









































Nwagu, E. N. 
Global Journal of  Transformative Education (2020) Vol 2 
DOI  10.14434/gjte.v1i2.27424

Open Access

Published by the Global Insitutute of Transformative Education (http://www.gite.education)
© Nwagu, 2020. Open Access This journal is distributed under the terms of the Creative Commons Attribution 
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Transformative Learning Potentials of Trainee Health 
Workers in Nsukka, Enugu State, Nigeria

Evelyn N. Nwagu

Abstract
This study investigated transformative learning and the influence of learning experiences and demographic 

characteristics of the learners on transformative learning of trainee health workers in Nsukka, Enugu state, 
Nigeria. Descriptive survey design was used for the study. The instrument for data collection was a fixed-
choice and open-ended questionnaire. Frequencies and ANOVA were computed. Thematic content analyses for 
open-ended questions were done. Participants indicated a high degree of transformative learning. Programme 
type, gender, age and level of study had no significant influence on the transformative learning potentials of 
the students. The most frequently selected learning components were field trips and presentations. Students’ 
responses to the open-ended questions covered themes such as better understanding of health, illness and 
health care.  The study demonstrated the importance of discussion and debate in developing critical reflection 
among learners.

Keywords: Transformative learning, Critical reflection, Change, Health workers, Health, Illness, Health care.

Full listing of authors and contacts can be 
found at the end of this article.

Introduction
Worldwide, the transformation and scaling up of 

health workers’ education and training are important 
issues of concern. A large proportion of health workers 
in Nigeria and other Sub-Saharan African countries are 
trained in post-secondary health institutions and they 
form the major health workforce in health facilities in 
many communities in Nigeria. While training institu-
tions for health workers in developed nations of the 
world are undergoing reforms to increase the compe-
tencies of health workers trained in such institutions 
(Stubbs, 2015; World Bank, 2018), there is a scarcity of 
information and research about health workers training 
in Sub-Saharan Africa, particularly Nigeria. Albeit, there 
is a need for all health professionals and health workers 
in all countries to be educated to mobilise knowledge, 
engage in critical reasoning, and practice ethical con-
duct so that they are competent to participate in patient 
and population-centred health systems as members of 

locally responsive and globally connected teams (Frenk, 
Chen, Bhutta, Cohen, Crisp, Evans, …Zurayk, 2010). The 
training of health workers should, therefore, give rise 
to personal and social transformation which is one of 
the United Nations Educational, Scientific, and Cultural 
Organization’s (UNESCO) five pillars of learning for sus-
tainable development: Learning to transform oneself 
and society (UNESCO, 2010). 

Literature Review
Transformation is an internal fundamental change 

in one’s beliefs for action (Palinkas, 2013). It is quite 
different from mere change in behavior. While change 
uses external influences to modify actions, transfor-
mation modifies beliefs so actions become natural and 
thereby achieve the desired result. Change amends the 
past while transformation creates the future. Change 
and transformation could result from the learners’ 
experiences.

Experiential learning has been described as the 
type of education whereby knowledge and meaning are 
contextualized in actual experiences (Perry, 2011).



61

health workers. Communicative learning is born out 
of a need to understand others and make it easier for 
interlocutors to understand each other by navigating 
language, values, beliefs, and feelings (Cranton& Roy, 
2003; Mezirow, 1997). The learners, their teachers 
and the clients within such institutions have diverse 
values, beliefs, feelings and even languages. Interacting 
with each other in these institutions could bring about 
reflective reasoning that can trigger transformative 
learning.

Experiential Learning Theory (ELT) provides direc-
tion as to how we can develop the type of action-orient-
ed experience that is likely to induce transformation. 
Experiential Learning involves concrete experience, re-
flective observation, abstract conceptualization, and ac-
tive experimentation. Concrete experience refers to an 
actual interaction a learner will have with the environ-
ment or a particular learning event. Reflective obser-
vation provides learners the opportunity to reflect on 
their experiences from different perspectives. It propels 
the learners into the abstract conceptualization stage, 
where the learners integrate their reflections from their 
experiences into new concepts about their learning 
experience and make deductions about their experienc-
es. The final stage is active experimentation where the 
learner takes their newly learned concepts and deduc-
tions from the abstract conceptualization phase and ap-
plies them in new learning settings. Through touching 
all of these bases, knowledge is constructed and learn-
ing achieved (Kolb & Kolb, 2005). Experiential learning 
associated with health worker training programmes 
can make a considerable impact on a student’s ability 
to understand globally complex problems (Kiely, 2004). 
Montrose (2002) explains that there is little under-
standing among providers and administrators of what 
exactly constitutes experiential learning and how it can 
be applied to improve programme structure.

