Introduction and Rationale for the Study
Nursing education continues to rely heavily on the lecture while students are expected to transfer and apply didactic knowledge in complex clinical situations. Bevis (1982) criticizes this practice and recommends active and clinical practice-oriented approaches to teaching, Pluckhan (1978) studied the communication and relationship skills of nurses suggesting that new instructional approaches, such as Carkhuffs training model, be used. There are several reports of the use of experiential teaching approaches in the nursing literature by Dietrich (1978), Reakes (1979) and others but no controlled comparisons of the effects of these approaches in teaching communication skills are available.
Survey of the educational research literature found no consistent differences in studies which compared the effects on student performance of lecture vs less conventional approaches in teaching varied content (Costin, 1972; McKeachie, 1970). However, these authors found that discussion was frequently superior to lecture in reaching higher level cognitive goals such as analysis and application. Learning theorists such as Bruner and Dewey have long held that learning is an interactive process involving learner, content, and learning process. More recently, there has been a great deal of interest in the effects of learning style on career choice and performance (KoIb, 1981; Witkin, Moore, Goodenough & Cox, 1976).
Encouraging nursing faculty to adopt nontraditional instructional approaches based on limited research with somewhat ambiguous results and applicability seemed unlikely to produce change. For this reason it seemed valuable to undertake a carefully controlled study using random assignment to determine the effects of selected learner attributes (learning style and maturation) and method of instruction on instructional outcomes for the selected content area of basic communication skills.
The research question was: Do significant differences exist in perceived satisfaction, cognitive performance, retention and transfer of knowledge to the practice setting between:
A. traditional and nontraditional students when taught communication skills by a) lecture or b) role play?
B. students characterized as field dependent or field independent in learning style when taught communication skills by a) Jecture or b) role play?
FACTORIAL DESIGN OF THE STUDY
The Study Design
A factorial design (Table 1) was selected and students were randomly assigned to two treatment groups: lecture instruction or role play and discussion. Time requirements, media used, and format were held constant as the study procedures were repeated at three different times to achieve a sizable group (N=147) of traditional and nontraditional students at identical points in the BSN curriculum.
Analysis of variance and covariance were used to identify significant main effects and interactions of the treatments and the selected student attributes on performance outcomes. Outcome measures included 1) objective test items administered immediately following instruction and comparable items administered one month later, and 2) instructor ratings of student process recordings of actual nursepatient interactions on four dimensions of communication - respect, caring, concreteness and empathy. The rating scale for each of these dimensions contained criteria ranging in points from 1 (highly inappropriate) to 5 (neutral) and 9 (mastery level of the skill). Chi square was used to analyze differences between students assigned to lecture or to role play on Likert Scale criteria evaluating perceived satisfaction with the method of instruction.
Operational definitions used in the study included learning style, traditional-nontraditional status, communication content and method of instruction.
Field dependent-independent learning style is a concept derived from the work of Witkin and others (1976, 1977). The Hidden Figures Test (Part 1) was administered to all students. Those scoring above the mean for all students were categorized as field-independent and those scoring below the mean as field-dependent. Witkin (1976) suggests that field dependence is associated with a global response, social sensitivity and involvement with people while field independence is associated with an analytical approach, systematic planning and individual goal setting. The factor being tested involves the ability to hold a visual image in mind and differentiate it from other images in a distracting visual field.
Traditional-nontraditional status refers to groups of nursing students at comparable levels of the BSN program of instruction - the sophomore level course in introductory nursing concepts. Traditional students in this private, midwestern school of nursing tend to be young (age 20 to 21), female (97%), white (99%), and have completed one year of college. Nontraditional students are composed of students who enter the nursing program following a college degree in another field and completion of all prerequisite coursework. They are older (age range is 22 to 55 years of age with a mean age of 28 years), are made up of a higher percentage of male students (25%), and have a wider range of previous academic and life experiences. Roughly described, this mixture of age and experience could be generalized as a maturity factor.
