Establishing links between theory and practice has been a challenge and a concern in nursing education for decades. Contemporary nursing leaders support the linkage as essential to professional nursing education and practice (Hawkins, 1981; Infante, 1985; Torres & Yura, 1974), yet the challenge of teaching integration of theory and practice continues.
When nursing is described as theory-driven, two perspectives emerge: nursing theory and scientific theory. Nursing theory gives a guiding framework for theorizing about concepts such as nursing, wellness, health care needs, and client systems. Scientific theory gives a fundamental basis to the practice of nursing, which is built on knowledge of the natural sciences (physics, anatomy, physiology, biology, and microbiology). Without precise identification of scientific concepts and principles, safe and comprehensive care is compromised.
This research focused on teaching strategies that develop links between scientific theory and basic nursing skills. A traditional approach to teaching basic nursing skills was compared with an innovative approach using two strategies that consciously link theory with practice. The strategies were Vee heuristics, which identify specific concepts, principles, and theories related to basic nursing skills, and concept maps, which teach students how to create schematic drawings of their mental understanding by organizing and linking relevant concepts.
Statement of the Problem
When baccalaureate nursing students are taught in college laboratories with Vee heuristics and concept maps rather than with traditional modes, is there a difference in the ability to identify principles of scientific theory related to basic nursing skills? Is there a difference in performance of basic nursing skills in practice situations? Do students perceive learning as more meaningful?
Review of the Literature
Teaching connections between theory and practice is not a new educational idea. Tyler (1949) urged that correlation of theory and practice was essential to professional education. The American Nurses Association (ANA) has called for professional nursing practice to be theory-oriented rather than technique-oriented (1965). The National League for Nursing (NLN) publication, Characteristics of Baccalaureate Education in Nursing (1987), supports theory-based thinking skills when it specifies that graduates "synthesize theoretical and empirical knowledge from nursing, scientific, and humanistic disciplines with practice" (p. 2).
In spite of the fundamental significance of natural science theory as the underpinning of nursing practice, Wilson (1975) sees curricula ill-defined and unstructured in terms of specific links between science theory and nursing practice. She finds the application of scientific theoretical knowledge in nursing education haphazard.
Akinsanya (1987) believes theoretical input from the life sciences must be clearly defined for nursing practice. He stresses the value of understanding concepts, principles, and theory from the life sciences in order to understand rationales for every nursing action. Akinsanya calls for (1) identification and categorization of nursing skills in relation to scientific underpinnings, (2) innovative curricular approaches to link theory and practice, and (3) the "progressive development of professional responsibility through a more conscious linking of theory with practice in nursing education" (p. 272).
Drew (1988) warns nursing not to devalue the theoretical knowledge base of the natural sciences, which helps to evaluate human responses and to direct nursing practice. She stresses that although technical skills can be performed without a clear theoretical understanding by technicians, professional nurses provide a higher level of care by giving comprehensive, theory-based care with knowledge from natural sciences.
Although theory-based care is essential, Fahy (1969) asserts that skill competence is the first responsibility of a practicing professional. According to Larson's (1984) findings, a nurse's technical competence is the attribute most valued by patients. Settlemyer (1978) believes that the small role of technical skills competency must be successfully accomplished for patient safety and the nurse's self-esteem before developing higher-level roles such as patient advocate, educator, counselor, researcher, and clinical expert. Infante (1985) defends the value of professional competence in skill performance for patients' needs. Nursing students reinforce the perception of practice as supreme. Mastery of skills is felt by nursing students as the "rite of passage" into nursing (Gendron, 1981). After many liberal arts courses, nursing students are finally introduced to "real nursing," the performance of nursing skills.
Yura et al. (1986, p. 226) support present nursing model curricula that develop "students who can discover, create, express meanings, and think, rather than merely accumulate facts." Curricula that integrate the practice of nursing with a well-defined theory base continue to be a major goal for professional nursing education.