Transformative learning for health workers in com-
munities in Low- and Middle- Income Countries (LMIC) 
has the potential of bridging the gap in the formal 
health services and communities (Black et al.; WHO, 
2016). The disparity in the health of individuals living 
in LMIC particularly rural communities raises questions 
as to beliefs and practices relating to health, illness and 
the quality of health care in such communities. Health 
workers training programmes have been accused of 
not producing competent professionals who are able to 
adequately positively impact the health of the people 
for whom they care. This lack of competence is largely a 
result of fragmented, outdated, and static curricula 

Nwagu, Learning Potentials of Trainee Health Workers

Meeting new and challenging experiences could lead 
to the uncomfortable situation described by Mezirow 
(1991) and could lead to a learning outcome. Mezirow 
stated that only through reflection, active learning, and 
placing ones selves in uncomfortable situations are 
individuals able to develop their understanding of the 
world and of themselves, allowing a potential change to 
their perspectives and frames of reference. Strange & 
Gibson (2017) noted that by applying the basis of 
experiential learning to the potential outcomes of 
transformative learning, it may be possible to further 
direct educational programming for the better. 
Experiential and transformative learning are associated 
with the desired goals of health workers training 
programmes. It is apt to use them both as frameworks 
to assess the transformative learning potentials of 
trainee health workers. Experiential learning can, thus, 
provide guidance in designing health worker training 
programmes such that they will include activities that 
are “more hands on.” 

Transformative learning theory (TLT) focuses 
on the processes involved in changing an individu-al’s 
frames of reference (Stange & Gibson, 2017). The 
transformative learning theory was propounded by 
Jack Mezirow in 1978. Mezirow asserted that adults 
make meaning of their experiences and that the specif-
ic social structures within which the experience takes 
place enable adult learners to read meaning into their 
experiences. Where such meanings are found to be 
dys-functional they change their meaning of them 
(Cranton, 2006; Mezirow, 1991; Taylor, 2007). The 
process of evaluating meaning structures starts with 
instrumental learning, passes through communicative 
learning and then transformative learning (Mezirow, 
1998, 2003). These three domains though distinct are 
interrelat-ed (Mezirow, 1981) and they occur through 
critical reflection and rational discourse (Moyer & 
Sinclair, 2016). Instrumental learning occurs when the 
learner manipulates and controls the environment, 
predicts observable physical and social events, and 
takes appro-priate actions (Cranton & Roy, 2003). The 
environment in training institution for health workers 
is a source of instrumental learning. Students admitted 
into such institutions are capable of manipulating the 
environment to an extent that can bring about 
transformative learning. Students can search out 
information from the Internet, interact with other 
students, get themselves involve in discussions and 
debates and also interact with clients during the 
training programme. Hence this study explored 
whether or not transformative learning occur in health 
workers in institutions of training for 

Global Journal of Transformative Education (2020) Vol 2



Nwagu, Learning Potentials of Trainee Health Workers 62

Global Journal of Transformative Education (2020) Vol 2

(Frenk et al, 2010). There is a need for a serious shift 
in the mindsets of health workers for meaningful and 
sustainable change to occur (Agyepong et al., 2017). 

This calls for a re-examination of the health care 
workers’ educational programme, to ensure that the 
curricula of health workers are able to provide the 
needed transformation that will help health workers 
assume and develop their personal, professional, and 
social roles. Results from such studies are essential in 
planning effective training methodologies and materials 
to improve the efficacy of knowledge-sharing of health 
personnel (Mbuya, Menon, Habicht, Pelto, & Ruel, 2013; 
McCalman, Jongen, & Bainbridge, 2017). 

