Nursing education is designed to optimize how students gain the specialized knowledge, understanding, and skills necessary to practice nursing (Chung & Hsu, 2007). The success rate on the national licensure examination for RNs in Taiwan is a critical component of an effective nursing program. The Fundamental Nursing Course is one of the subjects included in the national licensure examination, and it helps students in obtaining the basic nursing knowledge needed to care for patients and the principles, objectives, and operating procedures of various nursing techniques. Formally, the fundamental nursing courses were conducted during the second years of all nursing schools. In Taiwan, many nursing schools provide several nursing review courses, such as fundamental nursing review courses in their final semester, to review the fundamental nursing course material and better prepare students for success on the national licensure examination for RNs. The objective of the review courses is similar to NCLEX-RN preparatory courses in the United States.
Two of the most common teaching approaches, didactic instruction learning and test-enhanced learning, are used in the majority of fundamental nursing review courses in Taiwan. Lecture learning (i.e., didactic instruction), a teacher-centered method of instruction in which teachers deliver and students receive lessons, is a knowledge transmission approach to teaching (Nie & Lau, 2010). A previous study has pointed out that the lectures are most effective if the students have some prior knowledge of the subject, making it easier to reflect as the lecture proceeds. The students receive rapid feedback to their questions and reflections (Reime, Harris, Aksnes, & Mikkelsen, 2008). Didactic instruction emphasizes memorization, drills, and practicing, which may contribute to students' tendency for rote memorization (Nie & Lau, 2010). Based on the study from nursing students' experiences of learning through different didactic strategies, didactic strategies support a broad base of knowledge on nursing and the professional role of nurses (Westin, Sundler, & Berglund, 2015). Traditionally, educational testing has been used primarily for assessment purposes, such as measuring students' learning, assigning grades, and evaluating curriculum efficiency. Recent researches have demonstrated that testing with feedback may actually promote learning and the long-term retention of tested information in various disciplines (DelSignore, Wolbrink, Zurakowski, & Burns, 2016; Fazio, Huelser, Johnson, & Marsh, 2010; Hernick, 2015; Larsen et al., 2015; Messineo, Gentile, & Allegra, 2015), improve metacognitive and test-taking skills (Freda & Lipp, 2016), and determine that repeated testing with feedback produces more favorable skills retention (Sennhenn-Kirchner et al., 2017).
Given that repeated testing appears to promote long-term knowledge retention, it is surprising that to date, no published research exists that has examined test-enhanced learning in a nursing education evaluation setting. Research that focuses on didactic strategies to support learning in this area is lacking as well. A comparison of the different teaching approaches when used in fundamental nursing review courses in Taiwan nursing schools has not been fully studied. To verify the value of teaching strategies in nursing review courses, information about the students' learning outcome is needed. Two objectives were explored, including (a) to study whether didactic learning instruction and test-enhanced learning approaches have a great benefit to the students' academic performance and (b) to study the effects of didactic learning instruction and test-enhanced learning approaches on the academic performances of the three nursing student performance levels.
The study conducted was a quasi-experimental design and retrospective analysis of objective test scores of 84 final-year students in a nursing school in southern Taiwan who were enrolled in one of two fundamental nursing review courses. Each course was taught by one instructor, who used one of the two teaching approaches over the course of one semester. The participants were selected via purposive sampling. In conjunction with the review course syllabus, a comprehensive examination covering the taught material was given to the students.
Measurement and Composite Measures
The test tools used in this study were three comprehensive multiple choice examinations administered to both classes approximately once every 2 months. Each examination's format simulated the national licensure examination for RNs and contained questions from past nursing licensure examinations selected by other nursing instructors at the school, not by the course instructors themselves. In this study, the two nursing teaching approaches used distinct review course formats. Both teaching approaches were grounded in principles of systematic approaches that have been developed to help students in achieving desired academic results. Two teaching approaches were classified as follows:
- Didactic instruction learning: The didactic class centered on the traditional lecture to provide students with an organized knowledge base to prepare for the examinations. The students reviewed course material through a traditional lecture presentation led by the instructor.
