Journal of Nursing Education

Developing Analytic Thinking Skills in Early Undergraduate Education

Barbara Bowers, PhD, RN; Donna McCarthy, PhD, RN



This article describes how a required prenursing health issues course was substantially restructured to increase the opportunities for students to develop analytic skills and for faculty to gain greater insight into how the students processed course content. Using writing-to-learn (WTL) strategies based on theories of adult cognitive development (Kinneavy, McCIeary, & Nakadate, 1985; Kohlberg, 1978; Perry 1978), course readings, writing assignments, and exam questions were revised continuously over five semesters. This article describes the purpose and process of redesigning the course and some reflections on the outcome.



This article describes how a required prenursing health issues course was substantially restructured to increase the opportunities for students to develop analytic skills and for faculty to gain greater insight into how the students processed course content. Using writing-to-learn (WTL) strategies based on theories of adult cognitive development (Kinneavy, McCIeary, & Nakadate, 1985; Kohlberg, 1978; Perry 1978), course readings, writing assignments, and exam questions were revised continuously over five semesters. This article describes the purpose and process of redesigning the course and some reflections on the outcome.


A central purpose of both lecture and clinical courses in nursing is to facilitate the development of the students' ability to use theory and/or knowledge effectively across a variety of clinical settings. Clinical faculty have expressed concern over the apparent inability of some students to apply knowledge from readings, lectures, and seminars to patient care situations. Faculty in lecture courses express similar concern over students' difficulty with exam questions that require them to apply course content to hypothetical clinical situations. This difficulty in applying or contextualizing course content is also reflected in student protests over "relearning the same content* in subsequent courses. For example, learning about diabetic care in a course on health problems in acute care settings is perceived by some students as redundant if diabetic care has been presented in another course on community care, chronic illness, or even pathophysiology. These protests reveal that at least some students view changing the context as simply redressing the problem, while leaving it basically intact. Thus, psychosocial and socioculturel considerations are viewed as additive rather than transformative. This type of thinking makes it difficult to appreciate the complexity and situational nature of most knowledge.

As experienced clinicians can affirm, changing the context of a clinical problem not only alters the terrain around it, but may significantly reorder the internal structure of the problem, substantially redefining the situation (Benner & Tanner, 1987). A new context often renders the essence or meaning of a situation fundamentally different, calling for very different nursing assessments and interventions (Benner, 1984; Benner & Tanner; Carnevali, Mitchell, Woods, & Tanner, 1984; Wurzbach & Colucciello, 1985).

The difficulty that students experience in applying or transferring content might at least partially be the consequence of our failure to provide students with opportunities to learn the cognitive skills involved in making transitions across contexts. The ability to shift perspectives, to comprehend the logic of perspectives other than one's own, to contextualize or apply "the same data" to different situations is prerequisite to the ability to use content effectively in clinical settings (Clinchy & Zimmerman, 1981; Perry, 1978). Although analytic thinking is only one of several ways that nurses come to understand clinical practice, analytic thinking skills are crucial for both the novice and the expert nurse. Novice nurses in particular rely on analytic skills while learning to safely follow rules as they take account of constantly changing contexts (Benner, 1984).

The analytic skills necessary to shift contexts enable students to engage in other forms of complex clinical problem-solving as well, especially in situations where a decision must be made despite the elusiveness of a single right answer (Alien, Bowers, & Diekelmann, 1989; Clinchy & Zimmerman, 1981; Kinneavy et al, 1985; Perry, 1978). This is the nature of most ethical dilemmas encountered in health care settings. For example, to understand disagreements between patients and providers, between patients and their families, or among family members about which is the best of several options to pursue in the terminal phase of an illness requires the analytic ability to simultaneously understand a variety of differing perspectives. An effective advocate or mediator must be able to recognize and separate his or her own perspective from those of patients, families, and coworkers.

