J Canc Educ DOI 10.1007/s13187-015-0869-1
Evaluation of Learning in Oncology of Undergraduate Nursing with the Use of Concept Mapping Mariane Trevisani 1 & Cibelli Rizzo Cohrs 2 & Mariângela Abate de Lara Soares 2,3 & José Marcio Duarte 4 & Felipe Mancini 4 & Ivan Torres Pisa 4 & Edvane Birelo Lopes De Domenico 2
# American Association for Cancer Education 2015
Abstract This study aims to identify whether the use of concept mapping (CM) strategy assists a student to extend and revise their expertise in oncology and analyze the abilities developed in a student in order to go through theoretical to practical knowledge. This study is descriptive and qualitative, with 20 undergraduate students of the Undergraduate Nursing Course of Paulista School of Nursing of Federal University of São Paulo, Brazil. The critical incident technique and content analysis were used. There were 12 categories represented by facilities, difficulties, and learning applicability in oncology provided by CM strategy during the surgical and clinical nursing discipline. The graphics resource, CMapTools®, and the clinical case data arranged in mapping for resolution generated an active search and exercise of self-learning in oncology. Despite the challenges of the use of CM as a teaching strategy—pedagogical, the results suggested an increase of autonomy and clinical reasoning in nursing practice.
* Mariângela Abate de Lara Soares [email protected] Edvane Birelo Lopes De Domenico [email protected] 1
AC Camargo Câncer Center, São Paulo, São Paulo, Brazil
2
Paulista School of Nursing, Federal University of São Paulo (Unifesp), São Paulo, São Paulo, Brazil
3
Complexo Educacional FMU, São Paulo, São Paulo, Brazil
4
Departament of Health Informatic, Federal University of São Paulo (Unifesp), São Paulo, São Paulo, Brazil
Keywords Oncology teaching . Concept mapping . Critical thinking and clinical competence
Introduction According to the National Cancer Institute of Brazil, the estimate for the year 2014, also valid for the year 2015, is approximately 576,000 new cancer cases, including non-melanoma skin cases, enhancing the magnitude of the cancer problem in the country. The type of nonmelanoma skin cancer (182,000 new cases) will be the most frequent in the Brazilian population, followed by prostate tumors (69,000), female breast (57,000), colon and rectum (33,000), lung (27,000), stomach (20,000), and cervical cancer (15,000) [1]. In relation to professional formation, epidemiological data justify the concern with the teaching of oncology at graduation to equip the future health professionals to assist the demands of patients’ care, who will get sick by malignant neoplasms. Despite few national studies, it is noticed that the inclusion of oncology, although not as a structured discipline on curricular courses in the health area, prepares future professionals who will face a patient with this profile, in any of the attention levels, from basic to tertiary [2]. Learning in oncology requires knowledge of basic disciplines of biological sciences, which are fundamental to understand the complexity of the malignant tumor formation (oncogenesis), and the specific disciplines in which the principles of diagnosis, staging, treatments required case by case (chemotherapy, radiotherapy, and surgery), and palliative care should be addressed [3]. In this sense, the diversity of these contents must be connected and interrelated for skills development for the transposition from theory to practice, requiring in education, employing strategies in order to use preexisting
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knowledge of the undergraduate students because they optimize time and efficiency in learning [4]. In practice, it is desired that the health professional could have skills of critical thinking and clinical practice skills. This union takes place by means of knowledge, attitudes of investigation, quality of inferences, generalizations and abstractions, and finally, in decision making that combines the formal theoretical knowledge with clinical experience [5, 6]. This process is dependent on the cognitive, psychomotor, and affective development of the professional who is hardly operationalized in the passive attitudes of the students inherent to expository classes [7, 8]. The challenge is to find, among the resources of educational technology, strategies associating the concept study, with skills and attitudes. The concept mapping (CM) has shown in previous studies some advantages, such as promote curiosity among students on the interdisciplinary contents, the wish to investigate and combine relevant data, and motivation to find out more on scientific findings that could help them to innovate basic interventions [4, 7, 8]. The CM tries to reproduce, by a diagram, the non-linearity of the cognitive process, i.e., from previous knowledge, new concepts are aggregated in order to take advantage about what the undergraduate student has already known, accelerating the learning process and facilitating, at the same time, the development process of clinical reasoning [8]. The CM was developed by Novak and Gowin (1984) as a result of researches on the construction of teaching process and learning. The CM allows the student to develop concepts and organizes them into their cognitive structure, in a network of relationship with multilinear characteristics, not restricted to cartesian thought, which, for the teaching of clinical reasoning, it is fundamental [9]. From these considerations, the strategy of CM was applied in consecutive years, from 2008 to 2012, in the resolution of clinical cases for teaching the content of basic oncology and oncology nursing for nursing undergraduate students in the discipline of clinical nursing. It was considered that, in this discipline, taught in the 5th semester of the course, the student would have knowledge of the previous subjects on epidemiology of non-transmissible chronic diseases, molecular biology, genetics, immunology, pathophysiology, pharmacology, and among others necessary for the development of clinical reasoning in oncology. The teachers prepare the clinical cases, and these are based in the real clinical oncology stories and include medical diagnosis; signs and symptoms; results and test;, proposed treatment;, and psychological, social, and cultural data of cancer patients. The students are stimulated to review the contents and to look for new knowledge to solve the clinical case according to the three steps of the nursing process: assessing, analyzing (nursing diagnoses and outcomes), and planning (nursing interventions). During the period of the CM construction, the teachers are available to clear all doubts the students
may have. The effective learning is characterized by an anchoring process that happens when the previous information can help understand the new one (concept, idea, proposition) and, thus, to develop a cognitive structure more complex and correlated. In this process, there is an interaction between the new knowledge and the existing knowledge in which both are switched. Figure 1 exemplifies a CM with the resolution of a clinical case in lung cancer. Note that parts of the CM were enlarged, so the contents of the boxes and connecting words could be read. Thus, the use of the CM strategy elicited the following study questions: Does the use of CM strategy helps the student to extend and revise their knowledge in oncology, adding complexity to the previous contents, linking the different contents of different sciences? Does the strategy of CM encourages the development of skills to take theoretical knowledge to practice and guide decision making regarding care when the student is in the context of actual practice? Given the above questions, the objectives of this study were to evaluate the learning content of oncology through CM among nursing undergraduates, identify whether the use of the CM strategy helps the student to extend and revise their knowledge in oncology, and analyze if the CM strategy encourages the development of student skills to take this theoretical knowledge to practice and to guide decision making regarding care when in a real context.