Health workers in training are adults and upon 
graduation, their health care job is often with adults. 
Adult learning involves critical thinking and reflection 
on what is already known in order to change and adopt 
a new way of doing things (Gibby, 2013). Sharing of 
knowledge that will produce positive result requires 
that health workers should believe and be convinced of 
the right values and practices. There is a need for health 
workers to drop unhealthy values and socio-cultural 
norms that do not allow them to actively participate in 
effective and health-promoting practices. Hence there 
is also a need for the training programme of health 
workers to give them adequate opportunity to reflect 
on their previous knowledge, values and practices with 
a view of transforming them positively. Such trans-
formative learning according to Renigere (2014) will 
stimulate trainee health workers to learn to think in-
dependently in order to dispose of the knowledge that 
has at times been acquired as a result of life experience 
without ever thinking or asking questions.

This study, therefore, examined how the students’ 
learning experiences have influenced their transfor-
mative learning. Transformative learning is a possible 
outcome of instrumental and communicative learning 
when modification of premises, assumptions, and deep 
meaning structures result in a transformation of action 
and behaviour (Cranton, 2006).

Therefore, presenting appropriate learning experi-
ences to trainee health workers that will enable them 
to reflect on any value and meaning they may have had 
prior to the training may bring about transformative 
learning in health workers. Transformative learning 
encompasses a life-enhancing change (Mezirow, 2003). 
When learners experience transformative learning, 
they often become more inclusive, distinguishing, open, 
reflective and emotionally able to change, ultimately 
showing higher connectedness to the global environ-

ment (Mezirow, 2003). 
Educators engaged in teaching health workers 

should be able to identify ways of promoting students’ 
ability to find purpose and meaning from their ex-
periences through a variety of learning components 
(Bidabadi, Isfahani, Rouhollahi, & Khalili, 2016). If 
health workers should develop their personal, profes-
sional and social roles, they need to develop their rea-
soning ability. Such reasoning hopefully will give them 
the opportunity to better understand the lives of other 
people. For instance, being able to identify the emotion-
al states of their clients and putting themselves in oth-
er’s shoes. These will help them to understand others’ 
beliefs, feelings, experiences and intentions. Thus, they 
become able to think about things from others points of 
view (Lieberman, 2007). 

Nigeria, like many other countries in Sub-Saharan 
Africa, faces infectious diseases, malnutrition, child 
and maternal mortality, emerging challenges from an 
increasing prevalence of chronic conditions, mental 
health disorders, injuries, and health problems relat-
ed to climate change and environmental degradation 
(Agyepong, et al., 2017). Life expectancy and public 
health indicators remain low in Nigeria compared to 
that of other middle-income countries in other parts 
of the world. There is need to find a viable and lasting 
solution to bridge this gap in health status between 
individuals of diverse socio-economic statuses in many 
communities in Nigeria. 

Many studies on health care services have looked 
at the type of services provided by health workers in 
low-resource communities and only a few have looked 
at the preparation of health workers for such service 
(O’Rourke, Howard-Grabman, & Seoane, 1998; Laugh-
lin, 2004; Matare, et al., 2015; Lamstein, et al, 2014). 
If efforts are made in the right directions, Nigeria has 
the potential to improve the health status of its popula-
tion if the nation will make effective use of its available 
human resources (Adeloye et al., 2017). There is a need 
for health workers to have a change of approach in the 
way they view certain things and the way they act.

Health workers in most rural health facilities and 
in urban slums in Nigeria comprise: Community Health 
Extension Workers (CHEW), Junior Community Health 
Extension Workers (JCHEW), Nurses, Midwives and Lab 
Technologists. The World Health Organization (WHO) 
(2016) advocated that training of health workers 
should adopt an approach that is people-centred and 
inspired by progress and adapted to the country’s spe-
cific needs. The basic training of these cadres of health



Nwagu, Learning Potentials of Trainee Health Workers 63

Global Journal of Transformative Education (2020) Vol 2

workers is largely done at post-secondary training 
institutions, many of which are hospital based. The 
contributions of Community Health Workers (CHWs) 
are globally recognized as capable of closing the gap 
between formal health services and communities 
(Black et al., 2017; WHO, 2016). Community Health 
Workers are among the WHO Global Strategy for Hu-
man Resources (Maher & Cometto, 2016) and they are 
considered an integral component to reach impact and 
equity goals (Lewin et al., 2010). Nurses and midwives 
have been identified to be actively involved in both 
hospital and community health practices (Adib-Hajba-
ghery, 2013). The basic laboratory services provided 
by laboratory technicians are very crucial for improv-
ing the potential of the Primary Health Centres (PHC) 
as centres providing primary health care. Inadequate 
training of lab technicians has been blamed for the poor 
laboratory service in PHC (George, 2011). The question 
then arises; are the training programmes in the various 
institutions of training of these cadres of health care 
workers capable of producing transformative learning 
among students trained in these training institutions?

