Nurse Education in Practice (2004) 4, 39–44

Nurse
Education
in Practice
www.elsevierhealth.com/journals/nepr

A case study of transfer of learning

in a family health nursing course for students
in remote and rural areas
William Laudera, Siobhan Sharkeyb,*, Simon Boothc

a
Central Queensland University, Rockhampton, Qld., Australia
b
University of Stirling, Highland Campus, Inverness, Scotland, UK
c
University of Stirling, Stirling, Scotland, UK

Accepted 7 April 2003

KEYWORDS Summary This paper describes a case study detailing one approach to tackling the
Knowledge transfer; problems of knowledge transfer in an undergraduate course on Research, Decision-
Family health nurse; Making and Evaluation in Family Health Nursing. Transfer is the ability to access and
Case studies; utilise ones intellectual resources in situations where these may be needed [Nursing
WebCT Diagnosis 3(4) (1992) 148–154]. The discussion will explore the related issues of
transfer of learning, casuistry, and teaching and learning on a course for experienced
community practitioners. This course serves as a case example to tease out how
teaching and learning can be structured to promote effective transfer of knowledge
from the classroom and virtual classroom to clinical practice.
c 2003 Elsevier Ltd. All rights reserved.

Introduction practice (Jenicek, 1999). Situated Learning Theory

The Family Health Nurse (WHO Pilot Project)
course which forms the basis for this paper was a 14
week research, decision-making and evaluation
unit in the Family Health Nurse Pilot Project Course
at the University of Stirling. The unit comprised a
1-week series of campus-based lectures, 3 weeks
on-line distance learning and nine weeks clinical
placement. Teaching and learning within the
course were guided by a synthesis of a number of
ideas and concepts drawn from a range of theories
including Situated Learning Theory (Lave and
Wenger, 1991) and casuistry in evidence-based
*
Corresponding author.
E-mail addresses: w.lauder@cqu.edu.au, s.b.sharkey@stir.
ac.uk.
proposes that knowledge must to be presented in
an authentic context (you learn to be a Family
Health Nurse whilst working with families) and that
effective learning requires social interaction and
collaboration. Lave and Wenger (1991) believe that
as the beginner becomes more active and engaged
within in a community of practice she/he assumes
the role of expert. As the first ever group of family
Health Nurses this group were an exception to the
rule as they were both learners and arguably the
most knowledgeable practising Family Health Nur-
ses in UK. This raises interesting questions about
the boundaries between novice and expert and
student and clinician which are blurred in courses
such as the one described here.
In attempting to understand how students–cli-
clinicians move from experiencing new knowledge


1471-5953/$ - see front matter c 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S1471-5953(03)00017-9
40
and skills to become the prototype Family Health
Nurses, this paper will explore the role of knowl-
edge transfer within the Family Health Nurse
course. Knowledge transfer and associated con-
cepts will initially be discussed and subsequently an
attempt to apply these concepts within the Family
Health Nurse course will be presented.
Learning and transfer of learning
Transfer has been seen by some educationalists as
the key and unifying concept in learning (Prawat,
1989), and in the development of skilled nursing
practice (Lauder et al., 1999). If knowledge and
skills are to be effectively and efficiently trans-
ferred from one learning situation to another the
learner must be able to access existing knowledge,
skills and metacognitive strategies (Renkl et al.,
1996). Problems with knowledge transfer are a
common cause for failures in learning and perfor-
mance (Lauder et al., 1999). Effective and efficient
access is promoted when learners’ knowledge is
stored in well organised cognitive schemata, when
they are aware of this knowledge and when ap-
propriate metacognitive strategies are available
for use. Metacognition is the active monitoring and
self-regulation in which one’s own mental activi-
ties become the object of reflection (Jo, 1993).
