Nursing research is critical to establish the science for the discipline and to provide a foundation for evidence-based practice (EBP), which is the basis for excellence in health care (Smadu, Murphy, & Petrucka, 2010; Tingen, Burnett, Murchison, & Zhu, 2009). All nurses need to understand the research process and engage in research at the level for which they are prepared, whether they are actively involved in the conduct of research or using the evidence generated through research to practice more effectively. The American Association of Colleges of Nursing (AACN, 2006a, 2006b, 2008, 2011) delineates the research expectations for various levels of nursing practice. At the Baccalaureate in Nursing Science (BSN) level, the graduate is expected to integrate reliable evidence from multiple sources to inform practice and make clinical judgments (AACN, 2008). Knowledge is changing so rapidly that what students learn in nursing school may be obsolete shortly after they graduate. It is essential that students engage in EBP to keep their practice current. To do this, BSN-prepared nurses need to know how to find, read, analyze, synthesize, and apply research findings to engage in EBP.
Faculty of the college of nursing in a large university in the southeastern United States use debates in a large, online undergraduate course (approximately 240 students) to teach the skills necessary for successful EBP. The purpose of this article is to describe the authors’ experience in successfully implementing this innovative teaching–learning strategy.
Challenges to Teaching EBP to Undergraduate Baccalaureate Nursing Students
Students who are enrolled in nursing programs other than the Doctor of Philosophy (PhD) frequently have difficulty appreciating the relevance of research to their careers and often regard courses in research as unnecessary and competing for valuable time needed for clinical courses (Halcomb & Peters, 2009; McCurry & Martins, 2010; Meeker, Jones, & Flanagan, 2008). This is especially true of BSN students. EBP courses are often taught early in the curriculum in the same semester as students’ beginning clinical nursing courses. In the authors’ program, students take the EBP course in the second semester of their junior year, together with medical–surgical, obstetrics–pediatrics, or psychiatric–mental health nursing clinical courses. Only one EBP course is offered in the undergraduate curriculum. At that point in their education, students are familiar with the term evidence-based practice, but they have no knowledge about the research and EBP processes. Students see the EBP course as a distraction from the “real” nursing courses, such as fundamentals of nursing or a medical–surgical course. Students find the hands-on courses exciting, whereas they often characterize EBP courses as dry and boring. With little or no nursing experience and limited discussion of EBP in the concurrent nursing courses, nursing students sometimes have difficulty understanding the relevance of EBP to their current clinical experiences and their future practice (Mansour & Porter, 2008; Spiers, Paul, Jennings, & Weaver, 2012). The language and content of the research process and EBP requires abstract thought and critical thinking. If the EBP course occurs early in the curriculum, many students have not yet developed those skills, which makes the content challenging to present at the same time that they are learning the language and skills of clinical nursing (Halcomb & Peters, 2009; Spiers et al., 2012). All of these factors may contribute to negative attitudes toward EBP.
Learning theorists have long proposed that learning is most effective when learners are actively collaborating and engaging with others. Engaged learning has been defined as a collaborative learning process in which teacher and students partner in constructing knowledge. According to Conrad and Donaldson (2011), students working in groups to explore appropriate resources to answer meaningful questions is a key element of engaged learning.
Engaged learning is particularly important for online courses. If learners are not engaged in an online course, they are likely to feel isolated and disengage from the course (Conrad & Donaldson, 2011). Therefore, it follows that interaction is the key to an effective online course, and designing activities that engage students with the material and with each other is the most important role of faculty of an online course.
Debates as an Engaged Learning Strategy to Build Skills for EBP
To be a successful professional nurse whose practice is evidence based, students need several critical skill sets. Knowledge is changing so rapidly that students need to be prepared to be lifelong learners who can find the latest, most up-to-date evidence on which to base their practice. Critical thinking is important for nurses and is an important part of EBP. Critical thinking can be defined as a higher order, complex phenomenon that involves analysis, interpretation, evaluation, and communication of information to make judgments and decisions (Burrell, 2014; Kim, Sharma, Land, & Furlong, 2013). In short, it is critical thinking that allows nurses to engage in the flexible, individualized, situation-specific problem solving that is required in complex nursing situations (Kong, Qin, Zhou, Mou, & Gao, 2014).
Nurses are part of a health care team; consequently, they need to know how to work with a group, delegate and coordinate tasks within a group, give constructive feedback, and evaluate the performance of other group members. Success of the group depends on effective leadership and strong communication skills among group members.
The use of debates as a learning tool is a strategy that requires students to engage with each other to practice the skill sets needed for EBP. Debates require students to collaborate in data retrieval, analysis, evaluation, and synthesis to build successful arguments. All of those tasks are activities that foster critical thinking (Kennedy, 2009; Kim et al., 2013). Debates also promote mastery of content and problem definition. Students gain experience assessing the credibility of sources, challenging assumptions, recognizing inconsistencies, and prioritizing the relevance and salience of points within an argument. In addition, debates foster knowledge about new issues and clarification of one’s position on controversial issues. Conducting debates requires the development of persuasive writing and oral communication skills. Learning both sides of an argument contributes to other important attributes in nursing, such as open-mindedness and empathy (Kennedy, 2009). When debates are conducted within groups, students assume leadership positions, develop a plan for getting the work completed, delegate tasks and responsibilities, maintain clear communication among group members, work collectively to accomplish the learning objectives, and evaluate the performance of other group members (Huff, 2014).
