Professional education programs in nursing are faced with the challenge of providing adequate preparation for students who will enter professional practice in a relatively short period of time. Students are called on to master a large body of information, not only to remember detailed facts, but also to make practice applications based on their knowledge of complex subject matter. In addition, professional graduates must meet other demands as well. The National League for Nursing (1993), other educators, and the Pew Commission (Shugars, O1NeU & Bader, 1991), argue that in this challenging environment, new graduates must learn to communicate well, to be able to educate consumers, and to be knowledgeable about fiscal management. They must be able to think critically and provide advocacy for their clients.
To prepare graduates to respond to these diverse and possibly contradictory demands, nurse educatore must be willing to re-examine traditional training models and develop more appropriate educative strategies. The faculty role is perhaps best viewed as one of fostering students' critical thinking and research skills instead of providing them with masses of information that must be memorized and recalled on tests.
In 1992, the nursing faculty at the University of Hawaii at Manca adopted a teaching strategy designed to foster critical thinking that modifies the principles of problem-based learning (PBL) to meet the needs of a nursing curriculum. The goal of this study was to identify the adaptations (if any) that students made to their study habits in response to this type of teaching methodology.
Nursing education literature in the 1990s (Heliker, 1994; Greedy, Horsefall & Hand, 1992; Ryan & Little, 1991) advocates PBL as an approach that promotes conceptual understanding, the development of clinical reasoning skills, and self-directed learning strategies. PBL was initially designed to encourage medical students to transfer learning from the classroom to the clinical context (Barrows & Tamblyn, 1980). Even though students had completed earlier courses, and presumably had passed examinations on the content, they had forgotten basic knowledge, appearing to have never been exposed to the information (Heliker, 1994).
To make course content more relevant, and therefore memorable, the basic approach of PBL is to place the learners in a context that is similar to one they will face in professional practice. It is expected that students will take more responsibility for identifying and seeking out the information they need for practice, be more likely to learn for understanding, and be much more likely to retain the knowledge when they are actively involved in inquiry.
To promote this type of learning, faculty at the University of Hawaii School of Nursing adapted the basic principles of PBL to develop and implement inquirybased learning (IBL). While similar to PBL, this strategy more closely fits a nursing model that is humanistic, focusing on strengths, yet encouraging students to assume responsibility for their own learning. Faculty adopted the following definition of IBL:
An orientation toward learning that is flexible and open and drawa on the varied stille and resources of faculty and studente, in which faculty are co-learnera who guide and facilitate the student-driven learning experience to achieve goals of nursing practice. This includes an interdisciplinary approach to learning, problem solving, critical thinking, as well as an assumption of responsibility by students for their own learning.
Learning experiences in IBL are practice-based, using clinical encounters or other simulations that provide the context for case studies. Students are given information about the situation in stages, in the same way that information is presented by clients or others in a clinical situation. Each section is designed to stimulate discussion about general principles baaed on current knowledge. Later sections containing relevant information are presented to students to stimulate further inquiry. Instead of relying on the teacher to give them the information needed to "solve" the case, students work together in both small and large groups to identify their learning needs and negotiate strategies to gather the required information.
Ban-rows and Tamblyn (1980) describes four broad objectives of PBL that are fully employed in the above process: 1) structuring of knowledge for use in clinical contexts; 2) development of clinical reasoning process; 3) development of effective self-directed learning skills; and 4) increased motivation for learning. The IBL process helps students develop an orderly way of exercising critical thinking while working together to learn all they can from the care situation. As Paul and Heaslip (1995) discuse, critical thinking begins for students when they seriously question, "What do I really know about this nursing care situation and how do I know it?" Faculty serve as both co-learners and resource persons, encouraging the development of critical thinking skills by regularly questioning students about their evidence for certain statements, interpretations, deductions, and conclusions.
