ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

Competency and an active learning program in undergraduate nursing education Hyunsook Shin, Sohyune Sok, Kyung Sun Hyun & Mi Ja Kim Accepted for publication 22 September 2014

Correspondence to S. Sok: e-mail: [email protected] Hyunsook Shin PhD RN CPNP Associate Professor College of Nursing Science, Kyung Hee University, Seoul, South Korea and Visiting Scholar, College of Nursing, University of Illinois at Chicago, Illinois, USA Sohyune Sok PhD RN Associate Professor College of Nursing Science, Kyung Hee University, Seoul, South Korea Kyung Sun Hyun PhD RN Professor Emerita College of Nursing Science, Kyung Hee University, Seoul, South Korea Mi Ja Kim PhD RN FAAN Dean Emerita College of Nursing, University of Illinois at Chicago, Illinois, USA

S H I N H . , S O K S . , H Y U N K . S . & K I M M . J . ( 2 0 1 5 ) Competency and an active learning program in undergraduate nursing education. Journal of Advanced Nursing 71(3), 591–598. doi: 101111/jan.12564

Abstract Aims. To evaluate the effect of an active learning program on competency of senior students. Background. Active learning strategies have been used to help students achieve desired nursing competency, but their effectiveness has not been systematically examined. Design. A descriptive, cross-sectional comparative design was used. Two cohort group comparisons using t-test were made: one in an active learning group and the other in a traditional learning group. Methods. A total of 147 senior nursing students near graduation participated in this study: 73 in 2010 and 74 in 2013. The active learning program incorporated high-fidelity simulation, situation-based case studies, standardized patients, audiovideo playback, reflective activities and technology such as a SmartPad-based program. Results. The overall scores of the nursing competency in the active group were significantly higher than those in the traditional group. Of five overall subdomains, the scores of the special and general clinical performance competency, critical thinking and human understanding were significantly higher in the active group than in the traditional group. Importance-performance analysis showed that all five subdomains of the active group clustered in the high importance and high performance quadrant, indicating significantly better achievements. In contrast, the students in the traditional group showed scattered patterns in three quadrants, excluding the low importance and low performance quadrants. This pattern indicates that the traditional learning method did not yield the high performance in most important areas. Conclusion. The findings of this study suggest that an active learning strategy is useful for helping undergraduate students to gain competency. Keywords: active learning, importance-performance matrix, nursing competency, simulation, standardized patients

© 2014 John Wiley & Sons Ltd

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Why is this research or review needed? ● Teaching students how to be competent is a major goal of education. However, traditional learning strategies for achieving this goal have not been as successful. ● Active learning strategies using simulation and standardized patients have been used to help students achieve desired nursing competency, but their effectiveness has not been systematically examined.

What are the key findings? ● An active learning program motivated students to participate more in the clinical practicum and classes and helped them to be more competent and to think critically. ● Nursing programs should develop teaching and learning strategies for improvement in the areas of clinical competencies, critical thinking and evaluation. ● The effects of an active learning program on nursing student competency included the balanced achievement of all subdomains of nursing core competency, and better clinical competency.

How should the findings be used to influence policy/ practice/research/education? ● Findings of this study can be used as a guide for nurse educators to use active learning programs in baccalaureate education. ● Results of the importance-performance matrix can be used to identify areas for improvement.

Introduction Competency, particularly clinical competency of new graduates, has been identified as an area with statistically significant deficiency in nursing education (Beischel & Davis 2014). Assessing nursing competency of new graduates, Berman et al. (2014) found that few of them demonstrated an appropriate level of understanding and implementation of the nursing process, particularly in foundational psychomotor skills. Only 10% of nurse executives perceived new graduate nurses as fully prepared to give safe and effective nursing care and only 25% of them were satisfied with new graduates’ clinical skills (Berkow et al. 2009). These findings clearly suggest the need to find more innovative and effective ways of teaching and learning. Active learning strategy has been used to improve students’ competency (Hoke & Robbins 2005). Active leaning strategy refers to a teaching and learning strategy based on 592

