The amount of information in both the content and application of nursing knowledge has escalated in the last decade. Although this information is readily available and often research-based, it is decontextualized and fragmented and may be of questionable quality. In addition, the half life of information is decreasing, requiring frequent revisions and updates so that valuable information is being discarded. Conversely, the volume of new information to add to nursing curricula is overwhelming. The increased volume of information in nursing requires conceptualization and synthesis of nursing knowledge and new approaches to teaching (Diekelmann, 2002; Giddens & Brady, 2007; McBride, 1999; National League for Nursing, 2005). Current models of teaching are no longer efficient in communicating the complexity of concepts and skill sets required to prepare practitioners for contemporary health care settings. Practice arenas, in particular, necessitate rapid and accurate linkage and application of concepts between disparate and changing contexts (Institute of Medicine, 2011). Hence, conceptual learning is imperative for students at all levels of nursing education. In this article, we link a concept-based curriculum to principles from semiotics and provide an overview of specific teaching methods that promote conceptual learning.
Call for Conceptual Teaching
Current nursing curricula are replete with facts and content isolated to individual clinical situations and settings, as noted by the Institute of Medicine (2011) report on the future of nursing. The same information is taught and replicated for each population (e.g., clinical specialties, illness experiences, patient acuities, and social groups), to the extent that repetitive learning for each group is impractical. Concept-based curricula are logical resolutions, enabling synthesis and transferability of nursing knowledge across multiple contexts (Giddens et al., 2008; Ironside, 2004; Milligan & Wood, 2010). Conceptual curricula relieve educators from attending to miniscule particulates of overly contextualized items of information. Unlike nursing curricula in the 1970s and 1980s, with programs constructed around relatively abstract mid-range theories, concept-based curricula focus less on abstractions and are more useful as bases for practice.
Concepts can be defined as a collection of social, cultural, and historical constructions and ideas that, over time, maintain similar form, structure, and patterns. Concepts vary on level of abstraction—from general to specific. For the purposes of this article, we divide concepts into two categories: scientific concepts and lay concepts (Morse, 2004). Scientific concepts are physiological and behavioral in nature, defined by experts, and operationally defined and measured for research purposes. Lay concepts are socially constructed or created and arise in daily life, eventually becoming common nomenclature and formally defined in the dictionary.
Lay concepts are often explored by qualitative health researchers to better understand how meanings and associated behaviors affect health. Lay concepts are often adopted by quantitative researchers and operationalized for the purposes of measurement and prediction. For nurses and educators, both scientific and lay concepts are central components of practice and education. Concepts are codes for ideas and descriptions of behaviors that are communicated between individuals. Concepts both describe and construct behaviors and meanings. These ideas and meanings are cultural, social, and historical in origin.
Theoretical Underpinnings: Semiotics
Teaching conceptually entails focusing on how meaning is produced and used. We use a semiotic approach to language to frame our argument. The broad field of semiotics, commonly defined as the study of signs and symbols and their use and interpretation, is instrumental to constructivist pedagogy. In this article, we use semiotics as a method to understand the constructed relationship between signs and meaning. Semiotics has historical roots in linguistics and focuses on systems of representations or signs (Allen & Hardin, 2001; Chandler, 2007). In the branch of semiotics defined by Saussure (Chandler, 2007), a sign consists of two components—the signifier and that which is signified. The signifier is arbitrary and considered the referent (e.g., a written word, sound, image, or mannerism). Signifiers are codes for mental ideas and notions, otherwise known as concepts. The idea or notion that is being referenced is labeled as the signified. For example, in nursing, the written word care (signifier) is a code for a set of ideas and behaviors (signifiers) associated with assisting in the well-being of others. The squiggles and lines on the page that comprise the word care do not represent anything outside of the context in which it is used. As a verb, the word care is also used in association with negative preferences. For example, in the sentence “I don’t care about you,” the word care takes on a meaning different from its use to describe interactions between nurses and patients in the amplified phrase to take care of. Consequently, the meaning of the word care is dependent on how it is being used in a sentence.
Holding to the tenet that the signifiers are meaningless unless used in a context, educators have a springboard from which to teach. Just as understanding of a word expands for the reader when the word is placed in a sentence, the meaning of the word is further expanded when the sentence is placed within a paragraph. Similarly, learners begin with a personal and perhaps highly solipsistic understanding of a concept that, when applied to multiple contexts and situations, is amplified and expanded beyond individual experience. After a basic concept is learned, meaning is extended according to the population, setting, and condition being studied. Concepts are not learned by providing a list of facts and content-laden information. Concepts are learned through integrating factual information within a context, so that concepts, not only facts, become the foundation of understanding.
Core Components of Conceptual Teaching
In changing to conceptual curricula, the theoretical tools used in semiotics offer alternative approaches to teaching fact-based and content-based curricula. We refer to Wiggins and McTighe (2005) for assistance with designing conceptual curricula. In this article, we review three tenets that we believe to be central to executing the curricula: (a) addressing misconceptions, (b) building enduring understandings, and (c) developing metacognition (Donovan & Bransford, 2005).