Method Study of educational evaluation, qualitative nature by understanding a set of interpretive practices that explain the meanings attributed by the subjects, in this case, is the evaluation of teaching the CM strategy for learning in oncology [10]. The subjects of the study were undergraduate students of Paulista School of Nursing who had taken clinical nursing discipline in the 3rd year (5th semester) according to the inclusion criteria of having built the two CM of the discipline and taking part in practical activities in outpatient units and/or hospitalization where there were patients with cancer. The study was conducted at the Paulista School of Nursing, Federal University of São Paulo, Brazil, in accordance with the guidelines of Resolution 466/2012 of the National Health Council, CEP 0010/08. Data were collected through an instrument consisting of two stages. In both stages, the data collection was carried out between October and November 2012, via collective, electronic mail available by the students. The first stage has identification and semi-structured questions which were prepared to meet the first specific goal. At this stage, the questions were: “Do you assess that the construction of CM helped to obtain new concepts in Oncology and review your knowledge previously learned?” and “The construction of CM for
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Fig. 1 Concept map done by a student of the 5th semester of Undergraduate Nursing in solving a clinical case of a patient with a medical diagnosis of lung cancer
resolution of the clinical case facilitated the identification of the clinical problems and Nursing diagnoses?” The second stage consists of the description of a critical incident (CI); it was designed to obtain answers to the second specific objective: to evaluate the ability of the CM strategy to encourage the development of skills from the theoretical to practical transposition. The CI is a method that allows the narrative description, with as many details as possible, including the intentions and interpretations of events, as well as the chronology of the action and results, enabling the emergence of domains and subjects skills [11]. To identify the capacity that the construction of CM generated in the decision making of the students on oncology patients, it was proposed that they described a self-printed, sent by an attached file through electronic message, critical incident that characterized the transposition of a teaching strategy for the real experience. After the invitation to participate in the research, via e-mail to all students (n=81), 38 of them attended the meeting
personally for guidance on research and signed the consent term with their e-mail addresses. After sending the first part of the research to the students, 20 students returned with the completed files. For the data analysis obtained, content analysis technique, proposed by Bardin [11], was used. The technique was applied considering the overall meaning of the discourses by having as references the units of analysis previously elected from the intentionality of the use of teaching CM strategy for solving clinical cases in oncology: (a) acquisition of new concepts and reorganization of previous concepts and related; (b) ability to identify clinical problems and diagnostic process; (c) ability to investigate non-validated data; and (d) ability to make decisions for actual and potential problems. Thus, it was sought to interpret the contents, cut and group them into units of analysis, constituting the units of record. The categories that emerged, both the frequency of reporting units, as by
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its exclusivity and convergence for the interpretation of the phenomenon, were established in the third phase.
clinical situation (n, 11), CM able to promote comprehensive care (n=4), and no clear perception of the influence of CM on the practice situation (n=3). The categories are shown in Table 2.
