Effectiveness of Mirror Therapy on Upper Extremity Functioni

Effectiveness of Mirror Therapy on Upper Extremity
Functioning among Stroke Patients
Rohini T. Chaudhari1, Seeta Devi2, Dipali Dumbre3
1MSc Nursing, 2Asst. Professor, 3Tutor, Symbiosis College of
Nursing, Symbiosis International
(Deemed University), Pune
ABSTARCT
Background: The prevalence of stroke in the general population
varies from 40 to 270 per 1000,000 in
India. Approximately 12% of all strokes occur in those older
than 40 years. Stroke may require a variety of
rehabilitation services. One of them Mirror therapy is a simple,
inexpensive and most importantly patient
directed treatment that may improve hand function after stroke.
Objective: To assess the effectiveness of mirror
therapy on upper extremity functioning among
stroke
patients at selected neurorehabilitation centres
Method: A quantitative research approach was used
in this study. Research design was Quasi-
experimental: pre-test post-test. Sample size was 50 post stroke
patients who receive stroke rehabilitation
at Neurorehabilitation centres. The 25 subjects were
randomly divided into two groups, experimental
group
and control group. The experimental group has received mirror

therapy with the conventional therapy for 3
days in a week for 4 weeks. Other side the control group has
received only conventional therapy for 4 weeks,
and 3 days in a week. The effectiveness was
evaluated by Modified Brunnstrom’s motor
function test
Result: An average hand functioning score in
pre-test was 8.2 which increased to 12.6 in
post-test and 7.6
which increased to 13.4 in post-test for upper extremity
functioning among experimental group, following
for the control group as in pre-test an average
was 8.3 which increased to 11.2 for hand and
8.1 which
increased to 11.7 of upper extremity.
Conclusion: The findings of the study show
that there is significant difference between
the scores of
experimental and control group.
Keywords: Mirror Therapy, Upper Extremity Stroke , Neuro
Rehabilitation Centre
INTRODUCTION
As human, we move our bodies to explicit our wants,
needs, emotions, thoughts, and ideas. Basically, how
well we move- and how much we move- decides how
well we engage with the world and make our full purpose
in life. Mostly the active movement helps us in function
completely, interact with the world, feel well physically
and emotionally, connect and build relationship with
others, and communicate and express ourselves. Also
the movement helps us recover if our brainis

injured
or inflamed. Body movements are comparable
important
for smooth and effective day to day activities.1
Nervous system is a one of the system of our body,
which perform all the sensory and motor function
of body. The reason a healthy nervous system is so
important is because it’s what runs everything in
our
body. When nervous system is functioning
correctly,
body is able to perform all the things it needs to do.
However, when the nervous system is compromised, or
not working efficiently, body begins to break
down.2
Stroke is the third biggest killer in India after heart
attack and cancer and is a major public
health concern.1
Stroke occurs when there is (1) lack of blood
flow to a
section of brain or (2) haemorrhage into the brain that
results in death of brain cells. The predominance of stroke
in the population varies from 40 to 270 per 1000,000 in
India. Approximately 12% of all strokes occur in those
olderthan 40 years. It was projected that by 2015
the
number of cases of stroke would be increase to 1666,372
DOI Number: 10.5958/0973-5674.2019.00026.1
Indian Journal of Physiotherapy and Occupational Therapy,

January-March 2019, Vol.13, No. 1 129
in the country. A predicted 5.7 million people died from
stroke in 2005 and it is projected that these deaths
would
rise to 6.5 million by 2015.3
Impact on daily life, 4 out of 10 stroke survivors
leave hospital requiring help with daily living activities
but almost a third receive no social service visits. Around
a third of stroke survivors experience depression after
their stroke.4
15 million people suffer from stroke worldwide
each
year. Of these, 5 million die and another 5 million are
permanently DISABLED.5Ischemic stroke 10% in 30
days, 23% in 1 year and 52 % in 5 year. Same as Intra-
cerebral haemorrhage 52% in 30 days, 62% in 1 year
and 70% in 5 years. The sub-arachnoid haemorrhage
was 45% in 30 days, 48% in 1 year and 52 %
in 5 years.
They also concluded that this prevalence of stroke may
increase till 2020. Stroke patient may require a variety of
rehabilitation services like physiotherapy, occupational
therapy, speech therapy etc. One of them MIRROR
THERAPY is an inexpensive, simple and patient
directed treatment. The principle of mirror therapy is use
of a mirror to create a reflective illusion of
an affected
limb in order to trick the brain into thinking movement
has occurred without pain. 5
METHODOLOGY
A quantitative research approach was used in this

study. Research design was Quasi-experimental: pre-test
post-test. Content validity was obtained by experts of
medical surgical nursing and physiotherapy opinion. Tool
reliability (0.8) was calculated by inter rated reliability
method. The consent was taken from the subjects
for
participation in study. Data collection was carried out
from 14/02/2018 to 15/03/2108. Sample size was
50
post stroke patients who receive stroke rehabilitation
at Neurorehabilitation centres. The 25 subjects were
randomly divided into two groups, experimental group
and control group. The experimental group has received
mirror therapy with the conventional therapy for 3 days
in a week for 4 weeks. Other side the control group has
received only conventional therapy for 4 weeks, and
3 days in a week. The effectiveness was
evaluated by
Modified Brunnstrom’s motor function test before
and
after intervention. Data was compiled and analysis was
done by using inferential and descriptive statistics.
RESULTS
Fig. 1: Effectiveness of mirror therapy in stroke
patients on the functioning of hand
In pre-test, all the experimental and control group stroke
patients had poor functioning of hand. In post-
test, 48% of
the experimental group samples had poor functioning of
hand and 52% of them had average functioning of hand.

In control group, 68% of the samples had poor
functioning
of hand and 32% of them had average functioning of hand.
This shows that the mirror therapy remarkably improved
the hand functioning of stroke patients.
Table 1: Paired t-test for effectiveness of mirror therapy in
stroke patients on the functioning of hand
N = 25, 25
Group Day Mean SD T Df p-value
Experimental
Pre-test 8.2 1.37
12.8 24 0.000
Post-test 12.6 1.71
Control
Pre-test 8.3 1.41
10.6 24 0.000
Post-test 11.2 1.72
Researcher applied paired t-test for effectiveness of
mirror therapy in stroke patients on the functioning of
hand. In experimental group, average hand functioning
score in pre-test was 8.2 which increased to
12.6 in post-
test. T-value for this test was 12.8 with 24 degrees of
freedom. Corresponding p-value was of the order of
0.000, which is small (less than 0.05), the null hypothesis
is rejected.

130 Indian Journal of Physiotherapy and Occupational
Therapy, January-March 2019, Vol.13, No. 1
In control group, average hand functioning score
in pre-test was 8.3 which increased to 11.2 in
post-test.
T-value for this test was 10.6 with 24 degrees of freedom.
Corresponding p-value was of the order of 0.000, which
is small (less than 0.05), the null hypothesis is
rejected.
Average for experimental group in post-test is higher
as compared to that for control group. Mirror therapy
is proved to be significantly effective in
improving the
hand functioning of stroke patients.
Fig. 2: Effectiveness of mirror therapy in stroke
patients on the functioning of upper extremity
In pre-test, all the experimental and control group
stroke patients had poor functioning of upper extremity.
In post-test, 56% of the experimental group samples had
poor functioning of upper extremity and 44% of them
had average functioning of upper extremity. In control
group, 92% of the samples had poor functioning of upper
extremity and 8% of them had average functioning of
upper extremity. This shows that the mirror therapy
remarkably improved the upper extremity functioning
of stroke patients.
Table 2: Paired t-test for effectiveness of mirror
therapy in stroke patients on the functioning of

upper extremity
N = 25, 25
Group Day Mean SD t Df p-value
Experimental
Pre-
test
7.6 1.15
14.6 24 0.000
Post-
test
13.4 1.80
Control
Pre-
test
8.1 1.17
11.0 24 0.000
Post-
test
11.7 1.51
Researcher applied paired t-test for effectiveness of
mirror therapy in stroke patients on the functioning of
upper extremity. In experimental group, average upper

extremity functioning score in pre-test was 7.6 which
increased to 13.4 in post-test. T-value for this test was
14.6 with 24 degrees of freedom. Corresponding p-value
was of the order of 0.000, which is small (less than 0.05),
the null hypothesis is rejected. In control group,
average
upper extremity functioning score in pre-test
was 8.1
which increased to 11.7 in post-test. T-value for this
test was 11 with 24 degrees of freedom. Corresponding
p-value was of the order of 0.000, which is small (less
than 0.05), the null hypothesis is rejected.
Average post
test score for experimental group is higher as compared
to that of control group. Mirror therapy is proved to be
significantly effective in improving the upper
extremity
functioning of stroke patients.
Table 3: Two sample t-test for comparison
of experimental and control group for hand
functioning
N = 25, 25
Group Mean SD T df p-value
Experimental 4.4 2.8
4.3 48 0.000
Control 1.7 1.3
Researcher applied two sample t-test for comparison
of average change in hand functioning score of
experimental and control group. Average change in hand
functioning score of experimental group was 4.4 which
was 1.7 for control group. T-value for this comparison