Purpose of the Study
The purpose of the study was to investigate the 

transformative learning potentials of different cadres 
of trainee health personnel in Nsukka, Enugu State, 
Nigeria. Specifically, this study examined the influence 
of experiential learning and the influence demographic 
characteristics of participants on transformative learn-
ing outcomes.

Research Questions
1. Does transformative learning occur in trainee health 

workers in institutions of training of health workers?
2. How have learning experiences influenced transfor-

mative learning among students?
3. How do the demographic characteristics of age, gen-

der, programme type and level of study influence the 
transformative learning of trainee health workers?

Methods
Design 

The descriptive survey design was used to measure 
the degree of transformative learning by trainee health 
workers. The questionnaire was used to elicit demo-
graphic information from the students, their transfor-
mative learning as well as the experiential components 
of their programmes. The primary analysis tools were 
frequencies, means, standard deviation, percentages, 

ANOVA, and thematic content analyses of open-ended 
questions. 

Data Collection 
Ethical approval for the study was granted by Bish-

op Shanahan Hospital ethical review board. Data were 
collected from students in four training institutions 
for health workers in the area of study. The researcher 
made contact with the principal of each school to ob-
tain permission for the study. Informed consents were 
obtained from the participants. The questionnaire was 
distributed and collected on the spot to avoid omission. 

Participants 
The study population consisted of all trainee health 

workers in health training institutions in Nsukka. The 
total size of the population was 647 students (Students’ 
class registers for 2017 academic session). A sample of 
245 students was drawn from the five health workers’ 
training institutions in Nsukka using the stratified ran-
dom sampling technique. The stratification was done 
based on gender, age, level of education and course of 
study. A random sample proportionate to a stratum’s 
size was taken from each stratum. The demographic 
characteristics of the respondents are shown in Table 1.

Table 1. Demographic characteristics of respondents
Variables Frequency Valid %

Gender
Male 18 7.3
Female 227 92.7
Total 245 100

Level of education
Year 1 102 41.6
Year 2 78 31.8
Year 3 65 26.5
Total 245 100

Age in years
Less than 20 64 26.3
21-30 164 67.5
31-40 15 6.2
Total 243 100

Course of study
Nursing 19 7.8
Midwifery 30 12.2
JCHEW 52 21.2
CHEW 72 29.4
Lab Technology 72 29.4
Total 245 100



64Nwagu, Learning Potentials of Trainee Health Workers

Instrument 
The instrument used in this study consisted of a 

fixed-choice and open-ended response format ques-
tionnaire. The questionnaire contained three sections. 
Section one was used to collect the respondents’ de-
mographic information. Section two consist of twelve 
items on transformative learning adapted from Strange 
and Gibson (2017) test of transformative learning as 
shown in Table 2. In order to assess whether trans-
formative learning has occurred, Brock (2010) noted 
that it is important to question the learners about 
any change which they may have experienced in their 
beliefs or values. The response options for items in this 
section were dichotomous (yes = 1 or no = 0). Section 
three measured program information and experien-tial 
learning (see Table 3). The open-ended questions 
addressed the students’ transformative learning experi-
ences and their experiential learning. The open-ended 
questions consist of the following questions: 1) During 
your study in this school did you experience a situation 
that changed your beliefs or values about patient care? 
Please explain. 2) Do you think your study in this insti-
tution changed your expectations of health care in life? 
Please explain. 3) What was the most important thing 
you learned about health, illness and health care? 4) 
What did you learn about yourself? Please explain. 5) In 
what ways do you feel the program impacted your life? 
Please explain. 6) How long is your programme? 6) Do 
you feel that the length of your program is adequate to 
meet your goals? Please explain. 7) Did the components 
in your program impact your learning? How? 8) Are 
there any program components that were excluded that 
you feel would have been beneficial? 

