. The person's intense interest and involvement with the problem prevents
emotional distance from the problem, and allows feelings and emotions which are C-
quadrant related, to play a role during this phase. It is speculated that the dreams and
daydreams which give rise to the illumination phase, may originate as a result of the
emotional involvement during the incubation phase. The illumination phase is dominated
by D-quadrant processes as evident in the visual experiences, and conceptual, metaphoric
and synthesising processes which are active during dreams and sudden insights.
The verification phase is again strongly dominated by the A-quadrant (logical, critical
and factual presentation of the solution) and the B-quadrant (structured, sequential and
detailed presentation of the end product). The D-quadrant is, however, also active during
this phase especially in the synthesizing and integrating processes of the end product or
solution. The role of the C-quadrant during this phase can be seen in the expressive,
aesthetic and personalised finish of the end product (see figure 3.3).
76
Figure 3.3
The whole brain creativity model
Preparation: A+B
Incubation:
Illumination:
Verification:
D+C
D
ABDC J creative process
Interest Application
A D
Logical thinking Visualisation
Analysis of facts Cerebral Imagination
Processing numbers mode Conceptualisation
Preparation + ~ ~ Illumination +
Incubation
Verification ~
Planning approach Limbic Gut reaction

Organised facts mode Sensory response
Detailed review Interpersonal
oil( ,.
c
ITERATIVE MODEL

77
Apart from Herrmann's metaphor, the interactive effects of the left hemisphere and right
hemisphere processes have been emphasised by other recent cognitive-oriented
metaphors for the creative process. Parnes (1977) regards the integration of the special
abilities of both the left and right hemispheres as essential for creativity. Torrance (1978)
supports this concept as manifested in his words:
In creative thinking, it is especially important to understand the special-

ised functions of the right and left hemispheres, since almost by definition
both kinds offunctioning are required (Elliott 1986:204 ).
3.5.3 The whole brain teaching and learning model
In addition to the whole brain creativity model, Herrmann (1989:218-219) developed a

whole brain teaching and learning model. The learning process is divided into the four
brain quadrants which are placed in two categories; structured and unstructured. The
structured modes (A- and B-quadrant) focus on logical, rational, analytic and quantitative
activities as well as the planned, organised, sequential and procedural elements of the
learning process. These are in sharp contrast with the unstructured modes (C- and D-
quadrant) which focus on non-verbal, visual, conceptual and simultaneous processes,
involving emotional, interpersonal and expressive activities (Herrmann 1989:220-221)
(see figure 3.4).
The expanded whole brain teaching and learning model (figure 3.4) based on Herrm~nn's
research, can serve as a guide for those who wish to improve nursing and possibly other
forms of education. This model, together with Herrmann's whole brain learning and
design considerations which are discussed below, can serve as a guideline for the
organisation of the teaching/learning situation in order to stimulate and facilitate whole
brain learning.
Figure 3.4
Whole brain teaching and learning model
·~et\ /,iq~
1\\~
~e~tfo-e1 Left hemisphere Intellectual Right hemisphere ~Ce ~i-.
~c ~
A \'erbal Visual D
Analytical Cerebral Intuitive
Logical • • b Conceptual
Rational ~ ~ 'fi
Quantitati' e ~
~
;f Simultaneous
Holistic
~~ ~ 0~1$
. ' I
. -....J
00
2: ~ M'°g
~ rll
... "i ~ ...
= :§..c:i
=.... ~ -e
1:2 c:&.
&! = >
s~
Cj
~
Structured Experiential
'a.
<
!.
= 'S. =
~ ~ S"
~ SID 1:1
=-~8
=
t..i!l ~ Q!I
b
~ ~
~
0-c;; Limbic ~~
()
• • nterpersona
Kinaesthetic
B c
Kinaesthetic
l'~f ~~et\
~~~~
~i-~ ~ee
79
According to Herrmann (1989:419), A-quadrant dominated individuals learn by

acquiring and quantifying facts, applying analysis and logic, thinking through ideas,
building cases and formulating theories. They respond to formal lectures, fact-based
content, case studies, programmed learning and textbooks. When the left hemispheric
functions (based on split brain research and summarised in table 3 .1) are taken into
consideration it becomes evident that the A-quadrant processes correspond to most of
these functions. Teaching strategies including seminars, individual projects and reading
assignments, can be added to Herrmann's list to assist A-quadrant dominated learners as
they stimulate the verbal rational and abstract processes of the left hemisphere (see figure
3.5).
The B-quadrant dominated individuals learn by organising, structuring and sequencing

content, evaluating and testing theories, acquiring skills through practice and implement-
ing content (Herrmann 1989:419). They respond, like the A-quadrant individuals, to
formal lectures, programmed learning, case studies and textbooks but thorough planning
and sequential order are emphasised. Because of a stronger focus on organisation and
practical application in the B-quadrant, learning could be assisted by providing
opportunities for demonstrations, practice sessions in a simulation laboratory, clinical
'
learning experiences and group discussions (see figure 3.5).
The whole brain teaching and learning model (figure 3.4) leads to the conclusion that the
A- and B-quadrant of the left hemisphere have a lot in common. This is evident in the
need for a structured teaching-learning environment wherein the learners are disciplined,
rational and verbally oriented, and are concerned with the "know how" of information.
' B-quadrant result from the differences between the
The differences between the A- and
left cerebral hemisphere (perceived as intellectual and fact based) and the left half of the
limbic system (kinaesthetically oriented and controlled). This explains the phenomenon
that A-quadrant dominant individuals are achievement driven whereas B-quadrant
dominant individuals are task driven.
80
Figure 3.5
Teaching strategies for whole brain teaching and learning
A D
Imagery and fantasy

Patient case history
Metaphorical thinking
Clinical assignment
Simulation
Role play
B c
81
In contrast to the left hemispheric thinking processes are those of the right which are
divided into the D- and C-quadrant. Herrmann (1989:419) views the D-quadrant
dominated individuals as those who learn by taking initiative, relying on intuition and
self-discovery, exploring hidden possibilities, constructing concepts and synthesising
content. He suggests that they respond to visual displays, experiential opportunities,
aesthetic qualities, and future oriented case discussions. They tend to be spontaneous,
playful, individualistic and enjoy being involved in the learning process. Compared to
the right hemispheric functions (see table 3.3) the preference for non-verbal information
and analogy or metaphor (knowledge achieved through images, visual displays), as well
as holistic perception, synthesising abilities and intuitiveness are evident in D-quadrant
functioning. Teaching strategies which could assist learning include individual patient
case history, formal lecture combined with transparencies and posters, imagery and
fantasy, simulation, role play and challenging clinical assignments, such as the
development of health education brochures for individual patients (see figure 3.5).
The C-quadrant dominated individuals prefer to learn by feeling, moving and emotional
involvement, integrating experiences with the self and harmonising with the content, and
listening and sharing ideas. They tend to respond to sensory movement and music,
experiential learning, people oriented case discussions and group interaction (Herrmann
1989:419). It can be deduced that, because of the emphasis on the affective aspects in
the C-quadrant, learning could be assisted by teaching strategies which include group
discussions, values clarification, role play, simulation, clinical post-conferences and field
trips (see figure 3.5).
Considering the whole brain teaching and learning model (figure 3.4), it is obvious that
the right hemispheric oriented individuals prefer experiential learning opportunities
which allow for an unstructured teaching-learning environment which provide oppor-
tunities for spontaneous and explorative learning. They are good at non-verbal learning
and are concerned with the "know why" of information. The differences between the
D- and C-quadrant result from the specialisation of the right cerebral hemisphere which
82
is more intellectually oriented and open-minded, in contrast with the right half of the
limbic system, which is kinaesthetically oriented with a strong emphasis on feelings and
emotions. This elucidates the reason why the D-quadrant dominant individuals are
independence driven while the C-quadrant dominant individuals are feelings-driven.
3.6 SYNTHESIS
The insights into personality differences and preferred modes of knowing provided by
the whole brain creativity model, based as it is on the triune brain theory and the left
brain/right brain theory, can in many respects be employed to clarify some of the major
concepts in the different theories of creativity.
Considering the cognitive theories, Guilford's structure-of-intellect model comprises

convergent production which can be ascribed to left brain processes and divergent
production which refers to right brain processes with special emphasis on D-quadrant
processes. Although Guilford only links the divergent thinking operations and the
products involving transformations to creativity, it is not possible to produce a creative
product without involving convergent production as becomes evident through the work
of Poincare and Helmholtz (see 2.5.1.2).
When analysing Torrance's key-creative abilities it becomes clear that sensitivity to

problems can be linked to C-quadrant processes since it is only through emotional
involvement that needs and deficiencies can be detected. Flexibility refers to divergence
which is a D-quadrant process, and penetration involves both A- and D-quadrant
processes because factual knowledge is a prerequisite for penetration of a situation and
intuition is necessary to distance oneself from the obviousness of it. Synthesis refers to
a D-quadrant process. Elaboration requires B-quadrant processes in order to describe
the detail, D-quadrar:t processes to show appreciation for aesthetics, and C-quadrant
processes which show the intense emotional involvement and enjoyment in finishing the
creative end product.
83
The Gestalt theories focus on pattern identification which refers directly to a D-quadrant
process (see 2.5.1.4). In linking creative thinking to productive thinking, Wertheimer
regards the problem-solving process as marked by grouping, organisation and
structuralisation. Grouping requires analysis (A-quadrant process) whereas organisation
and structuralisation are B-quadrant processes. The problem-solving process also
requires evaluation and synthesis (B- and 0-quadrant processes) which are considered
productive thinking skills.
The humanistic theories especially emphasise the affective dimensions of creativity (see
2.5.3). Rollo May includes both cognitive and affective aspects when he says that the
bringing together of the emotional and intellectual forces produces creativity - thus
referring to both right brain and left brain processes. Maslow emphasises self-actualising
creativity which involves greater wholeness and integration, and implies a willingness to
live one's life to its fullest capacity, the assumption being that self-actualisation cannot
be reached if all the processes of the human brain are not developed and utilised.
The personality theories which indicate that certain personality types are more capable
of expressing creative behaviour (see 2.5.2.1 ), concur with Hemnann's view that already
creative people who have a primary preference for the D-quadrant, are supported by
strong secondary preferences in the other quadrants and that development of the
supporting quadrants enhances the original preference (see 3.5.2). This provides a strong
argument for the development of whole brain learning and education.
The psycho-analytic theories contribute towards the concept of creativity by emphasising

the role of the unconscious and pre-conscious (see 2.5.4). Freud's description of primary
process thinking as the expression of emotional urges generated by the unconscious, and
the fact that this mode of thinking also involves divergent and analogical thinking,
indicate the involvement of the C- and D-quadrant of the right hemisphere. However,
mental functioning and whole brain functioning are much more complex and involved,
and scientific research has not yet provided a full understanding of the human brain and
84
its processes. As Gowan comments: Sub-conscious mental processes in ordinary

creativity may be somewhat better defined in the extreme cases (Gowan, Khatena &
Torrance 1981 :290).
3.7 CONCLUSION
Split brain research has been responsible for increasing scientific advances in our
knowledge of the human brain and has lead to a new understanding of the nature and
process of learning. Traditional education has been criticised for over-emphasising left
brain thinking skills while neglecting right brain thinking skills, but recent research
findings have provided a basis for a new approach towards whole brain education. This
new concept has enormous potential for nurse educators who wish to guide their students
towards self-actualisation and self-development so that they will be able to realise their
fullest capacity and thereby function more effectively.
It should, however, be remembered that any model, including the whole brain creativity
model, does not present absolute truth but is merely a way of ordering information and
explaining new knowledge. The whole brain creativity model presents the two halves
of the cerebrum but does not include the cerebellum, the pons and the medulla oblongata
- all the regions of the brain and the relationships between them, are thus not accounted
for.
Th~ whole brain creativity model can assist educators to implement a more holistic
approach towards teaching, but the uniqueness of every human being should never be
totally ignored. Roger Sperry emphasised this concept in his Nobel Prize lecture:
The more we learn, the more complex becomes the picture for predictions
regarding any one individual and the more it seems to reinforce the
conclusion that the kind of unique individuality in our brain networks
makes that offingerprints or facial features appear gross and simple by
comparison (Zdenek 1985:23).
85
CHAPTER4
The nature of creative learning
4.1 INTRODUCTION
Analysis of investigations into learning styles and theories of learning reveal they have
one element in common - they attempt to explain and describe how individuals learn.
When learning styles and theories of learning are analysed, finer distinctions can be
made as to the when, where and how of learning. The circumstances and conditions
under which rote learning, meaningful learning and productive learning take place are
explored and described. Instructional objectives serve as guidelines for the individual
in the learning process, as they usually indicate whether rote learning, meaningful
learning or productive learning is required. The nature of creative learning becomes
explicit if elements related to creativeness are identified in various learning styles.
Theories of learning and instructional objectives should serve as guidelines for creative
outcomes.
86
4.2 COGNITIVE STYLES (LEARNING STYLES)
In the literature the phrases cognitive styles and learning styles are used interchangeably.
Research on cognitive styles, which commenced during the 1940s with the new look
movement in perception, attempted to re-establish a focus on the person in perceptual
studies. Cognitive styles refer to consistent individual differences in the manner in
which information is organised and processed. These differences have some roots in
personality structure (Witkin & Goodenough 1981: 1).
Cognitive styles are defined by Kogan in Garity (1985:12) as the individual variations
in modes of perceiving, remembering and thinking, or as distinctive ways of apprehend-
ing, storing, transforming and utilising information. Woolfolk ( 1990: 147) explains them
as being the different ways of perceiving and organising information, whereas the view
of Herrmann is that they are the preferred modes of knowing, which are concerned with
the how and what individuals choose to learn. An individual's preferred mode of
processing information is regarded as his predominant learning style.
According to Witkin, Moore, Goodenough and Cox (1977: 15) cognitive styles refer to
individual differences in how individuals perceive, think, learn, solve problems and
relate to others. Cognitive styles indicate individual differences, not only in the way that
people perceive, learn and think, but also in the way that they relate to others and to their
environment - the concept of cognitive styles is thus comprehensive and encompasses
both the conscious and unconscious mind of the human being.
Amongst the number of cognitive styles which have been identified, several researchers,
including Floyd (1976), Wilson (1981), Messick (1984) and Witkin and Goodenough
(1981 ), single out the field-dependent/independent dimension as being of particular
significance for the teaching-learning situation as it is considered to have the widest
application to educational problems (Joughin 1992:4). It is for this reason that the field-
dependent/independent cognitive styles are discussed and related to whole brain
87
creativity in this thesis. This discussion includes Kolb's model of four different learning
styles. As this model emphasises both cognitive and affective aspects, it reflects a
holistic picture which relates to whole brain creativity and for this reason it is of
particular relevance to nursing as a humanistic, practice-oriented profession.
4.2.1 The field-dependent/independent cognitive styles
Field-dependency refers to a cognitive style in which patterns are perceived as wholes.

Individuals who display this cognitive style, find it difficult to separate specific aspects
of a pattern or situation. They also experience difficulty in learning material which lacks
inherent structure and benefit when externally defined structure and salient cues are
provided. They tend to be unable to reorganise information and need more explicit
instruction on how to solve problems. Smith (1982) in Joughin (1992:7) reports that
when problem-solving involves analysis, field-dependent individuals are not at their best
and rely on applying rules and using intuition.
Field-dependent individuals rely more on external referents for self-definition and

require externally defined goals and reinforcement. They perform better in learning
tasks when feedback is given on a regular basis. These individuals are good at learning
and remembering social material and are oriented towards people and social relation-
ships. They work well in groups, are sensitive to the feelings of others and are highly
affected by both positive and negative criticism (Slavin 1991 :281; Witkin, Moore,
Goodenough & Cox 1977:18-19, 21; Woolfolk 1990:148-149). Field-dependent people
prefer subjects such as history, literature and social sciences. According to Witkin et al
( 1977: 11-13 ), they favour educational-vocational areas in which involvement with others
is a central feature. Research has shown that they are sensitive to social cues and that
they are drawn to other people by their extreme interest in the sayings and doings of
others. They are perceived as warm, tactful, considerate, socially outgoing and
affectionate. They prefer courses which emphasise interpersonal skills, enjoy working
in groups and prefer the group discussion as a teaching method (Garity 1985: 13 ).
88
A study conducted by Koran, Snow and McDonald ( 1971) indicated that field-
dependents are visual learners. While examining teachers for their ability to acquire a
teaching skill from video modelling and written procedures, they found that those who
were field-dependent benefited more from the video modelling, whereas the field-
independent teachers did as well with the video modelling as with the written procedures
(Witkin et al 1977:22, 26).
Field-independency refers to a cognitive style in which separate parts of a pattern are

perceived and analysed. Individuals exhibiting this cognitive style have the ability to
recognise the parts that make up a large pattern and are good at analysing and
reorganising situations. They can impose their own structure on unstructured material
and are able to solve problems without explicit instructions and guidance. Field-
independent individuals have internalised frames of reference to which they adhere as
guides to self-definition and they tend to have self-defined goals and reinforcement.
They learn more under conditions of intrinsic motivation and are motivated by meeting
challenges. Their performances are not influenced by feedback. Field-independent
individuals are governed by general principles which they actively abstract from their
experiences and they apply these as mediating structural rules to facilitate learning. They
have a greater self-nonself segregation which enables them to function with greater
autonomy. They assume leadership functions, and readily test out their ideas and
opinions. They work well on their own and are less affected by criticism. Field-
independent individuals appear to be impersonal and are more interested in the abstract
and theoretical. They need assistance with materials containing social information
because they are less sensitive to social cues. They are good at numbers, science and
problem-solving tasks, do well with written material and prefer the lecture method of
teaching (Garity 1985:13; Slavin 1991:281; Witkin et al 1977:12-13, 19, 20, 21, 23;
Witkin & Goodenough 1981:50; Woolfolk 1990:148-149).
89
4.2.1. l Field-dependencylindependency in relation to whole brain learning
From the description of the field-dependent cognitive style, it appears that this mode of
thinking and perceiving is right brain dominated with a strong emphasis on the C-
quadrant, which is the emotional, interpersonal and feeling-based quadrant (see figure
3.2). This explains the field-dependent individuals' positive orientation towards people
and social relationships, their sensitivity towards the feelings of others and their
vulnerability to criticism. Their warm, tactful, considerate and affectionate attitude
towards others is also related to C-quadrant functioning. The slightly lesser emphasis
on D-quadrant modes of thinking (holistic, intuitive, synthesising and integrative
thinking) is evident in their tendency to perceive patterns as wholes and to solve
problems by using intuition. They may, however, experience a problem with synthesis
as this can only be accomplished after the ability to analyse has been mastered. Those
research studies which do refer to the field-dependent's lack of ability to analyse,
organise and structurise information, ascribe it to an under utilisation of left brain (A-
and B-quadrant) processes.
In order to provide field-dependent students with opportunities which facilitate the

development of whole brain learning and creativity, the educator should both strongly
support right brain thinking processes and assist and stimulate the development of those
of the left brain. According to Messick (1984:69), matching of cognitive style is
required when the aim is to enhance immediate subject-matter achievement, but
mismatching may be essential when the aim is to promote flexible and creative thinking.
Conflict, opposition, obstacles and challenge are needed to stimulate individual
development and creativity.
It is my view that the individual preferring the field-independent cognitive style is left
brain dominated. Both the A-quadrant processes (logical, analytical, fact-based and
quantitative thinking) and the B-quadrant processes (planned, organised, detailed and
sequential thinking) appears to be equally emphasised (see figure 3.2). The field-
90
independent persons' tendency to analyse information, and to perceive the parts of a

pattern, as well as their preference to work with numbers, their affinity for problem-
solving and their interest in the theoretical, all refer to A-quadrant thinking processes.
Their tendency to organise and structurise material, and their preference for the lecture
method, indicate the utilisation of B-quadrant thinking processes. The preference of
field-independent persons for subjects such as science and mathematics (ie those
characterised by factual detail and sequential order which require logical, analytical
thinking) also refer to A- and B-quadrant thinking processes. These individuals' lack of
sensitivity for social cues, their apparent impersonal attitude and seemingly indifferent
attitude towards criticism and peer pressure, indicate that they neglect the C-quadrant
thinking processes. It appears as if they do make use of integrative thinking (D-quadrant
processing) because they tend to impose their own structure on unstructured material, but
there is, nevertheless, no indication of holistic thinking, synthesis or intuitive thinking.
Noppe (1985:95) reports, however, that creativity is facilitated by a mobile field-
independent cognitive style.
Apart from supporting field-independent students' left-brain processes during the

organisation of the teaching-learning environment, it is also necessary to provide
opportunities for the stimulation and development of right brain processes to enable
them to develop whole-brain functioning.
4.2.1.2 Educational implications of the field-dependent/independent cognitive

styles
Cognitive styles as preferred modes of perceiving, thinking and knowing, have crucial
implications for human learning and thus for education. Witkin et al ( 1977: 15) have
found cognitive styles to be stable over time, but this does not necessarily imply that
they are altogether unchangeable. The aim of the educator should be to organise his
teaching methods to facilitate learning for both field-dependent and field-independent
students, and also to stimulate those thinking processes not utilised by these two groups
91
in order to move towards whole brain creativity. The value of integrating and applying
knowledge on cognitive styles in nursing education is highlighted in the following
reports.
Skipwith (1982) found that student nurses who were aware of their own cognitive styles
experienced more success in their course work. Smith and Frazier reported that when
teaching methods were compatible with cognitive styles, learning and achievement were
enhanced. These studies emphasise the advantage of an educator knowing his students'
cognitive style so that his teaching methods may be correspondingly organised (Garity
1985:14).
In another investigation cited by Garity (1985: 14) it was found that when, in certain
specific courses in a nursing curriculum, teachers and students were matched according
to learning styles, the failure-withdrawal rate appeared to be less than otherwise was the
case.
In the light of these research findings and the available information on the differences
in the field-dependent/independent cognitive styles, the following suggestions are made
for the facilitation ofleaming by students possessing one of the two respective cognitive
styles:
( 1) Field-dependent cognitive style
The field-dependent student will not need special assistance with social content which
in the nursing curriculum comprises subjects such as psychology, sociology, the history
of nursing, community nursing science, psychiatric nursing science and ethos and profes-
sional practice. She will benefit from teaching strategies which include role play, group
discussions, simulation, games, values clarification, panel discussions and group
projects. These strategies provide opportunities for human interaction as well as visual
learning (role play and simulation) and should be complemented by creative teaching
92
techniques which enhance right brain learning - visualisation, fantasy, poetic writing,
metaphorical thinking, synectics, and sociodrama (discussed in chapter 7) (Davis
1986:142; Williams 1983:30-34).
As field-dependent individuals rely heavily on feedback and extrinsic motivation, the

teacher should consistently provide feedback and only offer criticism very carefully.
Clear objectives should be provided and students must be assisted to formulate their own
short- and long-term goals. Reinforcement must be given in the form of praise,
appreciation, encouragement and moral support as they are motivated by social approval
and acceptance.
The teacher should provide extra assistance to this group of students in subjects such as
biophysics, biochemistry, anatomy, physiology and pharmacology by presenting well
structured lectures complemented wherever possible by analogies and visual presenta-
tions. Transparencies, posters, diagrams, video material, anatomy models and laboratory
sessions should accompany formal lectures.
Field-dependent students need assistance in solving problems and it is therefore

suggested that the case study method be used with the teacher giving structured
guidelines while leading students by way of divergent questioning (see table 7 .1 ).
Apart from assisting field-dependent students with their preferred mode of right brain
thinking they need to receive left brain stimulation to enable them to develop whole
brain learning. They should be provided with the opportunity to analyse and structure
material. Small projects can be given to students divided into groups of two and four,
or field-dependent students can be paired with field-independent ones to enable them to
learn how to analyse and structure material from the examples set by their fellows.
93
(2) Field-independent cognitive style
The field-independent students should be approached differently from those who are
field-dependent. They will not need extra assistance in subjects such as anatomy,
physiology, biophysics, biochemistry, microbiology or pharmacology as these subjects
are factually-oriented and necessitate logical, analytical and sequential thinking.
Effective teaching strategies for this group include formal lectures, learning packages,
individual projects, reading assignments, programmed learning and problem-solving,
because they work well on their own, prefer to participate actively, and can analyse and
give structure to learning content. It is not crucial that visual material be included as a
teaching aid as these students are not oriented towards visual learning, but rather to the
written and spoken word.
Field-independent students will need additional assistance with subjects such as ethos
and professional practice, psychiatric nursing, community nursing, sociology and
psychology because these disciplines are socially oriented. The students should
therefore be involved in role play, simulation and the case study method to stimulate
their right brain thinking processes and to learn to work in groups together with other
individuals. The practice of nursing requires that individuals work and collaborate with
all other health professionals and function within a health team. The field-independent
student should be provided with challenges such as leading group projects, and sending
them out on field trips, eg visits to health clinics, to do individual projects. They should,
however, also be subjected to creative teaching techniques such as brainstorming,
creative problem-solving, and metaphorical thinking in order to lead them towards whole
brain creativity (see chapter 7). This group of students should be additionally exposed
to sociodrama, values clarification, and particulary personal analogies as these strategies
will provide them with opportunities to become aware of and sensitive to the feelings
of others.
It is essential for nurse educators to organise their teaching in order to facilitate and
94
enhance learning for both field-dependent and field-independent students, and also to
provide stimulation for the opposite sides of the brain of both these groups. Certain
nursing specialities such as intensive care nursing, surgical nursing and operating-theatre
nursing depend strongly on left brain modes of thinking, whereas psychiatric nursing and
community nursing require right brain modes because of the psychological and social
aspects involved. A study conducted by Quinlan and Blatt (1972) on student nurses,
reported that psychiatric student nurses who were regarded as good by their tutors, were
field-dependent whereas surgical nurses described as good by their mentors, tested field-
independent (Witkin et al 1977: 16).
4.2.2 Kolb's experiential learning model
Kolb (1976) identifies four learning styles in his theory of experiential learning. He
views these as acquired, consistent patterns of learner-environment interaction
(Laschinger & Boss 1984:375). Each of the four is a combination of two of the four
learning modes of the learning process, as described by him.
Kolb considers his model of learning to be a theoretical one which integrates perception,
cognition, behaviour and experience (Holbert & Thomas 1988 :31 ). It has considerable
potential for guiding the design of whole-brain learning and creativity in nursing.
According to Kolb (1984:64), people programme themselves by their choices of

experience to perceive reality through varying degrees of emphasis on apprehension or
comprehension (the two different modes of knowing about the world).
In relation to the whole brain model, comprehension is congruent to left brain thinking
processes - abstract, symbolic, analytical, verbal, linear and sequential; whereas
apprehension concurs with right brain thinking processes which include concrete,
holistic, spatial, analogic, synthesis, and intuitive processes. Kolb explains that people
transform these prehensions through extension (behavioural actions) and/or intension
95
(intellectual operations), and concludes that this self-programming determines the extent
to which individuals utilise the four modes of the learning process (Kolb 1984:48-49,
52, 64) (see figure 4.1).
4. 2. 2. 1 The modes of the learning process
(1) Concrete experience focuses on being involved in experiences and immediate

human situations while dealing with them in a personal way. The emphasis is on
feeling as opposed to thinking. It involves being concerned with the uniqueness
and complexity of present reality as opposed to theories and generalisations.
Problem-solving is approached in an intuitive artistic way. Individuals with a
concrete experience orientation enjoy and value relating to other people. They
are good intuitive decision makers, function well in unstructured situations and
have an open-minded approach to life (Kolb 1984:68).
Concrete experience appears to be right brain oriented with a strong preference

for the C-quadrant processes because of the emphasis on feeling, interpersonal
aspects, and the kinaesthetic nature of real life situations. A lesser utilisation of
D-quadrant processes is indicated by the reliance on intuition during problem-
solving and decision-making.
(2) Reflective observation focuses on understanding the meaning of ideas and

situations by observing and describing them. Understanding is emphasised as
opposed to practical applications. Reflection is emphasised as opposed to action
and the concern is about truth and how things happen as opposed to what will
work. Individuals with a reflective observation orientation enjoy intuiting the
meaning of ideas and situations, are good at seeing the implications and look at
situations from different perspectives while appreciating different viewpoints.
They prefer to rely on their own thoughts and feelings to form opinions, and
value patience, impartiality and thoughtful judgement (Kolb 1984:68-69).
96
Figure 4.1
Kolb's experiential learning model indicating the basic

knowledge forms, the cycle of learning modes
and the learning styles
Concrete experience
Accommodative
knowledge
l
Grasping via
comprehension
Divergent
knowledge
I
Active Transformation Transformation
Reflective
experi,ntation via extension via intension observation
Convergent Grasping via

J
Assimilative
knowledge apprehension knowledge
~ Abstract con~eptualisation /
(Adopted from Kolb 1984:42)

97
This learning mode relies on right brain functioning with a strong emphasis on D-
quadrant thinking processes as indicated by the preference for understanding (a
neocortex function, not limbic), intuiting, divergence in considering different
perspectives, and the ability of vision. A lesser preference for C-quadrant
processes is manifested by the reliance on feel in gs and observation, which are
kinaesthetically oriented.
(3) Abstract conceptualisation focuses on the use of logic, concepts and ideas and
emphasises thinking as opposed to feeling. There is a concern for developing
general theories in contrast to intuitively understanding unique specific phenome-
na. Problems are approached in a scientific way rather than an artistic way. In-
dividuals with abstract conceptualisation orientation are good at quantitative
analysis, manipulation of abstract symbols and systematic planning. They value
precision, analysis of ideas, and the aesthetic quality of a neat conceptual system
(Kolb 1984:69).
Abstract conceptualisation is related to left brain thinking processes. The

tendency towards quantitative analysis, logic, the use of abstract symbols and
concern with theories, indicate A-quadrant functioning. A lesser emphasis on B-
quadrant thinking processes is shown by their preference for systematic planning,
precision and discipline.
(4) Active experimentation focuses on changing situations and actively influencing

people. The emphasis is on practical applications as opposed to reflective
understanding, and on doing in contrast to observing. A pragmatic concern
towards what works is relevant as opposed to the absolute truth. Individuals with
an active experimentation orientation are good at getting things accomplished and
are willing to take risks in order to achieve their goals. They value having an
influence on their environment and enjoy seeing results (Kolb 1984:69).
98
Active experimentation refers mainly to left brain functioning. A particular

emphasis on B-quadrant thinking processes is indicated by the preference for
doing, the need for practical application of knowledge and ideas, the goal-
directedness and the need for accomplishment and active involvement. A slight
preference for D-quadrant processes (right brain related) can, however be seen in
the willingness to take risks.
Kolb describes human learning as a four stage cycle moving from concrete
experience to reflective observation and then on to abstract conceptualisation and
to active experimentation (figure 4.1 ). All four modes of learning are needed for
effective learning but it has been shown that people usually prefer two modes of
learning above the other two and that this is reflected in their learning styles
(Hodges 1987 :341 ).
4.2.2.2 Kolb 's four learning styles
According to Kolb, learning style refers to the way an individual masters content and
skills as well as the way he adapts to reality. Its peculiar manifestation for an individual
depends on his hereditary equipment, his particular past life-experience and the demands
of his present environment (Highfield 1988:30; Kolb 1984:77). Kolb designed the
Learning Style Inventory (LSI) to assess individual orientations towards learning. It
measures an individual's emphasis on each of the four modes of the learning process as
well as two combination scores indicating emphasis on abstractness over concreteness
and emphasis on action over reflection. Although this instrument has been tested for
reliability and validity, the latter have been questioned by Fox ( 1984) and Sewall ( 1986),
and Kolb has been criticised for using unnecessarily complex language in its protocols
by Smith (1982) in Joughin (1992:7). However, Kolb's model is based on a holistic
framework because it ir.cludes the cognitive, affective and psychomotor domains of
learning and it emphasises both theoretical and experiential learning. It is therefore a
particularly appropriate model for a humanistic, practice-oriented profession such as
99
nursmg. The four learning styles are:
( 1) Convergent learning style
Individuals who exhibit this learning style rely primarily on the learning modes of
abstract conceptualisation and active experimentation. Their greatest strength lies in
problem-solving, decision-making and the practical application ofideas. Convergers are
good in situations where a single correct answer or solution to a problem is required and
they organise knowledge to focus on specific problems through hypothetical-deductive
reasonmg. They prefer dealing with technical problems rather than social and
interpersonal issues and are relatively unemotional (Kolb 1984:77; Partridge 1983 :247).
(2) Divergent learning style
This learning style relies on the concrete experience and reflective observation modes
of the learning process. The greatest strength of this style is found in imaginative ability
and awareness of meaning and values. These learning strengths are viewed as being the
opposite from convergence. The divergers adapt by viewing concrete situations from
many perspectives and tend to organise many relationships into a meaningful gestalt.
Adaptation through observation rather than action, is emphasised. These individuals
perform well in situations that require the generation of alternative ideas and implica-
tions. They enjoy relating to other people and are emotional and feeling-oriented (Kolb
1984:77-78; Partridge 1983:247).
(3) Assimilative learning style
The learning modes preferred by individuals exhibiting the assimilative learning style,
are abstract conceptualisation and reflective observation. Inductive reasoning, creating
theoretical models, and assimilating dissimilar observations into integrated explanations,
are the strengths of this learning style. Assimilators are more concerned with ideas and
100
abstract concepts although ideas are judged less by their practical value because it is
more important for them that theory be logically sound and precise. These individuals
are less focused on people, and therefore have some aspects in common with convergers
(Kolb 1984:78).
(4) Accommodative learning style
This learning style emphasises the use of concrete experience and active experimentation
as learning modes. The greatest strengths are opposite to those of the assimilation style.
Accommodators adapt through opportunity seeking, risk taking and action. They find
it easy to adapt to rapidly changing circumstances. Plans or theories are easily discarded
in situations where they do not fit the facts. Problems are solved in an intuitive trial-and-
error manner and these individuals rely more on others for information than on their own
analytic ability. Accommodators are at ease with people but are sometimes perceived
as impatient (Kolb 1984:78).
4.2.2.3 Educational implications for whole brain learning and creativity
Whole brain education has a dual purpose. It is the task of the educator to organise the
teaching-learning situation in such a way as to provide learning activities which are
congruent with the student's cognitive style not only to enhance learning, but also to
stimulate the student to use his less preferred modes of learning in order to achieve
whole brain functioning. According to Holbert and Thomas (1988:32), Kolb suggests
that students also be taught to develop skills in their less preferred learning modes, so
that they become more flexible holistic learners.
The educational implications of Kolb's model for whole brain learning and creativity,
are discussed below according to the four learning modes. The researcher has not found
it feasible to categorise the four learning styles within the four brain quadrants as
identified by Herrmann (1989). Kolb's learning styles do not appear to be merely left
101
brain oriented or right brain oriented, but seem to comprise a combination of left and
right brain processes (see figure 4.2).
( 1) Concrete experience (divergers and accommodators)
As concrete experience refers to immediate personal involvement in human situations

with an emphasis on the affective domain, teaching strategies which would enhance this
mode of learning include role play, simulation, individual case studies, values
clarification, sociodrama, group discussions, ward rounds, and assigned patient
interviews in the clinical situation. These strategies provide students with opportunities
to learn about human emotions since they facilitate engagement in interpersonal
relationships with peers and patients.
Sociodrama can be used to teach students more about the role of emotions, values and
attitudes during conflict situations, and synectics can be implemented to stimulate
imagination, divergent thinking and kinaesthetic awareness, and to increase concentra-
tion, and evoke a sense of humour (Davies 1986:142; Parnes 1992:394).
Patient case histories and patient interviews give students the opportunity for a concrete
experience in the real-life situation wherein they can discover first hand information
themselves. Values clarification, role play and group discussions allow students to
become aware of a diversity of feelings, values and viewpoints and to learn how to
express their own views. The above-mentioned teaching strategies allow for unstruc-
tured learning situations and are feelings-oriented.
Clinical learning experiences such as ward-and-unit placements, involve both concrete

experience and active experimenting and are therefore valuable learning opportunities
(Hodges 1988:344).
102
Figure 4.2
Kolb's learning cycle and learning styles

in relation to the four quadrants
of the whole brain model
(C-quadrant)
Concrete experience
Accommodator Di verger
(B + C + D) (C + D)
Active experimentation Reflective observation

4---~~~--+-~~~~
(B-quadrant) (D-quadrant)
Converger Assimilator
(A+ B) (A+ D)
Abstract conceptualisation
(A-quadrant)
103
(2) Reflective observation (divergers and assimilators)
The focus in this learning mode is on observing and reflecting (understanding and
intuiting the meaning of ideas and situations) and not on active doing. Holbert and
Thomas (1988:32) suggest teaching strategies including observational experiences
followed by structured group discussions. Assignments to visit clinical departments to
observe certain procedures (for example a specific operation in theatre, a gastroscopy
being performed, blood tests being done in the laboratory) will result in more effective
learning. Students can be asked to discuss their impressions afterwards during a group
discussion. They can also be prompted during these discussions to report on incidents
in the clinical situation in order to express their views and impressions on how these
situations were handled and how they think they could have been handled more
effectively. Visual displays, eg films, videos or pictures, can be presented to students,
followed by divergent questioning (see details in table 7.2) to stimulate creative thinking.
Demonstrations of clinical procedures can be given with students being encouraged to
ask questions and suggest improvements while the teacher is demonstrating and
afterwards. Opportunities should, however, also be given for individual projects on
issues which require personal opinions and understanding, such as ethical issues and
complicated problems which require intuitive thinking. According to Hodges
(1988:344), most seminars and paper-written assignments provide for the reinforcement
of reflective skills as they are perceptually and symbolically complex.
Creative thinking techniques such as metaphorical thinking, guided fantasy and

expressive writing (discussed in 7.4, 7.6 and 7.8) can also provide opportunities for
reflective thinking, intuiting the meaning of ideas and situations and enhanced learning.
(3) Abstract conceptualisation (convergers and assimilators)
This mode oflearning emphasises thinking as opposed to feeling. Hodges (1988:344)

regards formal lectures and textbook reading as exemplifying symbolically complex
104
situations which expand one's capacity for abstract conceptualisation. To this list can be
added written assignments, case studies and learning packages, as they all provide for
analysis, abstract conceptualisation and the development of theories.
The teaching-learning environment must be structured since factual information, detail,

systematic planning, analysis and abstract thought are emphasised. This mode of
learning corresponds with the left hemisphere A-quadrant thinking processes. Herrmann
(1989:56) reports on the necessity of structure and detail required by individuals
preferring this mode, in order to be comfortable with a new learning experience.
Additional learning experiences whereby these individuals will benefit are health team
conferences and group discussions where students and lecturers can discuss and analyse
concepts and theories. Problem-solving should involve crucial problems in nursing
which necessitate a direct scientific approach and not a divergent approach. As
individuals who prefer this mode of learning may oppose most creative thinking techni-
ques, brainstorming might provide a challenge to them and can enhance their ability to
present more creative end products.
(4) Active experimentation (accommodators and convergers)
This learning mode focuses on active doing as opposed to observation and reflection.
Students should be allowed to practice procedures in the simulation laboratory and to
adjust procedures when necessary to improve them. Self initiated projects in the clinical
situation should be encouraged. Students should be assigned to take charge of hospital
wards to allow them the opportunity to take risks and influence their environment, and
to challenge their abilities for systematic planning and pragmatic application of relevant
aspects. Demonstrations and clinical learning experiences should be emphasised since
they provide opportunities for practical application of student knowledge.
Creative thinking techniques, including synectics and creative problem-solving, may

appeal to this group of students since these may assist them to find practical solutions
105
to problems.
4.2.2.4 Synthesis
After analysing Kolb's four learning styles an attempt was made to relate them to the
thinking processes of each of the four quadrants of the whole brain model. This did not,
however, appear to be possible since no learning style proved to be single quadrant
oriented. On the other hand, after examination of his learning modes it did appear that
these could be related to the four quadrants, and, on comparison, the following pattern
emerged:
concrete experience C-quadrant thinking processes

reflective observation D-quadrant thinking processes
abstract conceptualisation A-quadrant thinking processes
active experimentation B-quadrant thinking processes
A cross comparison between the learning preferences of the four learning styles, as
represented by a combination of two of the four learning modes and the thinking
processes of the four quadrants of the whole brain model, revealed the following:
di vergers preference for C- + D-quadrant thinking

assimilators preference for A- + D-quadrant thinking
convergers preference for A- + B-quadrant thinking
accommodators preference for B- + C- + D-quadrant thinking
(see figure 4.2)
This picture concurs with Herrmann's (1989:85) findings of the distribution of brain
dominance which can either be single-, double-, triple- or quadruple dominant.
106
4.2.3 Cognitive style, brain dominance and professional occupation
Kolb (1984:88) reported that his research has shown that undergraduate education is a
major factor in the development of an individual's learning style. It is not clear,
however, whether this is because individuals are shaped by the fields they enter or
whether people choose fields that are consistent with their learning styles. Kolb states
that in case of a mismatch between the field's learning norms, and the individual's
learning style, people will either change or leave the field. This view is congruent with
Herrmann's findings of occupational patterns related to brain dominance (Herrmann
1989:100-101) (see figures 4.3 and 4.4).
Research studies have repeatedly reported student nurses to be either accommodators or

divergers. These include reports by Laschinger and Boss (1984:378), Highfield
(1988:30), Christensen and Bugg (1979) and Bennet in Kolb (1984:89).
Figures 4.3 and 4.4 show interesting similarities between Herrmann's distribution of
occupational patterns according to brain dominance, and the distribution of professional
groups according to Kolb's learning styles.
According to Herrmann (1989:100-103), multiple dominance can be detected in

occupations requiring the ability to rely on more than one mode. He has found triple
dominants occurring in nursing and social work, and reports that in the typical nursing
profile the greatest preference is in both the B- and C-quadrant. Figure 4.3 shows
nursing hovering between accommodator and diverger - which include the B-, C- and
D-quadrant as found by the researcher after analysis of Kolb's learning modes (compare
figure 4.3 to figure 4.2).
107
Figure 4.3
Scores of various professional groups
Concrete
Elementary
education •
Physical • • Social work

therapy
Accommodator Diverger
(B + C + D) • Nursing (C + D)
Agriculture • Secondary education

•
•
Educational administration
Con verger Assimilator

(A+ B) (A+ D)
Accounting • • Management
•
Engineering
Abstract Medicine •
Active Reflective
(Kolb 1984:89)
108
Figure 4.4
Occupational patterns
l
Artists
Entrepreneurs
Strategic Planners
(Herrmann 1989:100)
109
Similarities between Herrmann's and Kolb's findings are also illustrated with reference
to engineers (A- or A- + B-quadrant), bookkeepers (B- or A- + B-quadrant) social
workers (C- or C- + D-quadrant) and educators (C- or C- + D-quadrant) (figures 4.3 and
4.4).
4.3 INSTRUCTIONAL OBJECTIVES
Instructional objectives determine what is to be taught and what is to be learned.

Specific behavioural objectives describe precisely the required terminal behaviour of the
student after a specific learning experience. When teaching for creativity, objectives
which require creative thinking should be clearly set as these are quite distinct from
objectives which demand mere reproduction of knowledge.
Bloom's taxonomy, the most used and well known taxonomy of instructional objectives,
provides two distinct levels in the cognitive domain which are associated with creative
thought. These are opposed to those in the affective domain in which all levels are
involved during the creative process (Bloom 1974:89).
De Corte and co-authors' classification of instructional objectives provides an interesting

combination of behaviours, referred to as productive operations, which are directly
linked to productive thinking and creativity (De Corte, Geerlings, Lagerweij, Peters &
Vandenberghe 1981:51).
4.3.1 Bloom's taxonomy
Bloom's taxonomy of instructional objectives comprises three domains: cognitive,

psychomotor and affective, subdivided into hierarchical levels. For many years
educators have been accused of emphasising and evaluating only the lower levels of the
cognitive domain which rely on recall and reproduction of information. Treffinger,
Isaksen and Firestien in Parnes (1992:93) comment that contemporary educators and
110
theorists have identified the need to go beyond fact-finding and recognition or recall, and
to move to more complex and creative outcomes of learning and instruction. Creativity
experts view the higher levels of Bloom's cognitive domain, synthesis and evaluation,
as creative skills, and conclude that these are the productive operations which are
absolutely essential to creative problem-solving and creative production (Neethling
1993). The cognitive and affective domains are discussed to illustrate their relationship
to creativity.
4.3.1.1 Cognitive domain
Knowledge, as the lowest level of the cognitive domain, involves the memorisation of
information which makes recollection the main learning skill. Comprehension, the
second level, refers to the understanding of the meaning of the learning material and is
the ability to recall information from memory and to use it in a context similar to that
in which it was learned. Comprehension includes translation (to put a communication
into other terms), interpretation (reordering of ideas into a new configuration), and
extrapolation (the making of predictions based on the understanding of conditions
described in a communication). Application which follows, is the ability to use learned
material in a new situation where no solution is given (Bloom 1974:89-90; Steyn
1991 :17-19). These first three levels of the cognitive domain do not stimulate creativity,
as behaviour involving knowledge, comprehension and application, represent mere
reproduction. They are, however, essential to develop the body of knowledge on which
creativity is based.
Analysis, the fourth level of the cognitive domain, refers to the ability to break down
learning material into its elements and to perceive the existing relationships between the
parts in order to see the organisational structure. Analysis includes the ability to
recognise differences and similarities between aspects and the identification of the parts
that make up the whole (Steyn 1991: 19). Although analysis by itself cannot produce a
creative product, it serves as a pre-requisite for synthesis and evaluation, the two levels
111
of the cognitive domain involved during creativity. Analysis is a distinct phase of the
creative problem-solving process as described by Osborn (1953) (see 2.5.1.2).
Synthesis, the fifth level, refers to the ability to create something new from existing
elements. It comprises the putting together of elements and parts to form a whole or a
pattern not clearly there before. Synthesis involves a re-combination of aspects from
previous experience with new material, reconstructed into a new and well-integrated
whole (Bloom 1974:162). This level is the one that most clearly provides for creativity,
as it brings something new and novel into being.
As comprehension, application and analysis also involve the putting together of elements
and the construction of meanings, they tend to be more partial and less complete than
synthesis. They do not require originality and uniqueness as do synthesis. They involve
studying a given whole in order to understand it better, but synthesis depends on the
ability to draw upon elements from many different sources and to construct a new
pattern not clearly there before. Bloom (1974:162) refers to the tendency among
educators to place questions requiring the composition of essays in the synthesis
category. These do, however, very seldom fit into this category as they generally require
only comprehension and analysis in their compilation and very seldom is something new
and original produced.
Torrance (1979: 117) regards synthesis as the highest level of thinking in Bloom's
taxonomy and considers that this category has been neglected by educators. Synthesis,
as a right brain process, cannot be accomplished without knowledge, comprehension,
analysis, internal visualisation and openness to experience.
Evaluation, the sixth level of the cognitive domain, involves making a judgement about
the value of something while at the same time substantiating the judgement by referring
to criteria, facts or principles. Evaluation presents a major link with the affective
behaviours where valuing is one of the central processes involved. Although evaluation
112
is placed last in the cognitive domain and includes all the preceding levels, it is not the
last step in the problem-solving process. Evaluation must take place during each phase
of the problem-solving process in order to provide a better end product or solution
(Bloom 1974:185).
Evaluation is present throughout the creative process. It is employed, for example, when
ruling out irrelevant elements during the preparation phase, considering and selecting the
best ideas during the incubation phase, assessing ideas during illumination, and guiding
logical thought and creative thought when these combine during the verification phase
in order to produce a creative end product.
Educators who wish to grant their students the opportunity to develop their creativity
should focus more on challenging learning activities which stimulate thinking on the
analysis, synthesis and evaluation levels of Bloom's cognitive domain (see figure 4.5,
Treffinger's creative learning model, which shows Bloom's six levels of the cognitive
domain in relation to creative learning). Isaksen reports that many curriculum planners
and facilitators rely most heavily on the lowest levels of the creative learning model,
thereby stressing the cognitive techniques (Parnes 1992:95).
4.3.1.2 Affective domain
The affect refers to reactions rising from feelings or emotions. In the past, the latter have
been regarded as a block to the creative process, and no facilitating role could be
determined either for them or for feelings except in some types of creative expressive-
ness. This view has been replaced by a widespread acceptance of the important role that
the affect plays during creative thinking. Emotional factors must be understood and
used for breakthrough ideas - the ahas, satori or illumination - to occur (Klein 1973: 122;
Torrance 1979:86).
113
Figure 4.5
Creative learning model
Cognitive
Affective
Independent inquiry
Self-direction Internalisation
Resource management of values
Product development Commitment to pro-
"The practicing professional" ductive living
Towards self-actualisa-
tion
Cognitive Affective
Application Awareness development

Analysis Open to complex
Synthesis feelings , conflict
Evaluation Relaxation, growth
Methodological and research Values develop-
skills ment
Transformations Psychological safety
Metaphor and analogy in creating
antasy, imagery
Cognitive Affective
Fluency Curiosity
Flexibility Willingness to respond
Originality Openness to experience
Elaboration Risk taking
Cognition and memory Problem sensitivity
Tolerance for ambiguity
Self-confidence
(Treffinger et al 1982: 19)

114
The role of the affect in creativity is demonstrated in several definitions and theories of
creativity. Anderson's definition of creativity refers to affection for an idea, intensity of
encounter, delight and ecstasy- all of which encompass feeling and emotion. Helmholtz
has mentioned the happy ideas which came to him unexpectedly and without effort
during the incubation phase of a creative process. His conclusion is that these ideas did
not appear without emotional involvement. Torrance considers that a sensitivity to
problems is one of the key-creative abilities. Sensitivity, according to Klein (1973: 123 ),
represents an awareness of your immediate environment, and the use of your percep-
tions to make cognitive statements and identifying feelings. The distinction between
sensitivity and perception is that sensitivity demands an emotional reaction.
The affect is regarded by psychologists as an essential part of a well-balanced

personality and an essential ingredient of a creative person. Treffinger includes affective
dimensions on all three levels of his creative learning model (see figure 4.5).
The affective domain of Bloom's taxonomy of objectives, as categorised by Krathwohl

(1964 ), encompasses emotions, attitudes and values which can be developed and
changed during the learning process. The development of the affective domain depends
heavily on the simultaneous acquisition of knowledge (cognitive domain).
Receiving, as the lowest level in the affective domain, involves becoming aware of
stimuli (sights, sounds, events) and a willingness to receive and give selected attention
to stimuli. The concept of increasing emotional awareness to facilitate creative learning
has been addressed by the Creative Education Foundation's creative problem-solving
courses and is in their 1977 guidebook on creative problem-solving. Parnes, Noller and
Biondi discuss various affective techniques to increase awareness of internal and external
stimuli. These include altered states of consciousness, awareness training, deep
relaxation, fantasy, and meditation (Steyn 1991:22; Torrance 1979:88).
The second level of the affective domain, responding, refers to the active participation
115
of the student in the learning situation. Responding may be voluntary or involuntary

according to a pattern which is consistent with the particular value a student holds. No
element of commitment is, however, present at this level. A student may, for example,
play a voluntary role in a role play by taking a role that portrays attitudes he/she
complies with. Emotional involvement and expressiveness are regarded as extremely
important for success in all the creative expressive arts, as well as for creative work in
the helping professions, such as social work, psychotherapy and counselling. According
to Torrance, a high level need for the skills of empathy (an imaginative kind of
understanding of another person that transcends cognitive, intellectual and rational
boundaries) is associated with these professions. Nursing as a humanistic science views
empathy as an all important skill during the interaction between nurse and patient (Steyn
1991 :23; Torrance 1979:93).
Role play (discussed in 7.9) can be beneficial for the development of the first two levels
of the affective domain, receiving and responding. It increases awareness and
concentration, sharpens the senses, enhances the discovery and control of emotions and
increases empathic understanding of others. Role play can assist students to become
sensitive to situations and problems, and to become open to experience - the concept
which is regarded as essential to creativeness by several theorists (see figure 4.5 for the
two levels mentioned which are included on the first level of the creative learning
model).
Valuing, the third level of the affective dom(;lin, involves the recognition of the worth
of a situation, object or behaviour, and the ability to assess situations, objects and
behaviour. Students become capable of accepting values and displaying a preference for
certain values, and they show a willingness to commitment. According to Torrance
(1979: 12, 93 ), the perseverance and deep involvement required to achieve satori or
eureka level thinking, requires a very high degree of commitment, which he refers to as
creative motivations. This kind of commitment is referred to as love of one's work, a
deep emotional attachment that goes beyond reason and logic. Torrance has identified
116
this characteristic in his thirty year study of the beyonders, and many of history's creative
geniuses have commented that they fell in love with something at an early age and
retained this emotional attachment. Amabile (1986), one of the foremost creativity
researchers, says that extraordinary talent, personality and cognitive ability appear not
to be enough but that it is the labor of love which determines creativity (Steyn 1991 :23-
24; Torrance 1993:131, 133).
Organisation, the fourth level of the affective domain, comprises the investigation of
attitudes and values together with the organisation of various values relevant to a specific
situation. Organisation requires the conceptualisation of a value in a certain form.
Organisation comprises interaction between the affective and cognitive domains as
conceptualisation is a higher cognitive function, comprising analysis, synthesis and
evaluation. Role play and sociodrama can be used to assist students to develop the
affective skill of organisation. Conflict situations can be enacted in a sociodrama and
the students who act as the audience can be asked what values, attitudes and emotions
were displayed by which characters. They can then further debate on the relevant
importance of different values and attitudes in specific situations. Both valuing and
organisation appear on the second level of the creative learning model (see figure 4.5)
(Parnes 1992:398; Steyn 1991:24).
Characterisation, the fifth and last level of the affective domain, involves the
perception of ideas, attitudes and beliefs as a coherent whole. When a student has
characterised a value system, he/she will behave in a predictable manner, displaying
certain values as a behaviour pattern (Steyn i 991 :25). Values clarification as a teaching
strategy can assist student nurses to explore their own values, attitudes and beliefs and
to realise the importance of characterisation of a value system which will enable them
to act consistently when dealing with ethical issues or patient problems. According to
Perkins in Sternberg and Smith (1988:331 ), distinctive fields require distinctive values,
and expertise means that the potencies and values which are distinctive to a field
discipline (mathematics, physics, nursing, etc) have been internalised. Over and above
117
the mastery of the cognitive and psychomotor skills, the characterisation of the values
pertaining to the nursing profession are essential in order to develop into a creative nurse
practitioner (see figure 4.5).
The importance of the affective nature of creative talent has been emphasised by many
creativity experts including the personality theorists and the humanistic theorists.
Edward de Bono has declared emotions as more important than anything else in thinking
and explained that emotions precede thinking and give it its power (Torrance 1979:87).
Herrmann (1989) emphasises the importance of emotions (seated in the limbic system
of the brain) in whole brain creativity.
In conclusion it can be said that the aesthetic quality of creative products speaks for itself
in the language of the affect.
4.3.2 De Corte's classification
De Corte and co-authors view the categorisation of objectives as the concretisation of

more general aims of education but their taxonomy is less explicit than that of Bloom
and co-workers. Two major categories are distinguished; receptive-reproductive
operations and productive operations. Each of the seven categories included presents
a determined intellectual behaviour pattern. The receptive-reproductive operations are
functional when information is available or can be obtained to reproduce. The
productive operations become functional when students are confronted by a problem
which cannot be solved merely by reproducing information (De Corte et al 1981 :51;
Steyn 1991 :35).
It is the productive operations which are related to creativity. Aschner and Bish view
productive thinking as embracing the operations of creative thinking and problem-
solving. They compare the seven stages of the creative process as described by Rossman
(see 2.5.1.2) to the five stages of problem-solving according to John Dewey which
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comprise: recognition of a problem, analysis of the problem, suggestion of possible

solutions, testing of the consequences, and judgement of the selected solution.
According to them, a problem for an individual does not exist unless there is a need for
novel thinking. If no change in behaviour is needed to cope with a problem, there is no
problem. They conclude that all problem-solving which is genuinely problem-solving,
is creative; and they find the term creative problem-solving redundant (Aschner & Bish
1965:8-9).
4.3.2.1 Receptive-reproductive operations
Apperception of information refers to the discovery of new information in specific

given material, by selective and comparative observation, based on existing information
obtained earlier. Recognising information involves the recognition of previously
learned material when it is presented again in a similar or different context. Reproduc-
tion of information is actively recalling information from memory and reproducing it
in a similar form to that in which it was stored. It includes the reproduction of
procedures (De Corte et al 1981 :51-52; Steyn 1991 :35-36).
These categories in De Corte's classification include the knowledge and comprehension

levels of Bloom's taxonomy and reproduction of information also includes the
application level. The receptive-reproductive operations are not congruent to creative
thinking but they are pre-requisites for creative thought since creativity cannot emerge
without thorough knowledge of a subject.
4.3.2.2 Productive operations
The productive operations are related to creative thinking and problem-solving since they
rely on the presentation of something new to solve a problem and not on mere
reproduction of already known information.
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Interpretive production of information refers to the explanation, paraphrasing,

exposition or summarising of given new information. The student is supposed to
recognise relationships between components and must be able to abstract the most
important content from the material (Steyn 1991 :37). This category includes the
comprehension and analysis levels of Bloom's taxonomy, as material must be
comprehended and analysed in order to be able to abstract the most important content
from it. This operation also comprises some of the key-creative abilities as described
by Torrance. It includes internal visualisation - visualising beyond the exterior to pay
attention to internal dynamic forces in order to expose hidden aspects. Penetration is
applied to get underneath the problem and away from the obvious in order to explain
and paraphrase, and sensitivity to problems is required to be able to understand and
abstract the most important material.
Convergent production of information refers to problem-oriented thought. The

student is presented with a problem which he has to solve by using available information
from the problem itself as well as by actualising appropriate knowledge from memory.
The previously learned information may include principles, concepts, rules and
techniques. Convergent production means that there is only one solution to the problem,
logically determined by the data given - information included in the problem itself (De
Corte et al 1981 :55; Steyn 1991 :38). This category involves the knowledge,
comprehension, application and analysis levels of Bloom's taxonomy. The student has
to recall appropriate and applicable information from memory. Analysis of a problem
is necessary to break up the given data into smaller parts and to determine from there
what data are still needed before the problem can be solved. Convergent production is
included in Guilford's structure-of-intellect-model and refers to giving the right answers
based on factual information (Aschner & Bish 1965 :27). This operation is part of the
creative process; convergent thought, as a left brain process, includes rational and logical
thought and is present during the preparation and verification phases of the creative
process as described by Wallas (see 2.5.1.2).
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Evaluative production of information involves the evaluation of information by

making a value judgement based on the testing of the information according to specific
criteria. The criteria can be either internally based on the logical structure, consistency
and composition of the information or they can be externally based on the purpose or
efficiency of the material for a specific goal and generally accepted norms for the
evaluation of such material. This operation meets the criteria of critical thought (De
Corte et al 1981:55-56; Steyn 1991:38). It includes the knowledge, comprehension,
application, analysis and evaluation levels of Bloom's taxonomy. Evaluation relies
heavily on cognitive processes but it can never be totally dissociated from the affect. It
involves left and right brain processes and is present during all phases of the creative
process.