To help students acquire these skills, educators must provide them with contextual variation as well as opportunities to learn the analytic skills required to respond to them effectively. Providing opportunities for experiencing contextual variation in clinical situations is an integral part of all nursing curricula. Facilitating the development of the higher-level analytic skills required to deal with them, however, demands careful attention to the way lecture or content course assignments are constructed, sequenced, and evaluated.

Theoretical Foundations

Based on research reported by several authors, it seems that college students move through a predictable path of cognitive development more or less successfully during their college years (Clinchy & Zimmerman, 1981; Kinneavy et al, 1985; Perry, 1978). There is some evidence that students in the humanities and social sciences attain a higher level of cognitive abilities by the end of their undergraduate years than do students in tbe physical sciences (Kinneavy et al). This has been attributed, at least in part, to the emphasis on facts and information as well as the predominant use of objective multiple-choice evaluation strategies and the focus on memorization in the physical sciences.

Writing-to-learn (WTL) programs are based on Perry's model of the stages of adult cognitive development (1978). The first of these stages is characterized by dualistic thinking in which students experience knowledge as absolute. There is a right answer. All other answers are wrong. At this stage, students report facts but are unable to organize, prioritize, or interpret them. Courses that approach learning as the amassing of information perpetuate the equation of knowledge and understanding with the collection of facts and information, reinforcing dualistic thinking. Students at this stage have difficulty appreciating the contextual nature of knowledge or the existence of multiple perspectives.

This stage of concrete thinking is followed by multiplism, a stage of cognitive development that is characterized by a sense that all knowledge is relative. Students begin to appreciate that there can be many equally valid interpretations of any issue. They believe that one's perspective is valid simply because it is one's perspective. Perspective and opinion are used synonymously. Students at this stage experience much of their learning as a game in which they must discover what the teacher's opinion is and "tell her (him) what she (he) wants to hear." They continue to believe, however, that the teacher's opinion or perspective has no more validity than their own. The difference between opinion and informed perspective is not yet appreciated. Not surprisingly, students in this stage feel unjustly challenged or criticized when asked to support or defend their position. Questioning their interpretation is experienced as tantamount to a personal attack.

The third stage in the development of analytic thinking, contextualism, emerges when students begin to understand that there are multiple positions or interpretations of any issue, but that the position one takes is dependent on context, i.e., that knowledge is contextual, and that some answers may be better than others in a particular context. This is the point at which students are able to understand how learning about diabetes in an acute care setting differs from learning about living with diabetes in the community.

Finally, the stage of informed commitment is characterized by the ability to evaluate the merits of each perspective, to understand the contextual nature of each, and to make an informed personal commitment to one, while maintaining an understanding of and a respect for the others. This is the point at which gender differences in knowledge and understanding seem to be most pronounced. How the merits of a position or perspective are evaluated and how decisions and commitments are made appear to vary somewhat predictably with gender (Gilligan, 1982).

Redesigning a Course to Enhance Cognitive Skills Development

The course selected for this project is a two-credit, interdisciplinary health issues course that is required for all nursing majors. The majority (70% to 9O%) of students are prenursing freshman and sophomores. However, a significant number (10% to 20%) of students are majoring in other health-related fields, and an increasing number of students are older, second-degree, RN and/or transfer students. The course consists of a 50-minute lecture once each week and a 50-minute weekly discussion in groups of 20 to 30 students, each facilitated by a course faculty person. This discussion time provides an opportunity for the faculty to model clear analytic thinking for the students by demonstrating the logic of each perspective, showing students how to construct, support, and critique a position.

Prior to the implementation of WTL strategies in the course, the readings were all taken from a single source, The Nation's Health (Lee & Estes, 1992), the written assignment was a term paper of 10 to 20 pages handed in at the end of the course, and both the mid-term and final exams primarily tested the students' ability to recall the information contained in the readings. Lectures were presented on a wide range of topics by experts in nursing, medicine, law, occupational therapy, and social work.