was 4.3 with 48 degrees of freedom. Corresponding
p-value was 0.000, which is small (less than 0.05).
This indicates that the mirror therapy has significantly
improved the functioning score of hand as compared to
that of control group.
Table 4: Two sample t-test for comparison of
experimental and control group for upper extremity
functioning
N = 25, 25
Group Mean SD t df p-value
Experimental 5.8 3.6
4.9 48 0.000
Control 2.0 1.6
Researcher applied two sample t-test for comparison
of average change in upper extremity functioning score
Indian Journal of Physiotherapy and Occupational Therapy,
January-March 2019, Vol.13, No. 1 131
of experimental and control group. Average change
in upper extremity functioning score of experimental
group was 5.8 which was 2 for control group.
T-value
for this comparison was 4.9 with 48 degrees of
freedom.
Corresponding p-value was 0.000, which is small (less
than 0.05). This indicates that the mirror therapy has
significantly improved the functioning score of

upper
extremity as compared to that of control group.
This shows that mirror therapy was effective on
upper extremity function among stroke patients.
DISCUSSION
The literature includes some studies that support
the use of Mirror Therapy in post-stroke rehabilitation.
However, researches involving MT have evolved over
the past years, acquiring better methodological quality.
The studies found in this review assessed individuals
in the post-stroke and showed similar effects
concerning
the effectiveness of MT on recovery of the motor
function.
The above findings of the study are supported by
a study conducted by, Pournima Pawar, vijaykumar
biradar to evaluate the effectiveness of the constraint
induced movement therapy (CIMT) and combined
mirror therapy for patient’s rehabilitation of the
patients
with subacute and chronic stroke patients.Twenty
patients were enrolled and divided into two groups
CIMT group, CIMT with Mirror therapy group. CIMT
group 6 hours a day for 4 days per week for 4 weeks
,and CIMT with Mirror therapy group 30 minutes of
mirror with CIMT for 4 days per week for 4 weeks .
The fugl-meyer motor function assessment (FMS) and
Brunnstrom Voluntary control grading were evaluated
4weeks after the treatment. The score of the Brunnstrom

Voluntary control grading p value (P value 0.0001)
and Fugl-meyer scale P value (0.0001), mirror therapy
combined with CIMT showed more improvement than
the CIMT after 4 weeks of treatment.6
Kil-Byung Lim, Hong-Jae Lee, Jeehyun Yoo,
Hyun-Ju Yun, Hye-Jung Hwang conducted study on
efficacy of mirror therapy containing tasks in
post stroke
patients to investigate the effect of mirror
therapy on
upper extremity function and activities of daily living.
The samples were randomly divided into two groups
that were mirror therapy group and sham therapy
group, each group contains 30 samples. The mirror
therapy group has undergone a mirror therapy with
conventional therapy for 20 minutes per day on 5 days
per 4 weeks. The Fugl Meyer assessment, Brunnstrom
motor recovery stage and modified barthel index
were
evaluated 4 weeks after the treatment. After 4 weeks of
intervention, improvements in the FMA (p=0.027) and
MBI (p=0.041) were significantly greater in the mirror
therapy group than the sham therapy group. The mirror
therapy containing functional task was effective in
terms
of improving the upper extremity functions.7
CONCLUSION
The findings of the study show that there is
significant
difference between the scores of experimental and
control group. The finding shows that the mirror

therapy
brought a significantly effect in pre-test and
post-test on
upper extremity functioning.
Conflict of Interest: Nil declared
Source Funding: Self
Ethical Clearance: This study is ethically approved by
Symbiosis College of nursing, Symbiosis International
(Deemed University)
REFERENCES
1. Krista Scott-Dixon, The Real reasons
healthy
movement matters [Internet], Available From:
www.precisionnutrition.com/healthy-movement.
2. Lewis, Medical Surgical Nursing, Second
South
Asia edition, ELSEVIER publication, volume- II,
2015, pg no- 1445.
3. Snehal Narsinha Waghavkar and Suvarna
Shyam
Ganvir, Effectiveness of Mirror Therapy to
improve hand functions in acute and sub-acute
stroke patients, International journal of Neuro-
rehabilitation., 2015 2(4), 1-3. doi:10.4172/2376-
0281.1000184.
4. Rothgangel, S, Braun,S, Beurskens,A, Seitz,R,
Wade,D, The clinical aspects of mirror therapy in

rehabilitation: a systematic review of the literature,
Journal of Rehabilitation Research, 2011, 34(1);
1-13, doi: 10.1097/MRR.0b013e3283441e98.
5. Fiona c Taylor, Suresh Kumar, Stroke
in India –
factsheet (updated 2015), Available From : https://
www.researchgate.net/publication/264116605.
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6. Pournima pawar, Vijaykumar biradar,
Compare
the effect of cimt versus mirror therapy on
hand
function in sub-acute and chronic stroke, European
journal of pharmaceutical and medical research,
ejpmr, 2017,4(1), 535-540, ISSN 2394-3211.
7. Kil-Byung Lim, Hong-Jae Lee,
JeehyunYoo,
Hyun-Ju Yun, Hye-Jung Hwan, efficacy of mirror
therapy containing tasks in post stroke patients,
Ann Rehabil Med 2016;40(4):629-636, pISSN:
2234-0645 • eISSN: 2234-0653.
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Research Article
Training Nursing Skills: A Quantitative Study of Nursing
Students’ Experiences before and after Clinical Practice
Elisabeth Solvik and Solveig Struksnes
Faculty of Medicine and Health Sciences, Department of Health
Sciences Gjøvik, NTNU (Norwegian University of
Science and Technology), Postboks 191, 2802 Gjøvik, Norway
Correspondence should be addressed to Solveig Struksnes;
[email protected]
Received 15 August 2017; Revised 3 December 2017; Accepted
18 January 2018; Published 11 March 2018
Academic Editor: Florence Luhanga
Copyright © 2018 Elisabeth Solvik and Solveig Struksnes. This
is an open access article distributed under the Creative
Commons
Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the
original work is
properly cited.
Introduction. Requirements for Patient Safety suggest that
students encounter patients well prepared. In clinical laboratory
practice
(CLP), the students simulate patient situations as a preparation

for internship. Various CLP models have been tried out to meet
the
students’ prerequisites and learning strategies. Objectives. The
purpose of this study was to try out two different learning
sessions
related to the bed bath procedure. Design and Methods. The
study has a descriptive, quantitative design with elements from
clinically
controlled trials. Sample. The population of 160 first-year
students was randomly divided into two classes. Questionnaires.
Two
questionnaires were answered with six-month intervals: Form 1
immediately after the first training session and Form 2 a short
time
after clinical practice. Findings. A majority of the nursing
students reported that the exercises in the clinical lab were a
good way to
prepare for the practice, although most of them did not perceive
that the procedure conducted at the university resembled how it
is conducted in clinical practice. Age or level of discomfort
related to organization of the skills training did not have impact
on the
students’ confidence in mastering bed bath in clinical practice.
Students without previous experience were less confident to
master
the procedure in clinical practice, but the results evened out
during the internship. Conclusions. The results from this study
could
indicate that the students’ age to a larger extent should be
considered in the universities’ facilitation of nursing students’
clinical
preparations, to improve the transition to “real life” as smoothly
and meaningfully as possible to nursing students.
1. Introduction

The practice field is a significant learning arena for nursing
students in Norway, as half of the bachelor’s program takes
place in clinical practice [1]. Thus, preparations for the stu-
dents’ meeting with real patients constitute a substanti al part
of teaching efforts within the university. The comprehension
of the transfer value of these preparations when it comes
to clinical practice probably has an impact on students’
achievements in the field of practice [2]. It has been argued
that nursing education is inadequate in preparing students for
practice and contributes to burnout syndrome among nurses
and an earlier retirement from the profession [3, 4].
Nursing students have various backgrounds and differ-
ent prerequisites for goal achieveme nt in accordance with
the National Curriculum of Nursing [1]. Requirements for
Patient Safety [5] suggest that students encounter patients
well prepared and with the proper knowledge and practical
skills required within an increasingly specialized healthcare.
Consequently, several nursing education institutions have
introduced clinical skills tests ahead of clinical practice
periods.
At the Norwegian University of Science and Technology
(NTNU), simulated patient scenarios are used to a large
extent as preparation for the students’ clinical studies in
practice. In clinical laboratory practice (CLP) the students
simulate patient situations at various levels, from basic
simulation in which fellow students play the roles of “patient”
and “nurse” to more advanced scenarios with technologically
advanced simulators (manikins) [6, 7]. The practical exercises
are usually organized with student groups (10–12) working
together under the supervision of one lecturer per group.
Each student experiences merely one supervised training per
procedure, due to the fact that this is a resource intensive
learning activity. A single training session is not sufficient

