Journal of Nursing Education

Educational Innovations 

Student Voices During Action Research Impact Outcomes in Nursing Quality Improvement Project

Rita Sperstad, EdD, RN; Shelley Rae Pehler, PhD, RN; Steve Ackerson, BSN, RN; Kristin Brunsell, BSN, RN; Emily Gyorog, BSN, RN; Hannah Sisto, BSN, RN

Abstract

Background:

A systematic evaluation plan is required in nursing education to determine achievement of curricular initiatives and to improve program student learning outcomes. An innovative approach that included direct involvement of students was implemented in the evaluation of a quality improvement (QI) initiative aimed at enhancing student success.

Method:

Through the use of action research (AR), students became coresearchers to critically appraise educational strategies implemented in an undergraduate curriculum improvement plan.

Results:

The purpose of this article is to describe the student and faculty reflections and experiences while using AR to evaluate outcomes in an undergraduate QI project. Two critical variables were discovered based upon student voice, which changed the course of the project.

Conclusion:

Action research methodology successfully increased the rigor of evaluating a QI initiative by a faculty–student research team. Student voices uncovered two powerful variables which expanded the project to effectively improve nursing education. [J Nurs Educ. 2020;59(1):42–45.]

Abstract

Background:

A systematic evaluation plan is required in nursing education to determine achievement of curricular initiatives and to improve program student learning outcomes. An innovative approach that included direct involvement of students was implemented in the evaluation of a quality improvement (QI) initiative aimed at enhancing student success.

Method:

Through the use of action research (AR), students became coresearchers to critically appraise educational strategies implemented in an undergraduate curriculum improvement plan.

Results:

The purpose of this article is to describe the student and faculty reflections and experiences while using AR to evaluate outcomes in an undergraduate QI project. Two critical variables were discovered based upon student voice, which changed the course of the project.

Conclusion:

Action research methodology successfully increased the rigor of evaluating a QI initiative by a faculty–student research team. Student voices uncovered two powerful variables which expanded the project to effectively improve nursing education. [J Nurs Educ. 2020;59(1):42–45.]

Nursing education programs are required to provide evidence in demonstrating successful accomplishment of student learning and program outcomes. An innovative approach was implemented by a faculty–student research team applying the action research (AR) methodology to evaluate an undergraduate quality improvement (QI) project. The purpose of this article is to describe how students as coresearchers in the AR team process stimulated the discovery of two crucial variables that expanded and had a major impact on the overall QI project.

Background

A midwestern U.S. undergraduate baccalaureate nursing program initiated a major curriculum revision in fall 2013. The first full cohort of baccalaureate nursing (BSN) degree students graduated from this revised curriculum in spring 2016. Areas to enhance student success were identified by faculty review of program evaluation data from standardized tests and program learning outcomes. Based on the undergraduate curriculum continuous improvement plan, faculty authors implemented two evidence-based educational strategies in fall 2016 and spring 2017 that were intended to promote student success. One intervention was monthly undergraduate student educational enrichment sessions. Sample topics in these sessions included:

  • What is critical thinking?
  • NCLEX® test-taking skills.
  • How to apply critical thinking with NCLEX questions.

The second intervention offered the same faculty as tutors to all undergraduate students—particularly those meeting risk criteria. Referrals to faculty tutors were initiated by course coordinators for students identified as at risk or by individual student self-referrals. In preparation for the evaluation of these QI initiatives, faculty researchers desired the participation of undergraduate nursing students to gain their valued perspectives. A strong tradition of this midwestern university engages students in faculty research and scholarship projects that are identified as a high-impact practice. A university faculty–student research grant was secured for this purpose.