To enhance the development of analytic skills, several course modifications were implemented. The course was restructured to integrate readings, lectures, and writing assignments around helping students understand the nature of perspective as it relates to ideas about health, illness, and health care. This was intended to help students learn the difference between truth (facts and information} and perspective (the selection, organization, and meanings of facts), a conceptual skill that is basic to the transition from dualism to multiplism, the developmental stage most characteristic of students during their early college years.

Reading Assignments

Readings were selected based on their clarity and on how well the authors supported their positions. A considerable amount of effort went into selecting course readings that were both well written and appropriate for the topic. It was easy to find readings that covered the content in great detail. However, the perspective taken by the authors was often not clearly articulated or was presented as fact rather than as perspective, obscuring the distinction between truths and perspectives.

Whenever possible, readings that presented diverse and sometimes conflicting perspectives on a topic were selected. For example, students were assigned an article arguing that drug abuse is socially caused, as well as an article arguing that drug abuse is physiologically caused. Students were then given newspaper articles reflecting a particular perspective on drug abuse. Discussion time was used to identify the underlying perspective and to discuss how the story would have been reported differently if the underlying perspective had been different. Later in the course, students were expected to locate and bring in newspaper articles on the week's topic so that the class could discuss various perspectives taken in the articles and how these perspectives influenced the details and organization of the articles.

For the week related to issues on costs and access to health care, students were assigned one article supporting the position that health care is a right, and another article, equally well constructed, reflecting the position that health care is a privilege. The strengths and weaknesses of each position were examined and critiqued in discussion.

Several course topics were presented and discussed in this way, creating considerable cognitive dissonance among students. At least some of them interpreted this as a trick in which the faculty were refusing to tell them which position was right (dualistic thinking) or which was preferred by the instructor (multiplistic thinking). Students whose thinking could be characterized as dualistic viewed these different perspectives as either right or wrong. The majority of students were muJtiplistic thinkers and were unwilling to agree that one perspective might be better than another. They tended to begin each comment with statements such as "this is just my opinion but . . ."

After selecting the perspective that they wished to support, students were asked to discuss why one was better or how the author had or had not supported the position. The most difficult aspect of this assignment for students was to critique the logic of a position they rejected, especially if the rejected position was supported by a classmate. They often could not get beyond disagreeing or disliking a position.

Written Assignments

Four evenly spaced focused writing assignments related to the WTL paradigm were assigned during the 13-week semester. The WTL paradigm is based on the assumption that writing is an important strategy for learning content in any discipline, and that engaging students in a dialogue with their authence (self and teacher) will make inconsistencies in their logic and gaps in their knowledge apparent (Alien et al., 1989; Fulwiler, 1982; Fulwiler & Young, 1990; Lunsford, 1979; Rideout, 1983). The WTL paradigm incorporates the belief that rewriting with thoughtful, ongoing feedback allows the teacher to enter the thinking process of the student as it evolves. The consequences for both student and faculty are very different from when the instructor is evaluating only a completed product such as a term paper. The instructor becomes an active participant in the process of learning, rather than simply judging what the student has accomplished (Alien et al., 1989; Black, 1987; Clinchy & Zimmerman, 1981; Perry, 1978; Wurzbach & Colucciello, 1985).

Focused writing assignments are structured to require a particular thinking skill, using the content of the discipline they are learning. These writing assignments have been used successfully in math and science courses as well as in humanities and social sciences (Bean, 1982; Fulwiler, 1982). The advantages of focused writing assignments are that they are short, often only a few sentences; they can be designed to correspond to the students' cognitive abilities as well as their command of a knowledge base; and they reveal not only what students know but how well they understand and communicate that content. Assignments can be designed to require prioritizing, integrating, summarizing, contextualizing, persuading, proving, etc. Assignments requiring only recai], or that encouraged the development of single-truth contextual answers such as defining terms or memorizing facts, were eliminated from writing assignments.

