Learning outcomes and self-assessments of Baccalaureate students in an Introduction to Nursing Course

Expertise arises from constant examination and analysis of performance through active purposeful reflection (Andrews, 1996, p. 513).

Introduction

Expertise is a prized attribute in nurses that is developed over time and practice, and cannot be taught in a classroom. It is the culminating step in the ongoing evolution of a nursing student from beginner to expert clinician. Nursing education has as its goal the creation of competent providers of basic nursing care, and is also concerned with this evolution of the novice nursing student into a competent generalist by graduation, and ultimately an expert nurse. An attribute of an expert nurse is one who uses mindful practice to reflect upon one's skilled nursing care practices, decisions made and patient-family-health care team interactions (Benner, 1982; Epstein, 1999). Mindful practice is a reflective experience that transforms immediate experience through its automatic cognitive processing (King & Hibbison, 2000).

One learning strategy that can be used by educators to support the development of mindful practice in students is reflexive practice, which provides opportunities for critical reflexion on events, interactions, choices made and outcomes of one's choices through the use of diaries, journals, class and small-group discussion, and other critical reflection exercises (Brookfield, 1995). Little is known, however, about how these reflexive practice activities are associated with nursing students' learning processes as they progress from novices to competent generalists, and then to experts in nursing care. Specifically, little is known about how beginning nursing students evaluate their own learning of the competencies that demonstrate their understanding and application of course content, and how this self-evaluation relates to their success in each course and in their academic program.

The purpose of this non-experimental field study is to investigate how students in a beginning nursing course self-assess their learning of course competencies without prodding or cueing, using the process of critical reflective inquiry. Naturalistic inquiry was the method used to investigate this process of academic development. Naturalistic inquiry is a process of observation and questioning that attempts to not disturb or manipulate the naturally occurring phenomenon under study (Streubert & Carpenter, 1995). The phenomenon under study was: (1) the degree of mindfulness that students displayed about their own academic growth, and (2) the ability to link their learning activites to the degree of personal learning they experienced. The primary research question that guides this naturalistic inquiry is: Is ability to critically reflect, demonstrated by richness of recall, description, explanation and insight, associated with other indices of academic success?

Sophomore students in a baccalaureate nursing program at a North American university were the subjects of this study. The independent variable used for general linear model multivariate regression analysis was self-reflection ability as demonstrated through responses to a critical reflective analysis exercise (Self Assessment Content and Description, or SACD). Contextual variables were: count and richness of description of competencies that each student claimed he/she had learned, high school standardized academic testing (SAT) total score, age and gender of student. The dependent variables were: progression in the program as measured by course final grade, GPA at beginning of junior year, and registration in junior year courses. Results of this study describe the beginning stages of the process by which students become competent and aware of their competence as providers of basic nursing care. Results also contribute to the body of nursing knowledge about this process of competency development in nursing students as they progress from novices to competent practitioners of general nursing care.

Literature Review

The conceptual framework that guides this study is based upon Pat Benner's (1984) model of skill acquisition as a developmental process in nursing students as they progress from novices to experts (Carlson, Crawford & Contrades, 1989). This model was, in turn, adapted from the Dreyfus model of skill acquisition which postulates that skills are learned and performed in a progressive manner, by which the learner progresses through five stages of proficiency: novice, advanced beginner, competent, proficient and expert (Benner, 1984; Dreyfus & Dreyfus, 1980). The expert is defined as “a reflective practitioner who works intuitively, drawing almost unconsciously on a repertoire of context-specific paradigm cases” (Rolfe, 1997, p. 93). Key to this process is the role of experience as the engine that drives the progression, as nursing students begin to test and refine their hypotheses and skills and challenge their assumptions and expectations. This phenomenon is considered the students' immediate, or primary experience of any event, and it is the transaction between this immediate experience and the students' interpretation of it that generates the learning that occurs (Ryan, 1994).

Reflection has been defined as: “the retrospective contemplation of practice undertaken in order to uncover the knowledge used in a particular situation, by analyzing and interpreting the information recalled” (Fitzgerald, 1994, p.67), or “thinking back about something of interest” (Pierson, 1998, p. 165). The student uses reflection as the primary process that imbues experiences and cognitions with personal meaning. It is this experiencing of an event and its subsequent interpretation that is termed the “mediate-immediacy” (Ryan, 1994, p. 29) learning that occurs when primary experience together with reflective experience transforms learning through cognitive processing or layering. A goal of nursing education is to produce nurses who engage in this mindful practice.