Divergent production of information involves a problem situation in which there is

more than one solution. Apart from relying on pre-learned information, students also
have to think in divergent directions in order to come up with different solutions to the
problem. This operation is directly linked to creative thought and gives them an
opportunity to be flexible in their thinking (De Corte et al 1981 :56; Steyn 1991 :39). It
includes all the levels of Bloom's taxonomy with special emphasis on evaluation and
synthesis. Torrance's key-creative abilities (2.5.1.1) are strongly represented during
divergent production.
Sensitivity to problems and penetration are needed to see deficiencies and the unusual,
and to get underneath the problem and away from the obvious. Internal visualisation can
contribute to a wider understanding of, and an insight, into the problem if the student is
able to visualise beyond the exterior in order to pay attention to the internal dynamics
of the problem. Once this is established, psychological openness accompanied by
fluency and flexibility (which require practice and patience) can contribute towards a
variety of possible solutions. This creates the right atmosphere for the emergence of
originality, synthesis, elaboration and redefinition. A unique solution can be synthesised
from many alternatives and elaboration and redefinition can produce a more effective
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and original end product.
Figure 4.6 shows the relationship between De Corte's classification of objectives and the
operations of Guilford's structure-of-intellect model. Guilford's operations comprising
cognition and memory concur with De Corte's receptive-reproductive operations which
do not require creative thought. It is the productive operations as identified by De Corte
which are required for creative thought and these concur with Guilford's operations
involving convergent production, evaluation and divergent production.
4.4 THEORIES OF LEARNING
Leaming as a process which causes a permanent change in knowledge and behaviour,

has been studied in various schools of psychology. The behavioural learning theories
which focus on observable behaviour, do not have a significant influence on creativity
as these theories postulate a controlled, authoritarian and rigid teaching-learning
environment where emphasis is placed on external motivation. This is directly opposed
to a creativity inducing environment which requires an unstructured teaching-learning
situation that allows active involvement, psychological freedom, exploration, deferred
judgement, humour and enjoyment. The cognitive learning theories which focus on
mental processes and emphasise intrinsic motivation, and the humanistic learning
theories which focus on affective learning, have much more in common with creative
learning. As creativity involves a combination of cognitive and affective processes,
some cognitive and humanistic theories and concepts are discussed below in relation to
creativity. The cognitive and humanistic theories ofleaming are of particular relevance
to nursing science as nurse practitioners have to develop, apart from their technical skills
(psychomotor abilities), both cognitive and affective skills in order to render holistic care
to mankind.
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Figure 4.6
The relationship between De Corte's classification and Guilford's

structure-of-intellect model
Operations (Guilford) Objectives (De Corte)
• Cognition
I A pperception of
infom1ation
Re ccpt1 'v c-rcp roducti \ c
I Recognising information operations
I Reproduction of
information
• Memory
• Convergent
I Interpretive production
production _____.. of information
I Convergent production
of infonnation Productive operations
• Evaluation _____..
[ Evaluative production
of infom1ation
(creativeness)
• Divergent
Divergent production
production _____..
of information
(Adopted and adjusted from De Corte et al 1981:51)

123
4.4.1 Cognitive theories of learning
The cognitive perspective on learning is a generally agreed upon philosophical

orientation. Cognitive psychologists are interested in how people learn concepts and
solve problems. They view people as active processors of information who initiate
experiences that facilitate learning and seek out information to solve problems.
Cognitive psychologists are concerned with the structures of knowledge and they study
memory, perception, attention, problem-solving, comprehension, concept learning and
meta-cognition (Woolfolk 1990:160, 228-230).
Cognitive learning theory seeks to explain unobservable factors, such as knowledge,

meaning, intention, feeling, expectations, creativity and thought. Cognitive psycholo-
gists regard intrinsic motivation as very important and emphasise the need to stimulate
students' curiosity, involve them actively in the learning situation and offer interesting
and enjoyable learning experiences (Woolfolk 1990:303 ). This view is congruent to that
of the personality theorists (see 2.5.2.1) who cite that creative people are intrinsically
motivated and find a deep enjoyment in their work.
4.4.1.1 Problem-solving and creative thinking
Problem-solving is a very important concept within the cognitive perspective as it

indicates transfer of learning. Ordinary problem-solving as an analytical step-by-step
process requires careful reading and thought, but not necessarily creative thinking. Many
problems can, however, be solved more effectively if creative thinking is applied.
Frederiksen (1984) in Slavin (1991:187-188) proposes six elements to be applied when

teaching creative problem-solving. These include:
(1) allow time for incubation (to pause and reflect on the problem and consider many
alternative solutions)
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(2) suspend judgement (all possibilities are accepted before ideas are evaluated)
(3) establish an appropriate climate (creative problem-solving is enhanced by a

relaxed, playful environment)
(4) analyse and juxtapose elements (to list the characteristics of a problem)
( 5) teach the underlying cognitive abilities (generating many ideas and unusual ideas)
(6) provide practice with feedback (an important aspect of creative problem-solving
is to offer students many opportunities to practice on a wide variety of problems)
The need for incubation, ideational fluency and flexibility, penetration, psychological
freedom, and freedom of perception during the creative process, is once again
emphasised in Frederiksen's explanation.
4.4.1.2 Metacognition and creative thinking
Metacognition is knowledge about thinking and refers to a person's ability to think about
his own thinking, and to exercise control over his thinking and learning activities.
Metacognition has been linked to creative thinking by several researchers who claim that
metacognition is an essential ingredient of creative thinking. Creative thinking
techniques are directly related to metacognition as these techniques assist individuals to
monitor and regulate their thinking and behaviour (Pesut 1990:105-107; Woolfolk
1990:252).
According to Woolfolk (1990:252), metacognition involves two separate components:
(1) an awareness of the skills and strategies necessary to perform a task effectively,
ie knowing what to do, and
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(2) the ability to use self-regulatory mechanisms to ascertain successful completion

of a task, ie knowing how and when to do what.
The strategies of the first component include identification of the main idea, forming
associations and images, organising new information, and note taking; whereas the
regulatory mechanisms include predicting outcomes, evaluating effectiveness of
attempts, testing strategies, and switching to other strategies if necessary. When these
two components of metacognition are compared to Pesut's definition of creativity,
several similarities can be determined. Pesut (1985:5) defines creativity as a metacogni-
tive process which generates novel and useful associations, attributes, elements, images,
abstract relations, or sets of operations and better solves a problem, produces a plan,
or results in a pattern, structure ofproduct not clearly present before.
The reference to identification of the main idea indicates holistic viewing as well as
penetration because a problem must be understood in its overall context which
necessitates going beyond the obvious. Generation of images, associations, attributes
and abstract relations refer to the utilisation of both left and right brain processes (see
table 3.1 ). The final production of a structure or product not clearly there before, can
only be brought about after evaluation of the effectiveness of several attempts has taken
place. The processes preceding final production involve openness to experience,
flexibility, synthesis, redefinition, elaboration and novelty - the key-elements of the
creative process as identified by Torrance. The presence of metacognition is also
evident in the descriptions of the two creative geniuses, Helmholtz and Poincare, as a
deep understanding of the what, where and when of their cognitive processes becomes
noticeable in their descriptions of their experiences (see 2.5.1.2).
Herrmann indirectly refers to the important role of metacognition when he postulates

that once people acquire knowledge of their own brain dominancy they can start
developing the lesser used processes of their brain which will enable them to move
towards whole brain creativity.
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Pesut (1985: 5) regards the development of nursing theory as a creative process that
requires metacognitive flexibility which facilitates the process of analysis, synthesis,
induction, deduction and reproduction. He regards this as essential to the creation and
verification of concepts describing the phenomenon of concern in nursing. Pesut
concludes that nurses with metacognitive knowledge can self-regulate creative thought
which enables them to practice more effectively and to develop and synthesise concepts
that enhance the development of nursing science.
4.4.1.3 Piaget: formal operational thought
Jean Piaget's theory on how thinking develops, has had an enormous influence on
developmental psychology. His theory of cognitive development comprises four stages -
sensorimotor, pre-operational, concrete operational and formal operational. It is the
formal operational stage which is related to creativity.
According to Piaget, formal operational thought involves abstract thinking, testing

hypotheses and forming concepts which are independent of physical reality. It is the
ability to deal with potential or hypothetical situations, to consider alternatives and to
analyse one's own thinking. Formal operations include what is normally referred to as
scientific reasoning - formulating hypotheses, setting up and testing mental experiments
and controlling variables. Individuals capable of formal operational thought can imagine
ideal worlds, think beyond the information presented to them and determine in an
organised way the number of different possibilities that exist within a limited framework
(Slavin 1991 :35, 37 & Woolfolk 1990:54-56).
Formal operational thought, as a higher cognitive ability, relates to various key-elements

of creative thinking. It concurs with Torrance's definition of creative thinking with
respect to the formulation and testing of various hypotheses and the consideration of
many alternatives in a given problem situation. The abilities of abstract, analytical,
linear and rational thinking, characteristic of formal thought, refer to left brain processes
127
whereas divergent thinking and analogical thinking which are also implied, refer to right
brain functioning. Ideational fluency (the ability to produce a variety of ideas or
possible solutions to problems), flexibility (to use a variety of approaches) and
penetration (to get underneath the problem and away from the obvious) seem essential
during formal operations.
The role of formal thought in creativity was reported by Saami ( 1973) who tested young
adolescents on two of the standard Inhelder and Piaget tasks. He found that formal
operational students obtained significantly higher ratings on two productive thinking
problems. Arlin (1975) examined the relationship between cognitive development and
creativity and found a significant correlation between formal thought tasks and scores
obtained in a divergent questioning task (according to Guilford's structure-of-intellect
model) as performed by a sample of female college seniors. He concluded that formal
thought was a necessary but not an adequate condition for creative problem-solving
(Noppe 1985:89). This conclusion appears to be realistic as creative problem-solving
and creativity do require more than formal thought. The illumination phase of creative
problem-solving, with all its processes, has not been described as part of formal thought,
and the intense emotional involvement, dedication and love for the task which are
characteristic of creative endeavour are certainly not present in all situations depending
on formal thought. As many adults achieve formal operational thought in only a few
areas (according to Piaget and others) there is a possibility that perceptual frameworks
in these areas might hinder psychological openness (as described by the Gestalt theorists)
which is so crucial to creativity.
Anderson (1975) refers to formal thought when he describes the creative thinker as being
a logical, intuitive and cognitively complex person who is interested in the possibilities
behind the facts, rather than just the facts themselves. He adds that both formal
operational logic and a deep repertoire of experimental structures are required for
creativity as exclusive dependence on logical processing does not allow for sufficient
material to facilitate creativity (Noppe 1985 :94-95). This concept is congruent with
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Herrmann's view of whole brain creativity and the emphasis he places on structured as
well as experiential learning settings (see figure 3.4).
Noppe (1985:89, 95) is of the opinion that present research identifies the achievement
of formal operational thought (probably for a specific domain and mediated by a flexible
cognitive style) as the hallmark of creativity. Noppe's own research indicates that
creativity is facilitated by a mobile field-independent cognitive style and formal
operational thought.
Nursing science needs nurse theorists who can enhance nursing's body of scientific
knowledge and it appears as though this level of thinking and functioning necessitates
formal operational thought. The South African Nursing Council's policy with regard to
professional nursing education states that the goal of nursing education is to develop the
abilities of analytical, critical-evaluative and creative thought in students (SANC
1993 :4 ). These abilities necessitate the development of formal operational thought.
4.4.1.4 Bruner: Discovery learning
Bruner, one of the foremost cognitive psychologists, follows an eclectic approach to

psychology. Eclectic theorists reject large-scale theorising (system building) and
selectively borrow ideas and concepts from existing systems and arrange them in eclectic
bodies of knowledge that exhibit more or less internal consistency (Bigge & Hunt
1980:21, 392). Bruner views the different modes whereby a person acquires knowledge
as examples of a problem-solving process, and proposes that students must learn
through inquiry and discovery. His discovery learning model, based on problem-
solving, is regarded as one of the most influential cognitive instructional models.
Discovery learning can be directly related to creative learning as most of the internal
concepts are interrelated.
According to Bruner, the most fundamental principle ofleaming is the understanding of

129
the structure of a field of knowledge. The structure of subject matter comprises the
fundamental framework of ideas, relationships or patterns - the essential information.
Bruner suggests that the structure must be discovered by the students themselves through
inductive reasoning. Teachers should provide students with many examples to enable
them to discover interrelationships which will lead to general principles and eventually
to the structure of the subject matter.
An important concept within Bruner's cognitive eclectic approach is that of coding

systems which he believes constitutes the structure of one's knowledge. He defines a
coding system as a set of contingently, related, non-specific categories and describes
coding as a process during which concepts are combined into generalisations or
knowledge structures. Formal codes are subsumed under principles of logic, whereas
informal (probabilistic) codes are generalisations acquired inductively or intuitively
(Bigge 1982:242-243). According to Bruner, it is a person's coding system that enables
him/her to go beyond given information in order to develop inventive or creative
behaviour. An individual goes beyond given information by placing available empirical
facts into a more generic coding system and then, based on previously learned principles
of related material, he deduces additional information from his coding system. As an
ever increasing number of concepts and generalisations are related and code upon code
is built, the individual achieves a deeper understanding of the problem situation or
subject material (Bigge & Hunt 1980:403- 404). Going beyond given information,
relates to some of the key-creative abilities as described by Torrance. Penetration -
getting underneath the problem and away from the obvious, internal visualisation -
visualising beyond exteriors to pay attention to internal dynamic workings, psychologi-
cal openness - taking time to understand a problem and consider alternatives, synthesis -
forming relevant associations into new configurations and redefinition - reorganising in
new ways, are all involved when going beyond given information.
Bruner views the various modes whereby individuals acquire knowledge as examples
of problem-solving and identifies the two major steps as:
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(1) an intuitive leap from available sense data to a tentative hypothesis by relating
incoming information to a coding system, and
(2) a confirmation check whereby the tentative hypothesis is tested against further
sense data, after which the hypothesis may be maintained or altered (Bigge
1982:247; Bigge & Hunt 1980:399).
The involvement of both intuitive and analytical thinking indicates the utilisation of a
combination of left and right brain processes. Bruner regards intuition as a much
neglected but essential feature of productive thinking, and suggests that teachers should
encourage students to make guesses based on incomplete evidence and then subsequently
to confirm or disprove these guesses systematically. He accuses traditional educators
of discouraging intuitive thinking by rewarding safe and uncreative answers and
punishing wrong guesses. According to Bruner, teachers should not tell students how
to solve problems, but should only provide the appropriate materials and then encourage
them to make observations, formulate hypotheses and test solutions (Bruner 1977:14;
Woolfolk 1990:289-290).
Discovery learning encourages students to have experiences, conduct experiments and

solve problems on their own or in groups; it arouses their curiosity which stimulates
intrinsic motivation (an important aspect during creative performance (see 2.5.2.2.4);
and it helps them to gain independence. Students are encouraged to consider many
alternatives during problem-solving and time should be allowed before assistance with
solutions is given - this implies deferred judgement which is crucial to a creativity
inducing environment as explained by Parnes (see 2.5.2.2.2). Questioning techniques
which stimulate the development of fluency and flexibility are advocated (Slavin
1991:192, 194; Woolfolk 1990:290-291).
When the nature of discovery learning, as described by Bruner, is related to Herrmann's

whole brain teaching and learning model (figure 3 .4), this form of learning is seen to
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lean heavily towards right hemispheric functioning. The focus is on experiential,

explorative and spontaneous learning, and open-mindedness and independence are
advocated. Left hemispheric functioning is, however, not neglected as the problem-
solving process during discovery learning also depends on logical, rational, organised
and sequential thought. Discovery learning seems to provide ideal opportunities for the
development of creativity.
The South African Nursing Council requires that student nurses be able to solve
problems effectively in order to apply a scientific approach to nursing (SANC 1993: 10)
and identifies in their teaching programme the objective (SANC 1985 :2) that students
should be encouraged to evince an enquiring and scientific approach to the problems of
practice. Discovery learning would be an appropriate strategy to stimulate and develop
these abilities.
4.4.2 Humanistic theories of learning
4.4.2.1 Humanistic psychology
Humanistic psychology, which started as a reaction against Behaviourism and Freudian

psycho-analysis, has certain basic tenets which are deeply rooted in Existential
philosophy. Humanistic psychologists view man as a unique, integrated whole, who is
free to make his own choices. They see man as becoming, striving towards fulfilness
and self-actualisation. Man is self-determined and has creative potential (Hjelle &
Ziegler 1987:366-367). The basic tenets of Humanistic Psychology are of specific
significance to nursing science as a human health science. Man is regarded as a physical,
psychological, spiritual and social being and must be approached and cared for in his
totality. Each individual, including the nurse and her client, has freedom of choice, but
this is a freedom with responsibility. Student nurses are specifically guided towards
developing responsibility, accountability and personal and professional autonomy in
nursing and they can only reach this level of development if they are self-determined and
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have reached self-actualisation. It is the nurse educator's responsibility to guide students

towards attaining their full potential as individuals and as professional nurses. This
concept includes developing their creative potential - self-actualised creativity, as
Maslow has defined it (self-actualisation is on the highest level of Treffinger's creative
learning model - figure 4.5).
Humanistic education protests against the overuse of drill and rote memorisation in
education. It focuses on the affective outcomes of learning, such as feelings, attitudes,
beliefs, purposes and values and is concerned with learning how to learn and with
enhancing creativity and human potential. Humanistic psychologists stress the
importance of intrinsic motivation and regard the role of needs, especially the need for
self-actualisation, as central to motivation. Students must explore and experiment and
learn to think for themselves; they must be self-directed and self-motivated. This could
be accomplished in the educational situation by focusing on students' existing interests
and needs, providing opportunities for problem-solving and allowing flexibility,
spontaneity and informality in the classroom. Humanistic psychologists stress student-
centred learning and favour discovery learning. They advocate that these approaches
stimulate students' curiosity, sharpen their reasoning powers and allow them to become
self-reliant and responsible. Learning through discovery is more satisfying and
meaningful and more fun (Gage & Berliner 1992:479-481; Kolesnik 1975:32, 53, 57,
60, 61; Slavin 1991:264; Woolfolk 1990:305).
The development of the student nurse's affect is of the utmost importance to effective
nursing practice. The patient's feelings, beliefs, attitudes and values must at all times be
taken into consideration. Student nurses need to internalise their own feelings, attitudes
and values before they can take care of their patients' psychological and social needs as
well as make decisions on ethical issues which are of benefit to the patient. The South
African Nursing Council requires that the professional nurse masters the skill of moral-
ethical reasoning when studying the subject Ethos and Professional Practice of Nursing
(SANC 1992:13). The values emphasised by humanistic education, such as
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consideration, cooperativeness, mutual respect and honesty (Slavin 1991:365) are

essential to effective nursing practice. Honesty and cooperativeness between the nurse
practitioner and her patient, as well as all the other members of the health team, are
important for the total well being of the patient and the effective deliverance of health
care. Consideration and respect must be highly valued by nurse practitioners who wish
to act persistently on the best behalf of their patients.
The essential role of the affect in creativity has been acknowledged in definitions of
creativity and the creative process (illumination phase), and in the personality and
environmental theories on creativity. Personality theories focus on the affective nature
of creative talent and emphasise the abilities of openness to experience, sensitivity, self-
control and self-reliance (see 2.5.2.1)
Torrance (1993) in his study of the beyonders comments on the passion, drive,
dedication and enthusiasm which he identified repeatedly in creative people - all aspects
which refer to the affect. Herrmann (1989) emphasises the role of the affect in his whole
brain creativity model (figure 3.3) and refers specifically to the right half of the limbic
system as the seat of emotions.
The concepts of intrinsic motivation, self-directedness, flexibility, curiosity, problem-

solving and discovery learning which are emphasised by humanistic education, are
congruent with the requirements for creative learning. Many creativity theorists,
including Hennessey and Amabile, Crutchfield (1962), Lepper and Greene (1978), have
stressed intrinsic motivation as essential to creative learning (see 2.5.2.2.4). Self-
directedness, curiosity and being needs (Maslow) are deeply involved in intrinsic
motivation. Problem-solving and discovery learning provide opportunities for
productive thinking, personal growth and meaningful learning, all of which contribute
towards the development of creativity. Problem-solving and discovery learning are of
special importance when teaching the health and social sciences in the nursing
curriculum. The complexity of contemporary health and patient problems necessitates
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divergent thinking skills and creativity in order to find effective solutions.
The flexible, spontaneous, experimental, psychologically free and informal learning

environment advocated by the humanistic psychologists is congruent with Parnes'
concept of the open teacher and the relevant concepts pertaining to the facilitation of
creative learning (see 2.5.2.2.3). The application ofhumanistic educational concepts can
contribute towards the development of especially the right brain processes as is evident
in Herrmann's whole brain teaching and learning model (see figure 3.4).
4.4.2.2 Rogers: Student-centred learning
Rogers formulated a student-centred approach to learning which relates to the concepts

of creative learning and which is of particular significance to nursing education.
According to Rogers (1969), significant learning takes place when information has
relevance for the student's own purposes and is acquired through responsible participa-
tion in the learning process. He regards self-initiated learning which involves the
intellect as well as feelings, as more lasting and pervasive and states that independence,
self-reliance and creativity are facilitated when self-criticism and self-evaluation are
applied. External threats and threat to the self should be kept low in order for learning
to proceed. Rogers emphasises the importance of the relationship between educator and
student and singles out genuineness, trust, acceptance and emphatic understanding, as
being the essential qualities for this relationship (Gage & Berliner 1992:479, 483; Quinn
1989:43-44).
When the requirements of a creativity inducing learning environment are taken into
consideration, it becomes apparent that Rogers' principles of student-centred learning
comply with these requirements.
Active participation in the learning process and self-initiated learning involving both
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intellect and feelings are imperative in creative learning. The love for one's work,
dedication, intrinsic motivation, independence and self-reliance emphasised by Torrance
and the personality theorists (see 2.5.2.1) are all concepts which are advocated by Rogers
as important to facilitate meaningful learning. The concepts of self-criticism, self-
evaluation and the lowering of external threats, are imperative in a creativity inducing
learning environment, as are discussed under the open teacher (see 2.5.2.2.3). The
affective abilities of trust, genuineness, and emphatic understanding directly relate to the
nurturing of creativity as students need to experience a psychologically safe environment
before they are willing to experiment and take risks. Openness to experience, as a key-
element of creativeness, has been emphasised by all creativity theorists. The principles
of student-centred learning, as advocated by Rogers, are represented in Herrmann's
whole brain teaching and learning model (see figure 3.4).
In nursing education, one way of lowering external threats and threats to the self is
attained by giving students opportunities to practice psychomotor skills in the clinical
laboratory before they perform procedures on patients. This lowers the risk for the
patient and allows for the development of psychomotor skills in a physical and
psychologically safe environment. The kind of relationship between educator and
student, as described by Rogers, is of special importance in nursing education. Students
need to develop a relationship characterised by genuineness, respect and trust with their
patients in order to provide optimum nursing care. Nursing practice needs self-reliant,
independent, responsible, knowledgeable and compassionate practitioners to render
effective, holistic care to patients.
4.4.2.3 Maslow: Self-actualisation
Maslow's theory of human motivation relates to many aspects which are essential to
creativity. He distinguishes between deficiency needs (physiological, safety, love, and
esteem) and growth or being needs which include the need to know, understand things
and appreciate beauty, and the need for self-actualisation.
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Maslow advocates that deficiency needs must be satisfied before the individual will
strive towards fulfilling the higher needs, the being needs. He regards self-actualisation
as congruent with creativity, and advocates that the goal of education should be to assist
the student to achieve self-actualisation in order to become the best one that is able to
become (Gage & Berliner 1992:479; Quinn 1989:42; Slavin 1991:321-322).
Maslow's theory can be applied to nursing education with the aim of nurturing creativity
in student nurses. The organisation of a psychological learning environment that takes
care of safety needs and the needs for love and self-esteem, can be attained in an open
and trusting relationship between educator and student. This reflects mutual acceptance
and emphatic understanding. Students need to feel loved, appreciated and capable
before they are able to strive towards the higher being needs, such as the search for
knowledge and understanding, creativity and openness to new ideas, which are
characteristic of the self-actualising person. The ideal for the student nurse is to reach
the level of self-actualisation as this will enable her to act as a more effective practitio-
ner. The characteristics of the self-actualised person, as identified by Maslow, are the
characteristics that the nurse educator would like to recognise in the graduating student
nurse.
In 1971 Maslow made the following scientifically cautious statement which has
promising implications for nurse educators who wish to nurture creativity in their
students: ... The concept of creativeness and the concept of a healthy, self-actualising,
fully human person seem to be coming closer and closer together, and may turn out to
be the same thing. Maslow identified those characteristics of self-actualised people
which support this statement. These are that self-actualised people accept themselves
and others, and are spontaneous, self-sufficient, independent, autonomous and
democratic. They are strongly ethical and moral in individual ways, are capable of
detachment from their culture and can objectively compare cultures. These people
express deep feelings of brotherhood with all mankind, have a zest in living, a high sense
of humour and an ability to handle stress. They perceive reality more objectively and
137
accurately, tolerate ambiguity and are problem-centred, not self-centred. Self-actualised

people are inventive and original and tend to do most things creatively, although they do
not necessarily possess great talent (Davis 1985 :4-5).
The South Afucan Nursing Council stipulates in the programme objectives for the course
leading to a registered nurse (SANC 1985 :2), that the newly qualified nurse should
show respect for the uniqueness of man in his sociocultural context and that man be
understood as a psychological, physical and social being. It is stipulated further that the
nurse practitioner should maintain the ethical and moral codes of the profession, interact
with patients emphatically, practice independently and accept responsibility thereof, and
evince an enquiring and scientific approach to the problems of practice while initiating
and accepting change.
The professional nurse needs to possess the characteristics of the self-actualised person
in order to comply with all of the abovementioned requirements.
4.5 CONCLUSION
The nurse educator who wishes to nurture creativity in her students needs to have a
thorough knowledge of individual learning styles and theories of learning supplemented
by a sound background knowledge of the theories of creativity. She must be able to
identify her students' learning styles and adjust her teaching approaches accordingly. She
must know what theories of learning are applicable when creating a creativity inducing
learning environment. She must be skilful at setting objectives on the higher levels of
Bloom's cognitive and affective taxonomies and on De Corte's productive operations
level, in order to stimulate creative thought in her students.
138
CHAPTERS
Educational models and creativity
5.1 INTRODUCTION
The literature on instructional design contains various definitions for educational models.
Joyce, Weil and Showers (1992:1) view models of teaching actually as models of
learning, as they assist students to acquire information, ways of thinking, skills, values
and ideas. Reigeluth (1987:2) refers to models of instruction as sets of strategy
components that have been combined to optimise the quality of instruction. Maker
( 1982: 1) describes a teaching-learning model as a structural framework which guides the
development of specific educational activities and environments. As education is a more
comprehensive concept which encompasses aspects concerned with both teaching and·
learning, the term educational models will be used.
Educational models have in common an identified purpose; underlying assumptions

about the characteristics of learners and the teaching-learning process; guidelines
regarding specific learning experiences; requirements for these learning activities and
139
evaluation of their effectiveness (Maker 1982: 1).
Adult learning, mastery learning, experiential learning and open learning are
discussed in this chapter. These four models have been selected because of their student-
centred approach in which the student's needs are of primary concern. Each of these
educational models is in its own special way applicable to nursing education, as nursing
is a humanistic science and a professional discipline with an overall practice component.
There are other educational models such as Gagne and Briggs' prescriptive model of
instruction, Bruner's social learning and Ausubel's reception learning which are also
useful in the teaching of nursing. The four selected models, however, are more
comprehensive in nature and more widely applicable in nursing education.
The specific relevance of each of these models to nursing education will be elaborated
on during the discussion. In order to better understand what teaching for creativity
encompasses, elements relating to creativity will be identified and explored as the models
are analysed.
5.2 ADULT LEARNING
5.2.1 Nature of adult education
Adult education includes all forms of education which treat the participants as adults -
capable, experienced, responsible, mature and balanced people. Adult education is
viewed as a purposeful effort towards self-development, as adulthood is marked by a
growing awareness of self and by a readiness to make existential choices (Brookfield
1991 :91 ). The concept of existential includes being individually involved, committed,
open and individually valuing.
Adult education is viewed as being liberal as it is value-laden and culturally bound, and
embraces liberal, technical, religious and community education as well as literacy and
140
degree programmes (Hake and Morgan 1989: 16-17; Rogers 1989: 19). Its comprehen-
siveness is evident in William Allen Nielson's view of it: ... Effectiveness in work, in
citizenship and the enjoyment of life depends on the persistence of the effort to grow in
breadth and depth, and to bring more of the universe within the scope of our individual
organised thinking (Kahler, Morgan, Holmes & Bundy 1985:18).
Brookfield's reference to growing self-awareness and a readiness to make existential

choices, and Nielson's view of the individual's growth in breadth and depth, relate to
Maslow's concept of self-actualising creativeness. According to Maslow, self-actualised
individuals are self-sufficient, independent and autonomous; they demonstrate an
openness to experience and tend to be problem-centred. He associates self-actualising
creativeness with growth and health and the willingness to live one's life truly and to its
fullest capacity (see 2.5.3 and 4.4.2.3).
Knowles (1986:29) views adult education as presenting a challenge to static concepts

of intelligence, standardised limitations of conventional education and to the theory
which restricts educational facilities to an intellectual class. Russel in Kahler et al
(1985: 18) states that the aim of adult education is to inspire grownups to be something
more than they are now and to do their work better than they now do it. Both these
opinions indicate a resistance to accept things as they are and a need to move towards
self-development and excellence.
Adult education is essentially student-centred and built upon the assumptions of

andragogy. These assumptions form the fundamental tenets of adult learning (Nielsen
1992:149-150). Patterson (1986:99) pointed out that there are remarkable parallels
between creative learning and learning by using andragogical principles. He states that
andragogy fosters creativity which in tum promotes effective adult learning. This issue
is explored further in the last section (5.6) of this chapter.
141
5.2.2 Assumptions of adult learning
The assumptions of adult learning, originally identified by Knowles, are:
5.2.2.1 The need to know
Adults want to know why they need to learn and how they can use the knowledge in real-
life situations. According to Knowles (1986:55-56), it is the function of teachers to raise
their students' level of awareness of the need to know. He suggests that real or simulated
experiences must be provided to enable them to discover for themselves the gaps
between where they are and where they want to be.
If the learner perceives the learning material as being meaningful and applicable in
his/her situation, learning will be enhanced. Steyn (1994:7) points out that learning
material should be presented in a pattern that the learner is able to perceive and in a way
that is compatible with the learner's experience, in order to establish meaningfulness.
5.2.2.2 The learner's self-concept
Through the ability to form abstract ideas man is allowed to think about himself and how
he appears to others, and this knowledge defines the self. All new experiences and
knowledge are organised into some relationship to the self. Adults with a positive self-
concept are more ready to learn and to accept change. Adults have an independent and
responsible self-concept which allows them to be self-directed. Self-directedness refers
to the adult's ability to independently plan, conduct and evaluate learning abilities
(Brookfield 1991:40; Brundage & Mackeracher 1980:23-24).
Smith (1982) regards skills, such as the ability to identify one's own learning style and
to use one's intuition, as essential for self-directed learning. Cheren (1983) remarks that
there is a whole-person aspect to self-directed learning. The self-directed learner is
142
viewed as the humanistic ideal, the self-actualised person. Houle ( 1961) describes this
person as someone who approaches life with an air of openness and an inquiring mind
(Oddi 1987:27).
Studies conducted by Brookfield (1981) and Gibbons et al (1980) show that self-directed
learners acquire knowledge through inquiry, and that they use experimentation, problem-
solving, casual encounters and informal conversations to develop their expertise in areas
of interest (Oddi 1987:23, 27). Vygotsky, a cognitive psychologist, refers to self-
directed learning as a higher mental function, a tool ofthought (Grow 1991:128). These
findings and viewpoint indicate that self-directed learning involves productive learning,
the emphasis being on the higher cognitive skills.
Bell and Bell (1983 :27) comment that self-directed learning is criterion-referenced and
allows and encourages students to work together in a cooperative manner. It thus
facilitates interaction and the exchange of viewpoints which challenge the higher
cognitive processes as well as affective development.
Various research studies have revealed that there are varying degrees of self-direction.
Grow has developed a model on how to facilitate learning for students in the different
stages of self-directed learning. He has found that self-direction can be situational,
meaning that students may have it in one, but not all, subjects (Grow 1991: 126, 132).
5.2.2.3 The role of the learner's experience
Adults enter the educational situation against a background of a great variety of

experience which serves as a rich resource of learning for fellow students. According to
Knowles (1985: 1O; 1986:57), adults feel rejected when their experience is ignored
because they d~rive their self-identity from it. He suggests that experiential techniques,
such as group discussions, problem-solving activities, the case study method and
laboratory methods, be used to draw from the experience of adults. Knowles, however,
143
also draws attention to the negative effects of experience - the tendency to develop
mental habits, biases, and presuppositions that tend to cause us to close our minds to new
ideas, fresh perceptions and alternative ways of thinking. He suggests that adult
educators should discover ways of helping students to open their minds to new
approaches, and that techniques such as sensitivity training, values clarification and
mediation, could be useful (Knowles 1986:58).
According to Brundage and Mackeracher (1980:33), adults use transformations when

they incorporate new knowledge into existing knowledge. During transformations,
individuals become aware of both figure and ground, and learn to move some of the
ground forward while at the same time moving some of the figure back. In this way
some of the relationships are reorganised on a new basis. Wertheimer (see 2.5.1.4) refers
to this process as the formation of a better gestalt, which indicates the formation of new
perceptions.
Feringer (1978) and Ornstein (1972) suggest that experience should be used as the basis
for analogy and metaphor. According to them, transformation of knowledge can be
facilitated more effectively if students are exposed to analogies, synectics, brainstorming,
simulation, games, case studies and mythology. When these divergent, non-sequential,
cognitive processes are combined with convergent sequential cognitive processes, adult
learning based on past experience can become more productive (Brundage &
Mackeracher 1980:34).
5.2.2.4 Readiness to learn
Adults become ready to learn when they experience a need to know, or when they realise
that their existing knowledge is deficient to cope effectively in real-life situations.
Coping involves dealing with change and, when in doing this, we need to innovate,
creativity is the vehicle for innovation (Patterson 1986:102). Aspects such as curiosity,
mastery and challenge would thus influence readiness to learn. According to Knowles
144
(1986:58-59) readiness can be induced through exposure to simulation exercises or to

models exhibiting superior performance.
5.2.2.5 Orientation to learning
Adults' orientation to learning is life-centred and problem-centred. They learn in order

to be able to complete a task, solve a problem or live in a more satisfying way. Knowles
states that adults acquire new knowledge and skills more effectively when these are
presented in the context of application to real-life situations. He suggests that a
curriculum should be organised around life situations and the acquisition of coping skills.
Teaching should not emphasise memorisation of rules and facts, but should rather focus
on the extraction of principles from examples given to students. Walklin states that
problem-solving is a very complicated form oflearning behaviour and that it leads to the
formation of new principles of a higher order (Walklin 1990:12; Knowles 1985:12;
Knowles 1986:59-60).
5.2.2.6 Motivation to learn
Although adults do respond to external motivators, the more potent motivators are
internal and include quality of life, job-satisfaction, recognition, self-esteem and self-
actualisation. All normal adults are considered to be motivated to keep growing and
developing but according to Knowles (1986:61 ), this motivation is frequently blocked
by barriers such as a negative self-concept, time constraints, inaccessibility of oppor-
tunities or resources, and programmes that violate the principles of adult learning.
Walklin (1990:1) reports that factors, such as challenge, mastery and curiosity, can lead
adults towards great efforts in order to attain a goal. Intrinsic motivation is thus a strong
driving force in adult ]earning.
145
5.2.3 Learning environment and teaching strategies
Knowles (1985:14) regards climate setting in adult learning as extremely important. A

comfortable physical environment with good lighting and ventilation, colourful decor
and comfortable chairs is regarded as essential to facilitate optimum learning. An
informal arrangement of chairs and tables is recommended to encourage group participa-
tion.
Regarding the psychological environment, Knowles (1985:15) and Brookfield

(1991 :120) agree that a climate of collaborativeness is necessary to enable adults to learn
from each other's experiences. Paterson (1970) states that adults discover their whole
beings when presenting their interpretations of their experiences in a group discussion.
Open discussion is regarded by both Paterson and Brookfield as essential to adult
learning. Brookfield states that to participate in this authentic form of mutual address,
in this collaborative search for meaning, requires personal courage and analytic ability
of a higher order (Brookfield 1991: 139-140). In order to establish collaborativeness,
the group discussion can be advantageous in adult learning as well as in creative learning.
Brookfield (1991:136) illustrates this clearly with his statement: But it is when one's
nascent, inchoate ideas and concepts are tested out in the company of others that a
certain creative tension comes into play. This view is supported by Rees and Reilly
(1990:76) who regard discussion as a powerful tool for adult learning as it allows the
individual to explore, develop and refine his ideas and arguments, and in this way it
encourages lateral thinking.
Mutual respect and trust are essential for the facilitation of adult learning. If adults are
approached authoratively or if their experiences are ignored, they tend to spend an
excessive amount of time dealing with negative feelings. They must be acknowledged
as individuals with their own unique contributions. It is the educator's duty to ensure that
trust is established as this contributes towards students' feelings of self-worth and
independency (Brookfield 1991:13; Knowles 1985:16).
146
According to Knowles (1985:16) and Seaman and Fellenz (1989:18), adults learn better
when they are supported than when they are being judged or threatened. This implies the
need for a non-threatening and non-judgemental environment. A climate of openness
and authenticity is essential. Knowles ( 1985: 16) states that when individuals feel free
to be open and natural, they say what they truly think and feel, and are more willing to
examine new ideas and risk new behaviours. Brookfield ( 1991: 14) agrees with Knowles
that the educator should model openness and authenticity, and adds that, when this
climate setting is applied, it encourages adults to feel free to challenge one another and
to feel comfortable when they themselves are challenged.
Knowles' conviction that a climate of pleasure should be established to facilitate adult

learning, is supported by Tough (1971) in Seaman and Fellenz (1989:17) who states that
most adults engage in learning to satisfy curiosity and to enjoy the content and the
pleasure of learning. Knowles believes that learning should be spiced with the
excitement of discovery, and that it should be a pleasant and gratifying experience as this
is the way that individuals achieve their fullest potential (Knowles 1985: 16).
Teaching methods appropriate for adults include those which encourage active
participation/cooperative-learning/problem-solving/independent learning. Strategies,
such as the case study method, role play, simulation, games, workshops, group
discussions and learning packages, are all considered to be conducive to adult learning
(Foster 1990:24).
5.2.4 Significance of adult learning to nursing education
As adult learning is life-centred and problem-centred, it is especially applicable in

nursing education. Both the theory and practice of nursing require the knowledge and
skill of problem-solving. Student nurses need problem-solving skills to enable them to
make effective decisions in practice. Holbert and Abrahan (1988:23) regard problem-
solving as an essential dimension of the nursing process.
147
The following is an example of how adult learning can be applied to nursing education
in order to establish whole brain learning:
Knowledge of the many different disease patterns is essential to enable nurse

practitioners to deliver safe patient care. When a teacher is required to teach students
about Parkinsonism, she may proceed as follows. Students are given a written
assignment on the topic which is to be completed within a two-week time period.
Relevant text references are given as well as an opportunity to visit a geriatric unit or an
old age home in order to do a patient case history should they wish to do so, and they are
supplied with an outline of what is expected of them and of the objectives of the
exercise. After the two-week period has expired, a class session is held in which an
interview between a physician and a patient suffering from Parkinsonism is simulated.
The students are required to estimate the severity of the patient's condition, make a
diagnosis and substantiate their conclusions. A group discussion then follows during
which they discuss their findings and experiences (if any) with patients suffering from
Parkinsonism. The teacher can provide any missing details and information. Students
with past experiences with individuals or relatives suffering from Parkinsonism can be
asked to role play certain scenarios in order to demonstrate interpersonal relationships
between the nurse and the patient as well as the patient's experience of his/her condition.
This will enhance affective learning and deepen the students' understanding of the impact
of this disease on the individual's quality of life. Students should subsequently be
assigned to clinical practice in a geriatric ward, old age home or an out-patient clinic
where they will have, inter alia, the opportunity to care for patients suffering from this
particular condition (see figure 5.1).
148
Figure 5.1
-,
Example: Adult learning versus whole brain learning
1 Assignment
3 Simulation
4 Group
discussion
2 Patient case
history 5 Role play
4 Group discussion
Characteristics of ad ult Teaching strategies

learning
Student-centred (numbers 1, 2, 3, 4 and 5)
Problem-centred (numbers 1, 2, 3, 4 and 5)
Active participation (numbers 1, 2, 3, 4 and 5)
Excitement and enjoyment (numbers 2, 3, 4 and 5)
Cooperative learning (numbers 3, 4 and 5)
149
• Figure 5.1
The written assignment with a selection of reading options will appeal to the A-quadrant
dominant students (discused in 3.5.3) as they tend to be highly verbal, analytic and
rational. This group will also enjoy the group discussion where they can exchange their
information. The B-quadrant dominant students may choose the written assignment with
the option to include a patient case history as they tend to prefer action. They will also
benefit from the group discussion as they would want to ascertain that they have all the
necessary detail. The simulation might appeal to the D-quadrant dominant students
because of their highly visual, holistic and conceptual orientation. The C-quadrant
dominant students may benefit from the role play as they tend to be expressive,
emotional and kinaesthetic (see 3.5.3 and figure 3.4).
The given example encompasses many of the principles of adult learning. The teaching
methods are student-centred and involve problem-centred learning, inquiry and active
participation. Past experiences can be shared during the group discussion and the role
play. Excitement and enjoyment may specifically be experienced during the simulation
and role play and to a lesser extent during the group discussion and the taking of the
patient case history. The simulation, group discussion and role play, facilitate
cooperative learning.
Adult learning is specifically applicable to nursing education because of its problem-

centredness and because most student nurses are in that stage of their lives in which they
are in the process of becoming mature, responsible adults and independent professional
practitioners.
150
5.3 MASTERY LEARNING
5.3.1 Nature of mastery learning
Mastery learning is based on the assumption that most students can master a subject or
attain learning objectives provided they are given sufficient time and appropriate
instruction. This stands directly opposed to the assumption held by many authorities that
the degree of learning achievement is primarily a product of students' intelligence or
abilities. Mastery learning attempts to accommodate individual differences among
learners in order to promote the fullest development of each learner. The main focus in
the mastery learning approach is the attainment of specific objectives (Kulik, Kulik &
Bangert Drowns 1990:265; Slavin 1991 :233; Woolfolk 1990:339).
One of the strongest arguments supporting mastery learning is its capacity to ensure that
each student will, at the end of a course, have a history of successful and rewarding
learning experiences. This contributes towards shaping positive affective development,
especially the development of self-confidence and a positive self-concept. Research has
revealed that students following a mastery learning approach exhibit a markedly greater
interest in and positive attitude towards the subject learned as compared to non-mastery
learning students. Dramatic cognitive and affective outcomes were reported (Block
1971:9-10).
According to Bloom (1987:508), mastery learning is essential in order for schools to

improve the educational effects for the majority of students. This supports Slavin's view
of the underlying assumption of mastery learning, which is that almost all students are
capable of learning the essential skills in a curriculum. Slavin emphasises the
appropriateness of this form of learning when high levels of mastery are needed to form
a basis for later learning (Slavin 1991 :296, 298).
Bruner in Reilly and Oermann (1992:44) gives a strong argument in favour of mastery
151
learning. The pursuit of excellence must not be limited to the gifted student. ... The
quest is to devise material which will challenge the superior student, while not
destroying the confidence and will to learn of those who are less fortunate.
5.3.2 Assumptions of mastery learning
Several models for mastery learning exist. The more influential of them include Carroll's
model (1963) which identifies three major factors in learning, namely, student aptitude,
student motivation and task difficulty, Bloom's Leaming for Mastery (LFM) which is
teacher controlled; and Keller's Personalized System of Instruction (PSI) which requires
written material for monitoring purposes and is self-paced by students (Gage & Berliner
1992:460; Kulik et al 1990:265).
Although the various models for mastery learning differ slightly from each other, they
are all based on the same assumptions which include the following:
( 1) The aptitude of the learner for a particular learning task influences learning. This
refers to the amount of time required by the learner to attain mastery of a learning
task. Some students require more effort and time to achieve a high level of
mastery. The time allowed for learning will differ from student to student,
depending on his or her aptitude. According to Bloom (1976), students should
be given as much time and instruction as necessary to obtain mastery of a subject
(Block 1971 :54-55; Slavin 1991:293). Mueller (1976) and Cox and Dunn (1979)
believe that mastery learning and PSI cause faster learners to wait around while
slower learners catch up. Slavin acknowledges that mastery learning can have a
Robin Hood effect: stealingfrom the rich to help the poor, but disagrees that this
effect occurs in PSI (Gage & Berliner 1992:462, 464).
(2) The quality of instruction has an effect on the outcome of learning. Quality refers
to the degree to which the presentation, explanation and organisation of elements
152
for the learning task approaches the optimum for a particular learner. In mastery
learning, the quality of instruction and learning time allowed are more appropriate
to the characteristics and needs of each learner. Different types and qualities of
instruction are needed by individual students because of the variety of students.
Some students need more concrete instructional cues, more practice and more
reinforcement than others (Block 1971 :50, 52).
(3) The learner's ability to understand instruction influences the outcome oflearning.
This refers to the ability of the student to understand the teacher's communica-
tions, the nature of the task and the procedures to be followed. According to
Block (1971 :52-53), in our highly verbal educational institutions, verbal ability
and reading comprehension are highly correlated with achievement and attainment
of grade points.
(4) Perseverance is an important factor in successful learning. It refers to the amount

of time the learner is willing to spend in learning. Perseverance will depend on
the attitude towards, and the interest in, the learning task. If past efforts in a
similar task were successful, a student will spend more time i~ieammg_.
Perseverance is mainly a product of the student's motivation to learn. Intrinsic
motivation is the underlying concept in this case (Block 1971: 54; Slavin
1991 :233).
( 5) Mastery learning requires the breaking down of content into smaller units for
study purposes. Specific objectives must be set for each unit. Keller's PSI uses
several behavioural principles which include specific objectives and small steps.
(6) A variety of learning activities and materials must be offered which enables
students to recycle them until the objectives have been met.
(7) Several tests (formative evaluation) must be set for each unit and frequent
153
feedback, immediately followed by corrective instruction, must be given.
The Keller Plan (PSI) allows students to move through units at their own pace, after
completion of which they are obliged to undergo oral or written tests administered by
proctors (students who have already successfully completed the unit) who provide
immediate feedback. Students must master the unit (levels of mastery are pre-
determined) and if unable, repeat the unit and take another test (Woolfolk 1990: 185-186,
339).
A variety of instructional methods is suggested in order to accommodate individual

differences such as lecture discussions, small group discussions, peer-tutoring, computer-
assisted instruction, workbooks and programmed instruction. The latter two are of
special benefit to students who have difficulty in learning from highly verbal types of
instruction. Programmed instruction has the additional advantage of being comprised
of small learning steps with immediate and frequent reinforcements. The use of
examples, pictures, diagrams and demonstrations are advocated in order to upgrade the
quality of instruction which is such an important principle in mastery learning (Block
1971:53; Slavin 1991:234).
Formative and summative evaluation instruments must be prepared for each study unit.
Evaluation of the results of formative evaluation (tests achieved by students) provide an
in-depth picture of what skills each student has or has not learned and should be
continually used to develop ways in which instruction can be improved or supplemented.
These instruments are not graded but marked with either mastery or more work needed.
This kind of mastery marking may generate interest and positive feelings and attitudes
towards learning. Summative evaluation instruments have to define mastery as this is
necessary to establish an absolute performance standard against which the sufficiency of
each student's learning can be judged and graded (Block 1971 :68-70).
154
The criterion referenced evaluation used in mastery learning, is useful for diagnosing
student difficulties and estimating students' ability in a particular area, when mastery of
a skill is of primary concern and when certification of competence is necessary. It also
encourages student cooperation (Gage & Berliner 1992:576). Criterion-referenced
evaluation promotes extended effort, persistence and cooperation between students rather
than competition.
The learning environment for mastery learning is open in the sense that self-pacing is
allowed, judgement is withheld and students are encouraged and supported and provided
with immediate and constant feedback, until they are ready to take the tests.
Several research studies conducted on mastery learning have indicated that self-pacing
by students, the use of proctors, mastery requirement, immediate feedback and frequent
testing over relatively small study units, lead towards higher student achievement. A
study done on Keller's PSI showed raised examination scores for students engaged in PSI
as opposed to conventionally taught students (Gage & Berliner 1992:578).
5.3.4 Significance of mastery learning to nursing education
In nursing education, achievement of a mastery level in subjects such as anatomy,

physiology and biochemistry is essential in order to establish a sound basis for the
understanding of subjects such as pharmacology, pathology and nursing science.
Mastery learning is, however, especially relevant to teaching the psychomotor skills of
nursing practice. Procedures such as catheterisation, palpation, wound irrigation,
administration of injections, application of sterile dressings and monitoring vital signs,
necessitate a certain level of mastery and competency before they can be safely
performed on patients. Reilly and Oermann (1992:285) view psychomotor learning as
an egocentric process which requires that the learner feel comfortable with her-
self/himself in the performance, before the skill can be performed on a more sophisti-
155
cated level in nursing practice.
The following is an example of how mastery learning can be applied in nursing education
in order to establish whole brain learning (discussed in 3.5.3). When students are taught
the psychomotor skill of catheterisation, a demonstration on a model is given in the
clinical laboratory. Each step is explained by the teacher and students are encouraged
to ask questions while they observe the procedure. A film or videotape presentation is
shown afterwards to give a holistic view of the procedure and to enable the students to
get an overall view of the action pattern. Additionally, programmed learning in the form
of computer-assisted instruction can be offered to provide the students with combinations
of verbal and visual cues in order to facilitate cognitive learning. Students then practice
the procedure in the clinical laboratory until mastery is achieved. During this period the
teacher and peers give feedback. When the students are ready and confident they
formally demonstrate the procedure to the teacher for evaluation purposes. Only when
they have perfected the skill in the clinical laboratory, and after they have witnessed at
least one real catheterisation on a patient are they allowed to perform the procedure on
a patient under supervision. In cases where sophisticated educational media are not
available, the film or video tape presentation can be replaced by a senior student
repeating the demonstration (peer-teaching) and the computer-assisted programme by a
learning package (see figure 5.2).
• Figure 5.2
The demonstration would appeal to the B-quadrant dominant students as these

individuals tend to be organised, sequential and procedural (discussed in 3.5.3). They
will enjoy practising the procedure. They will also benefit from the programmed
learning because of the verbal nature and sequential steps which appeal to left brain
oriented individuals. The A-quadrant dominant students will benefit mostly from the
programmed learning or learning package, as they are highly verbal, analytic and
logically oriented.
156
Figure 5.2
Example: Mastery learning versus whole brain learning
Computer-assisted 2 Video/film
learning 5 Peer demonstra-
6 Learning package tion
Demonstration
Computor-assisted 2 Video/film
learning 4 Practicing proce-
Practicing procedure
dure
Characteristics of mastery Teaching strategies

learning
Self-pacing (numbers 2, 3, 4 and 6)

Cooperative learning (numbers 1 and 5)
Reflective observation (numbers 1, 2, 4 and 5
Small steps and feedback (numbers 1, 3, 4 and 5)
Aptitude and perseverence (numbers 2, 3, 4 and 6)
157
The film or videotape presentation would be a significant learning opportunity for the
right brain oriented students. The visual display and holistic picture provided will
specifically appeal to the D-quadrant dominant students. The C-quadrant dominant
students will concentrate on the emotional, expressive and interpersonal aspects which
are conveyed by film and videotape presentations and on kinaesthetic aspects during the
practicing of the procedure.
Several of the principles of mastery learning are illustrated in the example. Self-pacing
is allowed as students can practice the procedure in the clinical laboratory as many times
as they wish. They may review the film or videotape in their own time and also work
through the computer-assisted programme a few times. Through peer interaction
cooperative learning is established during the demonstration as well as during the peer
demonstrations. The demonstration, film or videotape presentations, peer demonstra-
tions and practice sessions stimulate reflective observation and thinking. Small steps
followed by feedback are provided by the computer-assisted programme, during the
demonstration, and again during the practice sessions. Student aptitude and perseverance
are accommodated as the students themselves decide when they are ready to demonstrate
the procedure to the teacher for evaluation purposes.
Mastery learning is essential to teaching the psychomotor skills of nursing practice in

order to produce technically competent nurse practitioners.
5.4 EXPERIENTIAL LEARNING
5.4.1 Nature of experiential learning
Experiential learning is the learning that results from experience. It encompasses

personal experience, reflection on the experience, and the transformation of knowledge
and meaning as a result of the experience and action (Burnard 1989:3). The role of
reflection and metacognitive approaches in experiential learning is emphasised by Caine
158
and Caine (1990:67) and Ellison (1993: 15).
Experienced-based education has become a widely accepted form of instruction since the
focus of educational methods shifted from that of the mere transmission of content to the
bringing of theory and real-life experiences closer together. The development of the
skills of inquiry, problem-solving, and critical and creative thinking are regarded as
extremely important in order to increase the effectiveness of individuals in coping with
future situations.
The experiential learning approach has roots in Humanistic psychology, Gestalt

psychology, Phenomenology and Pragmatism. Dewey, Lewin and Piaget are regarded
as the intellectual ancestors of experiential learning theory. Dewey's influence is from
his philosophical perspective of pragmatism as illustrated in his words: I take it that the
fundamental unity of the newer philosophy is found in the idea that there is an intimate
and necessary relation between the processes of actual experience and education (Kolb
1984:5). Lewin's influence is from the phenomenological perspective of the Gestalt
psychology. Experiential learning ... involves direct encounter with the phenomenon
being studied rather than merely thinking about the encounter or only considering the
possibility of doing something with it - as quoted by Keeton and Tate (1978) in Kolb
(1984:5). Piaget's theory describes how intelligence is shaped by experience where
action is the key. According to him abstract reasoning and the power to manipulate
symbols arise from actions in exploring and coping with the immediate concrete
environment (Kolb 1984:8, 12).
The focus in these three approaches is on the bringing together of concrete experience
and abstract thinking which characterises experiential learning. It does not occur through
accidental casual encounter with the real phenomenon - it is the combination of actual
experience and the purposeful reflective thinking about the experience that results in this
form of learning.
159
Most experiential learning methods emphasise the uniqueness of human experience and
interpretation of the world and pay particular attention to the affective aspects of the
individual's experience. The humanistic influence becomes explicit in the student-
centeredness and the personal learning nature which contribute towards the development
of the self-concept (Burnard 1989:7, 14).
Pendleton and Myles ( 1991: 146) view experiential learning as the keystone of humanistic
education theory. It provides a holistic, integrative perspective on learning because it
combines experience, perception, cognition and behaviour (Kolb 1984 :21 ).
5.4.2 Assumptions of experiential learning
The assumptions of experiential learning derive from Lewin's, Dewey's and Piaget's
models on the subject.
5.4.2.1 Learning is conceived as a process
Ideas are never fixed - they are formed and reformed through experience just as concepts
are derived and continuously modified by experience. Freire (1974) cites that knowledge
emerges only through invention and reinvention and through the continuing inquiry men
pursue in the world and with each other. According to Bruner, the purpose of education
is to stimulate inquiry and skill in the process of attaining knowledge. He encourages
students to have experiences during discovery learning as it arouses curiosity which
stimulates intrinsic motivation. Leaming is thus viewed as a process in which continuing
inquiry and the formation and reformation of ideas takes place by way of discovery and
experience (Kolb 1984:16, 26-27).
5.4.2.2 Learning is a continuous process
Learning is a continuous process grounded in experience. This implies that all learning
160
is relearning. Dewey explains the continuity of experience as a powerful truth of human

existence, and central to the theory of learning: .. . The principle of continuity of
experience means that every experience both takes up something.from those which have
gone before and modifies in some way the quality of those which come after ... (Kolb
1984:27).
Piaget describes this phenomenon through the concepts of integration (ideas which
become highly stable parts of the person's conception of the world) and substitution
(which means changing the content of a concept) (Kolb 1984:28).
Learning is thus an ongoing process which results in increased knowledge and a better
understanding of the world as the content of learned concepts are changed as past and
present insights are compared.
5.4.2.3 Learning requires the resolution ~{conflicts between dialectically opposed

modes of adaptation to the world
According to Kolb models of experiential learning describe conflict between opposing

ways of dealing with the world, and learning results as a resolution of these conflicts.
Dewey regards the major dialectic as between the impulse which gives ideas their moving
force and reason which gives desire its direction. Paulo Freire demonstrates the dialectic
nature oflearning and adaptation in his concept praxis which he describes as reflection
and action upon the world in order to tramjorm it. Lewin's model of experiential
learning emphasises two dialectics - the conflict between concrete experience and
abstract concepts and the conflict between observation and action (Burnard 1989:9~ Kolb
1984:29-30).
The questions that arise are how can one act and reflect at the same time, and how can
one be concrete and still be theoretical? This can perhaps be explained by the iterative
function of the human brain which refers to the back and forth movement of signals
161
among its specialised regions which can occur within (A<---> B or C <---> D quadrants)
or between (A<---> Dor B <---> C quadrants) of the hemispheres (see 3.4.2 and figure
3.1).
Leaming which results from experience as described above is productive learning (rote
learning is excluded). This refers to the higher categories of Bloom's taxonomy of
cognitive objectives and the productive operations in De Corte's taxonomy of objectives
which are linked to creative thinking (see 4.3.1and4.3.2).
5.4.2.4 Learning is a holistic process of adaptation to the world
Experiential learning implies the central process of human adaptation to the social and
physical environment and as it involves the integrated function of the total organism -
thinking, feeling, perceiving, behaving, it is a holistic concept. Kolb (1984:31-32) views
learning as the major process of human adaptation which encompasses other more
limited adaptive concepts, such as creativity, problem-solving and decision-making. He
advocates that creative research emphasises the divergent (concrete and reflective)
aspects in adaptation, for example, ambiguity, flexibility and metaphorical thinking,
whereas research on decision-making emphasises convergent (abstract and active)
adaptive aspects, for example, rational evaluation.
Kolb's view of experiential learning as a holistic process can be compared to Herrmann's

whole brain creativity model as the different processes mentioned by him are represented
by all four quadrants of the brain as proposed by Herrmann (see figure 4.2).
5.4.2.5 Learning involves transactions between the person and the environment
In experiential learning theory, the transactional relationship between person and

environment is symbolised in the dual meanings of the term experience which refers to
the person's internal state (subjective, personal) as well as the external state (objective,
162
environmental). Kolb (1984:35-36) prefers transaction to interaction, as interaction

involves unchanged, separate entities that become intertwined - but the separate identities
are retained. Transaction implies a more fluent, interpenetrating relationship between
subjective experience and objective conditions resulting in change, once these become
related. Kalb's description of transaction implies that productive learning takes place.
The skills of analysis, synthesis and evaluation are essential when separate entities are
changed and brought into a new relation to each other.