One often overlooked aspect of transfer in
nursing is the impact of group learning on knowl-
edge transfer, particularly the way in which groups
influence individual learning. Situated Learning
Theory places much emphasis on the social di-
mension of learning where learners become in-
volved in a “community of practice”. The role of
collective cognition, mental models and team
knowledge has been well documented within hu-
man relations and organisational literature (Mo-
hammed and Dumville, 2001), but these concepts
have not thus far had a major impact in nursing
curricula. Creating such a community of practice
for students who worked in remote and rural areas
in the Highland and Islands of Scotland was the
single biggest challenge faced by course designers.
There is a pressing need to develop better the-
ories to guide work behaviour in groups (Gibson,
2001). Teams are the fundamental learning unit in
modern organisations – with collective strategies
being efficient ways of creating and disseminating
knowledge. Goffee and Jones (1998) introduce the
notions of mutuality and co-operation (much in the
sense of human capital) when they claim that a
sense of group “culture” is likely to influence
learning and knowledge transfer by individuals
within such groups.
W. Lauder et al.
The importance of paying attention to the way in
which learning takes place within health care or-
ganisations in general and specifically with a widely
dispersed group of students in remote and rural
areas cannot be underestimated. Nutley and Davies
(2001) highlight the need to pay more attention to
collective (organisational) learning – particularly
issues relating to how knowledge gets used and
deployed within the NHS. They advocate that
“generative” (double-loop) learning is required,
where attention is given to cultural values and
structural mechanisms used to facilitate learning.
What we are left with to consider is the potential
value of recognising the role of collective learning
and level of mutuality (co-operation) on group (or
team) learning in health care and the extent to
which variations in “collective cognition” and co-
operation influence transfer. This brief overview of
knowledge transfer has illustrated a number of is-
sues which were considered during the course de-
sign process. These issues included how learning is
structured and processed by individuals and
groups; how learning is organised (team or indi-
vidual learning models); and links between learning
and work environments (Sharkey and Sharples,
2001).
Course design and transfer
The course was developed in a way in which all
aspects of teaching and learning would facilitate
transfer of research and evidence-based family
health nursing from abstract concepts, to the real
world of practice. Consequently four key areas
were identified as important in the design of the
course: (1) acting in unfamiliar situations (dynamic
transfer); (2) the psychology of professional prac-
tice; (3) the creation of an interactive learning
environment for students studying in remote and
rural areas; and (4) the use of evidence-based
teaching and learning methods such as advance
organisers.
The notion of dynamic transfer was important as
the role students were preparing for did not exist
as such in UK. The Family Health Nursing course is a
WHO pilot project and consequently there were no
clear role models in UK to guide students nor well-
established clinical protocols for practice. The
concept as it was to be implemented on the ground
was plagued by a lack of clarity and detailed
planning. In effect these students, and subsequent
cohorts, would develop an operational definition of
Family Health Nursing in remote and rural com-
munities whilst still learning to be Family Health
Nurses. Although students were experienced com-
A case study of transfer of learning
munity nurses they would still encounter situations
which were new to them. Consequently the dy-
namic notion of transfer in which one can act ef-
fectively and efficiently in new and novel situations
was crucial to the success of the course and for
that matter the success of the pilot project itself.
The psychology of practice is more than simply
reflective practice (Lauder, 1994). Eisenhardt
(1989) argues that professionals develop a more
sophisticated understanding of clinical practice by
internalising the many cases they encounter. She
believes the study of individual cases is consistent
with the way in which clinical expertise develops
over time. There are clear parallels to be seen be-
tween the educational concept of transfer and
generalisability in case study research. Both seek to
understand how knowledge of a single case can be
utilised to understand and act in other cases. Al-
though generalisations are problematic since cases
are neither time- nor context-free there may be
some transferability of knowledge from one case to
another case, depending on the degree of temporal
and contextual similarity (Guba and Lincoln, 1982).
Temporal similarity reinforces the need for theory
and practice to be contiguous or co-exist whilst
empirical support for the importance of similarity in
transfer is found in the literature (Robbins, 1986).