Results Among the 20 participants, 18 (90 %) were female and 2 (10 %) were male. The age range of most participants was 21–28 years (80 %), followed by participants up to 21 years old (15 %) and 28–35 years (5 %). When asked about the ability of teaching CM strategy to assist them in obtaining, reviewing, and correlating concepts, the justifications given allowed two categorizations: difficulty of learning with the use of active methodology (n=7) and motivation for the use of active methodology (n=13). In the sequel, it was questioned whether the construction of the CM for resolution of the clinical case in oncology facilitated the identification of relevant clinical problems and diagnostic process. The responses generated two categories with opposite directions: effective strategy, systemic view of the problems in obtaining diagnoses (n, 15), and ineffective strategy, low familiarity with the teaching CM strategy and also with the diagnostic process (n=5). The process of analysis of these contents is shown in Table 1. In the second part of the instrument, the critical incident technique was used as a mean for the participants to characterize objectively the benefits from the construction of the CMs of clinical cases in oncology. This item has not been answered by four students (20 %). Thus, 16 students (80 %) answered the five questions guiding the critical incident (CI). In the first question that was asked, the data about the context of CI were described in detail. Such data included place, time of the day, professionals involved, working conditions, and other information considered relevant to the interviewee. The place of living with the cancer patient for 14 undergraduate students (87.5 %) occurred in a hospital unit and for the other two (12.5 %) in an outpatient unit. The morning period (75 %) prevailed over the afternoon (25 %) in the occurrence of CIs. All participants reported at least one professional from the multidisciplinary team who was present at the site, and when asked about the conditions of the work environment, most (n=14) stated that the environment was organized, but there was little space for professionals’ performance, and these professionals were performing more than one task at the time of the incident. In later issues, the students were asked to describe on the ability of the association of the CM strategy to the actual situation, about the way the situation was handled, and if learning with CM was useful in practical situation. The statements obtained could be encoded into five categories: complexity of the resolution of CM similar to the real context (n, 15), CM not representative of the actual situation (n=3), CM able to favor the multilinear reasoning for understanding the
Discussion The predominance of the female population was evidenced by the ages between 21 and 28 years in most. The professional body of nursing in Brazil is still predominantly composed of women [12]. Qualitative data were analyzed separately according to each category presented in the results. Thus, the category motivation for the use of active methodology and difficulty of learning with the use of active methodology revealed the current condition of college student shared between the traditional pedagogical school and the innovative [8]. Most part of respondents stated that for the resolution of the clinical case, there was a need to review previously learned concepts, search for theoretical and scientific foundation, and interconnect the concepts, considering that there is a multiplicity of active issues involved in the case, which leads to characterize the subject as a student who has facility for self-learning. The literature shows that the use of the CM strategy has precisely this goal, to promote a classified movement as “continuity and rupture” [13]. The continuity is expressed in the possibility to relate new knowledge with the previously learned. In this process, the rupture occurs when the unpublished contents become challenges, requiring critical analysis and providing the expansion of knowledge [9,13]. The respondents who were grouped into the second category made it clear in their speeches the profile of the reproductive student, whose crucial didactic of learning is the expository class and dependent on the teacher’s dialogue. Studies in this area highlight behaviors that hamper learning by active strategies; among these are the excessive dependence in relation to the teacher and the lack of willingness to think [4,8]. The effective Strategy category, systemic view of problems in obtaining diagnoses, resulting from questioning about the CM, was able to facilitate the identification of relevant data, and consequential ED showed that students’ supporters of the active methodologies were able to recognize, in the form of representative construction of CM, its advantages in solving a clinical case. The CM applied to the resolution of a clinical case is a strategy in which the relevant patients’ data should generate other boxes related on the revision of concepts and steps of the nursing process. Thus, users of this strategy can see in a systematic way how the data are related and, in a more complex
NO (n, 5)
CM as effective YES (n, 15)
NO (n, 7)
Examples of testimonials “Search for scientific literature and development of clinical reasoning. The multiplicity of problems encountered exercised the preparation of the care plan.” (R18) “Assisted me in the search and deepening of the subject and helped me to build a better clinical reasoning.” (R14) “Easier to learn with someone explaining, reading and copy of the contents of the books; lack of learning.” (R1) “It helps but demands more time to prepare and because some concepts have not been clarified in the classroom becomes learning difficult.” (R2) Examples of testimonials “The clinical reasoning generated by CM favored the identification of patient’s problems and perform diagnostic.” (R1) “The graphics resource facilitated the visualization of problems, the clinical trial, reunification and the establishment of nursing diagnoses.” (R7) “Complex exercise due to inexperience with the tool and the different dynamics of CM.” (R3) “Need for prior basis to identify what is relevant or not. Otherwise, the layout of the data was insufficient to identify relevant problems.” (R20) Difficulty for unconventional eaching strategies and/or unfamiliarity with the diagnostic steps.
Inferential analysis Graphics resource + exercise of clinical reasoning to identify problems and choice of diagnostics.
Passive learning through teacher’s dialogue; reproductive student; limited availability for learning how to learn; receptor student behavior.
Inferential analysis Willingness to learn how to learn; perception of the complexity of the problems; motivation for action; development of criticality and reflection.