Students' understanding of the assignments was greatly enhanced by a one-hour workshop conducted by the University of Wisconsin Writing Lab. The staff of the writing lab set up a series of seminars designed to walk students through the process of summarizing. Course faculty also attended these workshops. This was especially important for new faculty in the course so that expectations would be clear and consistent. Although the writing lab has been a valuable resource for the faculty and students, teaching students to summarize could also be taught by course faculty. Another possibility would be to establish a collaborative relationship with English composition faculty on campus, many of whom teach these skills routinely to English majors.

Initially, the workshops were set up during the second week of class, the week before their first assignment was due. Many students requested a repeat of the workshop after their first paper was returned. Workshops are now set up for the week the first paper is due. Since the change in timing, many of the students have been bringing their papers to the workshop and appear to be much more engaged in the process.

The focused writing assignments were initially used to reveal the students' cognitive level. After two semesters of using focused writing assignments, we concluded that most of the students were multiplistic thinkers. Some had progressed further than others through this stage, but very few were still in a dualistic stage and very few had gone beyond multiplism to either contextualism or informed commitment. This discovery was used to further redesign reading and writing assignments for the course as well as to design writing assignments for subsequent nursing courses. Flexibility was maintained in course assignments to accommodate the plurality of students. For example, an important exception to the predominance of multiplistic thinking was the group of older, returning adult students, some with prior college degrees, who were often in the higher two stages of cognitive development. Writing assignments designed to move students from dualism to multiplism had very little meaning for students moving from multiplism to contextualism or from contextualism to informed commitment.

Discovering cognitive level

The first writing assignment was used to discover at what cognitive level each student was operating. For example, this assignment asks students to "briefly summarize the main point of the lecture on domestic violence, not a list of topics covered but a statement summarizing the main thesis of the lecture (reading).*

An example of dualistic thinking is demonstrated by the response:

Many women are abused. Abuse is a problem in all social classes regardless of race, income, or geography. Men can aleo be victims of domestic violence. Many people think it's just a woman's problem but that's not true. There isn't enough money to care for all the victims - either counseling them to leave or finding a place for them to live. Some women who leave are killed by their spouse later, anyway.

This paper demonstrates the ability to remember information with little or no understanding of how these separate facts could be integrated into a coherent summary of this important social issue. Dualistic thinkers tend to make lists such as this one, having great difficulty selecting a central theme. Students whose papers reflected dualistic or early multiplistic thinking were asked to meet in groups with faculty to walk through the assignment and to practice summarizing.

When asked to summarize the same lecture on domestic violence, a multiplistic thinker responded:

Some people blame women for being abused. Some people think they ask for it. Other people feel that society is the cause. I believe society should do more. After all, many women don't have enough money to do what they should.

This response demonstrates a general tolerance for ideas other than his or her own, but does not indicate any understanding of the internal logic or consequences of either perspective. Students at this level also tend to state their opinion about or reaction to the article they have read, often eliminating any statement of the speaker's perspective. Forcing them to represent the speaker's perspective before reacting to it often takes perseverance on the part of both faculty and student.

Responding to the same question about domestic violence, a student thinking contextually stated that:

Poor women are often forced to remain in an abusive situation because they don't have the resources to leave, while women with greater resources have more options.

An example of more sophisticated thinking, informed commitment, can be seen in the response of an older, second-degree student:

There are currently two predominant ways of thinking about domestic violence, The psychological perspective, which is the most pervasive, posits that women incite abuse and that the best way to deal with domestic violence is to counsel these women, while encouraging them to remain in the family. The second perspective suggests that domestic violence is so pervasive because it is socially tolerated and because women have few alternatives. Believing in this perspective would lead to interventions directed at increasing resources for these women, allowing them to leave, not counseling them to stay as the psychological perspective would do.

Reaching higher cognitive levels

Writing assignments that nudge students from dualism to multiplism and to higher levels of multiplistic thinking encourage students to examine the logic of an argument and to understand the process of constructing and supporting an argument (perspective). The second writing assignment in the course asks students to summarize a lecture or an article and to identify three pieces of evidence from lecture and readings that best support the summary statement. Asking students to ascertain and report the essence of a lengthy article in two or three sentences forces them to integrate, organize, and prioritize. Another common response to this assignment is for students to describe their personal reaction to the article, rather than a summary of it.