to assure the level of the students’ skills before passing the
Hindawi
Nursing Research and Practice
Volume 2018, Article ID 8984028, 9 pages
https://doi.org/10.1155/2018/8984028
http://orcid.org/0000-0002-5860-307X
http://orcid.org/0000-0003-4688-7746
https://doi.org/10.1155/2018/8984028
2 Nursing Research and Practice
Table 1: Questionnaires.
After training session After clinical practice
Before the training session I was well prepared by reading the
Procedures in Clinical Practice in Nursing© (PCPN) We should
have more time to practice in the laboratory
The training session was organized in a good way I am content
with my preparedness to conduct the procedurebefore clinical
practice
I discovered during the session that I should have prepared
myself better
The training session contributed to a good basis for conducting
the same in clinical practice
Students in my group used the training time effectively It was
easier than expected to perform the procedure in clinicalpractice
I’m confident that I will master the bed bath with a real
patient in clinical practice
To conduct the procedure in clinical practice was similar to the

one in the training session in the laboratory
The training session made me want to seek more knowledge
about the procedure
I am confident that I will master the procedure with a real
It’s my responsibility as a student to practice the procedures
until practiced The internship has strengthened my decision to
become a nurse
Training sessions in the laboratory is a good way to prepare
oneself for clinical practice
tests required to enter clinical practice. Hence, students are
encouraged to familiarize themselves with the procedures
before and after the organized CLP. The development of
electronic textbooks, with evidence-based descriptions and
instructive videos of relevant procedures, has been produced
to support the students in these unsupervised study activities.
It is uncertain to what extent this has been done. Various CLP
models have been tried out, some of these in cooperation
with nurses from the clinical fields [8, 9]. It is also ques -
tioned to what extent the preparations within the university
should be extended, so that training sessions (simulation)
can replace some of the time spent in clinical practice
[10, 11].
The current project was completed for freshmen in
bachelor’s nursing in the spring of 2014 and was part of the
CLP before the first clinical practice in nursing homes. This
includes skills training in various procedures before their first
practice period in community healthcare setting.
2. Objectives

The overall goal for CLP is to ensure that nursing students
who enter their first clinical practice period in community
healthcare settings have the proper defensible knowledge and
practical skills required to take care of patients in a safe
manner.
The purpose of this study was to try out two different
learning sessions related to the bed bath procedure. Six
research items were described:
(1) To investigate the students’ degree of satisfaction
with the learning session’s organization and relevance
before and after practice
(2) To compare the perceptions of the project group and
the control group
(3) To compare perceptions of students with different age,
with and without previous clinical experience and
with unequal extent of training
(4) To explore whether there are correlations between
the perceptions before and after the clinical practice
period.
3. Design and Methods
The study has a descriptive, quantitative design, and contains
elements that characterize clinically controlled trials [12]. It
is a cross-sectional study in which data were collected using
two questionnaires answered with six-month intervals.
The study was approved by the Norwegian Social Data
Services (NSD). All nursing students in their first year of
the bachelor’s program were informed both orally and in

writing about the project and the opportunity to participate,
two–four weeks prior to implementation.
Participating in the training session was mandatory, but
to deliver the questionnaires was voluntary.
3.1. Sample. The population of 160 students was randomly
divided into two classes, Class 1 (� = 79) and Class 2 (� =
81). Class 1 was chosen to be a control group, while Class 2
was chosen to be the project group. Each class was divided
into half so that the total was held in four training sessions.
3.2. Questionnaires. The forms were inspired by a ques-
tionnaire developed for the National League for Nursing
[10]. This form was translated into Norwegian at NTNU
in 2010, and it was in this connection that permission was
given to use it further [13]. The instruments were translated
from English into Norwegian and then translated back into
English, according to Polit and Beck [12]. Both translators
were bilingual.
Form 1 was completed immediately after the first training
session, whereas Form 2 was filled out a short time after
clinical practice (Table 1).
In both forms the respondents reported to what degree
they agreed/disagreed with the statements, according to
a five-point Likert scale. The value of one represents a high
Nursing Research and Practice 3
Table 2: Elements of the implementation of the two groups.
Control group (CG)

(Class 1,�=79)
Project group (PG)
(Class 2,�=81)
Written and oral information about the practical
implementation in advance ✓ ✓
Encouraging preparation before the training session ✓ ✓
Video viewing before the training session ✓ O
Information about organization ✓ ✓
Supervisor resources 1 pr. group (8–12) 1 pr. two groups (16–
24)
Supervisor’s role Active participation with specificsupervision
Available only for practical arrangements
and equipment supply
Services on hardcopy of (PCPN) O ✓
degree of disagreement with the statement and five represents
a high degree of agreement.
Demographic data collected included the respondents’
age, whether they had experience from practice before, and
how many hours they had trained with the procedure in
question before clinical practice.
The implementation was somewhat different for the two
groups as regards preparation for the exercise and teaching
role, which is outlined in Table 2.
The project group experienced a more problem-oriented
and student-active approach than was the case in the control
group. Thus, there were half as many supervisors attending,
and the supervisors’ roles were different within the two

groups. In the control group the supervisors followed up the
students’ activity closely and presented verbal and practical
guidance and solutions. The supervisors of the project group
had a minimal role and were only available for questions
related to helping to facilitate the training session by pro-
viding sufficient equipment. The least experienced lecturers
were chosen for the sessions with the project groups, on
the assumption that they could more easily take this role
than the experienced supervisors. How the roles should be
practiced was incidentally discussed with the supervisors
for both groups, to ensure an approximately equal approach
during the sessions.
3.3. Data Collection. Immediately after the exercise, the stu-
dents in both groups were asked to fill out the questionnaire
individually and put it at the designated place before they left
the rehearsal hall. The second form (after clinical practice)
was handed over to the supervisor in charge during the last
week of clinical practice.
3.4. Data Analysis. The questionnaires were coded with
numbers that represented the individual student and class
affiliation, with the answers registered into SPSS, version
22. Frequency tables were set up, and both Mann–Whitney
� test (two groups) and Kruskal–Wallis test (three groups)
were conducted to compare statements between defined
groups according to the research questions. Lastly, correlation
tests (Pearson’s �) were done to assess possible relationships
between statements in Forms 1 and 2.
Table 3: Respondents.
Questionnaire 1, after training
session
�=160

Questionnaire 2, after clinical
practice
�=158
� (%) 154 (96) � (%) 96 (61)
Former practice 82 Former practice 55
Not earlier
practice 69
Not earlier
practice 38
4. Results
Results are presented according to the research objectives.
Table 3 shows an overview of the demographic data of the
respondents.
4.1. Students’ Level of Satisfaction with the Clinical Exer -
cise’s Organization and Relevance. Respondents’ perceptions
immediately after the training session (Table 4) and after
clinical practice (Table 5) were analyzed.
A large proportion of respondents reported that the
exercises in the clinical lab were a good way to prepare
for the practice. During the exercise, almost half (47%) of
them detected that they should have been better prepared. A
majority (85%) agreed or strongly agreed that they would be
able to master bed bath with a real patient in practice after the
training session. Moreover, the respondents’ answers from
Form 2 were analyzed (Table 5) in relation to the respondents’
perceptions after clinical practice.
Experiencing clinical practice strengthened the decision
to become a nurse for 95.4% of respondents. When it comes
to the question of whether the procedure conducted at the

university resembles how it is conducted in clinical practice,
70.6% were undecided or disagreed. Respondents also report
that they were confident of mastering a bed bath with a real
patient (92% agree/strongly agree).
4.2. Comparing the Perceptions of the Two Training Sessions.
Based on Questionnaire 1, the groups’ beliefs about the
teaching program were compared as shown in Table 6.
Both control group and project group seemed to perceive
that training sessions in a clinical laboratory were a good
way to prepare for practice. However, the project group was
Table 4: Perceptions of all respondents immediately after the
training session (Questionnaire 1).
�=160 � (%) Mean SD
Before the training session I was well prepared by reading the
PCPN 154 (96) 3.36 1.181
The training session was organized in a good way 154 (96) 3.72
.889
I discovered during the session that I should have prepared
myself better 153 (96) 3.31 1.096
Students in my group used the training time effectively 153 (96)
4.24 .744
I’m confident that I will master the bed bath with a real patient
in clinical practice 154 (96) 4.05 .851
The training session made me want to seek more knowledge
about the procedure 154 (96) 3.81 .831
It’s my responsibility as a student to practice the procedures
until practiced 154 (96) 4.65 .578
Training sessions in the laboratory is a good way to prepare

oneself for clinical practice 154 (96) 4.82 .414
Scale: 1 = strongly disagree, 2 = disagree, 3 = unsure, 4 =
agree, and 5 = strongly agree.
Table 5: Perceptions of all respondents, after clinical practice
(Questionnaire 2).
�=158 � (%) Mean SD
We should have more time to practice in the laboratory 95 (60)
3.26 1031
I am content with my preparedness to conduct the procedure
before clinical practice 96 (61) 3.99 .584
The training session contributed to a good basis for conducting
the same in clinical practice 94 (60) 3.46 1103
It was easier than expected to perform the procedure in clinical
practice 87 (55) 3.88 .817
To conduct the procedure in clinical practice was similar to the
one in the training session in the
laboratory 85 (54) 2.98 .922
I am confident that I will master the procedure with a real
patient in clinical practice 88 (56) 4.23 .797
The internship has strengthened my decision to become a nurse
88 (56) 4.55 .589
significantly less satisfied with the organization of the session
than the control group (53.8% versus 92.2% agreed or strongly
agree). Respondents from the project group discovered to
a significantly greater extent during the exercise that they
should have prepared better than the control group (� =
.013), as 52% agreed or strongly agreed, while 42% in the
control group had had this experience. One can also note
that 33.9% of respondents in the control group disagreed or
strongly disagreed with the statement about preparedness,