The first step in teaching conceptually is ascertaining what meanings students arrive with and then assigning them to concepts. Students bring their own history and experiences to the educational setting. These experiences and meanings associated with their experiences are the starting point from which they integrate new material (Donovan & Bransford, 2005). Faculty must acknowledge and correct students’ misconceptions prior to the integration of new material. If misconceptions are not addressed, new material will be built on misinformation and, consequently, students will be prevented from learning both basic and complex concepts. However, for students to misapply a concept, they already must have some understanding of what it means and how it operates. Therefore, identifying misconceptions is an opportunity to encourage students that the learning and transfer of knowledge has already taken place, albeit incorrectly (Wiggins & McTighe, 2005).
Building Enduring Understandings
The goal of nurse educators at all program levels is to teach students how to become lifelong learners (Institute of Medicine, 2011; National League for Nursing, 2005). When concepts are truly understood by students, understandings will endure and transfer across educational and clinical contexts (Wiggins & McTighe, 2005). The nurse educator’s work is to expand, enrich, and make flexible and nuanced the mental constructs that students are learning. This process of learning, not just the content learned, will prepare students to become lifelong learners.
To become a lifelong, flexible learner, students must be taught metacognition, which is the ability to understand and monitor one’s own thinking (Bransford, Brown, & Cocking, 2000). Metacognition is the internal dialogue that accompanies the learning process. Making the learning process explicit is an essential component of critical thinking. Students with meta-cognitive skills will more readily transfer knowledge from one context to another.
In this section, we provide teaching techniques that are particularly effective for conceptual teaching and learning. These methods explore concepts deeply and link concepts to each other, thereby maximizing creativity and exploration. Adhering to the theoretical tools in semiotics, concepts are ideas that are understood only when used contextually, and these methods honor the student’s prior understandings while concurrently challenging previous perceptions. We offer five methods for educators that teach learning for understanding, build enduring yet fluid understandings, and promote metacognition.
Misconception and Preconception Check
The misconception and preconception check is a short and simple questionnaire designed to elicit information from students about their beliefs and ideas regarding troublesome misperceptions, myths, and misinformation that are likely to interfere with learning about one or more concepts (Angelo & Cross, 1993). This method is most effective when teaching about the concept and not as an exemplar of the concept (e.g., sexual development, not heterosexual expression in adolescents). The question items may be multiple choice, short answer, or Likert type. An example of an item stem on a misconception quiz is:
The average American using food stamps is unmarried, African-American, female, with three children.
I am certain that is true.
I am fairly certain that is true.
I am unsure.
I am fairly certain that is false.
I am certain that is false.
Student anonymity must be ensured to maximize validity of student responses. The instructor must inform the students about how the information will be used prior to administration of the questionnaire.
The information can answer three questions: (a) what misconceptions the students have, (b) how many students have them, and (depending on how the instructor worded the questions) (c) how deeply embedded are the students’ beliefs and ideas. On the basis of the answers to these three questions, the instructor will be able to adjust teaching methods and materials to suit the needs of the cohort. Revealing answers to all students in real time in the aggregate can be a powerful teaching tool in mid-enrollment to large-enrollment classrooms.
For some students, sensitive concepts are frequently referred to only dichotomously (i.e., right/wrong), are constructed and used in private or limited settings (i.e. religious or sexual beliefs), and, from a semiotic framework, are highly personally contextualized. Personally contextualized concepts based on misinformation can be painful to unlearn because the concept is enmeshed with central identities such as self, family, race, religion, and world view. Beliefs and ideas that are deeply embedded require active learning techniques, multiple exposures to others’ roles and experiences, and more than a semester to unlearn.
The Discrepant Event
Long used in science education, particularly in primary and secondary education, the discrepant event has been slow to gain favor in other disciplines, although it has great potential for provoking thought, challenging assumptions, and initiating creative lines of inquiry. A discrepant event is a situation contrary to what is expected, puzzling students and leaving them at a loss to explain what has taken place. Through the discrepant event method, students improve observation and data-gathering skills, develop the ability to imagine or predict possible events, and discover the advantages of avoiding premature closure while investigating or linking concepts.
Commonly, the discrepant event begins by instructing students to focus attention on certain key elements in a situation. The situation is then demonstrated and students are asked to explain or solve what happened. With or without instructor guidance and individually or in groups, students search for an explanation. A final and key step is to resolve all student questions that have arisen. A classic example of a discrepant event in concept-based nursing education occurs in domestic violence scenarios, when the abused spouse who has separated from the abuser returns to the abuser. (Note: domestic violence is an exemplar for the concept of violence, whereas in other models, it is a concept whose exemplars include verbal abuse, spousal rape, and child abuse.)
Discrepant events provoke cognitive disequilibrium because the event falls outside the personal understanding of the students’ concept. With or without instructor assistance, students search to resolve the discrepancy and form a new, more sophisticated conceptual understanding that embraces the event. Students are now better equipped to approach novel situations (Koballa, n.d.).
