Collaboration among team members is necessary for success in the current health care environment (Green, Worthey, & Kerven, 2018). The Quality and Safety Education for Nurses (QSEN) Institute (n.d.) lists teamwork and collaboration as essential nursing competencies to provide safe, high-quality care. Thus, it is important to engage students in collaborative processes during their academic program of study. Collaborative testing is an active-learning educational strategy used during course examinations to introduce students to the concept of collaborative teams (Burgess & Medina-Smuck, 2018; Hanna, Roberts, & Hurley, 2016). Collaborative testing encourages positive interactions with classmates and hands-on experiences with critical thinking, compromise, and teamwork (Sandahl, 2010). Peer support provided during collaborative testing may assist students in learning both course content and test-taking strategies (Eastridge, 2014).
The collaborative testing approach may be used as an evaluative strategy and for test review. As an evaluative strategy, collaborative testing may yield higher test scores than individual testing and may improve student perceptions of the testing experience (Hanna et al., 2016). As a posttest review, collaborative testing may facilitate students' understanding and retention of the course content (Centralla-Nigro, 2012; Green et al., 2018).
Collaborative testing has been explored in the undergraduate nursing student population, and the participating students provided overwhelmingly positive feedback about the benefits of the collaborative testing experience (Hanna et al., 2016; Martin, Friesen, & De Pau, 2014). Students reported increased critical thinking and decreased test-taking anxiety with the collaborative testing experience when compared with traditional individual testing (Wiggs, 2011). In medical student education, themes regarding collaborative testing included learning about the content, getting to know other students, and interpersonal interactions (Levine et al., 2018). Although research exists to support the benefits of collaborative testing platforms in both undergraduate nursing school curricula and in medical school programs, research is lacking about the utilization of collaborative testing in graduate nursing education. The purpose of this project was to assess the effects of collaborative testing in graduate nursing education in regards to test performance, content retention, and student perception.
The study setting is a southeastern U.S. liberal arts university with undergraduate, graduate, and doctoral nursing programs. The family nurse practitioner program is a hybrid program and requires on-campus visits during clinical courses. To investigate the influence of collaborative testing among graduate nursing students, the faculty team used both a quasi-experimental and a descriptive design for the study. The study was approved by the university institutional review board prior to the start of the fall 2018 semester. All students in the nurse practitioner course focusing on primary care of adults (N = 28) participated in the collaborative testing portion of the study. All students were invited to participate in the descriptive portion of the study by completing a survey at the conclusion of the semester about their collaborative testing experiences.
Twenty-eight students were placed into nine groups of either three or four students. All students took the four course examinations individually and collaboratively. All tests were computerized using the university's learning management system. Students were randomly assigned to groups for each examination with each group consisting of at least one student from the top, middle, and bottom third of rankings based on the average individual examination score from the preceding examination. For the first examination, groups were assigned based on the average examination score during the preceding advanced health assessment course. After completing the individual examination, each group completed an online collaborative test using the learning management system. Only one collaborative test was submitted per group, and all group members received the same number of points. Students who achieved a grade of A or B on the collaborative examination received an additional 2 points or 1 point, respectively, on their individual test grades. To evaluate content retention, five comprehensive questions were included on the fourth examination. Comprehensive questions were chosen based on the following criteria: (a) at least 50% of students chose the correct response on the initial individual test, and (b) at least 75% of students chose the correct response on the collaborative test.
Students were given a maximum 60 minutes to complete the individual tests and a maximum of 25 minutes to complete the group collaborative tests. One student was allowed 90 minutes and a private testing environment to complete the individual tests due to testing accommodations. This student was able to participate in collaborative testing after completion of the individual examination. Paired t tests were used to compare individual and collaborative examination scores. The mean and standard deviation of each student's individual test scores were compared with the student's collaborative test scores to determine whether there was a statistically significant difference in test scores after the collaborative testing experience.
To evaluate student perceptions of the collaborative testing experience, a 16-item descriptive survey was administered at the end of the course, with permission from the authors (Cortright, Collins, Rodenbaugh, & DiCarlo, 2003). Survey items were scored using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree). Item scores were analyzed as ordinal data and displayed as percentages of responses in each response category. Additionally, demographic information and four open-ended questions were included for students to further express feelings about the collaborative testing experience. Students had the opportunity to take the anonymous computer survey at the conclusion of the final collaborative testing experience.