5.4.2.6 Learning is the process of creating knowledge
Knowledge is created through the transaction between objective (social knowledge) and
subjective (personal knowledge) experiences during a process called learning. Kolb
suggests two different ways in which knowledge is created from the conflicts between
the adaptive modes of concrete experience versus abstract conceptualisation, and active
experimentation versus reflective observation. Leaming through the concrete/abstract
dialectic occurs through apprehension (reliance on tangible felt qualities of immediate
experience) or comprehension (reliance on conceptual interpretation and symbolic
representation). Leaming through the active/reflective dialectic occurs via transformation
which represents either intention (grasping through internal reflection) or extension
(active external manipulation of the external world) (Kolb 1984:37-38, 41) (see figure
5.3 and figure 4.1).
The relationship between whole brain learning as a process of creating knowledge, is

illustrated in figure 5 .3 wherein apprehension is represented by C-quadrant processes,
comprehension by A-quadrant processes, intention by D-quadrant processes and
extension by B-quadrant processes.
163
Figure 5.3
The relationship between learning as a process of

creating knowledge and the four quadrants of
the whole brain creativity model
c
concrete experience
apprehension
i
(rely on tangible, felt
qualities of immediate experience)
active • extention - transformation - intention Ill( reflective

B experi- (active external (grasping through observation D
mentation manipulation of internal reflection)
the external world)
(rely on conceptual interpretation

and symbolic representation)
t
comprehension
t
abstract conceptualisation
(Adjusted from Kolb 1984:42)

164
Kolb (1984:16) refers to the relevance of brain research to experiential learning by

indicating that the modes of knowing associated with the left and right hemispheres of
the brain correspond directly to the distinction between abstract cognitive and concrete
experiential approaches to learning. Holbert and Thomas (1988:31) indicate that Kolb's
model emphasises the critical role that experience plays in the process of learning and
human development. It links education, work and personal development.
5.4.2.7 The experiential taxonomy: experiential learning involves five stages,

initially proposed by Steinaker and Bell (J 979)
( 1) Exposure means consciousness of an experience. Sensory stimuli are very

important during this stage. The teacher should stimulate in the learner a desire
to pursue the experience by evoking interest and curiosity which leads to intrinsic
motivation. This could be achieved by presenting a puzzle, problem or challenge,
together with effective audio-visual media. The teacher's role is that of motivator.
Cain and Caine (1990:68-69) refer to the brain's spatial memory which does not
need rehearsal but allows instant memory of experiences. This system is
motivated by novelty and drives the search for meaning. Spatial memory is best
evoked through experiential learning and this promotes the transfer of learning
and the development of understanding.
(2) Participation involves the decision to physically become part of the experience.
Representation can be covertly (private, vicarious) by imagination or analogy or
it can be overtly which refers to real interaction in a group. Modification takes
place when the individual reflects on past experience. Fluency is important during
this stage. The use of analogies and imagination can enhance learning during the
participation stage. The teacher acts as a catalyst.
(3) Identification indicates the union of the learner and what is to be learned. This
165
encompasses emotional and intellectual involvement. Several researchers have

reported that the ability of the human brain to perceive and generate patterns
seems to be important during this stage. Life relevant approaches to learning are
emphasised because of the personal involvement of the learner. The brain
apparently resists having meaningless patterns imposed on it and the involvement
of emotions is regarded as critical to patterning (Caine & Caine 1990:67; Ellison
1993: 15). Experiential learning thus supports patterning as real-life experiences
are involved. The teacher acts as moderator during this stage.
(4) Internalisation means that the experience continues to influence the individual's
lifestyle in order to increase effectiveness. Changing attitudes and activities are
important during this stage and depend on changing perspectives as explained by
the Gestalt (see 2.5.1.4). According to Reilly and Oermann (1992:321), the
essence of affective learning appears to be internalisation and continuity. During
this stage the teacher plays the role of sustainer.
(5) Dissemination goes beyond internalisation in that the individual starts influencing
and motivating others to have an equivalent experience. This may indicate a joy
and enthusiasm in the individual, a total cognitive and emotional involvement
which leads to the need to share the experience with others. The teacher is both
critic and evaluator during this stage (Quinn 1995:151, 156; Steinaker & Bell
1979:10-15, 112-116).
Quinn (1995: 153) describes the ideal environment for experiential learning as
characterised by support, trust, a climate of acceptance, consideration of students' needs,
an element of negotiation, and encouragement of students to take responsibility for their
own learning. Kolb (1984: 10-11) emphasises an open atmosphere, where individuals
can be challenged and stimulated by each other's perspectives, as a learning environment
166
which is marked by vitality and creativity. To this he adds the necessity for a spirit of
inquiry, expanded consciousness, and choice and authenticity in relationships (the basic
values of a humanistic scientific process).
Brink emphasises that the learning environment should encourage students to discover
knowledge for themselves, and that the teacher, as facilitator, should also provide
opportunities for learning. She considers that when experiential learning is implemented
in nursing education, a caring relationship should be established between teacher and
students (Mashaba & Brink 1994: 158).
A wide variety of teaching methods suitable for experiential learning have been reported
in the literature. These include guided fantasy, field work, role play, case studies,
counsellor workshops, computer simulations, self-awareness activities, small group
discussions, psycho-drama and values clarification. Experiential learning methods
especially used in nursing education have been reported by Burnard (1991). Amongst
these are the practising of clinical nursing skills, problem-solving activities, empathy-
building exercises, Gestalt exercises and structured group activities (Mashaba & Brink
1994:157; Pendleton & Myles 1991:149, 157, 158).
5.4.4 Significance of experiential learning to nursing education
The practical aspects of nursing have been taught experientially for decades through the
actual nursing process, role play, patient case histories and patient-centred group work.
These enable the students to acquire the necessary affective skills. The essence of
affective learning appears to be internalisation and continuity. In addition, Reilly and
Oermann (1992:320-321) regard experiential learning opportunities as essential when the
ethical, moral and value issues of the profession are addressed.
Bradshaw (1978) attributes the justification for the use of experiential learning in nursing
education to the phenomenon that most nurses are of the sensing-feeling type. Such
167
individuals perceive their world to a major extent through their senses - touch, feel,
smell, sight and taste. They are categorised as concrete thinkers because they determine
the reality of an object by whether it can be taken in by the senses - in other words,
experiencing, which thus becomes the key-word and major activity (De Tornay &
Thompson 1987:31 ).
Miller and Rew (1989:86) plead that greater attention be given to experiential forms of
learning in the nursing curriculum, with the emphasis being placed particulary on the
problem and process, rather than on the solution.
The application of experiential learning to nursing education, with the aim of establishing
whole brain learning, is illustrated in the following example.
In order to teach students how to care for and support the terminally-ill patient, each is
given a clinical assignment in the form of an interview with a patient suffering from
cancer, AIDS or other fatal disease). Written notes must be made during or after the
assignment. The interview provides a concrete experience to the students during which
exposure, participation and identification take place. When they return to the classroom
with their notes, a role play session is held during which several students take turns in
playing the roles of the patients they have interviewed. Scenarios between patients and
nurses or relatives are, in this way, acted out and, it is hoped, the different emotional
phases through which the majority of terminally-ill patients pass through, for example,
denial, aggression, and eventual acceptance will be illustrated. During these role play
scenarios, the identification stage of experiential learning is reinforced, while analysis
and reflective thinking take place. The scenarios are succeeded by a values clarification
session during which the students explore the prevailing values of the patients and
identify their own values regarding terminal illness and dying. Abstract conceptuali-
sation occurs during this stage and internalisation is accomplished. After this initial form
of exposure to experiential learning concerning terminally-ill patients, the students are
assigned to wards or out-patient clinics where they are required to broaden their clinical
168
experience by giving special attention to the affective care of such patients. This affords
them the opportunity for active experimentation and application of their knowledge, and
it also completes the internalisation phase of experiential learning. On completion of this
clinical experience, a post-clinical conference is held to discuss the students' individual
experiences with the aim of stimulating further reflective thinking and abstract con-
ceptualisation which actualise the dissemination phase of experiential learning (see figure
5.4).
• Figure 5.4
The clinical assignment will appeal to the A-quadrant dominant students (discussed in
3.5.3) as verbal and analytic skills are required during patient interviews. This group will
also benefit from the post-clinical conference where reason and rational thinking are
required. The B-quadrant dominant students will benefit from the clinical assignment
as they are detailed and sequentially oriented. They may also benefit from the clinical
experience as they tend to enjoy active experimentation. The C-quadrant dominant
students will benefit from the role play, values clarification and the clinical experience
as they are emotional, expressive and kinaesthetically oriented. The D-quadrant
dominant students will benefit from both the clinical assignment and the clinical
experience because of the holistic nature of these activities. This group is visually,
intuitively, conceptually and holistically oriented and derive their cues and knowledge
from the overall situation.
In the above example teaching strategies are presented which, in the clinical assignments
and experiences, role play scenarios and values clarification session, emphasise self-
directed learning, problem-solving and active participation. In addition cooperative
learning is facilitated during the role play scenarios, values clarification session and post-
clinical conference. It is essentially student-centred and the affective domain is
involved in each teaching strategy mentioned.
169
Figure 5.4
Example: Experiential learning versus whole brain learning
Clinical assign- 1 Clinical assign-

ment ment
5 Clinical post-con- 4 Clinical expe-
ference rience
2 Role play
Clinical assigment 3 Values clarifi-
Clinical experience cation
4 Clinical expe-
rience
Characteristics of Teaching strategies

experiential learning
Self-directed learning (numbers 1, 2, 3 and 4)

Problem-solving (numbers 1, 2, 3, 4 and 5
Active paticipation (numbers 1, 2, 3, 4 and 5)
Student-centred (numbers 1, 2, 3, 4 and 5)
Affective domain (numbers 1, 2, 3 and 4)
170
Experiential learning is vital to nursing education as nursing is a humanistic, practice

discipline.
5.5 OPEN LEARNING
5.5.1 Nature of open learning
The general shift in educational research trends from those of teaching and instructional
design to learning and the particularity of individual students' responses, which
commenced during the 1970s, led to the development of the concept of open learning.
It became evident that differences in social and educational background, life experience,
intelligence, ethnic origin, personality and learning styles influenced learning.
Individualised instruction became a key-word in education and open learning practices
were instituted as a result. These offer a flexible response to the changes which are
taking place not only in society but also in the purposes and values of education (Thorpe
& Grugeon 1987:1, 3).
Open learning is a flexible and student-centered approach to learning with less focus on
the educational establishment and greater emphasis on how the learner studies which
includes the physical and social conditions that facilitate study. It incorporates tutorial
guidance and support, multimedia learning materials and a wide range of teaching
strategies especially those emphasising independent and individualised learning. Open
learning encompasses individualised instruction, and self-directed learning. It should be
kept in mind that distance education is not synonymous to open learning, as it is but one
variant of open learning, planned on the geographical separation between students and
teachers (Jeffries, Lewis, Meed & Merritt 1990:iii; Quinn 1995 :330)
Open learning is grounded in the humanistic movement which focuses on metacognition,

creativity and enhancement of human potential. It is based on the premise that students
should actively participate in directing their own education. Humanistic educators value
171
affective goals as highly as cognitive goals and are opposed to letter grades, standardised
testing and other formal methods of evaluation. A meta-analysis performed by Giaconia
and Hedges ( 1982) on 150 research studies on comparisons between traditional and open
classrooms showed that open education improved creativity, cooperativeness and
independence, to a moderate degree (Gage & Berliner 1992:489; Slavin 1991:272).
Hodgson, Mann & Snell ( 1987: 164, 166) have further revealed the humanistic influence
in open learning by distinguishing between open learning as dissemination and open
learning as development. In the former, the emphasis is on creating open access to
education to ensure an adequately prepared and updated workforce, while the latter
stresses the development of the whole person and his ability to construct meaning in and
throughout his life.
Openness in open learning means that the system is more readily accessible than
conventional courses with the same learning objectives. It implies the removal of the
barriers of time, place and pace, and the facilitation of access to educational programmes.
According to the Further Education Unit (FEU) open learning should be considered as
a continuum rather than a category, as educational programmes vary widely in the degree
of control that students have over their learning (Pendleton & Myles 1991: 169; Spencer
1980:19; Thorpe & Grugeon 1987:4).
The hidden philosophy behind the open learning concepts appears to be the idea that
people should be offered the opportunity to develop by themselves - as Maslow has
stated, to develop to thefr fullest potential, self-actualising creativity.
5.5.2 Assumptions of open learning
Open learning systems have the capacity to meet national educational priorities on a large
scale. They are attractive to governments and communities as they are cost-effective and
have relatively short time-scales (Tait 1991 :2). A variety of courses can be offered
172
which may include certificate and diploma courses and/or undergraduate and postgradu-
ate programmes. According to Daniel (1991:5), the Open University in England has
introduced glasnost (the Russian word for openness) to the academia, by making degree-
level knowledge accessible to everybody.
The basic assumptions of this form of education are universal although there are
differences in the ways that it is being offered.
( 1) The two key-principles of open learning are access and control. Access refers to
the opening of doors to further education to a large number of the population with
or without the normal university matriculation requirements. It also serves to
overcome barriers such as geographical distance, and personal or work commit-
ments. Control refers to the degree of control exercised over the organisation;
pacing and timing of curricular content and processes (Pendleton & Myles
1991:169).
(2) The student has a high degree of control as he/she can decide what, when and how
to study. Its degree does, however, vary from programme to programme. A
student can negotiate about the curriculum and its objectives, pattern of at-
tendance, utilisation of learning materials, assessment and pace. The system
offered by the Open University provides for student representation on senate level
- students have thus the opportunity to influence decision-making (Pendleton &
Myles 1991:169; Quinn 1995:330; Unisa 1995:34).
(3) Open learning is essentially student-centered as the focus is on the needs of the
student as an individual with unique qualities and preferences for learning (Slavin
1991 :267).
(4) The provision of multimedia and a variety of learning activities is essential and
students must have the opportunity to choose among these in order to satisfy their
173
own individual needs and preferences (Gage & Berliner 1992:489; Quinn
1995:330).
(5) In the provision of learning programmes, teaching models must be adaptable and
focused on the needs of students. Thorpe and Grugeon (1987:71) state that the
strength of open learning lies in its flexibility and ability to meet quickly specific
short term needs for education quickly and efficiently.
(6) Student support is a very important aspect. This is provided for by tutors,
counsellors, study centres, compulsory summer schools, individual contact or
face-to-face tutorials. Open learning does not mean unsupported and marginal-
ised learning; it is, in essence, supported self-study (Jeffries et al l 990:vi; Unisa
1995: 11 ).
(7) Personal growth is one of its outcomes as it is an individualised, student-centred

and active learning approach which emphasises experience, practice, feelings and
attitudes (Thorpe & Grugeon 1987:5).
(8) A team approach in the preparation of courses and material is currently being
preferred. This enhances quality in the presentations of study material and
provides built-in student support because students are included in the team (Unisa
1995:6).
The openness and accessibility that characterise open learning, which includes a wide
variety of choices and accommodates individual student needs, stand in direct contrast
to traditional education with its over-controlled teacher-oriented approach. Open
learning thus provides an opportunity for the development of the self in a creative way,
as the barriers that stifle creativity in traditional education, are largely removed.
174
The open learning environment is flexible, open and student-centred. Although students
engage in self-study (often alone in their own homes) they are not totally isolated from
fellow students.
Slavin (1991 :268) emphasises the role of guided discovery and the use of cooperative
learning and discussion among students in open learning systems. Jeffries et al
( 1990:29) focus on the important role of counselling which, in an open learning system,
involves encouragement, induction, advice, information, negotiation and feedback. The
teacher has thus a supportive and facilitating role.
Another important aspect is the flexible time-table which permits students to set their
own pace for learning. This contributes towards decreased anxiety and allows sufficient
time for explorative and productive learning rather than rote learning (Jeffries et al
1990:29).
Most open learning systems offer a variety of learning activities which may include
weekend courses, short courses, part-time day and evening classes, group or individual
tutorial arrangements, learning packages, workshops, laboratory work and media such
as audiotapes and videotapes (Spencer 1980:94). Students, for example, may be given
a choice to attend a two-week course or to use materials and media in their own homes
supplemented by individual or group tutorials at the educational institution.
Open learning systems which are offered through distance education make use of the
written word, radio and television broadcasts, telephone communication, CD-rom based
learning, and video and computer conferencing, as well as annual residential schools and
class teaching at study centres (Quinn 1995:331; Stewart 1993:3; Unisa 1995:21).
Evaluation in open learning is done frequently in order to provide ongoing feedback to

175
students. A variety of evaluation methods from which the student can choose is usually
available, but only criterion-referenced evaluation systems in the form, for example, of
seminar papers, projects, dissertations, or checklists, are used (Hodgson et al 1987:10;
Thorpe & Grugeon 1987:5).
Open learning is becoming central to education and training across the world. An
increasing number of educational institutions are viewing it and distance education as a
way of expanding their provisions and are diverting their resources into these systems.
The demand for continuing professional education for nurses, has prompted many
colleges in the United Kingdom, as well as the Open University, to offer continuing
nurse education programmes (Quinn 1995:330, 332).
5.5.4 Significance of open learning to nursing education
Open learning models provide opportunities for registered nurses to continue their
education. All nurse practitioners need refresher courses in order to keep abreast of new
developments in health care delivery. Open learning offers the ideal opportunity to nurse
practitioners, tied by work and family commitments, to develop themselves and further
their education.
The following example illustrates the application of open learning in continuing nursing
education and shows how whole brain learning is facilitated through open learning.
If an advanced diploma in midwifery is offered, I suggest that the learning activities

include reading assignments with definite referrals to specific textbooks and journal
articles, and that audio-visual material is made available to provide students with a choice
of relevant audiotapes, videotapes, films and computer programmes. They must have
access to learning centres with well equipped libraries and audio-visual facilities. Week-
end courses or periodic workshops or group tutorials are to be held at a variety of venues
to provide for cooperative learning and support and guidance by teachers and clinical
176
supervisors, the latter being specifically appointed for these tasks. It is essential for
students from remote rural areas to attend these organised workshops and tutorials as
well-equiped learning centres are not available in such areas. The students are required
to undertake and complete several assignments, projects and seminars, and given a
workbook to complete on pertinent clinical procedures. These learning activities serve
at the same time, as a part of the evaluation system. Oral or written examinations which
offer students a choice as to when they want to do the examination (when they feel they
are ready) form the final part of the system of evaluation (see figure 5.5).
• Figure 5.5
The A-quadrant dominant students will benefit from the reading assignments, projects,
seminars, group tutorials and workshops as they have a preference for verbal, analytical,
rational and logical processes (discussed in 3.5.3). The B-quadrant dominant students
will prefer the projects, computer programmes, workshops, clinical procedures and
completion of the workbooks since they are procedural, detailed and sequentially and
actively oriented. The C-quadrant dominant students will benefit mostly from listening
to audiotapes, watching the films, participating in the group tutorials and clinical
procedures as they are expressive, emotional, interpersonal and kinaesthetically oriented.
The D-quadrant dominant students will benefit from the videos and films, workshops and
clinical procedures as they tend to be holistic, visual, intuitive and synthesising.
Many of the principles of open learning are evident in the example. The teaching
strategies and learning activities are essentially student-centered while facilitating active
participation. Flexibility is assured by the great variety of activities and media.
Cooperative learning is provided for by the group tutorials, workshops and seminars,
whereas individualised learning is accommodated by reading assignments, projects
workbooks and clinical procedures. Student support is provided by teachers and clinical
supervisors.
177
Figure 5.5
Example: Open learning versus whole brain learning
Reading assignment
Workshop 3 Video/film
Group tutorial 5 Workshop
Project 9 Clinical procedures
Seminar
4 Computer pro-
2 Audiotapes
gramme
Workshop 3 Video/film
Project 6 Group tutorial
Clinical procedures 9 Clinical proce-
Workbook dures
Characteristics of open Teaching strategies

learning
Student-centred (numbers 1, 4 to 10)
Active participation (numbers 4 to 10)
Flexibility (variety of learning activities)
Individualised learning (numbers 1 to 4, 7, 9 and 10)
Student support (numbers 4, 5, 6, 8 and clinical
supervisors)
178
Open learning provides nurses with opportunities to develop themselves and continue
their professional education in a manner that is compatible with their lifestyles.
According to Lewis (1986: 12), this method of tuition is a breakthrough for nursing as it
has always been difficult to combine nursing and higher education.
5.6 THE RELATION BETWEEN THE FOUR EDUCATIONAL MODELS

AND CREATIVITY
The exploration of the nature of the four educational models reveals remarkable
similarities with reference to the principles of creativity and the creativity stimulating
environment.
5.6.1 The relation between the four educational models and creativity
Table 5.1 illustrates the congruence of the aims and assumptions of the four educational
models and creativity.
( 1) The common aim of adult, mastery, experiential and open learning models, is to
facilitate the fullest development of the individual to enable him/her to cope
more effectively in life and work. This concurs with the humanistic theories of
creativity, which view the individual's tendency to develop, expand, extend,
mature and actualise himself to achieve his potentialities, as the primary
motivation for creativity (see 2.5.3). Maslow specifically associates self-
actualising creativeness with growth. According to Litterst and Eyo (1993 :273 ),
growth encompasses the abilities of rhetorical sensitivity, interpersonal compe-
tency, awareness, transformation, self-esteem, self-confidence, motivation and
empowerment. Growth occurs within oneself and in interaction with others, and
involves three dimensions - cognitive, affective and behavioural. The abilities
associated with growth have also been mentioned by Torrance and the personality
theorists, as essential to creativity.
Table 5.1
Relation between the four educational models and creativit
(1) Aim: fullest development of each in- roots in hwnanistic psychology, grow1dcd in hwnanistic move- I self-actualising creativeness
self-development, growth, cffcc- dividual, achievement of objec- focuses on unique huntan expe- ment, development of whole
ti vcncss in life and work tives rience, growth crson
Assumntions
(2) Student-centred: individual needs considered, self- ex'})crience involved, develop sclf- students' needs considered, self- self-directed, self-reliable, self-
towards self-direction, indepen- paccd, corrective instmction conccpt independence, self-con- dirccted, flexibility, accessibility discipline, ego-strength
dent ositivc sclf-conccot fidence
(3) Active participation: direct prescribed expcnencc, immediate segmenting experience guided discovery, explorative variety or experiences, indivi-
broad existential experience, pre- guided discovery, practice until situation, cognitive, affective, and dual can only be creative in a
fer doing and immediate applica- mastery is achieved psychomotor involvement wcll-knmvn area
tion .......
-..J
(4) Problem-centred: focuses on mastery of skills and emphasis on problem and process, problem-solving, reflective creativity as process, creative \.0
life-centered, inquiry, experimen- objectives reflective thought, metacognition thought, productive learning problem-solving. reflective
tation, discove thought. life-Ion
(5) Cooperative learning: corrective instruction, peer feed- reflective observation, learn from reflective thought, metacognition, creative growth stems from ex-
learn from each other's experien- back, correct each other's learning other's ideas, feelings, social development changing ideas, flexibility, fluen-
ces, explore, develop and refine errors perspectives cy. elaboration
ideas
(6) Intrinsic motivation successful learning ~ greater inte- interest, curiosity, challenge self-development, interest, chal- curiosity, enjoyment, passion
self-esteem, self-actualisation, re- rest; frequent feedback -· positive lenge
cognition, iob satisfaction attitudes
(7) Variety of learning corrective instruction - to assist whole person involvement, cogni- individual needs considered. facilitate whole brain learning
activities: individual preferences tive, affective and psychomotor includes independent and coope-
to acconunodatc differcnt learning domains rative activities
stvles
(8) Self-evaluation: criterion-referenced evaluation: self-evaluation: continuous reflec- criterion-referenced evaluation self-evaluation, increases re-
enhances self-esteem promotes effort, persistence and tive thought and self-evaluation sponsibility and self-esteem
self-evaluation
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(2) Student-centredness is a key-assumption in all four models. It refers to the self-

directedness and independence of the learner. The learner takes responsibility for
his own learning and decides what, when and how he wants to learn. This
contributes towards increasing self-confidence and the development of a positive
self-concept. In mastery learning, consideration of individual students' needs
specifically indicates student-centredness, whereas in open learning, student-
centredness is emphasised by accessibility and flexibility. Freitas, Lantz and Reed
(1991 :7) report that creative teaching is more student-centred and less inhibited
than the traditional methods. Creative people display the traits of independence,
self-reliability, self-discipline and ego-strength (discussed in 2.5.2.l ). Sedlak
(1992:27) emphasises the ever-increasing need for nurses who are independent
and critical thinkers to provide present and future competent nursing care.
(3) Active participation in the learning experience is an integral part of the adult
learning model as adults draw from previous experiences, prefer active participa-
tion and want to apply knowledge immediately. They rely on broad existential
experience. Mastery learning focuses on guided discovery and self-practice in
order to achieve objectives. Direct, prescribed experiences are involved during
mastery learning. In experiential learning the learner is totally involved in an
immediate concrete experience. Cognitive and affective learning take place
through direct discovery. Open learning focuses on explorative and discovery
learning through individualised and cooperative learning activities. Variety of
experience contributes towards creativity - an individual can only be creative in
a field he knows well. Torrance (1993: 134) states that diversity of experience is
dominant in creative people's lives. Wonder and Blake (1992:173) believe that
a considerable period of preparation is necessary before a person can display
creativity in a particular field. This principle is exemplified by the diligence and
hard work in their areas of interest of creative people such as Helmholtz and
Poincare (discussed in 2.5.1.2).
181
Saylor (1990: 10) refers to nursing as an applied science that cannot be fully
developed in the classroom or clinical laboratory. The complexities of the clinical
setting necessitate learning through immediate concrete experience. It is here that
creative thinking is often required as each situation is unique and has to be
approached contextually.
(4) Problem-centred learning is stressed in the four educational models: inquiry,

discovery, experimentation and concrete experience. According to La Belle
(1974:57), problem-solving fosters the kind of intellectual activities which lead
to productive and/or creative thinking. Holbert and Abraham (1988:23) affirm
that problem-solving fosters both convergent and divergent thinking.
Productive thinking includes the higher cognitive skills of analysis, synthesis and
evaluation. These skills are necessary for creative thinking (discussed in 4.3.1)
and are listed on the second level of Treffinger's creative learning model (figure
4.5). Effective problem-solving requires the student to think at a formal
operational level (Piaget). The link between formal operational thought and
creative thought has been discussed in 4.4.1.3. Pickard (1990:7) states that,
according to Piaget, a person has to be a formal operational thinker in order to
think creatively. It is thus clear that problem-solving, productive thinking, and
formal operational thought are related and that they are linked to creative thought.
According to La Belle (1974:59), a problem-solving approach to patient care

situations is a means of teaching for reflective thinking which is a vital part of the
problem-solving process and experiential learning. Dewey (1933) states that
reflective thinking involves a state of doubt, hesitation, perplexity, mental
difficulty in which thinking originates, and an act of searching, hunting,
inquiring, to find material that will resolve the doubt, settle and dispose of the
perplexity (Farra 1988:2-3). Dewey links reflective thought to creativity when he
states that training in reflective thought is necessary to produce creatively rigorous
182
thinkers. The relation between reflective thought and creativity is well illustrated
in Dewey's view that reflective thought makes an intuitive grasp for something not
directly perceived or for a new combination of things coming into existence.
Reflective thinking encompasses whole brain creativity as it involves left brain
processes (hypothesising, analysing, testing, checking) and right brain processes
(intuition, suggesting, inference, forecasting). Farra (1988:3, 5) reports that
reflective thought should always be flexible in order to maintain creativity. As
creative people can tolerate ambiguity their reflective thinking leads to intelligent
action. Those who find ambiguity and searching and insecurity uncomfortable,
forsake reflective thought and make hasty decisions.
According to Saylor (1990:9, 11), the ability to reflect upon one's practice is
essential for competency in nursing. During reflective thinking new questions,
strategies and objectives are formulated which are based on the professional
nurse's repertoire of theoretical principles, technical knowledge and experience.
Saylor views reflection as the artistry of combining a professional repertoire with
current clinical problems, in order to invent unique responses to a unique
situation.
The development of problem-solving skills is of vital importance to student

nurses. Klaassens (1992:30) affirms that the complexity of nursing practice
requires of students a high level of these skills and abilities. She adds that it is
imperative to use innovative strategies to stimulate or enhance the higher levels
of cognitive thought. Holbert and Abraham (1988:23) view problem-solving
skills as essential in order to cope with a rapidly changing health care system.
( 5) Cooperative learning is advocated and emphasised in all four educational

models. Adult, experiential and open learning generally make use of cooperative
learning activities whereas mastery learning especially uses cooperative learning
activities during corrective instruction. Cooperative learning involves small
183
groups of students who work together to maximise their own, as well as each
other's learning. Several research studies have reported that cooperative learning
produces higher achievement and promotes a higher level of cognitive and moral
reasoning than competitive or individualised learning (Davidson & Worsham
1992:122).
During cooperative learning individuals share their ideas, knowledge, perspectives

and approaches to learning with peers. Through vocalising, explaining and
elaborating their own ideas, while listening to those of others, and after summaris-
ing the knowledge gained, the individual proceeds to a higher level of understand-
ing and reasoning. This is viewed by Torrance (1988) and Sternberg (1977) as
an ideal opportunity for the development of divergent and creative thinking.
Cooperative learning has been said to be a training ground for metacognitive skills
(Davidson & Worsham 1992:16, 123-124). The link between metacognition and
creative thinking, is discussed in 4.4.1.2.
As cooperative learning provides diversity of ideas and social and intellectual

interaction among peers, students become more precise, persistent, flexible,
curious, thoughtful, creative, self-aware and emphatic towards others (Davidson
& Worsham 1992:42, 64). These qualities have been identified as key-abilities
of creativity by Torrance and Rogers (discussed in 2.5.1.1 and 2.5.3). Sternberg
( 1977) suggests that metaphor or analogical thought can be developed through the
dialogue between peers during cooperative learning, whereas De Bono (1970)
expresses the same idea about lateral thinking (Davidson & Worsham 1992:3).
From the above discussion it is evident that cooperative learning promotes

reflective thinking, metacognition and creative thinking. Cooperative learning is
vital to nursing education as the diversity of nursing practice (each patient case is
a unique situation) necessitates that students learn from each other's experiences,
ideas and perspectives. According to Ellison ( 1993: 14) student nurses learn more
184
when interacting in a caring, non-threatening environment. Miller and Rew

(1989:86) suggests that cooperative learning through brainstorming sessions,
group visualisation and group discussions focuses on questions rather than
answers, and in this way encourages reflective and intuitive thinking which are
essential to competent nursing practice. Caine and Caine (1990:67) affirm that
cooperative learning provides support and facilitates metacognitive and reflective
thinking.
(6) Intrinsic motivation appears to play a key-role in the four models. Adult
learners strive towards self-actualisation, a higher self-esteem, recognition and job
satisfaction. Mastery learning students show greater interest and positive attitudes
on receiving frequent feedback and achieving success. Experiential learning
stimulates interest and curiosity by providing challenges and opportunity for total
involvement. Open learning stimulates interest and provides challenges because
of its accessibility and flexibility - these learners strive towards self-development.
Intrinsic motivation has been identified by several researchers as the driving force
behind creativity (see 2.5.2.2.4). Intense involvement, deep interest, passion,
enjoyment, and a willingness to accept challenges and take risks, have been
singled out as intrinsic motivational forces which lead to creative performance.
It is essential that an individual who enters a nursing programme, be intrinsically

motivated by the need to serve mankind. Nursing is a dynamic and demanding
profession, and therefore requires total involvement and dedication from the nurse
practitioner. Real caring in nursing practice can only be realised when the nurse
practitioner is intrinsically motivated which implies an affective involvement and
a humanistic orientation. Sedlak (1992:26) has found that junior student nurses
are extrinsically motivated by patient feedback, but that the more experienced
student nurse is internally motivated through self-evaluation of her accomplish-
ments.
185
(7) A variety of learning materials and activities is propagated by all four

educational models. These include individualised and cooperative learning
activities as well as audio-visual media. Individual needs and differences in
cognitive style (discussed in 4.2) and specifically the four cognitive styles
described by Kolb in his experiential learning model (see 4.2.2.2) are thus
accommodated. Treffinger, Isaksen and Firestien (1983:13-14) emphasise the
need for the individual to be familiar with and skilled in drawing from many
different theoretical and practical perspectives, in order to facilitate creative
learning.
The variety of learning activities offered by the four educational models concur
with the concept of providing a diversity of activities in order to facilitate whole
brain learning and creativity (discussed in 3.5.3). Summers, Carty and Hoffman
(1993:38) quote Herrmann (1988) who suggests a variety of teaching-learning
strategies according to brain dominance profiles. Caine and Caine (1990:66)
affirm this concept when stating that no one method or technique can by itself
adequately encompass the variations of the human brain. According to Holbert
and Thomas, (1988:31) research suggests that educational approaches which use
a wide variety of teaching-learning strategies are essential to nursing education.
(8) Either self-evaluation or criterion-referenced evaluation or both, are emphasised

by the four educational models. Self-evaluation is specifically important in adult
and experiential learning. In adult learning it focuses on objectives achieved,
whereas in experiential learning it occurs through continuous reflective thought.
Mastery learning emphasises criterion-referenced evaluation with frequent
feedback, whereas open learning uses mainly criterion-referenced evaluation.
Self-evaluation protects the learner from the fear of failure and rejection and
provides information as to what extent objectives have been achieved. Self-
evaluation is encouraged in creative thinking and creative production (see
2.5.2.2.3), and, according to Sedlak (1992:26), it contributes towards motivation
186
and self-confidence. Effective nursing practice demands constant self-evaluation

from the nurse practitioner as the patient's progress is of utmost importance in
health care delivery. Saylor (1990:9) emphasises the need for reflection during
self-evaluation.
Criterion-referenced evaluation promotes extended effort, persistence and

cooperation among students, rather than competition. This contributes towards
a creativity stimulating environment. The negative influence of external and
norm-referenced evaluation on creativity has been reported by several researchers
(see 2.5.2.2.2 and 2.5.2.2.3).
Criterion-referenced evaluation is important in nursing education as a certain level

of competency must be achieved before certification. It is especially relevant
when teaching the psychomotor skills of nursing practice. Self-evaluation in
nursing practice involves constant reflective thought because of the nurse's
continuous direct involvement in complex patient care situations. According to
Saylor (1990:9), self-evaluation is essential to professional autonomy.
A reflection of the four educational models discussed can be found in Treffinger,

Isaksen and Firestien's (1983: 13) reference to the major movements in education
which provide support for concepts of creative learning. These include
individualisation and learner-centred instruction, experiential curricula, demo-
cratic education (Dewey), humanistic and affective education and process
education.
5.6.2 The relation between the learning environments of the four educational
models and creativity
Table 5.2 shows the congruency in the ideal learning environments for adult learning,
mastery learning, experiential learning, open learning and creative learning.
Table 5.2
Relation between the learning environments of the four educational models and creativity
(1) Openness: Open environment: Open atmosphere: Openness: Psychological openness:

challenges one another self-pacing challenging and stimulating choice, self-pacing psychological safety, emphatic
understandino
(2) Authenticity: Authenticity: Authenticity: Authenticity: Authenticity:

trust, respect, risk-taking respect, \'alue e\'el)' student's mutual trust acceptance of the individual's trust, respect, acceptance
abilities worth, respect, trust
(3) I Collaborativeness:
individual and mutual discovery
I Collaboration: I Collaborativeness:
during corrective instruction - reflective observation - peers
Collaborativeness: Collaborativeness:
I-'
co
during cooperative activities brain stonning, flexibility -.J
eer interaction
(4) Non-judgemental: Non-judgemental: Non-judgemental: Non-judgemental: Deferred judgement:

criticism not allowed each individual a chance to ac- each student experience in his/ eriterion-refcrenced evaluation relaxed atmosphere
hieve obiectives her uniaue wav
(5) Relax, enjoy, pleasure Enjoy because of achievement Enjoyment because of affective Enjoy because of availability of Humour, enjoyment, playful-
and cognitive involvement choice ness
(6) I Student-support: Student-support: Student-support: Student-support: Student-support:

encouragement, non-threatening frequent feedback, corrective respect and acceptance, spirit of advice, counselling, encourage- acknowledge all contributions,
environment, allow spirit of instruction mquiry mcnt encouragement
inquiry
(7) I Student-controlled: Student-controlled: Student-controlled: Student-controlled: Individually-controlled:

self-directed, enters with a consider individual student direct involvement, expanded accessibility, flexibility curiosity, persistence, risk-
wealth of experience needs, adjust teaching consciousness, choice takino
188
( 1) Openness in the learning environment is regarded as essential to the optimal

facilitation of learning and understanding. The following existential concepts
come into play in an open learning environment: honesty, responsibility,
commitment to freedom, respect, self-directedness and self-discipline (McDaniels
1983:63). These existential concepts establish psychological safety which
encompasses a sense of acceptance, respect for other's opinions, willingness to
listen attentively to others, and knowing how to disagree without attacking
(Davidson & Worsham 1992: 11 ). This contributes towards developing emphatic
understanding, a concept regarded by Rogers as essential to a creativity
stimulating environment (see 2.5.3). When these elements exist in a learning
environment, a spirit of inquiry is established where students feel free to take risks
and challenge each other. This type of learning environment is referred to by
Kupfer (1983) as the aesthetic classroom, where students learn to listen to each
other and take part in conversations. Dialogue, opinion giving and argument are
allowed, contributions are modified and integrated, and conceptions are
reconstructed (Litterst & Eyo 1993:72, 273).
(2), (3), (4) and (5)

Authenticity implies mutual trust, respect and acceptance, and contributes
towards collaborativeness in the learning environment. Students feel safe to
explore and discover together and exchange ideas and opinions. Authenticity and
a non-judgemental environment enhance learning because of the absence of
threat. According to Orenstein and Sobel (1987), research indicates that stress
and threat affect the brain, and that the brain is influenced differently by peace,
challenge, boredom, happiness and contentment (Caine & Caine 1990:66). Fear
decreases brainpower as the limbic system influences long-term memory (Ellison
1993:12). There is considerable evidence in the literature that laughter reduces
stress and anxiety. Laughter and humour relax individuals and relaxed people are
more open to learning (Watson & Emerson 1988:89). Adult learners engage in
learning to enjoy the content and the pleasure of learning - a relaxed and
189
humorous environment will thus enhance learning. In mastery learning, students

experience joy and pleasure because of the reward of success in the end.
Experiential learning experiences provide pleasure and enjoyment because of the
total involvement of the student - affectively, and cognitively, and with psycho-
motor involvement. The open learning environment provides enjoyment because
of its flexibility, accessibility and wide variety of choices. The creativity
stimulating environment is characterised by playfulness, humour, pleasure,
enjoyment and spontaneity (see 2.5.2.2.3).
(6) Student-support is an important aspect in all four models although there are
subtle differences. Adult learning focuses on encouragement in a non-threatening
environment and stimulation of a spirit of inquiry. Mastery learning focuses on
frequent feedback and corrective instruction, whereas experiential learning
emphasises acceptance of, and respect for students' interpretations of their
learning experiences. In open learning student support is extremely important and
encompasses advice, counselling, encouragement, negotiation and feedback.
Student support in creative learning involves acknowledging all contributions and
encouraging flexibility, fluency and persistence; assisting students to cope with
frustration and failure; and assisting students to become more sensitive to other's
feelings, and social, personal and academic problems (discussed in 2.5.2.2.3).
(7) The learning environments in the four educational models are student-controlled,
while the role of the teacher is that of facilitator. In adult learning student-control
is characterised by self-direction and the wealth of experience the learner brings
with him to the learning situation. Mastery learning recognises individual
differences and provides corrective instruction to meet the students' needs. In
experiential learning the student has direct control because of total involvement
in the learning experience. In open learning student-control is emphasised by the
accessibility and flexibility which provide opportunities and choices. This
concurs with the creativity stimulating environment where the individual is in
190
control. Freedom to explore, experiment, hypothesise, investigate, imagine, make

wild guesses, take risks, and manipulate materials, ideas and concepts, are
allowed. The teacher displays an open attitude and has a guiding, facilitative and
supportive role (see 2.5.2.2.3).
5. 7 SYNTHESIS
Adult, mastery, experiential and open learning all show remarkable similarities in
aims, assumptions and learning environments. These similarities indicate a close
relationship to the principles of creativity and the creativity stimulating environment.
These models have a flexible approach, and attempt to match teaching methods and
learning activities to cognitive styles. They accommodate individual differences and
focus on the personal and academic development of the student. Self-direction,
independence, responsibility and the development of a positive self-esteem are
encouraged. Students are supported by the teacher who acts as facilitator, co-explorer,
counsellor and guide in a learning environment characterised by freedom, challenge, risk-
taking, trust, openness, liveliness, playfulness and humour. This type of learning
environment facilitates debate, conflict and idea support. It provides the opportunity for
the development of the higher cognitive skills - metacognition, reflective thinking,
productive thought and formal operational thought - as well as affective skills.
Adult, mastery, experiential and open learning support whole brain education, as has
been indicated in the examples discussed. The application of a combination of these
models to nursing education can thus contribute towards a fuller development of the
potential abilities of student nurses in order to produce innovative nurse practitioners who
are life-long learners and effective problem-solvers.
Figure 5.6 provides an instant picture of the relationships between the four educational
models and creativity indicating their relevance to nursing education.
191
Figure 5.6
Synthesis: The four educational models and creativity
Self-actualising creativeness
Student-centred
Active participation
Problem-centred
Cooperative learning
Intrinsic motivation
Variety of learning act1v1t1es
Self-evaluatwn and criterwn
referenced evaluation
192
CHAPTER6
The practice of nursing
6.1 INTRODUCTION
Nursing is a profession which serves the health needs of mankind. It defines itself as a
scientific field comprising components which make it both a profession and a discipline.
The professional dimension is concerned with the practice of nursing whereas the
disciplinary dimension relates directly to the science (knowledge and theory) of nursing.
These two dimensions cannot be isolated from one another; they provide a challenge to
be melded in such a way that both enrich and complement each other (Germann 1991 :1,
217).
Nursing as an evolving and maturing professional discipline is experiencing a major

paradigm shift as a result of rapid changes in health care delivery throughout the world.
The increasing depersonalisation of health care due to specialisation and advances in
scientific, medical and technological knowledge, is threatening to submerge nurses into
a progressively bureaucratic and technologically oriented industry. Nursing's greatest
193
dilemma is the commitment to care in a society that refuses to value caring since it has
moved from the traditional scientific medical model (with the emphasis on diagnosis and
treatment of physical disease) to a holistic, humanistic-existential, phenomenological
paradigm (Johnson 1990:129; Kurtz & Wang 1991:4).
The need for innovative nurse practitioners who will be able to cope in a continuously
changing society and health care setting, is clearly indicated.
This chapter focuses on the practice of nursing and the foundations on which it is based.
6.2 DEFINITIONS OF NURSING
Nursing has been defined and redefined for many years and, although no single definition
exists on which all nurses agree, there is consensus that the basic concern of nursing is
caring for the ill and injured, with the emphasis being placed on the prevention of disease
and promotion of health.
The word nursing derives from the Latin, nutrire, which means "to nourish", whereas the
word nurse originates from the Latin, nutrix, meaning "nursing mother". Care of the sick
has been provided by the women in a family since the beginning of mankind. During the
early Christian era deaconesses and other designated groups of women rendered care to
the ill which comprised mainly the provision of nourishment and spiritual support.
Nursing thus evolved as a service performed by women out of humility and love
(Donahue 1985:4; Zerwekh & Claborn 1994:33).
Since nursing has changed through the years as a result of societal, philosophical and
scientific influences, definitions of nursing have varied considerably. The following
definitions of nursing have been selected on the basis of their comprehensiveness as well
as their relevancy for modem nursing practice:
194
(1) Harmer (1922)
Nursing is rooted in the needs of humanity and is founded on the ideal of

service. Its object is not only to cure the sick and heal the wounded but to
bring health and ease, rest and comfort to mind and body, to shelter,
nourish, and protect and to minister to all those who are helpless or
handicapped, young, aged or immature. Its object is to prevent disease
and to preserve health. Nursing is, therefore, linked with every other
social agency which strives for the prevention of disease and the
preservation of health. The nurse finds herself not only concerned with
the care of the individual but with the health of a people.
(George 1995:71)
Harmer indicates the humanistic foundation of nursing when she emphasises service to
the individual and society and the holistic nature of nursing is elucidated by the need to
care for both body and mind. A modem day comprehensive approach is embraced in the
definition by including the curative, preventive, and promotive and rehabilitative
(preservation) dimensions of nursing care. She also clearly mentions the function of
nourishing. Harmer's view that nursing is linked to every other social agency involved
with the preservation of health, indicates the close relationship between nursing and other
health professions and agencies.
(2) Henderson (1966)
The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health, or its recovery
(or to a peaceful death) that he would perform unaided if he had the
necessary strength, will or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible. This aspect of her
work, this part of her function, she initiates and controls; of this she is
195
master.
(Hunt & Wainwright 1994:13)
Henderson's definition is still one of the most popular definitions of nursing. By

emphasising the supporting role of the nurse, which aims to guide the individual towards
independent functioning and self-care, she illustrates the humanistic-existential elements
of nursing. She also refers to the nurse's role of advocacy, that is to act on behalf of the
patient (which is discussed and explained below in 6.4.2). Her reference to the nurse as
master of the function of assisting the patient, and of the initiation and control of this part
of her work, is a direct shift from the concept of the nurse as being the physician's
assistant to the nurse as being the assistant to the patient. This is a departure from the
medical model in which nurses mainly react to the physician's orders to one in which
there is a more humanistic-existential approach where nurses accept responsibility and
accountability for their decisions and actions as well as the consequences thereof.
(3) The South African Nursing Council (SANC) (1978)
Definition of nursing:
Nursing is a caring profession which enables and supports the patient, ill
or well, at all stages oflife, to achieve and maintain health or where this
is not possible, cares for the patient so that he lives in dignity until death.
Accompaniment is fundamental to all nursing.
Definition of nursing science:
A clinical health and human science that constitutes the body of

knowledge for the practice of persons registered or enrolled under the
Nursing Act as nurses, midwives or nursing auxiliaries.
196
Within the parameters of nursing philosophy and ethics, it is concerned

with the development of knowledge for diagnosing of health states,
treatment and personalised health care ofpersons exposed to, suffering
or recovering from physical/spiritual/mental ill-health. It encompasses
the study ofpreventive, promotive, curative and rehabilitative health for
the nursing of individuals, families, groups and communities and covers
man's life-spanfrom before birth.
(SANC 1993:1, 2)
In its brief definition of nursing, the SANC regards the nurse as assistant to the patient,
as the most important aspect of nursing. The supporting role of the nurse is thus
emphasised. This concurs with Henderson's view.
The more explanatory definition of nursing science, acknowledges nursing as a human

science and mentions a scientific body of knowledge. A holistic approach is indicated
by the reference to physical, spiritual and mental ill-health. Service to society is
mentioned explicitly in the last sentence.
In the definitions portrayed, service to mankind is the central focus. This stresses the
humanistic tendency of nursing. The influence ofholism is evident in each definition's
view of the individual in totality. It is, however, only the SANC's definition which refers
to nursing's scientific body of knowledge. As nursing has only developed as a science
since the beginning of the 1970s, Harmer and Henderson did not mention nursing as a
science, but defined it as an activity. The more recent definition of the SANC indicates
the significance of science in the contemporary era of scientific and technological
advances.
According to Oermann ( 1991 :2), definitions of nursing have been influenced throughout
history by the social context within which nursing was practiced. This statement is well
illustrated in the above three definitions.
197
6.3 PHILOSOPHICAL FOUNDATIONS OF NURSING
Florence Nightingale's philosophical heritage to nursing has persisted regardless of the

diverse philosophies that have accompanied the changes in nursing through the years.
Her belief in the dignity and value of human life and health, her religious conviction and
Judeo-Christian ethic, together with the classical education she received, made her a
classical humanist, a humanism which continues to be a force in contemporary nursing
(Bevis 1987:3).
Nursing was influenced by Asceticism from its inception until the 1920s, when
Romanticism took over. It probably provided a welcome escape from the drudgery of
self-denial and the narrow confines of Asceticism's religious and spiritual goals.
Romanticism was characterised by values ofpersonal glory, pride in devotion and loyalty
to physicians. The acceptance of the medical model for nursing can be attributed to the
influence of Romanticism. One of the romantic notions was that the physicians and
hospital administrators knew best what nursing should encompass. During the era of
Romanticism nurses lacked autonomy, independence and assertiveness (Bevis 1989:37-
38).
It was only after World War II that the influence of Romanticism was replaced by
Pragmatism. Nursing during the war was no romantic adventure and neither were the
post war nurse shortages. It was Pragmatism with its emphasis on the practical
consequences of acts and the practical application of all ideas that lead to physician-
specialty areas and the habit of referring to patients as the appendicectomy in room 4 or
the cerebral incident in ward B. The focus was on the disease or problem, not on the
person who suffered from the disease.
During the early 1960s the pragmatic values eventually gave way to Humanism and
holism. Nurses became concerned about the individual, the family and the community,
as non-hospital settings for nursing care of patients began to increase. They realised that
__,J
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the patient was not only a person with a physical ailment but an integrated human being
with physical, psychological, social, and spiritual dimensions (Bevis 1989:38-39).
Classical humanism remains the humanism of world nursing today. It values the full
participation in the richness and variety of human relationships. People are morally
committed to elevate the human condition as part of the divine will. As nurses from all
over the world hold in common a belief in the worth of human life regardless of their
religious beliefs, they are committed to serve humans in their strive towards health.
Contemporary nursing has moved away from the limitations of positivism (the physical
world of science and medicine) towards a new paradigm of humanism in which the
spiritual and existential significance of human life is valued. Nursing has adopted
elements of Existentialism and incorporated them into Classical humanism. This has
caused a shift from an occupation based in self-sacrifice, obedience and dependence, to
a profession that emphasises individualism, accountability, autonomy, logic and other
existentially related ideas (Bevis 1987:4; Fitzpatrick & Whall 1989:371)
Humanism emphasises the power and dignity of human beings, the worth of personality,
freedom with responsibility, and the development of human potential. Humanistic
philosophy draws from Existentialism the concern with human longing and search for
meaning within the self (Leininger & Watson 1990:237).
Humanism derives primarily from the existential-phenomenological philosophies. The

I-thou dialogue which requires mutual respect, dignity and appreciation for the
uniqueness of every individual is emphasised. The phenomenological philosophy asserts
that reality lies in a person's perception of an event and not in the event itself. Humanism
is concerned with the individual as a human being; his thoughts, feelings, attitudes,
values and experiences. Humanistic existentialism is concerned with human growth,
individual fulfilment and self-actualisation, and with people as individuals (Leininger &
Watson 1990:236; Quinn 1995 :9).
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Existentialism focuses on the individual as he experiences the actuality of his existence,

his own world. Every person is viewed as unique, worthy and responsible to shape his
own life. Human beings have freedom of choice and are forever becoming, always in
transit and never complete. The uniqueness of man is regarded as inexplicable by
scientific or metaphysical systems. This forms a natural part of the philosophy ofholism
which proposes that the whole of a human being is different from its parts (Bevis
1989:41; Mellish & Brink 1990:16; Quinn 1995:100).
Holism derives from halos which means complete, entire, total. The central tenet of
holism is that living organisms are unified and indivisible units. The parts are
interrelated and interdependent and form a unique quality (the individual) which is
interrelated to larger systems - the family and the community. The whole cannot be
understood by the examination of the parts because the whole is greater than the sum of
the parts. Unique behaviour is characteristic of unified wholes and this is called synergy
(Chaska 1990:246).
Today's nursing model is humanistic-existentialistic, holistic, subjective, intuitive,

phenomenological and human-experience oriented. The patient is viewed from a holistic
contextual perspective.
6.4 PROFESSIONAL PRACTICE
6.4.1 Professionalism
The word profession derives from the Latin profiteri which means to make a public
statement of one's beliefs and intentions. The concept was copied from the medieval
guides wherein the members of highly skilled trades bonded together to train neophytes
in particular crafts, socialised them into brotherhoods and protected them. The
associations that were formed, professed particular levels of knowledge, specific skills
and beliefs, upheld high standards and eventually became known as professionals. The
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modem definitions of a profession, as given by various dictionaries, are less descriptive,

for example:
(1) Webster's New Collegiate Dictionary, 1980:
A calling requiring specialised knowledge and often long, intensive

academic preparation.
(2) The Shorter Oxford English Dictionary, 1973:
A vocation in which a professed knowledge of some department of

learning is used in its application to the affairs ofothers, or in the practice
of an art founded upon it.
(Pyne 1992:4; Searle 1982:4)
The underlying concepts which can be deduced from the above-mentioned descriptions
are that a profession possesses a special body of knowledge, declares specific beliefs and
mastery of particular skills and therefore maintains high standards, and offers a service
to others.
Throughout the years the concept of a profession has, however, expanded. Nursing
complies with the seven characteristics of a profession as cited by Kay (1993: 116, 117).
The criteria for professionalism include:
( 1) services that are vital to humanity and the welfare of society

(2) a special body of knowledge which is continuously enlarged through research
(3) practitioners who are motivated by service
(4) a code of ethics that guides decisions and conduct of practitioners
( 5) an organisation that encourages and supports high standards of practice
(6) a service that involves intellectual activities and individual responsibility and
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accountability
(7) independent practitioners who control their own policies and activities - autonomy
Nursing's main concern is the welfare of the patient, to assist him/her in maintaining
optimal health, as is highlighted in the definitions given in 6.2. Its special body of
knowledge is based on a broad foundation of theoretical knowledge drawn from the
biological, physical, medical and social sciences, the empirical knowledge accumulated
from the instrumental (cognitive and psychomotor skills) and expressive (affective skills)
functions of the nurse, and the ethical and legal foundations whereupon professional
practice rests.
Nursing is a demanding profession (psychologically and physiologically) and only those

who are truly motivated to serve mankind, remain in the profession. The nurse
practitioner's conduct and decisions are guided by a code of ethics, and the profession
is controlled by a legalised body that regulates and prescribes high standards of practice
while at the same time, protecting the public against misconduct.
This endorses the nurse's responsibility, accountability and autonomy in the execution
of her duties. The professional nurse in South Africa is prepared over a period of four
years by a specialised programme of education at a recognised tertiary education
institution. Licensure to practice follows after successful examination at the end of that
period by way of registration with the South African Nursing Council, the legal
controlling body of the nursing profession in South Africa (Mellish & Brink 1990:6).
The modem day professional nurse practitioner is well described in Darley's (1961)
words:
The truly professional person is one, who, by virtue of intellectual
capacity, education and moral outlook, is capable of the exercise of
intellectual and moral judgement at a high level of responsibility.
(Searle & Pera 1992:73)
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6.4.2 Code for Nurses
A profession's values, beliefs, goals and moral concerns are expressed in a code of ethics.
It is regarded as a system of rules and principles by which a profession regulates its
members and demonstrates its responsibilities to society. The present Code for Nurses
was adopted by the International Council for Nurses in 1953, from the American Nurses'
Association. It is recognised by the World Health Organisation and is in worldwide use.
The Code guides curriculum development, nursing practice, legislation and licensing
(Bandman & Bandman 1990:24, 31, 32; Searle & Pera 1992:73).
Briefly summarised, the Code for Nurses makes provision for the nurse to
( 1) provide services with respect for human dignity and the uniqueness of the client
(2) safeguard the patient's right to privacy by protecting information of a confidential

nature
(3) act to safeguard the patient when health care is affected by incompetent, unethical
or illegal practice of any person
(4) assume responsibility and accountability for individual nursing judgements and
actions
(5) maintain competence in nursing
(6) exercise informed judgement and use individual competence and qualifications
as criteria to accept responsibilities and delegate nursing activities to others
(7) participate in activities which contribute to the ongoing development of the

profession's body of knowledge
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(8) participate in efforts to implement and improve standards of nursing
(9) participate in maintaining conditions of employment conducive to high quality

nursmg care
(10) participate in the profession's effort to protect the public from misinformation and
misinterpretation
(11) collaborate with members of the health professions and community members to
promote community and national efforts to meet the health needs of the public
(Bandman & Bandman 1990:24-30)
The key-concepts which derive from the Code for Nurses are discussed below:
• Advocacy
The professional nurse has a central role as the patient's advocate because her primary
commitment is to her client's care and safety. She has a duty to listen to patients,
understand their wishes and take appropriate action within her competence. The patient's
rights and autonomy as an individual have to be respected and taken into account. It is
the nurse's duty to protect the patient against incompetent, illegal or unethical practices
from other members of the health team. Nurses have a professional right to advocate
patients' rights against physicians if their orders are medically or scientifically contra-
indicated or against their patients' wishes (Bandman & Bandman 1990:26, 36, 147; Hunt
& Wainwright 1994:189; Perry & Jolley 1991:157).
The following example highlights the advocacy role of the nurse:

204
Example 1
An experienced nurse gave an account of a 17-year-old male admitted with a C-spine

fracture. The patient was quadriplegic but alert with stable vital signs. He was intubated
after 24 hours in the intensive care unit as a result of poor ventilatory efforts. As he was
extremely apprehensive about his intubation his respiratory rate increased into the 40s
while his PCO, dropped. He was unable to decrease his respiratory rate because of his
anxiety. The physicians wanted to repress his respiratory drive through stronger sedation
in order to have his ventilation controlled by the respirator. The nurse realised that this
message increased the patient's anxiety and that the complications which could arise
would add to the young man's already monumental problems with recovery and
rehabilitation. According to the nurse, she had a gut feeling that the respiratory problem
could be resolved in a different way. She intervened on the patient's behalf and asked
the physicians for more time. The nurse sat down with the patient and started explaining
what was happening to him and reassured him that the health personnel cared about him
as an individual. She described his dilemma as follows: He could not speak, as he was
intubated He could not write, as he was quadriplegic, and we didn't allow him to nod
his head due to his unstable neck fracture. His only method of communication was with
the use of his eyes and his amazing ability to mouth words clearly and understandably.
It took three and a half hours before he began to relax and when his respiration rate was
in the 20s, his words to the nurse were: Thank you. You've really helped me a lot. I
don't want to imagine what would have happened to me ifyou weren't here and hadn't
cared (Benner 1984:52).
• Accountability and responsibility
Professionalism is linked to accountability. The Code for Nurses is formulated to bring

about good and minimise harm or injury and, by providing guidelines to practice, holds
nurses accountable for professionally acceptable standards of nursing care. The nurse
is answerable to the patient, her professional colleagues for standards of practice, the
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employer with whom she holds a contract and, finally, to the law (Bandman & Bandman
1990:24, 35; Perry & Jolley 1991:23).
The professional nurse assumes responsibility and accountability for individual nursing
judgements and actions, or failure to act in a particular situation.
Nurses are subject to statutory regulation and disciplinary action by the SANC or
prosecution by a court of law. The SANC promulgates regulations regarding the scope
of practice of registered nurses, acts and omissions and the conditions of practice.
Together, these documents underline the accountability of the nurse (Bandman &
Bandman 1990:27; Searle & Pera 1992:127, 128).
The most basic pre-requisites for accountability are knowledge, skill and attitude. Other
requisites are responsibility and authority, which means legitimised power to carry out
the responsibility (Perry & Jolley 1991:23).
