Although nursing leaders agree that scientific inquiry is essential for professional nursing practice, both graduate and undergraduate nursing students often exhibit a lack of interest in learning and using research skills (Brogan, 1982; Bzdek & Ganong, 1986; Kissinger & Youngkin, 1975; Leach & Champion, 1982; Ludeman, 1981; Muhlenkamp, 1981; Munro, 1985; Sakalys, 1985; Schare, 1977; Selby & Tuttle, 1985; Spector & Bleeks, 1980). Concerned, nursing educators seek to identify teaching strategies that facilitate the development of a positive "research attitude" (Sakalys, 1985); evaluation of strategies for teaching and integrating research into the nursing curriculum has been designated a top priority for research in nursing education (Tanner & Lindeman, 1987).
In response to concerns that our graduate students were not interested in research, we restructured a required nursing research course according to Guided Design (Wales & Stager, 1977), an active learning method that has been used to teach a variety of subjects, mostly in the sciences and humanities (Adams, 1983; Goldberg & D'Amour, 1976; Hoggard, 1980; Lawrence, 1980; Marshall, 1981; Miller, Breyer, & Haucke, 1983) but also in nursing (de Tbrnyay & Thompson, 1987; Selby & Tuttle, 1987; Wales & Hageman, 1979; Wold, 1986). In this article, we describe the Guided Design model for teaching nursing research, report on improvements in knowledge of research and in attitudes toward research among students taught by this method, and offer suggestions for the use of this teaching strategy.
Grounded in educational psychology, Guided Design incorporates creative problem solving and simulation (Bloom, 1956; Dewey, 1933; Maslow, 1954), role modeling (Bandura & Walters, 1963), reinforcement (Skinner, 1968), and small group teaching strategies (Miles, 1971). Learning experiences are structured to be nonthreatening and relevant to the learners' lives and careers (Rogers, 1969).
Guided Design operates on three learning levels. The lowest level is the learning of a fundamental knowledge base, the intermediate level involves application of the newly learned material to closed problems, and the highest level focuses on synthesis of learning through open-ended problem solving. The Guided Design system guides the learner through these levels, with major emphasis on the highest level.
FIGURE 1. The Guided Design research course is designed to guide students step-by-step through each learning level at each step of the research process; the major emphasis is on Level 3 learning at each research step. The instructor selects Level 1 and Level 2 learning activities most appropriate for class needs, and designs the Level 3 hypothetical situation, which includes a professional as a role model, to be relevant to student career goals; the situation cannot be resolved without research.
In the Guided Design model for teaching nursing research (Figure 1), fundamental research concepts, principles, and skills (Level 1) are introduced in lectures and reinforced in an instructor-prepared study guide, assigned readings, and class discussion. Learning on closed problems (Level 2) is accomplished through completion of exercises and assignments with one "best" answer, as well as through participation in class discussion. Periodic examinations evaluate mastery of Level 1 learning and also provide Level 2 learning experiences. Creative problem solving on open-ended problems (Level 3) occurs in small groups in which students utilize research skills to address a problem in a hypothetical, but reality-based, nursing situation. A hypothetical professional, facing the same situation, serves as a role model for the students' decision making.
The instructor designs the clinical situation and the role model to maximize their relevance to students' career aspirations. The role model should encounter problems and controversies that students are likely to experience in future practice, not simply those they already have mastered; the situation should present a challenge. Most importantly, the situation must be structured so that the hypothetical professional - and the students who model the professional's behavior - cannot resolve the problems without conducting research.
Presented with the hypothetical situation, students in a Guided Design research course are called upon to identify a researchable problem; this need not be the same problem identified by the professional. Then, throughout the course, students are guided in the development of a research proposal that addresses the problem. At each step in the research process, the instructor provides Level 1 and Level 2 learning experiences relevant to the appropriate research step. Then, working in small groups in the classroom, the students make decisions regarding the corresponding step in their research proposal (Level 3), while the instructor circulates and provides guidance. Students also engage in group activity outside class and may arrange additional meetings with the instructor. Upon completion of each research step, students learn how the professional approached that particular step. They also receive feedback from the instructor and their classmates. Students have the opportunity to modify their own proposals as they receive feedback; however, they need not agree with the professional's choices, so long as the rationale for their own decisions is sound.