A literature review of an educating theory by Novak and Gowin (1984) reveals the application of Vee heuristics and concept mapping in numerous classroom and science laboratory studies. Researchers find that using these strategies helps students organize and understand knowledge (Colling, 1984; Fuata'i, 1985; Gurley, 1982; Mollura, 1979). Learning to map is perceived by students as difficult although they claim to value consequential meaningful learning much more than rote mode learning (Colling, 1984; Fuata'i, 1985; Gurley, 1982). Presentation of content as a conceptual hierarchy with overt and repetitious reinforcement results in increased numbers of concepts and understanding of concepts in one's knowledge structure (Cullen, 1983; Mollura, 1979; Ring, 1969). Finally, Buchweitz (1981) finds that epistemological analysis of curricula with Vee heuristics and concept maps provides valuable assessment data.
The theories of Novak & Gowin (1984) and Ausubel (1978) form the major components of the theoretical framework for this research.
Novak views learning as occurring on a continuum, from rote mode (memorization) up to meaningful learning. Most school learning falls into the rote mode, i.e., learning is a verbatim incorporation of new knowledge into the cognitive structure and is not related to experience with events or objects. Meaningful learning is defined as a process of consciously integrating new knowledge with one's previous knowledge in ways that strongly link the two.
Since professional nursing's body of knowledge is based on knowledge (theory and facts) from the sciences and humanities, it is essential for students to recall, understand, and build on their prior knowledge from liberal arts courses. As students begin to learn basic nursing skills, prior knowledge from physics, anatomy, physiology, biology, microbiology, sociology, and psychology is fundamental to their understanding and practice. Nursing educators prefer "using the knowledge already at hand more effectively rather than continually increasing present amounts of knowledge. They seek to bring together and connect the concepts of different disciplines as a way of using present knowledge more effectively" (Yura et al., 1986, p. 225).
Structure of knowledge
The second component of the theoretical framework relates to the learner's structure of knowledge. Learners can construct mental pictures of their knowledge in schematic depictions called concept maps (Novak & Gowin, 1984). To draw concept maps, learners perceive concepts, recall prior knowledge, and connect new knowledge to prior knowledge in a conceptual hierarchy. Concepts are organized with the broadest concepts on top of the map and more specific concepts subsumed under larger ones. Linking words connect concepts to specify relationships between and among concepts. The more links that exist between various concepts, the more interconnected, the concepts are in one's knowledge structure. Figure 1 is an example of a concept map for the basic nursing skill of dangling a patient.
Figure 2. Vee heuristic for dangling.
Students identify new concepts and use prior knowledge from liberal arts courses in the process of learning basic nursing skills. Concept maps help the student and instructor to identify the student's knowledge structure about basic nursing skills. A bonus benefit of concept mapping is the ease with which misconceptions can be noted. When misconceptions can be identified and corrected before new learning occurs, learning can proceed more accurately. Mapping is, therefore, a powerful tool for clarifying misconceptions before new learning is built on prior misconceptions.
Linking theory and practice
The third component of the theoretical framework is the belief that learning should include both theory and practice perspectives. Clear linkages must be evident between practice and theory to conclude that practice is theory-driven rather than rote steps. It is the theorydriven nature of practice that gives intended meanings to procedural steps.
Learning the practice of nursing by understanding the theoretical basis of each practice step reflects optimal learning. To help conceptualize this theory/practice integration in learning, Gowin (1981) has developed the Vee heuristic, which asks a focus question about an educative event (i.e., learning a basic nursing skill) and answers with theoretical and practice perspectives. The particular "V* shape of the heuristic is not critical to its use but does represent the coming together of theory and practice in an educative event (Figure 2).
Gowin sees "laying the Vee" on an event as a way of (1) analyzing previous knowledge (or identifying lack of previous knowledge), (2) understanding theory and practice of an event, and (3) constructing new knowledge.
The way to "read" a Vee is by first reading the focus question, which asks a fundamental question about what is to be learned in that specific Vee. Since the focus question is answered by the educative event (learning the basic nursing skill), the event is read next.