compared to 17.1% in the project group. A comparison of the
groups after clinical practice was done as shown in Table 7.
In total, 158 students carried through clinical practice. Of
these, 96 responded (61%), out of which 45% came from the
control group and 55% from the project group.
Highest score for both groups was related to the statement
that getting out in clinical practice had strengthened their
decision to become a nurse. The lowest score was linked
to that the procedure in clinical practice resembled the one
they had trained for in the laboratory. Still, the majority of
both groups were confident that they would master the bed
bath with real patients in clinical practice with 97.3% (control
group) and 87.2% (project group), respectively, agreeing or
strongly agreeing with the statement.
The control group perceived to a significantly larger
degree (.002) that the training session for the bed bath
provided a good basis for practice.
4.3. Comparison of Students with and without Previous
Clinical Experience. It was required to see whether the
respondents’ previous experience with healthcare affected
their perceptions of the training session (Table 8). Initially, no
significant differences were found between the project group
and the control group in regard to the distribution of previous
clinical experience.
Respondents with previous clinical experience reported
to a significantly larger extent that they were confident to
master the bed bath with a real patient in clinical practice, as
95% agreed/strongly agreed with the statement. Among those
without any previous clinical practice, 74% reported the same.
Out of those who did not have any clinical experience, 78%

wanted to seek more information about the procedure, while
60% of those who had clinical experience agreed/strongly
agreed with this statement. This difference was significant
(.004).
After clinical practice, students with work experience
from healthcare were significantly more satisfied with their
preparation for practice than those without any experience
as 93% and 87%, respectively, agreed/strongly agreed. Other
differences emerged (Table 9).
There were also significant differences in the respondents’
perceptions of the exercise as a good basis for practice.
Sixty-seven percent of the group with work experience
agreed/strongly agreed with this statement, compared with
47% of respondents in the group with no previous practice.
4.4. Comparing Perceptions Related to Age. There were no
significant differences in the project group and control group
with respect to range or mean of age. The respondents were
divided into three age groups: 19-20 years (Group 1), 21–23
years (Group 2), and >23 years (Group 3). A frequency
Table 6: Comparison of control and project group, after training
session.
Total
N = 160
CG
� = 79

PG
� = 81
Mann–Whitney
� test,
(2-tailed)
� (%) Mean SD � (%) Mean SD � (%) Mean SD � �
Before the training session I was well prepared by reading
the PCPN
154 (96) 3.36 1,181 76 (96) 3.49 1,172 78 (96) 3.23 1,183 1,377
.169
.889 76 (96) 4.13 .525 78 (96) 3.32 .987 5,521 .000
I discovered during the session that I should have
prepared myself better
153 (96) 3.31 1,096 76 (96) 3.07 1,112 77 (95) 3.55 1,033 2472
.013
4.24 .744 75 (95) 4.29 .693 78 (96) 4.19 .790 −.685 .493
154 (96) 4.05 .851 76 (96) 4.17 .700 78 (96) 3.92 .964 1,466
.143
The training session made me want to seek more
knowledge about the procedure
154 (96) 3.81 .831 76 (96) 3.74 .789 78 (96) 3.88 .868 1,380
.168

It’s my responsibility as a student to practice the
procedures until practiced
154 (96) 4.65 .578 76 (96) 4.67 .551 78 (96) 4.63 .605 −.400
.689
Training sessions in the laboratory is a good way to
prepare oneself for clinical practice
154 (96) 4.82 .414 76 (96) 4.87 .377 78 (96) 4.78 .446 1,433
.152
Table 7: Comparison of control and project group, after clinical
practice (Questionnaire 2).
Total
�=158
CG
� = 78
PG
� = 80
Mann–Whitney
� test,
2-tailed
3.26 1,044 42 (54) 3.10 1135 53 (66) 3.42 .949 1.378 .168
I am content with my preparedness to conduct the

procedure before clinical practice
96 (61) 3.98 .580 43 (55) 4.07 .402 53 (66) 3.91 .687 1.085 .278
The training session contributed to a good basis for
conducting the same in clinical practice
94 (60) 3.47 1,104 42 (54) 3.88 .832 52 (65) 3.13 1.189 3.104
.002
It was easier than expected to perform the procedure in
clinical practice
87 (55) 3.87 .804 39 (50) 3.79 .951 48 (60) 3.94 .665 −.555 .579
To conduct the procedure in clinical practice was similar
to the one in the training session in the laboratory
85 (54) 2.94 .930 37 (47) 3.00 .943 48 (60) 2.90 .928 −.684 .494
I am confident that I will master the procedure with a
real patient in clinical practice
88 (56) 4.22 .780 39 (50) 4.41 .559 49 (61) 4.06 .899 1849 .064
The internship has strengthened my decision to become a
nurse
88 (56) 4.56 .584 39 (50) 4.56 .598 49 (61) 4.55 .580 −.171 .864
Table 8: Comparison of students with and without previous
practice in healthcare, after training session.

�=160
Total
� = 151
Not practice
� = 69
Practice
� = 82
Mann–Whitney
� test
2-tailed
Before the training session I was well prepared by reading
the PCPN
151 (94) 3.34 1,183 69 (100) 3.51 1,171 82 (100) 3.20 1,180
1,705 .088
.884 69 (100) 3.74 .885 82 (100) 3.68 .887 −.335 .737
I discovered during the session that I should have
prepared myself better
150 (94) 3.29 1,096 69 (100) 3.45 1,119 81 (99) 3.16 1,066
1,603 .109
4.23 .743 68 (99) 4.22 .666 82 (100) 4.23 .806 −.520 .603
151 (94) 4.04 .848 69 (100) 3.71 1,001 82 (100) 4.32 .564 4,195

.000
The training session made me want to seek more
knowledge about the procedure
151 (94) 3.81 .836 69 (100) 4.04 .695 82 (100) 3.62 .898 2,849
.004
It’s my responsibility as a student to practice the
procedures until practiced
151 (94) 4.64 .581 69 (100) 4.57 .630 82 (100) 4.71 .533 1,551
.121
Training sessions in the laboratory is a good way to
prepare oneself for clinical practice
151 (94) 4.82 .418 69 (100) 4.83 .382 82 (100) 4.82 .448 −.183
.855
Table 9: Comparison of students with and without previous
practice in healthcare, after clinical practice.
Total
�=96
Not practice
� = 38

Practice
� = 55
Mann–Whitney
� test
2-tailed
3.26 1,039 38 (100) 3.35 1033 54 (98) 3.19 1049 −.857 .391
I am content with my preparedness to conduct the
procedure before clinical practice
93 (97) 3.99 .571 38 (100) 3.84 .442 55 (100) 4.09 .628 2614
.009
The training session contributed to a good basis for
conducting the same in clinical practice
91 (95) 3.47 1,114 37 (98) 3.17 1159 54 (98) 3.67 1,043 2,109
.035
It was easier than expected to perform the procedure in
clinical practice
85 (89) 3.88 .822 35 (92) 3.68 .945 50 (91) 4.02 .699 1,487 .137
To conduct the procedure in clinical practice was similar
to the one in the training session in the laboratory
83 (87) 2.96 .920 33 (87) 2.75 .880 50 (91) 3.10 .928 1,745 .081
I am confident that I will master the procedure with a
real patient in clinical practice

