Nurse Education Today 35 (2015) 1240–1245
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Identifying student knowledge and perception of what is valuable to professional practice: A mixed method study Judith K. Anderson a,⁎, Lyn Croxon b,1, Denise E. McGarry c,2 a b c
School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Ave., Bathurst, NSW 2795, Australia Undergraduate Program Leader, Bachelor of Nursing School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Tony McGrane Place, Dubbo, NSW 2830, Australia School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Ave., Bathurst, NSW 2795, Australia
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Article history: Accepted 14 April 2015 Keywords: Nursing Education Curriculum Students
s u m m a r y Background: Bachelor of Nursing programmes are designed to prepare Registered Nurses for professional practice. The Bachelor of Nursing curriculum under discussion was shaped by the conceptual framework of primary health care philosophy, including themes of social justice, Indigenous health, caring philosophy, and the advancement of the discipline through research, scholarship and application of nursing knowledge and evidence-based practice. Objectives: This study was designed to identify what students and graduates found valuable in a Bachelor of Nursing curriculum conceptual framework and what value they placed on a conceptual framework and underpinning themes. Design: A small study was designed to identify the student perceptions of themes which may be valuable to the new curriculum of the Bachelor of Nursing. A mixed methodology was selected as being appropriate to allow students to indicate the value that previous and completing students placed on each of these items and to explore their perceptions. Settings: The setting for this small study was a regional university in NSW, Australia. Participants: Previous and completing (final year) students were invited to complete the online survey and any who were willing to be interviewed were asked to provide their contact details. Methods: The research was conducted via a questionnaire through Survey Monkey, using a Likert scale and open responses and follow up interviews were conducted with willing participants. Results: A total of 128 responses to the survey were received and ten were interviewed. Overall responses were positive. Students were aware of and valued all aspects of the current and proposed conceptual framework. There were some themes; however which were better understood than others. Conclusions: The majority of graduated students indicated that they were well prepared for the workforce. All aspects of the conceptual framework of the curriculum were valued by the majority of students. © 2015 Elsevier Ltd. All rights reserved.
Introduction When reviewing a curriculum a great deal of discussion takes place about what to include and what can be removed. Many stakeholders have different opinions about the value of some aspects over others and decisions cannot possibly reflect everyone's opinion equally. However, there is a great deal of value in obtaining those opinions. Graduates
are unique in their understanding of current courses and how well it has prepared them for practice. For that reason this study sought their opinions on conceptual frameworks and underpinning themes and their value in structuring a nursing curriculum. Final year students were also involved due to their insight into how well prepared they felt for practice.
Background/Literature ⁎ Corresponding author. Tel.: +61 2 6338 4640; fax: +61 2 6338 4408. E-mail addresses: [email protected] (J.K. Anderson), [email protected] (L. Croxon), [email protected] (D.E. McGarry). 1 Tel.: +61 2 68857325. 2 Tel.: +61 2 6338 4546.
http://dx.doi.org/10.1016/j.nedt.2015.04.007 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
The review of the current Bachelor of Nursing included an appraisal of the underlying conceptual framework which subsequently led to queries about student involvement and interest in a conceptual framework and underpinning themes. Literature related to nursing education
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demonstrates an ongoing interest in and discussion about which conceptual frameworks are most useful to student learning (Benner et al., 2010; D'Antonio et al., 2013; Martyn et al., 2014). In these discussions the ‘voices’ of several groups are heard clearly, including policy makers and lecturers. Student voices, however, are not always so clear. Salyers et al. (2010), describe an evaluation of a pedagogical framework which was used to structure a nursing curriculum and found that both students and academic staff benefit from a framework which reflects the general thinking and learning processes of the discipline. McIntosh et al. (2013, p. 1183) suggest “involving students more deeply in curriculum design, thereby giving them a stake in defining the essential components” of the course. Kumm and Fletcher (2012) in discussing the design of a new bachelor of nursing curriculum do not mention students as stakeholders in the process of designing a new curriculum and although D'Antonio et al. (2013) discuss the value of internal stakeholders (including students) in curriculum design they do not describe students being involved in the undergraduate curriculum renewal process. Naturally most universities survey student satisfaction and perceptions about their courses (Adams and Shearer, 2012). Student feedback has been used to evaluate learning and satisfaction in the clinical environment (Henderson et al., 2012; Loewenson and Hunt, 2011; O'Mara et al., 2014; Papastavrou et al., 2010; Papathanasiou et al., 2014; Roxburgh, 2014; Skaalvik et al., 2011; Sundler et al., 2014) and some literature which relates to preparation for practice examining undergraduate and graduate satisfaction with models of clinical learning and preparation for practice (Hickey, 2010; Milton-Wildey et al., 2014). Other literature relates to evaluation of programmes for nursing students undertaking international experiences (Kulbok et al., 2012), but this does not give them a voice in the conceptual structure