In order for an educative event to be theory-driven, the left side of the Vee is used to analyze the theoretical domain of the event. By listing all relevant concepts, one is forced to analyze what is being studied at a finite and definitional level. Next, principles are stated that reflect relationships among concepts to identify scientific knowledge. "Principles tell how events or objects appear or behave, whereas theories tell why they do so" (Novak & Gowin, 1984, p. 65). Theories are collections of principles organized into broad and inclusive systems of beliefe (e.g., the theory of gravity, learning theory). Even broader in interpretation is philosophy that expresses the overriding value of the entire theoretical domain. When the left side of the Vee is well developed, an educative event has a valuable theory base.
Once concepts, principles, theories, and philosophies are clarified, that understanding is used to underpin learning the practice side of the Vee. Moving up the right side of a Vee heuristic from the event, the practice domain is addressed by first making records of the event (e.g., observations of skill performance). These records are transformed into useful, "workable" data such as performance evaluations. Knowledge claims are the new pieces of information guided by theory and used in the practice of the event (e.g., specific steps of a basic nursing skill). Finally, value claims reflect the inherent worth and usefulness of the practice domains.
The right side of a Vee addresses practice aspects of an event within the framework of the theoretical left side. Interplay between left and right sides shows how (Da basic nursing skill is theory-driven, and (2) prior knowledge (previously known scientific concepts, principles, and theory) guides the understanding of new knowledge (new practice skill). Although the "V" shape appears to suggest a split or separation of theory and practice, its purpose is to identify both so as to unite them in the event. Hence, a nursing skill is always grounded in theory.
Understanding the theory that guides nursing practice can be a nebulous, frustrating experience for students who are anxious to "do" nursing. Students perceive the laboratory as a place for practice rather than a place for analyzing theory as the driving force behind nursing practice. This concrete strategy is a powerful way to link theory and practice for nursing curricula.
The study was quasi-experimental with a nonequivalent control group design. All students enrolled in a fall semester, junior-level, upper-division nursing course that taught basic nursing and assessment skills were invited to participate. Forty-two subjects comprised the convenience sample of students who volunteered (five chose not to participate). Students were divided in nonrandom fashion at registration into lab groups of no more than eight. Students had no knowledge of instructor assignment to lab sections at registration. There was no pattern of assignment, since the university registrar used a computerized registration system. Although much variability existed within each group, demographic data that were analyzed later established homogeneity between different lab sections for the following variables: age, sex, employment during the current semester, type and average number of employment hours per week, type or amount of prior work experience, type or amount of prior life experience, type or number of prior nursing-related courses, status as educationally disadvantaged, and cumulative GPA before beginning the semester with the research intervention.
Group design resulted from course structure and instructors' assignments to laboratory sections. Each laboratory section had one instructor for a three-hour weekly college laboratory practice time. Three instructors (the researcher and two other instructors) were scheduled to have two laboratory groups each per week. Instructors were introduced to the theoretical framework and taught how to use the two research strategies. Throughout the research, internal consistency between instructors and labs was assessed by periodic observers in labs. Each instructor taught both a traditional and a treatment mode each week to control for individual teaching differences. Each instructor's comparison and treatment groups could be compared with the others, since homogeneity between groups was established.
Description of traditional and treatment modes
The traditional mode followed in the college lab required students to complete assigned weekly textbook readings, film viewing, and definitions of glossary terms before each lab. The students asked questions and discussed the week's basic nursing skills. Lab content was specifically itemized in the instructor's laboratory manual to assure that all instructors covered necessary course content. Next, the instructor demonstrated the skills. Finally, the students practiced the skills in the simulated setting and gave satisfactory return demonstrations to the instructor.
Lab structure for the treatment mode followed the traditional mode described, except as follows. In each treatment group's first lab, students were oriented to Vee heuristics and concept mapping. In subsequent labs, students used discussion time differently than comparison groups. Incorporated with student questions and discussion of basic nursing skills were one or two Vees each week that the researcher had made (in counsel with the other instructors) regarding the skills presently being learned. Vees were discussed for clarification of meaning. When appropriate, previous Vees were also referred to for building on prior knowledge. Vees were available as references to stimulate thinking of related principles while instructors demonstrated and students practiced skills.