Guba and Lincoln (1982), in the context of research
methods, offer the notion of fittingness as an al-
ternative to generalisation. By this they mean that
findings can be transferred from one situation to
another depending on the degree of fit between
each situation. In the light of the synergy between
cases and transfer it can be suggested that the study
of cases approximates the psychology of clinical
practice and that case studies provide an inherently
suitable vehicle to support transfer of research
concepts to evidence-based practice.
Having accepted that the study of cases was
central to teaching and learning practices, the next
issue which was considered was whether to teach
general metacognitive strategies which were inde-
pendent of course content or whether it was nec-
essary to teach very specific strategies which are
presented in the context of course content. Halpern
(1998) describes a general strategy as focusing on
the underlying structure of problems which then act
as cues for knowledge retrieval. The dilemma faced
when teaching for transfer is the tension between
general metacognitive strategies and specific
strategies. Specific strategies are easily teachable
but transferable to only a few situations. General
strategies are very difficult to teach but are appli-
cable to a larger number of situations. Halpern
(1998) claims that when one teaches for transfer
students must be assisted to recognise situations
41
when a specific skill or metacognitive strategy might
be useful. The relationship between knowledge and
action is not linear but multi-directional and very
fluid depending on the specific learning task. Family
Health Nurses’ actions inform their knowledge-base
which in turn informs future actions. It was decided
therefore to structure the initial lectures and on-
line learning element of the course in such a way as
to provide key content and to expose students to
general transfer strategies.
Whilst it is easy to understand the notion of
general strategies at a conceptual level it is much
more difficult to translate this into practices and
techniques which can be taught and learned. Pra-
wat (1989) suggests that there is a trade-off be-
tween the teachability and power of specific
strategies, such as the use of mnemonics for pro-
cedure acquisition, and the weaker, less prescrip-
tive but more generalisable strategies such as
executive self-regulatory skills. Therefore a com-
bination of general transfer strategies and specific
strategies were utilised during the period of clini-
cal practice. General control strategies such as
analysing and predicting (Pesut and Herman, 1992)
were encouraged through analyses of three re-
search papers with specific instructions to docu-
ment how findings would impact on very specific
aspects of Family Health Nursing practice. Specific
strategies include the use of Ecomaps and Geno-
grams (Wright and Leahey, 1999) as part of their
family assessment process. These assessment tools
can also be conceptualised within a learning
framework as heuristic devices which serve to fo-
cus on aspects of each and every case. As such they
provided tools which allowed students to explore
the underlying dynamics in each case and over time
would gradually be internalised to facilitate un-
derstanding across cases. This strategy also opti-
mised group learning opportunities by providing
frameworks for on-line discussion and sharing.
Promoting dialogue
Dialogue is an effective method in promoting
transfer (Coleman et al., 1997). It is difficult to
provide opportunities for dialogue with students
who live and work in remote and rural areas. In
remote and rural practice opportunities to interact
with others students and academic staff are on the
whole limited. All students were provided with a
PC equipped with a modem to enable access to the
Internet. The primary purpose of the PC was to
create a virtual community of practice by allowing
students to access the online web-based learning
environment WebCT (www.webct.com). WebCT
42
(Web Course Tools) provides a rich set of tools to
organise, deliver and manage online learning. The
communication tools were used to enable the stu-
dents to stay in contact whilst off-campus. There
were three communications tools: bulletin
board(s), private mail and chat in WebCT. Bulletin
boards provided a public space where messages
could posted by a student and read by the other
students. The private mail tool is very similar to
traditional email but is restricted to course mem-
bers only and can only be read within the WebCT
environment. The last of the communication tools
was chat. Chat allowed for synchronous communi-
cation between students. It worked by allowing
each student to type messages into the chat tool
and then displaying the message to all the students
currently engaged in the chat session.
The bulletin board was the main mechanism of
communication for the students. It was used to
post questions (which either other students or staff
could respond to), to arrange chat sessions and for
general, non course-based, communications. Some
851 messages were posted to the board (an average
of 77 per student). The bulletin board facility and
its ability to let the students stay in touch when
they were off-campus was very much appreciated
by the students and from an IT prospective was
easily the most successful component of the
course. All the students after finishing the course
have remained in touch using the bulletin board (a
special board with the course has been established
for the 2001 cohort of students).