Concept map as a facilitator of learning in oncology and its effectiveness for the development of clinical reasoning
CM as a facilitator YES (n, 13)
Table 1
Ineffective strategy: low familiarity with the teaching strategy (CM) and also with the diagnostic process
Categorization Effective strategy: a systemic view of the problems for diagnostic purposes
Difficulty to learn with an active methodology
Categorization Motivation for the use of active methodology
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Absent (n, 3)
Interdisciplinary (n, 4)
Attributes of MC in the real situation Complexity(n, 11)
Difference (n, 3)
“Developing the application of the nursing process, combining concepts learned to the real context.” (R3) “Getting relate the data through research to find answers.” (R14) “Hearing the wishes and concerns of the patient to alleviate their psychological suffering and select the best behavior.” (R4) “When thinking clinically, raises questions and discuss with the nurse possible conducts.” (R11) “Understanding and acting not influenced by the theoretical knowledge acquired with the construction of CM, but the content and reasoning developed through graduation.” (R10) “Difficulties to propose solutions that interfere with patient care.” (R3)
Examples of testimonials “Patient with many doubts and sorrows on the diagnosis and unfavorable social, psychological and financial conditions. The CM helped in the development of patient and family care plan.” (R3) “Use of clinical reasoning with more security, data collection for preparation of nursing care. Increased awareness of the potential risks to which the individual is exposed.” (R6) “Understanding and acting not influenced by the theoretical knowledge acquired with the construction of the CM, but the content and reasoning developed through graduation.” (R10) “Strategy cannot be used to solve real problems.” (R13) Examples of testimonials in full
CM capable of promoting comprehensive care
No clear perception of the CM influence of in practice situation
Development of skills influenced by the traditional academic experience
CM capable of favoring the multilinear reasoning for understanding the clinical situation
Categorization
CM not representative of the real situation
Categorization Complexity of the resolution of the CM similar to the real context
Ability to active listening and psychological support to alleviate the others’ suffering and exercise the ability to communicate and interact with the multidisciplinary team
Skills development, active search, and better theoretical and practical association
Inferential analysis
Skills development influenced only by the traditional activities of theoretical and practical training
Inferential analysis Biopsychosocial aspects approach of the patient, use of clinical reasoning, care planning, and evaluation of potential risks also required in the context of nursing practice
The strategy of concept map and the association with the real context: degree of approximation and attributes
CM versus actual situation Similarity (n, 15)
Table 2
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way, to understand the situations of cause and consequences, including those relating to actions to be implemented [7,14]. In the context of cancer patient, for the first question of the second part of the data collection instrument, the CI, the majority of students reported living, established in the hospital context, since it is increasing the demand for oncology patients requiring admission and comprehensive care of high complexity [15]. All participants stated that at least one professional from each member of the multidisciplinary team was present at the site, which in oncology, it is desirable for the complex demand of patient care [16]. Regarding little space for professionals to work and the employees work overload, the literature shows that the work organization acts in the genesis of psychic distress through some easily identifiable elements, which are as follows: the long working hours, accelerated rhythms of production, the clearly repressive pressure and authoritarian installed in a rigid and vertical hierarchy, lack of rest breaks throughout the working hours, the alienation of work and the worker, the task fragmentation and deskilling of work performed, and therefore, from who performs it. [17] Such associated factors contribute to decrease productivity and therefore the risk to worker health and the patient safety [18]. When asked about the CM strategy and the association with the real context, the students responded negatively to the association by offering complementary justifications that are the result of low familiarity with active learning, the inconsistency of clinical reasoning and the complexity perception of the cancer patient. It was interesting to note that despite the CM is in favor of multilinear thought, some testimonials suggested that the sum of the knowledge obtained through the semesters were not mobilized in the construction of the CM but in real life. This data is relevant to the teacher, using this strategy, to make sure that the understanding of the students regarding the needs of the boxes are interconnected with the verbs (mainly) and prepositions that allow associations of concepts, expanding their knowledge, from interdisciplinary connections and thus multidirectional [19]. The difficulties that students found after living with cancer patients, not only brought as result categories that expressed the need for preparation for clinical reasoning and decision making but also denounced the lack of preparation for the patient’s psychosocial approach. The oncologic disease may be clinically, psychologically and socially very debilitating. Studies focusing on the quality of life of cancer patients highlight the need for comprehensive approach to care because actions for the social, psychological, and spiritual support tend to improve signs and biological symptoms [18, 19]. Students who reported having the CM as a facilitator for the construction of their own clinical reasoning and the
development of skills such as autonomy and security in making decisions, denoted to understand their active role in the learning process. For some authors, the multilinear construction of CM raises in the student the academic curiosity, need to investigate and address new health issues, besides instigate curiosity about scientific findings that may assist them to show the patterns of existing interventions. Therefore, each student is the regulator of their own learning, and this is certainly an intentional gain of this education [4, 9] strategy.
Conclusion The proposed objectives in this study were achieved, and the benefits and risks of the use of the CM strategy associated with resolution of clinical cases in the teaching of oncology for undergraduate students of nursing were demonstrated. Because it is a graphic resource and a strategy that promote the active search and self-managed exercise, CM helped the student to revise and expand knowledge in oncology and develop fundamental skills for nursing practice, the multilinear reasoning for understanding the clinical situation and the importance of comprehensive care. Among the limiting aspects on the use of CM for learning in oncology showed the difficulties of the students in learning with an active teaching methodology, besides the difficulties in relation to the assessment process, diagnosis, and intervention in nursing. Importantly, it is desired that students overcome intellectual passivity and seek for knowledge actively, learning to become reacquainted with new strategies of unconventional teaching, since the construction of learning depends almost exclusively on the self-interest of the own student. The study results reaffirmed the importance of employing teaching strategies that prepare future professionals to assist the patient in a qualified and integrated manner.
Limitations of the Study The CI as a technique to learn the meaning of the learning experience is valid and reliable; however, it must give clear explanations and the availability of the researcher for clarification of doubts. The constitution of a sample of participants via e-mail proved ineffective because the researchers believed that a greater number of students would integrate the research. The study design could have included an objective assessment of knowledge before and after the exercise to reflect, more appropriately, what the students knew before and after to use the CM to solve the oncology clinical case.
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Contributions to Practice The use of CM for solving clinical cases demonstrated acceptance by the majority of the students who, through data collection, showed the expected qualities in the use of this strategy: ability to interrelation concepts, interdisciplinary data, complexity of the relationships between different contents, and conformation of the learning network.