- Test-enhanced learning: The test-enhanced learning class centered on practice examinations and establishing familiarity with the nurse licensure examinations. The students reviewed practice questions from past multiple choice nurse licensure examinations in every class session and received explanations of correct answers from the instructor. This allowed students to ask questions.
A total of three examinations were administered at the beginning, middle, and end of the semester (referred to as the first, second, and third examination) to assess the learning progression of the students in both courses. Based on their scores on the first examination, prior to beginning the review course, the students were evenly divided into low-, intermediate-, and high-score groups, based on the 33rd and 66th percentiles, as a way to examine any differences in the performance of students in each subgroup of both courses. SPSS® version 21 software for Windows® was used for data analysis. Statistical methods were used to test the differences between classes and groups, including two-way analysis of variance, the Bonferroni comparison procedure for post hoc, mixed model of repeated measure for three examination scores, and main effect analysis for interaction term factor. In all examinations, p-values (p < .05) were interpreted as statistically significant. G*Power analysis (Faul, Erdfelder, Buchner, & Lang, 2009) revealed that the sample size was 84 for the analysis of variance repeated measurement. F-tests were conducted on the two groups with number of repetition of 3, effect size of .30, and two-sides alpha of .05. Post hoc analysis computed that achieved statistical power was .91.
Comparing the baseline data from the first examination score averages for the didactic class (75.34 [±11.38]) and the test-enhanced learning class (72.07 [±10.64]) revealed no statistically significant differences (t = 1.361, p = .177) between the two classes (Table). A repeated measurement was conducted, and the class, score, and group items were manipulated in the main effect analysis. The performance of didactic class students (i.e., didactic instruction learning) (F = 23.402, p < .001), as well as the test-enhanced learning class students (i.e., test-enhanced learning) (F = 9.959, p < .001), demonstrated that the two teaching methods were effective. However, no significant difference in score improvement existed between the two classes in terms of the final scores (t = 0.060, p = .806) (Table). The results indicated that the average score of the three examinations in each class showed significant differences (F = 28.750, p < .001) (Table). A post hoc analysis indicated that the students performed better on the second examination than the first one, and their performance on the third examination was significantly higher than that of the first and second examination. These results seem to indicate that academic performance could be improved with more class sessions.
Repeated Measure and Two-Way Analysis of Variance of Students' Academic Scores by Class and Group (N = 84)
The influences of the two teaching methods on the students were analyzed based on the low-, intermediate-, and high-score groups. Significant difference existed in the score improvement among three groups in terms of the final scores (F = 30.495, p < .001). The low-score group (F = 13.798, p < .001), intermediate-score group (F = 3.942, p = .024), and high-score group (F = 3.150, p = .048) improved their performances on the examinations. However, these two teaching methods did not lead to significant score differences in the low- (t = 0.876, p = .358), intermediate- (t = 1.080, p = .309), and high-score groups (t = 0.322, p = .575) (Table). Overall, the score difference of the low-, intermediate-, and high-score groups reached the level of significance (F = 80.363, p < .001). A post hoc comparison indicated that the high-score group performed significantly better than the low and intermediate-score groups, and the intermediate-score group performed significantly better than the low-score group. The interaction effect was not significant between the class and score items (F = 0.101, p = .903), between the class and group items (F = 0.684, p = .507), and among the class, score, and group items (F = 0.692, p = .598).
Although the results indicated no significant differences between the scores of both classes on each examination, further analysis of the crossing means indicated significant differences between the improved performance (i.e., the score increase between third examination and the first examination) of the low- and the intermediate-score groups (Figures 1–3). The test-enhanced learning class's low-score group (Δ [test-enhanced learning class third examination − test-enhanced learning class first examination] = 11.41 ± 3.28) performed better than their didactic class counterpart (Δ [didactic class third examination − didactic class first examination] = 8.83 ± 3.33) (t = 2.073, p = .048) (Figure 1), and the didactic class's intermediate-score group (Δ [didactic class third examination − didactic class first examination] = 6.36 ± 4.43) performed better than their test-enhanced learning class counterpart (Delta; [test-enhanced learning class third examination − test-enhanced learning class first examination] = 3.00 ± 3.42) (t = −2.145, p = .043) (Figure 2). These results seem to indicate that the test-enhanced teaching method had stronger influences on improving the learning of the low-score group, whereas the didactic teaching method had stronger influences on improving the learning of the intermediate-score group. This could suggest that the low-score group students prefer to receive the test-enhanced teaching method, whereas the intermediate-score group students prefer to receive the didactic teaching method.