of course design. There is also literature around student perception of problem based learning (Cooper and Carver, 2012; Rowan et al., 2009) learning statistics (Hagen et al., 2013) and an increasing focus on simulation (Kelly and Fry, 2013; Reid-Searl et al., 2011) and blended and online learning (Gaudet et al., 2014; Hodges and Cowan, 2012; Lee et al., 2011; Smyth et al., 2012). This literature around nursing education and clinical learning experiences was found across global sources. Methods This study took place at a regional university in New South Wales, Australia. The university has close to 40,000 students in total and approximately 1500 are enrolled in the Bachelor of Nursing. Less than 10% of nursing students come from non-English speaking backgrounds, over 50% are studying part-time and over 50% are mature age students (Charles Sturt University, 2015). A mixed methodology study was implemented to measure the value that previous and completing students placed on different aspects of the current and proposed conceptual framework and underpinning themes and to allow the researchers to explore these results in greater depth. Ethics approval was granted through the School of Nursing, Midwifery and Indigenous Health Human Research Ethics Committee (approval number: 409/2013/04). Links to a survey were emailed to all students who had graduated from the course in the previous 2 years (n = 491) and to current students (n = 256) from a regional university in NSW, Australia. In total the response rate was 23% (n = 111) graduates and 7% (n = 17) current students. The survey used a Likert scale and open responses. Participants who were willing to be interviewed were asked to provide their contact details. A purposive sample of those students who indicated a willingness to be interviewed was then contacted. This sample was representative of age, gender and metropolitan/rural areas. Ten interviews were conducted of approximately 1 hour each, digitally recorded and transcribed verbatim. These were then thematically analysed by a different team member to the interviewer and the themes that emerged were checked by the researcher who conducted the interview. In order to maintain their
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confidentiality, participants were given pseudonyms and although two males were interviewed, they were also given female pseudonyms. Results A total of 128 responses were received, 111 (86.7%) from previous graduates and 17 (13.3%) from current final year students. Most of the respondents were female (91.4%) which is consistent with gender percentages within the course. Respondents represented fairly evenly those between 19–25 years of age (25.6%), 26–35 years of age (27.1%) and 46–55 years of age (32%). The overwhelming majority of graduate participants were working in the health industry and 95.5% in nursing (the survey included double degree graduates, who may have sought work in other areas). On completion of their degree, 61.2% felt that they were prepared and a further 12.6% felt that they were very prepared for practice. Graduate and student participants were asked about the relevance of current and proposed central themes of the curriculum to their current or future practice. Most graduates were positive about the value of these themes as can be seen in Fig. 1, indicating that current and proposed themes of the curriculum framework were applicable to their practice. These responses are all supportive of the proposed curriculum framework and underpinning themes. Students and graduates were asked to indicate their recognition of the presence of the five themes of the conceptual framework of the current curriculum: Evidence-based practice, person-centred care, primary health care, social justice, and Indigenous health. They were then asked whether the proposed additional themes — cultural competence, strengths based nursing, clinical reasoning and ethical comportment — would be valuable additions to the new curriculum. The responses of ‘agree’ or ‘strongly agree’ are summarised in the following chart, showing responses from graduates and students. As can be seen in the chart, all themes were reasonably equally valued. It was gratifying that these participants did recognise the existence of the conceptual framework and underpinning themes in the curriculum and its application for practice. The focus of the interviews with the participants was around the major themes of the conceptual framework of the current Bachelor of Nursing and the proposed themes of the revised Bachelor of Nursing course. An understanding of the themes that were present in the current curriculum was highlighted in the results. An understanding of three of the proposed themes, strengths based nursing, cultural competence and ethical comportment, was less evident. The themes that were discussed were the value of the conceptual framework; evidence based practice, primary health care, clinical reasoning, person centred care; social justice, Indigenous health, strengths based nursing, cultural competence and ethical comportment. Value of Conceptual Framework All participants in interviews identified the conceptual framework and underpinning themes as being very important. It was seen to offer cohesiveness to the curriculum and to instil overall values within it. Participants confirmed the need to have identified frameworks for curricula and were pleased to have been asked for their opinion about them. Participants stated that it was: I think it's absolutely critical, absolutely critical that there is an overarching framework that everyone is working from. [Toni] Whilst recognising its value, participants also suggested how a conceptual framework acts: It helps to guide us, I think, without one in our course, there are some people who would not actually follow the standards that are set and I think that the nursing board having seen this has also helped to guide our subject and objective delivery and to see that we learn what we need to. [Michelle]
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Fig. 1. Relevance of current and proposed themes to practice. *Proposed curriculum themes.