Organization of Large Online Courses
Conducting debates in a large online course provides an opportunity for engaged learning that could not otherwise be easily accomplished in a large classroom with more than 200 students. However, organization of the debates and the entire course has to be impeccable or the exercise could quickly become chaotic, leaving students feeling confused about the process and how to meet expectations. Prior experience with online learning and consistency of online course design within the program helps students to stay organized and focused on learning.
Faculty should work with an instructional designer to optimize course structure and teaching strategies. All online courses in the authors’ program are designed with the same format, and the teaching approach emphasizes interactivity and prompt feedback on all learning activities. At the core of the design are weekly course guides, which provide students with a list of activities and resources necessary for each week, including readings, lectures, quizzes, and surveys. Students always know what is expected of them in any given week and have ready access to the tools necessary to complete all tasks. All courses include a mix of individual (e.g., quizzes) and group assignments (e.g., debates and projects). At the beginning of each week, instructors provide a short video with evaluative comments on the completed assignments of the previous week and an overview of the upcoming activities.
Using computer-graded assignments, tightly structuring written assignments that require manual grading, and addressing feedback to groups, rather than individuals, saves instructor time and makes it possible for one faculty member to teach large numbers of students online. Another time-saving strategy is to encourage and train students to ask questions using the course discussion board, rather than contacting the instructor individually through e-mail.
Organization of the Debates
The entire course content is taught in the first 8 weeks of the semester so that students develop a basic understanding of EBP before beginning the debates. The debates take place on the course discussion board in the Blackboard™ course management system in the last 6 weeks of the course, and the debates are the sole activities during this time. All debate material and instructions, with the exception of the debates themselves, are in a separate section of the course labeled “Online Debates and EBP Recommendations.” An orientation video that guides students through all steps of the debates is the first item posted in this section. This section includes a list of debate topics and an interactive wiki, where student groups can sign up for their chosen topic. A table listing all of the teams and showing what each team is doing in any given week is provided so that it is easy for students to stay on track. Finally, a document is available that provides students with the title of threads (e.g., First Affirmative Statement) to post and a schedule of when to post them.
To emphasize the relevance to clinical nursing, debate topics are chosen that are related to students’ experiences in concurrent clinical courses. Topics are presented as propositions, and a mini scenario is written for each topic. The following is an example of a debate topic:
You are a BSN graduate. The infection rate is up on your unit. Your nurse manager wants to make sure that the soap that is available on the unit is the most effective for reducing infection, but she is unsure whether gel sanitizers or soap and water is best. She gives you the task of reviewing the evidence and making a recommendation to her on which type is most effective. The proposition that you will be debating is: Gel sanitizers are better than soap and water to prevent infections.
In the course, clinical groups in the concurrently running clinical nursing courses become the debate teams. Eight students comprise each group, and each group decides which four students will argue each side of the proposition. A total of 30 groups are involved, and five to six groups at a time are actively debating during one week of the final 6 weeks of the course. Teams that are not debating in any given week participate in the process by having an assigned debate to follow and critique. The entire course is encouraged to contribute to the debates by posting comments on the discussion board in the Class Response thread of a debating team; therefore, all students are engaged throughout the duration of the debate activity.
The debate format used was designed by Gunawardena and Lowe (Gunawardena, Lowe, & Anderson, 1997). The authors of the current study modified the original format by including a class response stage. Each debate lasts 8 days and unfolds in the following four stages: (a) first affirmative/negative statement, (b) affirmative/negative rebuttal, (c) class response, and (d) affirmative/negative summarization. Each team has their own forum on the discussion board in which to post their debate threads. Each team is responsible for posting each thread on time. After the conclusion of the debate, debating teams have 1 week to come together, decide which side has the best evidence, and write EBP recommendations based on that evidence. EBP recommendations from all groups are posted in a wiki for everyone to see.
Grading of the Debates
Students receive a group grade for the debates and EBP recommendations. The instructor uses a grading rubric that delineates requirements and point allocation. The students are referred to the rubric throughout the semester. For debates, points focus on threads being posted on time, the quality of arguments, grammar and spelling, and quality of evidence. For EBP recommendations, points focus on the evidence of critical appraisal of findings, presentation of best practice recommendations, and a reference list prepared in American Psychological Association style. Each team completes a peer evaluation of their team members that asks about the value of contributions and teamwork. Individual grades can be adjusted based on consistent peer review of poor performance.
A separate grade is given to each student for completing the required critiques of other teams’ debates. Each student critiques the debate of three other groups, contributing a total of 15 points (5 points each) to the final course grade. Student critiques of other teams’ debates are conducted by survey and include the following questions:
- How well did the affirmative/negative team define their position?