This one-group before/after quasiexperiment, conducted in the master's nursing program of a large public university, evaluated the effectiveness of Guided Design in increasing students' research skills and improving their attitudes toward research. In this setting, most students enroll in the three-semester-credit-hour research course in their first semester of study, since it is a pre- or corequisite for most coursework in the graduate nursing program. A two-group experiment originally was proposed but was administratively unfeasible. It was not possible to add a randomized control group nor to control classroom conditions outside the Guided Design course.
The research course was conducted according to the Guided Design model, as described above. In the hypothetical situation developed for the course, students were introduced to a clinical nurse specialist (CNS) in her first position since receiving her master's degree. The CNS, hired with a mandate to evaluate and improve nursing care, was confronted with problems in the areas of nursing performance, administration, staffing, and education, as well as specific problems related to client illness and health. When the course was pilot tested (Selby & Tuttle, 1985), some students felt constrained by the particular health problems chosen for the situation. Therefore, in subsequent semesters the situation was expanded to include a greater variety of illnesses; however, the basic challenges and dilemmas remained the same. In order to achieve and document success in any of the problem areas, the CNS - and the students - found that research skills were necessary.
Three cohorts totalling 96 students enrolled in the Guided Design research course in summer 1983 (pilot test, n = 25), fall 1983 (n = 43), and spring 1984 (n = 28). Demographic characteristics of students varied considerably, but the distributions in the three cohorts were similar. Therefore, for the major analyses in this project, the three cohorts, including the pilot group, were examined together. Over 90% of the students were white and female; they ranged in age from 23 to 54 years with a median age of 29. Length of nursing experience varied from less than one year to 30 years. Nearly half (48%) of the students had graduated from nursing school within the previous five years; an additional 28% had graduated six to 10 years previously.
Students provided evaluative data for the project by completing a pre- and postcourse research knowledge test and an attitude survey. The knowledge test, given on the first and last days of class, was a required learning activity for all students in attendance; 83 students were present for both pre- and posttests. The postcourse attitude survey was voluntary; informed consent was obtained from the 86 students who completed it.
The pre- and posttest used to measure changes in knowledge of research consisted of 20 multiple-choice questions that assessed students' ability to apply the steps in the research process; i.e., students were required to select an appropriate research design for a given research question, choose an appropriate method of data analysis for a given data collection situation, interpret a statistical result, etc. Significance of changes in knowledge from prete posttest was measured by the two-tailed, paired t-test, alpha = .05 overall, .01 within cohorts.
Content validity of the research knowledge test was established by a panel of three doctorally prepared researchers engaged in nursing student thesis advisement. A degree of criterion-related validity was established in the pilot test (Selby & Tuttle, 1985) by a correlation of r = .75, ? < .0001, between the test scores at the end of the course and the students' research course grades. Internal consistency, measured by the split-half (odd-even) method with the Spearman-Brown prophecy correction (Polit & Hungler, 1987), was r = .80. Two- week test-retest reliability for six graduate students in an advanced nursing research course was r = .72.
The attitude survey asked students to evaluate changes in their own attitudes toward research as a result of the course and also asked them to evaluate the course in general. To measure changes in attitudes, students were asked first to decide whether they thought the course had changed their attitude in terms of how they "liked" research, and then to indicate whether their attitude was negative before the course and remained negative on completion of the course (no change), changed from negative to positive (positive change), was positive before the course and remained positive on completion of the course (no change), or changed from positive to negative (negative change).
The format of the second question permitted analysis of the overall significance of changes by the two-tailed McNemar Z-test (Daniel, 1978), with alpha = .05; changes within each cohort were tested at alpha = .01 by the exact binomial, the small sample alternate for the McNemar test (Sokal & Rohlf, 1969).