The following exemplifies the meaning of accountability and responsibility in nursing

practice:
Example 2
An experienced nurse and midwife appeared before the Nursing Council as a result of
incidents that occurred following the admission to an antenatal ward of a young woman
at 29 weeks gestation with antepartum haemorrhage.
The allegations against the nurse were that
• she performed a vaginal examination when it was contraindicated
• she administered a drug (Yotopar) intravenously without a written prescription

206
or other authority from a doctor
• she should have known that the drug was contraindicated by the patient's
condition (the drug delays premature labour but is contraindicated in antepartum
haemorrhage) (Pyne 1992:87, 164)
The controlling body found the nurse guilty of misconduct on three charges and
removed her from the register.
• Autonomy and authority
Autonomy relates to independence of action, which means that a person can perform
his/her total professional functions on the basis of his/her own knowledge and
judgement. To the professional nurse, it implies the freedom to make choices and
decisions about nursing care without interference, even if those decisions are not in
agreement with those of the health care team. The principle requires rational thinking
from the professional and may be challenged when the rights of others (in this case the
patients) are infringed upon. Both autonomy and accountability require a sound
knowledge basis for practice (Perry & Jolley 1991:24; Zerwekh & Claborn 1994:283).
Responsibility, authority, autonomy and accountability are inextricably linked, the first
two concepts mentioned, being necessary conditions for the latter two. Authority refers
to the rightful (legitimate) power to fulfil a charge. Nurses have the authority and
freedom to make legitimate decisions about the care and management of their patients
(Bowman 1995:74-75).
Example 2 illustrates the link between autonomy, authority, responsibility and

accountability. In this case the nurse's autonomy was challenged because she put the
patient's life and that of her unborn baby in jeopardy.
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• Competence
Nurses are expected to be competent and remain informed of new knowledge as effective
nursing care often is a major determinant of a patient's survival or death, recovery or
continued ill health. Continuing education and advanced formal education are essential
in order to keep ahead of scientific, technological and professional developments. The
task of maintaining competence is regarded as self-initiated and self-directed. The
professional nurse needs to assess ancillary personnel's competence before she delegates
nursing functions to them as she will be held accountable. The professional nurse is
accountable for all her actions and has to justify her acts of omission and commission
when called to account. If a nurse is found guilty of incompetence, she will have to face
sanctions or penalties, for example, disciplinary action by the registration body (SANC),
dismissal from service, or civil actions (Bandman & Bandman 1990:28; Searle & Pera
1992:92, 93).
Incompetence and ignorance are no excuses for practising professional nurses. Open
learning offers the ideal opportunity to all practitioners to participate in continuing
education in order to keep informed and competent (see 5.5.4).
• Respect for patients' rights
Every patient who receives health care is entitled to legally and ethically safe nursing
care. Patients have the moral right to be informed about their health status and the
proposed treatment. Information must be conveyed to them in a manner which will
ascertain their full understanding of detail and consequences to enable independent and
responsible decision-making. Patients have the right to be respected. This includes the
right to be told the truth in so far that it is known, and the right to accept or refuse
treatment. For example, health personnel have to provide competent, compassionate care
while a patient is dying enven if he/she refuses further medical treatment. The nurse has
to work with the patient and others to arrive at the best decision when caring for the
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dying patient. The nurse has a right to withdraw from a situation if she opposes the
nature of health care delivered (Bandman & Bandman 1990:25, 244-245; Searle & Pera
1992:62).
The responsibility of the professional nurse to respect patients' rights, is illustrated in

examples 3 and 4.
Example 3: A patient's right to know the truth
A 21-year-old young woman is dying of leukemia. She wants to know what is happening
to her and repeatedly asks about her worsening signs and symptoms. Her devoted
mother, who is a wealthy and influential woman, wants to shield her from the prognosis
and threatens to sue the hospital if her daughter finds out that she is dying. This moral
issue leaves the nurses in conflict as whether to support the young woman's right to know
or whether to acquiesce to the mother's wishes (Bandman & Bandman 1990:242).
The solution to this dilemma is for a nurse to inform the young woman about the
diagnosis of leukemia and her imminent death as she has the right to know the truth.
Example 4: Honouring a patient's wishes for a do not resuscitate directive
A 52-year-old woman with a possible malignancy of the brain asked not to be

resuscitated before going into surgery. Her order was written on her chart. An
inoperable cancer was found during surgery and when she suffered a cardiac arrest
following surgery, the nurse resuscitated her. The outcome of this situation was that
after three days her kidneys which she wished to donate for transplantation into another
person became unusable for this purpose. She was thus prevented from aiding another
person (Bandman & Bandman 1990:243).
The nurse acted incorrectly when she resuscitated the woman because she should have
209
respected the patient's wish not to be resuscitated.
• Confidentiality
The relationship between the nurse and patient should be one of trust and mutuality. If
the patient discloses intimate information in confidence, the nurse is obliged to keep it
confidential. However, any data related to the patient's health status needs must be
shared with other members of the health team as the common goal is patient welfare.
The patient's consent must be obtained before any information is used for research or
other purposes (Bandman & Bandman 1990:25).
The keeping of confidence is one of the fundamental requirements of professional health

care ethics. Some form of confidentiality has been included in virtually all the codes of
ethics (Searle & Pera 1992:92).
The rights to confidentiality and privacy are crucial autonomy rights and merit high
moral consideration. There are, however, extenuating circumstances in which the
paramount right to the prevention of harm overrides even the right of confidentiality and
privacy, such as when withholding the truth can bring harm to innocent people
(Bandman & Bandman 1990:204).
• Collaboration
The delivery of health care is beyond the capacity of any single profession.
Interdisciplinary team effort where members share knowledge, skills and responsibilities
for total patient care requires the nurse's recognition of her limitations of expertise in
all the required fields. It is not possible for any one profession to possess all the
knowledge, skills and resources, required to meet the total health care needs of society
(Bandman & Bandman 1990:28; Pyne 1992:64).
210
This implies that the nurse has to work together with the physician, physiotherapist,
social worker, speech therapist, occupational therapist, psychiatrist, and possibly others
to fulfil all the patient's health needs. Example 7 illustrates collaboration between the
nurse and the physiotherapist.
6.4.3 Scope of practice
The practice of a profession requires knowledge of its scope of practice which is an

authorisation of what a professional in the particular field concerned may do. The
professional nurse is autonomous and self-directing and maintains this position because
society is convinced of her trustworthiness, knowledgeable skill and ethical conduct as
well as of the status of the profession as being the most reliable authority on nursing care
(Hunt & Wainwright 1994:9).
A theory of nursing provides a framework for the definition of a scope of practice. In

South Africa this framework is founded on Nightingale and Henderson's definitions of
nursing and the SANC's definition of nursing science. A scope of practice consists of
broad concepts and is legitimised in South Africa by regulations promulgated under the
Nursing Act, 1978 (Searle & Pera 1992: 124, 126).
The practice of nursing is discussed in relation to the concepts (marked a, b, c, etc)

included in the regulations relating to the Scope of Practice of Registered Nurses,
Regulation R2598 of November 30, 1984, as amended (South Africa, 1984:2-3).
(a) the diagnosing of a health need and the prescribing, provision and
execution of a nursing regimen to meet the need of a patient or group of
patients or where necessary, by referral to a registered person
This is a very comprehensive concept as it encompasses the coordinating, collaborating,

and patient advocacy functions of the nurse; execution of physicians' prescriptions;
211
preventive, promotive, curative and rehabilitative care; and the nursing process.
The nursing process is the methodology of nursing practice. It encompasses sequential,

interrelated and interdependent actions which aim to meet the patient's health needs to
the level of optimum wellness, and provides a framework for individualising nursing
care. The actions inherent in the process include the cognitive, affective and
psychomotor domains. Concept formalisation, inference reasoning, judgement,
decision-making, application of theories, ideas and concepts, and value judgements
based on respect for human dignity and the worth of the individual, are involved during
the process. It is based on a philosophy of holism, as wholeness is acknowledged by
keeping in mind all the phenomena (physical, psychological, spiritual, social,
environmental) acting upon an individual in the health/illness spectrum (Reilly &
Oermann 1992:55-66, 85, 95).
The sequence of the phases in the process does not suggest a rigid, linear and
mechanistic pattern of actions as closure of one action is not a criterion for the onset of
the next series of actions. There is a dynamic interaction among the various phases
which accommodates new cues, insights and meanings. The sequence of the nursing
process is comparable to the problem-solving process but other processes are involved
which, through synthesis, result in a unified whole of action, namely, nursing care
(Reilly & Oermann 1992:59-61).
The four phases constituting the nursmg process are assessment, planning,
implementation and evaluation.
• Assessment
This phase includes problem recognition, data gathering and analysis, and nursing
diagnosis. It involves observations on the physical appearance of the patient as well as
hidden cues, history taking (family and personal), a physical examination and the
212
collection of specimens for laboratory analysis. The nurse relies heavily on cognitive
skills, such as problem-solving, inference, judgement, perceptions, intuition, decision-
making, communication, and critical thinking during this phase.
The nursing diagnosis made at the end of this phase consists of a clinical judgement that
includes a statement of the health problem of the patient, aetiological factors, and a
description of signs and symptoms (Reilly & Oermann 1992 :62, 65).
• Planning
Short- and long-term goal setting, priority determination and intervention strategies are
the major functions during this phase. It is imperative that both the nurse and the patient
have the same perception of the desired goals (Reilly & Oermann 1992:73).
• Implementation
This phase encompasses cognitive skills, such as observation, decision-making, clinical

judgement, perception and continuous evaluation as well as affective and psychomotor
skills (Reilly & Oermann 1992:77).
• Evaluation
This is mainly a cognitive phase applied continuously throughout the nursing process
and comprises the total care programme of the patient. Evaluation necessitates
continuous adjustments in assessment, planning and implementation (Reilly & Oermann
1992:96).
The continuous interaction amongst the phases of the nursing process is elucidated in
examples 5 to 8 and 10.
213
(b) the execution of a programme of treatment or medication prescribed by

a registered person for a patient
(c) the treatment and care of and the administration of medicine to a patient,
including the monitoring 'of the patient's vital signs and of his reaction to
disease conditions, trauma, stress, anxiety, medication and treatment
(i) the supervision over, and maintenance offluid, electrolyte and acid base
balance of a patient
(m) the supervision over and maintenance of elimination of the patient
The concepts in the above four phases are all realised in the following incident which
required considerable knowledge and skill from one of the nurses who was principally
involved.
Example 5
An experienced nurse described a crisis situation which developed in an intensive care

unit where she was required to care for a patient who had undergone open heart surgery.
When the patient was returned to the unit from the operating theatre she was connected
to a respirator, intravenous catheters, chest tubes and a foley catheter, and, as a result
of the routine treatment of sick patients to reduce body temperature during the operation,
she was hypothermic. In order to re-establish normal blood volume, the usual procedure
following an operation of this nature was initially to administer relatively large volumes
of intravenous fluid and then gradually over a period of time to reduce them, as well as
to warm the patient up. Generally, as the body temperature increases towards the
normal 37,4 °C, the blood pressure, which is invariably higher than normal, drops and
then stabilises to a more acceptable level. This particular patient, however, despite the
treatment, continued to be hypovolaemic with a low blood pressure and low central
214
venous pressure, and, as a result of continued diuresis, was losing large volumes of
fluid. The nurse increased the volume of the intravenous fluid she was administering,
but she was unable to balance its volume with that being excreted. At that stage the
body temperature had returned to normal (and the blood pressure should have been
within acceptable limits), but the blood pressure was not within acceptable limits. In
order to receive assistance on what further steps she should take to stabilise the
condition of her patient, the nurse attempted unsuccessfully to contact telephonically the
surgeon and his assistant. In the meantime she continued, on her own initiative, to
administer intravenous fluid because the diuresis continued unabated. In her assessment
of the likely causes of the patient's deteriorating condition, she considered that
hyperglycaemia was a strong possibility. She therefore ordered that a blood glucose
level test be conducted and the result of it confirmed her suspicion - the blood glucose
level was more than 600 mg per cent. By then she had managed to contact the assistant
surgeon who, with the help of the information received from the nurse, prescribed a
course of treatment which eventually stabilised the patient (Benner 1984:116-117).
(d) the prevention of disease and promotion of health and family planning by
teaching to and counselling with individuals and groups ofpersons
This concept refers to the communication and counselling skills of the nurse and her
health education functions. For example, a patient who has suffered a coronary
thrombosis requires health education regarding his future lifestyle which should include
advice on diet, daily exercise and recreation, adequate rest, and kinds of activities to be
avoided, and discouragement from smoking. These measures can prevent chronic heart
failure and are promotive in the sense that the patient adjusts to a more healthy lifestyle.
The nurse needs to use her communication and counselling skills because she has to
convince the patient and gain his cooperation. Patients must be involved in their own
care and objectives must be set together with the nurse.
Another example, which endorses the above-mentioned concept, is the offering of health
215
education regarding family planning to groups of patients at post-natal clinics and

family planning clinics.
( e) the prescribing, promoting or maintenance of hygiene, physical comfort

and re-assurance of the patient
The following example illustrates the realisation of this concept in nursing practice:
Example 6
A nurse cited a situation in which an 86-year-old woman who had suffered from chronic
obstructive pulmonary disease for many years was admitted to hospital in a very serious
condition. Her son discussed her situation with the attending physician who made the
decision that the health personnel would not continue to provide her with further
medical support but that she should be made confortable and allowed to die peacefully.
The nurse in whose care she was placed knew her from her previous admissions to
hospital and was aware that she was a very neat and meticulous woman. The nurse is
quoted:
She was my patient. And you know, just because they are not going to do
anything else for her doesn't mean that I stop caring for her. So I gave
her a bath. She had a little suitcase there with all her little things ... so I
put her in one ofher gowns and propped her up all around in her bed with
pillows. I didn't feel that I was doing anything special for her. But her
son told me at the end how much it meant to him to see that the nurses still
cared/or his mother (Benner 1984:55-56).
(f) the promotion of exercise, rest and sleep with a view to healing and
rehabilitation of a patient
216
(g) the facilitation ofbody mechanics and the prevention ofbodily deformities
in a patient in the execution of the nursing regimen
(n) the facilitation of communication by and with a patient in the execution

of the nursing regimen
These concepts are realised in the following account given by an experienced nurse:
Example 7
A nurse described her experience concerning a concert pianist who, while recovering
from a mild cerebral incident, was depressed about the continued weakness in her right
hand. She was, however, reluctant to take the necessary steps which might help her
regain full use of the affected hand. The nurse realised that unless she herself took the
initiative the patient would not take the necessary steps of her own accord. One day she
had an intimate conversation with the patient with the intention of persuading her to
undergo a course of physical therapy, but while listening and talking to the patient she
did not divulge this intention. Instead, she drew her attention to the fact that she could
move her fingers a little more than she had been able to two days previously, and
focussed on the positive aspects of her condition by telling her that this progress was the
result of exercise and reminding her that when she had been admitted to the hospital she
had even needed a lot of help to eat. Now, however, she could hold a cup by herself,
raise the arm above her head and even move her fingers - movements she could not
master a few weeks previously. By the end of the conversation the patient of her own
accord had realised that continued improvement depended on herself and she
subsequently undertook a course of physical therapy (Benner 1984:59-60).
(k) the facilitation of the maintenance of bodily regulatory mechanisms and

functions in a patient
217
( s) the provision of effective patient advocacy to enable the patient to obtain

the health care he needs
The following example illustrates how these two concepts are implemented in practice
and shows that the nurse does not use blind intuition, but senses subtle changes in the
patient's appearance and behaviour and stands in as the patient's advocate.
Example 8
An experienced nurse gave an account of a 60-year-old woman whose vital signs were
satisfactory when she was returned to the ward after undergoing an oesophageal
dilatation procedure in the radiology department. A short while later, however, she
developed nausea and streaks of a very light pink material appeared in the fluid being
drained from her oesophagus. The latter could be accounted for as a result of the
dilatation procedure. However, the nurse had a feeling that something more significant
was wrong. Despite the fact that the patient's vital signs were stable, the nurse
summoned the physician and requested that blood for transfusion be ordered. The nurse
pointed out to the physician that the patient's nail beds were cyanotic. The physician
was unimpressed and a transfusion was not administered. When the patient started
having shills a short while later and developed a fever, the nurse once again called the
physician and persisted in her request that something positive should be done for the
patient. It was subsequently determined that the patient was suffering from a rupture
of the oesophagus and aspiration pneumonia as a result of the procedure, but by this
time her pulse rate had increased to 150. The physician afterwards praised the nurse for
her persistence in requesting that early treatment be instituted - something which
eventually made a significant contribution to the patient's eventual recovery (Benner
1984: 100-101 ).
(r) the coordination of the health care regimens provided for the patient by
other categories of health personnel
218
The example below not only illustrates the nurse's coordination function but also the
holistic picture gained by the nurse as the key-person in the health care delivery system:
Example 9
The nurse in charge of an emergency department described the occurrence of a typical

scenario that had occurred within the space of two hours one particular Sunday evening:
At 21 :00 there was only one medically urgent patient present in the large treatment
room. Suddenly a man suffering from chest pain arrived by private transport, followed
almost immediately by a severely asthmatic person. Soon afterwards another two
patients arrived by ambulance, one with chest pain and the other bleeding internally.
At that stage all the four nurses on duty at the time were engaged assessing these
patients and initiating treatments. Another ambulance arrived bringing in it a young girl
suffering from insulin shock. The nurse in charge sent this patient to the trauma room
as two nurses were immediately required to care for her. When a 17-month-old baby
manifesting a febrile seizure arrived soon afterwards, the head nurse called the
supervisor and requested that she comes and lends a hand. Then a drunk man who had
also taken an overdose of drugs arrived. As he was very belligerent while in the
treatment room he had to be moved to the trauma room. In order to cope with this
sudden influx of patients, the head nurse had to move the asthmatic person and the
patient bleeding internally to the holding room in the care of one of the nurses. The
latter then was sent to the radiology department for arteriograms to be taken. The
supervisor by that time, together with one nurse, were in the trauma room attending to
the baby and young girl who were both becoming stabilised. The medically urgent case
had been examined by a consultant and was ready for admission to the intensive care
unit. The consultant then attended to the man suffering from chest pain who was sent
to the cardiac care unit. The belligerent patient was placed in a private room.and the
baby was allowed, after treatment, to go home.
The nurse in charge reported that this scenario in an emergency room was typical and
219
that she, or whoever was in charge, had continually to assess the state of the unit in
order to maintain the flow of patients in an orderly manner. She was the one who has
to do this as the attending physician seldom knows the overall picture (Benner
1984:113-114).
U) the facilitation of the healing of wounds and fractures, the protection of

the skin and the maintenance of sensory functions in a patient
(p) the establishment and maintenance, in the execution of the nursing

regimen, of an environment in which the physical and mental health of a
patient is promoted
The latter concept refers to both the instrumental and expressive roles of the nurse. The
instrumental role involves the acquisition and utilisation of scientific knowledge which
includes observation, diagnosis, therapeutic planning and intervention. The expressive
role refers to the establishment and maintenance of an effective therapeutic environment
and assisting the patient to become receptive to therapeutic intervention. It encompasses
organisation of a calm milieu, the administrative aspects of which relate to the
establishment of a safe, pleasant and purposeful environment in which the patient is
accepted unconditionally and supported through all stages of nursing care (Searle &
Pera 1992: 173-174).
According to Skipper (1965), we violate the caring concept if we make distinctions

between the instrumental role and the expressive role. The expert nurse melds these
two roles together (Benner 1984: 170).
The following example illustrates Skipper's view:

220
Example 10
An experienced nurse returned to the bedside of a newly arrived patient after a group
of physicians had discussed the case and departed. She removed all the dressings which
had been applied to his abdomen, thus exposing six abdominal wounds. She then spent
several hours cleaming the area and dressing the wounds. This entailed removing the
aluminium paste which had previously been applied as a skin protector. In some of the
wounds irrigating catheters had been placed, and from one of them large clots of blood
were oozing. Following this, she assessed the type of drainage, the tube placement and
the most effective dressing that would be required for each of the wounds, and
determined which of the skin protection strategies available would be most effective
while taking into consideration the nature and location of the drainage. Although the
patient was semi-conscious, she talked to him all through the procedure, reassuring him.
She then wrote up a description and wound management plan for her patient. He said
afterwards that he remembered her voice and her reassurance. After several months the
patient improved enough to be able to be sent home (Benner 1984:130).
In this situation, skilled performance and assessment were critical. As a considerable

range of products and materials is available for use in wound management, a nurse's
competency includes keeping herself to date with the newest and most efficient
technology available. A skilful integration of cognitive, psychomotor and affective
skills is demonstrated in this case. The nurse's reassurance to the patient, as well as her
competence and confidence which was sensed by the patient even in his semi-conscious
state, is a clear example of the melding of the instrumental and expressive roles.
(h) the supervision over and maintenance of a supply of oxygen to a patient
Oxygen is usually prescribed by physicians and administered by nurses. The

implications of its use must be understood by nurses when planning care related to
medical prescription, and a knowledge of the patient's diagnosis is crucial. For example,
221
two patients may have difficulty in breathing, yet the concentration of oxygen which may
be safely administered to a patient with bronchitis could kill a patient suffering from
emphysema. The nurse also has to know, understand and be able to handle all the
different devices of oxygen administration (Faulkner 1985: 119, 189, 190).
The administration of oxygen requires a combination of cognitive, psychomotor and

affective skills. Patients in need of oxygen are usually in an anxiety state because of the
difficulty of breathing and require psychological support and reassurance from the nurse.
The nurse has to integrate and apply the knowledge she has acquired from the biological
sciences, such as physiology, pathology and biochemistry, in order to understand the
complete picture and be able to act competently.
(1) the facilitation ofthe maintenance of nutrition ofa patient
Disease may have an effect on the absorption of different foods or upon their action.
The nurse's knowledge not only of normal physiology especially, in this context, of the
gastro-intestinal system but also of the pathophysiology of various diseases, is of great
significance when planning a patient's nutritional needs. In some cases ignorance
regarding these aspects can place a patient's life in jeopardy, for example, a diabetic
patient could lapse into a coma if given the wrong diet (Faulkner 1985: 12).
(o) the facilitation ofthe attainment of optimum health for the individual, the
family, groups and the community in the execution of the nursing regimen
This concept encompasses preventive, promotive, curative and rehabilitative care on an

individual as well as on a community basis. For example, antenatal care and health
education about the dangers of smoking is regarded as preventive care; health education
on family planning and the offering of these services are promotive care; post-operative
care is regarded as curative; and stoma care falls within the rehabilitative category.
222
( q) preparation for and assistance with operative, diagnostic and therapeutic

acts for the patient
Pre-operative care, and diagnostic and therapeutic acts, necessitate a holistic approach.
The patient needs to understand the procedures to which he will be subjected. Patients
may ask numerous questions because of the fear for the unknown and the nurse will
have to use all the communication skills she possesses in order to give them moral
support. Skin preparation is often required, body temperature, pulse rate and blood
pressure have to be monitored, and specimens for urine and blood analysis may have to
be taken. Pre-operative care also includes the administration of a premedication
(usually containing an analgesic and sedative) which is given intramuscularly (Faulkner
1985:269-272).
(t) care of the dying patient and the care of a recently deceased patient
within the execution of the nursing regimen
The focus of care of the dying patient will be on alleviating symptoms where possible
and in minimising other symptoms as they arise. Pain relief is very important as pain
can be a more consuming problem than the actual thoug~t of death. Many patients need
reassurance that they will not die in pain and it is the nurse's duty to let the patient know
that adequate pain control will be available (Faulkner 1985 :348).
The patient's sense of self-respect, dignity and choice must be supported until the last
moment of life. The nurse has to provide calm, sensitive, individualised care. Patients
differ in their attitudes towards death and symptom control is important to the self-
esteem of the patient. For example, pain, mental dysfunction, nausea, respiratory
problems, infections, bedsores, are distressing. Most of these can be controlled by
well-known measures and the remainder through aggressive therapies. Specific nursing
techniques, such as positioning, suctioning, skin care, providing an aesthetic
environment free from noxious smells, administering analgesics timeously and assisting
223
the patient with personal hygiene, are all relieving measures during a patient's last days.
Social and religious needs should be met. If a dying patient decides a visit from relatives
or friends is more important than a dressing change or stoma care, this priority should be
respected.
The central principle is that the nurse acts as advocate for the dying patient and seeks to
protect the basic human values of dignity, respect and autonomy (Bandman & Bandman
1990:260; 262-263).
The following example illustrates the ethical dilemmas nurses can encounter when caring
for the dying patient:
Example 11
A nurse who came on duty in the oncology unit after a week's holiday, could hear the
moans of a young man suffering the effects of metastatic bone cancer. He had been
hospitalised a few months previously for a course of chemotherapy and then discharged.
He was re-admitted with no prognosis. The metastatic growths in his spine were
causing him excruciating pain while brain stem metastases were hastening his death.
The goal of his nursing care was to keep him as comfortable as possible. The nurse was
astonished to find that the patient had received 780 mg of morphine by continuous
infusion during the last eight hours as well as 20 mg boosters every four hours. This
type of dosage was enough to cause respiratory repression even in a patient weighing
85 kg. The head nurse explained that the patient's tolerance was very high probably
because of the fact that he had been addicted to heroin as a teenager. The nurse felt that
she should give him another 20 mg booster to relieve his pain but was a little
apprehensive as he might arrest afterwards. She was concerned because she knew she
might kill him in the process. She also knew that patients develop tolerances to
morphine which require increased dosage rates to produce the desired analgesic effect.
The nurse was in conflict because she wanted to benefit her patient by giving the
224
injection but there is an independent moral principle that prohibits killing. To cut a
lengthy discussion on ethical principles short, the answer is provided by the American
Nurses Association's (ANA) Code for Nurses which states:
Nursing care is directed toward the prevention and relief of suffering

commonly associated with the dying process. The nurse may provide
interventions to relieve symptoms in the dying client even when the
interventions entail substantial risks of hastening death.
The ANA does apparently not condone direct active killing but recognises that it is
appropriate to take the risk to kill a patient if one's intention is to relieve suffering
(Veatch & Fry 1987:167-169).
The examples given and their discussions were chosen with the aim of reflecting on the
interpretation and realisation of the broad concepts of the scope of practice in
professional nursing practice.
6.5 THE SCIENCE-ART OF NURSING PRACTICE
Nursing is a scientific as well as a humanistic discipline. The human science of nursing

is founded upon an epistemology that includes metaphysics, aesthetics, humanities, art
and empirics. As a human science is about, for and~ofhumans, it has a humanistic base
rooted in art. It respects intuition, compels logic and reason, exacts discipline,
necessitates critical thinking, requires creativity, views the individual holistically and
has caring as its ethical imperative. The uniqueness of nursing as a discipline is
characterised by its humanistic and holistic viewpoint based on a fundamental ethic of
caring (Bevis & Watson 1989:220, 221; Chaska 1990:101, 227; Watson 1985:29).
Carper (1978) identified four fundamental patterns of knowing in nursing. These are
empirics (the science of nursing), ethics (the moral component), personal knowledge and
225
aesthetics (the art of nursing). Each pattern of knowing is necessary for mastery of the
discipline, yet they cannot stand alone but are interrelated and interdependent. This
indicates the complexity and diversity of nursing knowledge. Carper explains it as
follows:
Nursing thus depends on the scientific knowledge of human behaviour in

health and illness, the aesthetic perception of significant human
experience, a personal understanding of the unique individuality of the
selfand the capacity to make choices within concrete situations involving
particular moral judgements.
(Perry & Jolley 1991:24; Silva, Sorrell & Sorrell 1995:3; White 1995:75)
Empirics, the science of nursmg, represents knowledge gained from sensory

experiences. It involves principles, laws and theories for the purpose of describing,
explaining and predicting phenomena of concern to nursing. For example, empirical
knowledge related to pain control might be expressed as theories, interpretive
descriptions of the etiology of pain, facts reflecting the pathology, and clinical opinions
about how to manage pain. This is the linear and factual component of nursing (Carper
1978:13-14; Jacobs-Kramer & Chinn 1988:130, 132).
Ethics, the moral component of nursing, focuses on matters of obligation or what ought
to be done. It encompasses knowledge of ethical theories and codes and involves
valuing, clarifying, advocating and ethical decision-making. The ethical pattern of
knowing requires an understanding of different philosophical positions and an authentic
interpersonal involvement and develops to its fullest through exploration of nursing
practice (Carper 1978:20-21; Jacobs-Kramer & Chinn 1988:134; White 1995:78).
Personal knowledge, as a fundamental pattern of knowing in nursing, refers to an

interpersonal process involving interactions, relationships and transactions between the
nurse and the patient. It is concerned with the knowing, encountering and actualising
226
of the individual self. The nurse approaches the patient not as an object, but strives to
actualise an authentic personal relationship, which results in the therapeutic use of the
self. Personal knowledge, to know the self, develops through personal encounter with
another. It is an important aspect for the actualisation of real caring as it includes
intuitive knowing (Carper 1978:18-19; White 1995:79-80).
Aesthetics, the art of nursing, is expressed through action taken to provide for the
patient's needs. This pattern of knowing can be conceptualised as a separate knowledge
form or as a synthesis of all knowledge forms. As a separate form it constitutes
knowledge about artful nursing practice while as a synthesis of knowledge patterns, it
encompasses the total knowledge spectrum integrated in nursing practice. Benner's
reference to the expert nurse illustrates this synthesis. The aesthetic pattern involves
perception of balance, rhythm, proportion and unity of the whole situation. Experience
is essential to aesthetic practice. Context-specific experience allows for engaging,
interpreting and envisioning. Aesthetics thus requires involvement in a situation and an
all-at-once interpretation of a situation (Carper 1978: 17-18; Jacobs-Kramer & Chinn
1988: 136; White 1995 :82).
Carper's four patterns of knowing encompass the cognitive, affective and psychomotor
domains of nursing. Empirics refer to the cognitive; ethics and personal knowledge to
the affective; and aesthetics to both affective and psychomotor domains. The
interrelatedness of the patterns of knowing and the domains, is illustrated in Isabel
Stewart's (a great nurse leader of her time) words:
.. .the real essence of nursing,

as of any fine art,
lies not in the mechanical details of execution,
nor yet in the dexterity of the performer
but in the creative imagination,
the sensitive spirit,
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and the intelligent understanding lying back

of these techniques and skills ...
(Appleton 1993:899)
Aydelotte in Benner (1984:v) refers to the mystery of expert nursing practice and calls
for respect for this mystery rather than to dispel or standardise practice by submitting
it to rules and procedures. Schein (1972) refers to the important component of a
professional programme as training for uncertainty. It implies a willingness to take
responsibility for key-decisions that may be based only on partial information and the
willingness to make decisions under conditions of high risk (Reilly & Oermann 1992:7-
8).
Both Aydelotte and Schein have divergent thinking skills in mind when they speak
about having to deal with ambiguities and risk-taking. Professional nursing practice
encompasses convergent aspects (when one action is possible and the rationale is
supported by theory) as well as divergent aspects (when multiple actions are possible
because no one theory can provide support for the response).
According to Benner (1983), nursing practice is always more complex (than to put
theory learned in the classroom into practice) and presents many more realities than
can be captured by theory alone (Reilly & Oermann 1992:5).
Benner's view is expressed from a different perspective by Stewart: Technique, mind,

soul and imagination are all essential in the foundation of a true artist. The nurse as
a true artist is essential to the progression of nursing into something other than a highly
skilled trade (Donahue 1985 :467).
Nursing practice is a synthesis of the science and art of nursing.

228
6.5.1 Psychomotor skills
Psychomotor skills are an extremely important aspect of the practice of nursing as

nursing is largely a practical endeavour. These skills are used during both the
assessment and implementation phases of the nursing process and constitute a
significant portion of nursing interventions. Motor skills relevant to nursing fall in the
third category of Oxendine's classification namely: ( 1) maturation-dependent skills eg
walking, speaking; (2) educational-related skills eg writing, reading; and (3) intrinsic-
value skills eg recreational and vocational skills (Quinn 1995:56-57; Reilly & Oermann
1992:24 7-248).
Psychomotor skills in nursing are those dimensions of practice which involve the ability
to act efficiently in a situation that requires neuro-muscular coordination. They are
purposeful, complex actions based on principles. Their application in practice is an
integrated phenomenon that involves the cognitive, psychomotor and affective domains.
The teaching of these skills is a significant component of the education of nurses (Reilly
& Oermann 1992:248, 261).
Unlike other forms of learning, motor skills require practice in order to be learned.
Practice encompasses repetition of a procedure under specific conditions. Physical
practice is always followed by mental practice (visualising the task through imagery).
Apart from feedback from the teacher which is extremely important, students receive
kinaesthetic feedback from their own bodies. They become aware of the muscles and
joints they are using which informs them of the position of limbs and the action of
movements (Quinn 1995:58).
Kinaesthetic feedback makes the students aware of the fine nuances in the performance
of motor skills which in the end perfects the skill to such a level that the patient suffers
minimum pain or discomfort. For example, a student who has practiced giving
intramuscular injections many times in the clinical laboratory on oranges and models,
229
and a few times on patients, learns exactly how to control muscle coordination related
to the angle, speed and power of insertion of the needle, in order to give a painless
injection.
Research studies have shown that psychomotor skill learning requires moderate
motivation and immediate feedback, and that the learner feels comfortable with herself
in the performance, before the skill can be applied on a more sophisticated level in
nursing practice. Bruton (1976) found that perceptual awareness of bodily kinaesthetic
cues and appropriate response to the cues contribute towards mastery of the skill (Reilly
& Oermann 1992:256-257, 266, 285).
Skilled performance encompasses the following characteristics: accuracy, speed,

efficiency, timing, consistency, anticipation, adaptability and perception. Whereas the
student nurse and novice practitioner can achieve the first five requirements, mastering
of the last three only comes with expertise in practice (Quinn 1995:56).
Psychomotor skills relevant to nursing practice can be categorised as follows:
(1) gross motor skills which involve large muscles or the whole body, eg patient
positioning, cardiac massage or ambulation
(2) manual skills which refer to manipulative tasks that are repetitive and usually
involve eye-arm action, eg physical assessment, body hygiene, suctioning, chest
drainage
(3) fine motor skills which involve muscular coordination of fingers and wrists
aimed at precision-oriented tasks, eg administering injections, insertion of IV
catheters, and surgical dressings requiring instrumentation (Reilly & Oermann
1992:250)
230
Psychomotor skills can only be learned in the clinical laboratory or in the clinical field
because they need to be rehearsed and practiced. Motor skills need to be performed
within a coordinated behaviour pattern characterised by a realistic time, motion and
speed context. The teacher needs to consider the level at which the student must learn
the skill. When considering the characteristics of skill performance as mentioned, it is
evident that students cannot achieve the highest level for every skill they learn. Even
experienced nurses will vary in the relative degree of skill amongst the nursing
procedures they practice (Quinn 1995:59; Reilly & Oermann 1992:284). The most
appropriate educational models for the learning of psychomotor skills are experiential
and mastery learning (see 5.3.4 and 5.4.4).
As has already been mentioned, psychomotor skill performance does not occur in
isolation and the cognitive domain forms a very important part of these skills. Newly
qualified nurses find that performing skills they have been taught in the clinical
laboratory, require more varied and complex skills in real practice (Benner 1984: 121 ).
The following example illustrates the integration of the cognitive and psychomotor
domains and the complexity of skill performance in the contextual situation that
characterises nursing practice. The starting and maintenance of intravenous therapy has
been selected as an example since most patients receive IV therapy or blood products
when hospitalised and because the applied technology of IV therapy has grown
tremendously.
Example 12: Starting intravenous therapy
A professional nurse is quoted:
A lot of questions need to be asked. How do you choose between a

butterfly or an IV intracath? You have to consider why you want the line
in. And just learning the insertion alone is difficult. You take into
consideration the length of time you will be leaving the line in and the
231
kinds of medications that will be given, or whether it's a short-term, keep-

open IV With limited medications, then the butterfly IV is more
comfortable and presents less of a threat of phlebitis. Doctors vary in
their preferences as well, and you have to take that into consideration.
And, of course, the condition of the patient and his veins makes a great
deal of difference. For example, with older patients special skill is
required. They look as if they are going to be easy to get in because the
veins look large, but they are so fragile. Ifyou do not use a very, very
slight tourniquet, the thin membrane of the older patient's vein will just
pop open.
(Benner 1984:124-125)
Example 12 illustrates the inquiring attitude of the professional nurse and how she has
to integrate scientific knowledge from various fields such as pharmacology, anatomy,
physiology and pathology as well as personal knowledge gained from nursing
experience, when she has to perform a psychomotor skill. The example also reveals the
contextual quality of each practice situation as no two patients who require the same
procedure present with identical circumstances.
Example 10 (in which the nurse had to change the patient's dressings) provides an
excellent example of how the experienced nurse integrates the psychomotor, cognitive
and affective domains.
Skilled psychomotor performance is an art, as there are no ideal, perfect situations in the
illness continuum where motor skills can be directly and involuntarily applied Nurses
must know how to adjust procedures in unique situations. This refers to aesthetics (as
identified by Carper) as a synthesis of the four knowledge patterns.
232
6.5.2 Affective skills
Affective competencies include value based behaviour and moral reasoning that are
essential elements in expert nursing practice. They deal with the realm of feelings,
attitudes, beliefs, and ethics which constitute the caring functions. They transcend all
aspects of practice and characterise nursing as an art and as a humanistic discipline
(Quinn 1995:278; Reilly & Oermann 1992:291).
The affective domain is included in Carper's ethics pattern of knowing in nursing. The
goals of affective learning are to develop skill in moral reasoning in order to manage
ethical and moral dilemmas and to develop a value system which incorporates the values
espoused by the nursing profession. These values are embedded in ethical codes for
nurses, in the rules and regulations of the controlling bodies of the profession and in the
philosophy underlying nursing. The affective component of practice is personal and
value based and can only be taught through experiential learning. The development of
self-awareness and a non-judgemental attitude is essential to nursing practice. This
implies that the nurse must become aware of her own emotional needs, biases,
blindspots and impact on others, and that she should realise that whereas feelings cannot
be controlled, behaviour can. Effective nurses control their behaviour to prevent their
own prejudices, beliefs and needs from intruding into nurse-patient relationships.
Therapeutic use of the self begins with the ability to convey acceptance to the patient.
It has been demonstrated that it is not essential to like a patient in order to be
therapeutically effective. When tempered with moderation, disclosure of a nurse's
negative feelings toward a patient can be put to optimal therapeutic advantage because
some patients cannot tolerate attitudes of unconditional positive regard (Holden
1990:70-71; Kay 1993:342-344). Patients can sense whether a nurse is knowledgeable
and competent. It is through this knowing that they feel secured in crisis situations.
The therapeutic use of the self is a central concept of the affective domain of practice
and forms an integral part of transpersonal caring. It is also an integral part of the
233
personal knowledge pattern identified by Carper.
Caring has emerged as the dominant paradigm of nursing practice, and is viewed by
Watson (1985) as the moral ideal of nursing. It encompasses the whole spectrum of
affective skills. Among the 27 different caring constructs which Leininger (1981)
identified, are empathy, concern, compassion, nurturance, presence, support, trust,
sensitivity and love. Norris ( 1989) views caring as the fusion of thinking, feeling and
acting, and adds that it requires a vast amount of knowledge, experience, wisdom and
expertise in a professional practice. Caring as a process and an art, involves knowledge
and commitment; it energises action, increases intimacy and self-actualisation and
empowers both participants in the nurse-patient relationship (Caffrey & Caffrey
1994:12-13; Kurtz & Wang 1991:5; Reilly & Oermann 1992:298; Watson 1995:29).
The constructs of caring which have been mentioned in the above paragraph, are
elucidated in the nurse-patient relationship in Example 1, where the nurse played
advocate for the 17-year-old quadriplegic.
Caring transactions and transpersonal human care are viewed as those scientific,
professional, ethical, aesthetic, creative and personalised giving - receiving behaviours
and responses between two individuals. In transpersonal caring the nurse enters into the
lived experience of another person and that person enters into the nurse's experience.
Caring is contextual, relational and subjective. It is the nurse's perception of actions,
not the action itself. If nurses focus only on the obvious, for example, immobilisation,
anger, obstinacy, and hostility, the intersubjective field possibilities are ignored. The
idea behind transpersonal caring is to look beyond the person suffering from a physical
ailment in order to discover the spirit within (Parker 1990:281-282; Reilly & Oermann
1992:298).
The difficulty to capture the comprehensiveness and complex nature of caring, is

somewhat explained in Krysl's words: Caring for others takes place, so to speak, in the
234
metaphysical realm. We cannot see this realm, but we experience it (Parker 1990:279).
The following poem by Krysl reflects the complex yet basic human intersubjective
energy present in a transpersonal caring moment:
Example 13
Sunshine Acres Living Center
The first thing you see up ahead is Mr

Polanski, wedged in the
arched doorway, like he means absolute
to stay there, he who shouldn't
be here in the first place, put in here
by mistake, courtesy of that grandson
who thinks he's a hotshot, and too.busy raking in
the dough to take time for an old
man, If he had anyplace to go, you know he'd be out
instantly, if he had any
money. So he intends
to stay in that doorway, not missing

a thing, and waiting
for trouble. Which of course
will come. And could be you - you're handy, you look
likely, you have
the authority. And you're

new here, another young
whippersnapper, doesn't know
235
ankle from elbow, but has been given

the keys. Well he's
ready, Polanski. So you go right
to him. Mr. Polanski, good
morning - you say it in Polish,
which you learned a little of
when you were little, and your grandmother taught you
a little song about lambs, frisking
in a pen, and you
danced a silly little dance with your grandmother
while the two ofyou
sang. So you sing it
for him, here in the dim, institutional

light of the hallway, light which even you find
insupportable, because at that moment
it reminds you of the light in the hallway
in the resthome where, when your grandmother
died, you weren't
there. So that you're also singing
to console yourself. And at the moment you pay her
this silly little tribute, Mr. Polanski
steps out of the doorway. He
who had set himself to
resist you, he who had made himself
a first, Mr. Polanski,
contentious
ojien combative
and always inconsolable
236
hears that you know

the song. And he steps out
from the fortress of the
doorway, begins
to shuffle
and sing along.
(Parker 1990:279-281)
Mr Polanski could also have been an abandoned, vulnerable person suffering from major
depression, schizophrenia, cancer or AIDS. The nurse was presented with an
opportunity to decide how to be in that caring moment. She looked beyond the obvious,
sensing Mr Polanski's innermost needs and from connections from her own past
experiences, and sudden illumination, she formed a new synthesis which resulted in a
special caring moment that brought peace of mind to Mr Polanski.
The special sensitivity exhibited by the nurse in Krysl's poem, is viewed by Holden
(1990:72) as a sensitivity which is accompanied by a perceptual mode capable of
understanding the mind of the patient from within, and perceptively intuiting the hidden
intentions and conflicts underlying the observed behaviour. It is an excellent example
of personal knowing as identified by Carper.
The two persons in a human caring situation are both in a process of being and
becoming. Each brings with him a unique life history and phenomenological field and
both are influenced by the nature of the transactions. Moustakas describes a
transactional human caring relationship as follows:
The opportunity to engage in genuine caring is a process of intuitive

awareness, sensing and knowing, a recognition of the mystery, the awe,
the capriciousness, the unpredictability oflife, the possibility ofthe power
237
ofsilence and of real dialogue with others in the deep moments of life ...
and indeed spiritual qualities of our energy interchange via the caring
relationship.
(Parker 1990:282)
The role of the affective competencies in nursing practice will become more and more
important as the contemporary and future world indicate an increasingly complex
society where moral decisions, value conflicts and ethical issues will be increasingly
intricate.
6.5.3 Cognitive skills
Cognitive skill development is a significant aspect of nursing practice. It is separate

from the affective and psychomotor domains in the sense that each has special
characteristics of performance, but the three domains are inextricably interrelated.
Cognitive skills essential for nursing practice encompass concept learning, problem-
solving, decision-making, critical thinking and clinical judgement (Reilly & Oermann
1992:207, 240). I would like to add creative thinking, as the expert nurse practitioner
has to be an innovative thinker.
6.5.3.1 Concept learning
A concept is a mental image, an idea in one's mind formed by a generalisation from

specific concrete experiences linked to empirical knowledge. It provides knowledge of
the essence of things. Conception means to know something beyond the level of
sensation (King 1988:22). The acquisition of facts and information is important in the
health fields but the vast mass of details can only be accomplished through the learning
of concepts. Concept learning provides a means for students to group together facts and
categorise new information. A concept is a general phenomenon which reflects a group
of events or objects that share common traits. These are the identifying features of a
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concept. Conceptualisation serves to reduce the complexity of the environment through

placing events or objects into categories. Concepts assists nurses in categorising events
and objects they deal with in practice (Reilly & Oermann 1992:209-211 ).
The nursing diagnosis is an example of a concept attainment task which requires from
the nurse to group characteristics or cues into a diagnostic category. Characteristics
such as decreased muscle strength, impaired coordination and stiffness of joints may be
grouped together as a nursing diagnosis of impaired physical mobility (Reilly &
Oermann 1992:210). Other concepts relevant to nursing practice include pain, empathy,
caring, immobilisation, ethical dilemmas, and asepsis. These concepts manifest in many
different situations in practice. For example, the principles of asepsis must be applied
during wound care, catheterisation, removal of stitches, shortening of drains, and when
assisting in the operating theatre.
Concept learning is enhanced through experiential learning. The concept empathy can
be learned through role play and psychodrama, whereas the concept immobilisation can
be learned through clinical practice experiences with post-operative patients, comatose
patients, and patients suffering from a cerebral vascular incident or bone fractures.
Concept learning is similar to what Bruner refers to as understanding the structure of a

subject. Both require comprehension and insight (see 4.4.1.4).
6.5.3.2 Problem-solving
Problem-solving and the nursing process are essentially the same processes as they have
in common data gathering; identification of the problem (in the nursing process this is
the nursing diagnosis); planning which implicates consideration of alternative solutions;
implementation of the solution or plan; and evaluation of the outcome. A belief in the
nursing process, however, as the prototype of reasoning in professional nursing practice,
ignores intuition as a recognised component of the perceived view of science and a
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legitimate way of knowing in nursing (Miller & Rew 1989:84; Zerwekh & Claborn
1994: 113).
Nurses are confronted daily by unique and complex patient- or setting-oriented problems
which require the ability to use concepts and theories in order to find solutions. Not all
problems lend themselves to resolution through application of theory and a technical
approach. Analytical reasoning is useful in structured settings but nursing practice
invariably involves highly complex interacting elements which require analytical and
non-linear thinking processes. Recent studies question the merits of exclusive attention
to a logical, analytical and linear process of reasoning in practice related problems
(Miller & Rew 1989:84-85; Reilly & Oermann 1992:211).
In nursing practice many problems do not present themselves as well-defined to which

previous learned rules can be applied. When a unique, complex problem presents,
reflection-in-action occurs according to Schon. By reflecting on the unexpected aspects
of a problem, the nurse frames new questions, strategies and objectives. This inquiry
may reframe the situation or suggest an experiment based on the professional's
repertoire of theoretical principles, technical knowledge and experience. The nurse
searches her mental data bank of knowledge and experience for the most likely
explanation or strategy for this unique clinical problem. The experienced nurse has a
greater repertoire to draw from and often allows vague hunches to guide her in finding
a solution (Reilly & Oermann 1992:213; Saylor 1990:9).
Benner affirms the role of intuition in solving clinical problems and making nursing
judgements. According to Benner, experts dare not stop with vague hunches, but
neither do they care to ignore those hunches that could lead to early identification of
problems and the search/or confirming evidence (Benner 1984:xix).
Example 9 illustrates the analytic and linear processes of problem-solving used by the
nurse in charge of the emergency unit in order to accommodate each patient's needs.
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6.5.3.3 Intuition
Intuition is a non-linear thinking process which is based on a perception of cues that are
linked together with basic knowledge and past experiences. Bruner (1963) describes
intuition as the intellectual technique of arriving at plausible but tentative formulations
without going through the analytic steps by which such formulations would befound to
be valid or invalid conclusions. Intuition is a sense of knowing without a preceding
rational analysis. It is synthesis, rather than analysis (Miller & Rew 1989:85; Reilly &
Oermann 1992:214).
Intuition is an essential component of the art of nursing and of the nursing process.
Expert nursing care, ethical dilemmas and the ability to predict behaviour based on
inadequate and ambiguous data necessitate the use of intuition. The emphasis placed on
the nursing process and on the breaking down of assessments into separate problems,
thus dismissing intuitive data, has been criticised in the nursing literature as it results in
missing the overall picture. For it is the combination of intuition and objective verifiable
approaches that enable nurse practitioners to deliver holistic care. According to Benner
(1984), intuitive nurses are the more experienced practitioners and are holistic versus the
fractionated or procedural (Correnti 1992:91-92).
In Example 8, the nurse relied on her intuition as she had a feeling all along that
something serious was wrong with the patient who had undergone an esophageal
dilatation procedure. She kept on searching for cues and persisted in seeking medical
help, until in the end she was proved right.
Intuitive thinking processes can be encouraged through experiential learning experiences

which include open group discussions where reflective thinking is emphasised, group
brainstorming, group visualisation, and mental imagery. Students should be prompted
to share ideas, use their intuitive sense and offer creative alternative solutions (Miller &
Rew 1989:86; Reilly & Oermann 1992:214-215).
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6.5.3.4 Decision-making
Decision-making has been identified as a critical component of nursing practice. The

ever-changing health care environment requires from nurses to be effective in both
problem-solving and decision-making. By definition, problem-solving and decision-
making are almost the same processes because both are initiated by a problem. In
decision-making, however, the objective may not be to solve a problem, but to deal with
the results of a problem. Whereas problem-solving is a more scientific process,
decision-making is value based (Pardue 1987:355; Zerwekh & Claborn 1994:14-115).
Quality of patient care depends on the ability of the nurse to effectively combine
problem-solving and decision-making. The latter involves data gathering, generation
of alternatives and selection of one of the alternatives. Effective decision-making
requires critical thinking. Decision-making is influenced by the nurse's knowledge base,
values, biases and cultural norms. Nurses must be attuned to their own value systems
and understand the effect it has on their thoughts and perception. The values associated
with a particular situation will limit the alternatives generated and the final choice of
decision. Whenever possible, decisions must be made with patients and/or other health
personnel, not for them, in order to gain their full cooperation (Faulkner 1985:125;
Reilly & Oermann 1992:215, 216; Zerwekh & Claborn 1994:115).
There is a distinction between a good decision and a good outcome, as a good decision
may or may not result in a good outcome. While it is desirable to attain both, the good
decision-maker is willing to take risks even if the outcome is not positive. The
following example illustrates this point:
Example 14
An evening charge nurse who had 24 patients in her unit, had to make the following
decision. One of the patients who was terminally ill seemed to be having a particular
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difficult evening but needed only basic comfort measures and not complex care. The
charge nurse had a choice of either assigning the patient to a professional nurse or to a
nurse aide. If her choice fell on the former, the workload for the other staff would be
heavier and she, herself would have to administer medications. In the end she did decide
on the professional nurse who, because of her experience, could offer the patient more
emotional and physical support than the aid would have been able to. This nurse spent
time sitting with the patient during the shift and, close to the end of it, the patient died.
The question is whether it was a good decision with a bad outcome or a good decision
with a good outcome (Zerwekh & Claborn 1994: 115 ).
It is my opinion that it was a good decision because the nurse in charge took the risk of
overloading herself and the other staff to give the dying patient the best care possible.
The patient had available a professional nurse who had, apart from the emotional support
she could offer, also the necessary scientific and technical skills, if needed. The outcome
was bad because the patient died, but due to a good decision, he was able to die
peacefully and comfortably.
6.5.3.5 Critical thinking
Critical thinking is one of the higher order thinking skills (involving comprehension,
application, analysis, synthesis, evaluation) required in the complex health care system.
It assists nurse practitioners in the development of alternative solutions to patient
problems and in the management of complex nursing systems, and enables them to be
safe, competent and skilful practitioners. In many aspects of practice there is no right
way and alternate modes of care must be examined as a result. Critical thinking
involves distinguishing relevant from irrelevant information, drawing clinical inferences
from the information, recognising unstated assumptions, weighing findings and
examining the basis for generalisations. It encompasses the evaluation of ideas when
assessing information, evaluating procedures or making judgements. It requires from
the nurse that she sets aside her own visions of the truth and reflects on alternatives
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(Pond, Bradshaw & Turner 1991:18; Reilly & Oermann 1992: 218, 232; Sullivan
1987:12).
Critical thinking is a rational process directed toward specific goals. The critical thinker
seeks reasons on which to base assessment, evaluation or judgement, the latter being
made objectively, impartially and nonarbitrarily. Considering the influence of
expanding knowledge and technology on health care, critical thinking is vital to
effective nursing care. It underlies problem-solving, decision-making and competent
clinical judgement (Reilly & Oermann 1992:217-218).
Critical thinking is exhibited in Examples 5 and 12. In Example 5 the nurse had to
evaluate the patient's vital signs in relation to medication and fluids administered and
to assess the patient's reaction against what normally holds for patients who have similar
surgery. Findings were examined and possible reasons for the patient's lack of progress
were sought. Through objective viewing of different alternatives, the correct judgement
was eventually made. Example 12 illustrates how the nurse had to weigh and evaluate
various alternatives, possible results, reactions and probabilities before she could start
the procedure of intravenous infusion.
Experiential learning experiences including case studies, group discussions, clinical

conferences, writing assignments and mental imagery are suggested for the development
of critical thinking skills. These experiences provide opportunities for reflective
thought, inquiry, discovery, struggling with dilemmas, and clarifying different
perspectives (Pond, Bradshaw & Turner 1991: 18-19; Reilly & Oermann 1992:231-232).
6.5.3.6 Clinical judgement
Expertise in clinical judgement is central to the practice of safe and effective nursing
care. It encompasses a series of decisions made by the nurse in interaction with the
patient. These are based on observations, evaluation of data observed, diagnosis and
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nursing actions to be executed on behalf of the patient. Problem-solving, decision-

making, critical thinking and creative thinking are all involved during the process of
clinical judgement (Reilly & Oermann 1992:222; Tanner 1987(a):154; Wurzbach
1991:27).
Two different theoretical perspectives have guided the descriptive research on clinical
judgement, namely the rationalist perspective which includes information processing
theory and decision theory, and the phenomenological perspective. Although much
more research is needed, the phenomenological perspective is gaining more impetus as
there is evidence that with increasing expertise, the emphasis shifts from the use of
abstract principles and rational approaches, to the use of practical knowledge in holistic
or intuitive judgements (Reilly & Oermann 1992:222-225; Tanner 1987(b):23-24).
The phenomenological studies have shown that the analytical processes of clinical
judgement are not the primary mode during this process, because they are used only
when the nurse detaches herself from the task. Benner provided evidence that expert
clinical judgement derives from a grasp of the whole situation. It encompasses a
perceptual assessment based on a combination of the senses of touch, smell and sight,
as well as an interpretation of a patient's physical, verbal and behavioural expression.
According to Benner, perceptual awareness is central to good clinical judgement and
starts with vague hunches and global assessments that initially bypass critical analysis.
A study conducted by Pyles and Stem (1983) identified the formation of a gestalt or
achievement of insight about a patient situation congruent to Benner's description
(Benner 1984:xviii; Benner & Wrubel 1982:12; Tanner 1987(b):25).
Intensive care nurses generally acknowledge that they rely on intuition to make sound
clinical judgements. They regard the following observations as critical to the analysis
of a patient's condition: saturation (blood gas levels), ECG and blood pressure; the
patient's alertness and general orientation in relation to the kind and strength of sedation
received and his cooperation with the ventilator; arterial and venous pressures;
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electrolyte balance; and urine output. However, their intuitive awarenesses, based on
their expanded knowledge base and wealth of experience, complete the picture. An
experienced intensive care night nurse's appreciation and acknowledgement of the role
of intuition during clinical judgement, is expressed in the following quotation:
Thanks to nurses' intuition and physicians' willingness to trust and abide

by it, a patient was falling off to sleep when he might otherwise have been
going into pulmonary edema.
(Correnti 1992: 94)
Examples 1, 5, 8, 9, 10 and 12 illustrate how experienced nurses approach clinical

situations from a holistic viewpoint and through using analytical, reflective and critical
thinking, while at the same time relying on their intuition, and making decisions which
often include risk-taking.
6.5.4 The expert nurse practitioner
According to Benner (1984:v), nurses change their intellectual orientation, integrate

their knowledge and refocus their decision-making on a different basis from the process
oriented way that they were taught.
The Dreyfus Model ( 1981) describes five levels through which student nurses pass
before they become expert clinical practitioners - novice; advanced beginner;
competent; proficient and expert (Benner 1984:xvii).
The expert nurse gets a gestalt on a situation and has an intuitive grasp of the situation.
She zeroes in on the accurate region of the problem without consideration of unfruitful
alternative diagnoses and solutions because of her background of experience. By using
concrete situations as paradigms, evaluating alternatives on the basis of comparison of
salient elements, and perceiving the situation as a whole, the expert nurse arrives at a
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holistic decision.
The transformation of a skill comes with mastery. When rules are followed, perfor-
mance is halting, rigid and mediocre. Expert performance, however, is marked by
fluency, flexibility, proficiency and vision. Expert nurses spend time thinking about the
future course of a patient, anticipating problems that might arise and contemplating on
how they would handle it (Benner 1984:xvii, 3, 31, 32, 34, 102).
From the above discussion it becomes obvious that the expert nurse functions on the
highest level of Treffinger's creative learning model (see figure 4.5).
A study conducted by Davies to determine whether observation of clinical role models

could lead to knowledge and discovery, revealed the following. Students reported that
they recognised creativity and flexibility in nurse practitioners and related these
attributes to the ability to provide individualised, context-specific care. They labelled
the more experienced nurses as calm, pleasant, spontaneous, helpful, flexible, very
interested, excellent, organised, well informed, brilliant, capable and outgoing (Davies
1993:631, 635).
When asked to cast their role models in the care provider role the students in Davies's
study recognised the following abilities and skills. The efforts of the nurse practitioners
to constantly adjust and adapt to changes in the profession, modifying approaches to suit
the context and dealing with conflicting needs. Practical competence in divergent
situations - where problems were contextually specific and not well defined and which
resulted in conflicting values - were also noted. Bevis and Clayton (1988), Smyth
(1988) and Speedy (1989) regard context specificity as the hallmark of creative and
individualised nursing practice (Davies 1993 :634).
The attributes of the expert nurse which include flexibility, intuition, vision, sensitivity,
perceptiveness, independency, ego-strength, openness to experience, persistence,
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knowledgeableness and inquisitiveness, concur with the characteristics of the creative

person (see 2.5.2.1). Many ofthese attributes became apparent in Examples 1, 5, 8, 9,
10 and 12.
It is my conclusion that the expert nurse practitioner is a creative and innovative nurse.
6.5.5 Creativity and the science-art of nursing practice
Carper's four patterns of knowing in nursing appear to include the four quadrants of
Herrmann's whole brain creativity model (see figure 3.2 and 3.3). Empirics, which
encompasses the cognitive skills, can be placed in the A-quadrant. The cognitive skills
which were discussed in this chapter are higher order skills which include abstract,
analytical, linear, rational, reflective, evaluative and productive thinking. These skills
are classified in Bloom's higher cognitive domain and De Corte's productive operations
(see 4.3.1 and 4.3.2). They are also inherent to metacognition and formal operational
thought (see 4.4.1.2 and 4.4.1.3).