When using concept maps, students draw or diagram how one or more concepts relate to each other (Angelo & Cross, 1993; Daley, Shaw, Balistrieri, Glasenapp, & Piacentine, 1999; Harpaz, Balik, & Ehrenfeld, 2004; Hsu & Hsieh, 2005). Students share maps (visually and verbally) with each other and may rework maps more than once as the course progresses. In small classes, students draw their maps individually; in medium or large classes, students collaborate on the map in groups. Concept maps can be particularly powerful when introducing new concepts into an established mental schema, such as familiar care settings or transitioning known concepts into unusual care settings. For the visual learner, concept maps are a welcome relief in the lexicon-laden academic setting. Concept maps are helpful when teaching about conceptual relationships but are not helpful when discussing exemplars.
Concept maps document the evolution of students’ conceptual understandings, including the relative strength of relationships and conceptual hierarchies. While describing maps to classmates, students increase their metacognitive abilities as they put words to their thinking and defend choices depicted in the web of relationships. For the instructor, assessment of the maps can highlight areas where further instruction is needed. From a semiotic framework, using a concept map graphically illustrates what is being signified, or referenced, when a concept is used.
The approximate analogy is one of the quickest teaching and learning activities to promote making connections between concepts (Angelo & Cross, 1993). The instructor supplies the first half of the analogy (e.g., A is to B), and students complete the second half (e.g., X is to Y). Examples of approximate analogies in concept-based curricula are: growth is to development as X is to Y, or perfusion is to oxygenation as X is to Y. Sharing and explaining answers is an important part of developing metacognitive skills. Because student responses increase in creativity as knowledge networks expand, the analogies are approximate. The ease of preparation and application of this activity makes it particularly useful in large classes. This is an approach that appeals to verbal and auditory learners especially.
Students, as well as instructors, will need examples and some practice rounds before becoming adept at using this activity for its intended purpose. Small-group work can be helpful, particularly for students with limited vocabularies or English skills or for those who are not widely read. Collecting and assessing student work can provide valuable information about student understanding and progress, as well as where instructors might provide concentrated teaching.
In conceptual learning, approximate analogies can be helpful as nursing students transition from concepts with which they have personal experience, such as sleep and insomnia and elimination, diarrhea, and constipation, to concepts with which we cannot assume they have familiarity, such as oxygenation and hypoxia and cognition, dementia, and intellectual disability. Approximate analogies as a teaching method are unique in that they can be used to help students link concepts to other concepts (e.g., pain to coping, leadership to professionalism), as well as to link concepts to exemplars (e.g., gas exchange to pneumonia).
Check Your Knowledge Quiz
A short quiz promotes conceptual learning when used as formative assessment and when the subject material is conceptual in nature. A Check Your Knowledge quiz is generally short and ungraded and is administered once because the purpose is to determine student understanding of the material at one point in time. To develop a Check Your Knowledge quiz when teaching conceptually, compose the quiz from unit objectives and emphasize only key points, as opposed to trivia that admittedly lends itself more easily to multiple choice formats. Drawing questions from scenarios and case studies can help ground the exercise in context, which is essential for conceptual teaching. Keep the quiz short; 10 questions or less is adequate. Emphasize that the activity is ungraded, and prior to administration, let the students know whether you will reveal anonymous, aggregate results to individuals or to the class, as well as stating its purpose.
Check Your Knowledge quizzes can be a small-group activity, with results revealed immediately and group scores posted for bragging rights. Students in small groups discuss each question, often vigorously, using reference materials to reinforce their positions. Peer debate while using data is critical for lifelong learning and evidence-based care, and immediate feedback on the accuracy of the group’s choices promotes metacognition. An ungraded assessment of students’ understanding of material can be informative for students and instructors alike. For both, results can identify areas that require further emphasis. For the student, understanding his or her progress in mastering material can help develop metacognition, regardless of whether results are shown or developed individually or comparatively. Test taking can solidify memory and understanding of complex ideas.
In addition to the five methods mentioned, techniques that are often associated with active learning can be adapted to conceptual teaching. One example is a variation of using audience response systems—after students respond but prior to revealing the correct answer, students convince a peer, who selected a differing answer, why their own answer is correct, supporting their argument with evidence. This method works only as a conceptual teaching technique if the questions were focused on concepts and not bits of content. In the act of challenging and being challenged, students engage in deep learning about the concept while developing metacognitive skills.
In this article, we provide a framework for teaching conceptually. As a framework, semiotics is a way to understand that words used in nursing and health care are meaningless unless contextualized. The context in health care is fluid and changing, making content-based curricula obsolete. Along with the explosion of knowledge availability and decreased half-life of information, it is imperative to move toward concept-based curricula that include compatible teaching methods.
Conceptual teaching methods are not hierarchically applicable in programs and can be used at all program levels. Our work as educators is to correct student misconceptions as concepts are introduced, unfreeze concepts from static understandings, and provide the best links to learn new and old concepts. While teaching conceptually, complexity is built into teaching techniques so that students focus on making connections and identifying relationships between concepts. Powerful learning transpires when students develop enduring understandings between concepts and have the ability to monitor their own thinking process.