experiential learning theory. It promotes students’ responsibilities for learning and instructors’ coaching role. Kolb’s experiential learning (Kolb 1984) posited that ‘learning is the process whereby knowledge is created through the transformation of experience’ (p. 59). It refers to learning that consists of concrete experience, reflective observation, abstract conceptualization and active experimentation. Studies focusing on increased student performance have reported that students became actively engaged in the topic when instructors created more opportunities for their participation (Stevenson & Gordon 2014). In addition, Oliva (2009) observed that students learned when curricular goals and content were transformed into experiences. Along with the student-centred approach, interactive teaching and learning is important in nursing education because it is critical for student nurses to achieve balanced core competencies for better clinical performance. Analysis of multiple nursing curricula revealed that inadequate attention was paid to integration of nursing core competency (Kantar & Alexander 2011). Given the increased morbidity and complexity of hospitalized patients, limits have been placed on nursing student practice (Webster & DiBartolo 2014). Instead, clinical practicum nowadays largely consists of observing staff nurses’ nursing care activities. This lack of direct practice of clinical skills with patients’ calls for new and innovative ways to equip nursing students with the necessary clinical skills. However, the importance of the context where nursing occurs and the content that nurses need to know for patient care (Tanner 2008) should be considered. Learning strategies using simulation and standardized patients were introduced to secure an interactive, participatory, communicative learning environment (Powell-Laney et al. 2012, Sideras et al. 2013). Standardized patients (SPs) are individuals trained to simulate patients with health conditions or caregivers; they play a critical role in healthcare professional education and clinical performance examination. Technologies such as high-fidelity simulators and use of SPs allow faculty members to apply more interactive teaching strategies in nursing education. Hence, SPs and simulation have been used to strengthen clinical skills and fill the gaps between nursing theory and practicum. Although the active learning was recognized as it increases student performance in science, engineering and mathematics (Freeman et al. 2014) and its concept was introduced over a decade ago in nursing education (Russell et al. 2007), previous studies on the active learning have been limited because they did not provide comprehensive use and systematic evaluation of the active learning in undergraduate nursing program (Tedesco-Schneck 2013). © 2014 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

This study aimed to fill this gap and evaluated the effect of active learning on nursing competency.

The study Aims The goal of this study was to evaluate the effect of an active learning program on nursing competency in baccalaureate nursing education. Specific aims were to: (1) assess the effect of an active learning program on nursing competency; and (2) identify domains of nursing competency for improvement.

Design A descriptive, cross-sectional comparative design was used to assess the effect of an active learning strategy on nursing competency.

Participants One hundred and forty-seven nursing students in their final week before graduation participated in this study: 73 in 2010 (traditional learning group [TLG]) and 74 in 2013 (active learning group [ALG]). Classes using active learning program were required and students completed the questionnaires voluntarily.

Data collection Active learning program The active learning program was based on the experiential learning theory and it aimed to get students more engaged in their classes. The key change was infusing active teaching and learning strategies into didactic education in the classroom, with emphasis on clinical practicum. This new program in nursing curriculum mainly consisted of simulation and use of SPs in the classroom or laboratory environment. The main goal was to enhance students’ clinical performance and competency for providing evidence-based care for patients. On the other hand, traditional learning program refers primarily lecture-based classes and traditional clinical nursing practicum including on-the-job training. Faculty preparation Faculty support such as teaching-fellowships and faculty workshops were key elements of preparing faculty for the curriculum change. All faculty members in the College of Nursing attended workshops on performance evaluation © 2014 John Wiley & Sons Ltd

Active learning program

strategies, nursing practicum operating strategies with a hybrid model (i.e. using simulation and SP in class) and outcome-focused curriculum-building strategies. These workshops provided in-depth training on how to: design a class using simulation and SPs, write scenarios and develop or apply performance evaluation methodologies. On completion of the workshop, faculty members were encouraged to submit proposals that included use of an active learning program in their classes. If selected, they received funding support for costs involved in running the program and staffing, and costs for the audio-video-equipped laboratory facility. One teaching fellow was funded by the grant, which enabled her to commit dedicated time and effort to the development and implementation of this new program. The teaching fellow worked as a change agent, consultant and supporter, and a curriculum coordinator and a mentor for new faculty. Implementing active learning program The new active learning program began for the students in their sophomore year and continued until they graduated (2011–2013). Several classes were designed under the umbrella of the active learning program. Initial classes in the program included health assessment, a paediatric nursing practicum with simple scenarios and an adult nursing class using SPs for a clinical performance examination. Gradually, the complexity was increased and more complex patient situations and integrated simulation with high-fidelity simulators or SPs were included in courses such as geriatric nursing, women’s health, administrative nursing, emergency nursing and fundamental nursing. In the third and final year of the active learning program, students spent 10% of hospital practicum hours using the active learning program; this was the maximum hours allowed by the Korean Accreditation Board of Nursing Education (Korean Accreditation Board of Nursing Education 2012). Sophomore students had one class (health assessment) with an active learning program; junior students had three such classes (adult nursing, women’s health and geriatric nursing); and senior students had three such classes (paediatric nursing, nursing administration and emergency nursing). SPs in this program were mostly members of an association of SPs and the program provided resources such as an audio-video-equipped simulation facility, SP costs, workshop fees, staff support and Smart Campus (smartphone, tablet PC-accessible, mobile platform building and content development). Types of simulation ranged from virtual computer-assisted to high-fidelity simulation. Some classes used a hybrid model that combined high-fidelity simulator and SPs. The program 593

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began in February 2011 and continued until the intervention group graduated in 2013. All participants completed a questionnaire, including general characteristics and assessment instruments of program outcome measures and nursing core competency at graduation.

completed on a voluntary basis. Personal participant information was kept confidential by using coded IDs instead of student names. The original author’s permission was obtained for the use of the KNCCS.