The Research Team

In fall 2017, a faculty–student research team was formed to implement the AR process in evaluating the two QI interventions. The formation of the AR team included two tenure nursing faculty (authors S. Pehler and R. Sperstad), the director of assessment and evaluation, and the director of the undergraduate program. Five undergraduate students, one from each level of the nursing program (sophomore 2, junior 1, junior 2, senior 1 and senior 2) were selected by the faculty researchers and invited to participate as coresearchers. Students were selected by faculty researchers based on ongoing relationships through academic advising, nursing honors advising, and/or class interaction. Although the method of self-selection is recognized as potentially biased, the role of students on the AR team was truly as coresearchers and not as subjects. Faculty were seeking student coresearchers with a high commitment to learning, interest in engaging with research as a high-impact practice, and appreciation for the importance of program improvement. Demographic characteristics of the student coresearchers included all White undergraduate nursing students, four traditional-aged female students from ages 18 to 22, and one nontraditional-aged male student.

Method

AR was selected as the methodology for implementing the new interventions in the QI project. The rationale for use of AR is that it provides a dynamic systematic approach, encourages involvement of student coresearchers, and increases rigor in evaluating the effectiveness of the QI interventions. As suggested by Carter, Mastro, Vose, Rivera, and Larson (2017), the collaboration of QI and research can enhance the effectiveness of nursing scholarship. The AR definition that guided this project was obtained from Moch, Vandenbark, Pehler, and Stombaugh (2016) as “a systematic research process that can be articulated by the researcher, involving data collection and analysis, as well as reflection and discussion with coresearchers or others for the purpose of making change in a situation over time” (p. 3).

AR team meetings occurred weekly. During the first scheduled team meeting, faculty and students reviewed and discussed the AR definition and process (Moch et al., 2016). Ground rules for team meetings were discussed including ensurance of individual/group confidentiality, mutual respect, and advocating for all individual perspectives to be shared. Faculty researchers explained to student coresearchers the background leading to the development and implementation of the two QI strategies. Initial conversations between faculty and student core-searchers began with open discussion and reflections on the general topic of teaching–learning and student success within the undergraduate nursing program. The two faculty researchers quickly recognized that student descriptions of experiences with teaching–learning revealed characteristics of incivility. At the second meeting, faculty shared their perceptions with student coresearchers and came to a consensus that faculty–student incivility was an accurate concern and a barrier to an effective culture of learning in the undergraduate program.

As a result of student voices revealing these significant variables, the original QI project was expanded to include an assessment of incivility and the culture of learning within the department of nursing. Institutional review board approval was obtained. Online student surveys measured effectiveness of student enrichment sessions and faculty tutoring, incivility was measured using Clark's Incivility in Nursing Education—Revised tool (Clark, Barbosa-Leiker, Gill, & Nguyen, 2015), and culture of learning was assessed through student focus groups at all levels of the nursing program, led by student coresearchers. Student participation in the AR process included high-impact activities such as conducting a literature review, obtaining institutional review board approval, developing student focus group questions, leading student focus groups, analyzing quantitative and qualitative data, and dissemination of results. The results of the QI project evaluation with the expanded variables of civility and culture of learning will be described in another article.

Reflections and Analysis of Action Research Process

At the conclusion of the QI evaluation project, the student– faculty coresearchers began reflecting on the AR process itself. All team members completed independent and anonymous reflections of their experience during the AR process. Individual reflections were collected in electronic format based on four open-ended questions:

  • What are your reflections on faculty–student relationships during the use of AR?
  • What are your reflections on the student–student relationship in the AR team?
  • How did the AR process influence your personal academic learning and your own learning?
  • What are your reflections on the AR process itself (e.g., How did the AR methodology help you understand the research process in general? What was beneficial to the weekly meetings with discussion and reflection? How do you feel the research evolved over time? Did it create change?).

Faculty and student reflection data were examined using qualitative content and thematic analysis (Polit & Beck, 2018). Initially, research team members analyzed student and faculty reflections independently before collectively identifying the similar and distinctive conceptual themes. The process of member checking (Lincoln & Guba, 1985) was performed by sharing the full discussion of the findings with all team members, who each supported accurate thematic analysis. This practice validated that the findings are shaped from coresearchers and not faculty or student bias.