Low score group.
Intermediate score group.
High score group.
This study showed that the participants' performance on the third examination was significantly higher than that of the first and second examination in both classes. These finding are consistent with other studies carried out in related areas. Studies found that students scored significantly higher and improved their performance on multiple choice questions after the didactic lecture (Bleske et al., 2014; Farland, Franks, Barlow, Rowe, & Chisholm-Burns, 2015). Study results indicated that practice tests enhanced performance and significantly improved knowledge long-term retention (DelSignore et al., 2016; Messineo et al., 2015). Consistently, repeated testing with feedback significantly enhanced students' learning and was beneficial for students regardless of working memory capacity (Sennhenn-Kirchner et al., 2017; Wiklund-Hornqvist, Jonsson, & Nyberg, 2014).
Didactic instruction learning improved students' performances more in the intermediate-score subgroup, whereas the test-enhanced learning improved the students' performances more in the low-score subgroup, indicating that different teaching methods have different degrees of influence on students' academic scores. No single best method of teaching exists, only a more appropriate method for each learner. Although student-centered teaching currently is a popular method of instruction, implementation is difficult because large class sizes in Taiwan and elsewhere (Hudson, 2014) have resulted in the compromise of the teaching and learning environments. Empirical analysis and comparison of the learning performance should be used to verify the effectiveness of the selected method.
Implications for Nursing Education
The results supported that both didactic instruction and test-enhanced learning strategies have value and usefulness in obtaining students' desired academic result and in supporting nurse educators in helping students' learning in this area. In addition, combining lectures and tests to improve the academic performances of nursing students in review courses and on nurse licensure examinations could be implemented.
Limitations and Recommendations for Future Research
Although the cognitive styles of students were not examined, the current study showed the effectiveness of such classification by comparing the two teaching methods with each other, and finding that different teaching methods affected different learning outcomes. Nurse educators need to be aware of the learning objectives of an institute and individual students, the nature of different subjects, and the characteristics and abilities of students to properly adjust teaching methods and determine an approach that suits a group of students. When arranging a course, students' existing learning styles should be taken into consideration, and either the didactic instruction learning or the test-enhanced learning method can be chosen. Future research may study whether students' satisfaction with different teaching methods can be used to determine their performance. Exploration of the different learning patterns of students can be used to provide a more tailored education.
The current study showed the effectiveness of such classification by comparing the didactic instruction and test-enhanced learning methods with each other and finding that different teaching methods effected different learning outcomes. To obtain better nursing education results among a variety of students, empirical analysis and comparison of their learning performances should be used and both didactic instruction and test-enhanced learning approaches need to be considered.
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Repeated Measure and Two-Way Analysis of Variance of Students' Academic Scores by Class and Group (N = 84)
|Item||n||Mean Scores||SD||Minimum Scores||Maximum Scores||95% CI||F or t||p||Bonferroni|
| First (beginning)||41||75.34||11.38||50||94||1.361||.177|
| Second (middle)||41||77.59||9.38||56||95|
| Third (final)||41||80.59||10.01||55||94|
| First (beginning)||43||72.07||10.64||43||94|
| Second (middle)||43||74.74||9.14||55||98|
| Third (final)||43||78.26||9.49||50||98|
|Three examination scoresc||28.750||<.001||middle > beginning; final > beginning, middle|
|Low score groupe||13.798||<.001|
|Three group scoresf||80.363||<.001||high > intermediate, low; intermediate > low|