86 (90) 4.24 .790 35 (92) 4.29 .524 51 (93) 4.20 .935 −.273 .785
The internship has strengthened my decision to become a
nurse
86 (90) 4.54 .591 35 (92) 4.41 .609 51 (93) 4.63 .566 1,789 .074
analysis showed that the oldest group (Group 3) had the
fewest number of respondents with previous experience
from healthcare. Data from the two surveys were tested by
Kruskal–Wallis, and several significant differences between
the groups were found. The results indicate that the oldest age
group perceived that the training session made them want to
seek more knowledge about the procedure to a greater extent
(.048) and that they should have spent more time training in
the laboratory (.009). After clinical practice, the oldest age
group was most confident as far as mastering the bed bath
with real patients in clinical practice (.048).
4.5. Comparing Perceptions Related to the Amount of Training
in the Laboratory. Students were divided into three equal
groups associated with the reported time spent on training
before practice: 1–4 hours, 5–9 hours, and 10–50 hours.
No significant differences between the project group and
control group were found in relation to training time, nor
were there differences between age groups or in whether
the respondents had previous clinical experience regarding
time spent on training. The Kruskal–Wallis test showed
no significant differences between the training time groups
regarding what they reported in either questionnaire 1 or 2.
5. Discussion
The findings summarized the students’ experiences of com-
fort and discomfort in the training session, their perceptions
of effort and mastery, and their perception of the practical

session’s usefulness and relevance to clinical practice.
5.1. Comfort and Discomfort in the Training Session. The
project group were significantly less satisfied with the orga-
nization of the training session than the control group. They
also did not find the training session as useful as a preparation
before clinical practice as did the control group. The organiza -
tion of the learning activities for the control group’s training
session was set up according to the principles of traditional
model learning [14], as the supervisors actively demonstrated
and intervened during the training. As for the project group,
the supervisors tried to promote a learning activity that
encouraged the students to actively seek solutions to the
challenges they faced by being available but withdrawn.
This may have increased the level of frustration in a
learning process [15]. Evaluation of learning activities often
shows that students are most satisfied with teaching methods
in which they adopt a more passive role. As opposed to several
studies arguing that student-centered- and active methods
provide more meaningful, significant in-depth learning, and
long-term learning outcomes [16–18] and that the students’
involvement and responsibility for learning are fundamental
to good learning outcomes [19]. According to Vygotsky [20],
this puts the learner in a place of being in a “discomfort
zone.” If this discomfort is manageable, the learning outcome
is more integrated and deeper than the case with learning
activities that allow the learner to stay in their comfort zone
and experience what is called surface learning. This emphasis
on the students’ own activity and learning outcomes also
clearly demands more student preparation before the lesson.
5.2. Perceptions of Effort and Mastery. When asked shortly
after the training session at the university, an overwhelming
majority of the students thought they would be able to master

the bed bath in clinical practice.
Students with previous practice were clearly most con-
fident regarding this issue, and all students strengthened
this conception after clinical practice. Although some of the
differences may be explained by the fact that the response
rates to Questionnaires 1 and 2 were 96%–60%, respectively,
this is not an unexpected result. More interesting is that
there was no difference between the control and project
groups’ responses to this statement after clinical practice. In
other words, clinical practice contributed to evening out the
students’ confidence regarding mastering a bed bath. These
results do not match the results from Struksnes and Engelien
[9], who found that the difference between students with
and without previous clinical experience lasted throughout
clinical practice. However, in the study in question, all
students had the same, traditional organization of the training
session.
Variables such as students’ age, maturity, or educational
background may affect the students’ sense of achievement
and actual performance in relation to the procedure in
question.
Concerning age, the students in our project were divided
into three age groups. Surprisingly there were more students
without clinical practice in the oldest age group, whereas the
three age groups had corresponding results before practice.
Even so, after the clinical practice the oldest group was more
confident in mastering the bed bath in practice than the
younger ones. Previous practice from healthcare is consid-

ered to be an advantage in nursing education. Our findings
indicate that age may compensate for lack of experience. In
general, age brings about a cognitive and motoric develop-
ment that could come into use when practicing nursing skills.
Students’ age can also have an effect on how and what they
learned and seen in relation to the teaching methods that
have been used [16, 21]. Andragogic learning is clearly an issue
that needs further research, in order to find out more about
the connections between age, learning strategies, teaching
methods, and learning outcomes.
Altogether, the students expressed immediately after the
training session that the practical exercise was useful. Still
there were differences between students with or without
previous experience from health services, as far as their
conception of mastering the bed bath in “real life.” Choice
of learning activities aiming at diminishing the difference
in confidence between these groups ahead of clinical prac-
tice should be explored further. Two alternatives could
be interesting: to organize different learning activities for
groups with or without previous experience, or to organize
the training session as cooperative or social learning, with
experienced students learning together with the novices
[3].
The extent of rehearsal before practice seemed to have no
significance to the students’ conception of being confident
in mastering the bed bath. Those who before practice were
confident in mastering the bed bath correlated with those
who believed that practical sessions were good preparation
before clinical practice (� = .264) and those who thought that
the bed bath session at the university provided a good basis
for practice (� = .279). This indicates that practical sessions
at the university before practice strengthen the students’
confidence in their mastering of the procedure, although the
project group and the control group clearly had different

opinions regarding the organization of the practical session
at the university.
It is important that the practical sessions at the university
encourage the students’ sense of empowerment. Research on
“meaningful learning” illuminates the significance of involve-
ment, activity, and a sense of achieving the expected learning
outcomes as a vital part of the learning process, regardless of
age [16, 22]. Nearly half the students discovered during the
bed bath session that they should have been better prepared.
The project group discovered this to a greater degree than
the control group. If students are well prepared, the training
session in clinical labs may be used more efficiently. There are
differences in students’ learning strategies and the amount of
time they have to spend to learn. For some, it might be best
to prepare ahead of the exercise, as they can prepare at their
own pace and manner.
Omitting the film on the web ahead of the training
session will also free more time for the students’ practical
activities during the session. Repetition is a well-known
learning principle for manual skills, and according to theories
of “learning by doing,” this will increase the level of learning
outcomes [23, 24].
Regarding preparations before the internship, the project
group discovered to a larger extent than the control group
that they should have been prepared for the practical session
in the bed bath. However, this experience did not have any
impact on how much they prepared on their own before the
internship, as the average number of training sessions is very
low for the total sample.
There was no difference between the project and control
groups in reported training hours before the internship,
neither did previous clinical experience, age, or rehearsal time

before practice have any significant influence on rehearsal
time. Students with previous clinical experience were signif-
icantly more satisfied with their own preparation than those
without (92.5 and 86.5%, resp.).
There were no differences on how satisfied students were
with their own preparation compared to rehearsal time.
However, there was broad agreement among the respondents
that it is the student’s responsibility to practice the proce-
dures before internship. This is in-line with the university’s
emphasis on students’ responsibility to be prepared for the
internship.
In summary, there should be more research on the
connection between rehearsal time in clinical labs and the
student’s skills performances in internship.
5.3. Perception of Usefulness and Relevance of the Training
Session. A large majority of the students thought that CLP
was a good way to prepare for the internship, and they
also experienced the fact that performing procedures in the
internship was easier than expected in advance. This indicates
that students were better prepared than they thought and that
the training session had fulfilled its intention.
Regarding relevance to clinical practice, the project group
agreed with the statement that exercises in the bed bath
provided a good basis for practice, although they to a
large extent conceived the training session as unsatisfactorily
organized.
It is reasonable to assume that the project group with
less instruction was more uncertain about the procedure
and therefore had to use the time at the training session to
familiarize themselves with the procedure. Since there was no
difference between the project and control group regarding

reported rehearsal time before clinical practice, this may
imply that the project group felt more unprepared to perform
the procedure in the internship.
One would think that those with previous clinical experi-
ence could lean on that experience in the training session and
accordingly feel more prepared than they report. This could
be explained by the very detailed descriptions of the steps
in the procedure, which may seem unfamiliar or irrelevant
for someone who has conducted the procedure based on
copying experienced employees in the clinical field. Still, with
respect to the statements after clinical practice “to conduct
the procedure in clinical practice was similar to the one in
the training session in the laboratory,” which received a mean
score of 3 points (“uncertain”) for the total sample, one could
question both the validity and relevance of the content and
organization of the training session. Nonetheless, those with
previous clinical experience had the highest score on the
statement, whether the exercise in the bed bath provided a
good basis for practice.
Respondents from control and project group had cor-
responding opinions about the statement that the training
session gave a need for further knowledge, but students
without any previous clinical experience tended to score
higher on this issue. It is essential that theory and practice
are connected during nursing education. Students need a
theoretical basis for the clinical procedures, in addition to
being able to work in an evidence-based manner. As a
nurse, you should be able to verify your actions, and there
are increasing demands that practice should be based on

knowledge [25, 26].
Those without any previous clinical experience may
require a more inductive learning process, or “learning-by-
doing” [23, 27], while experienced students reach the level of
integrating theory and practice in their clinical performances
at an earlier stage. It is debatable whether it is an inductive
or deductive way of learning that provides the best learning
outcomes, but student activity in the learning process seems
to be recommendable, both in the learning of manual skills
and cognitive development [28].
Students have different experiences and qualifications to
learn, and some students may benefit from studying the pro-
cedures themselves in advance, whereas others may learn best
by trying procedures first or together with fellow students.
Learning activities in higher education, especially those
linked to professions where practical skills are implemented
in the qualifications for the student to become a competent
professional, should enhance social learning strategies and
metacognition [29, 30].
There was a positive correlation between those who
believed that the practical session for the bed bath initiated a
need for knowledge and the fact that being in the practice field
had strengthened the decision to become a nurse (� = .365).
Those without any clinical experience were more likely to
seek knowledge. However, both groups equally stated that
being in the period of internship strengthened the decision
to become a nurse.
6. Conclusions
The majority of the nursing students reported that the
training sessions were useful and were confident to master
bed bath in clinical practice after the skills training session.