Results

After review of the reflections, the AR team identified three themes: (a) AR Cultivated an Effective Environment for Dynamic Engagement, (b) AR Fostered Student and Faculty Growth in Cognitive and Affective Knowledge, (c) Student Voices in AR Uncovered Critical Variables That Expanded the QI Project.

The first theme identified by faculty and students was AR Cultivated an Effective Environment for Dynamic Engagement. Faculty and student reflections strongly supported the methodology of AR in cultivating an open, honest, and mutually respectful environment that facilitated rich discussion. One student shared, “The environment encouraged mutual respect for the faculty and student roles and created a safe space for multiple perspectives to be shared” (Student #1). Two students recognized equality within the AR environment. One student stated, “An environment of equality was created that allowed for the elimination of any imbalances between students and between students and faculty.” A second student added, “Elimination of faculty and student power imbalances provided a working environment that fostered open and candid conversations” (Student #4). A faculty member and student both identified the value of ample time over the duration of the AR process, which “facilitated deep and rich discussion” (Faculty #1), as well as “fostered group comfort and confidence” (Student #3).

The second theme found by the research team was AR Cultivated Individual Student and Faculty Growth in Cognitive and Affective Knowledge. Students' reflections revealed an increased cognitive knowledge with research skills and inquisitive thinking. One student remarked, “First-hand experience with the AR project improved my understanding of research by allowing us to walk through the steps of research both individually and collaboratively with faculty mentors and peers” (Student #1). Faculty insight reinforced this finding: “It was fun to see students blossom in their understanding and skills with research” (Faculty #1). Both student and faculty reflections affirmed that the AR process created deep inquisitive thinking such as constant questioning, remaining open minded, and change from product to process thinker. One student stated, “Researchers were encouraged to remain open minded while constantly questioning and assessing the appropriateness of the research direction” (Student #2). Another student reflection confirmed a change in thinking: “The openness of the AR methodology was challenging and difficult because I tend to be a product-based thinker. [AR] has allowed me to think out of the box and allowed me to be [think] more creative and successful” (Student #3). The value of group inquisitive thinking was confirmed by a faculty member, who shared “Faculty and students gained insights from various levels of the program which was rewarding as we put all the pieces together” (Faculty #2).

Students' growth in affective knowledge resulted in positive peer–faculty relationships, increased confidence, discovery of integrity in their student voice, and a sense of pride with accomplishment of the research project. A student shared, “My student-to-student relationship with peers was positive within the AR process. [All] students were able to gain credibility by describing examples from across the curriculum” (Student #1). A student described confidence with the research process: “I gained confidence in articulating the research and process effectively with other students and faculty” (Student #4). Another student described affective growth by stating, “I am so proud of the project we completed and I feel strong pride because we played a role in the foundational steps of the process. We were not handed a topic of study, but rather helped to grow the project from conception” (Student #3). A faculty member reinforced student pride in the project, stating “They took ownership in the project as active coresearchers and not as assistants” (Faculty #2).

Student Voices in AR Uncovered Critical Variables That Expanded the QI Project was the third theme found by the research team. AR methodology encouraged student voices to reveal the variables of incivility and culture of learning. Both students and faculty reflections supported the discovery and value of these new variables to the project. A student succinctly shared the essence of this theme, “Through AR, our project changed and addressed a problem [incivility] that we, as students, brought up to the faculty as something that was contributing to the overarching goal of student success” (Student 5). One faculty reflected, “The work to create an environment of mutual respect and inclusion of student input was crucial to the project's success. Student input was not just a by-product of the process—it was essential that students were active participants in the process” (Faculty #2). The other faculty added, “Faculty quickly recognized that student coresearchers' observations and experiences represented incivility. Without student voice, the true meaning of this research would have been ignored” (Faculty #1).