Many participants were insightful about the role of a conceptual framework and underpinning themes and felt privileged to be asked for their opinion about something they regarded as being so important. The insight gained through asking new practitioners about the conceptual framework and underpinning themes which had impacted so much on their preparation for practice was also highlighted. Participants felt that several aspects of the framework were important and these are dealt with according to the level of importance assigned to them by participants. Evidence Based Practice Evidence based practice (EBP) was seen to be integral to the curriculum and nursing practice. This was the aspect of the conceptual framework and underpinning themes most valued by participants. EBP is defined as interdisciplinary approach to health care practice that bases clinical decisions on research studies that meet rigorous criteria when available (Hoffman et al., 2013). It was evident in the current curriculum especially from second year onward, EBP is related to practice and is evident when on clinical practice. All participants clearly understood the concept of evidence based practice. Participants, particularly those who were now in the workforce regarded evidence based practice as essential to their practice as described by Angie: Evidence based practice, I think is used everywhere, all policy is designed around it, so definitely, people need an understanding of, well nursing IS evidence based practice. [Angie] Evidence based practice was valued by all participants, even current students. However, as Michelle pointed out, this was something that she needed to learn about and did not understand upon entry into the course. It is well covered, it is important. I don't think that I have not had an assignment or a presentation that has not required evidence based practice. At first it was challenging, I thought that what I was presenting
was evidence based practice and then I learned about peer review articles and receiving information from .org or .au websites and learning that research is completed and then implemented into hospitals and that then becomes the culture of research based practice … definitely should not be introduced later, it could be brought in earlier, it might have been, but I might not have paid enough attention. [Michelle] Evidence based practice was perceived by participants to be central to their course, assessments and their practice. It was the theme most valued by participants. This reinforces the connection between theory and practice which the majority of nursing courses are aiming for. Primary Health Care Primary health care (PHC) is defined as universally available health care that is based on evidence and provided in a culturally competent manner in collaboration with the communities serviced (McMurray and Clendon, 2011). It is viewed as the most important trend or direction in health care in the literature and by participants. It has been the overarching concept for the current and the proposed curriculum and participants agreed that it was regarded as very relevant to nursing practice. Participants described primary health care as involving: I think that primary health care is something that we as nurses can actually do a lot of, it is not necessarily medical officer based, necessarily, you know the simple things that we can do that advocate for that … you know that nursing is not just hospital based, so there are other options out there for people, not just ordinary things. [Angie] Participants also recognised the changing role of nursing in primary health care. Some acknowledged that as students perhaps they were not aware of it as much as they were now, but they also described an increased role for nurses in this area, which they described as: It is more prevalent now than when I graduated … only the last few years that I really noticed … from memory the focus of primary health
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care was on allied health, maybe community and mental health services, child and family health … but I think that is changing now to more nurse specific roles, popping up out there. You had the district nurses, but now you have a bigger proportion of people out there. [Sarah]
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All participants valued this highly and graduates indicated that it was a significant part of their continuing practice. This theme was very strong and very much valued by all participants as being significant in curriculum development and in nursing overall. Social Justice
Overall, participants agreed that primary health care was an important aspect of their curriculum and relevant to health care in general. They felt that its inclusion was essential for the progression of nursing into future roles and addressing health care needs as they continue to evolve. Clinical Reasoning Clinical reasoning is defined as a process of collating cues, understanding problems, planning interventions, evaluating outcomes and reflection and learning from the process (Levett-Jones and Lapkin, 2013). The development of clinical reasoning is seen as area of strength in the current curriculum, but was not previously articulated as a theme of the conceptual framework. It is highly valued and linked to evidence based practice. It is theme that is proposed to carry into curriculum renewal. Angie described it as:
Social justice is defined as valuing human rights and recognising the dignity of every individual and based on principles of equality (Donnelly, 2013). Participants demonstrated a sound understanding of the importance of equity and access in terms of health care and the roles of nurses in this area. I think nurses could be at the very front line of that and probably are in some respects, especially in rural and regional areas. It's not that there's many nurses out there either but I think that nurses are more sympathetic maybe to that and trying to bridge gaps between service access. Accessing services for us in public hospitals is a central theme, and part of our business plan as surrounding access to services. I think there's a great opening for nurses in the community to be gap fillers, if you like for want of a better word. [Sarah]
For me would be using evidence based practice and our knowledge to put it into our practice and to work out what we are actually going to achieve, what would we do in that situation, how we can best help our patient … definitely a useful theme. [Angie]
This concern for equity and access was not limited to graduated students, but also reflected in the comments of current students. As Toni, a mature age student, pointed out, one of the reasons that this theme was so important was that not all students came into the degree with the same background and understanding, so it was necessary to ensure that everyone understood the concept.
Jane confirmed the usefulness of this theme and the valuable role that she believes clinical reasoning plays in nursing:
I think it's really important because I mean how many 17 or 18 year olds are coming in whose entire understanding of the world is what they've seen over the back fence or what their parents have told them over dinner? I think that I'm across to a small degree over these issues, but I think it's absolutely important, I think that, yeah, it's absolutely fundamentally critical. [Toni]
Being able to use your judgement and justify why you have performed a procedure or why you're going to do something or why you need to do something for a patient using your clinical judgement as reasoning to why you're going to do something. [Jane] Both Angie, now a registered nurse and Jane in her final year of the programme felt that clinical reasoning was important to their careers. They agreed with the findings of the survey that this theme was an important part of the conceptual framework and underpinning themes and should be strengthened in the new curriculum. Person-Centred Care Person-centred care, arising from aged care paradigms, refers to a way of caring that treats each as a unique individual whose behaviour is meaningful. The concept emphasizes appreciating the other's pointof-view and how they may be feeling (White et al., 2008). This is viewed as a top priority to guide practice by Sarah: It's what I was taught that everything is person-centred care, it didn't get lost along my career … it's a top priority … actively re-introduced, not that its ever gone, but actively re-introduced … it's always been important, but now it's starting to make its way into our [health service] structure and business. [Sarah] This focus on person-centred care was reinforced by Angie, who felt that it was a useful component of the curriculum. I think it is relevant because no two individuals are ever the same and the way we deal with people, we don't even realise that we are doing it. You have to treat them as an individual, it's not about what the doctors' want, it's what they want, and it enhances the curriculum. [Angie]
Participants in the focus groups reinforced the results of the survey, indicating that social justice was an important concept within the Bachelor of Nursing. Not only did they recognise the concept of social justice within the curriculum, but they also identified their roles and how they were implementing this concept in the everyday practice. Indigenous Health All participants viewed Indigenous health as an important theme in the conceptual framework. The general term Indigenous health was used to refer to the health needs of Aboriginal and Torres Strait Islander peoples. Participant discussion often mentioned the clinical placement for this subject, which they did not always find relevant to Indigenous health. Most participants felt that this theme was threaded throughout the subjects in the Bachelor of Nursing curriculum and made relevant to rural nursing practice. Indigenous health was described by participants as being very important to their studies: They [Indigenous Health concepts] were threaded throughout the curriculum … especially relevant to practice out here, certainly in our practice out here. [Michelle] As Michelle pointed out Indigenous health concepts were not only considered to be an important part of the curriculum, but were also directly relevant to her current practice now that she had graduated. This relevance was not lost on other participants, who also pointed it out: It is very important; we all know the sad statistics on the health of Aboriginal people in this country and working for the X health service.