Nurse educators often use the reflective process to assist students in contemplating and reviewing their actions and then translating the self-knowledge that is produced by that activity into an intuitive grasp of the learning event (Colina & Medina, 1997; Rolfe, 1997). One example of this is the common use of clinical logs or journals requiring students to reflect upon their clinical experiences and then connect them to concepts, information or theories taught in the classroom (Chambers, 1999; Marland & McSherry, 1997). Key to this learning experience is the educator's provision of sufficient time for students to process their recalled events, and use of questions that facilitate this self-examination, as well as structuring a safe environment in which learning can occur (Billings & Halstead, 1998). Benner's research uncovers these hidden mental processes of learning ( Paley, 1996) that generate perceptual awareness and a growing competency in the nursing student (Benner, 1982; Carlson, Crawford & Contrades, 1989). This growing demonstration of a perceptual awareness by the student can be described as working from an intuitive base (English, 1993), or an “understanding without rationale” (Benner & Tanner, 1987, p. 23). This intuitive practice is based upon an ability to recognize relationships between and among events and responses (Benner & Tanner, 1987). It can be taught by helping students to focus on the whole event, or Gestalt, and using feedback gained from reflection to review the accuracy of their assessments and clinical judgements. This process is termed reflexive practice (Colina & Medina, 1997).

Reflexive practice can be taught through the use of the twin processes of reflective inquiry and critical reflective inquiry. Reflective inquiry uses controlled and directive reflection to analyze an event or problem in order to improve practice (Schmeiding, 1999). Critical reflective inquiry uses the steps of : (1) describing an event or incident of practice; (2) comparing these self-narratives with ethical standards and scientific information, and theories; then (3) identifying how individual aspects of the event shape one's response and affect one's practice; and (4) comparing one's intentions in responding with one's actual clinical response. Results of this self-analysis are deeper understandings of the conceptual frameworks that guide one's practice (Kim, 1999; Smith, 1998), since it is considered an effective way for learners to connect theory learned in the classroom with clinical experiences (Davies, 1995). The understanding that is created can further direct and change behaviors, thus demonstrating the learning that has occurred (Chambers, 1999).

Reflexive practice is an intentional learning activity, with a goal of improving practice (Andrews, 1996; Richardson & Maltby, 1995), but it has its limitations. It should be used in situations where students understand that they will not be judged and their reflections will not be evaluated or graded, in order provide a non-restrictive environment that facilitates such reflection (Saylor, 1990). However, it is recognized that reflexive practice leads to the development of tacit knowledge, which is a form or “automatic knowing” based upon learned theory and prior experiences, that cannot be immediately brought to mind, but guides clinical response (Clinton, 1998). This tacit knowledge is also called intuitive practice (Benner & Tanner, 1987).

Nursing educators seek to develop a sense of cognitive and personal awareness in nursing students, called a personal knowing, or “the inner experience of becoming a whole, aware self”(Carr, 1999, p. 26.). Personal knowing has been linked with a growing self-confidence, as students are able to make sense of their new experiences (Munhall, 1993). This sense of personal knowing is facilitated through the use of educational approaches that incorporate reflection, recall and contemplation of events and responses (Wilkinson, 1999). Key to this educational approach is the tenet that neither experience alone nor contemplation of a proposition in isolation transforms learners and propels them through the stages from novice to expert (Heath, 1998). Rather, it is the contemplation of experience, or reflection-in-action, and reflection-on-action which produces the transformation of the learner, heightening self-awareness of one's personal knowing and integrating cognitive learning with emotional and experiential learning (Jacobs-Kramer & Chinn, 1988; White, 1995). This study of the development of nursing students from novice to competent generalist investigates the first stage of this transformative process by examination of the reflective abilities and contextual variables of students in a beginning nursing course as they develop this tacit knowledge along with development of technical skills.

Methods

Research design

Subjects

Procedure

Data analysis

Data/ Results

Descriptive statistics for the sample

Descriptive statistics for course competencies identified

Multivariate analysis results

Multiple correlation coefficients were calculated to measure the degree and direction of any relationship between the variables of: degree of reflexive practice score as measured by responses to the SACD, gender, age, SAT total scores, progression in program , GPA at beginning of junior year, and final grade in Introduction to Nursing course, A significant relationship was found between final grade in the Introduction to Nursing course and SACD (r=.676, p <.000.), as well as GPA at beginning of junior year (r=.420, p < .037). Table 1 displays results of multiple correlation coefficients on all variables.

Figure 1

Table 1. Correlations between variables

A general linear model multivariate regression analyses was performed, using the reflexive practice score as the independent variable, and progression in the program, measured by overall GPA at the beginning of junior year, registration in junior year courses, and final grade in the Introduction to Nursing course, as the dependent variables. Results suggest that the reflexive practice score was a significant predictor of progression as measured by final grade in the course (adjusted R2 =.541, F = 15.139, df = 2, p < .000). The reflexive practice score did not significantly predict registration in junior year courses nor did it predict GPA at the beginning of junior year (see Table 2 for display of results).