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9.
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Evaluation of Learning in Oncology of Undergraduate Nursing with the Use of Concept Mapping Mariane Trevisani 1 & Cibelli Rizzo Cohrs 2 & Mariângela Abate de Lara Soares 2,3 & José Marcio Duarte 4 & Felipe Mancini 4 & Ivan Torres Pisa 4 & Edvane Birelo Lopes De Domenico 2
# American Association for Cancer Education 2015
Abstract This study aims to identify whether the use of concept mapping (CM) strategy assists a student to extend and revise their expertise in oncology and analyze the abilities developed in a student in order to go through theoretical to practical knowledge. This study is descriptive and qualitative, with 20 undergraduate students of the Undergraduate Nursing Course of Paulista School of Nursing of Federal University of São Paulo, Brazil. The critical incident technique and content analysis were used. There were 12 categories represented by facilities, difficulties, and learning applicability in oncology provided by CM strategy during the surgical and clinical nursing discipline. The graphics resource, CMapTools®, and the clinical case data arranged in mapping for resolution generated an active search and exercise of self-learning in oncology. Despite the challenges of the use of CM as a teaching strategy—pedagogical, the results suggested an increase of autonomy and clinical reasoning in nursing practice.
* Mariângela Abate de Lara Soares [email protected] Edvane Birelo Lopes De Domenico [email protected] 1
AC Camargo Câncer Center, São Paulo, São Paulo, Brazil
2
Paulista School of Nursing, Federal University of São Paulo (Unifesp), São Paulo, São Paulo, Brazil
3
Complexo Educacional FMU, São Paulo, São Paulo, Brazil
4
Departament of Health Informatic, Federal University of São Paulo (Unifesp), São Paulo, São Paulo, Brazil
Keywords Oncology teaching . Concept mapping . Critical thinking and clinical competence
Introduction According to the National Cancer Institute of Brazil, the estimate for the year 2014, also valid for the year 2015, is approximately 576,000 new cancer cases, including non-melanoma skin cases, enhancing the magnitude of the cancer problem in the country. The type of nonmelanoma skin cancer (182,000 new cases) will be the most frequent in the Brazilian population, followed by prostate tumors (69,000), female breast (57,000), colon and rectum (33,000), lung (27,000), stomach (20,000), and cervical cancer (15,000) [1]. In relation to professional formation, epidemiological data justify the concern with the teaching of oncology at graduation to equip the future health professionals to assist the demands of patients’ care, who will get sick by malignant neoplasms. Despite few national studies, it is noticed that the inclusion of oncology, although not as a structured discipline on curricular courses in the health area, prepares future professionals who will face a patient with this profile, in any of the attention levels, from basic to tertiary [2]. Learning in oncology requires knowledge of basic disciplines of biological sciences, which are fundamental to understand the complexity of the malignant tumor formation (oncogenesis), and the specific disciplines in which the principles of diagnosis, staging, treatments required case by case (chemotherapy, radiotherapy, and surgery), and palliative care should be addressed [3]. In this sense, the diversity of these contents must be connected and interrelated for skills development for the transposition from theory to practice, requiring in education, employing strategies in order to use preexisting
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knowledge of the undergraduate students because they optimize time and efficiency in learning [4]. In practice, it is desired that the health professional could have skills of critical thinking and clinical practice skills. This union takes place by means of knowledge, attitudes of investigation, quality of inferences, generalizations and abstractions, and finally, in decision making that combines the formal theoretical knowledge with clinical experience [5, 6]. This process is dependent on the cognitive, psychomotor, and affective development of the professional who is hardly operationalized in the passive attitudes of the students inherent to expository classes [7, 8]. The challenge is to find, among the resources of educational technology, strategies associating the concept study, with skills and attitudes. The concept mapping (CM) has shown in previous studies some advantages, such as promote curiosity among students on the interdisciplinary contents, the wish to investigate and combine relevant data, and motivation to find out more on scientific findings that could help them to innovate basic interventions [4, 7, 8]. The CM tries to reproduce, by a diagram, the non-linearity of the cognitive process, i.e., from previous knowledge, new concepts are aggregated in order to take advantage about what the undergraduate student has already known, accelerating the learning process and facilitating, at the same time, the development process of clinical reasoning [8]. The CM was developed by Novak and Gowin (1984) as a result of researches on the construction of teaching process and learning. The CM allows the student to develop concepts and organizes them into their cognitive structure, in a network of relationship with multilinear characteristics, not restricted to cartesian thought, which, for the teaching of clinical reasoning, it is fundamental [9]. From these considerations, the strategy of CM was applied in consecutive years, from 2008 to 2012, in the resolution of clinical cases for teaching the content of basic oncology and oncology nursing for nursing undergraduate students in the discipline of clinical nursing. It was considered that, in this discipline, taught in the 5th semester of the course, the student would have knowledge of the previous subjects on epidemiology of non-transmissible chronic diseases, molecular biology, genetics, immunology, pathophysiology, pharmacology, and among others necessary for the development of clinical reasoning in oncology. The teachers prepare the clinical cases, and these are based in the real clinical oncology stories and include medical diagnosis; signs and symptoms; results and test;, proposed treatment;, and psychological, social, and cultural data of cancer patients. The students are stimulated to review the contents and to look for new knowledge to solve the clinical case according to the three steps of the nursing process: assessing, analyzing (nursing diagnoses and outcomes), and planning (nursing interventions). During the period of the CM construction, the teachers are available to clear all doubts the students
may have. The effective learning is characterized by an anchoring process that happens when the previous information can help understand the new one (concept, idea, proposition) and, thus, to develop a cognitive structure more complex and correlated. In this process, there is an interaction between the new knowledge and the existing knowledge in which both are switched. Figure 1 exemplifies a CM with the resolution of a clinical case in lung cancer. Note that parts of the CM were enlarged, so the contents of the boxes and connecting words could be read. Thus, the use of the CM strategy elicited the following study questions: Does the use of CM strategy helps the student to extend and revise their knowledge in oncology, adding complexity to the previous contents, linking the different contents of different sciences? Does the strategy of CM encourages the development of skills to take theoretical knowledge to practice and guide decision making regarding care when the student is in the context of actual practice? Given the above questions, the objectives of this study were to evaluate the learning content of oncology through CM among nursing undergraduates, identify whether the use of the CM strategy helps the student to extend and revise their knowledge in oncology, and analyze if the CM strategy encourages the development of student skills to take this theoretical knowledge to practice and to guide decision making regarding care when in a real context.