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It is, it would be in the top 3 priorities, if not the top priority for our business plan is to close the gap, Indigenous Health. We've got, we have employed a lot of Aboriginal Identified positions within our hospital, educational officers, and liaisons, bridges hopefully to the Aboriginal community. Our new CE is really passionate about the health of our Indigenous people. [Sarah] The university that these participants were recruited from is a regional university with a large rural and remote catchment area. This could have influenced the relevance of Indigenous health to their practice when they graduated, as these students frequently stay in the catchment area after they have completed their courses.
Other Themes Interview participants did not have clear understandings of strengths based nursing, cultural competence or ethical comportment as individual themes. As these were not existing themes within the current curriculum, this was not surprising. They recognised their value, but identified their similarities with other themes within the existing curriculum. Strengths based nursing which encourages nurses to focus on a client's strengths when dealing with their problems and deficits (Gottlieb, 2012), were linked by some participants with PHC and they could see aspects of the theme currently in place in their subjects of chronic care, mental health and care of the older person. As Angie pointed out: The strengths of the individual and using them to their advantage … it's a bit of primary health care, empowering them to take control of their own health care … that's one of the biggest challenges to deal with a lot of different personalities. [Angie] Cultural competence was also not seen to require an individual theme by participants, who felt that it was covered by the theme of Indigenous health. I think to be honest I remember them talking about it because I didn't have the exposure I think back then. I thought, oh this is really relevant and da, da, da but that was all recapped again in our training our mandatory type training and obviously the Area Health has to tick boxes as far as their staffing, their commitment to Indigenous health. So I think it all came back to me when I was talking to them in terms of how they perceive things you say, your actions as does other cultures as well so they spoke about other cultures as well but particularly Indigenous health was a big one. [Frances] Most participants related the ethical comportment to ethics. However several students saw a relationship to professionalism and professional role. As Sarah commented: … professional conduct brings its own challenges, we have all these mandatory components we have to deal with … if you want to be identified as a professional you have to behave like a professional … they are all so focussed on tasks and getting things done. [Sarah] Overall, participants valued a conceptual framework and underpinning themes, other issues emerged that did not directly relate to the conceptual framework but rather the course in general. They are beyond the scope of this paper. Overall the graduates felt that they were as prepared as they could be to enter practice after completing the Bachelor of Nursing course.
Discussion Participants were able to recognise the major themes of the existing Bachelor of Nursing curriculum and had a greater understanding of their application to nursing than was anticipated by the researchers. They valued the idea of a conceptual framework and underpinning themes as an organising structure to ensure that linkages occurred throughout. Overall the majority of participants were aware that Primary Health Care was the basis of the existing curriculum. There was a sound understanding of the philosophy and of the relevance to nursing practice. This focus was based on the acknowledgement of a need to provide a skilled workforce which strengthens and improves how primary health care is provided in order to address current and emerging factors in the health care system (Australian Government Department of Health and Ageing, 2009a,b; World Health Organization, 2008). This framework supports the trends that are emerging in the health sector toward strengthening and expansion of primary health care services as health care is moved from hospitals to the community. Not only did participants value this overarching framework, but they identified the trends in healthcare both theoretically and in their current practice (for graduated participants). In applying this framework the focus for student learning was on families, communities and individuals and on health rather than illness. A strengths based approach is based on the underlying assumption that a community or individual can address its or their own problems, the community or individual knows best and uses an asset model (Lind and Smith, 2008; Gottlieb, 2012). This supports the overall philosophy of Primary Health Care and was a theme that both graduates and students saw as being very relevant to practice and was in their opinion sufficiently linked to primary health care for this theme to be subsumed rather than to gain its place as a stand-alone theme. Another theme which may be considered in future curricula revisions is solutionfocused nursing, which emphasizes change at several levels — client, nursing and society (McAllister, 2007). Several themes were valued by participants to continue to be included in future curricula. Evidence Based Practice was appreciated as the underlying basis for nursing practice. It was recognised as having a strong presence in the curriculum and teaching strategies and its presence is