The chat tool provided a way for a group of
students/staff to interactively communicate and
was used to provide tutorial support on a number of
occasions. It was also extensively used by the stu-
dents for non course-based communication. Again
the facility was popular with the students. Private
mail was the least used of the tools and almost
exclusively used by the students to ask questions to
staff, particularly technical support questions.
WebCT provided a host of opportunities for dialog
between the students as it provided, for this
course, a learning environment in which students
actively engaged with learning and had a support
network of fellow students and academic staff. The
bulletin board and chat were the most effective in
providing a space where the students could engage
with other either asynchronously (bulletin board)
or synchronously (chat).
Casuistry in teaching and learning
It has already been suggested that as professional
practice develops learners gradually build up a
W. Lauder et al.
reservoir of individual cases. A library analogy is
appropriate here with cases being stored in a way
which makes them easily accessible, in effect a
sort of cognitive library with case-bound knowl-
edge equating to books and journals. The ability to
search for and locate books and journal articles in a
very effective and efficient manner representing a
similar process to the metacognitive strategies
which allows learners to match current cases with
their own personal case-bound knowledge.
It follows that the notion of case-based learning
should inform teaching and learning. Jenicek
(1999) describes casuistry as the art of applying
abstract principles and analysis to particular cases
and is clear that medical (nursing) casuistry is
distinct from other casuistic approaches when he
states
The direction of inference in medical (nurs-
ing) casuistics is quite different from the di-
rection of inference in theology, philosophy,
ethics or business. While the latter apply gen-
eral concepts to specific cases medicine in its
will of understanding starts by studying spe-
cific cases and seeks to use them as a basis
for general concepts and as the starting point
for future research of the problem illustrated
by the cases. p. 47.
The approach to casuistry operated in this course
has parallels with the approach used by theologians
in the 15th and 16th century (Strong, 1999). Toul-
min (1990) has been at the forefront of the move-
ment to resurrect practical philosophy. He
advocates a return to the particular and timeliness
of decision-making. This concern with the single
concrete case should not be seen as “sloppy rela-
tivism” inasmuch as we are not be advocating a
return to the anecdote or unreflected practice.
One criticism of casuistic teaching and learning is
that it allows the student to learn a lot of about
individuals but not enough about general principles
and precepts. Sandelowski (1996) argues that in
fact case studies do permit generalisations of
an idiographic nature. She claims that to deny this
is to deny the case-bound casuistry of clinical
practice.
The notion of practical wisdom (Lauder, 1994)
proposes that Family Health Nursing students re-
quire to find answers to two types of questions in
their clinical practice. Technical questions require
the student to consider how they can prescribe the
most effective and efficient Family Health Nursing
interventions. Practical questions involve decisions
on how students ought to act, in essence ethical
and moral questions. Consequently a case study
approach to teaching and learning necessitates
A case study of transfer of learning
that students should be actively engaged in learn-
ing both technical-evidence based aspects of
nursing care as well as becoming a virtuous prac-
titioner who acts according to the best interest of
the family. The cases which structured the learning
experience required to provide students with an
opportunity to engage with both technical-empiri-
cal (evidence-based) and ethical (practical) prob-
lems within a context in which decisions are made
in a timely and consensual manner.
Braunack-Meyer (2001), in a qualitative study of
15 GPs, found that casuistic reasoning does play a
part in practitioner’s decision-making but this
process lacked a vital ingredient; clear paradigm
cases on which to base comparisons. The WHO
curriculum team provided an initial series of par-
adigm cases and these were supplemented over the
pilot project by cases documented by students.
Zimmermann (1998) argues that improved deci-
sion-making can be achieved by using casuistry as a
way of reconciling general principles and specific
problems. Casuistry has been attacked as being a
flawed process and some have advocated specified
principlism as an alternative (Strong, 1999). Strong
argues that this fails to provide answers as to how
to act in concrete cases. Nordgren (1998) suggests
that imaginative casuistry is preferred to princip-
lism. He argues that ethical principles “are inter-
preted as rules of thumb summarising the
collective wisdom concerning prototype cases”.