Ethics, the moral component of nursing, appears to belong mainly within the B-
quadrant. Moral reasoning and ethical decision-making require knowledge of the fine
detail of every ethical dilemma in which the nurse is involved, as well as of ethical
models and codes. The process of values clarification is procedural in nature involving
sequential steps.
Personal knowledge falls within the C-quadrant, has emotions and feelings are
intrinsically involved in the development of knowledge of the self. The affective
domain is entirely C-quadrant oriented.
Aesthetics, the art of nursing, as a strong D-quadrant orientation because of the intuitive
processes involved, the ability to view a situation holistically, and the ability to
synthesise. These qualities have been identified in the expert nurse. The psychomotor
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domain of aesthetics, however, relates to the B-quadrant as motor skills involve detail,
sequential and procedural processes.
The practice of nursing in all its dimensions, involves all the processes in the whole
brain creativity model. Although research has shown that nurse practitioners are mainly
B- and C-quadrant dominant (see 4.2.3), it is my opinion that the expert nurse needs to
be well-balanced in the A-, B- and C-quadrant, but slightly more dominant in the D-
quadrant.
6.6 CONCLUSION
The mystery, diversity, complexity and challenge inherent in the practice of nursing
have been illuminated in this chapter. The nursing model has moved from a medical
model - objective, lo gico-deductive, and treatment oriented, to a nursing care model -
humanistic-existentialistic, holistic, phenomenological and human experience oriented.
Where nursing practice was entrenched in a training modality in the past, it is now based
on an educational modality.
The nursing profession today seeks a nurse who can function in a highly scientific and
technological milieu. A nurse who can accept the ambiguities of a modem and dynamic
medical and health care world - a complex world in which there are no certainties or any
clear and easy solutions. A world where everyday judgements are fraught with ethical
and moral dilemmas that require re-evaluation of our most basic ideas about human life.
The nurse practitioner of today and tomorrow has to be more knowledgeable, insightful
of ethical issues and capable of critical thinking, more caring, compassionate and
human, more creative and open to new ideas and willing to accept change and
challenges.
The following quote from Bevis and Watson (1989:64) summarises the new paradigm
249
for nursing:
We must find a balance, a truce, a truly liberated climate of teaching, of

inquiry, so that we fuse the scientific with the metaphysical, and infuse a
new respect for those things uniquely human: morality, judgement,
intuition, reflection, imagination, creativity, values, meaning and spiritual
sensitivity.
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CHAPTER 7
Innovative teaching strategies
7.1 INTRODUCTION
In our rapidly changing world it is widely recognised that competence alone is no longer
sufficient, but that creative and innovative leadership is required to find successful
solutions to problems. Research findings have revealed that the level of creative produc-
tivity increases after creativity courses have been undertaken (Parnes 1992:14).
As nursing programmes become more complex, innovative approaches to teaching

require to be explored. The need for the development of problem-solving skills to be
used in nursing practice, is increasingly being recognised. Creative problem-solving
skills, however, do not necessarily emerge suddenly or even spontaneously - their
development and advancement must be encouraged and shaped through practice (Carroll
& Howieson 1991:68; Parfitt 1989:666).
Creativity experts criticise the traditional education system for stifling creativity because
251
of its directive approach. They feel therefore that it is imperative that educators should
revise their teaching attitudes and strategies with the aim of stimulating creativity in their
students. This, in tum, will enhance the development of problem-solving skills.
Innovative teaching strategies incorporate methods, many of which will be new, or even
unique, to many teachers and students alike, but which will motivate students, create a
pleasant learning environment, and maximise learning. Creativity in teaching implies
that the teacher implement strategies which arouse attention and interest, increase
concentration and make learning more fun. Nurse educators could, and should, employ
teaching strategies which stimulate both hemispheres of the brain and accommodate
different cognitive styles. When linear and visual materials are used together, students
are compelled to think in the non-preferred mode (Handfield-Jones, Nasmith, Steinert
& Lawn 1993:4).
The literature on nursing research repeatedly pinpoints the following teaching strategies
as being innovative or creative: role play, simulation, games, case study, guided fantasy,
group investigation and brainstorming (De Meneses 1980: 44 3; Ferguson 1992: 17, 18;
Freitas, Lantz & Reed 1991:5; Gaze 1991:54, 55).
The teaching strategies discussed in this chapter have been selected on the basis that not
only are they viewed by experts in the field as creativity inducing, but also that they are
of particular applicability to nursing. Each is described briefly and its application to
nursing education and relation to creativity, elaborated.
7.2 BRAINSTORMING
7.2.1 Description
Brainstorming refers to the spontaneous generation of ideas with the aim of generating
the greatest variety of possible solutions to a problem through free association. It was
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originally developed by Alex Osborn (1957) as a technique to help business groups

produce high-quality ideas. He believed that individuals could think more creatively
when exposed to the ideas of others. However, he later admitted that, despite the many
virtues of group brainstorming, individual ideation could be just as productive (Dacey
1989:123; Davis 1986:92; De Young 1990:112-113).
Brainstorming is part of a total process, creative problem-solving is the whole. It is an

essential part of the idea-finding stage of creative problem-solving. According to
Gehlbach (1986:38), brainstorming is the starting point for much real-world creative
problem-solving.
A central concept of brainstorming is that the generation of ideas should be kept separate
from the evaluation of their worth - deferred judgement is therefore applied. Based on
the assumption that quantity can lead to quality, brainstorming is subjected to four basic
rules:
( 1) Criticism is ruled out - deferred judgement is applied.

(2) Free-wheeling is encouraged - wild or funny ideas are accepted.
(3) Quantity is desired.
(4) Combination and improvement are sought (Dacey 1989:123; Sisk 1987:110).
The rationale behind these rules is that deferred judgement acts as reinforcement for
innovative and far-fetched ideas and that it is more likely to find a creative idea by being
wild first and then taming down. Quantity offers better chances of finding good ideas,
whereas combination and improvement become possible when one idea inspires the next
(Davis 1986:90).
Brainstorming encompasses two stages, namely:
• idea-generation (fact-finding and idea-finding, the free-wheeling stage)

253
• idea-evaluation (ideas are evaluated against selected criteria, eg cost, safety,

effect on other patients) (De Young 1990:114; Kim 1990:43)
During brainstorming sessions students are encouraged to build on the contributions of

others, produce a large quantity of ideas, offer wild and funny ideas, withhold editing
own ideas, and avoid criticising others' ideas. The lecturer or group leader must write
down all the ideas. The ideal group size is 10 to 12, and brainstorming is always more
productive with a heterogeneous group (Davis 1986:90).
The variations of brainstorming include the following:
• Stop-and-go method. Short sessions of idea generation (10 minutes free-

wheeling) are alternated with brief idea evaluation sessions. This helps students
to stay on the right track.
• Philips 66 method. This technique is used with large groups. The problem is
presented and the group is divided into smaller units each containing about six
students who brainstorm for six minutes. The leader of each unit has to write
down all the ideas or possible solutions. Each unit then has to report all, or only
their best, ideas to the large group.
• Reverse brainstorming. The basic problem is turned around in order to find

new perceptions and viewpoints. For example, How can medico-legal hazards
be increased in a surgical ward? or How can student attrition be increased?
This technique promotes suggestions that illuminate the real problem as the
students list what is actually happening. Group brainstorming is often superior
to individual efforts - those in a group can pool their knowledge to produce
higher quality thoughts (Dacey 1989:124; Davis 1989:93).
To increase the flow of ideas during brainstorming, Osborn's (1963) list of idea-spurring
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questions - incorporated by Eberle (1971) for ease of rememberance in the acronym,

SCAMPER- can be used. This is:
s substitute
c combine
A = adapt
M modify, magnify, minify
p put to other uses
E eliminate
R reverse, rearrange (eg opposite or upside down) (Du Rand 1993:52; Sisk
1987:111)
7.2.2 Advantages and limitations
Brainstorming enhances the students' belief in being able to hatch ideas. It provides a
springboard for thinking in new and different directions and builds the students'
confidence (Kawenski 1991 :264 ).
Students participate actively while drawing on previous knowledge and experience.

Brainstorming is fun and therapeutic as it offers students the opportunity to be flexible
in creating and constructing solutions. As judgement is deferred, it produces the
essential creative atmosphere (creative attitudes, psychological safety) - the single most
essential ingredient of innovative thinking (Burnard 1989:24; Davis 1986:88-89).
However, brainstorming cannot always guarantee a perfect solution. Deferred

judgement may not aid the production of creative ideas and individuals can often be
more creative when alone. Davis (1986:94) emphasises that forced creative thinking
techniques should supplement, not replace, original individual thinking.
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7.2.3 Application to nursing education
Brainstorming is a useful technique to identify the reactions of groups of students to

various situations, such as coping with bereavement or working with the mentally
handicapped. This could help the lecturer detect problem areas in clinical practicals or
difficulties experienced by an individual student in coping with these issues, which
would enable her to offer asistance where necessary (Burnard 1989:27).
As part of problem-solving and as a route to creative thinking, it can be used either in

the lecture room or during clinical conferences. Students can be asked to brainstorm
solutions to professional problems such as the image of nursing or burnout among
nurses (De Young 1990:112).
Brainstorming as a technique, can be used to determine the content of a course. It can

also be used at the beginning of a workshop (to draw on prior knowledge and
experience) or at the end (to identify the associations related to what the students have
learned). It can be implemented to explore the affective domain (feelings, emotions,
value systems, attitudes) as a means to develop the student's self-awareness. For
example, when the lecturer discusses the topic depression, the students can be asked to
brainstorm how they feel when they are depressed. A topic such as caring for the dying
person can elicit personal difficulties concerning their feelings or attitudes about the
issue - this may lead to a more productive discussion (Burnard 1989:25-26).
7.2.4 Relation to creativity
Brainstorming is essentially a problem-solving approach that stimulates divergent

thinking. Ideational fluency and flexibility are developed during idea generation and
synthesis and elaboration take place when students build on the ideas of others. These
are the key-abilities of creativity as identified by Torrance (see 2.5.1.1 ).
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Brainstorming is experiential in nature, draws on one's previous knowledge, and

facilitates active participation and cooperative learning in a relaxed and playful
atmosphere. This atmosphere can be attributed to a feeling of psychological safety
which is the result of an open atmosphere characterised by acceptance and freedom of
thought, and the withholding of judgement. These aspects are congruent with the
requirements for the fostering of creativity (see 5.6.2).
In relation to the whole brain creativity model, brainstorming stimulates D-quadrant

processes as visual thinking, imagination and intuition are used to generate ideas while
C-quadrant processes are engaged when feelings, emotions and values are explored. A-
and B-quadrant processes are utilised at the end of a session when ideas are evaluated
in order to find the best idea or solution. Logical, analytical, detailed and sequential
thinking is essential during the evaluation phase (see figures 3.2 and 3.3).
7.3 CREATIVE PROBLEM-SOLVING
7.3.1 Description
Creative problem-solving requires finding the greatest number of interconnections and

interrelationships and connecting them in both obvious and not so obvious ways. This
requires responsible creative action (Parnes 1981 :59).
The creative problem-solving (CPS) model was originally formulated by Alex Osborn
(1963) and further developed by Sydney Parnes (whose model is the most widely used)
to stimulate creativity. The CPS model encompasses five stages: fact-finding, problem-
finding, idea-finding, solution-finding and acceptance-finding. A unique feature is that
each of the stages first involves a divergent thinking phase during which many ideas
(facts, problem definitions, ideas, evaluation criteria, implementation strategies) are
generated, and is followed by a convergent phase during which the most promising ideas
are selected for further exploration - see figure 7.1 (Davis 1986:64, 66). According to
Figure 7.1
Creative problem-solving process
Fuzzy Plan
Problem Action
Change
N
(Jl
-...J
Divergent thinking
=think of many ideas and defer judgement
CPS
< Convergent thinking
=when focussing on one answer/response
(Sisk 1987:110)
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Glover (1980:95), creative problem-solving is the broad definition, but fluency,

flexibility, elaboration and originality are the specific behaviours.
Creative problem-solving develops productive, complex, abstract and higher level

thinking skills. It encourages students to focus on open-ended tasks, and to develop
products that challenge existing ideas and produce new ones (Sisk 1987: 113 ). Fuller
in Torrance ( 1979: 103) states that any genuinely creative idea requires the ability to put
things into context and this ability comes into play during brainstorming and problem-
solving. Ochse cites that the most crucial aspect of CPS is finding the problem. She
agrees with Torrance (see 2.5.1.1) that a sensitivity to problems is a notable characteris-
tic of creative people. Both Arlin (1975) and Getzels (1975) describe problem-finding
as a creative process in itself because the ability to view old problems from a new angle,
requires imagination and results in new advances in science (Ochse 1990:187).
Carroll and Howieson (1991:71) emphasise that CPS skills do not emerge suddenly but
need to be encouraged and carefully shaped through practice. This is affirmed by
Bruner (1960) as quoted by Parnes (1972:23): ... it is only through the exercise of
problem-solving and the effort of discovery that one learns the working heuristic of
discovery ...
The creative problem-solving process includes:
( 1) Fact-finding. At this stage the problem is ill-defined. All the known facts about
the problem must be listed and all information, impressions, observations,
feelings and questions should be explored. Parnes (1981:133, 137) suggests re-
examining the situation for more facts and emphasises a right brain focus through
visualisation of the situation. This might provide more information or clues. The
who, what, when, why, how and where questions should be asked during this
stage (Davis 1986:68; Du Rand 1993:33; Sisk 1987:109).
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Dacey (1989: 127) believes that no successful creative problem-solving is

possible without the presence of some combination of synectic methods
(discussed under 7.5). These methods are intended as psychological tools to
consciously tap the unconscious. During the fact-finding stage an analogy can
be used to make the strange familiar (see 7.5.1.1). The fact-finding stage
parallels the preparation phase of the creative process as described by Wallas (see
2.5.1.2).
(2) Problem-finding. The formulation of the problem is more important than

finding a solution. If the real problem is not addressed, the correct solution will
not be found. Redefinition of the problem is essential during this stage as the
problem is probably not the same as was first thought. Alternative problem
definitions should be listed. What is the real problem? What needs to be
accomplished? The problem can be stated in a well-defined procedure by using
the following kind of question: In what ways might I ... (Du Rand 1993 :43;
Parnes 1981 :137; Sisk 1989:109). For example, the problem encountered when
a patient does not give his cooperation to the nursing staff, can be addressed as
follows: In what ways might his cooperation be gained? or In what ways might
his attitude be changed, or How can he be convinced?
The individual could fantasise or daydream a scenario of how he would alter the
situation to be like he wants it to be. A fantasy analogy can be created to visualise the
ideal outcome (see 7.5.1.2). The creative individual's capacity for intuitive perception
(the recognition of associations and similarities among objects and concepts) is crucial
during this stage (Kim 1990:38; Parnes 1981:133).
(3) Idea-finding. This is the brainstorming stage. Ideas should be freely listed
without criticism or evaluation for each of the problem definitions accepted in
stage 2. The main focus is to generate as many ideas as possible by giving free
reign to the imagination. When functional fixedness hinders the search for ideas,
260
Osborn's idea-spurring questions (or Eberle's SCAMPER) as explained in 7.2.1,

can be used to increase or improve ideas. Prunes stresses quantity and freedom
of expression in the absence of evaluation, as being the abilities allowing free
reign to the imagination (Davis 1986:70; Prunes 1981:85; Sisk 1989: 109).
At the end of this stage, six to eight ideas which seem to be the most likely to
assist in finding a solution to the problem, should be selected.
(4) Solution-finding. Individuals should become aware of the multiple con-

sequences associated with the ideas being considered, and should picture the
changes from as many viewpoints as possible. The ·worst case analysis can be
used when formulating a potential solution to a problem. This refers to imagining
the worst possible result occurring which can lead to the asking of questions about
the solution that would not generally have occurred to the individual (Dacey
1989: 121-122; Prunes 1981: 133, 137).
Criteria for evaluating the selected six to eight ideas, should be established. Each
criterion must be applied to each idea objectively and rated to present a matrix
listing (see figure 7.2). If the solution with the highest score is not as acceptable
as one of the others, it can be bypassed. Du Rand (1993:58, 62) proposes that,
if two ideas/solutions end up with the same score, brainstorming can be used once
again to choose the one that suits the needs best.
(5) Acceptance-finding. The best idea should be developed as fully as possible,

before implementation. A plan of action should be developed while keeping in
mind who would accept or reject the plan. Brainstorming can again be used
during preparation for implementation. Individuals to ask themselves the
following two questions: What difficulties may arise? and What is the worst
possible that can happen? (Davis 1986:71; Parnes 1981:137; Sisk 1987:110).
261
Figure 7.2
Evaluation model
"'o "'o ~
~~
.~~ ·~~
~"'.; ·~ 0
~
~ ~ ~ca
.~~~
~ CJ~~ ~~ ~~ ~<f
'§~CJ ~ ·~~ CJc; • ~
~ ~~~
~
c?c;
Ideas ~ ~
~ ~
1 2 4 5 3 14
4 4 5 4 3 16*
Rating Scale
5 Excellent
4 = Very good
3 = Good
2 = Fair
1 = Poor
(Sisk 1987: 112)

262
Creative problem-solving is versatile and can be adjusted according to

circumstances - the five stages need not be followed sequentially. If the problem
is obvious and already well-defined, the starting point can be the generation of
ideas and if a few good ideas already exists, the starting point can be the
establishment of criteria (Du Rand 1993 :71 ).
Davis (1986:85) suggests turning the problem around, which can stimulate
personal creative thinking techniques, for example:
• To start with the goal and work backwards and deduce what is required to
reach the goal.
• To begin with the ideal/perfect solution (the problem-solving itself) and

work backwards to design a creative solution.
Creative problem-solving enhances problem-solving abilities to solve complex problems.

If several approaches are developed towards a problem, it is more likely to find more
satisfactory solutions (Glover 1980: 14).
When the brain is fuelled with facts, observations, problems, etc, it produces ideas and
associations which become the basis of new insights and perspectives. In this way more
of the positives inherent in any situation are discovered and the impossible is no longer
absolute (Parnes 1981:51).
Creative problem-solving, obviously, cannot answer all problems encountered in nursing

practice as some situations (such as resuscitation of a patient) demand immediate
convergent thinking and behaviour.
263
La Belle (1974:59) states that the application of creative problem-solving's deliberate,

disciplined methods increases the chances, but does not guarantee that truly original
creative solutions will be produced. If not used, however, anything more than marginal
improvement would rarely result. For example, a nurse familiar with creative problem-
solving would be more resourceful in rendering emergency care at the scene of an
accident where the necessary equipment is not available - she would, in many situations,
be able to improvise substitutes in order to render meaningful treatment. Practice in
creative problem-solving improves divergent thinking which is essential in the effective
handling of such situations.
Problem-solving has been identified as an important curriculum element in the education

of nurses. The knowledge which is needed in different patient care situations is varied
and dependent on aspects such as the patient's condition and his unique response to that
condition. According to Reilly and Oermann (1985:149), student nurses are continu-
ously confronted with problems which are client-setting oriented. The development of
problem-solving ability is thus a critical requirement of a nursing education programme.
Clinical judgement, the ability to make wise choices of nursing action in sometimes
ambiguous and stressful situations, can be improved through practice in creative
problem-solving. According to La Belle (1974:59), teaching students to approach
patient care situations through problem-solving is a means of teaching for reflective
thinking.
It is not only patient care problems which can be approached through creative problem-
solving, but also such issues as administrative difficulties, interpersonal relations and
medico-legal hazards. The following are examples of issues that can be addressed by
creative problem-solving:
264
• How to manage a surgical/medical ward with a shortage of nursing personnel.
• How to interact with an aggressive and arrogant physician in order to maintain

open communication canals.
• How to reduce medico-legal hazards in a paediatric unit.
Creative problem-solving stimulates both convergent thinking (analytical, logical,

evaluative) and divergent thinking (fluent, flexible, reflective) (see 4.4.1.1 ). It
facilitates active participation and experiential learning, and combines left and right
brain processes. Creative problem-solving differs from ordinary problem-solving in that
it makes use of synectic methods, imagination and fantasy, as well as of divergent
thinking. Its most valuable function is that it stimulates productive learning (see 4.3.2.2
- De Carte's classification).
The relation of creative problem-solving to the creative process, the abilities of

creativity as identified by Torrance (see 2.5.1.1), and whole brain creativity is illustrated
in table 7.1.
7.4 TEACHING BY METAPHOR
The greatest thing by far is to be a master of metaphor.

It is the one thing that cannot be learned from others.
It is the mark ofgenius.
Aristotle
(Williams 1983:80)
265
Table 7.1
Relation of creative problem-solving to the creative process,

key-abilities of creativity and whole brain creativity
(1) Fact-finding ] Psychological openness Thinking processes:

] Internal visualisation A-quadrant:
] • factual
] • logical
] • quantitative
] Preparation • analytical
]
] D-quadrant:
] • visualisation
]
]
(2) Problem-finding ] Sensitivity to problems B-quadrant:
Penetration • detail
Re-definition • sequential
(3) Idea-finding Incubation Fluency D-quadrant:

Flexibility • holistic
• intuitive
• integrating
(4) Solution-finding Illumination Synthesis A-quadrant:

Originality • logical
• analytical
D-quadrant:
• intuition
• holistic
(5) Acceptance-finding Verification Elaboration B-quadrant:

• detailed
• organised
• sequential
C-quadrant:
• emotional
• interpersonal
• feeling-based
266
7.4.1 Description
The ability to use and understand metaphors is a relatively new concept that is receiving
considerable attention in creative education. Various experts in the field suggest a
relationship between efficient metaphor use and creativity. Kogan (1983) views its use
as the distinction between ordinary divergent thinking and high quality divergent
thinking. A creative person must not only be able to think of many different things from
different categories, but must be able to compare these in unique, qualitatively different
ways (Dacey 1989:101-102).
Metaphorical thinking is the ability to make connections between two unlike objects
through recognising that they share common traits in the same way or exemplify a
common principle. This type of thinking does not proceed linearly but leaps across
categories and classifications to discover new relationships. A metaphor (analogy) is,
however, never exactly like the object to which it is being compared. There are always
differences and discrepancies present (Williams 1983 :33, 56, 67).
Davis (1986:51) explains metaphorical thinking as the ability to borrow ideas from one
context and to use them in another, or to borrow a problem solution from a related
problem. This explanation is exemplified in the way the telephone was invented. Bell
perceived the inner bones of a human ear as being massive when compared to the
delicate thin membrane that operated them. The thought occurred to him that, if such a
delicate membrane could move bones relatively so massive, then perhaps a somewhat
thicker membrane could move his piece of steel. This is how he conceived the telephone
(Barron 1969:134).
Metaphors can be used to introduce a unity, clarify a concept, evaluate comprehension

and stimulate divergent and productive thinking. The use of metaphors makes learning
easier and more effective (Joyce, Weil & Showers 1992:220; Williams 1983:57).
267
Williams ( 1983 :70-71) regards questions based on metaphor, as an excellent way to

evaluate comprehension, as they force students beyond memorisation to evaluate their
comprehension. The following two examples of questions illustrate this statement:
( 1) Use the main events which lead to the French Revolution and explain their
importance.
(2) How was the period leading up to the French Revolution, like the building up of
a thunder storm? (Williams 1983:71)
Whereas the first question only stimulates the student's memory, the second question
prompts visual images because of the comparison between the two events. The student
will search his mind for similarities and ways to describe the likenesses between the two
events and to use analytical and evaluative thinking, verbal and non-verbal thinking,
visualisation and synthesis. These thinking processes include both left and right brain
processes which will lead to a much more creative and detailed answer.
Davis ( 1986: 131) suggests that the following questions can serve to elicit deliberate
metaphorical thinking:
• What else is like this?, for example: How is caring in nursing like a polar bear?
• What could be copied?, for example: What else could be used to temporarily
immobilise a fractured femur if a splint is not available?
• What have others done?
• What would professionals do?
A distinction is made between sensory metaphors, which encompass visual associations

268
(how they look and feel like) and functional metaphors (Williams 1983 :78-79). The
following are examples of metaphorical thinking:
• Music composition: Comments such as inspired by or is based upon directly

indicate that ideas for a specific creation were metaphorically borrowed from an
earlier source by the particular composer.
• Cartoons which make fun of political events.
• A recipe for baking cookies, written in the language of a hospital operating

theatre.
• A comparison being made between a metal spring and hope.
• The invention of the knapsack - the Australians conceived the concept from the
kangaroo mother carrying her baby (Davis 1986:117-118, 123; Kawenski
1991:264).
The abovementioned metaphors are all functional metaphors except for the cartoons
which are visual metaphors. Metaphorical thinking is a skill which should be taught to
students. Offering students a connection through metaphor is only the beginning of
teaching through metaphor; it provides a model of metaphorical thinking, but does not
teach the skill. Students should be asked to generate and discuss metaphors themselves,
and the lecturer should help them clarify their thoughts. Metaphorical thinking plays
a vital role in synectics (see 7.5) (Dacey 1989:125; Williams 1983:58).
Davis (1986: 114, 205) regards metaphorical thinking as central to creativity, creative
problem-solving, creative ability and creativity techniques. Metaphorical thinking
269
involves taking ideas from one context and using them in another, thus producing a new
idea combination. This refers to synthesis, a key-element of creativity.
New ideas which come from mental operations (other than induction), lead to an
increase in semantic information. Metaphorical thinking is one such source. The
metaphorical mode of thinking is holistic and focuses on recognising and understanding
patterns and general principles (Williams 1983 :59).
Metaphors introduce conceptual distance between students and objects and prompt
original thoughts. They often bring forth a permanent change in one's perception of
something. The use of metaphorical thinking may therefore aid in breaking functional
fixedness, which enables one to look at something from a different viewpoint (Boden
1992:213; Joyce, Weil & Showers 1992:220).
Metaphorical thinking is basic to problem-solving and creativity because it involves the

ability to play with ideas and concepts. Apart from being effective, metaphorical
thinking is also fun; as it allows play to be part of the learning process (Williams
1983:80).
Metaphors draw on experiential learning, and as this is crucial to a practice discipline

such as nursing, nursing education may benefit tremendously by the use of metaphor.
Fontes (1994:20) describes how metaphor can be used to explain difficult concepts.
Nursing theory is an abstract concept which student nurses find hard to understand.
Fontes uses a geographical map, as a metaphor to a nursing theory. A map represents
the relationship of ideas about a certain geographical territory whereas a scientific
theory represents an abstract set of ideas about certain human phenomena. As a map is
not the actual territory it represents, a nursing theory about human phenomena is not
270
equivalent to the human phenomena that it attempts to describe. A difference between

the two concepts is that a map is more visual and a themy more verbal. As maps are
well-known to all students and as they are visual, students find it easier to make
connections between a map and a theory.
The following example of metaphor can be used in nursing education. When introducing
a new unit, metaphor can be used in the following way. A balloon can serve as a
metaphor to introduce students to the anatomy and physiology of the lung. Both are
inflated by air inlet and deflated by air outlet and both have the characteristic of elasticity
and react to changes in air pressure. The balloon, however, does not have alveoli and
bronchi.
Metaphor not only offers a verbal explanation but adds a visual image - this combination
enhances learning and understanding as both hemispheres of the brain are engaged.
The most outstanding functions of metaphorical thinking include the changed

perceptions, holistic view and visual images it evokes, and the facilitation of synthesis
and elaboration. These functions as well as other abilities of creativity, such as
psychological openness, flexibility and penetration (see 2. 5 .1. 1), are essential in the
search for similarities between two totally different and unlike objects which do have in
common some major characteristics or functions.
Metaphorical thinking aids productive learning (see 4.3.2.2) as students utilise existing
knowledge in the exploration of new concepts which lead to new insights, and a better
understanding of subject content. Experiential and discovery learning (see 4 .4 .1. 4) is
encouraged.
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7.5 SYNECTICS
7.5.1 Description
Synectics refers to the joining together of different and apparently irrelevant elements.
Synectic methods are conscious, metaphor-based techniques for bringing these elements
together. It is designed to lead the individual into a slightly illogical world in order to
provide opportunities to invent new ways of seeing things, of expression and of
approaches to problems. Synectics provides deliberate avoidance of logical thought
because the latter leads to an inadequate conception of the problem and thus an absurd
solution (Davis 1986:131; Joyce, Weil & Showers 1992:216).
Synectics should be part of creative problem-solving as it provides individuals with a

repeatable procedure that increases the probability of success and hastens the arrival of
an innovative solution (Prince 1971 :33).
According to Kawenski (1991 :264), synectics does not strive for quantity during
problem-solving as does brainstorming; it has a sterner goal, namely, to produce a single
new viewpoint. Davis (1986:132) views the purpose of synectics as making the
problem-solving process more effective by using analogies. Part of the skill in using
synectics, however, is to avoid analogies that are too exact, too obvious or not strange
enough (Alexander 1971:10).
Originally described by William Gordon in 1961, synectics has since become a classic
in the field of training for creative thinking. Synectics theory proposes an operational
theory for the conscious use of the preconscious psychological mechanisms present in
an individual's creative activity. Gordon based his theory on the assumptions that all
individuals can improve their creative abilities if they understand the underlying
psychological processes, and that the emotional, irrational components of the creative
process are most important (Dacey 1989:125; Gordon 1971:14, 15).
272
Synectic mechanisms aim to induce appropriate psychological states that promote

creative activity. These psychological states, which include empathy, involvement, play,
detachment and the use of irrelevance, are basic to the creative process, but are not
operational. According to Gordon, individuals cannot be persuaded to be intuitive,
empathise, become involved, play, tolerate irrelevance or be detached. Synectic
mechanisms, however, draw them into these required psychological states (Gordon
1971 :21).
Synectics theory applies to the integration of diverse individuals into a problem-solving

group, while the ability to tolerate and use the irrelevant is regarded as being of
fundamental importance for seeking a solution (Gordon 1971:15, 20).
The synectics process depends on two mechanisms, with metaphor playing a vital role:
• making the strange familiar (search for similarity)

• making the familiar strange (shed preconceptions and perceptual habits)
7. 5. 1.1 Making the strange familiar
As it is a basic human tendency to be threatened by any strange object or concept, the

individual tends to force any strangeness encountered into an acceptable pattern. The
mind compares the strangeness with existing knowledge and attempts to convert the
strangeness into familiarity. Three basic procedures: analysis, generalisation and
model-seeking or analogy are involved (Prince 1971 :33).
In any problem-solving situation, the individual's first priority is to understand the

problem. This is essentially an analytical and convergent stage. By using a familiar
metaphor, students are lead to analyse the problem - metaphor is used for analysing in
this case, and not for creating conceptual distance. The purpose is to increase the
student's understanding of the problem (Dacey 1989:126; Gordon 1971:14).
273
An example of making the strange familiar is in the use of a coffee filter as an analogy
for explaining kidney function. Both serve the function of filtering by sorting molecules
- certain molecules pass through, while others are retained. Similarities should be
sought and differences pointed out.
Making the strange familiar, usually leads to a variety of superficial solutions. Basic
novelty, however, demands a fresh viewpoint and this is facilitated by the next
mechanism (Prince 1971 :33).
7.5.1.2 Making the familiar strange
This is a conscious attempt to look at an old problem in a new way. Making the familiar
strange, is to distort, invert or transpose the everyday ways of looking and responding.
For example, the layman sees a tree as a collection of solids in an otherwise empty
space, but the sculptor consciously inverts his world and sees the familiar tree as a series
of voids or holes carved within a solid block of air (Dacey 1989: 126; Gordon 1971 :22;
Prince 1971:34).
Making the familiar strange, involves true creativity and uses four mechanisms, each
metaphorical in character: personal analogy, direct analogy, symbolic analogy and
fantasy analogy. In this case metaphor is used to create conceptual distance (Dacey
1989:126; Joyce et al 1992:230).
( 1) Personal analogy. This refers to personal identification with the elements of a

problem. It releases the individual from viewing the problem in terms of
previously analysed elements. By imagining yourself as the object through
personification, new insights into the functions or character of the object are
gained (Gordon 1971:23; Kim 1990:44).
Joyce et al (1992:221) describe personal analogy as emphatic involvement with

274
an object which requires loss of oneself as one transports oneself into another
object. Dacey (1989: 126) views personal identification with an object as a
process similar to empathy as one can identify with people's feelings or with
inanimate problems, such as movement of subatomic particles.
Gordon views role playing as a kind of personal analogy used to assist individu-
als in solving problems that are people-oriented. Torrance (1979:122) affirms
that personal analogy frequently involves role playing. The following example
illustrates how it can be used in nursing education. A student can be asked to
personify a patient dying from AIDS. This death scene can lead the student
towards greater understanding, empathy and insight into how to handle this type
of situation more effectively. This example illustrates the viewpoint of Gordon
(1971 :21) that the individual cannot be persuaded to emphasise or become
involved, but that synectic methods draw the individual into these required
psychological states.
According to Prince (1971 :38), both science and art abandon detached observa-
tions and analysis in favour of personal analogy. He quotes Keats' personal
analogy during the writing of Endymion: I leaped headlong into the sea, and
thereby have become better acquainted with the sounds, the quicksands, and the
rocks, than ifI had stayed upon the green shore and piped a silly pipe, and took
tea and comfortable advice.
(2) Direct analogy. This involves the direct comparison of parallel facts, knowledge
or technology. During this comparison knowledge and techniques from one
domain are used in another one. The function of direct analogy is to transpose
the conditions of the real topic or problem situation to another situation in order
to present a new view of the problem. In other words, when confronted with a
problem, the individual uses direct analogy when thinking of ways in which
related problems have been solved (Dacey 1989:126; Joyce et al 1992:222; Kim
275
1990:45).
Direct analogies may include persons, animals, plants or non-living things, for
example:
• When explaining the concept motivation, a cheetah can be used as a direct

analogy. The students should be asked: How is motivation like a
cheetah? Answers may include the following similarities: goal-directed
action, movement in one direction (when prey is hunted), speed, power,
energy.
• When explaining the concept therapeutical use of the self to student

nurses, they can be asked: How is the therapeutical use of the self like a
forest rain? (This example is explained in detail in 7.5.1.3.)
(3) Symbolic analogy (compressed conflict). This type of analogy is characterised

by its immediate appearance. It is a compressed description of the function or
elements of the problem as a specific individual views it. Symbolic analogy is
usually a visual image, immediate and poetic, disembarrassed of words. For
example, Maxwell made mental images to represent the elements of every
problem - he used symbols without words. Gordon ( 1961 :48) quotes Sir Francis
Galton: ... I fail to arrive at the full conviction that a problem is fairly taken on
by me, unless I have continued somehow to dis embarrass it of words. It can be
an objective and impersonal image which is aesthetically satisfying and captures
the essence of a relationship between a problem and a poetic response, but which
may not be realistic or technologically possible. Symbolic analogy, a complex
visual resolution fitting a number of requirements, is viewed as the inventor's
product (Barron 1969:134; Dacey 1989:126; Gordon 1971:25).
According to Kim (1990:45), symbolic analogy means to view the problem

276
through objective, impartial images, which may be pictorial representations,

mathematical formulas or other media.
Prince (1971 :36, 37) explains symbolic analogy as involving the procedure to
select the key-word and decide on the essence of its meaning. To feel for the
important connotations of the word and then to put these feelings into one or two
words, for example:
forest fire progressive ingestion
target focused desire
mixture = balanced confusion
These examples are referred to in the literature as book titles or compressed

conflicts. Compressed conflict is a symbolic analogy in which a two-word
description of an object is given while the words seem to be opposites or
contradictory. This enables the individual to incorporate two frames of reference
with respect to a single object. The greater the distance between the frames, the
greater the mental flexibility. Gordon gives the examples of life-saving destroyer
and nourishing flame, and Pasteur uses the expression, safe-attack (Joyce et al
1992:221). These examples will be explained further in 7.5.3.
Compressed conflicts can aid in approaching a problem from a different

viewpoint. Joyce et al (1992:216) give the example of the absenteeism problem
usually being addressed by some form of punishment, such as suspension. They
suggest that a sense of belongingness can be created by using analogies
describing the situation from a different perspective. Thoughts of the absentee
as an unhappy lark on a destructive vacation ending as an empty feast, can
generate empathy which will lead to an investigation into the cause of the
absenteeism as it is very often a result of the real problem. The use of com-
pressed conflicts can assist individuals to find more effective solutions to issues
because they facilitate a variety of perspectives on a situation.
277
(4) Fantasy analogy. When using fantasy analogy, the problem-solver identifies the
characteristics of the ideal situation and then seeks ways to realise the wish. It
can be viewed as working backwards from an ideal goal. The problem solver
thinks of fantastic, far-fetched ideal solutions which very often can lead to
creative yet practical ideas (Davis 1986:136; Kim 1990:45).
Fantasy is used in synectics as a way of freeing the imagination from the bounds
of the real world. According to Barron (1969:134), specific laws are imagined
as if they did not hold and the question is then asked: What would be the con-
sequences? For example, what would be the consequences ifthe law of gravity
did not hold?
Dacey (1989:126) indicates that fantasy analogy starts when the problem-solving
group asks the following question: In our wildest fantasies, how do we want the
solution to work?
An example of fantasy analogy is given in 7.5.3.
7.5.1.3 Synectics procedure
When synectics is applied to problem-solving, three types of analogies, direct, personal

and symbolic, form the basis of the process. The lecturer must seek analogical
responses by asking evocative questions (those requiring an analogical/metaphorical
answer) as these form the bridge between analysis and analogy. The lecturer determines
which type of analogy he/she wants, ie, direct, personal or symbolic (Joyce et al
1992:221; Prince 1971:34).
To illustrate the synectics procedure, one of the examples of direct analogy mentioned
in 7.5.1.2, is used.
278
When the lecturer wants to convey the meaning of the therapeutical use of the self to
student nurses, he/she may proceed as follows:
• Students can be asked to present a direct analogy for the mentioned concept
which may elicit the following responses:
blanket
forest rain
lioness
washing machine
• If forest rain is selected as the direct analogy, students must seek similarities
between the therapeutical use of the self and forest rain. This may evoke
responses such as: patients are dependent upon the nurse's psychological
support, just as the plants are dependent on the rain for healthy growth; the
approach of the nurse towards the patient is characterised by compassion and
sensitivity, which can be compared to the gentle falling of the raindrops on the
plants' leaves to prevent damage, and so on.
After the above discussion, a personal analogy can be requested from each of the
students in which they have to identify themselves with falling raindrops. They now
have the opportunity to get kinaesthetically and emotionally involved and this may
produce a diversity of viewpoints and more detailed information. This can be followed
by the lecturer asking for a symbolic analogy inferred fromforest rain, which may be
a two-word description presenting a paradox. Responses may, for example, be:
• enforced to gethemess
• soothing coolness
• colourful dialogue
279
From the diversity of responses given by the students, these symbolic analogies may add
to, extend and enhance the students' knowledge of the concept, the therapeutic use of
the self, as they explain them in relation to the concept.
Prince (1971:37) emphasises that analogies must beforce-fittedto the problem in order
to be effective. It is through the strain of the new fit that the problem is stretched,
pulled and refocussed which allow it to be viewed in a new way with increased insight.
The use of synectics brings the creative process to consciousness. Gordon regards the
emotional irrational component as more important than the rational. It induces open-
ended thoughts - a mental state in which new ideas are possible. He regards an
irrational state as best for exploring and expanding ideas and stresses that it is not a
decision-making stage. He views the understanding of the emotional and irrational as
a prerequisite for creativity (Gordon 1971: 17-18).
Analogies are important sources of creative ideas as knowledge acquired in one domain
can be applied to another domain. Novel ideas required for the development of a new
theory can be provided by analogies (Gordon 1971 :80, 446).
Analogies evoke images, kinaesthetic experience, cognitive and affective involvement.

They facilitate psychological openness, penetration, flexibility, fluency, synthesis and
originality.
Synectics does, however, need a lot of practice and can be time-consuming. Uncovering
the comparison of a direct analogy's ramifications requires substantial time, and so does
the process of personification in personal analogies (Gordon 1971 :25).
280
Synectics can be used in nursing education to explain difficult concepts, to aid students'
memory of factual information, to increase understanding of complex problems, and to
increase empathy with patients.
Lantz and Meyers (1986:64-65) give an excellent example of a personal analogy to aid
the teaching of medication administration, an essential part of patient care, but which
is a challenging and complex study unit of the nursing curriculum. In this example, each
student in the class is asked to become a different drug and to include in their personal
analogies the following:
• family characteristics, personal characteristics, behaviour, interaction problems

and adverse reactions
One student, who became valium gave the following description:
... My name is Val, I come from India ... I'll show you peace, love, inner
harmony and tranquility. ... I am known to many as Diazepam, of the
house of Benzodiazepines ... perhaps you know my brothers, Librium,
Xanax. ...Are you tense anxious, tired or agitated? ... If life is too tough,
come to me, come into my embrace of tranquility. I'll relax your large
skeleton muscles and have a direct effect on your brain. ... I am the light,
the peace, the calm, my lessons can be heavysome . ... Don't drive or
operate machinery when you are on the enlightened plane with me. For
some, the message of inner peace is too great and they become confused,
depressed, disoriented, have headaches, slurred speach. .. .I come in
white, yellow or blue tablets, or take me directly into your veins or flesh -
40 mg a day for the adult is my maximum strength ...
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The use of personal analogy provides a creative way to gain knowledge on medication
administration. The student in this example has analysed, interpreted, elaborated and
synthesised information.
An example of a direct analogy is illustrated by Fontes' (1994:20) comparison between

a geographical map and a nursing theory (described in 7.4 .3 ). This direct analogy aids
comprehension, analytical thinking, synthesis and reflective thinking.
Symbolic analogies can be used in nursing education to indicate both the positive and
negative aspects of concepts, medications or patient situations. Gordon's life-saving
destroyer can be used to explain the functions of chemotherapy. It kills cancer cells
thereby saving the patient from immediate loss of life, but it also destroys normal tissue.
Gordon's example of safe-attack can be used to describe cardio-pulmonmy resuscitation.

While carrying out this emergency procedure the purpose is to save the patient's life but
the procedure of cardiac massage necessitates physical strength and when viewed from
a distance, might look like an attack. This analogy emphasises the importance of doing
cardiac massage properly.
Fantasy analogy can be used by imagining how a hospital ward for caring of the
terminally ill should be organised - equipment, decor, atmosphere, nursing support -in
order to make it an ideal place in which such patients can spend the last moments of their
lives. This exercise will stretch the imagination and stimulate thought beyond the
ordinary, past the constraints layed down by the burocracy of hospitals, to produce a new
and refreshing perspective.
The use of synectics in nursing education makes the learning material much more
interesting, aids comprehension and stimulates productive thinking as students have to
integrate, analyse, synthesise and evaluate information.
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The most outstanding feature of synectics is that it leads the individual into an illogical
world in order to gain new perspectives. It allows the preconscious psychological
mechanisms to come forward which is regarded as one of the major reasons why
synectics can lead to the production of original ideas. The neo-psychoanalysts propose
that true creativity is only possible when the ego can draw ideas from the preconscious -
the preconscious is more free to form new associations (discussed in 2.5.4). Both Freud
and Jung refer to the unconscious/subconscious as encompassing a wealth of
experiences and memories. According to Freud it involves everything the individual has
experienced since conception, whereas Jung states that is concludes memories that go
back to the individual's forefathers (Prince 1971:31) (discussed in 2.3.4).
Synectics is an experiential learning activity which draws heavily on prev10us

knowledge and enhances whole brain learning. It stimulates the visual, intuitive and
holistic processes of the D-quadrant together with the emotional and kinaesthetic
processes of the C-quadrant. After utilisation of the right brain processes, synectics
returns to left brain processes when analysis and logical thought (A-quadrant processes)
and detailed and sequential thought (C-quadrant processes) are used to finally clarify the
concepts for which analogies were sought (see figure 3.2).
7.6 VISUALISATION: IMAGERY AND FANTASY
7.6.1 Description
Visualisation or visual imagery, refers to the ability to recall and construct visual images
within the mind. It can be defined as seeing with the mind's eye. Visualisation includes
imagination, memory images, dreams, visions and fantasies. It involves the use of all
the sensory modalities: seeing, hearing, smelling and feeling.
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Many of our ideas are transformed into images. Imagination may contain elements of
past perceptions, arranged in a different way than perceived, or may be made up of
newly created material. Fantasy, is the ability to generate and manipulate mental
imagery. Williams (1983: 116) describes fantasy as the door to our inner world, that
magical realm where the imagination creates its own realities unfettered by the
limitations we encounter in the outer world.
Imagery plays an extremely important role in creative thinking. Torrance (1979:126)

regards the ability to visualise objects, concepts, systems and processes as an essential
component of successful creative work in musical composition, writing, scientific
discovery and mechanical invention. Khatena (1984) affirms Torrance's view when
referring to creative imagination as the source material of musicians, writers, poets,
scientists and mathematicians (Sisk 1987:296).
Kim (1990:33) views images as central to creative ideation as inspirations occur mostly
in pictorial form, and cites the example of Poincare's sensual imagery which lead him
to sense a mathematical proof in its entirety at a glance.
It has been reported in the literature that Mozart could hear a whole new symphony all
at once, and that words did not seem to play a part in Einstein's thinking, but that
visualisation and imagery took over. Samuels and Samuels (1977:250) quote from a
letter Mozart wrote in 1789:
When I am, as it were, completely myself, ... - say, travelling in a

carriage, or walking after a good meal, or during the night when I cannot
sleep; ... my ideas flow best and most abundantly ... My subject (music)
enlarges itself, ... and the whole, though it be long, stands almost
complete and finished in my mind, so that I can survey it, like a fine
picture or a beautiful statue, at a glance. Nor do I hear in my imagination
the parts successively, but I hear them, as it were, all at once.
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Visualisation is regarded as a very effective strategy for problem-solving. To move from

a verbal statement of an idea to a visual representation requires thinking about the idea
in a new way to discover new possibilities. According to Parnes in Torrance (1979: 130),
many individuals experience a blockage in thinking about creative solutions because they
are not able to visualise an object as having more than one function. Imagery is thus seen
as a superior mode of mentation as it allows the individual to consider more ideas and
the opportunity to progress more.
Kim (1990:34-35) regards imagery as a critical component of thinking as pictures assist

in the initial exploration of ideas and in the communication of ideas to others.
Torrance (1979: 138) states that disciplined approaches to creative problem-solving make
deliberate use of fantasy because it provides an inexhaustible supply of analogies which
are useful in stating and solving problems.
7.6.1.1 Visualisation techniques
Amongst the several visualisation techniques described in the literature, guided im-
agery/fantasy and identification fantasy seem to be the most valuable for educational
purposes. The others are used during meditation.
Williams ( 1983: 116-118) has documented that disciplines like engineering and medicine
use fantasy in their planning of space colonisation, organ transplants and unconventional
healing methods such as laser therapy. Fantasy is also used to think through the logistic
problems of organ rejection and other catastrophic events. The deliberate use of fantasy
proves to be an effective approach to creative problem-solving. Fantasy is a valuable
teaching and thinking tool. It stimulates involvement in the teaching-learning situation,
increases motivation, offers new ways of remembering and facilitates a gut-level of
understanding that goes beyond the verbal presentation of a lecture.
285
7.6.1.1.J Relaxation exercise
The first step in learning how to improve the ability to visualise, is to achieve a state of
relaxation. A comfortable and quiet place must be selected and extraneous stimuli kept
to a minimum. According to Williams ( 1983: 121 ), the verbalisation of the left
hemisphere must be shut off in order for the right hemisphere to be heard. When the
outside world recedes, the inner world surges forth, presenting itself in the form of
visualisations (Samuels & Samuels 1977: 143 ).
Guided relaxation fantasy aims to encourage relaxation and gives the right hemisphere
the opportunity to take over.
Example: Guided relaxation exercise
First get your body in a comfortable position, one in which you can relax
easily. ... Now close your eyes. ... Become aware ofyour breathing. ...
Don't do anything about it, just be aware of how the air moves in and out.
.. . Allow the air to move deep into your abdomen but don't force it. ...
Become aware ofyour feet. ... Allow them to relax and feel warm and
heavy. ... Let that relaxed, warm heaviness spread up your legs ...
through your knees ... your thighs ... and into your body. ... Imagine the
relaxation spreading through your body ... filling your stomach ... chest
... back ... shoulders. ... Let your arms relax ... your hands. ... Now feel
your neck relaxing, becoming soft and warm. Finally, let your face
relax. ... Let your jaw become loose and easy. Feel your lips relax ...
your cheeks ... your eyes ... your forehead ... and your scalp. ... Continue
to be aware ofyour breathing and take a moment or two to enjoy the way
your body feels before we begin our fantasy journey.
(Williams 1983:121)
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7.6.1.1.2 Observer fantasy
An observer fantasy generates inner sensory imagery. It may be used to introduce new
material, to visualise the ideal solution to a problem, to visualise settings for community
studies or to provide stimulus material for creative writing. An example of an observer
fantasy which lead to a great invention in science, is Einstein's fantasy about himself
riding a ray of light - he discovered the theory of relativity through this observer fantasy
(Williams 1983: 117).
Example: Guided observer fantasy
This is a guided observer fantasy. Its aim is to

• introduce new material
• stimulate awareness of all the senses to aid retention
• increase the student's understanding of the patho-physiology of diabetes mellitus
Guide students through a relaxation exercise and then start the fantasy with the
following:
Imagine that you are shrinking ... allow yourself to become so tiny that
you canfit into the pancreas of the human body. You are now the size of
a body cell and are travelling through the acinar cells of the pancreas.
Look at the purple-pinkish colour of the inside of the pancreas, and feel
the moist softness of the cells around you. Slowly you drift to areas of the
pancreas where the islets ofLangerhans lie motionless like spotted islands
amidst the dark purple blue sea ofpancreatic acini - the dark purple blue
is caused by the more prominent nuclei of the acinar cells. You drift
silently closer to one ofthe islets and gradually become aware of the slow
movement of the darker alpha cells and listen to the soft murmur of the
lighter coloured beta cells as they secrete insulin in order to increase the
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rate ofglucose tramjer through the cellular membranes of the cells of the
body organs. Suddenly a jar (~ff ·rumbling is heard and you become aware
of an odour of sweet apples surrounding you. As you look around you
with the rumbling sound getting louder and louder until you.feel as though
your eardrums are going to explode any moment, you see an over-
whelming tide ofglucose rolling towards you, and within an instant ... it
floods the whole islet of Langerhans where you are struggling for breath
as you try to raise your head above the tide ... (the researcher's example)
This guided observer fantasy stimulates kinaesthetic awareness and imagery. It provides
aesthetic elements and takes the learner to a make-believe world where the irrational is
combined with the rational - the latter being represented by the factual information given.
7.6.1.1.3 Jdent!ficationjantasy (personal analogy)
Identification fantasy produces kinaesthetic experience and emotional response. It

generates inner sensory imagery and can be used to develop an understanding of difficult
concepts and course material (Williams 1983: 118).
Example: Guided identification fantasy
This guided identification fantasy aims to

• assist the student in developing empathy with a patient
• assist the student to render holistic patient care
• enhance the student's understanding of the anxiety patients experience when
connected to a respirator
The students should be guided through a relaxation exercise before proceeding with the
fantasy (the researcher's example):
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I am drifting, as if on a cloud ... I hear that sound again ... ssslh ... puff,
ssslh ... puff .. . and in between ... bleep . .. bleep . .. What is that?
Sometimes I hear voices, softly muttering, but I cannot understand what
they say ... and in between is that mixture of sounds always present. It is
so dark, I wonder where I am? What is that smell? ... the odour reminds
me of disinfectants ... it is not totally familiar, though. As the sound
increases in volume, I become aware of my own body ... I try to move my
fingers ... I can move them! ... but I cannot lift my arm ... it is too heavy.
I try to move my toes, yes, they can move! My chest feels as ifa huge rock
is resting on it and I feel a numb pain in my throat. I try to move my eyes,
to open them ... the light is very bright ... I strain my eyes against the light
... it takes some time, and then I recognise the white ceiling above me, the
white walls, I see the end of a bed ... my bed? .. .I am lying on that bed!
There's a huge machine standing next to my bed . .. this is where that
sound comes from. I look at the translucent corrugated pipes, two ofthem
coming from the machine, reaching up to my throat ... Suddenly it dawns
on me ... I am connected to that machine! I am in a hospital! An ice cold
iron hand grips my chest, crushing my heart as though it wants to wring
all life from me ... I feel my heart protesting, beating faster and faster, and
I hear that beep ... beep ... sound accelerating. I feel the cold dampness
of perspiration, running from my forehead, even my hands and my feet
feel damp. I am scared ... I am petrified! Why is this machine connected
to me? Why do I have that crushing heaviness on my chest? What if that
machine suddenly stops? Am I going to die? I try to call for help ... but
there's no sound coming from my lips ... I cannot even call for help!
The abovementioned example focuses on the affective experiences of a critically ill

patient who is connected to an electro cardiogram (ECG) monitor and a respirator via
a tracheostomy. A patient in this state needs a lot of psychological support and
technically skilled care which should be provided by a nurse having a sound scientific
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knowledge base. Patients can sense if a nurse is unsure of herself and this adds to their
anxiety. This learning activity aims at leading the student towards emphatic understand-
ing by providing her/him with the opportunity of becoming the patient through
personalisation.
Visualisation is a basic way of obtaining, processing and representing information. It

improves reading comprehension, aids memory, increases understanding, and stimulates
creativity. Visual thinking is a powerful tool which enables students to become more
efficient learners. As most information is unobservable, visualisation through mental
images is essential to bring complex phenomena into the students' grasp. Fantasy can
be used to translate verbally presented material into images, making the information
more accessible and comprehensible to students (Bradley-Springer 1993 :7; Williams
1983 :32, 92).
Imagination plays a part in the thinking of all subjects. It enables students to combine
previously unrelated ideas and to produce something new. Students can use visualisa-
tion in social relations to help them understand themselves and others, to overcome
stress, and to focus their attention. If lecturers use and explore visual imagery they can
assist their students to develop a growing consciousness and to refine the skill of
visualisation in order to access total brain power (Sisk 1987:300).
The use of visualisation techniques in education needs a lot of practice from the part of
the teacher as well as from the students, and can be time-consuming.
The nursing curriculum offers a wide variety of subjects and problem situations in which
the application of visualisation techniques can be used with success.
290
Greer and Levine (1991:252-253) report on a study in which the conjunctive use of
fantasy and intrinsic motivation enhanced creative writing performance - in this case,
Haiku-style poetry. Fantasy was induced through guided imagery - students were asked
to close their eyes, relax, and experience a fantasy about snow (the fantasy was designed
to elicit visual and kinaesthetic responses). Afterwards, they were asked to write a Haiku
poem on snow. This poem was compared to a Haiku poem they had previously written
without the aid of guided fantasy on laughter. Intrinsic motivation was induced by
asking the students to select from a list, the reasons why they enjoyed writing. This
seemed to increase subjective motivation. The authors found that the Haiku poem on
snow was the better one and it was written in a more creative style through the use of
evocative language.
The above example shows how fantasy can aid creative thinking as it provides direct
contact with an object or situation and enables awareness of all the senses. By
experiencing a situation (although only in the mind), much more detail can be gathered.
This leads to different views and increased knowledge and insight. The student obtains
much more infonnation in her/his mind which can enable her/him to deliver a better
product.
A study conducted by Speck (1990:346) showed reduced anxiety levels in first year
students learning to perform injections after they had been exposed to guided imagery.
The experimental group in this research study received guided imagery instruction by
using an audio cassette tape. This included relaxation, focusing on the topic, and
imaging the procedure. The students were guided to use their senses, eg smelling the
alcohol swab, feeling the patient's skin when checking for landmarks, and visualising
successful completion of the procedure. The control group who did not receive the
guided imagery, but was subjected to the same amount of practising in the clinical
laboratory as the experimental group, revealed, on testing, a much higher level of anxiety
when they had to perform their first injection on a real patient.
Speck's example reinforces the belief that guided imagery provides relaxation and
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reduces anxiety directly. Guided image1y can be used in this way to prepare students for
many highly stressful situations in nursing practice. For example, students can be taken
on a guided imagery about how they will handle the situation in their ward when a patient
suffers a heart arrest or develops pulmonary embolism. Going through the whole
procedure, such as the clinical manifestations and emergency treatment, in their minds
will prepare them to have more confidence and knowledge of how to handle the situation
effectively when it occurs in reality.
According to Bradley-Springer ( 1993 :7), guided imagery stimulates personalisation,

which serves two creative purposes, namely encouraging student relaxation, and allowing
students to visualise and focus on the selected problem. The author used it as an
innovative teaching strategy to teach student nurses about Alzheimer's disease. Her
objectives were to increase student understanding of the disease, empathy and retention.
She took the role of an old lady suffering from Alzheimer's disease, and wrote letters to
her son during the course of her illness. Letters to Henry describe the symptomatology,
physical and psychological deterioration, the way that the patient personally experiences
the disease, and the deterioration of social and family relations as the disease progresses.
These letters were read to her students. The results of this example of guided imagery
showed the development of increased insight, empathy, retention, and critical thinking
skills through personalised reflections.
Through the above teaching strategy Bradley-Springer managed to provide her students
with a very valuable learning experience. The aesthetic and emotional quality,
elaboration and synthesis of detail, and holistic picture that were portrayed in the letters,
will ensure that her students never forget the extent of this disease.
Leytham (1990: 179) used a guided fantasy exercise to enable her students to recognise
another person's dilemma and have empathy with, and a better understanding of the
other's situation. Jn this exercise, the students and a .fictitious (imagined) person, against
whom the students bore a grudge, were shipwrecked on an island. All managed to swim
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safely to the shore where the person found himself in a situation in which he was
completely at the mercy of the students. They had total control over him by means of
a magic power spell. Leytham prompted the students to subject the person to any kind
of hardship and deprivation they wanted to and for as long as they wished. When he
had reached a state of total helplessness, however, Leytham asked the students to cast
off the spell, to change their feelings towards the person to those of tenderness and
acceptance of the good and the bad in his character, and to treat him as a fellow
human-being.
After the exercise the students' feelings were explored. They all admitted that they now
felt sorry for the person against whom they had previously borne a grudge.
Examples such as this guided fantasy exercise, will assist student nurses to improve
interpersonal relationships with peers, seniors, patients and other members of the health
team. This will contribute towards a more positive psychological climate in a hospital
which will also be of benefit to the patients.
Visualisation in the form of imagery and fantasy is essentially a right brain process.
According to Wenger in Parnes (1992 :254 ), the main language of the right cerebral
hemisphere is one of sensory images and impressions.
Visualisation provides a new perspective on a problem through involvement of all the

senses. Flexibility, redefinition of a problem, synthesis and elaboration are some of the
abilities of creativity which are developed during imagery and fantasy. Individuals do
not see incomplete pictures in their minds; imagery and fantasy are always rich in detail
and colour. The departure from the rational and logical, presents openness and a total
freedom, which is not possible in the real world.
