The goals of baccalaureate nursing education and the National League for Nursing accreditation criteria for baccalaureate programs (NLN, 1992) call for increasing emphasis on cognitive development, which refers to the way in which individuals reason, view knowledge, manage diversity of opinion and conflicting points of view, and relate to authorities or experts. Students who demonstrate cognitive growth are able to employ independent decision-making, provide nursing care despite conflicting or ambiguous information, engage in critical thinking, and appreciate that a particular decision may be right for some but not for others.
This study was undertaken to describe the cognitive development of baccalaureate nursing students at the beginning and end of the freshman year and to describe the change in cognitive development that occurs from the beginning to the end of the freshman year. The study also was designed to determine the effect of developmental instruction strategies on the cognitive development scores of freshman nursing students and to investigate the relationship between cognitive development scores, grade point average, and SAT scores.
Despite the nature of nursing practice, which requires critical and independent thinking, studies related to the cognitive development of baccalaureate nursing students have revealed that the majority tend to be at the lower end of cognitive development, even upon graduation (Frisch, 1987; Keenan, 1988). However, advanced levels of cognitive development are necessary before one can think in more complex ways and engage in critical, independent thinking and moral reasoning (Anderson, 1989; Bandman & Bandman, 1991; Erwin, 1983; Franklin, 1985). Thus, a systematic approach to developing students' thinking and reasoning skills has relevance for nurse educators.
Perry's Scheme of Intellectual and Ethical Development
THEORETICAL FRAMEWORK AND LITERATURE REVIEW
Based on extensive work with undergraduate students about how they viewed knowledge, the role of the teacher and their roles as learners, Perry (1970) formulated a scheme of cognitive/intellectual and ethical development. This scheme is organized into four major categories (Dualism, Multiplicity, Relativism, and Commitment), and each category is described more thoroughly through a total of nine specific positions (Figure 1).
The first two positions in the scheme represent a view of the world of knowledge as dualistic. Dualistic students see the world as black-or-white, right-or-wrong. They believe there are right answers to all questions and that some authority (a teacher, the textbook, a parent) knows the right answer. They see themselves as passive learners or receptacles ready to receive truth, and they have difficulty managing conflicting points of view.
Positions three and four represent a view of knowledge as multiplistic. Multiplistic students accept that there is uncertainty in the world, but at first (position 3), they believe that uncertainty is only temporary until some authority finds the answer. Later in Multiplicity (position 4), students accept that multiple viewpoints and legitimate uncertainty exist; however, they believe one opinion is as valid as the next, and they have difficulty judging the soundness of an opinion or point of view.
Movement to recognition of knowledge as relative occurs in positions five and six. Relativistic students no longer expect or accept a universal truth, and they realize that individuals need to make choices and decisions based on their own values and experiences, and on what they perceive as "truth" for them. This requires a major shift in thinking, in the view of oneself as a learner, and in how one views the role of teachers and other "authorities." In essence, in order to fully engage in critical thinking and moral reasoning, students must achieve Position 5 thinking. They must undergo a dramatic shift to intellectual independence whereby they accept major responsibility for their own learning.
During positions 7, 8, and 9, students gradually accept responsibility within the pluralistic world and act through commitment to establish their personal identities. Students at the Commitment positions acknowledge that within themselves are diverse, conflicting personal themes and they must make choices. Such choices relate to career directions, relationships with significant others, and value systems.
Extensive research using Perry's framework indicates that most freshmen entering college exhibit relatively low levels of cognitive development and are frequently in the Dualistic stage; even graduating seniors typically are no farther along than Multiplicity (Boyer, 1987; King, Wood, & Mines, 1990; Kurfiss, 1988; Stice, 1987; Valiga & McGovern, 1993). However, longitudinal studies (Kitchener & King, 1981) demonstrate that there is a clear directional trend in cognitive development throughout the college years, and several researchers (King, Kitchener, Davidson, Parker, & Wood, 1983; King, Kitchener, & Wood, 1985) have documented that educational experiences influence that development.