One example of a writing assignment designed to move students away from dualistic thinking through multiplistic thinking is:

In a single sentence, summarize the lecture entitled "Is It Health Care We Deliver?" Your statement should reflect the main point of the lecture, what the lecture, os a whole, was about. This is not a list of topics covered. Next, provide three statements, drawn from both lecture and readings, that support and clarify the summary statement.

The instructions encourage students to summarize, rather than describe or list, both of which are lower levels of thinking - remembering, but not integrating or prioritizing. The purpose of this assignment is to encourage students to prioritize facts, recognizing that they are not all of equal importance. Hearing how their classmates have done the assignment demonstrates how more than one logical position can be constructed from the same facts. This exercise pushes students beyond facts to examining the use and organization of information.

The ability to state (or critique) a position, to provide supporting/conflicting evidence assumes the ability to distinguish between summarizing (selecting and prioritizing information) and simply providing accurate information. Students who were more focused on the accuracy of information than on the relevance, organization, or uses of information had difficulty with this assignment. Supporting statements were often only weakly supportive, sometimes not relevant at all, and in a few cases actually contradicted the summary statement. For example, when asked to explicate and support a position on whether access to health care is a right or a privilege, one student stated:

Summary: Health care is a right of every citizen. Supporting statements: (1) There is not enough money to provide health care to everyone who needs it. (2) Our nation's belief in equality includes quality health care. (3) Having health care does not assure good health.

The first supporting statement undermines the student's position. The third is true but not relevant, and the second is the only supportive statement offered. When confronted with this feedback, the student brought in class notes to "prove" that all of these statement are true. She was unable to shift from truth to logic. Faculty feedback focused on helping the student understand the difference between how the facts related to the main point and the accuracy of the facts. Some beginning students find this extremely difficult, continuing to focus on factual accuracy. Talking students through repeated rewrites and focusing on the logical consistency within the perspective fosters the students' ability to distinguish between information and understanding.

Students whose papers reflected dualistic and early multiplistic thinking could state whether they "agreed with" someone else, but stating why they agreed or disagreed (following the logic) was much more difficult. Therefore, requiring students to identify supporting evidence and to evaluate how effectively that evidence supported an argument facilitated their movement to the next level.

Facilitating the transition from multiplism to contextualism was accomplished by asking students to think about authences other than themselves and the faculty, requiring them to consider progressively more external audiences (Black, 1987). Asking students to explain an issue to different authences requires that they put themselves in someone else's place, see an issue from another perspective, and decide what information is appropriate, in what amount, at what level, and what language is used to support that perspective. This also assumes the ability to prioritize information based on the position that the student wishes to support. Students who are analytically more advanced are asked to select and support a position with which they do not agree. This allows some flexibility in the level of cognitive skill required while keeping some consistency in the assignment. The following class assignment serves as an example:

On the topic of domestic violence, write three separate 15to 20-line reports about the problem using the following criteria: (1) You are a journalist for a local newspaper writing an article for publication (Think about your authence.). (2) Write a letter to your congressional representative expressing your views on the topic. Be sure to make your position clear and support it well. (3) You have been asked to speak to several groups of second graders about the topic. Think about your purpose and the possible consequences of your presentation for this group.

The selection of different authences makes the relevance of context apparent to most students. Students were encouraged to shape and frame their positions keeping the authence in mind, selecting supporting information and stating it in language intended to make sense to their authence. The accuracy of facts does not change but the selection of the facts being reported and how they are organized changes significantly.

The shift from multiplism to contextualism was also facilitated by demonstrating to students that, depending on the purpose of the paper and the discipline from which the author writes, discussions on a single topic vary widely. An assignment used for this purpose asked students to construct an annotated bibliography consisting of widely varying perspectives and disciplines concerning a single topic of their choice. This assignment, usually late in the semester, also requires them to use the summarizing skills learned earlier.