293
Visualisation stimulates the D-quadrant processes of imagination and synthesis as well

as the emotional and kinaesthetic processes of the C-quadrant. It provides the student
with a much richer experiential learning activity and, although right brain processes are
emphasised, students use analysis, detail and organisation (which are left brain processes)
to serve as the basis for their imagery and fantasies (see figure 3.2). Visualisation is an
excellent teaching strategy for teaching the affective domain.
7.7 HUMOUR AS A TEACHING STRATEGY
7.7.1 Description
Much has been written about the use of humour in education. Humour is reported to
relax individuals and reduce stress and anxiety, which leaves individuals more open to
learning. As humour and laughter have specific physiological effects on the human body
such as muscle relaxation, stimulation of the circulatory system and an increased
production of endorphins, the result is a direct reduction of stress and anxiety and an
improvement in cognitive retention and task performance. Svebak (1982) in Parrott
( 1994: 36) states that laughter stimulates both hemispheres of the brain simultaneously,
coordinating all the senses. This produces a unique level of consciousness and a high
level of functioning (Robbins 1994:39).
The essence of humour can be identified as the juxtaposition of incongruous elements.

Humour is a quality which appeals to a sense of the absurdly incongruous. Wit, as a
manifestation of humour, can be described as swift perception especially of the
incongruous (Kim 1990:93). Parnes (1981:33) views creativity and humour as closely
related because both rely on appropriate absurdity and contain some opposing elements.
He describes humour as the mating of playfulness and seriousness; fantasy and reality;
nonsense and purpose; the irrational and the rational. Humour depends largely on being
able to see something in more than the obvious, expected way. One of the abilities of
creativity is to see something in a different way, away from the obvious (discussed in
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2.5.1.1 ). The characteristic of opposing elements found in humour is a phenomenon

which has also been described in creative people - the dichotomy of personality traits
(see 2.5.2.1).
Kim ( 1990: 101) views the factors of creativity as permeating all forms of humour and
summarises these factors as follows:
• The purpose of a humorous situation is to elicit an emotional response.
• The diversity factor in humour involves the fusion of two or more objects not
normally associated with each other.
• Fusion involves identification of relationships which tie the objects through a

unifying theme.
• Humour evokes striking images.
• A comic situation must be externalised.
Kim's explanation elicits the emotional involvement, divergent thinking, synthesis,

visual images and externalisation aspects of creativity. It also implies the presence of
psychological openness and penetration which is essential to recognise a humorous
situation.
Parrott (1994:36) views a humorous outlook as characterised by flexibility, spontaneity,

unconventionality, shrewdness, playfulness and humility. It is viewed as a necessary
tool in order to maintain some semblance of sanity in an often sobering and bizarre
setting. Nursing practice frequently demands having to deal with seriously ill patients
under stressful circumstances brought about by inadequate staffing and ill-equipped
facilities because of curtailment in health finances.
295
Humour can be a planned teaching strategy, a spontaneous event that helps to explain a
concept or principle, or it can be part of a planned teaching strategy.
Humour can be introduced into the teaching-learning situation by way of role play,
simulation, stories, comic strips, cartoons or problem-solving.
7. 7.2 Advantages and limitations
Zellman and Bryant (1983) in Robbins (1994:39) propose that relevant and well-
integrated humour leads to superior retention of information, enhances student-lecturer
rapport and makes learning an enjoyable experience.
Humour has a positive influence on cognitive as well as affective learning. Parrott

( 1994:37) reports that the advantages of humour include increased attention, interest,
comprehension, retention and motivation. Humour enhances the generation of ideas,
divergent thinking, creativity and productivity because of the playful and enjoyable
learning environment it creates. The affective advantages of humour as a teaching
strategy include the improvement of relationships, the establishment of a feeling of
connectedness which leads to mutual trust, a sense of freedom, decreased anxiety,
positive attitudes, and a positive self-image. Humour opens communication lines,
crosses social and cultural barriers, assists in dealing with awkward problems and may
help to solve problems by way of the different perspectives it offers. It also helps to
reduce boredom and class-monotony (Leidy 1992:206; Parrott 1994:36-37; Robbins
1994:39).
Watson (1988:89) explains that when humour is part of the teaching strategy,
communication between the lecturer and students is characterised by freedom and
psychological openness which sets a tone that allows human error and encourages
freedom to explore alternatives. The authoritarian position of the teacher is reduced and
fear and anxiety become less of a threat. Students become more relaxed and more open
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to learning as well as more flexible in their attitudes.
When humour is used as a teaching strategy, however, the humour must be relevant to
the subject and care should be taken against the pitfalls of humour namely, sarcasm,
ridicule, and racist or ethnic jokes (Robbins 1994:39).
Nursing is an extremely challenging, highly stressful, but rewarding profession. Nurse

practitioners have to deal with people at their very best and worst. Student nurses must
deal with many emotional situations - humour will help them to handle it better. Both
Parrott (1994:36) and Robbins (1994:40) regard humour as a coping and management
tool in stressful situations.
An example of using cartoons as an additional strategy to include humour in teaching,

is given by Robbins (1994:39). The author commented on the usefulness of placing
cartoons pertaining to health care, next to appropriate subject content. The aim was to
attract students' interest and create a playful and pleasant atmosphere in order to aid
learning and retention. Students reported that they enjoyed the learning experience more
and had a better student-teacher rapport, and that it improved their understanding of some
of the content.
Schuster (1987: 18) reports on the use of the well-known Garfield comic strips to
counteract waning student interest in learning thyroid disfunction. Garfield seems to
typify both hyper- and hypothyroidism. The lecture room was filled with stuffed
animals, balloons, pencils and posters representing Garfield. Garfield aided in retention
of content, understanding and motivation.
Parrott (1994:3) refers to the example of pinning comic strips which depict life but poke
fun at it, on bulletin boards. Examples of these are the love is ... series, Dennis the
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Menace, Garfield, and the Pink Panther. The aim is to emphasise particular issues and
reduce anxiety over certain topics, for example, aging, dieting, adapting to change or
death. The bulletin board must be changed with the introduction of each new content
theme. Students who were subjected to this learning experience reported that they found
the bulletin boards humorous and interesting and that it was a key teaching instrument
for retention of specific content.
These examples illustrate the pleasant, playful and relaxed influence that humour has on
the teaching-learning environment, and the resulting increase in student interest and
motivation. As cartoons and comic strips also convey a visual message, they contribute
towards retention, understanding and insight through the added perspectives given by
visualisation.
Parrott (1994:37-38) describes the use of humour in a role play with the aim of aiding
retention, motivation, increasing understanding and inducing a relaxed and pleasant
atmosphere. The teacher, another faculty member or a student visits the medical nursing
class as the character, Granny Grits, to help present content on aging. Granny Grits
offers her 86 years of wisdom, experience, philosophy and wit in a realistic, humorous
manner without being demeaning to the elderly. Tugging at her dress to make herself
more decent, sniffing, chewing tobacco, coughing, rocking and pill rolling, she listens,
interjects comments and tells stories. Included in the presentation of the content is
assessment, history taking, treatment and a description of medicare benefits. Parrott
reports that she has used this example with several classes and that students always enjoy
and remember it as a special learning experience.
Robbins (1994:40) gives a few examples on the use of humour to enhance learning in the
clinical laboratory. Her aim is to motivate students to aid retention and comprehension,
and to provide a pleasant and fun-atmosphere in the clinical laboratory. She regards
exaggeration as an excellent form of humour, as illustrated in the following two
examples:
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• A 50 ml syringe with a six inch spinal needle is used to introduce students to

parenteral administration.
• A demonstration is given whereby a size 24 Foley catheter is used to catherise

a female mannequin.
The absurdity and inappropriateness of the equipment reinforces the students'

understanding of why selecting the correct size is important. Through visualisation, not
only the funny side of mistakes, but also the danger it might hold for the patient, is
permanently imprinted on their minds. This is one example of the opposing elements
(eg absurdity versus reality) present in a humorous situation as explained by Parnes
(1981) (see 7.7.1).
7. 7.4 Relation to creativity
The use of humour as a teaching strategy develops flexibility, psychological openness,

penetration and synthesis (see 2.5.1.1). New connections are formed as students have
to look deeper for understanding and learn to view problems from different perspectives.
Humour provides a pleasant, playful and relaxed atmosphere - the type of atmosphere
conducive to the fostering of creativity as it is also characterised by openness, mutual
acceptance and spontaneity (see 2.5.2.2.2).
The use of humour in teaching, facilitates experential and cooperative learning and
focuses on reflective thinking. These aspects have all been related to creative learning
(see 5.6).
Humour is a combination of cognitive and affective skills as it requires the sterner

processes of the left brain (facts, detail, organisation) as well as the visual and emotional
processes of the right brain (see figure 3.2).
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7.8 WRITING AS AN INNOVATIVE TEACHING STRATEGY
7.8.1 Description
Recent research studies indicate writing as a powerful tool for students to master the
intellectual content of their courses. Students gain information and conceptual insights
through writing as it is an active mode of learning which facilitates active inquiry and
forces students to take responsibility for their own learning. To understand something
is to express it in one's own words! (Lantz & Meyers 1996:64).
Various authors suggest the use of free writing as a means of encouraging creative
analysis, synthesis and problem-solving. Writing assists students in discovering new
relationships through exploration of content. It increases understanding; enhances
thinking and personal growth; and develops higher-order conceptual skills, such as
problem-solving and reflective thinking (Bradley-Springer 1993 :9; Klaassens 1988: 17).
Rosenthal and Sauer (1985:384-385) distinguish three different styles of writing:
( 1) Expressive writing is a relaxed and personal style of writing which enables the
writer to examine his/her thoughts and feelings. Examples in nursing education
include diaries and logs about clinical experiences. Nurse educators read these in
order to detect problems which students experience during clinical practice.
(2) Transactional writing is written for a specific audience. It conveys factual

information with the aim of explaining and reporting. Examples include ward
reports and patient reports.
(3) Poetic writing is a form of art which uses both cognitive and creative processes.
It challenges students to combine theories and facts with feelings and rhythm.
Examples of poetic writing include poetry, songs, metaphors and parables.
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Poetic writing involves evocative language. The vocabulary is connotative and

associative, highly sensual, less precise (because it involves the rich, associative imagery
of poetry) and ambiguous in nature. For example, the poet Robert Bums, uses evocative
language when he writes: My love is like a red, red, rose . .. Bums is not concerned with
the exact colour of this rose, and he uses the word red repeatedly to evoke an image and
a set of associations. The meaning of these words will be slightly different for each
listener, as this type of language cultivates ambiguity, suggesting (not stating) and
working on the listener's subjective experience (Williams 1983: 32, 33 ).
Expressive and transactional writing depend mostly on left brain processes as specific
and detailed information, ordered in a logical form, is written down. The right brain
processes which include feelings, holistic and visual thinking, are used to a lesser extent.
Transactional writing requires precise and denotative language and prizes clarity - this
refers to left brain processes. Poetic writing depends on both left and right brain
processes because it combines factual information with feelings. The right brain
processes are, however, more important as imagery and evocative language are essential
ingredients.
Student nurses need to acquire writing skills to enable them to accomplish a variety of
required nursing tasks. These include documentation, referrals, reports, communications,
research and publications (Bradley-Springer 1993 :9). The writing styles required for
these tasks, however, are expressive and transactional writing. If poetic writing is
encouraged in nursing education, it will lead to the development of productive learning
and creative thinking. Poetic writing increases memorisation and understanding of
subject content, and stimulates the development of affective skills such as empathy,
compassion and caring.
Lantz and Meyers (1986:64) state that the act of writing promotes the kinds of creative
and critical thinking skills required of professional nurses. They quote Slaninka ( 1981)
to illustrate their viewpoint: Within the nursing profession, underdeveloped writing skills
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are ofparticular concern because of the extensive demands placed on the professional
nurse.
When writing is applied as an innovative teaching strategy, students develop both

cognitive and affective skills. Writing aids explorative and discovery learning,
memorisation, insight and understanding. It develops reflective, critical, analytical and
problem-solving skills (Bradley-Springer 1993 :9; Klaassens 1988: 17).
Writing involves students emotionally, enhances aesthetic knowledge and assists personal
and professional growth.
The only limitation of writing as a teaching strategy is that it is time consuming.
According to Bradley-Springer (1992:5), the nursmg revolution has called for

commitment to methods that incorporate holistic and phenomenologic principles into the
planning and implementation of learning experiences for student nurses. Phenomenology
uses reflection and introspection to discover meanings in human experience. The writing
of diaries and clinical logs, as well as the writing of poems related to patient conditions,
presents a holistic view of a situation and develops reflective, critical, analytic and
creative thinking, which leads to the discovery of new insights.
An example of using writing as a learning experience to discover the true meaning in

human experience and thereby enhancing aesthetic knowledge, is given by Smith
(1992:54 ). Students were asked to record in writing the details of a caring experience
which they had undergone during their clinical nursing practice. After Smith had read
each students' story, they were asked to elaborate in writing on particular issues. On
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reading these Smith identified several universal themes and elements describing a caring
presence, and gave a list of them to each student. A group discussion was held which,
through sharing each other's experiences, views, feelings and perceptions enhanced the
students' understanding of a caring presence. After the interpretive discussion, Smith
read several of the stories to the group as a means of assisting the students to expand their
views on the meaning of a caring presence. By reflecting on nursing practice, the
students became emotionally involved by recalling their experiences - warmth, love, joy
and fulfilment were mentioned and they became aware of the explicit and tacit meanings
associated with a caring presence; it enhanced their aesthetic knowledge.
Tiris is an example of an expressive writing exercise which went through the processes
of analysis, synthesis and elaboration. Students were presented with an opportunity for
active and cooperative learning, reflective thinking and emotional involvement. At the
end of the teaching session they had an extended knowledge and understanding of a
caring presence as compared to when they first wrote about their individual experiences.
Bradley-Springer (1992:5, 8-9) gives another example of using expressive writing to

improve writing skills and to enhance empathy and caring among student nurses.
Students were required to select any health care problem listed in their course syllabus
and to bring information about the symptomatology and treatment of the problem to
class. In order to establish evaluation criteria, an evaluation form, based on a creative
product semantic scale by Besemer, was presented to each of the students before they
started their writing assignment on the selected problem (see figure 7.3). The next step
was for them to personalise their health care problem. Guided imagery was used to
stimulate personalisation. They were subjected to a guided relaxation exercise followed
by an identification fantasy: Relax, take deep breaths, ... close your eyes ... be calm ...
center on some point inside ofyourself... now think of the health care problem you've
selected ... think ofpeople who have this problem. How are they similar? How are they
different? ... What ifyou were living with the problem? How would you feel?
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Figure 7.3
Abbreviated formative evaluation form for expressive writing
(Abbreviated from Bradley-Springer 1992:8)

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What would you do? (Bradley-Springer 1992:7, 8). As a last step before commencing
their writing assignment, an example of a creative paper on HIV infection was read to
them in order to give them a good idea of what was expected from them. The students'
writing assignments were subjected to self-evaluation and peer evaluation according to
the mentioned evaluation form, after which they had a two-week period in which to
complete their final papers. The result was that the students gained insight, empathy and
critical thinking skills through personalised reflections.
The combination of expressive writing and guided imagery which was used in the latter
example, enhanced active and cooperative learning, affective learning and reflective
thinking. It provided the students with the opportunity for personal development through
the freedom of expressing themselves in writing, and for professional development
because of the experiential and cooperative nature of the learning experience.
An illustration of poetic writing is elicited in an example described by Schuster

(1994:95). Haiku was used as a creative way for students to express their perceptions
and feelings about aging while covering the gerontology content of the nursing
curriculum. According to Higginson ( 1985), author of the Haiku Handbook, the central
act of Haiku is to let an object or event touch us and then to share the event with another
(Schuster 1994:96).
Haiku generally comprises three lines containing five, seven and five syllables
respectively. The following are examples of students' Haiku:
Let me drift away

Let my soul float to heaven
Let me die in peace
Reliving the past

The older man thrived on it
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It kept him going

(Schuster 1994:95)
The Haiku was the result of students' reflection on their own and others' feelings and
perceptions about aging. It enhanced their understanding and empathy and stimulated
productive thinking, as new knowledge and insights were gained. Haiku is a way of
developing students' creative potential as it draws on right brain processes: feelings,
emotions, holism, synthesis, and aesthetics. Affective learning, reflective thinking and
cooperative learning were facilitated when students read and discussed their Haiku poems
in class. They became aware of others' perspectives and emotions and had the
opportunity to share self-discovered knowledge.
Ishida et al ( 1994: 164) suggest that students write down significant learning experiences
which affect nursing practice, by way of weekly journal entries. Categories can be
established such as: things did not go as planned/was particularly demanding/captures
what nursing is all about, etc. This will increase students' understanding of events as they
write about their thoughts and feelings, the demands of the situation, satisfactory
experiences and a changed outlook for the future.
In order to increase poetic writing skills, students can be asked to write a parable
illustrating the emotional experience of a patient suffering from AIDS/terminal
cancer/cerebral vascular incident. A prerequisite for this assignment could be that they
find a metaphor connected to the selected condition and analyse similarities and
differences before they start writing. Metaphor can assist students to produce a more
creative end product through the use of evocative language elicited by the comparison
of two objects from totally different frames of reference. For example, the struggle of
the AIDS or cancer patient can be compared to the fight between two kudu bulls - an
encounter which often results in death when their horns become entangled.
In the same way, students can increase their expressive writing skills when asked to
306
write a story on subjects such as congestive cardiac disease/diabetes mellitus/chronic

renal failure (illustrating clinical manifestations, emotional experience and social
implications) by using imagery or identification fantasy to increase divergent and
productive thinking.
When writing is used as a teaching strategy, it enhances analysis, evaluation, synthesis,

and elaboration. These abilities are directly linked to creativity as they represent the
higher cognitive skills in Bloom's taxonomy (see 4.3.1.1) and have been identified as
abilities of creativity by Torrance (see 2.5.1.1 ).
Writing stimulates reflective thinking which aids problem-solving and leads towards
productive learning. It combines the visual, imaginative and affective processes of the
right brain with the analytical, logical and sequential processes of the left brain, thus
engaging the student in whole brain creative learning (see figure 3.3).
7.9 ROLE PLAY
7.9.1 Description
Role play involves the spontaneous acting out of a problem situation by two or more
participants. Leaming occurs through active participation, reflection and immediate
feedback. Role play is specifically directed at the affective domain and assists students
to gain new perspectives about human relationships. This strategy forces the participant
to think about the person whose role is assumed. A role play should be built upon
carefully structured problems which are based on real-life situations (De Tomay &
Thompson 1987:34; Mellish & Brink 1990:148).
Schoenly (1994:210) emphasises the need to set the right climate for role play as
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responding to exercises regarding beliefs and values requires a level of risk-taking by

the participants. An open, accepting attitude by the teacher and mutual respect, support
and freedom are necessary to facilitate learning in the affective domain.
The stages of a role play involve selecting a problem situation or critical incident;
writing a scenario; asking for volunteers to play the roles; briefing each participant on
his/her role; acting out the scenario in a 5 to 15 minutes drama; participants providing
feedback on their feelings; and observers evaluating the scenario. Debriefing is
sometimes necessary in cases where students become too emotionally involved (Burnard
1989:22; Gustafson 1988:119).
Discussion of the role play focuses on interactions, feelings, emotions and attitudes
observed and experienced. It is sometimes necessary to have two or more presentations
of the same scenario to illustrate different points of view. Reversal of roles is also
recommended to give students the opportunity to gain insight into another person's
behaviour, and to gain a better understanding of how people interact (Gustafson
1988:119; Mellish & Brink 1990:148). According to Freitas, Lantz and Reed (1991 :7),
student nurses should particularly be involved in playing the role of the patient or family
members in order to gain a better understanding of the patient's position and that of the
family members.
Role play is a very appropriate technique to teach the affective domain. It assists
students in exploring feelings, attitudes and values. Students learn to express their own
feelings and to accept those of other people. They gain insight into the values and
behaviour of others which enhances their understanding of interpersonal relationships.
Role play assists students in problem-solving and in resolving personal dilemmas a!ld
increases empathy as they get the opportunity to be in the other person's shoes. Lower-
level (receiving and responding) and mid-level (valuing and organisation) affective
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objectives are obtained through role play (see 4.3.1.2) (Burnard 1989:20; Gustafson
1988:118; Handfield-Jones et al 1993:5; Schoenly 1994:211).
Role play requires skilful preparation by the teacher and is time-consuming. There is
a tendency to use it without paying cautious attention to the basic rules and, as it may
embarrasses shy students, teachers should take extra care to debrief them after participa-
tion (Gustafson 1988:118).
Role play has always been a valuable teaching strategy in nursing education. However,
since the evolving concept of nursing has been explored in the context of caring, the
feelings, values and attitudes of nurses have become the focus of renewed attention.
Watson ( 1988) encourages nurse educators to attend to the education of the whole
person and recognise that learning is subjective, contextual, dialogic, and values driven
(Schoenly 1994 :209).
Chapman (1983:269, 270) proposes that most definitions of nursing emphasise that it
is an interpersonal activity that focuses on understanding the patient as an individual.
Such descriptions highlight not only the caring aspect but also the health maintenance
aspect. The nurse-patient relationship is regarded as a vital factor in patient recovery.
Role play is a very appropriate strategy to teach interpersonal skills, such as communi-
cating, counselling and interviewing.
Example:
The following is an example of a role play focused on the affective domain, illustrating
ability for and lack of interpersonal skills:
Scenario: Mrs Walker, a middle-aged lady is readmitted to the medical

309
ward with delirium tremens. She is well-known by the ward staff She
lives in a nearby hotel and spends most of her monthly allowance on
alcohol. Her husband died of cancer and her only son was killed in an
automobile accident at the age oftwenty. Mrs Walker claims that she has
nothing to live for and complains bitterly about nurse Smith, who treats
her very disrespectfully. She confides in nurse Thompson who has always
been very ~ympathetic towards her. It is a well-known fact amongst the
nursing staffthat nurse Smith's father died ofpancreatitis, a direct result
of his long-time abuse of alcohol. Afier having witnessed a conflict
situation between Mrs Walker and nurse Smith, nurse Thompson decides
to confront nurse Smith on the issue (Schoenly 1994:212).
This role play can be acted out two or three times, each time with different students
acting out the three roles. The following objectives could be obtained:
• exploration of other people's feelings

• identification of other people's values
• development of empathy through increased understanding of the possible reasons
for other people's behaviour
• realising the extent of a nurse's behaviour on a patient
• gaining different perspectives on a problem
• discovering the importance of maintaining good interpersonal relationships with
patients
Role play is essentially an affective and problem-solving strategy. It provides students

with self-discovered knowledge about the feelings, emotions and reasons behind the
behaviour of others. Students need to display psychological openness, flexibility,
fluency, and divergent thinking in order to play the roles of others. Penetration of the
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problem, analysis and synthesis take place and students' perceptions change, when they
view the problem from the other person's perspective.
Role play combines visual, imaginative and intuitive thinking (D-quadrant) with
emotions and feelings (C-quadrant) and although it necessitates analytical (A-quadrant)
and sequential (B-quadrant) thinking, it relies heavily on the irrational (referring to C-
quadrant processes). The emphasis is therefore on right brain processes. Role play
stimulates the development of the affective domain (discussed in 4.3 .1.2) which plays
an important role in creativity as cited by various researchers. The thinking and feeling
processes which can be developed by role play are on the second level of Treffinger's
creative learning model (see figure 4.5).
Role play provides active participation, cooperative learning, and reflective thinking and
is experiential in nature. These aspects contribute towards creative learning (see 5.6).
7.10 SOCIODRAMA (PSYCHODRAMA)
7.10.1 Description
The terms psychodrama and sociodrama have been interchangeably used in the
literature. Sociodrama is a variant of role play, originally developed by Moreno (1946),
and since adapted by Torrance and others. According to Torrance (1975), role play
provides one with the opportunity to shed the inhibitions which stifle the production of
alternative solutions. It gives a person a license to think, say and do things he/she would
not otherwise do (Dacey 1989: 127-128).
Sociodrama is a group problem-solving process. It involves the re-enactment of a real

life situation lived by 0ne or more of the group members, or acting out an imagery
situation with the aim of solving a group or social problem. Sociodrama has an
imaginative side to it, and can be used to solve future as well as present-day problems
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and conflicts (Burnard 1969:23; Dacey 1989:127).
As an experiential teaching strategy, sociodrama assists in the development of affective

skills. It develops emotional competence, intuition and sensory awareness. It provides
a deeper understanding of the dynamics of human interaction and probes into the
reasons behind individual behaviour patterns.
The stages of sociodrama are similar to those of standard role play and other group
problem-solving methods. The teacher or leader of the group has to guide the
sociodrama in an objective way and may provide music, decorations, or other mood-
setting techniques to create the correct atmosphere. Sociodrama includes the following
stages:
(1) Defining the problem. The teacher or leader of the group guides the discussion
towards defining the problem that will be the topic of the sociodrama. All
responses are accepted and no judgements are allowed.
(2) Establishing a conflict situation. The group must agree on a clear statement of
the problem or conflict situation, based on the various initial responses.
Judgement should be deferred and no direction for resolution should be given.
(3) Casting of characters. This is a sensitive stage. Participation should be

voluntary but the teacher should encourage experimentation. Different students
should take turns to play the same role in order to evoke different viewpoints.
(4) Briefing the characters. The actors must discuss their roles and the setting, and
ask observers to consider possible directions for the play. The observers can be
asked to identify with different points of view.
( 5) Acting out the drama. The skill and experience of the teacher is important as
312
he/she must employ a variety of production techniques to elicit constructive

dialogue and possible solutions. Care must be taken not to direct the play towards
a specific outcome and sensitivity to areas of conflict among the group must be
shown.
(6) Cutting the action. The teacher has to stop the play when a successful resolution
appears or when the actors become blocked or distressed. A new setting may be
restructured to act on the same problem.
(7) Discussing and analysing the results. The group has to redefine the problem and
state clearly the possible solutions which have arisen from the sociodrama.
(8) Further testing and1or implementation of ideas for new behaviour. Proposed
solutions generated in the initial sociodrama session may be tested in new sessions
or could be generalised to situations outside. Solutions are evaluated during this
stage (Dacey 1989:128-129).
The following variations can be implemented during sociodrama in order to serve

different purposes:
• Soliloquy technique. The aim of the soliloquy technique is to open up a

problem in order to expose the hidden possibilities. It can be used directly after
a conflict confrontation to bring the conflict out into the open and highlight it.
According to Torrance (1976: 169), problem and conflict situations usually
encompass a great deal of hidden feelings and factual information which are often
glossed over. Bringing out the hidden aspects of a problem into the open,
frequently produces an immediate solution.
During the soliloquy technique some of the actors are asked, especially after a
heated exchange, to soliloquize their feelings and emotions about what just
313
happened in the play. This may bring out an original idea not mentioned during
the dialogue of the play, or provide an opportunity for incubation which may
elicit the forthcoming of new ideas when the play resumes (Dacey 1989:129).
• Double technique. During this technique an actor in a conflict situation is

joined by another actor who takes on the role of his/her other self. The other self
should try to spur the actor towards deeper levels of expanded consciousness
(Dacey 1989:130).
• Multiple double technique. This involves more than two actors taking the same
role while each plays a different mood or perspective. For example, one actor
can play the good and another the bad side of a character in a conflict situation
(Dacey 1989: 130).
Burnard (1969:23) regards sociodrama as useful to encourage the development of

assertiveness and counselling skills, and to explore students' personal life problems.
Gaze (1991 :54) states that sociodrama can be integrated into all levels of nursing
education in order to produce more perceptive and intuitive nurse practitioners. Student
nurses gain greater individual awareness through the techniques of sociodrama and
begin to see patients less as objects. Sociodrama provides student nurses with the
opportunity to develop their intuitive sense, explore their emotional reactions to
incidents in practice and, most importantly, to develop their ability to empathise with
patients and relatives.
Muckle in Gaze (1991:54-55) views sociodrama as a teaching strategy that unlocks the
creativity in nursing as it enables nurses to be more perceptive and oper:i in the nurse-
patient relationship, and leads to a deeper understanding of human behaviour.
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Torrance believes that sociodrama can promote a holistic consciousness which arises
from the right hemisphere of the brain. According to him, certain production techniques
employed by the leader of the group can induce states of heightened awareness, rapture,
regression, meditation, and reverie (Dacey 1989: 129).
As sociodrama is a strategy which was originally developed for use in psychology, the
teacher must be well-trained to use it and must take special care to derole students after
emotionally traumatic sociodrama sessions. Although sociodrama can be time-
consuming, the many advantages it holds for educating student nurses, outweighs its
limitations.
According to Burnard (1969:23), sociodrama can be used to help in deciding when to

refer patients to other health professionals and to provide opportunity for reflective
thinking on working with dying patients and bereaved relatives.
Gaze (1991 :54-55) reports on a few hospital schools and colleges in the United
Kingdom that have integrated sociodrama and theatre workshops into all levels of
nursing education. The topics which have been covered include re-enacting incidents
from clinical practice, caring for elderly people, caring for HIV infected patients, coping
with loss, managing challenging behaviours, looking at the emotional consequences of
trauma and stress (as it affects both nurses and patients), and re-enacting true case
studies. There are also a few private companies which use a range of dramatic
techniques to act out incidents in clinical practice - they are contracted by the nursing
schools to present drama sessions to the student nurses. Some of these companies allow
student nurses to come up on stage to express feelings or needs which they feel the
actors have not expressed.
As is evident in the literature, sociodrama can be used widely in nursing education. The
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soliloquy technique can be used, for example, with ethical issues such as euthanasia.
Nurse practitioners often find themselves in the situation where an unconscious patient
is kept alive by a respirator. In cases of brain death the question is who is going to
switch off the machine? Many different perspectives and emotions have to be
considered - those of the family members, the nurse and the physician. Sociodrama can
help students to view the issue from many perspectives and to explore the hidden
emotions and influencing elements involved in this kind of situation.
The double technique is an excellent way for students to learn about the complicated
psychological defects in psychiatric nursing. A student can, for example, have an
interview with a schizophrenic patient with a third student playing the other self of the
schizophrenic patient. This might help students to gain a better understanding of the
schizophrenic's dilemma when he has to listen to the nurse while at the same time
experiencing auditory hallucinations.
The multiple double technique can be used to teach students how to relate to difficult
patients or health team members. Through exposure to the good and bad in other
individuals and a variety of perspectives, students are lead towards a deeper understand-
ing of human behaviour, empathy is developed and they become more skilful in
effectively handling difficult patients or team members.
Sociodrama is a group problem-solving strategy, focused on experiential learning. It is

strongly right brain oriented and develops particularly the affective skills. Sociodrama
encourages the use of imagination and intuition (D-quadrant processes) to a greater
extent than role play, by probing deeper into a problem/conflict situation to expose
hidden feelings and facts. This often leads to an immediate and original solution.
Penetration, openness and originality are abilities of creativity (see 2.5.1.1 ).
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By using the double and multiple double techniques, sociodrama probes deeper into the
complexity of human nature and thereby increases insight, understanding and empathy.
Emotions and feelings (C-quadrant processes) are explored.
The levels of receiving, responding and organisation in Bloom's affective taxonomy (see
4.3.1.2) are developed by sociodrama.
The affective skills of awareness, openness to complex feelings and conflict, and
imagery, which are developed by sociodrama, are on the second level of Treffinger's
creative learning model (see figure 4.5).
The cognitive skills developed during sociodrama include analysis (of feelings and
other's behaviour), reflective thinking, synthesis and evaluation. These refer to the
complex thinking processes on the second level of Treffinger's creative learning model
(figure 4.5). Analysis and evaluation are A-quadrant processes whereas synthesis is a
D-quadrant process (see figure 3.2).
7.11 SIMULATION
7.11.1 Description
The word simulation derives from the Latin, simulare, similis, which means like. To
simulate means to feign, resemble, or mimic. Simulation as a teaching strategy involves
the realistic presentation of the structure of a real situation or object. Persons,
environments or objects are used to represent original reality in a modified fashion. The
student participates actively by interacting with persons or objects in a particular
situation in order to deal with a problem, and receives feedback about responses without
having to be concerned about real-life consequences (De Tornay & Thompson 1987:26;
Gustafson 1988:123; Mellish & Brink 1990:146).
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Simulation is actually a problem-solving teaching strategy. It induces affective

involv~ment while at the same time stimulating cognitive development. As it has a
close resemblance to play, the activity must focus on a clear teaching purpose (Sisk
1987:114).
Simulation is particularly useful when the composition of a task is complex and difficult
to analyse. Rather than a one answer approach to a problem, it provides the opportunity
for students to become aware that there are often several ways of dealing with it, and
creative behaviour and divergent thinking are encouraged (De Tomay & Thompson
1987:41).
The different types of simulation used in the health professions include written and
computer simulations, mediated and role played simulations, physical simulators, live
simulated patients and simulation games.
Written and computer simulations offer practice in problem-solving, decision-making

and clinical judgement. An actual problem or patient case is presented and students
have to select from among relevant, irrelevant, beneficial and harmful options, each
leading to different end results. They are provided with feedback on each decision
about the effects of that action. Available nursing literature supports written and
computer simulations as valuable teaching/learning and evaluation tools for clinical
problem-solving and decision-making (De Tomay & Thompson 1987:32-33, 39).
Mediated simulation and physical simulators are very useful in nursing education
because of nursing's practice component. Mediated simulations include video tapes
illustrating interpersonal skills and interviewing techniques, and audio reproductions of
human cardiac or respiratory sounds. These are used for teaching interpersonal skills,
or for diagnostic or evaluation purposes. Physical simulators are three-dimensional life-
like models of the human body which are used for practising clinical procedures, such
as cardio-pulmonary resuscitation, catheterisation, colostomy care, venopunctures and
318
administration of IV fluids, until skill and mastery are obtained (De Tomay &
Thompson 1987:35-37).
Role played simulation involves problem situations or critical incidents depicting

conflict. It may be partly structured or completely spontaneous. The student does not
play a role, but responds as herself/himself. This technique involves statement of the
problem and objectives, designing a scenario including resources and character
identification, playing out the scene, and evaluating and providing feedback. Problem-
solving, decision-making skills and interpersonal skills are developed (De Tomay &
Thompson 1987:33-34; Sisk 1987:114-115).
The live-simulated patient technique is useful for both teaching and evaluation.
Individuals are trained to act the role of a patient and have to exhibit specific clinical
behaviours, provide a specific history and respond in certain ways. According to De
Tomay & Thompson (1987:38), this is an ideal technique for evaluation as objectivity
is increased, performances are measured to identical criteria, and feedback is provided
immediately, all of which enable students to strengthen their clinical skills.
Simulation games have the characteristics of both simulation and games. They provide
interactive problem settings, operate according to set rules, and involve an element of
competition. Games can deal with theoretical content, attitude changes, clinical
processes, evaluation or remedial work. They provide a high degree of enjoyment and
relaxation and stimulate recall and reinforcement of learning. A simulation game is a
powerful medium for facilitating learning because of the element of friendly competi-
tion. It allows learners to become involved, experience feelings and examine attitudes
(De Tomay & Thompson 1987:39, 49; Handfield-Jones et al 1993:6).
Simulation increases student motivation and interest because it builds on their curiosity
319
and gives them the opportunity to inquire and explore. Cognitive learning is improved
as students learn to develop decision-making and problem-solving skills and internalise
factual information, concepts and principles. Affective learning is enhanced through
simulation as it offers students the opportunity to gain insight into others' values and
attitudes. Empathy and self-awareness are enhanced and this leads to an increased
insight into interpersonal relationships (De Tornay & Thompson 1987:28-29; Sisk
1987:115).
When simulation is used by a lecturer as part of her teaching repertoire, learning tasks
are made less complex than they actually are in the real world, in order to give students
the opportunity to master those tasks which are extremely difficult in the real life
situation. Simulation provides the elements of a real life experience, without the risk
to the patient. The quality of learning can thus be improved before the student nurse has
to care for the patient. An additional advantage is that students learn from self-
generated feedback through their own senses (and not only from verbal descriptions)
and develop reflective thinking (De Tornay & Thompson 1987:41; Joyce et al
1987:361).
A limitation of simulation is oversimplification of reality which can lead students into

improper learning resulting in erroneous transfer to real situations. Role play simulation,
written simulations and simulation games can be time-consuming to design. Mediated
simulation and computer simulations are both time-consuming and expensive, while
physical simulators are very expensive.
Simplification may result in distorting, obscuring or confusing real-life circumstances.

Activities performed exclusively either alone or in a group may result in not all students'
needs being met (De Tornay & Thompson 1987:41; Gustafson 1988:123).
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Nurse educators frequently use the different types of simulation as they are very
appropriate for teaching a practice discipline. The literature on nursing gives a variety
of examples.
An example of a role play simulation is given by Howland-Regan (1982: 18-20). She

describes how she teaches the handling of a crisis situation creatively by giving students
the opportunity to experience a crisis. At the beginning of one of her lectures a
messenger brings a letter to the class which she reads out to the students. The letter
contains devastating news which may either involve the resignation of the entire teaching
staff of the faculty, loss of clinical affiliation, or loss of accreditation. The class turns
into total confusion as students give expression to their feelings and emotions. The
lecturer gives them about ten minutes of spontaneous interacting and then starts resolving
the crisis. Students are asked to report on their own physical and psychological reactions
and those observed by their peers to help them draw meaning from the crisis. Students
report that they find this learning experience highly motivating and exciting and that it
gives them valuable information about what people in a crisis really endure.
The abovementioned example illustrates the risk-taking and surprise elements of creative
teaching. It includes experiential learning, total affective and cognitive involvement,
active participation, divergent thinking (when trying to find possible solutions) and
reflective thinking during the evaluation of the session.
Bradley-Springer (1993:7) describes another example of a role played simulation in

which a student simulates her own death. The observers are asked to describe their own
feelings and the dead student has to describe her experience. The objective of this
simulation is to help students to empathise with patients and their families as they face
death.
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This learning experience is experiential, student-centred, emotionally and kinaesthetically

oriented.
An excellent example of a live-simulated patient is given by Parrott (1994:37-38) in her

description of the use of Granny Grits to present content on aging, as discussed in 7. 7.3.
This simulation technique can be used to teach the content of many disease conditions,
for example, major depression, paranoid schizophrenia, Parkinsonism, tuberculosis and
AIDS. It gives students the opportunity to use more of their senses in learning and
presents a holistic picture. Students hear, listen, visualise, become aware of the affective
domain and socially related aspects, and pick up non-verbal cues. They organise
information immediately because they receive it from different sources simultaneously.
This aids whole brain creative learning as processes from all four quadrants are engaged.
Games are often used in nursing education as they are valuable strategies in a variety of
teaching-learning and evaluation settings. Stem ( 1989:96) suggests the use of board
games such as Monopoly, Trivial Pursuit and Scruples to motivate students during
courses lasting six weeks or longer, for example, those on orientation, management, or
intensive care unit reviews. Apart from board games, Stem suggests the use of The
People's Court for problem-solving nursing ethical dilemmas on such topics as
confidentiality or accepting more patients to your unit when you have a shortage of staff.
This game illustrates the diversity of such problem situations and adds an element of
challenge, risk and fun to the learning experience.
Stern (1989:96) also mentions the Oxygen Relay Race, a game which was created to
induce curiosity and to make learning a fun-experience. A box containing pieces of
paper on which different methods of oxygen administration are written, is passed around
the class. Each student selects one of the pieces of paper and has one minute to get the
correspondingly correct equipment in a huge box comprising all the different masks and
cannulas. Students have fun while looking for their equipment and are afterwards
322
shown a 15 minutes videotape presentation on oxygen administration.
Another self-created game is reported by Ishida et al (1994:164). The germ game is

used to teach students the principles of asepsis. Apart from being a fun activity, it
provides visual stimuli and opportunity for critical thinking. During this game, one
student performs a procedure involving asepsis in the clinical laboratory. Any one of
the other students tosses a germ (made of coloured paper) into the field of operation
when a break in technique is identified. The first student then attempts to cite the
principle violated, suggests a remedy and implements it.
In the above-mentioned examples learning is enhanced in a stimulating and pleasant

environment. Students participate actively and are challenged cognitively - they are
offered the opportunity for critical and reflective thinking.
Simulation stimulates imagination and provides a holistic view of a problem. It is

essentially problem-centred and experiential in nature and creates an enjoyable and
relaxed learning climate. Students feel free to inquire, explore and take risks in a safe
environment where failure is allowed until mastery is eventually obtained. A creativity
inducing environment is thus established (see 5.7).
Whole brain creative learning is facilitated by simulation as both left and right brain
processes are stimulated. D-quadrant processes are represented by visualisation,
imagination, and the holistic view offered. C-quadrant processes are stimulated through
kinaesthetic and emotional experiences especially with physical simulators, games and
role play simulations. A-quadrant processes including logical and rational thinking, are
stimulated by all types of simulation and so are the B-quadrant processes including
organisation and sequential thinking (see figure 3.3).
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7.12 THE CASE STUDY
7.12.1 Description
The case study can be defined as a teaching strategy that stimulates thinking through
complex problem analysis of actual or hypothetical situations. Traditionally, it has been
associated with business and law courses as it was first instituted by the Harvard Law
School during the late nineteenth century. It is an excellent strategy for exploring the
dynamics of social, organisational and ethical relationships, and for teaching the clinical
aspects of health care. The case study provides a safe environment for the development
of problem-solving and decision-making skills. Case studies are often complex patient
situations which are presented for practice in decision-making and clinical judgement
(Johnson & Purvis 1987: 118; King 1984:85).
Case studies usually include background information on an organisational-, communica-

tion-, or patient-based problem in a specific institutional setting. They can be presented
as written scenarios, as reviews of cases encountered in clinical practice, or as videos
on interpersonal conflicts or ethical issues. However, not all the necessary information
is given, as in reality decision-makers never have all the information to hand (Davis
1986:97; Mellish & Brink 1989:193; Thompson 1991:21).
According to Lawrence (1953) in Johnson and Purvis (1987:118), a good case study
serves as a vehicle by which a chunk of reality is brought into the classroom to be pulled
apart and put together again before the situation can be fully understood.
In the implementation of the case study the lecturer presents the case and acts as group
leader. The students have to generate options and argue the merits of various solutions.
Different types of questions are asked in order to stimulate critical and creative thought.
During the discussion students work through all the stages of the problem-solving
process. There are a few variations of the stages involved in this process. After having
324
studied those given by King (1983), Orlich (1990) and Parnes (1981), the following are
suggested in order to stimulate creative thinking.
(1) Fact1inding. A sensitivity to problems must be developed, as well as the ability

to sense needs and deficiencies, and to see the unusual. Relevant and irrelevant
information should be distinguished, and the who, what, where, how, when and
why questions may be asked. All the known facts about the problem should be
listed without making inferences. Impressions, observations and feelings must be
explored. Parnes (1981:133) suggests visualisation of the problem situation in
order to get a holistic view of the problem, which, at this stage, is still ill-defined.
Questions 4, 8 and 12 given in table 7.2 can be asked.
(2) Problem-finding. The problem should be viewed from all angles. Penetration is
necessary in order to get underneath the problem, away from the obvious.
Psychological openness can be applied in an attempt to restructure the problem
away from mental set (functional fixedness). Questions to be asked include:
What is the real problem? and What must be accomplished? The actual problem
should be re-defined and subproblems defined. Parnes (1981:133) suggests
fantasising a scenario on how to alter the problem situation the way the individual
would like it to be. Kim (1990:38) proposes that the use of intuitive perception
is crucial during this stage. The questions 3 to 9 in table 7.2 can be asked.
(3) Generation ofideas/alternative solutions. Students should be encouraged to think

of as many ideas possible as well as a variety of different ideas or possible
solutions in order to increase fluency and flexibility. Brainstorming is a very
effective technique to use during this stage especially if a creative solution is
desired. Criticism and judgement must be withheld. Six to eight of the best ideas
which seem to be the most likely solutions, should be selected. The questions 1
to 4, 6 and 7 in table 7.2 can be asked.
325
(4) Evaluation of the alternatives. Each of the selected ideas or possible solutions
must be evaluated. The positive and negative consequences of each must be
considered, while examining both short-term and long-term goals. Intuition
should be allowed to play a role during the evaluation of alternatives. Internal
visualisation (the ability to visualise beyond the exteriors) can be applied in order
to get a view of the internal dynamics and to recognise logical inconsistencies.
Questions 3, 4, 5, 6, 7 and 9 given in table 7.2 can be asked.
( 5) Decision-making. The solution which seems to have the most favourable

consequences for the present situation, should be selected (this does not
necessarily mean the greatest number of positive consequences). During decision-
making, synthesis of ideas and thoughts takes place - new associations of
thoughts, facts and ideas are formed. The questions 10 to 14 in table 7.2 can be
asked.
(6) Evaluation ofthe decision. The final decision or solution should be discussed and
its advantages, disadvantages and effectiveness in the particular situation
evaluated. Questions 6 to 9 and 11to14 in table 7.2 can be asked (King 1983:42;
Klaassens 1988:16;Parnes 1981:133, 137; Torrance 1979:64, 73, 116, 168).
The case study provides a safe environment for the development of problem-solving and
decision-making skills. Through discussing relevant issues and verifying facts in order
to make judgements skill in reflective thinking is developed, and the ability to transfer
problem-solving processes from familiar to unfamiliar situations is learnt (Lowenstein
& Sowell 1992:15-16; O'Connell & Bates 1976:224-245).
326
Table 7.2
Questions for stimulating creative thinking
• Quantity question (encourages fluency)

(1) What are all the possible solutions to _ _ ?
(2) List as many ways as you can think of _ _ ?
• Viewpoint question (encourages flexibility, new perspectives, shift of viewpoints)
(3) What would _ _ mean from the viewpoint of a _ _ ?
(4) Describe _ _ from the viewpoint of _ _ .
• Personal involvement question - identification fantasy/personal analogy
(provides subjective experience and releases the individual from rigid, preconceived
perceptions)
(5) Become _ _ and describe your feelings.
• Conscious self-deceit question - fantasy analogy
(stimulates the ability to remove mental blocks, creates ideal situations and modifies
these situations in order to make them applicable to realistic situations)
(6) You have been given the power to _ _ , how will you use it?
(7) Suppose you could have _ _ in working on this problem, how would you
use it to - -?
• Analysis
(8) What factors are causing the patient/family/physician/nurse to act _ _?
(9) What assumptions are underlying your conclusion?
• Synthesis
(10) What might happen if you combined _ _ with _ _ ?
(11) What conclusions do you draw from _ _?
• Evaluation
(12) Do you agree that ?
(13) How effective can be?
• Play devil's advocate
(14) Ask students to defend their reasoning against different viewpoints.
(Demetrulias & Shaw 1985:15-16; Wink 1993:14)

327
Case studies provoke critical thinking by providing students with opportunities to

examine and scrutinise patient problems and ethical dilemmas. They learn to consider
alternatives, distinguish relevant from irrelevant information, examine their own and
others' viewpoints, rethink old ideas, make decisions and evaluate outcomes. Clinical
judgement is enhanced through the opportunity to apply theoretical knowledge in
situations which mimic real clinical practice (Pond, Bradshaw & Turner 1991:18-19;
Thompson 1991 :20).
During case analysis, group interaction is enhanced through the discussion of personal
values, beliefs, and viewpoints which contribute towards professional socialisation of
the student nurse. Ethical case analysis aids emotional and moral development as
students become aware of their own values and attitudes (King 1984:39; Thompson
1991 :21 ).
The case study increases student motivation because of the active involvement and
immediate feedback that they receive from their lecturers (Tarcinale 1987:341).
O'Connell and Bates ( 1976:245) regard the lack of ready-made material for case studies
in the nursing situation as a major limitation of this strategy. I do not agree on this point
as there is a wealth of critical incidents and ethical dilemmas which occur almost daily
in nursing practice, from which the nurse educator can select examples. A real
limitation of the case study is the necessity of keeping class size reasonably small in
order to give each student ample opportunity to work through all the stages. The case
study is also limited by the skill and preparation of the lecturer as a discussion leader
and as an expert on case material (Thompson 1991 :21 ).
The case study is frequently used in nursing education for the development of problem-
solving and critical thinking skills as well as for the integration of theoretical knowledge
328
and professional practice. Clinical case studies can be used to present leadership and
management content. This facilitates analysis and synthesis of new material with
previous learning and the promotion of application of theory to particular nursing
situations (Lowenstein & Sowell 1992:15).
Schoenly (1994:211) cites the case study as a popular strategy for teaching ethics in the
nursing curriculum. Thompson ( 1991 :20, 23) supports this view by indicating the value
of ethical case analysis for teaching ethics and integrating ethics content into
professional practice. The case study bridges the gap between theory and practice and
creates a safe, supportive environment for student learning in what is regarded as a
difficult area of nursing practice.
Tarcinale (1987:340) views the case study as the most common example of vicarious
learning in health professional teaching. He states that vicarious learning (learning
through imagined participation) is attained through the student's involvement in the
problem-solving activities built into the case study.
If the case study is viewed as vicarious learning, then creative problem-solving, role
play, sociodrama and simulation also fall within this category as students are encouraged
to use their imagination while participating in these learning activities.
Case studies provide a means for applying theoretical principles to nursing practice and
teach student nurses that problem analysis is not limited to single solutions. As
successful development of problem-solving skills improves logical reasoning, the case
study assists students in developing clinical decision-making skills (Dailey 1992:8).
Example of a case study:
A nurse is about to administer the last Surgical Unit

of a series of IV solutions that has General Hospital
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been ordered for a man who had sur-

gery two days previously. The nurse's
observations result in her questioning
whether he should have additional
fluids. It is 3 a.m. and she knows the
surgeon will be very angry if called
during the night. She struggles in
deciding whether she should be the
patient's advocate by calling the
surgeon, determining what would be
best, and possibly not administering
the solution, or alternatively whether
not to make the call, thereby
protecting the surgeon's sleep and
herse(ffrom his anger, and to blindly
administer the fluid which is probably
not in the patient's interest.
(King 1984: 123)
It is evident that not all the necessary information is given here. The incomplete
information in this case includes the type of IV solution, type of surgery (major
abdominal, or minor surgical procedure), age of the patient, bowel sounds present, urine
output, whether he may eat or may not eat yet, his general demeanour and condition
including blood pressure, pulse and respiration rates and temperature. This information
is crucial for the making of a sound decision.
The nurse's dilemma in this case is whether she should obey the doctor's orders -
disobedience might lead to legal action if the patient's health is placed in jeopardy.
Whether the nurse administers the last IV solution or not, she is liable for her own
actions. If either of these should adversely affect the patient, she will be guilty of
330
misconduct as she must be able to make independent decisions based on her evaluation
of the patient's condition at that time.
This case study may generate many alternative solutions based on possibilities
depending on relevant information that has not been given. It provides students with the
opportunity of exploring all possibilities and of probing deeper into the problem.
Critical thinking, analysis, synthesis, imagination and evaluation are stimulated.
The case study is a group problem-solving strategy which facilitates cooperative and
experiential learning and divergent thinking. It stimulates students' curiosity and
provides an opportunity for explorative and discovery learning. These aspects concur
with the essential elements present in creative learning (see 5.6).
The required skills of analysis, synthesis and evaluation are among the productive
operations as cited by De Corte's classification of objectives (see 4.3.2.2) and are linked
to creative learning. Sensitivity, openness, flexibility, penetration, redefinition and
elaboration which are essential during case study analysis, are all abilities of creativity
as cited by Torrance (see 2.5.1.1).
The case study focuses more on left brain processes as logical, analytical and rational
thinking (A-quadrant processes) and organised, sequential and detailed thinking (B-
quadrant processes) are essential to effective problem-solving. The right brain
processes, visual and holistic thinking (D-quadrant) and emotions and feelings (C-
quadrant) are used to a lesser extent during case analysis (see figure 3.2).
The strongest support for the case study as an innovative strategy that fosters creativity,
lies in the fact that it is problem-centred and facilitates productive learning.
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7.13 VALUES CLARIFICATION
7.13.1 Description
Values clarification involves the identification and sharing of personal values. It is a

means of opening up the student's skill in recognising her/his own values, and it offers
a way of learning the process of valuing. Values underlie all ethical decision-making
and are the standards which influence the nurse's behaviour (Schoenly 1994:212; Steele
1986:247).
The aim of values clarification is to make students consciously aware of their own
values and underlying motivations which guide their actions, and to offer them the
opportunity of clarifying and defending their values by using the valuing process
(Mellish & Brink 1990:190; Ewan & White 1991:134). As ethical problems are often
wrapped in emotions, individuals tend to resolve ethical dilemmas on the spur of the
moment, when they are least able rationally to do so. Values clarification is a rational
process in which each piece of information is given equal worth. Students learn ways
of valuing, but not a set of values, and discover their own viewpoints on issues (Mellish
& Brink 1990:191; Steele 1986:247).
The values clarification process is based on Rath's theory of valuing and involves three
states: choosing, prizing and acting.
( 1) Choosing: to choose freely from alternatives after thoughtful consideration of

the consequences of each alternative.
(2) Prizing: to cherish, and be happy with the choice; and to be willing to
affirm the choice in public.
(3) Acting: to do something with the choice; and to act repeatedly in the same
332
way.
(Ewan & White 1991:137)
It is important to establish the correct teaching-learning climate for values clarification

as values cannot be strengthened in an atmosphere of fear and mistrust. Risk-taking is
involved when students have to respond to questions and exercises regarding beliefs and
values. As the willingness to take risks is influenced by the perception of acceptance
from the lecturer and peers, the lecturer needs to display an open, accepting attitude.
A relaxed atmosphere, characterised by openness, freedom of expression, and the
absence of negative feedback, should be created. Each student's values must be
respected and mutual trust and support should be established (Mellish & Brink
1990: 191 ). The learning climate for values clarification concurs with the creativity
inducing environment as discussed in 2.5.2.2.2.
According to Mellish and Brink (1990:191), a values clarification session should

include the following steps:
• explaining to students that they do not need to discuss their viewpoints if they do
not wish to
• discussing the concepts of values and valuing
• introducing the theoretical framework (Rath's theory)
• providing values clarification exercises wherein the stages of the valuing process
are used
• clarifying with the students any congruences which they can identify between
their personal values and the values of the nursing profession
333
Values development leads the student towards self-actualisation as principled decision-

making requires higher levels of moral reasoning. Ethical/moral decision-making
requires responsible principled choices and these are based on critical and reflective
thinking. Schoenly (1994:209) reports that movement to the higher levels of moral
reasoning indicates inner growth and the development of a guiding value system
wherein the intellect and emotion are blended.
Values clarification results in increased awareness, empathy and insight. It promotes

self-discovery and enhances personal growth through increased self-awareness (King
1984:15; Schoenly 1994:212).
Values clarification is an excellent strategy of teaching ethics and ethical decision-

making. It leads nurses towards a more humanistic orientation, and assists in personal
and professional growth as nurses learn to act consistently and logically in ethical
decision-making in a principled way. Values which are consistent are established, and
it fosters the art of professional practice (Mellish & Brink 1990:191, 192).
According to Steele (1986:248), the valuing process involves changing your value
system as new evidence comes in. This refers to an open and flexible attitude which
directly opposes functional fixedness and therefore may facilitate creativity.
Nursing practice requires of nurses to make ethical and moral decisions almost on a
daily basis. Nurse educators have the responsibility of preparing students for the moral
dilemmas, ethical issues, and varied viewpoints and conflicts encountered in nursing
practice. Contemporary ethical issues include in vitro fertilisation, sperm banks,
abortions, active and passive euthanasia, surrogate motherhood, and donation of organs
334
for organ transplants. Nurses have to take care of these patients, give advice, converse
with relatives and sometimes have to act on behalf of the patient, always keeping in
mind the patient's best interest. Ethics in nursing involves the critical examination of
the moral dimensions of practice.
The rapid increase in the development and utilisation of technology, advances in

medical science, and the diversity of ethnic groups who are consumers of health
services, have added to the ethical issues and value conflicts which practising nurses
have to cope with daily (Gaul 1987:113; Schoenly 1994:212).
Gaul ( 1987: 113) regards ethical practice as essential to the development of autonomy
of the nursing profession.
The following are examples of values clarification exercises:
(1) Student nurses are asked to list four values which guide their daily interactions
and to rank these according to priority. They are then divided into groups of four
to discuss their values, give reasons why these values guide their actions, and
compare these to the values of the profession as laid down in ethical codes.
(2) Students are given alternatives such as those mentioned below, to rank and are
asked to mention the value which emerges in response to their first choice. The
students should be asked what would be the most difficult for them:
• to care for a woman who had an illegal abortion
• to counsel parents with a Downs' syndrome child
• to switch off the respirator connected to a patient who has been in a coma
for three years, on request of the family
335
By working through these exercises students learn to recognise their own values and
reasons behind their actions. They learn to think rationally about ethical dilemmas and
to act consistently in similar cases.
Values clarification facilitates experiential learning and reflective thinking and

combines the affective and cognitive dimensions in a problem-solving approach which
stimulates cooperative learning. These aspects concur with the aspects which have been
identified as beneficial to creative learning (see 5.6).
The higher levels (valuing, organisation and characterisation) of Bloom's affective

domain of objectives, can be realised through values clarification. These abilities have
been indicated as essential to creativity (see 4.3.1.2). The internalisation of values
which takes place during values clarification is on the third level ofTreffinger's creative
learning model (figure 4.5).
Values clarification draws heavily on C-quadrant processes (emotions, feelings) but

combines these with A-quadrant (logical and analytical thinking) and B-quadrant
(organised, sequential thinking) processes (see figure 3.2). Values clarification also
stimulates D-quadrant processes as a holistic view should be obtained of the situation
in order to make the correct decisions in a particular situation. It therefore facilitates
whole brain learning.
7.14 SYNTHESIS
(1) The teaching strategies discussed in this chapter arouse student attention and
interest through different and unconventional stimuli, provide a relaxed
atmosphere for problem-centred learning and foster creativity. Figure 7.4
illustrates the characteristics inherent in these strategies.
336
Figure 7.4
The relation between innovative teaching strategies
and creativity
Brain-
@ Innovative teaching strategies
Creativity inducing environment
Key-abilities of creativity
Nature of creative learning
• Problem-solving approach
'
'.337
(2) The required learning environment for the implementation of innovative teaching
strategies concur with the creativity inducing learning environment as discussed
in 2.5.2.2.2. This environment is characterised by mutual trust, respect and ac-
ceptance; deferred judgement; and psychological freedom. The relaxed and
enjoyable atmosphere which prevails tends to increase student interest and
intrinsic motivation.
(3) The processes which have been identified by Torrance as the key-abilities of
creativity (see 2.5.1.1) are stimulated. Students learn to be flexible and fluent in
their thinking; to penetrate and redefine problems by looking at them from
different viewpoints; and to use internal visualisation, synthesis and originality
in their thinking.
(4) Experiential, cooperative and discovery learning are facilitated through the active
participation in the learning experiences which are promoted by these strategies.
They are essentially student-centred in nature and stimulate productive learning
which encompasses reflective thinking, formal operational thought (Piaget),
metacognition, productive operations (De Corte) and the higher levels of Bloom's
cognitive taxonomy, namely analysis, synthesis and evaluation. All of these
processes have been linked to creative learning (see 5.6.1, 4.3.1.1, 4.3.2.2,
4.4.1.2, 4.4.1.3, 4.4.1.4 and 4.4.2.2).