Cognitive development occurs when individuals are confronted with diversity, multiple contexts, and experiences that are incompatible with their existing cognitive structures (Stonewater, Stonewater, & Hadley, 1986). Many researchers (Dunkhase & Penick, 1990; Leroux, 1986; Strong, 1985; Wang & Palincsar, 1989) report that specifically designed teaching strategies can encourage higher level thinking and problem-solving skills in college students. Weaver (1989) supports the notion that intellectual independence can be achieved via specially designed curricula and pedagogies in both liberal arts and professional programs.
Despite the findings that teaching strategies and curricular approaches can positively influence students' cognitive development, most studies implemented these strategies in non-required courses designed specifically for the research. In addition, few tested the effect of developmental instruction on students' cognitive development, and none involved nursing students or considered the unique features of a nursing curriculum.
The present study was undertaken to expand prior research by using a quasi-experimental design and focusing on a nursing student population enrolled in existing courses in the student's major which are prerequisite to other courses in a structured curriculum. The specific strategies used evolved from the concept of developmental instruction which was developed by Knefelkamp (1974, 1981) and based on Perry's (1970) theory of intellectual and ethical development.
This study was both descriptive and quasi-experimental in nature and employed a nonequivalent control group pretest-posttest design. A convenience sample of intact classes, scheduled by the university registrar, was used. One section received the experimental treatment (developmental instruction strategies), and the four other sections, each of approximately equal size, received traditional teaching and evaluation approaches and represented the control group. The experimental section was determined by the investigators' teaching schedules; neither investigator had prior knowledge of the names or characteristics of the students registered for any section.
Potential threats to internal validity such as history, testing, maturation, and instrumentation were controlled for because they would factor equally in both experimental and control groups. In addition, there was no differential recruitment into the experimental versus the control groups which would result in systematic differences between them, and mortality was not a problem in either group.
The population of interest was undergraduate students enrolled in a nursing curriculum. The sample was drawn from one baccalaureate nursing program at a private, church-related university. The subjects in this convenience sample were freshmen, enrolled in Introduction to Professional Nursing I during the fall semester (iV=99) and Introduction to Professional Nursing II during the spring semester (N=95).
The Learning Context Questionnaire (LCQ) (Kelton & Griffith, 1986) was used to measure stage of intellectual and ethical development, as described by Perry. It is a 50-item, Likert-type questionnaire which asks respondents to express the extent to which they agree or disagree with statements about learning, learning environments, grading, diversity, and the roles of the student and teacher. It is believed to be especially useful in determining change averaged within groups (Keen, 1990). The LCQ takes approximately 15 to 20 minutes to complete.
Kelton and Griffith (1986) assessed criterion-related validity for the LCQ using the Reflective Judgment Interview. Regression analysis produced a multiple R of .79, and test-reteet reliability was reported as .84. Internal consistency is supported by Cronbach's alpha reliability of .77 and a split-half coefficient of .75.
Scoring of the LCQ results in a Perry "score" between 1 and 9 that indicates the individual's "Perry position" or level of cognitive development on the 9-point schema. For example, a student with a Perry score of 3.02 is said to be in early Multiplicity; he/she recognizes multiple points of view but still searches for "the right answer." By comparison, a student with a Perry score of 4.82 is making the transition to Relativism and an understanding that knowledge is contextual.
On the first day of the fall semester, faculty invited students to participate in "a study of students' views about learning." Using a scripted introduction to the study, and an explanation of the students' rights as potential research subjects, faculty teaching the course invited students to participate and then distributed the LCQ. The questionnaire was completed during class time. Students who chose not to participate returned a blank questionnaire. This same procedure was used during the subsequent periods of LCQ completion. Students were identified only by social security number, and individual scores were known only to the researchers.
Each semester, the experimental group was taught by the investigators, using specific strategies designed to facilitate cognitive development. All four of the control group sections each semester were taught by one other faculty member, who used traditional, lecture-oriented teaching strategies. Both the experimental and control sections used the same syllabus, course objectives, topical outline, and textbook. Students completed the LCQ at the end of each semester. Because there is only one form of the instrument, some "practice effect" could occur; however, it was expected that this effect would be minimal since students were giving their opinions on the degree to which they agreed or disagreed with statements, and because there are no absolute answers to statements. In addition, there was a 4-month interval between testing periods; thus, it was assumed that any "practice effect" that might exist was minimal.