The reliability of the instrument was established by 
pre-testing the instrument on 20 trainee health work-
ers in Enugu east senatorial zone who share the same 
characteristics with the population but are not part of 
the study. Section two of the instrument yielded a rela-
tively high Cronbach’s alpha of α = .80. Two instructors 
from each school served as research assistants. Copies 
of the questionnaire were distributed to trainee health 
workers in the selected health training schools and the 
completed copies of the questionnaire were collected 
on the spot. 

Data Analysis
Data were analyzed using IBM SPSS (Statistical 

Package for the Social Sciences Version 21.0). Frequen-
cies and percentages were generated for all the vari-
ables. Homogeneity of variance was verified using the

Global Journal of Transformative Education (2020) Vol 2

Levene’s test of homogeneity of variance. The signifi-
cance of the Levene’s test suggested equal variance for 
the four variables; gender, level of education, age, and 
course of study (See Table 4). ANOVA was therefore 
used to analyze differences in transformative learning 
experiences on all the four variables. Items not re-
sponded to by some respondents were treated as miss-
ing data and were excluded from the analysis. Thus, 
some analyses were conducted with smaller sample 
sizes

Open-ended questions. 
The open-ended responses were analyzed to pro-

vide an in-depth evaluation of the students’ experienc-
es and transformative learning while in their training 
programme. Thematic analyses of the responses were 
done. The responses were transferred into a word file 
and printed out. The printout responses were reviewed 
and coded to identify initial categories. The open-ended 
questions were used as a framework for categorizing 
codes related to each research question. The initial set 
of codes were expanded and refined to better reflect 
the common elements that existed across the full data 
set. Patton (2002) asserted that this iterative style of 
analysis is a recognized characteristic of the qualitative 
research method. Patterns were identified inductively 
by analyzing codes associated with research questions. 
Further coding refinement occurred when all the codes 
associated with a particular open-ended question were 
examined for convergence. The qualitative content 
analysis was then used to identify themes across the 
codes. Examination of the response patterns across the 
data sets ultimately led to the emergence and 
identi-fication of themes. The data for transformative 
learning (research question one) and experiential 
learning (research question two) were organized as 
separate data sets. Response patterns were used to 
complement qualitative data on each research 
question.

Results
The responses of the students to the transformative 

learning questions are contained in Table 2. “I had an 
experience that caused me to question my ideas about 
health and illness behavior and health care received 
the highest positive responses,” 94.7% participants 
responded yes. Students’ responses to the open-ended 
questions covered the following themes; better under-
standing of health, illness and health care; values and 
beliefs about patients’ health care and patient’s right; 
and expectations of healthcare roles. Changes occur 



Nwagu, Learning Potentials of Trainee Health Workers 65

with respect to understanding health, illness and health 
care. Some students (18 %) expressed that they now 
realize that health and illness is a continuum and as 
such health status is not static. A better understanding 
of disease causation and treatment were also expressed 
by 47 % of the students. Thirty nine students (16 %) 
simply answered ‘yes’ to the question, “During your 
study in this school did you experience a situation that 
changed your beliefs or values about patient care?” 
but did not provide any explanation while seven stu-
dents (3 %) of the students simply answered ‘no’ to the 
question without any explanation. Myths about disease 
causation and treatment were dropped in 18 % of the 
students, for instance a second-year JCHEW student 
stated “before I came into the school, I use to think that 
stroke can only be caused by evil people not knowing 
that sickness like high blood pressure can cause it.” 
Thirty-six percent of the students reported that 
changes occurred in their values and beliefs about 
patients’ health care and patient’s rights. For instance, 

Global Journal of Transformative Education (2020) Vol 2

one student midwife said “I realized that drugs weren’t 
all that the patients needed most times but tender loving 
care.” With respect to patients’ rights, a third-year 
nursing student has this to say “Initially I felt patients 
have no choice than to abide by the nurses’ opinion 
always but I have come to know that patients also have 
rights too.” Again, a CHEW student stated “…I was 
thinking that a patient that is under your care should 
follow all your commands but it is not so.” Changes in 
expectation of healthcare roles were reported by 
twelve percent of the students. One student midwife 
said “I think I expected so much from providers (health 
providers) but now I realize that they are just humans 
capable of doing what they can at a time.” 

The second research question asks how learning 
experiences influenced transformative learning among 
students. Table 3 provides the data on the learning 
components that the students experienced in their 
programmes.