- How well did the affirmative/negative team support their position by evidence/research?
- To what extent did the debate affect your understanding of the issue surrounding the debate topic?
- What is your personal lesson learned from this debate?
The purpose of the debate critiques is not to provide feedback for the debating teams but to ensure that nondebating students are involved in the debate process each week. The critiques enable the instructor to monitor student engagement and acquisition of EBP skills. Students demonstrate these skills by assessing the quality of the arguments and evidence presented by the debating teams. These surveys are not shared with the debating teams because sharing them would place a significant demand on the instructor’s time. Students place more value on instructor feedback, compared with feedback from peers (Ertmer et al., 2007), and the instructor of a large course has to make deliberate choices when deciding how to allocate his or her time.
Six years of data from debate critiques are available. More than 60% of students reported that the debates greatly affected their understanding of the debate topics. Many students changed their positions after examining the evidence. The following are sample comments from the debate evaluation surveys:
- I learned to always put myself in somebody else’s shoes and not to judge them but to help them through their problem.
- What I am learning more and more about through these debates, as well as from this group, is that there are a lot of opposing and supporting facts for both sides of the argument.
- The personal lesson that I learned from this debate is that we have to be an advocate for the family, as well as the patient. We are in charge of protecting our patient, but we are also in charge of caring for the family’s emotional needs.
Instructor Responsibilities During Debates
The instructor of the course provides all feedback to students. In order for debates to progress smoothly, the instructor must function as a guide and act as a resource throughout the process. Before the debates begin, the instructor acts as a coach to help students find evidence on their topic. Often, students do not know what key terms to use in a search engine or what databases are appropriate to search. They also might be using inappropriate, nonscholarly sources from the Internet. Many times, students limit their searches to nursing databases and need feedback to widen their search. During the debates, the instructor has to follow each debate closely to assess whether the threads are posted on time, posted in the right place, and labeled correctly, and whether the arguments contain the most critical points. Debating groups receive immediate feedback after posting their threads. Feedback is provided to the entire group, not to each individual in the group. Prompt feedback is especially important if opening arguments are tangential to the topic or lack critical points. For example, in arguments for teaching birth control in public schools, if the debating team does not include evidence about parents’ concerns, they are missing critical points. The instructor also posts reminders during the first week of the debates to help debating teams stay on schedule. Finally, the instructor encourages all classmates to read the debates other than the ones to which they are assigned to evaluate and post comments in the Class Response thread.
Occasionally, debating teams develop conflicts. Typically someone from the group will notify the instructor that there is a conflict but that they would like to try to manage the conflict themselves. Occasionally, the instructor has to intervene and mediate.
The authors faced several challenges each year during the debates. One of the biggest challenges was discovering that some students have writing deficiencies or do not know how to cite studies in text. Students also may limit their searches to the nursing literature and need to be encouraged to use research from other disciplines. Sometimes, students have difficulty adhering to a scientific world view and some quote Bible verses. In addition, a few students may hold onto judgmental attitudes, even in the face of evidence. For example, one group of students decided, even in the face of contrary evidence, that women who abuse alcohol and other drugs while pregnant should be prosecuted, rather than treated. That judgmental attitude was addressed at the group level, rather than with the entire class, for two reasons: (a) addressing the judgmental attitude at the class level would be criticizing this group in front of the class, as all students know what groups debated each topic; and (b) the majority of students are not judgmental.
All of those challenges are addressed throughout the debates by instructor feedback. The authors developed a handout addressing appropriate writing and citation guidelines that was implemented for the first time in spring 2015. Finally, students do not consistently incorporate the instructor’s feedback into subsequent contributions. To emphasize the importance of attending to feedback, that point has been included on the grading rubric.
Over the past 6 years of using the format described in this article, the authors have identified their own best practices. Those practices include:
- Record an orientation video that covers all aspects of the debates.
- Create a dedicated Blackboard course section for materials related to debates and include clear, detailed instructions to minimize confusion.
- Provide a debate example for students to follow.
- Provide grading rubrics to clarify expectations.
- Create separate forums for each team’s debate to make the debates easy for others to follow.
- Assign debates to be critiqued by nondebating teams to ensure that all teams remain engaged.
- Within the course management system, use a survey tool for peer critiques to make it easy for debate teams to submit answers and for the faculty to review student input and participation.
One of the most important lessons learned is that the course elements will not be effective unless students read and understand the instructions. The authors have found that the only way to ensure that students read and understand instructions is to give a quiz on all aspects of the debate instructions 1 week before debates begin. Fall 2014 was the first time the quiz was implemented, and the debates progressed smoothly, with no student getting lost in the process or confused.
The authors have found that using debates to teach EBP skills engages students with each other, with the material, and with the instructor. Debates require that students practice many of the skills they will need to function on nursing teams, including critical thinking, teamwork, leadership, delegation, communication skills, and peer evaluation. Finally, debates foster the development of abstract thinking, information literacy, and skills required to evaluate evidence and develop and evaluate arguments. Those competencies provide students with the foundation to become lifelong learners and base future practice on best evidence.
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