Basic communication content for the purposes of the study included skills and attitudes from the work of Carkuff (1980) including:
1. Respect - demonstrating attending behaviors and honoring patient cues or expressed preferences.
2. Genuine caring - congruent behavior which demonstrates warmth and concern.
3. Concreteness - clarity of speech by the nurse and attempts to clarify vague patient messages.
4. Empathy - demonstrating understanding of the patient's meaning and experience from the patient's unique perspective.
Specific techniques of active listening; directive, clarifying and nondirective statements are included as they relate to these dimensions and the goal-directed content of the interaction.
Methods of instruction used were lecture or role play. Both groups shared the common elements of required readings and videotaped demonstrations of a) effective, and b) ineffective interactions for each of the four communication dimensions. The lecture was a didactic presentation preorganized in outline form and presented by the researcher. Student questions were permitted to amplify or clarify content and appropriate responses were made to these questions. The videotaped demonstrations were incorporated into the lecture as examples. The role play groups of three students each were provided with structured guidelines and situations to enact following viewing of the videotaped demonstrations of effective and ineffective communication. The role play sequence included 1) read the context and goal, 2) enact the nurse/patient roles, and 3) discuss the effectiveness of the communication demonstrated in playing the nurse role with feedback from the student observer. Questions from students in role play were redirected back to the students themselves for discussion. Faculty assisted only with structuring the groups and keeping to the time scheduled.
Limitations and Delimitations of the Study
Objective test items and the communication rating scale were nonstandardized. The items were keyed to the instructional objectives and required media for content validity and reviewed by other faculty familiar with the content. Level of difficulty ranged from .44 to .98 for the items (indicating the percent of students in the total group who correctly responded to each item). Point biserial correlations were positive ranging from .025 to .407. lest-retest reliability for the two cognitive test forms was R = .328 (p = < . 00002) indicating with reasonable confidence that scores on the two tests are related and not due to chance.
The sample was drawn from one nursing program with two BSN entry points - one for traditional and one for accelerated (nontraditional) nursing students. One of the assumptions of the study is that students in the study population do not vary significantly in their learning styles or ability from comparable students. The number of students in some subgroups in the total population for the study is small (e.g., males in the traditional student group).
Study Findings and Discussion
In comparing the effects of lecture vs. role play instruction, there were no significant differences on objective test performance or instructor ratings of student process recordings between the two groups. There was a significant interaction (p = < .05) for sex and method of instruction demonstrated. The mean score for males taught by role play was higher than for males taught by lecture, while the mean score for females taught by lecture was higher than for females taught by role play. This finding is of interest because it suggests that men and women may have different kinds of learning needs in relationship to communication skills. This may be related to differences in sex role socialization.
STUDENT EVALUATION OF METHOD OF INSTRUCTION
Students' responses on the evaluation criteria for each of the two methods of instruction demonstrated several significant findings (p = < .05) on chi square analysis (Table 2). Role-play students were more likely to agree with statements that the method of instruction promoted active involvement, held their interest and was a preferred learning approach. Lecture students were more likely to agree (p = < .05) with statements that the method met the objectives for the lesson and promoted understanding of the material. This was despite the absence of significant differences in cognitive performance between the two groups. This finding suggests that role-play instruction is preferred by students and has the benefit of actively engaging them in the process of learning. It can be used in teaching communication content without concern for overall logs of outcome performance and may be particularly useful for male students. Female students may benefit from the cognitive structuring of lecture on some key points related to differences between social and helping communication.
Analysis of student characteristics in relation to outcome performance demonstrated significant (p = < .05) findings on ANoVA with age as a covariant. The field independent student group had higher mean scores on both objective tests than did the field dependent group. This is not consistent with the theoretical expectation that field dependent students would be more interpersonally oriented and aware. This finding may reflect the analytical skills of the field independent students in taking objective tests. No differences in instructor ratings on process recordings were significant for groups characterized as field dependent or independent. A significant interaction was also demonstrated for learning style and traditional-nontraditional attributes (Table 3).