Table 2. Students’ Responses to Transformative Learning Questions 
Yes No 

f % f %
While in this training, I have had an experience that 209 86.7 32 13.3 
caused me to question the way I normally act. 
I had an experience that caused me to question my  232 94.7 13 5.3 
ideas about health and illness behavior and health care.
As I questioned my ideas, I realized I still agreed with 108 44.4 135 55.6 
my previous beliefs or role expectations.
As I questioned my ideas, I realized I no longer 130 53.7 112 46.3 
agreed with my beliefs or role expectations.
I realized that other students also questioned 204 84.0 39 16.0 
their beliefs.
I thought about acting in a different way from my 185 75.4 54 22.6 
usual beliefs and roles.
I felt uncomfortable with traditional social 175 72.0 68 28.0 
expectations.
I tried out new roles so that I would become more 217 88.9 27 11.1 
comfortable or confident in them.
I tried to figure out a way to adopt these new 217 88.6 28 11.4 
ways of acting.
I gathered the information I needed to adopt these 216 88.5 28 11.5 
new ways of acting.
I began to think about reactions and feedback 205 84.4 38 15.6 
from my new behavior.
I took action and adopted these new ways of acting. 200 82.4 43 17.6



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Global Journal of Transformative Education (2020) Vol 2

Table 3. Learning components experienced by students
S/N Learning component f % 
a. Essays 164 66.9
b. Formal quizzes 112 45.7
c. Field quizzes 65 26.5
d. Mutiple choice 126 51.4
e. Short answer exams 72 29.4
f. Essay exams 163 66.5
g. Open-book exams 29 11.8
h. Debates 69 28.2
i. Group projects 157 64.1
j. Student led discussions 202 82.4
k. Field lectures 105 42.9
l. Field trips 58 23.7
m. Presentations 200 81.6
n. Others (specify) 14 5

The students were asked to tick from a list of learn-
ing components the ones they experienced during their 
training programme. The component that received the 
highest identification was the student-led class discus-
sion (82.4%), followed by the presentation (81.6%) 
and experiments (71%). Only fewer than half of the 
students identified the open book exams (11.8%), field 
trips (23.7%), short answer tests (29.4%), debates 
(28.2%), field lectures (42.9%) and formal quizzes 
(45.7%) as learning components in their programme. 
Fourteen students specified other components such 
as demonstrations, and ward/clinical postings. The 
students were also asked to comment on how the com-
ponents available to their programmes impacted their 
learning. Their responses to this question fall under the 
following themes: boldness in communication, increase 
in understanding, acquisition of practical skills. About 
half of the students (48%) commented that student-led 
discussions, presentations and practical experiences in 
the health centres impacted them the most. One final 
year nursing student stated “presentations have made 
me bold and confident to speak out.” A first-year Com-
munity Health Extension Worker has this to say “group 
discussion improve student ability … and make you re-
member all that the lecturer has taught.” A second-year 
Junior Community Health Extension Worker believed 
field trip impacted her the most. She said “I learnt how 
to conduct delivery and give injections in my field trip.” 
A second-year male student lab technician said “they 
(presentations and student-led discussions) enabled me 
to conquer stage fright.” One midwifery student had a 
contrary view, she said “I don’t really like group things, - 
discussions and presentations, but I discover that

group discussions help to cover more (referring to class 
work).”

In order to expand on the experiential aspects, 
students were also asked, “Are there any program com-
ponents that were excluded that you feel would have 
been beneficial?” Ten students made suggestions that 
include: use of social media for students’ interaction 
on the topics taught, inclusion of debates to sharpen 
understanding, and on-the-job supervisions to enhance 
skill acquisition. 

There were no significant influence of gender, level 
of study, age and course of study on transformative 
learning at .05 level of significance (Table 4). 