Discussion

The perceptions of faculty and student research team members using AR in an undergraduate QI initiative were positive and strongly supported the characteristics of AR and students as coresearchers (Moch et al., 2016). Two themes of this AR project, the Development of an Engaging Environment and Acquisition of Research Skills, coincided with students' positive perceptions described in another participatory action research experience (Csiernik, O'Regan, Forchuk, & Rudnick, 2018). In comparison, other results from this study were distinctive to the AR process. Due to the deep inquiry by faculty and student coresearchers, unforeseen variables were discovered from student voices and expanded the outcomes of the QI project.

Limitations

A limitation of this research was identified in using the self-selection method for student involvement; however, the students' role was that of a coresearcher and not as a study participant. Faculty researchers do believe the AR method contributed to the development of team trust, as well as accuracy, credibility, and validity of the data. Although the AR methodology recognizes all team members as coresearchers, the power differential between faculty and students cannot be eliminated. Student reflections both independently, as well as collectively, revealed that the power differential did not affect student input nor impact the process. Involving a student coresearcher from all levels of the program created challenges for identifying a common meeting time. Yet, all members of the team were flexible and committed to the project; therefore, few absences by student coresearchers occurred.

Implications

The implications of using the AR process in this project demonstrate the power of including student voice in evaluating a QI project and its momentum for improvement. The variables of incivility and culture of learning stimulated significant changes within the department of nursing. Three student core-searchers participated in the interview team to hire a prelicensure academic success coordinator to continue the intervention of faculty tutoring. A strong need to develop a nursing code of conduct was recognized. Finally, a second student–faculty AR project is currently in progress to explore and implement interventions with faculty and students in promoting a culture of civility.

Conclusion

AR methodology served to successfully increase the rigor of evaluating a QI initiative. This project granted faculty and students an exceptional experience of engagement with deep inquiry in the AR process. Particularly, student voices led to uncovering two powerful variables, which enlightened and expanded the focus of the QI project. Valuable implications from this study suggest that inclusion of student voices within AR can effectively improve nursing education.

References

  • Carter, E.J., Mastro, K., Vose, C., Rivera, R. & Larson, E. (2017). Clarifying the conundrum: Evidence-based practice, quality improvement, or research? The clinical scholarship continuum. Journal of Nursing Administration, 47(5), 266–270. doi:10.1097/NNA.0000000000000477 [CrossRef]28422932
  • Clark, C., Barbosa-Leiker, C., Gill, L. & Nguyen, D. (2015). Revision and psychometric testing of the incivility in nursing education (INE) survey: Introducing the INE-R. Journal of Nursing Education, 54, 306–315. doi:10.3928/01484834-20150515-01 [CrossRef]26057424
  • Csiernik, R., O'Regan, T., Forchuk, C. & Rudnick, A. (2018). Nursing students' perceptions of participatory action research. Journal of Nursing Education, 57, 282–286. doi:10.3928/01484834-20180420-05 [CrossRef]29718517
  • Lincoln, Y. & Guba, E. (1985). Naturalistic inquiry. Thousand Oaks, CA: Sage.
  • Moch, S. D., Vandenbark, R. T., Pehler, S. R. & Stombaugh, A. (2016). Use of action research in nursing education. Nursing Research and Practice, 2016, 1–9. doi:10.1155/2016/8749167 [CrossRef]
  • Polit, D. & Beck, C. (2018). Essentials of nursing research: Appraising evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer Health.
Authors

Dr. Sperstad is Professor Emeritus, Dr. Pehler is Professor, Mr. Ackerson is Alumni, Ms. Brunsell is Alumni, Ms. Gyorog is Alumni, and Ms. Sisto is Alumni, College of Nursing and Health Sciences, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin.

The authors thank the Office of Research and Sponsored Programs, University of Wisconsin-Eau Claire, for a faculty–student research grant that helped to support this research.

Address correspondence to Rita Sperstad, EdD, RN, Professor Emeritus, College of Nursing and Health Sciences, University of Wisconsin-Eau Claire, Eau Claire, WI 54702; e-mail: Rita.sperstad@gmail.com.

Received: February 18, 2019
Accepted: September 23, 2019

10.3928/01484834-20191223-10

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