( 5) The focus of innovative teaching strategies is that of a problem-solving approach.

This bears many common features to creativity. Torrance's definition of
creativity is one concerned with problem-solving (see 2.5.1.1). Wallas'
description of the four stages of the creative process, namely preparation,
incubation, illumination and verification (see 2.5.1.2), refers to problem-solving.
Problem-solving thus lies at the very heart of creative endeavour.
Innovative teaching strategies stimulate both hemispheres of the brain (as are discussed
338
in this chapter at the end of each relevant section) and accommodate different cognitive
styles as they emphasise linear as well as visual thinking (see 4.2.1 and figure 4.2).
Although the analysis of the relation of these teaching strategies to creativity reveals
whole brain stimulation, it also indicates variations in primary focus. This finer
distinction is illustrated in figure 7. 5.
Based on both the cognitive and humanistic theories oflearning (see 4.4.1 and 4.4.2), the
teaching strategies elaborated on in this treatise have the potential of fostering creative
learning and of developing the necessary skills in student nurses which will enable them
to combine art and science into not only their present, but also, as qualified practitioners,
their future nursing practice.
339
Figure 7.5
Grouping of innovative teaching strategies within the

whole brain model, according to primary focus
A D
Metaphorical thinking
Imagery and fantasy
Sociodrama
Synectics
B c
340
I
I
CHAPTERS
A nursing education model for the fostering of creativity
8.1 INTRODUCTION
The overall aim of this research study is realised in this chapter, namely the
conceptualisation of a nursing education model encompassing innovative teaching
strategies. A detailed description of the model is given in order to clarify its significance
to nursing education.
The research that was done to enable development of the model, comprised an analytical
study of the literature on the determinants of the educational setting and of creativity.
The model is based on assumptions derived from an analysis of the literature. An
inductive approach was followed during the first stage of the development of the model
with the aim of determining relevant concepts. A deductive approach was used during
the final stage to ascertain a complete and holistic presentation.
341
In order to describe the model explicitly some of the information mentioned in foregoing
chapters is reiterated in this chapter. No guidelines for the implementation of the model
are given as nurse educators are familiar with the didactics of education. However, it is
suggested that nurse educators who wish to implement the model, read this thesis in its
entirety to enable them to attain a deeper understanding of what teaching for creativity
encompasses.
8.2 BACKGROUND OF THE MODEL
8.2.1 Aim
The aim of the model is the fostering of creativity in student nurses which will enable
them to become innovative and creative nurse practitioners.
8.2.2 Rationale of the model
The fostering of creativity in nursing education has been the subject of vigorous
discussions in recent years. In considering the complex problems confronting nurse
practitioners in current health care systems, nurse leaders have expressed increasing
concern regarding the lack of stimulation for the development of creativity in nursing.
Creativity has become a valued attribute as an answer to questions such as: How can
students be encouraged to think beyond traditional boundaries and learned limitations?
and How can students develop the ability to find new and better solutions to complex,
individual patient problems? (Holbert & Thomas 1988:34; Margolius & Duffy 1989:32;
Thomas 1979: 115).
The need for creative nurse practitioners has been emphasised by the American
Association of Colleges of Nursing in a report published in 1986 which recommended
that the education of the professional nurse should ensure the ability to appreciate the
role of the fine and performing arts in stimulating individual creativity, expressing
342
personal feelings and emotions, and building a sense of commonality of human

experience (Margolius & Duffy 1989:35).
A creative nurse practitioner is viewed as one who has had extensive knowledge and
experience with conventional methods ofpatient care as well as the judgement to know
when the conventional is not sufficient and the drive and resourcefulness to find other
choices and options (Margolius & Duffy 1989:32). The truth of this statement is
illustrated in the examples given in chapter 6 and in the discussion of the expert nurse
practitioner in 6.5.4.
Creativity is valued by nurse educators and practitioners as a means of coping with

individual patient problems in an environment marked by constant change due to
scientific and technological advances. Considering the anticipated role of nurses in the
future, students who are able to think divergently and creatively, will be better prepared
to enter the nursing profession (Ferguson 1992: 16).
Nursing education literature indicates that some nursing curricula inhibit and that others
promote creativity. The process curriculum which is designed on the philosophy of
promoting individuality and a problem-solving approach to nursing care, should logically
promote creativity, and the need for creative problem-solvers in nursing practice has
clearly been established (Thomas 1979: 116, 119). This research study has revealed that
problem-solving is the core of creativity. The four educational models included in this
nursing education model all focus on problem-solving, as do the innovative teaching
strategies described in this thesis.
Holbert and Thomas (1988:34) emphasise the need for a holistic approach in nursing
education programmes and the development of flexible, life-long learners and problem-
solvers. They suggest that a whole brain education approach be followed wherein
students' individual cognitive styles are considered. This model provides for whole brain
learning and emphasises a problem-solving approach as discussed in 7.14.
343
8.2.3 A prescriptive instructional model
Instructional models provide structural frameworks for guiding and developing particular
educational activities and environments. They offer a blueprint that indicates the
different ways in which various aspects can be organised in order to achieve outcomes
under anticipated conditions. The major components of theories and models of
instruction include conditions, methods and outcomes (Maker 1982: 1; Reigeluth
1983:15, 21).
Models can be used in many different ways and can be either highly theoretical and
abstract, or more practical. The nursing education model for the fostering of creativity,
is more practical as the major aim is that nurse educators should be able to implement
it in nursing education. Instructional models are also classified as prescriptive or
descriptive. This model meets the criteria for a prescriptive model. A prescriptive model
is goal directed, uses sets of conditions and desired outcomes as constants, and prescribes
the best methods as the variables of interest (Reigeluth 1983:22).
The goal of this model is to foster creativity in student nurses. The sets of conditions
include the setting of objectives on the higher cognitive and affective levels, considering
the philosophy of nursing by following humanistic and cognitive approaches to
education, and suggesting particular existent educational models that are compatible to
the education of nursing as a practice discipline. The desired outcomes include
productive learning, divergent and reflective thinking, flexibility, synthesis, originality
and whole brain learning. A variety of innovative teaching strategies is prescribed as
variabl~s of interest because they should be diversified in order to suit a student's
individual cognitive style.
8.3 ASSUMPTIONS WHEREUPON THE MODEL IS BASED
The nursing education model for the fostering ofcreativity is based upon the whole brain
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model, the theories of creativity and the nature of nursing practice. From a synthesis of
these theoretical viewpoints and the nature of practice, the following assumptions are
accepted:
• Development of whole brain learning leads to creativity.
• Stimulation of whole brain learning in student nurses produces innovative and

creative nurse practitioners.
• Nursing practice in a rapidly changing world necessitates effective, innovative

and creative nurses to render holistic, contextually-based care.
• The key-abilities of creativity can be developed in student nurses.
• The determinants that play a role in the development of creative thinking skills,
include theories of learning, objectives, educational models, cognitive styles,
teaching strategies and the learning environment.
• A philosophy of nursing guides the practice of nursing and forms the foundation
of nursing education.
• The four patterns of knowing in nursing practice indicate the need to include
cognitive and humanistic theories of learning in nursing education.
• The different domains of objectives give an indication as to which educational

models are more appropriate to ensure attainment of objectives.
• Theories of learning are directly related to the different domains of objectives

and are linked to particular educational models.
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• Teaching strategies should be compatible to the different cognitive styles of

students in order to enhance learning.
• Students' non-preferred brain quadrants should also be stimulated in order to

develop whole brain learning.
• Innovative teaching strategies stimulate and develop creative learning.
• The creativity inducing learning environment necessitates a specific psychological

atmosphere.
8.4 DESCRIPTION OF THE MODEL
The model is described in its entirety which encompasses its contextuality, visual
presentation and concepts, and interrelationships.
8.4.1 The context of the model
The context of this model is nursing education. It can thus be implemented in any
nursing education situation whether it be in the lecture room or clinical field, in basic
nursing education, in post-basic nursing courses, or as part of staff development in the
health service situation.
8.4.2 The structure of the model
The structure refers to the concepts which include conditions, methods and outcomes, as
well as the interrelationships among the major and related concepts. The visual
presentation of the model contributes to an immediate and deeper understanding of the
interrelationships and continuous flow of actions involved.
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8.4.2.1 Visual presentation
The visual presentation offers an overview of the conceptual relationships within the
model (see figure 8.1 ). Different structures including circles, triangles, rectangles and
eclipses are used to indicate meanings, positions and interrelationships between
concepts. Circles have been selected because of the association with the whole brain
model which is the primary focus of this thesis, as well as for their unlimited use for the
inclusion of many variables which show a coherence. The triangle has been chosen
because of its appropriateness to present the three domains of objectives on the three
different lines. The rectangles distinguish between educational models and objectives,
which are enclosed in the same circle. Eclipses have been chosen to indicate continuing
movement which implies never ending growth as nursing knowledge continuously
expands. Interrupted lines depict overlapping of concepts and fields, whereas arrows
show direction and continuous movement and flow.
The primary colours used in the visual presentation of the model correspond with the
colours of the whole brain model. These colours determined by Herrmann (1989), are
used worldwide during creativity courses which focus on the whole brain model.
Although Herrmann chose yellow to represent the more creative D-quadrant, I prefer to
use green to symbolise creativity because green indicates growth and new life in nature.
Edward de Bono (a well-known creativity expert) chose green for the creative hat in his
famous publication, Six Thinking Hats. The purpose of the more subtle colours is to add
to the visual attractiveness of the model. Visualisation and visual presentations are very
important aspects of creativity.
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8.4.2.2 Description of the concepts and interrelationships
The seven major and several related concepts and their interrelationships are described.
( 1) Philosophy of nursing
A philosophy of nursing forms the foundation of nursing practice and the basis on which
a nursing curriculum is built. Although each school of nursing formulates its own
philosophy, the philosophy underlying worldwide nursing today is rooted in humanism,
holism, existentialism and phenomenology.
Humanism emphasises the unconditional worth of each individual and the development
of human potential. The nurse educator has to respect the students, acknowledge their
worth as unique individuals, and guide each towards self-actualisation while allowing
and accepting individual differences. A holistic approach is characterised by a
relationship where attention is given to the physical, spiritual, psychological and social
dimensions of every student. The student has to be socialised into the profession and
when needed, counselling should be available. A relationship of mutual trust should
prevail.
Existentialism involves viewing each student as a unique human being, allowing

freedom of choice, understanding the relationship between choice and responsibility,
authenticity in tutor-student relationships, and guiding students along the process of
becoming. Phenomenology includes accepting ·students' individual perceptions of
reality and the giving of contextual guidance because each student experiences a
situation differently.
These philosophical views should also be realised in the nurse-patient relationship

during the practice of nursing. A more detailed explanation is given in 6.3.
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There is an interrelationship between the nursing philosophy and the theories of learning
which is relevant to nursing education. The humanistic, existentialistic and
phenomenological influences in the philosophy indicate a need for humanistic theories
of learning because of the emphasis on human relationships and the focus on the affect.
Holism indicates a need for humanistic as well as cognitive theories of learning -
nursing practice requires cognitive, affective and psychomotor skills as patients have a
right to holistic care.
The visual presentation of the model shows that nursing practice is enclosed by a
philosophy of nursing. The big yellow arrow indicates that both the nursing philosophy
and the nature of nursing practice determine which theories of learning are relevant to
nursing education.
(2) Nursing practice
Nursing practice is represented by the four patterns of knowing which nurses value and
use, as identified by Carper (1978) and which are discussed in greater detail in 6.5.
• Empirics refers to the science of nursing and thus represents scientific

knowledge, derived by the senses. It includes theory, principles, and concepts
and refers to the cognitive skills essential to nursing practice. It implies
knowledge of the basic, biological and medical sciences, and nursing theories.
Cognitive skills, including concept learning, critical thinking, problem-solving,
decision-making, intuiting and clinical judgement, are all part of this pattern of
knowing and indicate the need for the inclusion of cognitive learning theories in
a nursing education model.
• Ethics, the moral component of nursing practice, encompasses knowledge of

ethical codes of nursing, ethical theory, principles and guidelines. It involves
explicating different philosophical positions about what is good or right, and
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whose interest is being served. Valuing, clarifying and judgement are involved
when the nurse practitioner is confronted with ethical dilemmas (Chinn &
Kramer 1991 :8-9). Nurses cannot, however, make ethical judgements without
empirical knowledge about ethical principles and codes, different philosophical
viewpoints and the process of valuing - this indicates the interrelationship
between empirics and ethics. The development of affective skills is essential to
this pattern of knowing although it also requires cognitive skills.
• Personal knowledge represents the inner experiences of the individual. It is

only through knowing the self, that one is able to know another human-being.
Knowing the self facilitates meaningful, shared human experience. This pattern
of knowing is closely related to the therapeutic use of the self as explained in
6.5.2. Student nurses need to accumulate personal knowing before they can
engage in a real caring moment or relationship. Intuitive knowing plays an
important role. Personal knowledge is affect-oriented and requires the inclusion
of humanistic theories of learning in nursing education. Personal know ledge is
enhanced by empirics as scientific knowledge leads to a better understanding of
self, others and particular situations.
• Aesthetics refers to the art of nursing. It is made visible through the actions,
conduct, attitudes, and interactions of the nurse in response to others. When
aesthetic knowing develops, the nurse's actions become artistic. Unique,
meaningful, and deeply moving interactions with patients become elucidated
during the performance of psychomotor skills. Aesthetics only occurs
contextually, in the moment, and is unique to the particular aesthetic experience
(Chinn & Kramer 1991: 10-11 ). Aesthetics as expressed in the art/act of nursing
practice, involves empirics (scientific knowledge about illness and relevant
treatment), personal knowledge (understanding the patient's total situation) and
knowledge of ethics (making the correct decision in the patient's interest).
Aesthetics combines cognitive, affective and psychomotor skills and thus
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indicates the need for the inclusion of both cognitive and humanistic theories of
learning in a nursing education model.
None of the four patterns of knowing can stand by themselves, they are all
interrelated, and together form the whole of nursing knowledge. Each pattern
describes something about nursing knowledge and each is equally vital because
it uniquely contributes towards the whole of knowing (Chinn & Kramer
1991:5).
The interrelatedness amongst the four patterns of knowing is visually presented

in the figure by the surrounding overlapping and intermittent eclipses, The arrow
which points from the nursing practice paradigm to the theories of learning
illustrated on the periphery of the first circle (the one on the left hand side),
indicates that the nature of nursing practice influences the selection of theories
of learning appropriate to nursing education.
(3) Theories of learning
Theories of learning attempt to explain the different ways in which students learn. The
cognitive and humanistic theories of learning are of particular concern to nursing
education as student nurses need to master the cognitive and affective skills essential
to effective nursing practice. The psychomotor skills required for practice are included
under the cognitive theories as psychomotor performance cannot be separated from
cognitive involvement. The four patterns of nursing knowledge encompass the
cognitive, affective and psychomotor domains (see 6.5). In order to produce a creative
nurse practitioner, the cognitive and humanistic theories of learning are significant as
creativity involves both cognitive and affective processes (see 4.4).
• Cognitive theories are concerned with how individuals attend, perceive,

memorise, comprehend, learn concepts, solve problems, and think about their
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own thinking processes (discussed in 4.4.1 ). The following cognitive skills have
been selected as being significant to nursing education.
Problem-solving lies at the very heart of creativity and nursing practice. The
contextuality of nursing requires the solving of problems in continuously
changing and diverse situations and it is therefore part of the creative process
(discussed in 2.5.1.2, 4.4.1.1, 6.5.3.2 and 6.5.3.4).
Metacognition has been directly linked to creative thinking techniques because

both assist individuals to regulate their own thinking and behaviour. The
development of nursing theory has been described as a creative process requiring
metacognitive flexibility which facilitates analysis, penetration, synthesis and
reproduction (discussed in 4.4.1.2). Metacognition is an important part of ethical
decision-making as it enables one to make unbiased and just choices.
Formal operational thought plays a significant role in empirics as a pattern of

knowing in nursing because it refers to the ability of dealing with potential or
hypothetical situations and involves scientific reasoning. It is an essential
process for effective problem-solving and includes some of the key-abilities of
creativity such as ideational fluency, flexibility, penetration, synthesis,
redefinition and originality (discussed in 4.4.1.3). Student nurses need to attain
the level of formal operational thought in order to arrive at sound decisions,
develop critical thinking abilities and be effective at clinical judgement when
practising nursing (discussed in 6.5.3.4, 6.5.3.5 and 6.5.3.6).
Discovery learning stimulates productive learning and combines rational

analytical thought with intuition. The relevance of a combination of intuitive and
critical, analytical thinking for nursing practice, has been illustrated in the
examples given in chapter 6, and has been discussed in 6.5.3.3, 6.5.3.4, 6.5.3.5
and 6.5.3.6). Discovery learning is experientially based, explorative and
353
spontaneous in nature, and therefore stimulates creativity (discussed in 4.4.1.4 ).

It is essential to the development of the aesthetic and personal knowledge
patterns of nursing.
• Humanistic theories are concerned with the development of the affect and
focus on feelings, attitudes, beliefs and values. Affective skills are very
important in the development of the ethics, personal knowing, and aesthetic
patterns of nursing practice. Student nurses need to develop skill in moral
reasoning, therapeutic use of the self and caring (discussed in 6.5.2). The role
of the affect in creativity has been acknowledged in definitions of creativity as
well as by Torrance (1993) in his study of the beyonders and by Herrmann (1989)
in his whole brain creativity model. Affective traits, such as openness to
experience, sensitivity, passion, spontaneity, enthusiasm and dedication, have
been mentioned (discussed in 4 .4 .2 .1).
Rogers' and Maslow's theories are of particular significance to nursing as a

humanistic discipline.
Student-centred learning (as proposed by Rogers), emphasises self-directed.

learning and self-evaluation. This fosters independence, self-reliance and
creativity on condition that the relationship between the educator and student is
characterised by respect, trust, authenticity, acceptance and emphatic
understanding. External threats in the learning environment should be eliminated
(discussed in 4.4.2.2). The principles of student-centred learning are of specific
relevance during psychomotor skill learning. A safe learning environment in the
absence of threat (such as the possibility of unintentional harm caused to patients
when the student has not yet mastered the skill) is provided in the clinical
laboratory (discussed in 4.4.2.2 and 6.5.1).
Self-actualisation (as proposed by Maslow), 1s an inherent part of the

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development of student nurses. They need to be socialised into the profession

and have to proceed through a maturation process in order to become
independent, responsible and accountable professionals. The professional nurse
needs to acquire the traits of a self-actualised individual in order to fully
understand the uniqueness of human beings in their socio-cultural context and the
health-illness continuum. The self-actualised person posesses characteristics
such as self-sufficiency, autonomy, independence, spontaneity, sensitivity,
openness, a sense of humour and the ability to handle stress. These are the
characteristics described by Maslow as belonging to the self-actualised person,
and these were also found in expert nurses as reported by various researchers
(discussed in 4.4.2.3 and 6.5.4).
The visual presentation of the model shows theories of learning around the
circumference of the first circle containing the educational models and the
objectives. This illustrates the interrelationship between the different concepts.
Theories of learning guide the educator in the selection of suitable educational
models. The humanistic theories are more applicable when the models of
experiential and adult learning are implemented, because of the emphasis on
affective learning. Although the cognitive theories are suited to all four
educational models, they are slightly more applicable when mastery and open
learning are offered as these focus mainly on cognitive learning.
The triangle containing the different domains of objectives depicts the

interrelationships with the educational models.
(4) Objectives
Objectives describe the required end behaviour of students after particular learning
experiences. The preparation of students for nursing practice demands the setting of
objectives in the cognitive, affective and psychomotor domains.
355
The use of behavioural objectives has been criticised in recent nursing literature for
resulting in restrictive guidelines for evaluation, ignoring students' interest and stifling
creativity (Bevis & Watson 1989:30). Objectives are, however, valuable for guiding
instruction and learning. Creativity experts propagate that the setting of objectives on
the higher levels of the cognitive domain stimulate the development of creative thinking
skills (Neethling 1993).
• Cognitive objectives should be set on the higher levels of Bloom's taxonomy

which include analysis, synthesis and evaluation, in order to stimulate creative
thought. The lower levels, knowledge, comprehension and application, can,
however, not be omitted as they are necessary for the development of a sound
knowledge base which forms the basis of creative endeavour (discussed in
4.3.1.1).
When De Corte's classification is used for the setting of objectives, it is essential

to set these on the productive operation level which includes interpretive
production, convergent production, evaluative production and divergent
production of information. These are the activities which stimulate creative
thought. The setting of objectives on the receptive-reproductive operations level
materialises in reproduction of information which encompasses memorisation
and comprehension. These lower levels are again necessary to gain background
knowledge (discussed in 4.3.2.2 and 4.3.2.1).
Development of the cognitive domain is congruent to the empirics pattern of

knowledge in nursing practice (discussed in 6.5).
• Affective objectives include the levels of receiving, responding, valuing,

organisation and characterisation. The setting of objectives on all these levels
will stimulate creative thought as the affect plays a very important part during
creative endeavour. These activities result in the development of sensitivity,
356
expressiveness, commitment, perseverance and holistic perception, which have

been reported as part of creativity (discussed in 4 .3 .1.2). Development of the
affective domain plays an important role in acquiring knowledge in the aesthetic,
personal knowledge and ethics patterns of nursing practice (discussed in 6.5).
• Psycho motor objectives guide the teaching of psychomotor skills which are a
significant aspect of nursing because it is largely a practical endeavour. These
skills require practice and repetition in order to be learned. The characteristics
of a skilled performance include accuracy, speed, efficiency, timing, consistency,
anticipation, adaptability and perception (Quinn 1989:93-95). The characteristics
including anticipation, adaptability and perception only materialise with
experience which means having performed the skill in real nursing care
situations. These are the characteristics of skills as performed by expert nurses
and can be linked to creativity because the skills are adjusted in the presence of
a special sensitivity together with a kinaesthetic awareness, to suit a particular
situation. The development of the psychomotor domain involves both the
empirics and aesthetic patterns of knowing of nursing pra,ctice. As was
mentioned in 6.5.1, kinaesthetic awareness and cognitive ability are essential in
order to perfect a motor skill.
The visual presentation of the model shows the objectives in a triangle in the
middle of the circle surrounding the educational models. Each domain has been
placed on a particular side of the triangle for a specific purpose. The affective
side is joined to the experiential learning model because of its suitability to the
teaching of affective skills. In the same way, the mastery learning model is
connected to the psychomotor side which indicates its special appropriateness to
the teaching of psychomotor skills. The cognitive side is combined with both the
adult learning and open learning models which depicts their appropriateness for
teaching cognitive skills. However, all four models are compatible to the
teaching of cognitive, affective and psychomotor skills.
357
The interrelatedness amongst the cognitive, affective and psychomotor domains

is illustrated by enclosing them within a triangle. These interrelationships have
been discussed in 6. 5.
(5) Educational models
The four educational models have been selected on the basis of their particular
suitability to nursing education and their student-centred approach. Adult
learning is specifically applicable to nursing education because a significant
percentage of student nurses are adults whereas the remainder are at the stage
between adolescence and adulthood. Mastery learning is very appropriate for
teaching the psychomotor skills which are an important part of a practice
discipline. Experiential learning provides a perfect match for the teaching of
a humanistic practice discipline as it provides holistic and active participation in
learning experiences. Open learning offers ideal opportunities to nurse
practitioners for continuing education in a profession which constantly demands
the updating of its members' knowledge.
An analysis of the four educational models has revealed a common aim and assumptions
that are congruent to creativity and essential to nursing education when the aim is to
produce a creative nurse practitioner (discussed in 5 .6.1 ).
Self-development which involves growth, maturation, unique human experiences, and

self-actualisation appears to be the common aim. The abilities which are developed
during these processes include self-confidence, competency, empowerment and
sensitivity as well as the traits that characterise self-actualised individuals (discussed in
5.6.1 and 4.4.2.3). The professional nurse needs to be a self-actualised person in order
to cope with human suffering in a world which tends almost to be overwhelmed by
technology.
358
Student-centredness refers to self-directedness and independency. Students take

responsibility for their own learning and their needs have first priority. This fosters self-
reliability, self-discipline and independence and increases ego-strength. The student
nurse is therefore offered the opportunity to become an independent and effective
practitioner (discussed in 5 .6.1 ).
Active participation in the learning experiences is advocated by all four models. It

facilitates discovery learning, productive learning, reflective thinking and metacognition
by way of doing, experiencing and reflecting. Active participation is essential to the
learning of psychomotor and affective skills. Individuals can only develop their
creativity through direct experience (discussed in 5.6.1).
Problem-centred refers to inquiry, experimentation and discovery. It involves

formulating hypotheses, considering alternatives, fluency, flexibility, convergent and
divergent thinking, analysis and synthesis. It provides opportunities for the development
of formal operational thought and productive learning. Creative learning is problem-
centred (discussed in 2.5.1.2).
Cooperative learning involves learning from others' experiences, ideas, values,

attitudes, feelings and perceptions. This provides an expanded framework from which
the student can enhance her own knowledge base. Reflective thought, metacognition
and both social and personal development, are facilitated. Cooperative learning offers
security and psychological safety to the young student nurse through peer-support. This
leads to self-confidence, flexibility, openness and sensitivity which are pre-requisites
for creative growth (discussed in 5.6.1).
Intrinsic motivation is the driving force behind creative endeavour. It is derived from
interest, curiosity, challenge, enjoyment and passion and other factors arising from the
internal self of the individual. The student nurse needs to be intrinsically motivated in
order to become an effective nurse practitioner as nursing is a very demanding
359
profession (discussed in 2.5.2.2.4).
A variety of learning activities ensures that students with different learning styles are
accommodated and that opportunities are provided for cognitive, affective and cognitive
learning. It facilitates whole brain learning, and thus creative learning, as stimulation
is provided to all four quadrants of the brain (discussed in 5.6.1).
Self-evaluation is an important aspect of nursing education as nurse practitioners need

to continually evaluate themselves to establish whether they are effective in practice and
updated in their knowledge. It promotes persistence and increases responsibility, self-
esteem and self-honesty. Self-evaluation is conducive to the development of creativity
(discussed in 2.5.2.2.2, 2.5.2.2.3 and 5.6.1).
The visual presentation of the nursing education model for the fostering of creativity
depicts the common aim and assumptions of the four educational models encircled in
the first circle. The arrow which departs from the first circle containing the educational
models and objectives, points directly to the second circle which depicts the cognitive
styles on its periphery and the innovative teaching strategies internally. This indicates
the relationship between educational models, cognitive styles and teaching strategies.
Within the selected educational models, the educator has to organise teaching in such
a way that different cognitive styles are accommodated. This can be realised in the
choice of teaching strategies and the guidance given to students during learning
activities.
(6) Cognitive styles
Cognitive or learning styles refer to the different ways in which individuals perceive and
organise information. It is essential for the nurse educator to be familiar with the
cognitive styles of her students so that she can organise her teaching to accommodate
different styles with the aim of enhancing all her students' learning.
360
Field-dependent students tend to be right brain (D- and C-quadrant) dominated as they
prefer to learn through visualisation, perceive holistically, find it easy to learn social
material and show a sensitivity to others' feelings. They will thus benefit from
innovative teaching strategies which include imagery and fantasy, metaphorical
thinking, synectics, humour, role play, sociodrama and simulation. However, their left
brain (A- and B-quadrant) also needs stimulation as they find it difficult to analyse,
solve problems and structure information (discussed in 4.2.1.2). Teaching strategies
grouped within the A- and B-quadrant might be helpful (see figure 7.5).
Field-independent students prefer left brain processes and are good with problem-
solving, analysis and structure and reorganisation of information. They tend to be
autonomous and work independently. These students would prefer innovative teaching
strategies including brainstorming, creative problem-solving, writing, case study, written
and computer stimulations. This group of students should, however, also be stimulated
to use their right brain processes and need special assistance with the learning of social
subjects and the development of interpersonal skills such as communication and
empathy (discussed in 4.2.1.2). Teaching strategies grouped within the D- and C-
quadrant might be helpful (see figure 7.5).
The assimilator, diverger, accommodator and converger are the four cognitive styles
identified by Kolb (1976) and have been discussed in detail in 4.2.2.1, 4.2.2.2 and
4.2.2.3.
Assimilators learn through abstract conceptualisation and reflective observation which

indicate brain dominance in the A- and D-quadrant. These students prefer abstract
thinking and approach problems in a scientific way. They observe and describe ideas
and concepts in order to understand them. Practical applicability is not regarded as
important. They tend to use intuition when searching for the meaning of situations and
prefer to rely on their own thoughts. They are not feeling-oriented but value precision,
and the aesthetic quality of a structured conceptual system.
361
Divergers show a preference to learn through concrete experience and reflective

observation. This depicts brain dominance in the C- and D-quadrant. These students
use their imagination to view concrete situations from many perspectives. They prefer
action, enjoy relating to others and are feeling-oriented. They have an open-minded
approach, are good intuitive decision-makers and function well in unstructured
situations.
Accommodators use concrete experience and active experimentation which indicate a

preference for the C- and B-quadrant. These students prefer doing to thinking and solve
problems by trial-and-error. They are good at getting things done, adapt easily to
changing situations, seek opportunities and take risks. They rely on others for
information and are at ease with people. They use D-quadrant processes to a lesser
extent.
Convergers learn through active experimentation and abstract conceptualisation which

indicate a preference for B- and A-quadrant processes. These students are good at
problem-solving, decision-making and the practical application of ideas. They tend to
be unemotional and prefer to focus on problems requiring convergent thinking. They
prefer technical problems to interpersonal issues.
In the visual presentation of the model, Kolb's four learning styles have been placed on
the periphery of the circle indicating the whole brain model. They are situated in a way
that illustrates which quadrants of the brain they show a preference for. Figure 7.5 gives
and indication of the innovative teaching strategies from which students with different
cognitive styles would benefit.
The visual presentation of the model shows innovative teaching strategies in the centre
of the second circle with arrows pointing to all four quadrants to indicate that they
stimulate whole brain learning.
362
(7) Innovative teaching strategies facilitate a creativity inducing learning

environment and foster creative learning. They focus on problem-solving,
accommodate the different cognitive styles, stimulate all four quadrants of the
brain, and thus enhance whole brain learning. The strategies discussed in this
thesis have additionally been selected on the basis of their particular applicability
to nursing education. They include brainstorming, creative problem-solving,
teaching by metaphor, synectics, humour, writing, role play, sociodrama, values
clarification, visualisation (imagery and fantasy), case study and simulation, as
discussed in chapter 7.
• The learning environment is an important determinant in the facilitation of

creative learning. The implementation of innovative teaching strategies requires
the creation of an open psychologically free environment. This implies the
absence .of external evaluation and criticism, in a climate in which the student
feels free to explore, experiment and take risks. An atmosphere of authenticity
is established wherein the student is accepted as unconditionally worthy and
where mutual respect and trust prevail. A non-judgemental atmosphere is created
in which self-evaluation is encouraged and judgement deferred. This allows
students to become self-directed in their learning and to enjoy individual as well
as collaborative learning in a relaxed environment. They become more sensitive
to the moods and feelings of others and to external stimuli, and optimum learning
can thus take place. Intrinsic motivation is increased because learning is enjoyed
and external threats such as evaluation and competition are absent, and the
learning environment is student controlled. (The creativity inducing learning
environment is discussed in detail in 2.5.2.2.3 and 5.6.2, and is illustrated in table
5.2 and figure 7.4.)
• Creative learning is essentially problem-solving in nature and is facilitated

through experiential learning which implies active participation. It is developed
through discovery learning (allowing inquiry, exploration and experimentation)
363
and through cooperative learning (providing exposure to others' ideas and

knowledge which enhances one's own frameworks of reference and knowledge).
Experiential and discovery learning provide ideal opportunities for the
facilitation of productive learning. Students explore and become sensitive to
problems, deficiencies and gaps in knowledge, they search for solutions,
formulate hypotheses and test them, modify solutions and gain new knowledge
in the process. Productive learning involves reflective thinking, metacognition
and formal operational thought. These cognitive operations are characterised by
the abilities of analysis, synthesis, evaluation, intuiting, perception, internal
visualisation, penetration, fluency, flexibility, redefinition and originality. All
these processes are linked to creative learning (discussed in 2.5.1.1, 4.3.1, 4.3.2
and 4.4.1 ). Creative learning necessitates whole brain learning as thinking
processes from all four quadrants are essential (see figure 3.2). The visual
presentation of the model illustrates with an arrow that innovative teaching
strategies result in the production of a creative nurse.
(8) The concept creative nurse, is enclosed in a circle presenting the whole brain
model. This implies that the creative nurse uses thinking processes from all four
quadrants of the brain. The traits of an innovative and creative nurse are
congruent to those exhibited by the expert nurse practitioner. The expert nurse
is capable of critical and analytical thinking, and combines logical and rational
thought with intuition during clinical judgement. Expert nurses exhibit
flexibility, sensitivity, perceptiveness, vision, and proficiency. They approach
patient situations holistically and contextually and can anticipate potential patient
problems. They can synthesise opposite traits, for example, exhibiting outer
calmness while experiencing inner anxiety during emergencies, being
spontaneous in one situation and reserved in another, and being caring or being
detached, depending on what the situation requires. Maslow refers to this
phenomenon as a resolution of dichotomies found in the self-actualised
individual (see 2.5.3). The expert nurse is organised, well-informed,
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independent, compassionate and feeling-oriented, but also factual and procedural

(see examples in chapter 6, discussion in 6.5.4 and illustration in figure 3.2).
8.5 EVALUATION OF THE MODEL
The model is evaluated according to the criteria set by Maker (1982:10-11) which
include the criteria identified by Reigeluth (1983 :26) for the evaluation of instructional
models.
( 1) Appropriateness to the situation
This refers to the purposes of the model, whether it corresponds with the needs of the
students and the philosophy of the educational institution, and to what extent the
assumptions of the model fit reality.
The need for innovative and creative nurse practitioners in the contemporary and future
health care delivery system, is presented and discussed in chapter 6. The model has
been designed to educate students for nursing practice and is based on the general
prevailing philosophy of nursing. The underlying assumptions which state for example
that whole brain learning results in more effective nursing practice and that creativity
can be developed in students, are on par with reality. This was illustrated in the analysis
of the nature of nursing practice and the characteristics and abilities of the expert nurse
(see chapter 6).
(2) Comprehensiveness
This involves the total variation that can be accounted for which includes content-,
process-, product- and learning-environment modifications.
The content which is accounted for in this model includes the four patterns of knowing
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The content which is accounted for in this model includes the four patterns of knowing
in nursing and can be modified according to students' needs. Depending on whether
students need more development regarding empirics or personal knowledge, objectives
can be focussed on either the cognitive or the affective domains.
Process modification refers to the teaching methods used and the thinking processes
required from the students. This model includes a variety of teaching strategies which
stimulates the different thinking processes of all four quadrants of the brain. Teaching
strategies can also be varied to suit different cognitive styles.
Product modification is concerned with the end result of education, in this case the
newly qualified nurse practitioner. The modification provided by this model is that it
not only produces an educated nurse, but an innovative and creative nurse who can
function dominantly in any one of the four quadrants, depending on what the situation
requires. For example, a caring moment relies heavily on C-quadrant processes whereas
an emergency situation relies mainly on A-quadrant processes.
This model suggests various modifications to the psychological learning environment

in order to create an environment conducive to the fostering of creativity.
The model contains overall comprehensiveness because it includes a variety of

educational models, theories of learning, cognitive styles, objectives and teaching
strategies.
(3) Flexibility or adaptability
This refers to the ease with which the model can be adapted to all content areas and to
the administrative structure of the educational institution, whether it can be combined
with other models to provide a comprehensive programme and how adaptable it is to
individual differences in students.
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The model offers flexibility regarding the choice of educational models, objectives and
teaching strategies which can be selected to comply with the nature of the content. It
can be adapted to the administrative structure of any nursing education institution as
implementation depends on the skill and knowledge of the individual nurse educator.
It can be combined with other educational models (as mentioned in 5 .1) as long as the
basic principles of teaching for creativity are considered. The model is very adaptable
to individual differences as it offers a variety of theories of learning, educational
models, and teaching strategies, and considers different cognitive styles.
(4) Practicality
This concerns the availability of materials to implement the model, the cost of materials,
special training needed and the ease with which the model can be implemented in the
present situation.
The model can be implemented without any additional materials or costs because
teaching strategies can be varied and adapted according to circumstances (whether in
the presence or absence of media centres) (discussed in chapter 5). No special training
is needed except that nurse educators should be encouraged to read widely about
creative learning or to read this thesis in its entirety in order to arrive at a better
understanding of the concept of creativity in education. This model can be implemented
immediately in the present situation by nurse educators as an individual endeavour.
(5) Validity
The questions asked here are whether the model was developed by using appropriate
methods, and if it is defensible as a qualitatively different programme for student nurses.
Is the model internally valid or structurally sound, and how much research has been
done to show its effectiveness as an educational approach?
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The method used to develop this model was an analytical study of the literature
concerning all the concepts included in the model. The model is based on assumptions
derived from this analysis of research findings. It is defensible as a qualitatively
different approach to the education of student nurses as the teaching strategies and
required learning environment have been proved through repeated testing in creativity
courses. As this model has yet to be tested in practice, no research is available to show
its effectiveness in nursing education. However, according to Field and Morse
(1990: 13 9), validity in qualitative research refers to the extent to which the research
findings represent reality. On the basis of the homogeneity found on analysis of various
research studies in the literature which lead to the design of this model, the model can
be regarded as having internal validity.
8.6 CONCLUSION
The description of the nursing education model for the fostering of creativity marks the
consummation of this research study. The model presents a challenging, new approach
to nurse educators. It is hoped that they will disclose the vision, openmindedness,
flexibility and compassion, to instill in their students a free and inquiring mind, a
passion for nursing, and the courage to cope with change and challenges.
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CHAPTER9
Summary, conclusions and recommendations
9.1 SUMMARY
This study originated against the background of much debate on the need for the
development and expression of creativity in nursing. The focus of the concern is the
nurturing of creativity in student nurses. Students need to be prepared to solve the
complex problems in the health care environment resulting from ever-expanding
knowledge, advanced technology and changing human values. The complexity of
contemporary nursing requires that practitioners respond and adapt to unique patient-
situations. The ability to solve problems effectively and make high level decisions based
on a firm knowledge base, is expected of the professional nurse (Jones 1983:405;
Klaassens 1992:28) (see 1.1).
Nursing is a growing and changing profession and requires from practitioners innovative,
unconventional and independent thinking in order to cope with, and adapt to change.
Creativity is viewed as a means to help nurses cope with rapid changes in the health care
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environment, while at the same time providing for more holistic and individualised care.
Individualistic and imaginative patterns of patient care have become essential to
professional practice (Ferguson 1992:18-19; Lantz & Myers 1986:65).
As found throughout this study, much of the literature on nursing research repeatedly
indicates that there is an urgent need for nurse educators to stimulate creative thinking
skills and assist students to problem solve effectively, and to explore innovative teaching
strategies applicable to nursing education. The study was undertaken against this
background ie to determine the nature of creativity and the processes involved in creative
thinking and learning, and with these in mind to develop a nursing education model
which incorporates innovative teaching strategies.
More specifically, the aim of the study was to
• explore the concept creativity, by analysis of its various definitions and theories
• analyse the whole brain theory of creativity
• establish the relationship between cognitive styles and teaching for creativity
• indicate the role of learning objectives in the development of creative thinking

skills
• determine the relation between theories of learning and creativity
• identify educational models of specific relevance to nursing education which

facilitate creative learning
• analyse the practice of nursing in order to indicate whether creativity is needed

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• identify and describe innovative teaching strategies applicable to nursmg

education
• develop a nursing education model which would foster creativity in student

nurses
As a point of departure, the various theories of creativity and the whole brain theory
serve as the conceptual framework on which this study is based. The first chapter gives
the background and outline of the study. Chapters 2 to 7 involve an analytical study of
the literature, and chapter 8 encompasses a description of the designed model. This
chapter contains the conclusions reached from the study and recommendations for
further research.
9.2 CONCLUSIONS
The conclusions are discussed using the same headings as are given in the previous
chapters. They are derived from the analysis of the relevant literature.
9.2.1 Modern conceptions of creativity
There are basically two opposing views about creativity. The traditional view explains
it as a special talent which is inherited and belongs only to a few superior individuals.
The more recent view refers to it as an authentic human ability which can be further
developed by education and a suitable environment. Some researchers theorise that
although creativity may be biologically determined, it can still be enhanced through
environmental conditioning (see 2.2 and 2.3.4). This leads to the conclusion that
creativity can indeed be developed.
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9.2.2 Definitions of creativity
Although the various definitions of creativity either refer to the person, product or
process, certain common aspects are identifiable (see 2.4). It can be deduced from the
given definitions that creativity involves the ability to free oneself from one's own
conceptual frameworks of reference in order to see something from a different
perspective, to become intensively involved, in a given situation, or to synthesise and
to produce a novel idea or product.
9.2.3 Theories of creativity
9.2.3.1 Cognitive, rational and semantic theories
9.2.3.1. J Cognitive abilities
These theories view creativity as being largely set in the cognitive domain. They focus
on the creative process and product. In Guilford's structure-of-intellect model, the
operations involving divergent production and the products involving transformations
are linked to creativity. The abilities inherent to divergent thinking, are congruent to the
key-creative abilities as identified by Torrance: ideational fluency, flexibility,
elaboration, originality and semantic redefinition. Guilford' s transformations concur
with Torrance's concepts of synergy, synthesis and redefinition (see 2.5.1.1).
It can be deduced from Torrance's process and artistic definitions of creativity that it
involves both the cognitive and affective domains. Apart from the cognitive processes
mentioned above, the uneasiness resulting from tension mentioned in the process
definition, and the references to listening and singing in the artistic definition, refer to
involvement of the affect. From Torrance's survival definition of creativity, it can be
concluded from his use of the words ... taught ... self-discovered ... self-disciplined ... ,
that creativity necessitates practice, learning, intense involvement, effort and persistence
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(see 2.5.1.1).
9.2.3.1.2 Creative problem-solving
Research and theories on the creative problem-solving approach reveal that the creative
process involves four basic processes, namely, preparation, incubation, illumination and
verification. These prevail irrespective of whether theorists describe creative problem-
solving as encompassing five or seven stages. From the descriptions of various creative
geniuses, such as Helmholtz and Poincare, the following can be concluded: Creativity
requires a sound knowledge base, hard work and dedication (especially during the
preparation and verification phases). It takes some contemplation of a problem which
should be considered from many different perspectives and then, after leaving it aside
for a while, a creative idea often comes to mind - this is known as the incubation phase.
A creative idea appears when the mind is at rest, such as just before awakening from
sleep or when a person is in a relaxed state. This is referred to as the illumination phase
(see 2.5.1.2).
9.2.3.1.3 Associative theories
These theories refer to creativity as encompassing the connection of previously

unrelated ideas or levels of experience. Analysis of this cognitive operation leads to the
conclusion that it involves certain key-abilities of creativity, namely, fluency, flexibility,
penetration, synthesis and elaboration (see 2.5.1.3).
• Gestalt theories
Creativity is believed to involve the reconstructioning of a pattern, gestalt or problem,

and reference is made to the negative influence that rigidity or fixed mental sets have
on this process (see 2.5.1.4). It can be deduced that psychological openness, sensitivity,
penetration and flexibility (key-abilities of creativity, discussed in 2.5.1.1) are necessary
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to break away from such fixed mental sets. The ability to view something from a
different perspective is repeatedly mentioned in the various definitions of creativity (see
2.4).
Wertheimer specifically refers to the relationship between creative thinking and

productive thinking, as both involve grouping, organisation and structuralisation (see
2.5.1.4). It can be concluded that creative thinking is synonymous with productive
thinking, as they use the same cognitive processes, namely analysis, synthesis and
evaluation.
9.2.3.2 Personality and environmental theories
• Personality theories
The personality theorists believe that the creative person exhibits certain personality
traits, attitudes and behaviour. The creative individual is characterised by ego-strength,
independence, flexibility, sensitivity, perceptiveness, intellectual effectiveness, an
openness to experience, vision, and a positive attitude towards life (see 2.5.2.1 ). The
openness, flexibility and sensitivity have also been emphasised by the cognitive theorists
(see 2.5.1.1 and 2.5.1.4). Some theorists regard creative people's behaviour as non-
conforming.
A unity of opposites has been described in highly creative people. This implies that they
are at the same time more independent and more dependent, more non-conforming and
more conforming, more open and more self-acting (see 2.5.2.1). They can apparently
maintain an equilibrium between these opposing characteristics because of their
flexibility, perceptiveness and ego-strength.
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• Environmental theories
No comprehensive theories exist on the role that the environment might play in the
development of creativity, but specific issues are addressed.
Regarding social and cultural influences, it is evident that the exaggerated emphasis
placed on conformity, competition and success in the Western society has a negative
influence on creativity (see 2.5.2.2.1). The emotional blocks caused by a fear of
rejection, failure or being different, apparently freeze creativity.
The literature on the required learning environment for the enhancement of creativity,
repeatedly reveals the need for psychological freedom and security, the absence of
external evaluation (because it produces defensiveness), deferred judgement and
extended effort (see 2.5.2.2.2). It is deduced that an environment that adheres to these
criteria is conducive to the generation of creativity.
Teacher attitudes appear to play a very important role in the creativity inducing
learning environment. Reference is made to the negative influence that rigid and
authoritarian teachers have on their students' creativity. They do not allow individual
exploration and experimentation, overemphasise success and external evaluation and
therefore inhibit self-directed and self-responsible learning (see 2.5.2.2.3). Such
teachers stifle creativy. The open teacher who creates a learning environment conducive
to creativity encourages students to use their imagination and allows self-activity,
experimentation, hypothesising, spontaneous expression, and self-evaluation, while
accepting every student as being unconditionally worthy (see 2.5.2.2.3).
Research studies on rewards and motivation indicates that rewards and extrinsic
motivation do not stimulate creativity but that intrinsic motivation plays an important
role during creative performance (see 2.5.2.2.4). It is deduced that intrinsic motivation
which results from curiosity, interest, challenges and passion is essential to creativity.
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These same qualities have been found in the beyonders as reported by Torrance (see
2.5.2.1).
9.2.3.3 Humanistic theories
To the humanists, creativity is realised by a passion and commitment to live a full and
productive life. They emphasise the need for an intensive encounter of the person with
the real world, devoid of stereotyped views (see 2.5.3). This implies openness, freedom
from fixed perceptions, and cognitive and emotional involvement. These qualities have
also been mentioned by the cognitive theorists (see 2.5.1.4 and 2.5.1.1) as being part of
creativity.
The distinction made between special talent and self-actualising creativeness (see 2.5.3)
concurs with the two different approaches to creativity as mentioned in 2.2. It is
interesting to note that Maslow's description of self-actualising creative individuals is
congruent to the creative personality as reported by the personality theorists. The
corresponding traits include openness, independence, ego-strength, perceptiveness,
courage and expressiveness. Maslow affirms the personality theorists' view regarding
a unity of opposites in creative people, which he calls a resolution of dichotomies (see
2.5.3 and 2.5.2.1).
Rogers elaborates on the concept of psychological freedom which is such an important

factor in a learning environment conducive to creativity. Accepting the student as
unconditionally worthy, understanding emphatically and providing a climate where
external evaluation is absent, are essential elements in providing psychological safety.
From these assertions and Rogers' reference to the relationship between internal locus
of evaluation and creativity (see 2.5.3), it can be concluded that self-evaluation should
be encouraged during the fostering of creativity.
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9.2.3.4 Psychoanalytic theories
These theories view creativity as deriving from the unconscious and preconscious.
Their descriptions of the role of the unconscious, preconscious and primary process
thinking during the creative process (see 2. 5 .4) lead to a better understanding of the
concept creativity. Primary process thinking (whether as a preconscious or unconscious
process) occurs on the verges of sleep and involves remote associations and
metaphorical thinking, and is said to release creative ideas. It is deduced that it plays
a role during incubation and illumination because it concurs with Helmholtz and
Poincare's descriptions when they received their sudden inspirations. It can also be
. .
concluded that creativity necessitates both unconscious and conscious processes as both
preparation and verification involve conscious processes.
9.2.4 The whole brain theory of creativity
9.2.4.1 Left and right hemispheric specialisation
The differences between the functions of the left and right hemispheres, revealed by the
split brain studies during the 1960s, lead to the assumption that creativity resides in the
right hemisphere. The reason for this being that the right hemisphere was attributed
with holistic, intuitive and creative imaginative processes and the left hemisphere with
verbal, analytical, and logic processes. Recent research, however, shows that creativity
necessitates cooperation between the hemispheres (see 3 .1, 3 .2 and 3 .3 ). It can be
concluded that creative performance necessitates functions from both hemispheres as
the key-abilities of creativity such as analysis and redefinition, refer to left hemispheric,
and synthesis, sensitivity and synergy to right hemispheric functions (see 2.5.1.2 and
table 3.1).
The situational and iterative functioning of the brain explains how an individual moves
through the phases of the creative process by using left or right brain processes (see
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3.4.2). During the preparation and verification phases, left brain processes, such as
analysis and abstract thinking are used. This refers to situational functioning as the left
brain is activated (see table 3.1 ). When the individual moves from the preparation to
the incubation and illumination phases, iteration occurs between the left and right
hemispheres as intuition and visualisation are the processes required (see 2.5.1.2 and
table 3.1 ).
It can be deduced from the research findings on brain specialisation that individuals who
tend to approach problems analytically and factually are left brain dominated while
those who approach problems intuitively and visually are right brain dominated (see
3.5.1 and table 3.1). This dominance in brain functioning is believed to determine a
person's cognitive style (preferred mode of knowing).
9.2.4.2 The four quadrant model
The four quadrant model which was developed by Herrmann (1989) gives a finer
distinction of the left and right hemispheric functions. On the basis of the type of
questions he asked in his questionnaires and the four distinct clusters which appeared
on analysis of more than 500 000 questionnaires (see 3.5.1), it can be concluded that the
four quadrant model is valid and reliable.
The four quadrant metaphorical model (encompassing the A-, B-, C- and D-quadrant)
can be regarded as a whole brain model because it distinguishes between the left and
right cerebral hemispheres and the left and right halves of the limbic system and
therefore represents both conscious and unconscious thinking processes. The limbic
system is the centre for instinct and feeling and thus represents the id and the
unconscious as described by Freud (see 2.5.4 and 3.4.1). The left and right cerebral
hemispheres are referred to as the neocortex which is responsible for the higher thought
processes (see 3 .4 .1).
378
Herrmann's findings on the distribution of brain dominance reveal that most individuals
(60%) are double dominant which indicates that they show a preference for using two
particular brain quadrants. A smaller number of individuals are triple dominant (30%)
meaning that they tend to use three specific brain quadrants most of the time. A small
percentage is single dominant (7%) using only one brain quadrant and only a very few
(3%) are quadruple dominant (see 3.5.1). The latter group is believed to be highly
creative because they use all four quadrants (see 3.5.2).
9.2.4.3 The whole brain model in relation to creativity
The creative process as described by Wallas (see 2.5.1.2) relies on all four quadrants of
the whole brain model. From the thinking processes identified as characteristic of each
quadrant (see figures 3.2 and 3.3), it can be deduced that the creative process
necessitates whole brain thinking (see 3.5.2 for specific detail).
Various researchers view creative geniuses, for example, Da Vinci, Einstein and Kekule,
as being skilled in using both left and right brain processes and attribute their
extraordinary talent to their use of their non-dominant quadrants. It is postulated that
strengthening of the non-dominant brain quadrants, enhances the functioning of the
dominant quadrant (see 3.5.2). If this is the case, the conclusion can be drawn that
individuals can enhance their creative performance by exercising their non-dominant
quadrants.
The experiences of Einstein and Kekule who both encountered their periods of
illumination (when great discoveries were made) through dreams (see 3.5.2), concur
with those of Helmholtz and Poincare (see 2.5.1.2). It affirms the role of unconscious
processes during the creative process. The role of the C- and D-quadrant processes
indicated by the emotional involvement in dreams and the holistic and synergistic visual
images, are clearly illustrated. As no scientific problem can be solved without vigorous
rational, analytica~ detailed and sequential thinking, it can be concluded that the A- and
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B-quadrant processes were also used during the processes which lead to their great
discoveries. It is therefore deduced that whole brain thinking is essential to creativity.
Herrmann views creative people as having a primary preference for the D-quadrant with
strong secondary preferences in the other quadrants (see 3.5.2). As almost all
definitions of creativity make reference of synthesis (see 2.4), it can be concluded that
Herrmann might be correct as synthesis is a D-quadrant process.
9.2.4.4 The whole brain teaching and learning model
It can be inferred from Herrmann's whole brain teaching and learning model (see figure
3 .4) that a combination of structured and experiential learning activities are required to
facilitate whole brain learning. Students should be supported in their preferred mode
first, and then in their non-preferred modes in their efforts to develop whole brain
functioning.
The structured teaching-learning environment required for students showing a

preference for the A- or B-quadrant indicates that they are verbally oriented, rational and
disciplined, and have inquiring minds. The differences between the two are that while
the A-quadrant dominated students are analytical, fact-based, intellectually inclined and
achievement driven, the B-quadrant dominated students are procedural, controlled,
kinaesthetically inclined and task driven. The latter individuals are thus the more
practical (see 3.5.3 and figure 3.4). The similarities and differences are accounted for
by the teaching strategies illustrated in figure 3.5.
The experiential teaching-learning environment appropriate for students with a

preference for the D- or C-quadrant discloses that they are non-verbally oriented,
spontaneous, explorative and inquisitive. D-quadrant dominated students are, however,
visual, intuitive, open-minded and independence driven, whereas the C-quadrant
dominated students are emotional, expressive, and feelings driven (see 3.5.3 and figure
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3.4). The teaching strategies in figure 3.5 illustrate an emphasis on visualisation for the
D-quadrant and on interpersonal activities for the C-quadrant.
It is concluded that the whole brain teaching and learning model can assist educators to
implement amore holistic approach towards teaching.
9.2.5 Cognitive styles
Cognitive styles refer to consistent individual differences in the manner in which

information is organised and processed. Modes of perceiving, remembering and
thinking are involved. As Herrmann refers to an individual's preferred mode of
knowing as his preference for a specific brain quadrant, it can be deduced that cognitive
style and brain quadrant preference are related (see 4.2).
9.2.5.1 The .field-dependent/independent cognitive styles in relation to whole

brain learning
9.2.5.1.1 Field-dependency
Analysis of the literature on cognitive styles reveals that field-dependent individuals

tend to perceive patterns holistically, favour visual learning, are sensitive to others'
feelings, work well in groups, are dependent on frequent feedback and find it easy to
learn, social material (see 4.2.1). These preferences indicate utilisation of the D-
quadrant (visual, holistic) and C-quadrant (interpersonal, feelings, emotions) processes
(see 4.2.1.1 and figure 3.2). It indicates double dominance in the D- and C-quadrant.
9.2.5.1.2 Field-independency
Field-independent individuals' preference for analysis, abstract thinking and fact-based

theory, and their impersonal, independent approach refer to utilisation of A-quadrant
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processes. Their ability to organise, structure and generate principles and rules from
material and reorganise situations, depicts utilisation ofB-quadrant processes (see 4.2.1,
4.2.1.1 and figure 3.2). These preferences indicate double dominance in the A- and B-
quadrant. It can thus be concluded that field-dependent individuals are right brain
oriented and field-independent individuals, left brain oriented.
9.2.5.1.3 Educational implications for whole brain learning
The field-dependent student's preference for D- and C-quadrant processes should be

supported by selecting teaching strategies which facilitate visual and cooperative
learning. For example, fantasy, simulation, clinical assignments, role play, field trips
and values clarification can be used. They should be given clear objectives and frequent
feedback. Their non-preferred A- and B-quadrant can be stimulated by offering formal
lectures with visual media, case studies, group projects, learning packages, and
programmed learning (see 4.2.1.2 and figure 3.5).
Field-independent students must be presented with teaching strategies which enhance

independent problem-solving and analytical and sequential thought because of their
preference for the A- and B-quadrant. Teaching strategies including reading
assignments, individual projects, programmed learning and learning packages would be
suitable. These students will need additional assistance with the social sciences. Their
non-preferred D- and C-quadrant can be stimulated by simulation, clinical assignments,
values clarification, role play and clinical post conferences (see 4.2.1.2 and figure 3.5).
It suggested that nurse educators should familiarise themselves with their students'
cognitive styles. Field-dependent and field-independent students should first be
supported in their dominant quadrants and then in their less preferred quadrants to
stimulate whole brain learning and enhance creativity. The fact that psychiatric nurses
tend to be field-dependent and surgical nurses field-independent (see 4.2.1.2)
strengthens the case for the development of whole brain learning in student nurses as
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their basic education requires competency in the various fields of nursing.
9.2.5.2 Kolb 's experiential learning model
Kolb identified four modes of the learning process and each of the four cognitive styles
described by him encompasses a combination of two of the four learning modes. His
explanation of how individuals perceive reality through varying degrees of apprehension
or comprehension relates to the whole brain model. Comprehension appears congruent
to left brain processes (abstract, analytical, verbal, linear, sequential) and apprehension
concurs with right brain processes (holistic, concrete, spatial, analogic, intuitive). Each
of his learning modes appears to correspond with a different quadrant of the whole brain
model (see 4.2.2, figure 4.1 and figure 4.2).
9.2.5.2.J Modes of the learning process in relation to the whole brain model
• Concrete experience appears to be mainly C-quadrant oriented as individuals

with a preference for this mode focus on experience and feelings, and value
interpersonal relationships. An indication of a lesser utilisation of D-quadrant
processes is illustrated in their reliance on intuition during problem-solving and
their open-minded approach (see 4.2.2.1 and figure 3.2).
• Reflective observation tends to be linked to the D-quadrant. These individuals

prefer intuiting the meaning of situations, have vision and approach problems
from different perspectives. A lesser preference of the C-quadrant is elucidated
in their reliance on their own feelings to form opinions (see 4.2.2.1 and figure
3.2).
• Abstract conceptualisation is strongly linked to the A-quadrant as these

individuals approach problems in a scientific and abstract way and value logic
and analysis. A lesser preference for the B-quadrant is indicated by their valuing
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of precision and systematic planning (see 4.2.2.1 and figure 3.2).
• Active experimentation is mainly B-quadrant oriented as individuals who show

a preference for this mode are goal directed, focus on practical application, and
are good at getting things done. A slight preference for the D-quadrant is
indicated by their willingness to take risks to attain their goals (see 4.2.2.1 and
figure 3.2).
9.2.5.2.2 Kolb 's four cognitive styles in relation to the whole brain model and the
educational implications for whole brain creativity
Kolb's four learning styles cannot be directly categorised within the four brain quadrants
of the whole brain model. Each learning style appears to be double dominant and not
necessarily left or right brain oriented as some individuals present with a combination
of left and right brain processes (see 4.2.2.3 and figure 4.2).
• The convergent learning style relies primarily on abstract conceptualisation and

active experimentation which reveal double dominance in the A- and B-quadrant.