Developmental instruction is organized around the concepts of challenge and support, initially proposed by Sanford (1967) and refined by subsequent researchers. It offers support for the present level of cognitive development and affirms what has already been achieved, and it challenges cognitive growth by offering alternative explanations and contexts. Cognitive change is accomplished through the interaction of learners with increasingly complex environments.
Refinements of Knefelkamp's concept of developmental instruction (Knefelkamp & Slepitza, 1976; Touchton, Wertheimer, Cornfield, & Harrison, 1977) use four challenge and support variables: the amount of structure in the learning environment, the degree of personalism exhibited by the teacher, the degree of diversity allowed or encouraged in class and course work, and the type of learning experiences. Challenge is provided through diversity and vicarious learning, while support is provided through a high degree of structure and a highly personal atmosphere. Each of the four components of the model exists on a continuum (Figure 2). It is the task of the teacher to provide the appropriate balance of challenge and support that will promote growth.
The developmental instruction strategies used in this study were formulated within the context of existing course content, requirements, and assignments, the latter of which were modified to include elements of challenge and support. These strategies provided for diversity in course assignments and projects and in the way students learned the course material. They were designed to give students the opportunity to participate actively in course activities and engage in critical thinking; this was accomplished by requiring students to consider multiple perspectives, integrate previously learned material, form opinions, and provide rationale for their opinions or points of view. In addition, the strategies encouraged writing, debate, active participation, and group projects, and they allowed for ongoing course evaluation.
Developmental Instruction Model
Diversity pertains to the number of alternatives or perspectives that are encouraged or presented; extensive diversity encourages debate and creativity, and it allows students a choice of activities in meeting course requirements. In this study, diversity was provided in several ways, including purposeful exploration of divergent viewpoints on current issues or different interpretations of historical events and the involvement of guest lecturers, who introduce various perspectives and styles. Diversity also was provided by giving students a choice regarding their final course requirement: taking a final exam, writing a final paper, or completing a creative project (such as an audiovisual presentation, short story, poem, collage, or piece of music or art) which was presented to their peers.
Types of experiences refers to the extent to which students are directly involved in learning activities. To provide for direct learning, students interviewed practicing nurses about the unique aspects of their particular nursing role, their educational preparation, career goals, and so on. In addition, peer evaluation measures provided students with the opportunity to critique presentations made by other students. In order to provide an opportunity for vicarious learning, students reported summaries of significant points from assigned readings to their peers.
Structure refers to the amount of direction provided to students. Clear, written explanations were provided for all assignments, and criteria for grading were made explicit, thus providing some degree of structure for students. On the other hand, structure was minimized by altering the seating arrangement in the room and by moving the class site, thereby conveying the notions that learning does not occur in a "place," but rather in the individual and that learning can occur outside the "normal" context of a classroom.
Personalism refers to the ways in which the teacher and the learning environment communicate openness, mutual trust and respect, and a willingness to take risks in the process of learning. The most significant activity that demonstrated personalism and served as an ongoing source of dialogue between students and faculty was the use of the One-Minute Paper, which was adapted from Cross (1981) (Figure 3). Through the One-Minute Papers, it was possible to assess student understandings, misunderstandings, processing and integration of material, and the many ways in which the same information was interpreted by different students. Finally, extensive, personal feedback designed to stimulate thinking was provided on all written material submitted by students. In contrast to Anson's (1989) findings that teachers consistently respond to students in dualistic, surface-oriented modes and communicate their own assumptions about knowledge, the feedback provided here was designed to offer alternative views, new questions, and other challenges. For example, students were encouraged to consider their opinions about the role of the nurse in light of new information gained, reflect on their personal reasons for choosing nursing as a career, or express in class their disagreements with the literature.