Method Study of educational evaluation, qualitative nature by understanding a set of interpretive practices that explain the meanings attributed by the subjects, in this case, is the evaluation of teaching the CM strategy for learning in oncology [10]. The subjects of the study were undergraduate students of Paulista School of Nursing who had taken clinical nursing discipline in the 3rd year (5th semester) according to the inclusion criteria of having built the two CM of the discipline and taking part in practical activities in outpatient units and/or hospitalization where there were patients with cancer. The study was conducted at the Paulista School of Nursing, Federal University of São Paulo, Brazil, in accordance with the guidelines of Resolution 466/2012 of the National Health Council, CEP 0010/08. Data were collected through an instrument consisting of two stages. In both stages, the data collection was carried out between October and November 2012, via collective, electronic mail available by the students. The first stage has identification and semi-structured questions which were prepared to meet the first specific goal. At this stage, the questions were: “Do you assess that the construction of CM helped to obtain new concepts in Oncology and review your knowledge previously learned?” and “The construction of CM for
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Fig. 1 Concept map done by a student of the 5th semester of Undergraduate Nursing in solving a clinical case of a patient with a medical diagnosis of lung cancer
resolution of the clinical case facilitated the identification of the clinical problems and Nursing diagnoses?” The second stage consists of the description of a critical incident (CI); it was designed to obtain answers to the second specific objective: to evaluate the ability of the CM strategy to encourage the development of skills from the theoretical to practical transposition. The CI is a method that allows the narrative description, with as many details as possible, including the intentions and interpretations of events, as well as the chronology of the action and results, enabling the emergence of domains and subjects skills [11]. To identify the capacity that the construction of CM generated in the decision making of the students on oncology patients, it was proposed that they described a self-printed, sent by an attached file through electronic message, critical incident that characterized the transposition of a teaching strategy for the real experience. After the invitation to participate in the research, via e-mail to all students (n=81), 38 of them attended the meeting
personally for guidance on research and signed the consent term with their e-mail addresses. After sending the first part of the research to the students, 20 students returned with the completed files. For the data analysis obtained, content analysis technique, proposed by Bardin [11], was used. The technique was applied considering the overall meaning of the discourses by having as references the units of analysis previously elected from the intentionality of the use of teaching CM strategy for solving clinical cases in oncology: (a) acquisition of new concepts and reorganization of previous concepts and related; (b) ability to identify clinical problems and diagnostic process; (c) ability to investigate non-validated data; and (d) ability to make decisions for actual and potential problems. Thus, it was sought to interpret the contents, cut and group them into units of analysis, constituting the units of record. The categories that emerged, both the frequency of reporting units, as by
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its exclusivity and convergence for the interpretation of the phenomenon, were established in the third phase.
clinical situation (n, 11), CM able to promote comprehensive care (n=4), and no clear perception of the influence of CM on the practice situation (n=3). The categories are shown in Table 2.