SIGNIFICANT STUDY FINDINGS
The attribute of traditional vs. nontraditional status demonstrated significant (p = < .05) findings on ANOVA with age as a covariant. Nontraditional students had significantly higher scores on the objective test which immediately followed instruction but not on the second test one month later.
Nontraditional students also received significantly higher ratings on three of the four dimensions of communication used in instructor ratings of process recordings. The significantly higher means for nontraditional students were obtained on the dimensions of caring, Concreteness, and empathy. There were no differences on ratings of respect for the two groups. The differences on objective testing suggest only that the nontraditional students may have prepared better (required readings) for class than the traditional students or that their initial grasp of the content was better. These differences disappeared once all students had the opportunity to study the material, apply the content in actual practice settings and evaluate their communication in process recordings.
The higher mean performance levels for the nontraditional student group on three of four dimensions of communication are important findings suggesting that maturity level may be a significant factor in student ability to apply communication knowledge and skills in the practice setting. Only the dimension of respect did not demonstrate a significant difference and this dimension is the most basic involving eye contact, body positioning, environmental management, and response to patient cues. The other dimensions require more complex judgments and responses in order to clarify another's viewpoint and meaning, respond spontaneously and nonjudgmentally, and explore the perspective of another in a context which includes feelings and experiencing.
The nontraditional students were older, had completed a bachelor's degree in college and had opportunity for more diverse life experiences than the younger traditional students. Growth and development or maturity is a process of adaptation occurring in response to challenges (Heath, 1980). Maturity or growth in response to life experiences is logically associated with greater interpersonal awareness and effectiveness particularly on the communication dimensions described.
Implications of the Study
Several interesting considerations for further research are suggested by the study findings. It would be valuable to further explore whether field dependent-independent learning style is related to dimensions of performance for interpersonal skills using more precise and varied measurements. Further exploration of the interactive effects of sex and method of instruction on cognitive performance would be of value in determining whether males and females tend to have different learning needs in mastering basic skills of communication.
Nurse educators may confidently use role play or lecture strategies in providing basic content for communication skills with the knowledge that overall test performance and ability to transfer content to practice is not likely to differ. It is suggested that role play has an advantage in that it is preferred by students and actively engages their interest and involvement. It may be necessary to reassure students and faculty that learning outcomes are not likely to be decreased.
The most important study finding is the demonstrated significance of student maturity level over method of instruction and learning style as a factor influencing the student's ability to transfer and apply complex communication concepts and skills. Historically, communication content was taught in a psychiatric nursing course, which was generally offered later in the program of instruction to permit students to develop a greater degree of maturity before being confronted with the complexities of human behavior and mental illness. As the integration of curricular strands and broad concepts throughout the program of study became more popular, communication skills frequently were taught in part or in their entirety in initial courses or levels of nursing. These skills are the logical foundations to teaching, interviewing, and assessment skills as well as the helping-counseling role of the nurse. This study demonstrates the importance of careful consideration in the placement of communication content in the curriculum. Basic level students readily grasp the cognitive structure of interviewing for basic data collection and assessments organization, and are able to transfer and demonstrate knowledge pertinent to showing respect and consideration for the client and demonstrating attending behaviors. More complex skills are 1) nurse concreteness and clarification of the patient's vague and misleading comments, 2) genuine caring which implies nonpossessive warmth, congruence and a nonjudgmental attitude, and 3) empathy which implies the ability to understand others' feelings from their unique perspectives and experiences. These skills should either be placed later in the program or upper level provision added for development, feedback and reinforcement of these skills when taught earlier. This would assist students to effectively incorporate communication into clinical situations in a helping role. The curricular trend which acknowledged communication content as basic to nursing assessment and intervention in all areas of practice was a significant advance in nursing education. It must also be recognized that complex skills of therapeutic communication require a degree of student maturity in order to promote effective transfer and application. This finding merits attention and further study in curriculum development and evaluation.
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FACTORIAL DESIGN OF THE STUDY
STUDENT EVALUATION OF METHOD OF INSTRUCTION
SIGNIFICANT STUDY FINDINGS