The attitude survey also included questions that asked students to rate the Guided Design hypothetical situation as not helpful, somewhat helpful, or very helpful, and to provide written comments on the course. Responses to these items were analyzed descriptively.
Content validity of the attitude survey form was established by the same panel of researchers who reviewed the knowledge test. Reliability was established by a two-week test-retest among the six graduate students who participated in the knowledge test-retest; 100% test-retest agreement was obtained for these particular questions.
CHANGES IN RESEARCH TEST SCORES FOR MASTER'S NURSING STUDENTS IN GUIDED DESIGN RESEARCH COURSE
CHANGES IN ATTITUDE TOWARD RESEARCH AMONG MASTER'S NURSING STUDENTS IN GUIDED DESIGN RESEARCH COURSE
Students' knowledge of research improved significantly from pre- to posttest (Table 1). Overall, students nearly doubled their scores on the 20-item exam: mean pretest scores for the three cohorts ranged from 40% to 46%; mean posttest scores, from 76% to 84%. Students' attitudes toward research also were significantly more positive after the Guided Design course (Table 2), with very high percentages of the students attributing improvement in attitude to the course. In the first cohort, positive changes in attitude were attributed to the course by 73% of the students, or 80% of those who reported initially negative attitudes; in the second cohort, 59% of the group, or 85% of those initially negative, reported positive changes; and in the third, 72% of the total, or 90% of those who were initially negative, reported improvement. Only four of 86 students reported negative changes; all four were from the second cohort, the largest class.
Students gave high ratings to the hypothetical situation used as a basis for proposal development. Overall, 92% considered the situation at least somewhat helpful; 51% considered it very helpful. The ratings were similar across cohorts, except that students in the third cohort gave the highest ratings: 72% within this group rated it "very helpful." In the entire sample, only seven of 86 students rated the clinical situation as "not helpful."
Students' comments were overwhelmingly positive, e.g.:
"I enjoyed the course, although I had a very negative attitude at first."
"Until I started my lit review, I felt that there was still too much emphasis on nursing research. Now my mind is changing."
"I have dreaded this course, but it has been a positive learning experience."
However, a few students expressed feelings of being "boxed in" by the hypothetical situation; such sentiments were noted in each cohort even though the situation was broadened after the first cohort evaluated the course. Nevertheless, students formulated a variety of research projects: the relationship between nurses' attitudes toward charting and their job satisfaction; relationship between nurses' documentation of patient teaching and their attitudes about patient education; evaluation of two modes of allergy treatment; comparison of documentation of patient teaching before and after a staff development program on charting; and comparisons of various patient learning outcomes with respect to different teaching methods (e.g., video cassette versus in-person; group versus individual; explanation versus demonstration; lecture versus small group discussion).
Nursing research has been faulted for placing undue emphasis on findings from studies of small samples (de Tornyay, 1984), for neglecting to follow up on previous research (Brown, Tanner, & Padrick, 1984; O'Connell, 1983), and for failing to adequately evaluate strategies for teaching research (Overfield & Duffy, 1984; Parker & Labadie, 1983; Tanner & Lindeman, 1987). This study built upon a small pilot project (Selby & Tuttle, 1985), which showed positive changes in knowledge of research and attitude toward research among graduate nursing students taught by the Guided Design method; we confirmed these findings in a larger sample. Furthermore, our findings were consistently positive over three consecutive cohorts, helping dispel concerns that the early success of Guided Design was due to the novelty effect rather than to the educational experience itself. In fact, the course received its highest ratings the third, not the first, time it was taught.
Of course, our quasiexperimental evaluation of this teaching method was limited by lack of control for subject selection and attrition, testing and instrumentation effects, historical factors, and statistical regression; these factors, as well as other uncontrolled teacher-related variables, could have influenced the results of our study. Nevertheless, the students did learn and grow to appreciate research, and they themselves attributed the positive changes to the Guided Design method.