Results Among the 20 participants, 18 (90 %) were female and 2 (10 %) were male. The age range of most participants was 21–28 years (80 %), followed by participants up to 21 years old (15 %) and 28–35 years (5 %). When asked about the ability of teaching CM strategy to assist them in obtaining, reviewing, and correlating concepts, the justifications given allowed two categorizations: difficulty of learning with the use of active methodology (n=7) and motivation for the use of active methodology (n=13). In the sequel, it was questioned whether the construction of the CM for resolution of the clinical case in oncology facilitated the identification of relevant clinical problems and diagnostic process. The responses generated two categories with opposite directions: effective strategy, systemic view of the problems in obtaining diagnoses (n, 15), and ineffective strategy, low familiarity with the teaching CM strategy and also with the diagnostic process (n=5). The process of analysis of these contents is shown in Table 1. In the second part of the instrument, the critical incident technique was used as a mean for the participants to characterize objectively the benefits from the construction of the CMs of clinical cases in oncology. This item has not been answered by four students (20 %). Thus, 16 students (80 %) answered the five questions guiding the critical incident (CI). In the first question that was asked, the data about the context of CI were described in detail. Such data included place, time of the day, professionals involved, working conditions, and other information considered relevant to the interviewee. The place of living with the cancer patient for 14 undergraduate students (87.5 %) occurred in a hospital unit and for the other two (12.5 %) in an outpatient unit. The morning period (75 %) prevailed over the afternoon (25 %) in the occurrence of CIs. All participants reported at least one professional from the multidisciplinary team who was present at the site, and when asked about the conditions of the work environment, most (n=14) stated that the environment was organized, but there was little space for professionals’ performance, and these professionals were performing more than one task at the time of the incident. In later issues, the students were asked to describe on the ability of the association of the CM strategy to the actual situation, about the way the situation was handled, and if learning with CM was useful in practical situation. The statements obtained could be encoded into five categories: complexity of the resolution of CM similar to the real context (n, 15), CM not representative of the actual situation (n=3), CM able to favor the multilinear reasoning for understanding the
Discussion The predominance of the female population was evidenced by the ages between 21 and 28 years in most. The professional body of nursing in Brazil is still predominantly composed of women [12]. Qualitative data were analyzed separately according to each category presented in the results. Thus, the category motivation for the use of active methodology and difficulty of learning with the use of active methodology revealed the current condition of college student shared between the traditional pedagogical school and the innovative [8]. Most part of respondents stated that for the resolution of the clinical case, there was a need to review previously learned concepts, search for theoretical and scientific foundation, and interconnect the concepts, considering that there is a multiplicity of active issues involved in the case, which leads to characterize the subject as a student who has facility for self-learning. The literature shows that the use of the CM strategy has precisely this goal, to promote a classified movement as “continuity and rupture” [13]. The continuity is expressed in the possibility to relate new knowledge with the previously learned. In this process, the rupture occurs when the unpublished contents become challenges, requiring critical analysis and providing the expansion of knowledge [9,13]. The respondents who were grouped into the second category made it clear in their speeches the profile of the reproductive student, whose crucial didactic of learning is the expository class and dependent on the teacher’s dialogue. Studies in this area highlight behaviors that hamper learning by active strategies; among these are the excessive dependence in relation to the teacher and the lack of willingness to think [4,8]. The effective Strategy category, systemic view of problems in obtaining diagnoses, resulting from questioning about the CM, was able to facilitate the identification of relevant data, and consequential ED showed that students’ supporters of the active methodologies were able to recognize, in the form of representative construction of CM, its advantages in solving a clinical case. The CM applied to the resolution of a clinical case is a strategy in which the relevant patients’ data should generate other boxes related on the revision of concepts and steps of the nursing process. Thus, users of this strategy can see in a systematic way how the data are related and, in a more complex
NO (n, 5)
CM as effective YES (n, 15)
NO (n, 7)
Examples of testimonials “Search for scientific literature and development of clinical reasoning. The multiplicity of problems encountered exercised the preparation of the care plan.” (R18) “Assisted me in the search and deepening of the subject and helped me to build a better clinical reasoning.” (R14) “Easier to learn with someone explaining, reading and copy of the contents of the books; lack of learning.” (R1) “It helps but demands more time to prepare and because some concepts have not been clarified in the classroom becomes learning difficult.” (R2) Examples of testimonials “The clinical reasoning generated by CM favored the identification of patient’s problems and perform diagnostic.” (R1) “The graphics resource facilitated the visualization of problems, the clinical trial, reunification and the establishment of nursing diagnoses.” (R7) “Complex exercise due to inexperience with the tool and the different dynamics of CM.” (R3) “Need for prior basis to identify what is relevant or not. Otherwise, the layout of the data was insufficient to identify relevant problems.” (R20) Difficulty for unconventional eaching strategies and/or unfamiliarity with the diagnostic steps.
Inferential analysis Graphics resource + exercise of clinical reasoning to identify problems and choice of diagnostics.
Passive learning through teacher’s dialogue; reproductive student; limited availability for learning how to learn; receptor student behavior.
Inferential analysis Willingness to learn how to learn; perception of the complexity of the problems; motivation for action; development of criticality and reflection.