Almost half the students detected on the way that they should
have been better prepared, and most of them did not perceive
that the procedure conducted at the university resembles how
it is conducted in clinical practice.
The project group was significantl y less satisfied with the
organization of the session than the control group, while the
control group perceived to a significantly larger degree that
the training session for the bed bath provided a good basis
for practice.
Before the internship, students with previous clinical
experience were most confident to master the bed bath with
a real patient in clinical practice, but after the internship the
difference between the groups evened out.
Those who did not have any clinical experience to a larger
extent considered the exercise as a good basis for practice.
Students with work experience from healthcare were
most satisfied with their preparation for practice.
The oldest age group were more aware that they should
have spent more time training in the laboratory, and they
were most confident as far as mastering bed bath. The results
from this study could indicate that the universities’ facilita-
tion of nursing students’ clinical preparations may have an
impact on the students’ feeling of mastery and confidence
before their internship. Organization of the training session
or previous experience does not seem to have any significant
impact, but age and experiences in the internship seem to
influence the learning outcome. Thus, these findings should
be considered in the continuous work in the educational insti-
tutions, to improve the transition to “real life” as smoothly
and meaningfully as possible to nursing students.

Conflicts of Interest
The authors declare that there are no conflicts of interest
regarding the publication of this paper.
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/10
Journal of College Teaching & Learning – December 2011
Volume 8, Number 12
© 2011 The Clute Institute 53
Effective Strategies
For Engaging Adult Learners
Belinda Dunnick Karge, Ph.D., California State University,
Fullerton, CA, USA
Kathleen M. Phillips, Ph.D., California State University, San
Bernardino, CA, USA
Tammy Jessee, Dodson Middle School, Ranchos Palos Verdes,
CA, USA
Marjorie McCabe, Ph.D., California State University, San
Bernardino, CA, USA
ABSTRACT

Innovative methods in teaching should be used in every college
classroom to enhance student
engagement, support any teaching environment and encourage
inquiry among learners. Adults
learn best by participation in relevant experiences and
utilization of practical information. When
adult students are active in their learning they are able to
develop critical thinking skills, receive
social support systems for the learning, and gain knowl edge in
an efficient way. The authors
highlight several exemplary strategies for adult learners
including, Think-Pair-Share, Tell -Help-
Check, Give One, Get One, and the Immediate Feedback
Assessment Test.
Keywords: Strategies; Engagement; Adult Learners
he average college student is used to multitasking and
processing a variety of information at once.
Regardless of how one views the university classroom, the
instructor is on stage from the moment
he/she steps in front of the class (Schwartz & Karge, 1996). It
is critical to use proven and

innovative methods in teaching at all levels of education.
Furthermore, understanding the adult learner will enhance
instruction and ultimately motivate the student. This article will
highlight some of the key concepts related to adult
learning and focus on several easy to use research based
effective teaching methods for college instruction.
Knowles, Holton and Swanson (2005) have extensively
researched the principles of adult learning. They
coined the term, “andragogy” to signify the science of teaching
adults to learn (Merriam, Caffarella, & Baumgartner,
2007). Knowles et. al. purport that adult learners have a need to
know, a readiness to learn and an orientation to
learning; this combined with motivation creates a healthy
environment to acquire knowledge. Adults learn best by
participation in relevant experiences and practical information.
Adult learners need to be respected and valued.
Recent studies in neuroscience have validated these principles
(Jensen, 2005).
The traditional faculty/student relationship must be altered to
facilitate effective adult learning (Knowles,
Holton, & Swanson, 1998). The faculty members’ instructional
practices influence the education goals that students

adopt. The choices that faculty make about issues – such as
introducing and teaching course content, grading student
work, grouping of students, and how students are recognized for
their successes – all influence the types of goals
that students adopt. In turn, these goals affect a number of
important motivational outcomes.
Intrinsic motivation and extrinsic motivation play key roles.
Students who are intrinsically motivated will
engage in an academic task to learn for the sake of learning.
Students who are extrinsically motivated engage in
academic tasks in order to earn some type of reward, to avoid an
externally imposed punishment, or to make a
decision based on something they desire. This can be further
explored by looking at the works of Julian Rotter
(1966). Eric Schaps, founder of the Developmental Studies
Center, documents “a growing body of research
confirms the benefits of building a sense of
community…students with a strong sense of community are
more likely
to be academically motivated’ (2003, p. 31).
When students are active in their learning they are able to
develop critical thinking skills, receive social
support systems for the learning, and gain knowledge in an

efficient way. Faculty must enhance traditional lecturing
T
Volume 8, Number 12
54 © 2011 The Clute Institute
with carefully constructed effective teaching strategies designed
to enhance skills and gain content knowledge
(Feger, Woleck & Hickman, 2004).
One strategy for enhancing learning in the college classroom is
Think-Pair-Share. This strategy was
developed by Lyman (1987, 1981). For example, immediately
following a lecture or assigned textbook reading, the
instructor asks a question related to, describing, or interpreting
something. After giving the students a few minutes to
think of an answer, have them turn to a partner and share, i.e.
pair and share their response. Then ask the entire class
for volunteers who might want to share an answer.
There are many variations of this active learning technique. A
favorite of many educators is Think-Write-
Pair-Share. In this scenario, students listen while the teacher

poses a question, problem, concept or a task. As
indicated above, the students are given quiet time to respond to
the question in writing. Students are then cued to
pair with a neighbor and discuss their responses, noting
similarities and differences. It is important to give students
enough time to share their answers and how they arrived at the
answers with their classmates. After rehearsing
responses with a partner, students are invited to share publicly
using language for reported speech (e.g. My partner
pointed out…; My partner mentioned that…; We agreed that;
We decided that…). There are many advantages to
Lyman’s technique. The personal interaction motivates students
and engages the entire class. Quiet or shy students
are more likely to answer the questions or complete the task
with a partner instead of having to stand in front of the
entire class. The instructor can easily assess student
understanding by listening in on several groups during the
activity, and by collecting responses at the end. Fisher, Brozo,
Frey and Ivey (2007) offer another variation, the
Read-Write-Pair-Share. They indicate that the strategy provides
students with a scaffold experience. The student
reads a passage independently, and then composes his/her
reactions in writing. These ideas are shared with a
partner. The scaffold is enhanced by the discussion and

expansion of the thoughts with another classmate and they
indicate that some may feel confident once they have rehearsed
it by sharing with a peer and may volunteer to share
with the entire class. They note that use of this strategy assures
the instructor that everyone is engaged and using
academic vocabulary in both written and verbal form.
Tell-Help-Check (Archer & Gleason, 1994) is an excellent
strategy that provides adult students
opportunities to review and confirm their understanding of
critical information. Through interaction with partners,
students are able to participate, either orally or in writing, in an
activity that will assist in filling in knowledge gaps
of information. First, the instructor numbers the students as 1’s
and 2’s. The instructor poses a question to which
the 1’s respond. This may be done either in writing or orally.
The amount of time allotted to answer the question
depends on the depth of the question. Generally one or two
minutes are sufficient. Once the question has been
answered, 2’s provide help with the answer by adding
information or editing existing information. Once both team
members have given input on the answer, they check the text to
determine accuracy. The interactive nature of this
activity helps adult students maintain interest in the topics

covered. It also offers an avenue for students to tap into
related background knowledge. This strategy provides an
excellent opportunity for the instructor to assess student
knowledge of the given topic. While the teams are working on
the questions, the instructor can circulate the room to
determine the level of understanding of individuals and the
group as a whole. This time also provides an opportunity
for the instructor to provide feedback to individual students.
Problem-Based Learning(PBL) (Barrows &Tamblyn, 1980)
presents an avenue for students to actively
engage in learning communities by solving complex,
challenging problems/scenarios.By following the prescribed
steps, students collectively and creatively reach problem
resolution. The PBL process utilizes the students’ prior
knowledge and experience as well as curriculum and research
abilities to address problems/scenarios.
Problem Based Learning requires the instructor to facilitate
rather than direct and the students to take a lead
in developing solutions to real world problems. It is a
curricular approach to learning where students are encouraged
to take on the responsibility for their learning; even directing
that learning process by utilizing their experience, their

research, and their collaboration. Students are provided with an
“ill-structured” real life situation or problem. They
are given guidelines as to how to solve the problem while
working collaboratively with peers.
The specific steps to PBL begin with the instructor introducing
a problem or scenario to the class. It is
important that the instructor create the problem carefully so that
students have a concept of the problem solution but
Volume 8, Number 12
© 2011 The Clute Institute 55
cannot simply solve the problem using only prior knowledge.
The situation should be pertinent and should
challenge traditional knowledge. Using experiential knowledge
along with provided factual information, students
write what they know about the problem. Once the students
have all of the factual information compiled, they create
a statement of the problem. This can be refined as more details
are revealed. The students then collectively decide
what further information they need in order to fully understand
the problem and to begin to devise a solution. At
this point, the students should become acutely aware of the

importance of the curricular information and research
potential for resolving the problem. Students engage in the
necessary inquiry required to supplement the information
they already have and record any possible recommendations,
solutions, actions, or hypotheses. Finally they
formulate a solution. Once the group has a consensus on a
suitable solution, the students present their findings and
recommendations.
PBL engages students in active learning. They become involved
in the critical analysis of a problem and
collaboratively research possible solutions while also providing
input from relevant past experience and knowledge.
As the students gather the necessary factual knowledge that is
required, research skills are developed and students
become self-directed learners. These skills can then be applied
to other contexts and students become motivated by
seeing the relevance and applicability of what they have learned
(Savory, 2006).
Think-Pair-Share, Tell-Help-Check, and Problem Based
Learning are all engagement strategies designed to
ultimately expand learning. The term engagement signifies that
the student is sufficiently active. Engle & Conant