Treatment students came to labs with one concept map of selected glossary terms each week. Their maps were discussed and a researcher-made map was reviewed on an overhead projector. Later, the researcher reviewed all maps (without grading) and returned them to students before the following week's lab so that comments could help with subsequent maps. Students received personal feedback from the researcher that clarified connections between concepts and the omission of important links. The researcher supported efforts of mappers as well as encouraged progress when evidenced. When misconceptions were identified on maps, the researcher made alterations in the map and explained a correct conceptualization to the student. Sometimes researcher-made maps were returned with the students' maps for clarification when students seemed to need direction.
Three measurement tools were used: short-answer questionnaires in which students identified scientific principles underlying 10 nursing skills; evaluations of skill performance in return demonstrations in the practice lab; and taped clinical interviews in which students discussed self-perceptions of meaningful learning, preferred learning modes, and components of practice labs.
Analysis of Variance for Short Answers by Group and Instructor (n=42)
Analysis of Variance for Return Demonstrations by Group and Instructor (n=40)
To answer the first research question, responses to 10 short-answer questionnaires were analyzed by identification of principles for nursing care based on theoretical knowledge from the natural sciences. Criteria were established for each question to distinguish the quality of principle identification. Examples of poor principle identification related to why the nurse checks the patient's pulse after dangling were "check for changes ... to see how the circulatory system is handling the change . . . pulse may change . . ." An example of an excellent answer was "vasodilation causes blood pooling so circulating blood volume decreases and less oxygen goes to the brain; the heart responds with an increasing rate (pulse) to attempt to get more blood (oxygen) to the brain." All principles expected for excellent answers were covered in course content through lectures, readings, videotapes, or lab discussions. Principles were also on Vee heuristics used as interventions with treatment groups. Answers were coded according to the clarity and inclusiveness of identified principles.
Analysis of variance (SAS General Linear Models Procedure) controlling for group and instructor was analyzed for each question and the mean of all short answers. Although no significant differences were noted when analyzed by instructors, results (Table 1) show that the single mean calculated for all short answers was significantly higher for the treatment groups (F = 8.98, ? = .005). Means for the treatment groups were higher for each question except the last question concerning isolation precautions. Statistical significance (p<.05) was found for five of the 10 questions, indicating that for those responses, students in the treatment groups were significantly better able to articulate scientific principles specifying why given actions were appropriate.
Return demonstrations of practiced skills
Return demonstrations of selected skills were required for all students to establish level of skill mastery in the college laboratory during the first week of the spring semester (approximately five weeks after the course with the research intervention was completed). Since all skills could not be checked due to time and faculty availability, only those skills were measured for which control and treatment groups differed significantly in their shortanswer responses. To answer the second research question, the researcher investigated if those skills students described with qualitatively different principles were performed differently.
Results presented in Table 2 show that the treatment groups' means were higher for all return demonstrations. However, only body mechanics was performed significantly better when analysis of variance controlling for instructor and group was analyzed (F= 6.65, ? = .01). The mean for all return demonstrations was not significantly different.
Taped clinical interviews
Audiotaped clinical interviews were conducted by lab instructors for their own students at the end of the course after final evaluation forms and conferences were completed in order to decrease threats to students' candor. Tapes were analyzed and coded. No significant differences were noted when analyzed by variations in instructors. Results showed one significant difference between control and treatment groups. Fifty percent of the treatment group and 15% of the control group felt that they answered the interview question about studying and learning differently after taking this course. Although reasons were not specified as related to interventions, a significantly greater number of treatment students did experience a change in learning and studying styles.
When asked why any given parts of the laboratory helped them to learn, the treatment and control groups responded differently. "Knowing what to expect" (content and action) was valued by the control groups while the treatment groups valued "putting it all together" and "being forced to think." The content analysis of clinical interviews indicated that "putting it all together" referred to connecting knowledge and skills.
Responses to treatment interventions
During clinical interviews, students in the treatment groups were asked to give candid responses about using concept maps and Vee heuristics for learning. Positive reactions to learning with Vee heuristics were identified by 81% of the treatment students. Representative positive comments included:
At the time, they seemed stupid. Later I checked them and they helped me know why I was doing things. When you [instructor] said "remember the Vee principle ..." I did check it and things made more sense. Vees were good to study with - clear and spelled out.