Figure 2

Table 2. General linear model multivariate regression analysis to predict GPA, final course grade and registration in junior year courses (N=26)

Discussion

“In the paper, we had to make decisions to help set goals, and to logically organize our thoughts. This made the transitions easier.”

As this quote from one of the students in this study demonstrates, beginning nursing students not only can identify what they have learned, but how and by what mechanisms they have learned it. In this study, the identification of competencies learned and how they were learned is illustrative of how beginning nursing students represent nursing and how they view themselves as beginning providers of nursing care. This is important to the understanding of how novice nursing students develop into competent generalists by the time of graduation, because learning is context dependent. In other words, students' learning is affected by their perceptions of themselves and of the tasks at hand (Cowman, 1998).

Based on the descriptive analysis of the competencies identified in this study, the overall majority of students in this beginning nursing course already view themselves as critical thinkers, culturally competent at a beginning level, effective communicators, and able to manage resources. However, they enter the nursing program after attending college-level courses that introduce and integrate these concepts into course work, and have had opportunities to assimilate these attributes into their own personas. It could be that it is easier to recognize learning that involves these competencies because they are familiar with the concepts, and their perceptions are already positive regarding their own learning of these concepts. They have a much more difficult time identifying the learning competencies associated with a more sophisticated understanding and application of the nursing role.

Only 50% of the competent provider of health care and 37.5% of the manager of care competencies were identified in this study. However, this is to be expected, because the assessment learning exercises associated with this course provided the first opportunity for these students to interact with clients in the nursing role. It might take longer than one semester for most nursing students to recognize these competencies and to perceive themselves as learning these roles. The ethical and legal competencies were the hardest group of competencies for students to recognize as having been learned in this course. The students enter this course having taken a bioethical philosophy course which introduces the commonly used ethical principles such as deontology, utilitarianism, and beneficence. The Introduction to Nursing course requires groups of students to apply these principles in addressing certain ethical dilemmas in health care. It could be that results reflect a general uncertainty or discomfort with using formal procedures as a guide to resolving ambiguous, political and/or unpopular issues in health care. Their difficulty with identifying their own learning in this area might be a characteristic of novice students.

This possibility suggests that further studies of student mindfulness as they continue in school might yield useful information about the phenomenon of continued cognitive development in adults and the role that reflexive practice plays in its development. The cognitive development of adult students is of concern to all educators, regardless of discipline. Reflexive practice, critical analysis and student mindfulness are cognitive practices that are not limited to the nursing profession, but have been identified, studied and discussed in other disciplines, such as education and medicine. This naturalistic inquiry can be adapted for use by educators in determining degree of mindfulness in students, and in tracking the development of mindfulness in their discipline over time as they progress in their program of study.

Conclusions

“cognitive development is an apprenticeship—it occurs through guided participation in social activities with companions who support and stretch [one's] understanding of and skill in using tools of culture” (Rogoff, p. vii).

Results of this study suggest that one factor, an ability to self-reflect upon the processes involved with one's learning, might be a characteristic that is connected with academic progress. Reflecting on one's practice can also expand a student's understanding of and respect for the complexities of the nurses' role (Baker, 1991). This critical reflective analysis of one's own learning process can be used as a learning tool as well as an evaluative exercise for student and educator alike (Chambers, (1999). The results also raise the question of whether and/or how much the ability to act intuitively, to reflect critically upon one's experiences, and to contemplate and review in a mindful way, can be taught. In other words, it would be useful to know if the ability to engage in reflexive practice or to develop a mindful practice is inherently innate, and can be improved through guided teaching/learning experiences designed to improve critical reflexion, or is a learned skill that anyone can master with opportunity and experience. Additional information about the importance and nature of this mindfulness in nursing students would encourage nurse educators to design experiences that could challenge students to reflect upon, interpret and derive personal meaning from their learning experiences. Information about the learned and/or innate nature of these cognitive processes would also add to our understanding of the role these reflexive practice exercises should play in curricular design and delivery.

There is a need to examine the uses and meaning of reflexive practice as a learning tool in nursing education. This study takes this examination to another level, as students' self-perceptions of their learning are identified, coded and scored at the beginning of their nursing program. This allows for a tracking of this self-concept and their view of learning throughout the course of their undergraduate education. This completed study illuminates the complex internal strategies involved in the whole process of learning for nursing students. It adds to nursing education knowledge about the potential uses and value of reflexive practice, not only as a learning exercise, but also as a confirmatory process that cements a new nursing graduate's self perception as a competent provider of basic nursing care.

The quote used at the beginning of this section was originally used to describe the cognitive development of children. But it is apparent that our cognitive abilities continue to evolve throughout adulthood, providing new opportunities for self-discovery and concept mastery.

Correspondence to

Deena A. Nardi,
Lewis University College of Nursing and Health Professions,
One University Parkway,
Romeoville, IL, 60446