The informed commitment stage is reached by very few students in this early course. Therefore, assignments that facilitate the development and demonstration of these skills are reserved primarily for later nursing courses. The few students who are capable of working at this level are encouraged to write short papers taking a stand on each topic, supporting the logic of their own position while critically examining and refuting another or other possible interpretations. An in-class debate between two such students is an excellent strategy to give students an opportunity to try this while allowing other students to view the process. These assignments were used in place of the simpler ones.

Copies of students* papers were kept by individual faculty so that each subsequent paper could be compared to previous papers. In this way faculty were able to monitor how far students progressed during the semester. Comments about each student's paper were recorded and tracked during the semester. Students were given feedback on the evolution of their thinking and how effectively they integrated faculty feedback on consecutive papers. Written feedback given to students was determined by the level at which they were operating relative to their previous papers. For example, a paper that demonstrated very concrete dualistic thinking required feedback designed to push the student to multiplistic thinking. When a paper demonstrated multiplistic thinking, faculty suggested that the student attempt to identify and support a position other than their own, encouraging the student to integrate context into their statement.


Exams were also rewritten to shift the focus from retention to understanding. Students were asked questions that required them to integrate information in addition to remembering it. New exam questions were constructed in which more than one of the options was factually accurate but only one was an appropriate response to the question. Other exam questions were written so that students were asked to apply their understanding of an idea or perspective. For example:

Most Americans believe simultaneously in capitalism and egalitarianism. Which of the following statements best reflects the consequences for health care of holding both beliefs simultaneously? (1) Those who work harder and earn larger salaries should be able to purchase whatever they want. All others should be subject to rationing on the basis of need. (2) The poor will have to go without needed services. (3) Government officials and health care experts will decide what benefits will be available to everyone, or to anyone in particular. (4) Allowing the wealthy to purchase new health care services on the open market will raise expectations and demands of the poor for new services. The same services must then be provided to the poor through government subsidies.

This question required students to integrate information from multiple sources and to consider the relationship between the stem of the exam question and the options available. Students in the first few semesters had great difficulty with these exam questions. The average exam grade dropped and the range of the scores widened considerably. Students who were contextual thinkers did extremely well. Those who had been diligent about reading the assignments and had worked hard but were unable to think contextually during the exam generally received lower grades than they were accustomed to. Students who "crammed" for the exams almost always did poorly, even though this strategy had served them well in the past. Not surprisingly, many students expressed anger over the discrepancy between how "hard" they had studied or how well they usually did on exams and the score they received.

Faculty began telling students early and often that they would do poorly if they did not keep up with assignments on a weekly basis. They were given feedback from previous student evaluations attesting to the importance of allowing time to absorb and reflect on course ideas. Practice exam questions were brought to discussion sections so that students could try these out with the faculty before the exams. Since this has been done there is much less anger and the median scores have improved, although the range of scores remains wider than when accuracy depended primarily on recall. The sophisticated and dualistic thinkers continue to distinguish themselves as outliers on exam scores.

As before, students continue to contest the correctness of exam questions and how they are interpreted by faculty who wrote the exams. Students who wish to appeal a question based on their interpretation of it are invited to present their arguments to the faculty. It is clear that students who have in-depth understanding of the topic do not always do well on exam questions because of the context they bring to the question. This is why students who "know too much* don't always do well on multiple choice exams. Faculty unwillingness to acknowledge this is tantamount to claiming that context is not important. Such a position undermines the credibility of the faculty, frustrates the students (especially the more complex and sophisticated thinkers), and creates considerable (warranted) distrust on the part of the students. Insisting on the correctness of the instructor's interpretation in this instance simply reinforces the practice of context stripping, the idea that the faculty know the truth in its essential form, and the assumption that the world can be evaluated in terms of a right or wrong dualism. This works against our attempts to facilitate the application or contextualization of content.