The course team were confident that this literature
along with other evidence not considered here
provided sufficient support to justify the use of a
casuistic approach to teaching and learning ethical
and practical issues in clinical practice.
The students were initially introduced to evi-
dence-based practice through one week of campus-
based lectures and a 2-week distance learning
critical appraisal course. This provided students
with the type of subject knowledge which in effect
acted as advance organisers. Advance organisers
are seen as important building blocks for future
learning (Frazer, 1992; Entwhistle, 1997). Specific
examples of advance organisers, introduced early
in the course, included lectures on techniques for
critiquing research papers and some core elements
of the Critical Appraisal Skills Programme (CASP,
1999).
Students were asked to select three families and
submit an annotated case report on each case (see
Jenicek, Chapter 6 for a description of annotated
case reports). These annotated case reports were
part of the formal course assessment process as
this was judged to highlight the importance of both
case reports and clinical practice in the formal
academic assessment process. Annotated case re-
43
ports were selected as this format was a close
approximation of the type of information which
these nurses were likely to encounter in clinical
practice and which would have practical utility as a
form of working document. The ability to commu-
nicate complex and wide-ranging information in
succinct and concise formats encourages students
to focus on the underlying structure of a situation.
After analysing each individual case students were
required to conduct a systematic review of the
case and submit this as a formally assessed piece of
coursework. As stated earlier, Prawat (1989) be-
lieves access to knowledge is a central to effective
transfer. This can be facilitated by the concept of
similarity. Robbins (1986), in a review of the
transfer literature, identified similarity as a central
theme in effective transfer. Similarity of tasks has
been found to stimulate recall from memory, im-
prove problem solving and produce more effective
learning. In the systematic review students were
asked to select a number of cases which had
something in common such as using a particular
type of coping strategy. Students were required to
undertake a review of a number of individual cases
and identify similarities and differences by identi-
fying what factors cases had in common and what
made, what at first appeared a very similar case,
different and unique.
The course evaluations indicated that, from the
student perspective at least, this approach to
teaching and learning was seen as valuable and
acceptable. The course team believed that the
technological solution and the teaching strategies
used did facilitate the creation of the virtual
community of practice. We would accept that this
type of course evaluation is no substitute for rig-
orous empirical evaluation. It should be noted that
a comprehensive evaluation of the pilot project has
been undertaken by researchers at the Robert
Gordon University.
Summary
Transfer is a major goal in professional education
and as such the teaching and learning practices
which take place in a given course should be aimed
to achieve this end(s). The course itself has to be
designed in such a way as to facilitate transfer from
classroom and virtual classroom to clinical practice
and from one part of clinical practice to another. It
has been argued that the study of cases can be a
fundamental building block for course design which
has identified transfer of learning as its main goal.
The use of information technology to support a
distributed learning environment for students on
44
practice appeared very successful. This model has
much to recommend it to a profession in which
much professional education is part-time and co-
exists with the world of work. It is especially useful
in bridging the collective experience of classroom
learning and the individual experience of learning
in clinical practice. It is proposed that the prac-
tices documented in this case study may have a
more general applicability and can be transferred
to other courses of nurse education where simi-
larities exist.
References
Braunack-Meyer, A.J., 2001. What males a problems an ethical
problems? An empirical perspective on the nature of ethical
problems in general practice. Journal of Medical Ethics 27
(2), 98–103.
CASP, 1999. Evidence-Based Health Care; The Critical Appraisal
Skills Programme. The Critical Appraisal Skills Programme
and The Health Care Libraries Unit. Update Software, Oxford.
Coleman E.B., Brown A.L., Rivkin, I.D., 1997. The effect of
instructional explanations on learning from scientific texts.
Journal of the Learning Sciences 6 (4), 347–365.