Concept map as a facilitator of learning in oncology and its effectiveness for the development of clinical reasoning
CM as a facilitator YES (n, 13)
Table 1
Ineffective strategy: low familiarity with the teaching strategy (CM) and also with the diagnostic process
Categorization Effective strategy: a systemic view of the problems for diagnostic purposes
Difficulty to learn with an active methodology
Categorization Motivation for the use of active methodology
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Absent (n, 3)
Interdisciplinary (n, 4)
Attributes of MC in the real situation Complexity(n, 11)
Difference (n, 3)
“Developing the application of the nursing process, combining concepts learned to the real context.” (R3) “Getting relate the data through research to find answers.” (R14) “Hearing the wishes and concerns of the patient to alleviate their psychological suffering and select the best behavior.” (R4) “When thinking clinically, raises questions and discuss with the nurse possible conducts.” (R11) “Understanding and acting not influenced by the theoretical knowledge acquired with the construction of CM, but the content and reasoning developed through graduation.” (R10) “Difficulties to propose solutions that interfere with patient care.” (R3)
Examples of testimonials “Patient with many doubts and sorrows on the diagnosis and unfavorable social, psychological and financial conditions. The CM helped in the development of patient and family care plan.” (R3) “Use of clinical reasoning with more security, data collection for preparation of nursing care. Increased awareness of the potential risks to which the individual is exposed.” (R6) “Understanding and acting not influenced by the theoretical knowledge acquired with the construction of the CM, but the content and reasoning developed through graduation.” (R10) “Strategy cannot be used to solve real problems.” (R13) Examples of testimonials in full
CM capable of promoting comprehensive care
No clear perception of the CM influence of in practice situation
Development of skills influenced by the traditional academic experience
CM capable of favoring the multilinear reasoning for understanding the clinical situation
Categorization
CM not representative of the real situation
Categorization Complexity of the resolution of the CM similar to the real context
Ability to active listening and psychological support to alleviate the others’ suffering and exercise the ability to communicate and interact with the multidisciplinary team
Skills development, active search, and better theoretical and practical association
Inferential analysis
Skills development influenced only by the traditional activities of theoretical and practical training
Inferential analysis Biopsychosocial aspects approach of the patient, use of clinical reasoning, care planning, and evaluation of potential risks also required in the context of nursing practice
The strategy of concept map and the association with the real context: degree of approximation and attributes
CM versus actual situation Similarity (n, 15)
Table 2
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way, to understand the situations of cause and consequences, including those relating to actions to be implemented [7,14]. In the context of cancer patient, for the first question of the second part of the data collection instrument, the CI, the majority of students reported living, established in the hospital context, since it is increasing the demand for oncology patients requiring admission and comprehensive care of high complexity [15]. All participants stated that at least one professional from each member of the multidisciplinary team was present at the site, which in oncology, it is desirable for the complex demand of patient care [16]. Regarding little space for professionals to work and the employees work overload, the literature shows that the work organization acts in the genesis of psychic distress through some easily identifiable elements, which are as follows: the long working hours, accelerated rhythms of production, the clearly repressive pressure and authoritarian installed in a rigid and vertical hierarchy, lack of rest breaks throughout the working hours, the alienation of work and the worker, the task fragmentation and deskilling of work performed, and therefore, from who performs it. [17] Such associated factors contribute to decrease productivity and therefore the risk to worker health and the patient safety [18]. When asked about the CM strategy and the association with the real context, the students responded negatively to the association by offering complementary justifications that are the result of low familiarity with active learning, the inconsistency of clinical reasoning and the complexity perception of the cancer patient. It was interesting to note that despite the CM is in favor of multilinear thought, some testimonials suggested that the sum of the knowledge obtained through the semesters were not mobilized in the construction of the CM but in real life. This data is relevant to the teacher, using this strategy, to make sure that the understanding of the students regarding the needs of the boxes are interconnected with the verbs (mainly) and prepositions that allow associations of concepts, expanding their knowledge, from interdisciplinary connections and thus multidirectional [19]. The difficulties that students found after living with cancer patients, not only brought as result categories that expressed the need for preparation for clinical reasoning and decision making but also denounced the lack of preparation for the patient’s psychosocial approach. The oncologic disease may be clinically, psychologically and socially very debilitating. Studies focusing on the quality of life of cancer patients highlight the need for comprehensive approach to care because actions for the social, psychological, and spiritual support tend to improve signs and biological symptoms [18, 19]. Students who reported having the CM as a facilitator for the construction of their own clinical reasoning and the
development of skills such as autonomy and security in making decisions, denoted to understand their active role in the learning process. For some authors, the multilinear construction of CM raises in the student the academic curiosity, need to investigate and address new health issues, besides instigate curiosity about scientific findings that may assist them to show the patterns of existing interventions. Therefore, each student is the regulator of their own learning, and this is certainly an intentional gain of this education [4, 9] strategy.
Conclusion The proposed objectives in this study were achieved, and the benefits and risks of the use of the CM strategy associated with resolution of clinical cases in the teaching of oncology for undergraduate students of nursing were demonstrated. Because it is a graphic resource and a strategy that promote the active search and self-managed exercise, CM helped the student to revise and expand knowledge in oncology and develop fundamental skills for nursing practice, the multilinear reasoning for understanding the clinical situation and the importance of comprehensive care. Among the limiting aspects on the use of CM for learning in oncology showed the difficulties of the students in learning with an active teaching methodology, besides the difficulties in relation to the assessment process, diagnosis, and intervention in nursing. Importantly, it is desired that students overcome intellectual passivity and seek for knowledge actively, learning to become reacquainted with new strategies of unconventional teaching, since the construction of learning depends almost exclusively on the self-interest of the own student. The study results reaffirmed the importance of employing teaching strategies that prepare future professionals to assist the patient in a qualified and integrated manner.
Limitations of the Study The CI as a technique to learn the meaning of the learning experience is valid and reliable; however, it must give clear explanations and the availability of the researcher for clarification of doubts. The constitution of a sample of participants via e-mail proved ineffective because the researchers believed that a greater number of students would integrate the research. The study design could have included an objective assessment of knowledge before and after the exercise to reflect, more appropriately, what the students knew before and after to use the CM to solve the oncology clinical case.
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Contributions to Practice The use of CM for solving clinical cases demonstrated acceptance by the majority of the students who, through data collection, showed the expected qualities in the use of this strategy: ability to interrelation concepts, interdisciplinary data, complexity of the relationships between different contents, and conformation of the learning network.
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