As faculty worked with students, it became apparent that an important aspect of the curriculum evaluation process was to measure the effect of this instructional strategy on student learning and professional growth. The measurement of critical thinking has been an important aspect of the curriculum evaluation and has been reported by Inouye and Flannelly (1998, 1998). An additional study of critical thinking is in progress by this author and colleagues.
Faculty believed that it would be useful to have a knowledge of the impact of IBL on students learning habits as a way of testing the basic premises that students will become more self-directed and more fully motivated to learn for understanding. This study attempted to identify the adaptations (if any) that students made to their study habits in response to the change in teaching methodology.
The subjects for the study were one cohort of University of Hawaii at Manoa baccalaureate nursing students (n = 39) who were tested at entry (at the beginning of their sophomore year) and just prior to exit from the program. Although 39 students entered the program together, only 29 of the students (n = 29) were available for testing at the end of the program. The other students had withdrawn for various reasons.
The Cognitive Behavior Survey (CBS) was administered during a required nursing class at the beginning of the first semester (Time 1) and at the end of the final semester (Time 2) of the nursing program. Students were informed that they were part of a study and were given as much time as they needed to complete the CBS. Generally, all students were finished within one-half hour.
For this study, permission was obtained from Dr. Rudolph Mitchell (1994) to use an adaptation of his CBS tool to assess student approaches to study. The CBS is a self-reporting tool that seeks to determine the cognitive learning processes used by the student, approaches to studying, and estimations of the amount of memorization, conceptualization, or reflection employed. Dr. MitchelTs work was based on research on learning that had been in process for many years. In one of the studies, Marton and Saljo (1976) examined differences in the learning process that lead to qualitative differences in the level of learning. They distinguished between different methods of studying: 1) surface-level, which students use rote-learning strategies that lead to superficial understanding; and 2) deep-level, a process that seeks comprehension and a deep understanding of the material. Where the surface approach was characterized by a tendency to memorize facts that would need to be reproduced at a later time, the task was viewed in isolation both from the academic subject as a whole and from real life. By contrast, the deep approach involved an active attempt by the student to understand the author's meaning and to relate the ideas to the student's previous experience.
The work of Biggs (1974) and Entwistle and Ramsden (1979, 1983) was done independently, yet these authors identified three similar types of learning strategies. Newble and Entwistle (1986) furthered this research and proposed a model of learning that identified three styles: surface, deep, and strategic. Students were classed as surface learners when they learned by memorization, reproduced information exactly as it was presented, and learned only superficial levels of the material. Learners who were classed as deep learners were interested in the subject matter and sought to understand the material for its relevance to their needs. They learned by connecting ideas and relating them to evidence. Students who were strategic learners used whatever learning style was necessary (surface or deep) to acquire high grades.
Dr. MitchelTs work was also based on studies that identified additional cognitive processes such as model building, visualization, and the use of analogies and metaphors to gain an understanding of the content (Ramsden & Entwistle, 1981). He reported that when medical students were interviewed as part of the development of the CBS, they also described these processes as part of their learning strategies (Mitchell, 1994).
The CBS has five subscales. Three measure learning strategies used by students (memorization, conceptualization, or reflection). The fourth measures positive learning experience and is constructed to measure the degree to which students view learning as a positive experience. Finally, an epistemological belief section was developed to allow students to describe their views of nature and medical knowledge. In this scale, open-ended questions allow students to describe their beliefs about the mental attitudes required for success in medical school.
Item selection for the five subscales was accomplished when Dr. Mitchell performed correlations. This resulted in the final version of the tool. In the final version of CBS teste of reliability (Cronbach's alpha) yielded scores of .82, .79, .76 for memorization, conceptualization, and reflection, respectively. The positive learning experience scale was .91 (Mitchell,, 1994, pp. 164-166).
The version of the CBS used by the UH Manoa School of Nursing was restricted to the learning behavior scales. The tool was retyped to omit the positive learning experience and epistemological beliefs sections of the tool because of the limited time available for testing. It was also believed that the information most useful to faculty was the report of learning behavior.