Data analysis Validity and reliability/rigour Participants’ general characteristics (age, gender and religion and first-year GPA as a pre-nursing academic performance) were collected. The questionnaire also included three outcome measures (self-evaluated learning achievement by students, satisfaction on clinical practicum and general self-confidence at graduation) and an assessment of nursing core competency (described below). Korean Nurses’ Core Competency Scale (KNCCS) contains 70 items developed by Lee et al. (2010) to measure new graduate nurses’ nursing core competencies in Korea. It consists of five subdomains: (1) human understanding and communication: client understanding and needs assessment, individualized nursing, communication with patients or family, multidisciplinary communication; (2) professional attitudes: ethical practice performance, organizational effort towards professional advancement, leadership with delegation and quality assurance; (3) critical thinking and evaluations: problem identification, evidence-based practice, nursing priority setting, critical interpretation or judgment, decision-making, integrative nursing; (4) general nursing performance competency: patient assessment, nursing process application, clinical skills performance, use of nursing equipment, use of technology, medication, patient education and (5) special nursing performance competency: provision of critical care, understanding and application of complementary-alternative therapy and end-of-life care. The KNCCS uses a 1–4 Likert scale, with 1 = ‘not at all true of me’–4 = ‘extremely true of me’. Reliability of the KNCCS was reported as Cronbach’s alpha of 097; test-retest reliability alpha was reported as 084 for the total scale and 094, 092, 090, 091 and 084 (respectively) for the five subdomains (Lee et al. 2010). Furthermore, the explained variance for the factor analysis was 4994% and the item total correlation ranged from 0047–070 in the original study. In this study, the overall score for reliability using Cronbach’s alpha was 090.

Ethical considerations Institutional review board approval was obtained prior to the study. Instructions and a written consent form were provided with the questionnaire and the questionnaire was 594

SPSS 19.0 (SPSS, Chicago, IL, USA) was used to analyse the data. Descriptive statistics were used for participant characteristics and competency scores. A t-test was used to assess the differences in nursing competency between the 2010–2013 groups. Importance-Performance Analysis (IPA) (Joint Commission Resources Mission 2002, Kim et al. 2012) was used to analyse which subdomains of the nursing competency needed attention for improvement in the two groups (i.e. TLG and ALG). Factor loading scores of each subdomain were used to estimate important coefficients of subdomains. Performance was calculated based on average scores of subdomains for each group. The relationship between the importance (factor loading scores) and the performance (average scores of subdomains) was examined.

Results Participant characteristics Most participants in this study were female; general characteristics such as age and religion were not significantly different between the two groups. Due to the small number of male students in nursing, gender differences could not be compared. Student academic performance as reflected in freshman year GPA showed no significant difference between the two groups (Table 1).

Nursing competency in graduates Table 2 shows the average scores of participants’ nursing core competency using the KNCCS. T-test indicated that the overall scores of nursing competency in ALG were significantly higher than those in TLG. The scores of subdomains such as special and general clinical performance competency, critical thinking and human understanding were significantly higher in ALG than in TLG. The average score of professional attitude in ALG was also higher than in the TLG group, but the difference was not statistically significant. Students’ self-evaluation of learning achievement and satisfaction with the nursing practicum at graduation was significantly higher in ALG, while general self-confidence scores between the two groups were not significantly different. © 2014 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

Table 1 Characteristics of participants (N = 144).

Age Gender Female Male Religion Protestant Catholic Buddhist No religion 1st year GPA

Comparison of importance vs. performance between the two groups

ALG n (73)%

TLG n (71)%

v2/t

P

221 (07)

222 (11)

108

028

73 (1000) 0 (00)

68 (959) 3 (42)





16 7 6 44 30

19 13 5 34 32

340

033

159

011

(219) (96) (82) (603) (05)

(268) (183) (70) (479) (05)

Active learning program

Values are expressed as mean (SD). ALG, active learning group; TLG, traditional learning group.

Table 2 Nursing core competency and confidence scores at grad-

Figure 2 presents the results of IPA. Students in TLG presented a scattered pattern of subdomains (quadrants A and D), while the ALG students showed all subdomains clustered in the high performance and high importance area (quadrant B). This suggests that the priority for improvement for TLG was in the area of clinical competency (both general and special practice), and critical thinking and evaluation.

Discussion Teaching students to be competent in clinical nursing is a major goal of undergraduate nursing education. However, traditional learning strategies for achieving this goal have not been successful. The findings of this study showed the

uation. ALG Mean(SD) 851 (62)

793 (108)

v2/t 395

Human Understanding & Communication

P

538 (42) 564 (32)

518 (135) 503 (64)

119 736

024

Competency and an active learning program in undergraduate nursing education.

To evaluate the effect of an active learning program on competency of senior students...
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