Our evaluation did not attempt to establish that Guided Design is better than other methods for teaching nursing research; however, it did show that Guided Design, as implemented in this project, is good. In the case of nursing research, in which creative educational strategies are sorely needed (Duffy, 1987; Sakalys, 1985; Tanner & Lindeman, 1987), we believe this is sufficient justification for greater use of Guided Design. For those educators interested in developing a Guided Design research course, we offer some suggestions and cautions from our experience.
Guided Design emphasizes active learning of concepts and skills relevant to the lives and careers of the learners. In nursing research, students initially may not be interested in active learning because they consider research irrelevant to nursing practice. Therefore, the instructor must create a believable, reality-based nursing situation in which research is both necessary and beneficial; the hypothetical nursing professional in the situation must be one with whom the students can identify.
Because of the backgrounds and career goals of our students, our hypothetical professional was a clinical nurse specialist in a hospital-based clinic. In other academic settings, a different role model might be more appropriate; for example, for a section of public health nursing students, we recently designed a scenario about a nursing consultant in a health department. It would be useful to develop a number of Guided Design situations so that students from different specialties or majors could be provided with the role model most relevant to their career interests.
It is important to note, however, that the development of Guided Design course materials requires a major commitment of time and creative effort before a course can be implemented. Release time is desirable but rarely available; in its absence, word processing and/or secretarial assistance is essential. In our experience, we have found it possible, but difficult, to prepare portions of the study guide and feedback materials on an ongoing basis during the course; some feedback may be oral.
However, it is imperative to thoroughly pre-plan the research project of the hypothetical professional in order to avoid confusion or even disaster later in the course. For example, the data collection method chosen by the hypothetical professional should not require a method of statistical analysis that is not included in the course objectives - or the instructor's expertise. The ideal solution is to adapt and embellish, or correct if necessary, a relevant research project already conducted (if this is not the instructor's own study, it is advisable to obtain permission from the original researcher).
Because of the small group work, class size also can be a problem. In our case, the largest class size, 43, was more than one instructor could manage comfortably. Student evaluations, although still high, were lowest in this class (as was instructor morale). Thus, we do not recommend Guided Design for use in classes larger than 30; fewer than 25 is ideal, though larger classes might be feasible if additional faculty or experienced research assistants are available for small group guidance.
Some students complain of being "boxed in" by the hypothetical situation; they may be disappointed or even angry when the hypothetical professional, their role model, makes a decision that conflicts with theirs, even though they also receive feedback about the appropriateness of their own decision. For some students, the desire to be like their role model may be so strong that they box themselves in, changing their research proposals to correspond to the hypothetical professional's interests rather than their own. Students have suggested that the instructor more firmly emphasize their freedom to deviate from the role model.
Some research (Miller, 1981; Miller, Givens, & Breyer, 1984) suggests that students with certain psychological attributes respond best to Guided Design. Further research may be advisable to help document these characteristics in nursing students. If such traits are readily identifiable and choices are available, students could be directed to the research course most appropriate for their needs.
Although we obviously are pleased with Guided Design as a model for teaching nursing research, further research is needed to evaluate more thoroughly the effectiveness of this and other strategies for teaching nursing research, at both graduate and undergraduate levels. We suggest: a) if possible, controlled experimental studies of Guided Design and other methods for teaching nursing research; or b) if true experimental studies are not possible, quasiexperimental two-group studies, perhaps even with nonequivalent control groups supplied by collaborating investigators in other settings (we would welcome collaboration); c) meta-analytic studies of reported evaluations of all types of strategies for teaching nursing research; and d) longterm studies that measure the impact of Guided Design and other teaching methods on future research participation by graduates. Such studies will help nursing educators select the strategies most likely to be successful in teaching nursing research and in producing future researchers and consumers of research.
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CHANGES IN RESEARCH TEST SCORES FOR MASTER'S NURSING STUDENTS IN GUIDED DESIGN RESEARCH COURSE
CHANGES IN ATTITUDE TOWARD RESEARCH AMONG MASTER'S NURSING STUDENTS IN GUIDED DESIGN RESEARCH COURSE