(2002) remind us that evidence of productive engagement
requires that the activities lead somewhere and that the
instructor document student learning. One way to do this is to
give a test on the information most recently taught.
A good test should be more than just an assessment of
knowledge. It should offer a meaningful learning experience.
The Immediate Feedback Assessment Test (IFAT) (Epstein,
Lazarus, Calvano, Matthews, Hendel, Epstein, &
Brosvic, 2002) provides just such an experience by allowing
students to immediately view the accuracy of their
responses and participate in a collective dialogue regarding the
content. The IFAT protocol is simple to use for both
the instructor and the students. First, the instructor creates
multiple choice questions relating to the content
knowledge the students should have acquired. Each student
independently takes the multiple choice test in the
traditional manner. Once the individual has completed the test,
he or she is placed into a group. The group is given
one IFAT answer sheet.
The IFAT form is similar to a Scantron form that is used with
many multiple choice tests. For each
question, the students compare their answers and collectively
agree on the correct choice. One student scratches off

the opaque coating corresponding to the chosen answer; if the
choice is correct, a star appears in the box and the
group goes on to the next item. If the choice is incorrect, a
blank space appears. The blank space signals the group
to discuss the rationale for a better answer. In this way,
students engage in meaningful discussions and develop a
deeper understanding of the content. The group’s final choice is
always the correct answer ensuring that each
student leaves the testing session with knowledge of the correct
information.
Pedagogically, the IFAT has several advantages over traditional
multiple-choice test procedures. First,
traditional multiple tests are generally graded after the student
leaves, thus delaying feedback for the test items. The
IFAT is graded by the students immediately after each answer is
given. Since the feedback is corrective, the student
leaves the testing situation knowing the correct answer rather
wondering if s/he was right or wrong. IFAT provides
a simple and fair way for the instructor to give partial credit.
Because of this, students can still earn points even if
their first choice is not accurate. Finally, students leave the
testing situation already aware of their overall test score.
Epstein (2002) demonstrates that the experience of using the

IFAT system increases the students’ level of
content knowledge. DeBattista, Mitterer, and Gross (2004)
found that university students strongly prefer the IFAT
to the more commonly used Scantron form, with 83 per cent
saying that they would like to be able to use the IFAT
in all of their courses. The likeability of IFAT was not related
to student characteristics or test performance
variables. Students learn more with the system and actually
prefer it to more traditional multiple choice tests.
Instructing adult learners is invigorating and challenging. The
use of these strategies to enhance
engagement will support any teaching environment and
encourage inquiry among learners.
Volume 8, Number 12
56 © 2011 The Clute Institute
AUTHOR INFORMATION
Belinda Dunnick Karge, Ph.D. is a professor at California State
University, Fullerton.

E-mail: [email protected]
Kathleen Phillips, Ph.D. is a lecturer at California State
University, San Bernardino.
Tammy Jessee is a middle school teacher at Dodson Middle
School in Ranchos Palos Verdes, Ca.
Marjorie McCabe, Ph.D. is a professor at California State
University, SanBernardino.
REFERENCES
1. Archer, A., & Gleason, M. (1994b). Skills for school success.
Book 6. North Billerica, MA: Curriculum
Associates.
2. Barrows, H. S., & Tamblyn, R. M. (1980). Problem-based
learning: An approach to medical education.
New York: Springer.
3. Dibattista, D., Mitterer, J., & Gosse, J. (2004). Acceptance
by undergraduates of the immediate feedback
assessment technique for multiple-choice testing. Brock
University Canada, Teaching in Higher Education
9, (1) 17-28.
4. Engle, R. A. & Conant, F. R. (2002). Guiding principles for

fostering productive disciplinary engagement:
Explaining an emergent argument in a community of learners
classroom. Cognition and Instruction, 20,
399-483.
5. Epstein M. L., Lazarus A. D., Calvano T. B., Matthews K.A.,
Hendel R. A., Epstein B. B., & Brosvic G.
M. (2002). Immediate feedback assessment technique promotes
learning and corrects.
6. Feger, S., Woleck, K. & Hickman, P. (2004). Journal of Staff
Development, 25(2), 87-108.
7. Fisher, D., Brozo, W. G., Frey, N., & Ivery, G. (2007).
Content area strategies for adolescent literacy.
Columbus, Ohio: Pearson.
8. Jensen, E. (2006). Enriching the brain: How to maximize
every learner’s potential. San Francisco, CA:
Jossey-Bass.
9. Knowles, Holton & Swanson (2005). The Adult Learner (6
th
edition). New York. Elsevier.
10. Knowles, M. S., Holton, E. G., & Swanson, R. A. (1998).
The adult learner: The definitive classic in adult
education and human resources development. Houston, TX: Gulf
Publishing.
11. Lyman, F. (1981). "The responsive classroom discussion."
In Anderson, A. S. (Ed.), Mainstreaming
Digest, College Park, MD: University of Maryland College of
Education.

12. Lyman, F., 1987, Think-Pair-Share: An expanding teaching
technique: MAA-CIE Cooperative News, v. 1,
p. 1-2.
13. Merriam, S. B., Caffarella, R. S., & Baumgartner, L. M.
(2007). Learning in adulthood: A comprehensive
guide (3rd ed.). San Francisco: Jossey-Bass.
14. Millis, B. J., and Cottell, P. G., Jr. (1998). Cooperative
learning for higher education faculty, American
Council on Education, Series on Higher Education. The Oryx
Press, Phoenix, AZ.
15. Rotter, J. B. (1966). Generalized expectancies for internal
versus external control of reinforcement.
Psychological Monographs, 80. (Whole No. 609).
16. Savery, J. R., (2006).Overview of problem based learning:
Definitions and Distinctions, The
Interdisciplinary Journal of Problem Based Learning, 1(1) 1-12.
17. Schaps, E. (2003). Creating a school community.
Educational Leadership, 60(6), 31-33.
18. Schwartz, S. E., & Karge, B. D., (1996) Human Diversity:
A Guide for Understanding. New York:
McGraw-Hill.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.

99
Back to contentsPrevious Next
The rationale for writing on this topic area came about from my
experience
with teaching adults on a variety of evening programmes.
Students from a
variety of backgrounds tend to enrol on business type courses
that are accred-
ited by the Institute of Commercial Management and Institute of
Public
Administration. In some cases, the students in these courses left
education
at a young age, often before they had completed secondary
education, often
due to not being comfortable with the teaching style that was
adopted by the
teacher in the classroom. Students felt that the teaching style
did not promote
learning in the classroom and that students were not allowed to
question the
material discussed in the classroom. When these students
enrolled in evening
programmes they were often surprised that they were allowed to
contribute
to discussions in relation to a variety of topics. The difference
in the teaching
style often encouraged students to further their education and to
participate in
more courses at a later stage.
While there may be similarities between adults and children in
how they learn
(such as language, interaction and communication), many

writers argue that
adult learners are different from child learners in a number of
ways. The aim
of this article is to review how adults learn through examining
one particular
theory of adult learning.
Adult learners need to know why they are learning new
knowledge before they
are willing to participate. In the context of evening courses such
as those focus-
ing on business subjects, employers seek to convince adult
learners to partic-
ipate in a course by emphasising the benefits of acquiring a
qualification or
learning new skills. This can be evidenced in situations where
adults partici-
Reviewing the Evidence on How Adult
Students Learn: An Examination of
Knowles’ Model of Andragogy
valer ie mcg rath
100
Back to contents NextPrevious
pate in courses that focus on management, marketing and
accounting skills.
Students are encouraged to incorporate what they learn in the
classroom into
their everyday work lives via a work-based project. If adults are
aware why they

are learning new skills, there will be a ‘readiness’ to learn and
they will be more
willing to participate in discussions in the classroom or learning
context. Adult
learners who have been given a ‘second chance’ at education
might be more
motivated to learn than children or secondary school students
because they
will be able to draw a connection between the material that is
discussed in the
classroom and what is happening in their own lives. Unlike
children, adults
tend to take responsibility for their own learning and they do
not want to be
directed by the lecturer during class.
Two conflicting learning theories, known as andragogy and
pedagogy, have
a particular relevance to the adult educator. The pedagogical
theory assumes
that the student will simply learn what they have been told.
Some people would
associate pedagogy solely with children, but surprisingly it can
also be associ-
ated with adult learning. The majority of today’s adult learners
were exposed
to classroom learning in previous educational experiences that
promoted
pedagogical practices. As a result of this experience adults may
be unwilling
to participate in an adult education type course later in life as
they have the
perception that the same style of teaching and learning is still in
existence in
today’s adult classroom.