Discussion
The result of this study showed that transforma-

tive learning does occur in health professionals’ study 
programme (research question one). Items one (While 
in this training, I have had an experience that caused 
me to question the way I normally act. 86.7%) and 
two (I had an experience that caused me to question 
my ideas about health and illness behavior and health 
care. 94.7%) were experienced by majority of trainee 
health workers. Hence their training programmes were 
able to engender critical reflections in the students 
that made them aware of their wrong assumptions 
and beliefs about health and illness thereby producing 
what Mezirow (1991) defined as perspective trans-
formation. Mezirow (1991) identified 10 phases of 
perspective transformation beginning with a “disori-
enting dilemma” and culminating in “a reintegration 
into one’s life on the basis of conditions directed by 
one’s new perspective”. Eighty-two point four percent 
of the students in this study actually took actions and 
adopted new ways of acting. Students’ responses to 
open-ended questions showed that much of the chang-
es occurred in their understanding of the causation and 
treatment of diseases. Students acquired new knowl-
edge which made them drop myths and fallacies about 
disease causation and treatment. Belief systems were 
also transformed. Many of the students also expressed 
a change in their expectation of healthcare roles. This 
finding is consistent with results of similar studies 
among health workers that have shown different de-
grees of transformation among health workers with ap-
propriate learning/teaching methods (Altobelli, 2017; 
Renigere, 2014). It is however important to note that 
true transformation takes place only when learners are 
able to actively take steps that acknowledge their new 
belief (Mezirow, 1997). The study period of three years



Nwagu, Learning Potentials of Trainee Health Workers 67

Global Journal of Transformative Education (2020) Vol 2

may therefore not be enough for transformation to take 
place. 

Worthy of note is the fact that some students have 
no evidence of having actually experienced a transfor-
mation of their worldview and habits. Although the 
idea of transformation as a major, fundamental change, 
as opposed to minor, marginal, or incremental change, 
is widely agreed upon in both research and policy 
(Kapoor 2007; O’Brien, 2012), there is little consensus 
regarding the features that make change in human–en-
vironment systems “transformational,” and different 
from “non-transformational” shifts. In fact, as some 
have noted (Berkhout 2013; ISSC and UNESCO, 2013; 
Mustelin & Handmer 2013), the wider conceptual bases 
of transformation, notions of its forms, and processes 
have been the subject of debate. A logical question for 
trainee health workers educators therefore should 
be, “What can I do to bring a student into the realm of 
transformation?” Redefining the experience can make 
the educators to start thinking of starting the process of 
change and ramping it up to transformation.

The greater the difference between what came before 
and what took its place, the closer the individual move 
toward transformation (Burrus, 2017).

Moving from change to transformation may come 
from a simple question such as: “How can I offer my 
students the ability to do what they would want to do if 
only they knew it was possible?” In other words, rather 
than merely changing or even improving something, 
what utterly new service would health workers provide 
if they were aware of it and what it could do for their 
clients and the health system? Rather than looking to 
change something Burrus (2017), advocated that indi-
viduals should aim for transformation from the onset. 

It is, however, worrisome that health care workers’ 
training programmes are capable of producing trans-
formation yet the quality of care rendered by practicing 
health care workers in Nigeria has been described by 
many as very deplorable (Ephraim-Emmanuel, Adigwe, 
Oyeghe, &Ogaji 2018). The reason for this may be found 
in the assertion made by Mosadeghrad (2014) that fac-
tors such as the patient cooperation; leadership and

Table 4. The influence of the demographic characteristics of gender, level of study, age and course of study on 
transformative learning (ANOVA)
 Group statistics Levene’s Test ANOVA
Variables N Mean SD P F P
Gender    .309  
Male  18 9.67 1.46   
Female  227 9.40 1.90   
Variance between groups    .337 .562   

Level of study    .341  
First year 103 9.45 1.90   
Second year 78 9.38 2.05   
Third year 65 9.42 1.60   
Variance between groups    .028 .972

Age in years    .907  
Less than 20  64 9.60 2.13   
21 - 30  164 9.38 1.75   
31 and above 15 9.33 1.88   
40 and above 2 8.50 .71   
Variance between groups    .330 .719

Course of study    .301  
Nursing 19 9.21 1.69   
Midwifery 30 9.73 1.39   
JCHEW 52 9.57 2.42   
CHEW 72 9.15 1.79   
Lab Technology 72 9.50 1.70   
Variance Between groups    .762 .551



Nwagu, Learning Potentials of Trainee Health Workers 68

Global Journal of Transformative Education (2020) Vol 2

management styles in health facilities; collaboration; 
available referral system; job satisfaction of the health 
care providers are also necessary for improved quality 
of health care. Addressing the training programmes 
of health workers alone may not produce the needed 
result, but rather engaging in a comprehensive re-
structuring of health system as a whole to improve the 
health care delivery. Practices such as, discriminatory 
behaviour and attitudes toward patients with certain 
forms of diseases by health workers (Reis et al., 2005) 
should stop.