Vees were a great help. I used them to study and to understand rationales [for nursing actions] in my nursing care plans.
Vees pointed out exactly why ... I need to know why I do things. Used them to review for the mid-term. Yes, they were okay.
Vees helped me see why we do it, and what's not so important.
Feedback from instructors who taught with Vees identified the benefit of structured content in the Vees for incorporating information in laboratories. Instructors valued defining and clarifying the interrelatedness of theory and practice with Vees.
Sixty-nine percent of the students responded positively to concept mapping with such representative responses as:
Maps were hard but with feedback they were incredibly helpful for pulling things together and for studying.
I didn't mind doing them. They gave me a chance to think of how things fit together. Maps encouraged me to refer to readings and notes where I might not have.
Hard to get the skill [mapping]. It forced me to keep trying and going to the books for reference in order to think it out. The feedback comments were very helpful.
... I would have liked to choose my own words [other than the researcher's list of relevant concepts]. At the end I began to see how a lot more words could be added and would fit.
Instructors were less definitive in their opinion of concept mapping compared to Vee heuristics as applied in this research. Although instructors saw value in fostering conceptual organization of content and identifying misconceptions, map evaluation was seen as very difficult.
Students who were taught basic nursing skills with Vee heuristics and concept maps were better able to identify principles of scientific theory related to basic nursing skills. In the short-answer questionnaire, the overall mean and the mean for five of 10 questions indicated significantly better answers for treatment than control groups. Value in the treatment intervention is supported, since being able to articulate underlying scientific theory suggests that treatment students were better able than control students to link scientific theory to their practice, and to integrate prior learning with present learning of nursing practice. This integration of prior and present knowledge reflects meaningful learning as defined in this research.
There was a significant difference between treatment and control groups for mean scores of only one return demonstration, body mechanics. Research data did not support findings that the treatment groups' learning had improved overall skill performance in practice situations. Due to the issue of mastery learning of skills for passing the course, it may not have been realistic to expect differences in return demonstrations between control and treatment groups.
According to self-reports, students in control and treatment groups perceived their learning of course content to be meaningful. Both groups felt quite strongly that course content was meaningfully learned rather than memorized. However, short answer responses indicated that the treatment groups were significantly better able to state scientific theory originally learned in prerequisite courses and recalled in the present course. By definition, the integration of prior knowledge with present learning is meaningful learning.
Implications for Nursing Education
Nursing educators have long advocated the linking of theory and practice in teaching nursing. Most students had positive reactions to learning with Vee heuristics and mapping. They valued "putting it all together* in lab. Vee heuristics helped students view nursing care as grounded in scientific theory such that nursing actions took on rational meanings. Concept maps helped students construct individual knowledge structures. Feedback to students from the researcher highlighted and corrected misconceptions that may have gone unchallenged. Those misconceptions would also have been the basis upon which new learning was added with resulting errors and confusion. The students exposed to Vees and maps were better able to identify underlying scientific principles of basic nursing skills, thus supporting the worth of these strategies that link theory and practice in teaching basic nursing skills.
Empowerment for creative thinking is an aim of professional nursing education (Yura et al., 1986). Rather than a sense of powerlessness that students often embrace (e.g., memorize this content for this lab), treatment students had some control over constructing an understanding that made sense to them based on their present knowledge structure. When strategies encourage students to take control of their own learning, their value is inestimable.
This researcher believes that prior knowledge is often ignored or undervalued in education, which results in fostering a lack of responsibility for cumulative learning, and in underrnining the empowerment of students for self-educating as a lifelong process. The use of Vee heuristics highlighted the valuable interrelationship between prerequisite liberal arts courses and a present nursing course. If nursing educators hope to link scientific theory with the practice of basic nursing skills, content from prerequisite science courses needs to be consciously identified, built upon, organized by each learner, and incorporated into the processes of teaching and learning. Vee heuristics and concept maps can concretely integrate scientific theory and appropriate nursing practice.
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Analysis of Variance for Short Answers by Group and Instructor (n=42)
Analysis of Variance for Return Demonstrations by Group and Instructor (n=40)