Of the 99 freshman students enrolled in the fall semester, 66 completed the LCQ in September and 59 completed it in December; 71 of the 95 students enrolled in the spring semester completed the LCQ in May. Students enrolled in the introductory nursing course reflected the general characteristics of the university population: they were generally white, Catholic, 18 to 20 years old, middleto-upper class students from the New England and midAtlantic regions. In addition, they were predominantly female.
A one-way analysis of variance and i-test procedures compared the LCQ scores of the experimental and control sections for each of the three testing periods. Analyses of September, December, and May scores demonstrated no significant differences between the groups. The mean level of cognitive development (Perry position) for all freshman nursing students at each of the three testing periods was early Multiplicity (M=3.44, M=3.66, M=3.61). While subjects evidenced some cognitive growth by the end of the freshman year, mean scores remained at the lower Perry positions.
Individual scores were not analyzed; however, for the fall semester, students in the experimental group showed the greatest positive change in mean LCQ score (+.42 Perry position, in contrast to +.18 for the combined control sections). Because only five students were enrolled in both experimental sections (fall and spring semesters), comparative analyses of scores for students with 2 versus 1 semester of developmental instruction could not be conducted. The Table summarizes the number of students in the control and experimental sections each semester as well as the mean LCQ scores for each group.
Finally, LCQ score data were merged with student GPA and SAT data (N=57). Correlational analyses demonstrated: a) a significant relationship between SATMath and final GPA (r=0.31,p<.05), b) a significant relationship between initial LCQ score and SAT-Verbal (r=0.27, p<.05), and c) a significant inverse relationship between initial LCQ score and rate of change in LCQ score (r=-0.52,/><.001), with initial LCQ score accounting for 27% of the variability in LCQ score change (R*=0.268). In other words, subjects with higher initial LCQ scores showed a gradual increase in cognitive development, while subjects with lower initial LCQ scores evidenced a greater increase over time.
DISCUSSION AND IMPLICATIONS
The purpose of this study was to describe the cognitive development of freshman baccalaureate nursing students and to test the effect of developmental instruction on their cognitive development. While the study did not demonstrate a statistically significant difference in Perry position for the students exposed to developmental instruction strategies, explanations for this finding may relate more to the number of subjects, the variability among subjects, the nature of educational research, and the particular curriculum design than to the validity of the theory and instructional model.
The small sample size limited statistical power and thus limited the ability of the test to detect differences. The range of scores for the entire group was 2.23-5.65 and the SD was .71-.89, which reflect significant variability within the groups, as might be expected in educational research on intact groups. Further analysis of cognitive development data could be analyzed using repeated measures ANOVA and more qualitative investigation. The investigators did note qualitative differences between the learning environment and student reactions in the experimental sections and those during previous experiences teaching the same course.
Mean LCQ Scores for Each Testing Period
As with most nursing programs, the majority of nursing courses in the program under study are in the upper division. The freshman courses described here carried only one credit each, and most of the students' course work was outside nursing. Student energies typically are diverted to adjusting to college and to science courses, and the subjects in this study fit this profile.
Despite the limited amount of faculty-student interaction in the classroom each week, qualitative differences were evident on the One-Minute Papers of students who were involved with developmental instruction, and those students were better prepared for and more actively involved in class discussions than previous students. In addition, students in the experimental section were more willing to take risks with what they said in class, for example, by feeling free to disagree with the majority opinion. The investigators also perceived that participants were willing to do more and to engage in alternative learning activities than students in previous sections of this one-credit course, and they seemed to respond positively to the high expectations placed upon them. Interestingly, students who had participated in developmental instruction expressed an interest in enrolling in the investigators' section in subsequent courses, suggesting that they enjoyed this kind of active learning and student-teacher relationship. In addition, one student who had to leave the university after the first semester for financial reasons kept in contact with the investigators for 2 years and continued to comment on the value of her learning experience in the course.