Eisenhardt, K.M., 1989. Building theories from case study
research. Academy of Management Review 14 (4), 532–550.
Entwhistle, N., 1997. Contrasting Perspectives on Learning. In:
Marton, F., Hounsell, D., Entwhistle, N. (Eds.), The Experi-
ence of Learning, second ed. Scottish Academic Press,
Edinburgh.
Frazer, M., 1992. Promoting Learning. In: Barnett, R. (Ed.),
Learning to Effect. Society for Research into Higher Educa-
tion/OU Press, Buckingham, pp. 55–68.
Gibson, C.B., 2001. From knowledge accumulation to accom-
modation: cycles of collective cognition in work groups.
Journal of Organisational Behaviour 22, 121–134.
Goffee R., Jones, G., 1998. The character of the corporation:
how your company’s culture can make or break your
business. Harper, New York.
Guba E.G., Lincoln, Y.S., 1982. Epistemological and methodo-
logical bases of naturalistic inquiry. Educational Communi-
cation and Technology Journal 30, 233–252.
Halpern, D.F., 1998. Teaching critical thinking for transfer
across domains: dispositions, skills, structure training, and
metacognitive monitoring. American Psychologist 53 (4),
449–455.
W. Lauder et al.
Jenicek, M., 1999. Clinical Case Reporting in Evidence-based
Medicine. Butterworth–Heinemann, Oxford.
Jo, M.L., 1993. Hints and leaner control for metacognitive
strategies in problem solving. Proceedings of Selected
Research and Development Presentations at the Convention
of the Association for Educational Communications and
Technology, New Orleans, January 13–17.
Lave J., Wenger, E., 1991. Situated Learning: Legitimate
Peripheral Participation. Cambridge University Press, Cam-
bridge, UK.
Lauder, W., 1994. Beyond reflection: practical wisdom and the
practical syllogism. Nurse Education Today 14, 91–98.
Lauder W., Reynolds W., Angus, N., 1999. Transfer of knowledge
and skills: some implications for nursing and nurse educa-
tion. Nurse Education Today 19, 480–487.
Mohammed S., Dumville, B.C., 2001. Team mental models in a
team knowledge framework: expanding theory and measure-
ment across disciplinary boundaries. Journal of Organisa-
tional Behaviour 22, 89–106.
Nordgren, A., 1998. Ethics and imagination. Implications of
cognitive semantics for medical ethics. Theoretical Medicine
and Bioethics 19 (2), 117–141.
Nutley S.M., Davies, H., 2001. Developing organisational learn-
ing in the NHS. Medical Education 35, 35–42.
Prawat, R.S., 1989. Promoting access to knowledge, strategy,
and disposition in students: a research synthesis. Review of
Educational Research 59 (1), 1–41.
Pesut D.J., Herman, J., 1992. Metacognitive skills in diagnostic
reasoning: making the implicit explicit. Nursing Diagnosis 3
(4), 148–154.
Renkl A., Mandl H., Gruber, H., 1996. Inert knowledge: analysis
and remedies. Educational Psychologist 31 (2), 115–121.
Robbins, A., 1986. Transfer in cognition. Journal of Neural
Computing 8 (2), 185–203.
Sandelowski, M., 1996. One is the liveliest number: the case
orientation of qualitative research. Research in Nursing and
Health 19, 525–529.
Sharkey S., Sharples, A., 2001. An approach to consensus
building using the Delphi technique: developing a learning
resource in mental health. Nurse Education Today 21,
398–408.
Strong, C., 1999. Critiques of casuistry and why they are wrong.
Theoretical Medicine & Bioethics 20 (5), 395–411.
Toulmin, S., 1990. Cosmopolis: The Hidden Agenda of Moder-
nity. The University of Chicago Press, Chicago.
Wright L.M., Leahey, M., 1999. Maximising time, minimising
suffering: the 15 min (or less) family interview. Journal of
Family Nursing 5 (3), 259–274.
Zimmermann, M., 1998. Ethics and nursing: a contribution to
nursing education. Pflege 11 (4), 219–223.