For this reason, students who wished to appeal the interpretation of exam questions were invited to discuss their interpretations and to explain the logic of their "incorrect" responses. Those who did so were sometimes successful but more often learned why their responses had been incorrect. In most instances the student and faculty were able to agree on whether the student should receive credit for the question. The notable exceptions were those occasional students whose dualistic thinking prevented them from understanding how a correct statement could be an incorrect response.


The addition of these assignments, of course, increased the faculty work load. However, with only 10% to 20% of students taking advantage of the option to rewrite the assignments, which ranged from a single sentence to one-and-one-half pages, the work load was manageable. The percentage of students choosing to rewrite was consistent among discussion groups and across semesters. Some faculty expressed disappointment over the small number of students rewriting. Others felt that while more students could benefit from rewriting, many of them simply did not want to do the extra work. There is still a considerable amount of debate among faculty over whether to require more rewriting or to continue to allow students to choose.

Faculty who had been teaching in the course reported increased satisfaction. The short writing assignments allowed them to develop a much closer relationship with the students than had been possible with a single term paper at the end of the semester. The short focused-writing assignments, spaced throughout the semester, allowed faculty to have an ongoing dialogue with students, viewing up close how they were thinking, learning early in the semester what students were struggling with, engaging in that struggle, raising questions for students to consider, while giving detailed feedback about their growth over the semester.

Students were not used to the idea of each paper building on the last and had difficulty incorporating feedback from one paper into the next. Faculty continually worked at making these links clear by specifically referring to feedback from previous papers. Consequently, students were compelled to think about feedback and attempt to understand it rather than simply reacting to it. In this way, a dialogue and interaction began to occur. Students actually began asking for clarification and handing in rewrites rather than simply disagreeing with or complaining about faculty comments.

In order to facilitate this integration, assignments were carefully spaced and sequenced so that students always had one to two weeks between receiving feedback and writing the next assignment. This also meant that papers had to be returned promptly (five to seven days) to students.

Some of the students, understanding the development of their analytic skills, said things such as: "The assignments were very helpful, not only for this class but for all my classes ... * "I really hated these assignments until I figured out what you were trying to do." "It made me think about where I stood on different subjects . . . and to rethink my other points of view." "The emphasis was clearly on learning, not just doing work for work's sake." "I felt listened to and respected."

Others, who had difficulty with the assignments, said things such as, 0IfI wanted to take a writing class I would have signed up for one." Or "I don't want to be a children's author, I don't want to be a journalism major, and I don't have time to write my congressman because I spend so much time on these stupid assignments." Or, "Because of all the controversial issues in health care, it's impossible to find a solution."

In order to implement the writing assignments effectively, it was helpful to have consistent faculty who were familiar with the WTL purposes. It is necessary for faculty to be supportive of the purposes of the course. For some faculty this required a very different orientation to student writing than they were used to, primarily refocusing on conceptual development instead of editorial problems in writing or the accuracy of facts. More time was spent reading and responding to student writing, and papers had to be returned quickly. Formal evaluations of the course have consistently indicated that the students value, appreciate, and learn from quick, focused feedback. On the other hand, a few faculty had difficulty providing the kind of feedback that had been promised. One even refused to allow rewriting. Students in these groups felt cheated and angry.


Although we expect nursing students to develop sophisticated cognitive skills, to learn to think analytically, critically, and contextually, some of the more commonly used teaching and testing strategies may actually impede the development of these important skills. WTL strategies appear to enhance the evolution of cognitive skills in nursing students while, at the same time, they bring student and teacher much closer together, invigorating both.

The dialogue created during this process also diminishes the adversarial relationship that student and teacher often find themselves in. Teachers learn about themselves and about how their conversations with students influence what the students are doing. It becomes quickly apparent when students do not understand or cannot use specific feedback from faculty, thus helping teachers learn how to teach more effectively.


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