Qualitative analysis of the open-ended survey responses was conducted using Microsoft® Excel® and directed content analysis (Bengtsson, 2016; Hesse-Biber, 2017; Hsieh & Shannon, 2005). This directed approach aids the researcher to view a clearer descriptive summary of the experience with minimal interpretation. Initial coding was used to identify high-frequency words or nodes and focused coding aided in the solidification of themes. Two of the authors (T.A.P., T.P.G.) coded the survey questions to identify themes, and a third author (A.C.M.) reviewed the themes. Agreement was reached on any differences.
Twenty-three (82%) of the twenty-eight students enrolled in the course participated in the survey. Participating students included 21 (91.3%) women and two (87%) men, with 14 (61%) of those students reporting their age range as 26 to 35 years. Years of work experience was evenly distributed among the students between four groups (1 to 3 years, 4 to 6 years, 7 to 10 years, > 10 years).
Test Performance and Content Retention
All collaborative test scores were higher than the traditional test scores (traditional mean range = 80.78 [SD = 8.53] to 84.07 [SD = 7.41], collaborative mean range = 93.54 [SD = 3.77] to 94.07 [SD = 2.80], all p values < .001). Additionally, individual mean test scores improved on tests three and four when compared with the mean scores from test one. Thus, collaborative testing improved overall student test performance for the sample. Students did not demonstrate significant changes in mean scores for cumulative content on test four. Thus, collaborative testing did demonstrate improved content retention in this sample.
Students responded to a 16-item Likert scale survey items to evaluate their level of comfort and satisfaction with the collaborative testing experience. Student responses were positive regarding the experience. Of 80 total possible response items, only seven (8.7%) reflected a negative experience with collaborative testing.
Directed content analysis of the four open-ended survey questions revealed four themes: Enhanced Understanding of Content, Collaboration With Classmates, Socialization, and Improved Grades. The first theme was Enhanced Understanding of Content. The most frequently used term in student responses was “understanding,” which occurred six times. One student reported, “I think it gave me different ways to look at something I may not have understood before.” Another student said, “It increased my level of understanding.” One student said, “It reinforced learning of the subject matter.” The second theme that emerged was Collaboration With Classmates. The most frequent term was “rationale,” which was used seven times in student responses. One student stated, “It was a positive learning experience due to the ability to discuss rationales with the other students.” Another student said that collaborative testing “allows you to discuss the rationale with other classmates.” The next theme was Socialization. In this hybrid nurse practitioner program, students are in class together infrequently, so students felt it was positive to work with their peers on collaborative testing. One student said, “It promoted learning and socialization.” Another student reported that “getting to know classmates” was a strength of collaborative testing. The last theme was Improved Grades. Because the collaborative testing allowed students to increase their grades, this was a beneficial aspect of the project for students.
Of 38 responses to qualitative questions about the collaborative testing experience, six responses were negative (15.79%), and 32 were positive (84.21%). One student reported that it could be difficult to convince students of their answer for certain test questions, which “created a negative environment between students.” One student felt that “not being able to leave immediately after finishing the examination” was a downfall to collaborative testing.
The students' perceptions were strongly positive about the collaborative testing experience. It improved students' grades and their understanding of content and rationale for correct answers. In addition, students enjoyed the increased socialization, team building, and enhanced collaboration, which aligns with constructivist learning theory (Andersen & Watkins, 2018; Duane & Satre, 2014). These findings are consistent with the previous research that found positive benefits when implementing collaborative testing (Hanna et al., 2016; Levine et al., 2018; Martin, Friesen, & De Pau, 2014; Sandahl, 2010). Although Green et al. (2018) found improved content retention, the students in this project did not demonstrate improved retention on subject matter on the five cumulative questions. However, there were significant improvements in the individual mean test scores from test one to tests three and four, indicating that collaborative testing may aid in the understanding of material and with test-taking skills. The qualitative themes that emerged were similar to those found by Levine et al. (2018) with medical students and support the benefits of peer support and enhanced learning when using collaborative testing.
A limitation of this study is that it occurred over one semester in one hybrid nurse practitioner program. Given that many nurse practitioner programs are fully online, it may be difficult to implement in other nurse practitioner programs. A possible reason content retention on the five cumulative questions did not increase was because the fourth examination was not cumulative, so students did not have an incentive to study all the course content for that test.
In graduate nursing education, the use of collaborative testing may be an effective strategy to improve teamwork and communication skills, enrich relationships among peers and between students and faculty, and enhance critical thinking. Future studies should involve more graduate nursing courses with a larger cohort of students. In addition, future studies could look at the relationship between collaborative testing and student retention, due to the social support and relationships reported by students in this study.
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