Convergers are unemotional and are good at problem-solving, decision-making
and practical application of ideas (see 4.2.2.2 and figure 4.2). It is suggested that
they be offered teaching strategies appropriate to the A- and B-quadrant which
include case studies, individual projects, learning packages, programmed
learning and clinical learning experiences (see 4.2.2.3 and figure 3.5).
• The divergent learning style relies on concrete experience and reflective

observation which depict a double dominance in the C- and D-quadrant.
Divergers are feeling-oriented and enjoy relating to other people. They are
imaginative and observant, view concrete situations from many perspectives, and
can organise different relationships into a gestalt (see 4.2.2.2 and figure 4.2).
The most appropriate teaching strategies for divergers appear to be those
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classified for the C- and D-quadrant and include role play, simulation, values
clarification, clinical post-conference, imagery and fantasy (see 4.2.2.3 and figure
3.5).
• The assimilative learning style utilises abstract conceptualisation and reflective

observation which indicate double dominance in the A- and D-quadrant.
Assimilators use inductive reasoning and abstract concepts, and synthesise
dissimilar observations into integrated explanations. They are less interested in
people (see 4.2.2.2 and figure 4.2). It is suggested that assimilators be offered
teaching strategies appropriate for A- and D-quadrant oriented students which
include reading assignments, individual projects, case studies, metaphorical
thinking, imagery and fantasy, and clinical assignments (see 4.2.2.3 and figure
3.5).
• The accommodative learning style utilises concrete experience and active

experimentation. Accommodators appear to be triple dominant in the C-, D- and
B-quadrant (see figure 4.2). They adapt through opportunity seeking, risk-taking
and action. They solve problems in an intuitive trial-and-error manner, and are
at ease with people. They find it easy to adapt to rapidly changing situations.
(action refers to the B-, easiness with people to the C-, and risk-taking to the D-
quadrant) (see 4.2.2.2). It is deduced that the following teaching strategies from
the B-, C- and D-quadrant may appeal to accommodators: programmed learning,
learning packages, clinical learning experiences, simulations, field trips, clinical
assignments and patient case studies (see 4.2.2.3 and figure 3.5).
Although students must be supported in their preferred modes of learning, they should
also be taught to develop the processes of their less preferred modes (brain quadrants)
to enable them to become flexible and whole brain learners.
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9.2.5.2.3 The relation between cognitive style, brain dominance and professional
occupation
There appears to be a close relationship between brain dominance and occupation. It

is believed that individuals either choose occupations consistent with their cognitive
style or are shaped by the fields they enter. The literature supports the view that
individuals can strengthen their less preferred modes. Researchers have consistently
found a congruence between Kolb's four cognitive styles and particular oq;upations (see
4.2.3 and figure 4.3). Significant similarities are detected between Herrmann's
distribution of occupational patterns according to brain dominance and Kolb' s
classification of professional groups according to cognitive style (see figures 4.3 and
4.4). Both Kolb and Herrmann found nurses to be accommodators and divergers.
(Herrmann reported triple or double dominance in the B-, C- and D-quadrant.) Other
occupational groups included, reveal engineers and bookkeepers as convergers (A- and
B-quadrant), and educators and social workers as divergers (C- and D-quadrant).
Although double dominance is indicated according to Kolb' s classification, Herrmann' s
classification gives a finer distinction by depicting the slightly stronger quadrant for
each occupational group (see figures 4.3 and 4.4 ).
9.2.6 Instructional objectives
Teaching for creativity demands that objectives be set to stimulate creative thinking
skills. As creative behaviour involves the production of something new and original,
objectives which bring forth mere reproduction are not adequate. Analysis of Bloom's
cognitive and affective taxonomies and De Corte's classification has revealed the
following.
9.2.6. 1 Bloom's taxonomy
Educators are being criticised by creativity experts for emphasising mainly the lower
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levels of Bloom's cognitive taxonomy which lead to reproduction of information. It is

the higher levels which stimulate creative production (see 4.3 .1 ).
• Cognitive domain
The lower levels including knowledge, comprehension and application, are not regarded
as creative skills. They are, however, necessary to form the foundation of knowledge
in any field on which creativity is based (see 4.3.1.1 and 2.5.1.2). Analysis is not a
creative skill but is a prerequisite to synthesis and evaluation; it involves identifying the
elements presenting a whole. Synthesis and evaluation are regarded as creative skills.
Apart from being a key-ability of creativity, synthesis is included in all the definitions
of creativity. Evaluation involves the cognitive and the affect, and plays a role during
the preparation, incubation and verification phases of the creative process (see 4.3 .1.1,
2.5.1.1and2.5.1.2).
• Affective domain
It is concluded that the entire affective domain plays an essential role during creative
endeavour. The lower levels including receiving and responding are on the first, valuing
and organisation on the second, and characterisation on the third level of Treffinger's
creative learning model (figure 4.5). Empathy, a central concept in caring, involves the
two lower levels whereas the three higher levels require emotional commitment and
rational cognitive processes. Attainment of these levels is essential to enable nurse
practitioners to act effectively and consistently with regard to ethical issues (see
4.3.1.2).
9.2.6.2 De Corte 's classification
De Corte and his co-authors' classification of more general aims of education includes
two major categories, one of which the productive operations, is associated with creative
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learning (see 4.3.2).
• Receptive-reproductive operations include apperception, recognition and

reproduction of information which appear to concur with the first three levels of
Bloom's cognitive taxonomy (see 4.3.2.1). These operations cannot produce
creativity but are prerequisites for creative thought because they establish a sound
knowledge base.
• Productive operations are directly linked to creative thinking abilities and are
essential for effective problem-solving (see 4.3.2.2). Interpretive production of
information requires internal visualisation, penetration and sensitivity (key-
abilities of creativity - see 2.5 .1.1 ). Convergent production requires rational,
analytical and logical thought which are essential during the preparation and
verification phases of the creative process (see 2.5.1.2). Evaluative production
involves making a value judgement. It involves cognitive and affective
processes, and plays a role during all the phases of the creative process (see
4.3.2.2). Divergent production occurs when there is more than one solution to
a problem, and it encourages flexibility and fluency as well as the other key-
abilities of creativity, because it is directly linked to creative thought.
There appears to be a direct relationship between the operations in Guilford's

structure-of-intellect model and De Corte's classification of objectives.
Guilford' s convergent production, evaluation and divergent production concur
with De Corte's productive operations and indicate creative skills (see 4.3.2.2
and figure 4.6).
9.2. 7 Theories of learning
Apart from being of particular significance to nursing as a humanistic science, the

cognitive and humanistic theories appear to have a lot in common with creativity as they
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encompass the affective and higher cognitive processes (see 4.4).
9.2.7.1 Cognitive theories
The cognitive theorists seek to explain unobservable aspects such as thought, memory,
perception, concept learning, problem-solving and metacognition. They emphasise
intrinsic motivation, the need to stimulate students' curiosity, and the provision of
enjoyable learning experiences, which seem to be crucial to the development of
creativity as reported by the environmental theorists (see 4.4.1 and 2.5.2.2).
• Problem-solving and creative thinking
Ordinary problem-solving does not necessarily require creative thinking, but many
problems can be solved more effectively if creative thinking is involved. By providing
practice opportunities with feedback together with time allowance for incubation in a
relaxed and playful learning environment where judgement is suspended, a climate for
creative problem-solving can be set. This facilitates psychological freedom and
perceptual openness and stimulates fluency, flexibility and penetration as the
environment concurs with the requirements for the development of creativity (see
4.4.1.1 and 2.5.2.2.2).
• Metacognition and creative thinking
Metacognition refers to a person's ability to think about his own thinking and exercising
control over it. It involves forming associations and images, organising new
information, predicting outcomes, evaluating effectiveness of attempts and changing to
other strategies, if necessary. These processes require openness to experience,
visualisation, flexibility, fluency and redefinition which are all key-abilities of creativity
(see 4.4.1.2 and 2.5.1.1 ). Metacognitive thought thus involves creative thinking skills.
The point of view that the development of nursing theory is a creative process requiring
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metacognition, and that nurses who engage in metacognition can manipulate creative
thought which enables them to practice more effectively are expressed in the literature
(see 4.4.1.2). This affirms the relationship between higher cognitive skills and creative
thought.
• Piaget: formal operational thought
Formal operational thought is a higher cognitive ability which encompasses abstract

thinking, testing hypotheses, imagining ideal worlds, thinking beyond information
presented1 and forming concepts independent of physical reality. It concurs with
Torrance's definition of creativity (formulating and testing various hypotheses) and
requires flexibility, fluency, penetration, and redefinition (key-abilities of creativity)
(see 4.4.1.3 and 2.5.1.1 ). Formal operational thought is viewed as a necessary but not
adequate condition for creative problem-solving as it facilitates analytical, logical and
divergent thinking but lacks the affective processes essential to creative performance.
It is, however, important for nursing practice since it represents analytical, critical-
evaluative and creative thought, and is a requirement stipulated by the South African
Nursing Council (see 4.4.1.3).
• Bruner: discovery learning
Discovery learning, based on problem-solving, is one of the most influential cognitive

models. It emphasises inquiry, discovery, curiosity and intrinsic motivation, which are
congruent to the creativity-inducing learning environment (see 2.5.2.2.2 and 2.5.2.2.3).
Bruner's concept of coding systems (see 4.4.1.4) appears to play a significant role
during creative behaviour. It enables individuals to go beyond given information to
form many associations and to build in new codes which lead to a deeper understanding
of a problem. The creative behaviour materialises in psychological openness,
visualisation, penetration, fluency, synthesis and redefinition (see 4.4.1.4).
390
9.2. 7.2 Humanistic theories
Humanistic education focuses on the affective outcomes of learning: feelings, attitudes,

values and beliefs, and is concerned with creativity and human potential. Self-directed
and student-centred learning, intrinsic motivation and self-actualisation are emphasised
and problem-solving, spontaneity and psychological freedom in the learning
environment are encouraged. This concurs with the creativity inducing environment as
created by the open teacher (see 4.4.2.1 and 2.5.2.2.3).
• Rogers: student-centred learning
This approach emphasises self-initiated learning which involves the cognitive and
affective domains, active participation, self-evaluation and an educator-student
relationship characterised by authenticity, trust, acceptance and emphatic understanding.
Rogers' principles of learning comply with the requirements set by the environmental
theories of creativity. Psychological freedom is granted by the nature of the educator-
student relationship and by self-evaluation with the result that external threats are
minimised. Experimentation and risk-taking are allowed which stimulate openness to
experience, sensitivity and penetration. Apart from stimulating creativity, Rogers'
theory is very applicable to nursing education as his principles of learning reveal the
essential aspects of a caring relationship and environment (see 4.4.2.2 and 2.5.2.2.3).
• Maslow: self-actualisation
To Maslow, the ultimate goal of education is to assist the student towards self-
actualisation. He proposes that the self-actualised person is a creative individual. The
traits which he confers to the self-actualised individual have also been identified by the
personality theorists (see 2.5.2.1). These include independence, autonomy, a strong
ethical and moral outlook, self-sufficiency, spontaneity, flexibility, a sense of humour,
and perceptiveness. These are the qualities which should be developed in student nurses
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to enable them to become effective nurse practitioners as set out in the programme
objectives by the South African Nursing Council (see 4.4.2.3).
9.2.8 Educational models and creativity
Educational models provide structural frameworks which guide educational planning

and organisation of learning experiences. The four selected models are of particular
relevance to nursing as a professional, humanistic, and practice discipline. They appear
to have a lot in common with teaching for creativity, as they are essentially student-
centred (see 5.1 ). Conclusions on the required learning environments for the four
models are discussed at the end of this section.
9.2.8.1 Adult learning
Adult learning is a purposeful effort towards self-development and leads to a growing

self-awareness and a readiness to make existential choices. It relates to Maslow's
concept of self-actualising creativeness which involves openness to experience,
independence, self-sufficiency, commitment and a problem-centred orientation (see
5.2.1).
9.2.8.1.1 Assumptions of adult learning
Adults display a need to know because they want to use their knowledge in real-life
situations. This implies an eagerness to discover gaps in their knowledge (see 5.2.2.1)
which is also found in creative individuals (see 2.5.1.2).
The independent self-concept displayed by adults enables them to be self-directed, a

trait belonging to the self-actualised individual. Self-directed learners are capable of
identifying their own cognitive styles (involves metacognition), use their iµtuition, and
acquire knowledge through inquiry and problem-solving which lead to productive and
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creative learning (see 5.2.2.2 and 4.3.2).
The experience which adults bring to the educational setting form a basis for
transformations which encompass moving figure and ground and arriving at a better
gestalt (see 2.5.1.4). This, together with the possibility that experience can be used as
a basis for metaphor (see 5.2.2.3), indicates creative behaviour.
Adults become ready to learn when their existing knowledge proves to be deficient to
cope effectively. As coping involves having to deal with change, it points to innovation
and creativity is viewed as the vehicle for innovation. Readiness to learn is influenced
by curiosity, mastery and challenge which stimulate creativity (see 5.2.2.4 and
2.5.2.2.3).
Adults' orientation to learning which is life- and problem-centred concurs with that
of the creative individual. Problem-solving is viewed as complicated behaviour leading
towards the formation of new principles of a higher order (see 5.2.2.5).
The phenomenon that adults are motivated by factors such as recognition, self-esteem,
job-satisfaction, curiosity, interest and challenges, depicts intrinsic motivation which is
also the motivating force behind creative endeavour (see 5.2.2.6 and 2.5.2.2.4).
9.2.8.1.2 Significance of adult learning to nursing education
Adult learning is particularly applicable to nursing education because it is problem-

centred and student-centred, and encourages active participation and cooperative
learning. Nursing practice requires skill in problem-solving and continuous interaction
between the nurse, patient and other health team members.
The teaching strategies proposed by adult learning represent all four quadrants of the
whole brain model. It is thus concluded that whole brain and creative learning can be
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developed (see 5.2.4 and figure 5.1).
9.2.8.2 Mastery learning
The aim of mastery learning, to enable every student to attain the desired objectives and
to develop to his/her fullest capacity, concur with the view on the development of
creativity - freedom to develop one's own potential (see 5.3.1).
9.2.8.2.1 Assumptions of mastery learning
Student aptitude, perseverance and ability to understand instruction as well as the

quality of instruction and variety of learning activities, influence learning. The
breaking down of learning material into smaller units with specific objectives and the
setting of several tests to facilitate frequent feedback are advocated (see 5.3.2).
As student aptitude refers to the amount of time required to master a learning task and
perseverance to intrinsic motivation, a psychological free environment should be created
wherein the student is accepted as unconditionally worthy and where exploration and
practice are encouraged. The learner's ability to understand instruction, the variety of
learning activities and the quality of instruction which influence learning, lead to the
conclusion that whole brain teaching is required to provide stimulation for each
quadrant.
It can be deduced that the breaking down of learning material into smaller units and the
several tests set for each unit, followed by corrective instruction (see 5.3.2), support and
encourage students to strive towards mastery, and do not impose the usual threat of
external evaluation which is so detrimental to creative learning.
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9.2.8.2.2 Significance of mastery learning to nursing education
Mastery learning is of particular significance to nursing because a certain level of

mastery must be obtained in practical procedures in order to render safe patient care.
A specific level of mastery is also required in subjects including anatomy, pathology,
biochemistry and physiology to ensure safe practice (see 5.3.4).
Figure 5 .2 illustrates how the teaching strategies proposed by mastery learning can be
presented to facilitate whole brain learning and creativity. These strategies comply with
the requirements of mastery learning as they facilitate self-pacing, cooperative learning,
reflective observation, small steps and feedback, and make provision for aptitude and
perseverance.
9.2.8.3 Experiential learning
Experiential learning is pragmatic, phenomenological and humanistic in nature and aims

to merge abstract thinking and concrete experience. It is regarded as the key-stone of
humanistic education because it provides a holistic, integrative perspective on learning
by linking experience, perception, cognition and behaviour.
9.2.8.3.1 Assumptions of experiential learning
Learning as a process implies that it takes place through invention and reinvention
with the result that ideas and concepts are modified and reformed by experience. This
indicates the necessity to provide students with learning activities which stimulate
inquiry and exploration as is done by the open teacher to foster creative learning (see
5.4.2.1 and 2.5.2.2.3). Learning as a continuous process leads to increased
knowledge and a better understanding of the world (see 5.4.2.2). This phenomenon is
evident in the lives of creative geniuses such as Poincare and Heimholtz (see 2.5.1.2).
Learning requires the resolution of conflicts between dialectically opposed modes
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of adaptation to the world. The dialectically opposed modes of adaptation refer to the
resolution of conflict between abstract concepts and concrete experience which results
in learning (see 5.4.2.3). This phenomenon can be explained by the iterative function
of the brain which may occur between the two cerebral hemispheres (A- and D-
quadrant), or the limbic halves (B- and C-quadrant). It is known that the left brain is the
seat of abstract thinking and the right brain that of concrete processes (see 3.4.2 and
figure 3.1 ). Learning is a holistic process of adaptation to the world. This implies
that the individual is involved in the learning process in totality which includes thinking,
feeling, perceiving and behaviour. As the major process of adaptation, learning
encompasses creativity, problem-solving and decision-making which include both
divergent and convergent adaptive aspects. Herrmann's whole brain creativity model
illustrates learning as a holistic process (see 5.4.2.4 and figure 3.2). Learning involves
transactions between the person and the environment. Experiential learning
involves transaction which results in changed relationships. This involves productive
learning because it necessitates the skills of analysis, synthesis and evaluation. It is a
different process from interaction which appears to involve rote learning (see 5.4.2.5).
Learning is the process of creative knowledge. Knowledge is created from a
resolution of conflict between the concrete/abstract dialectic through apprehension or
comprehension (see 5.4.2.6). Apprehension involves C-quadrant processes and
comprehension A-quadrant processes (see figure 5.3). The other way in which
knowledge is created occurs through the active/reflective dialectic by way of extension
or intention. Extension involves B-quadrant processes and intention D-quadrant
processes. This leads to the conclusion that Kalb's explanation of how knowledge is
created involves whole brain learning (see 5.4.2.6 and figure 5.3).
9.2.8.3.2 The experiential taxonomy
The experiential taxonomy indicates that whole brain learning is involved during
experiential learning. Exposure and participation involve mainly C- and D-quadrant
processes as physical experience and visualisation are important during these stages.
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Identification links left and right brain processes because of intellectual and emotional
involvement. Internalisation and dissemination use mainly A- and B-quadrant
processes because rational and logical thinking as well as organisation are essential
during these stages. The right brain processes are, however, also utilised because of the
involvement of the affect (see 5.4.2.7 and figure 3.2).
9.2.8.3.3 Significance of experiential learning to nursing education
Experiential learning is of major significance to nursing as a humanistic practice

discipline. It provides for teaching the affective domain which pertains to the ethical,
moral and value issues of the profession, and offers ideal opportunities for the
development of problem-solving and practical skills (see 5.4.4).
The teaching strategies propagated by experiential learning represent the four quadrants
of the whole brain model and Kolb's experiential learning model (see figure 5.4).
Experiential learning thus appears to be very suitable for the development of creative
learning.
9.2.8.4 Open learning
The aim of open learning is the enhancement of human potential. It is a flexible and
student-centred approach which is more readily accessible than conventional courses
and removes the barriers of time, place and space (see 5.5.1).
9.2.8.4.1 Assumptions of open learning
The open learning model provides accessibility, a high degree of student control,
student support, multi-media, a variety of learning activities, and learning
programmes which are adaptable to individual student needs. It is essentially
student-centred and considers personal growth as a significant outcome of learning.
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A team approach (which includes student representation) is followed in the preparation

of programmes. These concepts concur with the requirements for creative learning as
every student is accepted as worthy and psychological openness and flexibility are
facilitated. Personal growth, student support and the consideration of individual
students' needs which are highly valued, lead to the conclusion that every student is
granted the freedom of unconditional development. It appears as though open learning
directly opposes traditional education by providing the opportunity for development of
individual creativeness while at the same time removing the barriers which stifle
creativity (see 5.5.2).
9.2.8.4.2 Significance of open learning to nursing education
Open learning offers the ideal opportunity for practising professional nurses to develop
themselves, further their education and update themselves with the latest scientific and
technological advances. It is a means of equipping nurses with the ability to adapt to
the rapidly changing health care environment and deliver innovative care.
The teaching strategies offered by open learning represent all four quadrants of the
whole brain model (see 5.5.4 and figure 5.5). Open learning thus creates a creativity
inducing learning environment and stimulates whole brain and creative learning.
9.2.8.5 The relation between the four educational models and creativity
Analysis of the nature of adult, mastery, experiential and open learning reveals the
following prominent common concepts which contribute towards the development of
creativity (see 5.6.1, table 5.1 and figure 5.6).
• A common aim towards the development of self-actualisation is evident which

concurs with Maslow' s self-actualising creativeness and portrays the abilities
required from the professional nurse.
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• Student-centredness facilitates the development of a positive self-concept and

self-discipline which are desired attributes of a creative person (see 2.5.2.1 ).
• Active participation facilitates cognitive, affective and psychomotor learning.

Creativity is developed through direct experience, exploration and discovery (see
2.5.1.2).
• Problem-centred learning develops metacognition, reflective, formal operational,

convergent and divergent thought and thus leads towards productive learning and
creativity. The development of problem-solving skills is fundamental to
effective, contextual nursing practice (see 5.6.1 ).
• Cooperative learning promotes the higher levels of cognitive and moral reasoning
(including metacognition, reflective and divergent thought, sensitivity and
perceptiveness) as students learn from one another's ideas and experiences (see
5.6.1).
• Intrinsic motivation is stimulated by interest, inquiry, challenges, enjoyment of

learning in a psychological open environment and frequent feedback on success.
It is essential to creative performance and effective nursing practice as both
require total involvement and dedication and a willingness to accept challenges
and take risks (see 2.5.2.2.4 and 5.6.1).
• The variety of learning activities provides for the different cognitive styles of
students and stimulates whole brain learning by offering activities which appeal
to the preferences of each of the four brain quadrants (see 5.6.1).
• Self-evaluation and criterion-referenced evaluation promote extended effort and

persistence, and are essential to maintain competence in nursing. These are the
only types of evaluation which is tolerated by creative persons as they do not
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present a threat (see 5. 6 .1).
The major movements in current education which provide support for creative learning
include individualised and learner-centred instruction, experiential curricula and
humanistic education (see 5. 6 .1). The four selected models appear to meet these
requirements.
9.2.8.6 Relation between the learning environments of the four educational

models and creativity
The nature of the learning environments advocated in the four models concur with the
creativity inducing environment (see 5.6.2, table 5.2, 2.5.2.2.2 and 2.5.2.2.3).
Psychological openness which facilitates safety, absence of threat and emphatic
understanding and authenticity which involves mutual trust and respect and
unconditional acceptance, prevail. Collaborativeness facilitates mutual discovery and
develops flexibility. The non-judgemental atmosphere offers a relaxed atmosphere.
Enjoyment and pleasure is experienced because of total involvement and the prospects
of success in the end as individual differences are considered. Student support is
established by providing acceptance, encouragement and frequent feedback. The
student-controlled environment facilitates self-directed learning, expanded
consciousness, persistence and risk-taking (see 5.6.2).
9.2.9 The practice of nursing
The challenge and art of nursing has always been the merging of the professional
(practice) and disciplinary (theory) dimensions, in such a way that both enrich and
complement each other. The nurse's greatest dilemma today is to adjust to the rapid
changes in the health care setting and to cope with the opposing demands of increasing
advances in technology and science, and basic human needs which require caring (see
6.1).
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9.2.9.1 Definitions of nursing
Although the definitions differ to some extent, they all indicate a humanistic foundation
which emphasise a service to mankind. A holistic approach is detected in their
references to caring for the physical, psychological, spiritual and social dimensions of
man. However, of the definitions given in this thesis, it is only the definition by the
South African Nursing Council which refers to nursing's scientific body of knowledge.
This indicates how nursing has developed as a science since the 1970s and how
important it has become in the contemporary era of scientific and technological
advances (see 6.2).
9.2.9.2 Philosophical foundations of nursing
Contemporary nursmg follows a holistic, humanistic-existentialistic and

phenomenological approach (see 6.3). Humanistic-existentialism is concerned with
individual worth and self-actualisation. This concurs with the humanistic view of
creativity (see 2.5.3), especially Maslow's concept of self-actualising creativity. As
phenomenology views reality to be in the individual's unique perception of an event and
not the event itself, it affirms the contextuality of every nurse-patient relationship. This
refers to pattern identification as described by the gestalt theorists (see 2.5.1.4).
9.2.9.3 Professional practice
9.2.9.3.1 Professionalism
Nursing is acknowledged as a profession on the basis of its scientific body of

knowledge, a code of ethics in which the profession's beliefs are declared, its control
over conduct of members by a legalised body which ascertains that high standards are
maintained, the requirements for mastery of specialised skills, and a central focus of
service to mankind (see 6.4.1).
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9.2.9.3.2 Code for nurses
The Code for nurses expresses the profession's value and beliefs and guides nursing
practice. The key-concepts which derive from the Code include the following:
Advocacy, accountability, responsibility, autonomy, authority and competence,

require from the nurse a sound theoretical knowledge base, clinical competence,
knowledge of the nursing act and regulations and a value system which adheres to the
profession's ethical codes as well as a passion for fellow man. Apart from being
knowledgeable, the nurse has to be independent, perceptive, sensitive, flexible,
experienced, self-confident, and caring. This is illustrated in examples 1 and 2 in 6.4.2.
These traits have been identified by the personality theorists as belonging to creative
people (see 2.5.2.1 ). Respect for patients' rights and maintaining confidentiality
demand mutual respect and trust. A patient's right to know the truth and his right to
have his wishes honoured must be adhered to (see examples 3 and 4 in 6.4.2). It
requires from the nurse a special perception and sensitivity which equal the creative
abilities mentioned in 2.5.1.1. Collaboration refers to the interdependent functions of
the nurse as a member of the health care team (see 6.4.2). Psychological openness,
flexibility, and sensitivity are valuable assets in order to maintain good interpersonal
relationships (see 2.5.1.1).
9.2.9.3.3 Scope ofpractice
Nursing's scope of practice encompasses broad concepts based on definitions and

theories of nursing which provide an outline and authorisation of the nurse practitioner's
role and functions (see 6.4.3).
The nursing regimen (a) mentioned in the scope of practice, refers to the nursing
process, a fundamental concept in practice. It appears that some of the key-abilities of
creativity (see 2. 5 .1.1 ), such as openness, sensitivity, penetration, are essential during
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the assessment phase which requires inference, problem-solving, perceptions, intuition,
critical thinking, observation and awareness of hidden cues (see 6.4.3). The planning
and implementation phases require openness, flexibility, fluency and sensitivity from the
nurse as she has to plan with the patient and adjust according to the needs and responses
of the patient. The evaluation phase necessitates penetration, sensitivity, flexibility,
synergy and redefinition in order to make the necessary changes according to the
patient's responses.
The concepts in the scope of practice including execution ofprescribed treatment (b),
administration of medicine and monitoring vital signs (c), maintenance offluid and
elimination (i) and (m) are illustrated in example 5 (open heart surgery) (see 6.4.3). It
indicates the need for the nurse to utilise whole brain thinking. She must have the
factual knowledge to enable her to think analytically (A-quadrant), consider all relevant
detail (B-quadrant) view the situation holistically and use her intuition (D-quadrant),
and have eompassion for the patient and go to any lengths to have the patient's
condition improved (C-quadrant) (see figure 3.2).
The maintenance of bodily regulatory mechanisms (k), and provision of effective patient
advocacy (s) are realised in example 8 (see 6.4.3). The significance of the nurse's
intellectual efficiency and the use of her intuition which derives from her wealth of
experience and knowledge, are illustrated. The abilities of analysis, planning,
persistence, sensitivity, penetration, synergy and holistic observation are demonstrated
when she acts on behalf of the woman who underwent an oesophageal dilatation
procedure. It depicts whole brain functioning as well as some of the key-abilities of
creativity (see figure 3.2 and 2.5.1.1 ).
The concepts includingfacilitation and healing of wounds (j), and establishment of an

environment in which physical and mental health are promoted (p), require the merging
of the instrumental and expressive roles of the nurse. This is illustrated in example 10
(see 6.4.3) wherein the nurse dressed the patient's wounds. She displayed empathy,
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sensitivity, fluency, flexibility, analysis and synthesis which refer to the key-abilities of
creativity (see 2.5.1.1).
The concept which refers to caring for the dying patient (t) necessitates true caring. The
abilities required from the nurse include sensitivity, flexibility, penetration,
psychological openness, synergy, a holistic perspective, intellectual efficiency,
compassion and a certain level of risk-taking. Example 11 (see 6.4.3) illustrates how
the nurse took the risk of administering more morphine despite the possibility of
respiratory repression. All these aspects indicate the need for creative behaviour from
the nurse.
It is concluded from the variety of examples citing nursing practice incidents, that the
abilities and skills expected from the effective nurse concur with those possessed by the
creative individual. The cognitive (see 2.5.1.1and2.5.1.2), personality (see 2.5.2.1),
humanistic (see 2.5.3), gestalt (see 2.5.1.4) and whole brain (see 3.5) theories are all
involved.
9.2.9.4 The science-art of nursing practice
Carper's four fundamental patterns of knowing in nursing give a very true picture of the
nature of nursing (see 6.5). Empirics, the science of nursing, involves the cognitive
skills, ethics includes cognitive and affective skills, personal knowledge which
emphasises interpersonal skills represents the affective domain, and aesthetics, the art
of nursing, involves affective, psychomotor and cognitive skills. Each pattern is
essential for mastery of the discipline but they are interrelated and interdependent which
indicate the complexity and diversity of nursing knowledge.
The science-art of nursing is often referred to as a mystery, as nursing practice cannot

be standardised or submitted to rules and procedures. The essence of nursing education
seems to be training for uncertainty as effective practice implies a willingness to take
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responsibility for key-decisions, based on partial information, and made under

conditions of high risk. The merging of science and art requires a mastery of the
necessary technique, and a special involvement of mind, soul and imagination (see 5.6).
A quest for creativity is inferred in this.
9.2.9.4.1 Psychomotor skills
Psychomotor skills form an extremely important part of the practice of nursing as it is

largely a practical endeavour. Both the assessment and implementation phases of the
nursing process require these skills (see 6.5.1) and when teaching them visualisation,
modelling, practice and kinaesthetic feedback are important. The mastery and
experiential educational models are thus appropriate.
Whole brain functioning is essential for acquiring skilled performance. The criteria
including accuracy, efficiency, consistency, and speed, refer to A-, B-, and C-quadrant
processes as they involve factual knowledge, analysis, detail, sequence and kinaesthetic
awareness (muscular coordination is essential). The remaining criteria, anticipation,
adaptability and perception refer to D-quadrant processes (see figure 3.2). The key-
abilities of creativity which are developed involve sensitivity, flexibility, and synergy
as each practice situation is unique.
Example 12 (6.5.1) illustrates the integration ofpsychomotor and cognitive skills when
the nurse institutes the administration of intravenous therapy, and example 10 (6.4.3)
(dressing of wounds) demonstrates the integration of psychomotor, cognitive and
affective skills. Aesthetics, as a synthesis of the four patterns of knowing, is also
evident in this example.
9.2.9.4.2 Affective skills
The affective competencies involve feelings, attitudes and ethics, and therefore
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represent the caring functions of the nurse. The aesthetics, ethics and personal
knowledge patterns of knowing are represented (see 6.5.2).
Two important concepts within the affective domain include therapeutic use of the self
and caring. Therapeutic use of the self is the art of conveying acceptance to the patient.
It is a central concept of the affective domain and forms an integral part of transpersonal
caring (6.5.2).
Caring, as the dominant paradigm of nursing, encompasses empathy, concern,

compassion, support, sensitivity, presence, love, trust, knowledge, experience and
expertise. Caring is an art, and is very well elucidated in example 1 (6.3) in which the
nurse acted as advocate for the young quadriplegic patient, and in example 13 (6.5.2),
in the poem about Mr Polanski. The poem reveals the nurse's ability to look beyond the
obvious, and to connect previously unrelated ideas and levels of experience. This is a
creative endeavour which concurs with the associative theories of creativity (see
2.5.1.3). Creativity is also evident in the nurse's use of intuition, her sensitivity and
perceptiveness of Mr Polanski's needs and the sudden appearance of illumination after
a synthesis and synergy of past experiences and knowledge. This is an excellent
example of personal knowing and aesthetics portraying the art of nursing.
The experiential educational model is appropriate for teaching the affective domain.
Attainment of the higher levels of Bloom's affective taxonomy is essential for student
nurses in order to be competent in the ethics, personal knowledge and aesthetic patterns
of knowing.
9.2.9.4.3 Cognitive skills
The cognitive skills required for effective nursing practice represents nursing as a
science and refer to the empirics pattern of nursing knowledge (see 6.5.3). These
include:
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• Concept learning enables students to master the vast mass of information

concerning the health-illness continuum by grouping together facts and
categorising new information (see 6.5.3.1 ). Concept learning necessitates
understanding something beyond the level of sensation and thus results in
meaningful and productive learning. The true understanding of concepts such as
pain, empathy, caring and ethical issues, involves the key-abilities of creativity
(see 2.5.1.1) and whole brain learning (see figure 3.2). For example,
understanding pain involves factual knowledge of the different kinds and causes
(A-quadrant process), planning for intervention and administration of pain relief
methods (B-quadrant process), showing empathy (C-quadrant process) and
obtaining a holistic picture and reacting on intuition (D-quadrant processes).
• Problem-solving and the nursing process are basically the same processes.
Nurses are confronted daily with unique complex problems (see 6.5.3.2).
Analytical and sequential thinking (A- and B-quadrant) are essential but because
of the need to solve problems within the contextuality in which they occur, both
linear and non-linear processes are required. Examples 1 (6.4.2), 5 and 8 (6.4.3)
illustrate how experienced nurses combine linear processes with intuition and
holistic thinking (D-quadrant) in the presence of compassion (C-quadrant) in
order to solve complicated problems.
• Intuition is a sense of knowing without a preceding rational analysis. It is a

synthesis of perceptual cues arrived at through the linking of basic knowledge
and past experiences. The literature reveals that expert nurses are intuitive and
holistic (see 6.5.3.3). It is deduced that they link knowledge, detail, intuition and
holistic perception with emphatic knowing which encompasses whole brain
thinking (see figure 3.2).
• Decision-making is a critical component of nursing practice. Both problem-

solving and decision-making are initiated by a problem, but decision-making has
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to deal with the results and is value based. The quality of patient care depends
mainly on the nurse's ability to effectively link problem-solving and decision-
making. Nurses should thus be aware of their value systems as they influence
decision-making and may limit the generation of alternatives (see 6.5.3.4). It is
concluded that the key-abilities of creativity including sensitivity, ideational
fluency, penetration and elaboration (2.5.1.1) might lead to better decision-
making.
• Critical thinking incorporates analysis, synthesis, evaluation, reflective thought,

inquiry, discovery and clarification of opposing perspectives (see 6.5.3.5). As
a higher order cognitive skill it is vital to effective nursing practice, as illustrated
by examples 5 (open-heart surgery) and 12 (intravenous therapy) (see 6.4.3).
Critical thinking requires analytical, sequential and detailed thought (A- and B-
quadrant) as well as holistic thinking and visualisation through reflective
thinking (D-quadrant). The C-quadrant is excluded.
• Clinical judgement is one of the central functions of the nurse practitioner. The
phenomenological perspective acknowledges the utilisation of both linear and
non-linear thinking processes during clinical judgement. The latter necessitates
perceptual assessment (touch, smell, sight) and an interpretation of the patient's
physical, verbal and behavioural expressions. It apparently begins with intuition
through vague hunches and holistic assessment, and only after detachment from
the situation is the nurse capable of analysis and critical thinking. The reference
to nurses working in intensive care units who acknowledge the important role of
intuition during clinical judgement, affirms this view (see 6.5.3.6). It seems that
whole brain thinking engaging the D- and C-quadrant and then the A- and B-
quadrant is essential. Examples 1, 5, 8, 9, 10 and 12 (see 6.4.2 and 6.4.3)
illustrate how expert nurses engage in risk-taking, holistic viewing, analytical,
reflective, critical and intuitive thinking. These link clinical judgement to
creative thought.
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9.2.9.5 The expert nurse practitioner
The description of the expert nurse in the literature refers to her ability to zero in on the
real problem, perceive intuitively, observe holistically, get a gestalt of the situation and
anticipate future problems (see 6.5.4). This implies utilisation of the key-abilities of
creativity (2.5.1.1) as well as the ability to identify patterns as proposed by the gestalt
theorists (2.5 .1.4 ).
The traits that students have identified in their clinical role models include spontaneity,
flexibility, independence, intellectual efficiency, competence in divergent situations and
the ability to provide individualised context-specific care and adapt to changing
situations (see 6.5.4). These concur with the characteristics attributed to creative
individuals (see 2.5.2.1 ).
9.2.9.6 Creativity and the science-art of nursing
It appears that Carper's four patterns of knowing represent the four quadrants of the
whole brain model (see 6.5.5 and figure 3.2). Empirics relates to the A-quadrant which
involves the higher cognitive processes in Bloom's taxonomy and the productive
operations in De Carte's classification (see 4.3.1 and 4.3.2). Ethics appears to relate
mainly to the B-quadrant as ethical decision-making requires detail and sequential steps.
The C-quadrant is, however, also indicated because of involvement of the affective
domain. Aesthetics indicates a strong relation to the D-quadrant as holistic viewing and
intuition are essential to the art of nursing practice. The psychomotor skills involved
in aesthetics relate to B-quadrant processes as detail, sequentiality and procedural
processes are involved (see 6.5.5 and figure 3.2).
It is concluded that the professional nurse of the future will have to be more
knowledgeable, capable of critical thinking, insightful regarding ethical issues, more
caring, compassionate and human, more imaginative, creative and open to new ideas,
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willing to take risks and accept challenges.
9.2.10 Innovative teaching strategies
Innovative teaching strategies encompass new and unique methods which increase
student motivation and maximise learning by encouraging active participation and
creating a pleasant and open learning environment (see 7.1).
Each of the teaching strategies discussed in this thesis is particularly applicable to

nursing education and stimulates creativity.
9.2.10.1 Brainstorming
The most outstanding feature of brainstorming is that a quantity of ideas is encouraged

in a relaxed and playful atmosphere in which judgement is deferred. Creative thinking
skills including ideational fluency, flexibility, elaboration and synthesis are developed
(see 7.2.1 and 7.2.4). Whole brain thinking is stimulated through visualisation,
imagination and emotional involvement during the idea generation phase, and analysis
and sequential thinking during the evaluation phase (see 7.2.4 and figure 3.2).
Brainstorming is particularly valuable to nursing education not only in situations when

professional problems are addressed, but also to generate ideas during group discussions
and creative problem-solving and to explore students' reactions and feelings after
experiences with bereavement and emergency situations (see 7.2.4).
9.2.10.2 Creative problem-solving
The value of creative problem-solving appears to be the great variety of cognitive skills
which are developed. These include analysis, logical, factual, quantitative, sequential,
detailed, visual, holistic, intuitive, convergent and divergent thought (see 7.3.1 and
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figure 7.1 ). There appears to be a interrelationship between the phases of creative

problem-solving, the creative process, key-abilities of creativity and the whole brain
model (see table 7.1).
Creative problem-solving differs from ordinary problem-solving as it makes use of

synectics, imagination and fantasy particularly during the fact- and idea-finding phases,
as well as divergent thinking (see 7.3.4).
Problem-solving is a critical requirement of effective nursing practice as each patient

problem presents a unique situation. Clinical judgement, ie the ability to make wise
choices of nursing action in ambiguous and stressful settings, can be improved through
practice in creative problem-solving. It can also be applied to solve administrative
problems and medico-legal hazards (see 7.3.3).
9.2.10.3 Teaching by metaphor
Metaphorical thinking is viewed as central to creative ability as it produces new idea

combinations, synthesis and originality (7.4.2). It makes learning more effective and
stimulates divergent and productive thought by prompting visual images and analytical,
evaluative, and holistic thinking. Evaluation questions which are based on metaphor
force students beyond memorisation to comprehension (see 7.4.1).
As metaphors offer a visual image and a verbal explanation they combine right and left
brain processes and thus enhance whole brain learning. Metaphors can be used in
nursing education to make learning m0re fun, to enhance student understanding of
difficult concepts, and to introduce new subject matter. An example is given in 7.4.3.
9.2.10.4 Synectics
The most outstanding feature of synectics is that it can induce particular psychological
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states (including empathy, involvement, play, detachment and the use of irrelevance)
which promote creative activity. Apparently people cannot be persuaded to be intuitive
or to empathise but need to be drawn into these required psychological states (see 7.5.1 ).
The analogies used in synectics evoke images, holistic thinking, kinaesthetic experience,
emotional awareness, and analytical, detailed and sequential thought. It therefore
stimulates whole brain thinking and learning (see figure 3.2). Synectics facilitates
psychological openness, penetration, flexibility, fluency, synergy, synthesis, elaboration
and originality - key-abilities of creativity (see 7.5.2 and 7.5.4).
Synectics can be widely applied in nursing education to teach the affective domain by
using personal analogy (see 7.5.3), to explain difficult concepts through using direct
analogy (see 7.5.1.2, 7.5.3 and 7.4.3) and to clarify the positive and negative aspects of
certain concepts such as chemotherapy by using symbolic analogy (see 7.5.1.2 and
7.5.3). Fantasy analogy can produce new and refreshing perspectives - see example in
7.5.1.2.
The use of synectics enhances student interest, provides a spontaneous and relaxed
learning atmosphere and stimulates productive learning.
9.2.10.5 Visualisation: imagery and fantasy
Visualisation plays a central role in creative thinking as it provides the source material
of much original thought which may lead to the creation of new concepts. The work of
the geniuses Einstein and Mozart are extreme examples of it (see 7 .6.1 ). Visualisation
is regarded as an effective strategy for problem-solving, because it requires thinking
about a problem in a new way.
Imagery and fantasy are essentially right brain processes as they involve visualisation,
holistic viewing, intuition (D-quadrant) and emotions, and feelings and kinaesthetic
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awareness (C-quadrant) (see figure 3.2). New perspectives on problems are provided
through involvement of all the senses. It is concluded that imagery and fantasy develop
whole brain learning as left brain processes including analysis (A-quadrant) and detail
and organisation (B-quadrant), serve as the basis for imagery and fantasy (see 7.6.4).
Fantasy can be used in nursing education to reduce anxiety levels in students who have
to perform risky psychomotor procedures for the first time. As it facilitates
personalisation, it can be used to aid memory and comprehension, and to teach affective
skills. It can enhance intrinsic motivation and provides a relaxed and enjoyable learning
atmosphere (see 7.6.3).
9.2.10.6 Humour as a teaching strategy
Humour appears to be closely linked to creativity as both combine playfulness and

seriousness, fantasy and reality, the irrational and the rational, and both depend on the
ability to see something in more than the obvious way. Other similarities include a
common purpose to involve the affect, the fusion of objects not normally associated
with each other and the evoking images. These activities lead to divergent thinking,
psychological openness, penetration, flexibility, imagery and synthesis (see 7.7.1).
Humour has a strong influence on the learning environment. It is believed to reduce

stress and anxiety and therefore contributes towards a relaxed atmosphere. Humour
improves relationships and establishes a feeling of connectedness which results in
mutual trust and thus psychological openness. It also increases attention, interest and
motivation. This concurs with a creativity inducing learning environment (see 2.5.2.2.2,
2.5.2.2.3 and 7.7.2). Humour combines cognitive and affective processes. It requires
the sterner left brain processes (including facts, detail, organisation) and the visual and
emotional processes of the right brain and thus stimulates whole brain learning (see
7.7.4).
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As nursing practice presents many stressful situations, humour can be used as a coping
tool to reduce stress. Student motivation and interest can be stimulated by the use of
cartoons or comic strips portraying well-known characters that relate to subject content.
It can also be used in role play or in the clinical laboratory in which case absurdity and
exaggeration can increase student learning (see 7.7.3).
9.2.10. 7 Writing as an innovative teaching strategy
Writing is viewed as a powerful tool for students to discover new relationships through
exploration and inquiry and to gain information and conceptual insight (see 7.8.1).
From the three different writing styles described in the literature, expressive and poetic
writing are valuable to nursing education in order to stimulate creativity. The example
of a writing assignment on a caring experience (described in 7.8.3) illustrates that
expressive writing stimulates analysis, reflective thinking, synthesis, elaboration and
emotional involvement. This experience facilitates productive learning which is linked
to creative learning. The combination of expressive writing and guided imagery
described in the example in 7.8.3 appears to enhance affective learning and critical
thinking skills.
Poetic writing involves evocative language and depends more on right brain processes
including visualisation, emotions and feelings. This type of language apparently
cultivates ambiguity (see 7.8.1). The example of poetic writing discussed in 7.8.3 about
the students who wrote Haiku poems during a gerontology course shows that students
gained new knowledge and insights. It enhanced their understanding and empathy and
stimulated productive thinking.
Writing stimulates whole brain learning as it combines the visual, imaginative and
affective processes of the right brain, with the analytical, logical and sequential
processes of the left brain (see 7.8.4).
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9.2.10.8 Role play
Role play is an excellent method for teaching the affective domain as it assists students
to gain insight into the behaviour of others, and develops empathy and interpersonal
skills (see 7.9.2). The levels of the affective domain which can be obtained include
receiving, responding, valuing and organisation (see 4.3 .1.2). These are on the second
level of Treffinger's creative learning model (see figure 4.5).
Role play focuses mainly on right brain processes as it combines visual, imaginative and
intuitive thinking (D-quadrant) with emotions and feelings (C-quadrant). Left brain
processes including analytical and organised thinking (A- and B-quadrant) are used to
a lesser extent when behaviour is interpreted (see 7.9.4).
As nursing is an interpersonal activity and a caring profession it requires development

of the affect. Role play can aid students' sensitivity, divergent thinking and flexibility
(see 7.9.4).
9.2.10.9 Sociodrama
Both sociodrama and role play focus on affective skills but whereas role play
emphasises comprehending others' feelings and behaviour, sociodrama has a sterner
goal, namely, to redefine a problem and to identify the possible solutions which arise
from the sociodrama. Sociodrama probes deeper into problem/conflict situations to
expose hidden feelings and facts. It stimulates sensitivity, penetration, openness and
originality which are all key-abilities of creativity.
Sociodrama develops the levels of receiving, responding and organisation of the

affective domain (see 4 .3 .1.2) and the cognitive skills of analysis, synthesis and
evaluation through reflective thinking. The affective skills including awareness,
openness to complex, feelings and conflict and imagery are on the second level of
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Treffinger's creative learning model as are the cognitive skills (see 7.10.4 and figure
4.5). It can therefore be concluded that sociodrama stimulates and develops creativity.
Sociodrama can be widely applied in nursing education to develop the principle of

caring, a central concept in nursing. Examples encompass re-enacting incidents from
clinical practice including caring for HIV infected patients; coping with loss and
emotional consequences of trauma and stress; interviewing a schizophrenic patient; and
ethical issues such as euthanasia (see 7.10.3).
9.2.10.10 Simulation
By facilitating active participation and providing a safe psychological learning

environment simulation increases student interest and motivation as they get the
opportunity to explore and build on their curiosity and to take risks (see 7.11.2). This
concurs with a creativity inducing learning environment (see 5.7).
Application of simulation techniques is very appropriate for teaching nursing (see

7.11.3). Mediated role play and life patient simulations particularly stimulate D-
quadrant processes including visualisation, imagination, intuition and holistic viewing,
as well as C-quadrant processes such as emotions and feelings (see 7.11.3 and figure
3 .4 ). Written and computer simulations and physical simulators focus mainly on
analysis and facts (A-quadrant) and on detail and organisation (B-quadrant). Simulation
games stimulate analytical, factual, detailed and sequential thought (left brain) as well
as feelings and visualisation (right brain). Simulation techniques therefore contribute
towards whole brain learning.
9.2.10.11 The ca.se study
The case study stimulates higher cognitive skills through complex problem analysis of
actual or hypothetical situations. The different phases of the problem-solving process
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stimulate different key-abilities of creativity. Fact-finding stimulates a sensitivity to

problems, and problem-finding develops the abilities of penetration, visualisation and
redefinition. Generation of ideas or solutions develops fluency, flexibility and
openness, whereas evaluation of the alternatives stimulates analytical, logical, visual
and intuitive thinking. Decision-making stimulates synthesis and originality.
Evaluation of the decision stimulates evaluation and elaboration (see 7.12. l ). It can
thus be concluded that the case study develops productive learning and creative learning
as these abilities include De Corte' s productive operations and the higher levels of
Bloom's cognitive taxonomy (see 4.3.2.1 and 4.3.2.2) and are on the second level of
Treffinger's creative learning model (see figure 4.5).
Case studies can be widely used in nursing education as a means of applying theoretical
principles to practice, integrating ethics content into professional practice through
ethical case analysis, and to develop problem-solving and clinical judgement skills (see
7.12.3).
9.2.10.12 Values clarification
Values clarification enables students to make rational decisions when confronted by

ethical issues (see 7 .13 .1 ). It leads to the development of principled decision-making
which involves the higher levels of moral reasoning and it contributes to the
development of inner growth and self-actualisation (see 7 .13 .2 ), as students become
aware of their own value systems and the underlying motivations which guide their
actions.
Values clarification develops the higher levels of Bloom's affective taxonomy which are
significant to creativity (see 4.3.1.2). The internalisation of values which takes place
is on the third level of Treffinger's creative learning model (see figure 4.5). It develops
whole brain learning as it combines the processes of the left and right brain. It involves
emotions and feelings (C-quadrant) and combines these with logical and analytical
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thinking (A-quadrant) and organised, sequential thinking (B-quadrant). It also involves

obtaining a holistic view (D-quadrant) of the situation before a decision can be made
(see 7.13.4).
9.2.10.13 Relation between innovative teaching strategies and creativity
As is illustrated in figure 7 .4, the central focus of the innovative teaching strategies
discussed, is problem-solving. These strategies stimulate creative learning as they
facilitate active participation, discovery and cooperative and experiential learning,
and develop reflective, formal operational and productive thought. The key-abilities
of creativity which are developed by them include flexibility, fluency, divergent
thinking, penetration, internal visualisation, redefinition, synthesis and originality.
A very crucial aspect to be considered when implementing innovative teaching

strategies is the learning environment as it plays a major role in the fostering of
creativity. The strategies require a learning environment which allows psychological
freedom, encourages mutual acceptance, trust and respect, offers deferred
judgement, enjoyment and a relaxed atmosphere, and stimulates interest and
intrinsic motivation (see 7.14, 2.5.2.2.2, 2.5.2.2.3 and figure 7.4).
9.2.11 General conclusions
The most significant conclusions pertaining to the aims of this study are:
• From the definitions and theories of creativity it is concluded that creativity

necessitates specific cognitive and affective abilities and that it can be stimulated
and developed in every individual.
• Knowledge of the whole brain theory of creativity and understanding of the

whole brain teaching and learning model can assist educators to implement a
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holistic approach to teaching.
• Analysis of the field-dependent/independent and Kolb's four cognitive styles has

revealed a definitive link to the whole brain model. Each cognitive style
indicates double dominance in specific quadrants.
• The setting of cognitive objectives on the higher levels of Bloom's taxonomy and
the productive operations level of De Corte' s classification seem to be of utmost
importance for the development of creative thinking skills.
• The cognitive theories of learning are particularly significant to the development

of creativity as they focus on the higher cognitive skills which are involved in
creative thinking. The humanistic theories of learning contribute towards
development of the affect which is an essential part of creative behaviour.
• Adult, mastery, experiential and open learning have many aspects in common
with creative learning and they comply with the requirements of the creativity
inducing learning environment. Each of these models is of specific relevance to
nursing education to facilitate competency in the cognitive, affective and
psychomotor domains.
• Analysis of the practice of nursing has revealed that the effective or expert nurse
has to be a creative nurse. She should possess the traits of the creative
individual, the key-abilities of creativity and the versatility to use whole brain
thinking skills.
• The teaching strategies which are discussed in this thesis are regarded as
innovative because they stimulate creative learning and require a creativity
inducing learning environment. They are particularly applicable to nursing
education because of their experiential and problem-centred focus.
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• It is considered that the nursing education model for the fostering of creativity
(discussed in chapter 8, figure 8.1) has the potential to develop creativity in
student nurses as it is based on the principles derived from the various theories
of creativity, the whole brain creativity model, theories of learning, educational
models which appear to promote creativity and the nature of nursing as a science
art.
9.3 IMPLICATIONS FOR NURSE EDUCATORS
The general conclusions of this study have specific implications for nurse educators, the
most significant of which are:
(1) Nurse educators are advised to read widely about the nature and theories of
creativity in order to come to a better understanding of the concept. The South
African Nursing Council refers to the development of creative thinking in its
policy statement on the aims of professional nursing education. It is thus
imperative that nurse educators understand the true meaning of the concept
before they can organise their teaching to stimulate creativity. The planning of
a creativity inducing learning environment is crucial to the fostering of creativity,
and nurse educators should devote a lot of attention to this aspect. This will
involve evaluating themselves to determine whether they are closed or open
teachers and then, if necessary, striving towards becoming more open teachers.
(2) Nurse educators should consider attending creativity courses offered by

organisations such as Sartori, the Creativity Foundation of South Africa, to
expand their knowledge on the whole brain theory of creativity in general and
methods which stimulate creative thinking. This will contribute towards a more
holistic approach to teaching and to skill in using innovative teaching strategies.
(3) If nurse educators familiarise themselves with their students' cognitive styles, it
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will enable them to adjust their teaching approaches and to select teaching
strategies and media according to individual preferences. For the students this
will contribute to enhancement of their learning abilities and the development of
creative thinking, and will make their learning experience more enjoyable.
(4) Nurse educators should focus on setting objectives and evaluation on the higher
cognitive levels to facilitate productive and meaningful learning and the
development of creative thinking skills.
(5) The exploration and integration of various cognitive and humanistic theories of
learning into educational planning, can enrich the quality of education offered by
nurse educators. This will produce students who are more goal-directed for their
role as professional practitioners and will enhance their cognitive and affective
skills, which are so essential to effective practice.
(6) Nurse educators should give serious consideration to the implementation of the
adult, mastery, experiential and open learning models in nursing education. If
\
this is done, it will assist their students in obtaining the objectives of the three
different domains and facilitate self-directed, cooperative, discovery, experiential
and productive learning, all of which contribute towards the development of
creative learning. A creativity inducing learning environment will also be
established in the process. It is, however, suggested that nurse educators also
explore other educational models, which may enhance creative learning.
(7) Nurse educators should strive to be enviable role models to their students,
displaying the traits of the self-actualising creative individual. In order to
achieve this they will have to engage in life-long continuing education to
maintain a sound knowledge base. In addition, they will regularly have to spend
time in clinical practice to keep themselves up to date in the practical
requirements of health care. They, themselves, must be creative in order to set
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an example to their students in this respect. An open and positive attitude

towards life, acceptance of others as unique and unconditionally worthy, courage
to accept change and challenges, and most important of all, to exhibit caring
towards students and patients, are essential attributes of the creative nurse
educator.
(8) The implementation of the different teaching strategies in nursing education

discussed in this thesis, could in students, facilitate meaningful and productive
learning and develop their creative thinking skills. Leaming will be made more
interesting and enjoyable, which should lead to increased student motivation.
(9) If the nursing education model for the fostering of creativity were to be
implemented in nursing education, nurse educators would become more creative
in their teaching and, at the same time, the creativity of their students would be
stimulated. Much of the necessary background information is contained in this
thesis.
9.4 RECOMMENDATIONS
It is recommended that the following issues be considered for further research:
9.4.1 Methods that stimulate creative thinking skills
The pursuit of this research study has revealed that there are a great variety of methods
which develop creative thinking skills. These are described in the literature and many
are presented in creativity courses. It is recommended that an entire research study be
devoted to methods stimulating creative thinking skills with specific relevance to
nursing education.
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9.4.2 Theories of learning
An investigation into all the relevant theories of learning which are of significance to
nursing education is suggested. A comprehensive and explicit discussion of how they
can be applied to nursing education, may facilitate the advanced planning of nursing
education, and would be of assistance to students by enhancing meaningful learning.
9.4.3 General educational models
A study on a variety of educational models not discussed in this thesis which may be
relevant to nursing and which may contribute towards the development of creative
learning, might expand the possibilities of teaching for creativity in nursing education.
9.4.4 The nursing education model for the fostering of creativity
It is of relevance that a study to test the validity of the nursing education model for the
fostering of creativity be conducted in practice. This could be done at a particular
nursing college, simultaneously at several colleges, or by individual nurse practitioners .
. During its implementation, it is suggested that both experimental and control groups be
set up in order to exclude extraneous variables as far as possible.
9.5 LIMITATIONS OF THE STUDY
Due to the extent of this research study it was not feasible to include all the theories of
learning and all educational models which are relevant to nursing education and have
significance for the development of student creativity. It was also not possible to
discuss in greater detail each theory and model selected for this study as each, it is felt,
could almost have been a research study on its own.
The existence of such a vast number of methods which stimulate creative thinking skills,
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made it extremely difficult to choose only a few. The ones that were chosen are of
particular relevance to nursing education, but there are others which can be used to great
advantage.
9.6 POST SCRIPT
This study supports the modem conception of creativity as being an authentic human
ability that can be developed by education in a suitable environment. It has indicated
that the educator who displays an open approach towards teaching and acknowledges
each student's unique human potential, contributes towards the development of creative
behaviour. The most significant aspects in teaching for creativity appear to be the
creation of a psychological open learning environment with a student-centred, problem-
solving focus, and the successful utilisation of both left and right brain thinking
processes.
It is trusted that this study will help to motivate nurse educators to become open teachers
who will assist and guide their students to become self-actualised professional
practitioners. It is hoped that serious consideration of the implications of this study
might lead to implementation of the suggestions. If this were done, it could possibly
inspire innovation in nursing education with the ultimate aim of producing more
effective, competent and caring nurses.
424
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Innovative Teaching Strategies Within A Nursing Education Model

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INNOVATIVE TEACHING STRATEGIES

WITHIN A NURSING EDUCATION MODEL

submitted in accordance with the requirements

DOCTOR OF LITERATURE AND PHILOSOPHY

DEPARTMENT OF NURSING SCIENCE

UNIVERSITY OF SOUTH AFRICA

PROMOTER: PROF HIL BRINK

JOINT PROMOTER: PROF PJN STEYN

• My colleagues in the Department of Nursing Science, Unisa, for their assistance

1 ~lt:s: 610. 730 715 POTG

brain learning; productive learning; science-art of nursing.

TABLE OF CONTENTS PAGE

Orientation to the study

TABLE OF CONTENTS PAGE

The nature of creativity

TABLE OF CONTENTS PAGE

Whole brain creativity

The nature of creative learning

TABLE OF CONTENTS PAGE

4.2.2 Kolb's experiential learning model . . . . . . . . . . . . . . . . . . . . . . . 94

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Educational models and creativity

5.1 INTRODUCTION .................................. . 138

TABLE OF CONTENTS PAGE

5.4.2.5 J Learning involves transactions between the person and the

The practice of nursing

6.1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

TABLE OF CONTENTS PAGE

6.4.2 Code for Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202