Students enrolled in the developmental instruction section appeared more tolerant of different perspectives, various approaches to learning, and different interpretations of the "same" material. Some of their comments included, "I never much believed in learning from your peers, but the class discussion was so helpful" and "It's always interesting to me to see how differently my peers feel about and react to controversial issues," views that are associated with more advanced levels of cognitive development. This beginning acceptance of multiple viewpoints was particularly evident in the students who were enrolled in the developmental instruction section for both semesters; while this group numbered only five and no statistical analysis of their scores was possible, their mean Perry position at the end of the spring semester was 4.19, a score representing late Multiplicity and the beginning acceptance of multiple viewpoints.
In addition to these qualitative differences, the investigators believed that the insights about the topics under discussion that seemed to be achieved by numerous students in the experimental section were far more sophisticated than what students had achieved in the past. For example, one student commented on her One-Minute Paper that she was impressed with "how a woman of [Florence Nightingale's] era could exert so much power and influence."
Due to the homogeneous population and non-random assignment of students to treatment groups, the generalizability of findings is limited. In addition, the LCQ has its limitations in that some researchers believe that intellectual development is best discerned through an interview or essay response procedure. The investigators plan to pursue this line of inquiry in future studies.
Valuable insights on the part of the teachers/investigators resulted from this study. It was clear that developmental instruction strategies could be designed within the context of existing nursing courses; that is, one need not design special courses particularly geared to enhance cognitive development but can use the structure and design of existing courses. Interestingly, faculty who continue to teach the freshman nursing courses described here have adopted many of the teaching and evaluation strategies developed for this research, thus indicating their value, relevance and feasibility. In addition, faculty who have used developmental instruction strategies report that teaching is more fun, more enjoyable, and more of a challenge to them.
These qualitative findings and other studies continue to suggest that developmental instruction does influence students' cognitive development and there is merit in pursuing these approaches to teaching and learning. Developmental instruction seems to promote critical thinking and empower students. In addition, it helps teachers consider their own prejudices and world views as they respond to student comments and give feedback on One-Minute Papers, and, thus, helps faculty remain sensitive to such behaviors. As noted, a higher level of cognitive development is necessary to advance to a higher level of moral development, and it is a precursor to critical thinking; thus, there is a legitimate reason for educators to be concerned about this area. As such, developmental instruction warrants further study and "experimentation" with approaches to implementing and integrating it into nursing courses.
Keen (1990) asserts that students must take what they learn from a class and gain further experience by applying their new knowledge in their own lives before they fully internalize it. This would argue for delayed assessment and testing students at a later date. The investigators did ask those students enrolled in the freshman course described here to again complete the LCQ at the end of their sophomore year; while many other experiences and variables would affect students, this follow-up evaluation at the end of the sophomore year showed a mean LCQ score of the total group (N=54) of 3.92. Thus, students advanced somewhat in cognitive development but were still in Multiplicity.
The experience of the investigators with this study suggests further areas of research. The study should be replicated with a larger sample and more heterogeneous student groups, as well as in a variety of programs and institutions. Since data indicate that students with lower levels of cognitive development realize a greater increase in LCQ scores, the developmental nature of the construct of cognitive development needs further investigation; variables such as age and the effect of the college experience itself, as well as the effect of specific educational interventions, should be studied.
The effects of developmental instruction in nursing courses with a lab or clinical component should be investigated, and the long-term impact after accumulated semesters of such teaching should be studied, as that may be needed before significant differences can be evidenced. In addition, further investigation of the relationship of cognitive development to variables such as SAT scores, GPA and NCLEX-RN results could yield valuable recruitment, retention, and pedagogical information.
In light of the thinking required to make reasoned decisions in nursing practice, the relationships among cognitive development, critical thinking, and moral development need to be explored. The relationship of faculty cognitive development to their use of developmental instruction strategies, the effects of strategies other than the ones used in this study, and correlations among various measures of cognitive development all are open to investigation.
Finally, the effects of developmental instruction using qualitative measures of cognitive development (such as the Measure of Intellectual Development) or as measured by qualitative assessments such as a content analysis of journals, entries on One-Minute Papers and student evaluations, warrant careful study. In these ways, nurse educators can identify approaches to teaching and learning that best serve our students.
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Mean LCQ Scores for Each Testing Period