The tool uses a 7-point semantic differential scale for studente to answer questions about memorization, conceptualizetion, and reflection. The memorization items elicit the amount of rote-learning techniques used by the student or the students' beliefs about the role of memorizetion in learning (e.g., it is an effective way to learn).
The conceptualization items, by contrast, show the processes that learners use make their own knowledge base. These include constructing analogies, visualization, model building, and synthesizing content. Statements describe measures to create meaning for details (e.g., I try to see patterns. I establish relationships among the details to see how they fit together) 1994, p. 163).
The reflective side of learning is defined by Mitchell as "the act of thinking about what one has learned as well as how one learns." Reflection statements describe reviews of other materials for application and assessment of ones level of understanding (e.g., I test out theories; I think about possibilities). Reflection on learning and the learning process may be private or done in a group discussion.
Cronbach's alpha procedure was used test the internal consistency and reliability of the CBS on the University of Hawaii student sample, with resulting alpha scores of .83 (Time 1) and .65 (Time 2) for memorization. The scores for conceptualization were .82 (Time 1) and .65 2). Reflection scores were .78 (Time 1) and .83 (Time 2).
Although it was anticipated that the students would show an increase in the amount of conceptualization and reflection reported, and a decrease in memorization, the memorization scale showed increase in the mean score from 53.15 (pre-test) to 56.18 (post-test). Paired sami-tests comparing the amount of change in each of the scales over the course of the curriculum (between Time 1 Time 2) showed no statistical significance.
The conceptualization scale showed an in the mean score from 59.74 (pre-test) to 62.81 (post-test). The reflection scale also showed an increase in the mean score. The pre-test mean was 27.9 and post-test 28.2. The ?-test continued to show nonsignificant changes on both.
In contrast to Mitchell's study that a relationship only between conceptualization and reflection, this study found significant correlation between all three scales in each administration. Memorization correlated significantly with conceptualization .465 (p <.01). Conceptualization correlated both with memorization (as noted) and with reflection .569 (p <.01). Reflection correlated only with conceptualization. The degree of correlation was similar in both beginning and end of the program surveys.
Although not statistically significant, the findings demonstrate that students continued to use memorization even after experiencing an innovative teaching methodology. Although the earlier work that categorized memorization as "surface" learning set the framework for this study, on second look, it can be argued that nursing students need to use memorization because they are required to reproduce detailed material (e.g., physiological facto, normal body parameters, etc.) on written tests and in the clinical setting. Students are aware that these facts will also appear on the nursing licensure examination. However, the material must be understood and relationships made apparent for the information te be retained and used as the basis for nursing practice.
Conceptualization is useful in that process, and was used by the students. Conceptualization and reflection may share a similarity in cognitive process that links them. Therefore, the combination of memorization, conceptualization, and reflection as study strategies is likely to lead to both an understanding of material and the retention of relevant facts.
It should be acknowledged that the nonsignificance of these findings may be attributed to the small sample size, showing the presence of a Type II error. In addition, the findings must be viewed cautiously because of the lack of a comparison group.
In this study, a brief version of CBS was used to examine the cognitive behavior of nursing students at the beginning of their nursing course work and at the end of the program. Because faculty were employing a teaching methodology that was designed to encourage the development of independent learning and learning for understanding, it was postulated that studente would decrease the amount of memorization employed while studying and increase the amount of conceptualization and reflection.
Although not statistically significant, student scores on the specific scales revealed that students increased the amount of all three of the strategies in their study. They did not decrease the amount of memorization employed. However, the significant correlation between memorization and conceptualization, and between conceptualization and reflection, shows that in addition to retaining "surface" facts, students were encouraged to understand concepts and see relationships for "deeper" learning. While memorization used as a single method of study will yield a "surface" level of understanding, the fact that there was significant correlation between memorization and conceptualization, and between conceptualization and reflection reveals that students were encouraged to strive for a deeper understanding of the material.
While further studies should be conducted to validate these findings, they suggest that IBL as a teaching strategy allows students to adopt learning strategies that lead to deep understanding.
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