The findings of this study have shown that trainee 
health workers learning experiences had influenced 
transformative learning in different ways (research 
question two). Learning experiences such as stu-
dent-led discussions, presentations and practical 
experiences influenced students the most leading to 
boldness in presenting their owns view and increases 
in understanding and acquisition of skills. White and 
Nitkin (2014) observed that for transformative learn-
ing to occur, learners need to be actively engaged with 
experiential learning. Therefore, using appropriate 
learning components such as student-led discussions 
and presentations in teaching such contents as food 
habits, cultural beliefs and practices, stigmatization and 
discrimination and other local conditions that have neg-
atively influenced the health of individuals and commu-
nities in Nigeria (Ojua, Ishor, &Ndom, 2013; Olalekan, 
Akintunde, & Olatunji, 2014) in teaching trainee health 
workers is capable of resulting in transformative learn-
ing. The trainee health workers will themselves become 
positively transform and will also be able to guide oth-
ers to become equally transformed. 

There were no significant influences of gender, level 
of study, age and course of study on transformative 
learning. While some previous studies found significant 
association between some demographic characteristics 
and transformative learning, some did not find such 
associations. For instance, Kumi-Yeboah (2014) in a 
similar study found that there were no significant asso-
ciation between gender, age group and programme of 
study and transformative learning experiences. Strange 
and Gibson (2017) also found that there was no statis-
tical difference among program type and the summated 
transformative learning score. Brock, Florescu, and Ter-
an (2012) however found only age and ethnicity to be 
the demographic variables to have significant relation-
ship with transformative learning among class stand-
ing, semesters completed, age, prior education, gender, 
and ethnicity. Future studies re-examining the 

influence of age, gender, programme type and level 
of study on transformative learning of trainee health 
workers is therefore necessary. The present study 
however shows that all health workers irrespective of 
profession, gender, age or level of study are capable of 
transformative learning. 

In order to expand on the experiential aspects the 
researcher also asked “Are there any program compo-
nents that were excluded that you feel would have been 
beneficial?” Ten students made suggestions including: 
use of social media for students’ interaction on the 
topics taught, inclusion of debates to sharpen under-
standing, and on-the-job supervision to enhance skill 
acquisition. 

The students’ request for the use of social media 
as an instructional component to enable interaction 
on the topics to which they were exposed in the pro-
gramme is not surprising. Extending the instructional 
component to information technology is an innovation 
that has great promise of success even in the training 
programme of health workers. Agyepong, et al. (2017) 
noted that information and communications technolo-
gies and social media have been and will continue to be 
important enablers of Africa’s transformation. Frenk et 
al. (2010) also noted that good professional education 
programmes mobilise all learning channels to their 
full potential noting that in many professional schools, 
students with handheld information technology devices 
are able to double-check in real time the accuracy of a 
lecturer’s presentation. 

Conclusion
This study has shown that transformative learning 

does occur in trainee health workers in institutions 
of training. The trainee health workers learning ex-
periences have also been shown to influence their 
transformative learning in diverse ways. Age, gender, 
programme type and level of study of trainee health 
workers had no significant influence on their transfor-
mative learning. Therefore, needed reforms in health 
workers services can be achieved through appropriate 
learning experiences tailored to enhance critical re-
flection and necessary adjustment in the needed areas 
of their services. Discussions and debates on issues per-
taining to health should be encouraged in the training 
programme of health workers. Professional educators 
are key players since they are the ones that will initiate 
and guide the students through the desired change. The 
training and education of health workers should focus 
less on memorising and transmitting facts and more on



Nwagu, Learning Potentials of Trainee Health Workers 69

the promotion of the reasoning and communication 
skills that will enable the health worker to be an 
effective partner, facilitator, adviser, and advocate 
(Frenk et al., 2010). However, future studies re-
examining the influence of age, gender, programme 
type and level of study on transformative learning 
of trainee health workers is suggested. Also, other 
factors such as patient cooperation; leadership and 
management styles in health facilities; collaboration; 
available referral system; job satisfaction of the health 
care providers should be investigated since these have 
be identified as capable of impacting the quality of 
health care (Mosadeghrad, 2014).

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