Of course in certain circumstances students come to a course
without having
any background knowledge of the field of study. For example, if
a person was
to attend an accounting course with no background knowledge
of the area,
the lecturer would have to use the pedagogical approach in
which they would
explain the basics of accounting to the student. As the course
progresses, the
student is asked to apply examples from their own interest or
field of practice
to the course so they can create a link between their own
experience and the
course material. However, by adopting this strategy it is very
difficult to change
direction and encourage the student away from being dependent
to being inde-
pendent learners because once the student is comfortable with
the style that is
being used in the classroom, they might fear a change in style of
teaching.
Even though Knowles was a keen advocate of the theory of
andragogy he noted
that ‘pedagogical strategy is appropriate at least as a starting
point (when
learners are indeed dependent) when entering a totally strange
content area’
(Knowles, 1998, p. 70). In a sense it is contradictory to what he
said previously,
101

but in reality lecturers in many instances use a pedagogical
style of teaching at
the start of a course in order to ensure that students gain an
understanding of a
topic that they may not be very familiar with. However,
pedagogy is not with-
out its criticism.
Knowles et al (1998, p.61) stated that pedagogy is based on the
following
assumptions:
• Firstly, students only need to learn what the teacher teaches
them.
Students need only learn material that will be used to answer
questions
during an exam.
• Secondly, the pedagogical theory of learning implies that the
adult learn-
ers experience is not necessary for learning so adults who have
no expe-
rience in an area can gain entry onto a course and learn a new
skill. For
example, institutions that have courses in computers for
beginners often
state that it is not necessary for students to have previous
experience to
attend classes.
• Thirdly, according to Knowles et al (1998, p. 63), the
‘teachers concept of
the learner is that of a dependent personality.’ This is true in
the case of

students who have no knowledge in a particular area and
therefore they
have to depend solely on the teacher to learn the basics.
They assumed that the teacher’s job was to fill the students
minds with their
own information and the students were not encouraged to
question what they
were being taught.
The majority of today’s adult learners were exposed to
classroom learning in
previous educational experiences that promoted pedagogical
practices. Of
course in certain circumstances students come to a course
without having
any background knowledge of the area. For example, if a person
was to attend
an accounting course with no background knowledge of the
area, the lectur-
er would have to use the pedagogical approach in which they
would explain
the basics of accounting to the student. As the course progresses
the student is
asked to apply examples from their own background to the
course so they can
create a link between their own experience and the course
material.
102
One learning theory that has attempted to overcome some of the

negative
aspects of pedagogy is a theory that was introduced by Malcolm
Knowles
known as andragogy. Andragogy according to Henschke
(1998:8) can be
defined as ‘a scientific discipline that studies everything related
to learning and
teaching which would bring adults to their full degree of
humaneness.’ This
theory tried to identify how adult learners learn and how to
involve them in the
learning process ‘to free them from the oppression of
pedagogy.’ Unlike peda-
gogy, andragogy is centered on the idea that the lecturer does
not posses all the
knowledge and that students are encouraged to participate in the
classroom by
utilising their own experiences.
‘Adult education is quite distinctive in its approach in that it
aims to do sub-
stantially more than simply impart information to participants’
(Connolly,
1996, pp. 38-39). The lecturer should act as a facilitator in the
learning process.
This can be achieved by asking students questions that they can
relate to their
workplace. For example, once students are taught the basic
principle of a sub-
ject, they could be asked to apply those principles via a work-
based project to
their company. This will enable them to understand how the
theory they have
spoken about in class relates to a real life situation. The lecturer
can manage
this by asking students relevant questions pertaining to their

workplace, which
will require the student to think about what happens in their
organisation on
a day-to-day basis. This is further supported in research carried
out by Laird
(1998, p. 126) who stated that ‘the andragogic model holds the
view that the
instructor should guide and not manage the content, which is the
traditional
approach in pedagogy.’
Andragogy might be classed under the category of cognitive
theories in that
adults are allowed to analyse the material given to them in the
classroom and
they learn to make connections between the material and their
own life expe-
riences. In contrast pedagogy is associated with the behaviourist
stream of
learning where the student takes for granted what is being said
to them and
they learn it word for word so that they can receive positive
feedback from
their lecturers. Laird (1998, p. 125) stated that lecturers who
adopt the andra-
gogical theory of learning will ‘use more questions because
adults do know a
great deal.’
Andragogy is based on five key areas. Firstly, there is the issue
that adults need
to be made aware of the reason why they have to learn certain
material. Knowles

103
has stated that it is important that students are informed of the
benefits of cov-
ering this material and how it will benefit them when the course
is finished.
It is imperative that students are furnished with the learning
objectives when
they start their course (Knowles et al 1998, p. 63). For the
majority of evening
courses students are given the course outline and objectives of
the course when
they enrol in the course.
The second area is the learner’s concept of himself or herself. If
the learner
is very self confident and what Maslow describes as having high
self-esteem
needs, then the lecturer has to ensure that they allow the student
to discuss or
present their views during the class session. If the lecturer starts
out using a
pedagogical method of teaching and encourages the student to
become depen-
dent on them for knowledge and then they are in essence
creating a dependent
student who will have low self-esteem, which will ensure that
the student never
questions what the lecturer says in class.
Thirdly, andragogy is based on is the experience of the learner
and the role that
it plays in the classroom. Andragogy assumes that the student
has a bank of

experience accumulated over their lifetime and that they would
like to apply
this ‘experience’ in the classroom so that they can understand
the material
that is being discussed in the session. Unlike pedagogy,
andragogical learners
resent having a lecturer’s ideas forced upon them and as stated
by Knowles, et
al. (1998, p. 65), ‘adults resent and resist situations in which
they feel others are
imposing their will on them.’ Therefore, they want to be
responsible for their
own learning. The andragogical model states that adults need to
be able to use
their experience in the classroom if they want to learn.
Lecturers should encourage the promotion of dialogue in the
adult classroom.
The use of dialogue in the classroom aids the students’
understanding of the
material discussed in the class (Quilty, 2003, p. 63). Dialogue
can be encour-
aged through the use of group work, where students are placed
in groups and
given scenarios or class studies that are relevant to the student’s
experience.
This may also encourage the quieter students in the classroom
to participate in
the learning process and to air their views through the group.
Fourthly, students want to learn. Motivation plays an important
part in adult
learning, firstly, in that if students are not motivated to learn
they may not par-
ticipate in the classroom and therefore may leave the course.
Secondly, as men-

104
tioned in the previous point, adult students may be more
motivated to learn
if the concept of groups were prompted by the lecturer. Maslow
stated in his
theory of motivation that people have a need to feel that they
belong. Students
are more motivated if they feel that they belong in the adult
classroom and for
most adult students they like to belong to a group that they can
discuss both
academic and personal issues.
Andragogy states that adults are motivated by both internal and
external fac-
tors. Lecturers have to recognise that by praising and building
on the self-
esteem of students as it motivates them to learn. Tough found
that ‘motivation
is frequently blocked by barriers such as negative self concept
and time con-
straints’ (cited in Knowles, 1994, p. 68). While adult learners
may respond to
external motivators such as bonuses from their employers when
they attain a
certain grade, it is the internal priorities that are more important
to the learner.
Fifthly, for andragogy to work effectively in the classroom the
lecturer must
promote a climate which provides a safe environment for the

student. Abraham
Maslow stated that students, especially those with low self-
esteem, need to have
a safe environment if they are participate in the learning
experience (Knowles,
1994, p. 14). In the instance where students are encourage to
discuss examples,
they are praised for their contribution and not mocked by either
the lecturer or
other students for their views on a particular issue. Students
could be further
motivated in the classroom if they are allowed to participate in
the planning of
the syllabi for the course.
However, in reality, the majority of syllabi are designed by
educational institu-
tions or other accreditation bodies such as FETAC or HETAC,
which result in
both lecturer and student having very little input in what should
be included
in the syllabi for the course. However, it should be remembered
that whether
an institution or an accreditation body designs the syllabi
students will learn
more effectively if they can apply their experience to the
subject matter being
discussed in the session. Adults will learn material if it is
presented in a way
that relates to real life situations. Lecturers who use the
andragogical method
of learning should therefore consider using case studies or
histories in class so
that students can apply the ‘theory’ to a practical situation.
Knowles (1980, p. 54) held the view that adults ‘tend to be

problem centered
in their orientation.’ This is something that lecturers or
facilitators need to
take into account when they are planning their classes, as they
have to allow
105
for problem solving as well as interaction with the student.
Some adult stu-
dents prefer to be problem centered but others want the lecturer
to lead them
through the course, therefore problems arise when adults
suddenly find them-
selves in a situation that they have to think for themselves and
participate in
the class. Rogers (1989, p. 3) stated that when teaching (adults)
the custom-
er, not the subject, should comes first and is always right and
the customer is
the learner. This is often forgotten by colleges who see students
as a financial
gain and sometimes they are unaware of the method of teaching
used by their
lecturers in the adult classroom. Therefore, it is imperative that
educational
institutions should distribute a questionnaire at the end of a
course to enable
students to air their views on how the lecturer has performed on
the course.
Educational institutions such as the National College of Ireland
ask students

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