supported by other research on curricula (Brown et al., 2010; Cronje and Moch, 2010; Zhang et al., 2012). Brown et al. (2010) found that attitude toward evidence based practice improved with higher academic level among undergraduate nursing students in America. This may be a bias within the sample in this study as such students may have had more pleasant memories of the course and thus been more likely to respond. Similarly clinical reasoning, person centred care and social justice were recognised by participants as having the same presence and sense of importance in the existing curriculum and participants supported their continued inclusion in the curriculum. Indigenous health was seen to be integrated throughout the subjects in the existing curriculum. It was seen to be very relevant to practice in the rural footprint of the university. Due to the regional demographics, a focus on Indigenous health was seen to be an important part of the curriculum. A subject dedicated to Indigenous health was seen to be a strength of curriculum design in 2008 and was still seen in that light by the participants of this study. Hunt et al. (2015) confirm the need for such a subject and identify improved attitudes among students toward indigenous peoples after its completion. The participants in this study identified cultural competence to be part of learning around Indigenous health and were not seen by the participants as being worthy of becoming a stand-alone theme. The results of this study are limited by it being completed at a single university, at a single point in time and due to limited numbers of participants. The results cannot be generalised broadly, but did indicate a distinct interest and willingness of graduates to have a voice about the conceptual framework of a Bachelor of Nursing course. Some of the changes recommended by the participants have been identified by the BN curriculum development team and implemented
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in the curriculum revision process. One of the most significant features of the interviews was the recognition by graduated students that they had not been aware of the significance of many aspects of the course and underlying conceptual framework until they had been in practice for some time. Conclusion This project confirmed that graduate and students' knowledge of the conceptual framework was at a high level and exceeded initial expectations. Further it affirmed value for the conceptual framework as a significant part of curriculum development. The results confirmed the participants' knowledge of and value of existing and proposed themes and the conceptual framework. All aspects of the conceptual framework of the curriculum were valued by the majority of students. The majority of graduated students indicated that they were well prepared for the workforce. From the survey data evidence based practice, primary health care and clinical reasoning were perceived to be the most important. It is gratifying that evidence based practice and primary health care were the most highly valued themes to emerge from the survey data. Themes which were ranked at lower levels (strengths based nursing, cultural competence and ethical comportment) were often described by interview participants as being incorporated into other themes and already well covered, rather than requiring individual focus. Although previous literature calls for student consultation very little demonstrates that this is in the practice of curriculum development. Further research would be beneficial into how best to support student involvement in curriculum development in the future. Providing more structure for student feedback on curriculum design may ensure that their responses have greater clarity. This study demonstrates the capacity, willingness and interest of students in contributing to this process. The students were attuned with the curriculum and underpinning themes. Involving students in future curriculum development may ensure that their needs are considered and assist in their voices being heard in the development of curricula which better meet their needs. References Adams, J., Shearer, D., 2012. Evaluating an advanced nursing practice course: student perceptions. Nurs. Stand. 26, 35–41. Australian Government Department of Health and Ageing, 2009a. Building a 21st Century Primary Health Care System: A Draft of Australia's First National Primary Health Care Strategy: Commonwealth of Australia. Australian Government Department of Health and Ageing, 2009b. Primary Health Care Reform in Australia: Report to Support Australia's First National Primary Health Care Strategy: Commonwealth of Australia. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical Transformation. Jossey-Bass, United States of America. Brown, C.E., Kim, S.C., Stichler, J.F., Fields, W., 2010. Predictors of knowledge, attitudes, use and future use of evidence-based practice among baccalaureate nursing students at two universities. Nurse Educ. Today 30 (6), 521–527. http://dx.doi.org/10.1016/j. nedt.2009.10.021. Charles Sturt University, 2015. Planning and audit website. Accessed: 14/3/15. http://www.csu.edu.au/division/plandev/. Cooper, C., Carver, N., 2012. Problem based learning in mental health nursing: the students' experience. Int. J. Ment. Health Nurs. 21 (2), 175–183. http://dx.doi.org/ 10.1111/j.1447-0349.2011.00788.x. Cronje, R.J., Moch, S.D., 2010. Part III. Reenvisioning undergraduate nursing students as opinion leaders to diffuse evidence-based practice in clinical settings. J. Prof. Nurs. 26 (1), 23–28. http://dx.doi.org/10.1016/j.profnurs.2009.03.002. D'Antonio, P., Brennan, A., Curley, M., 2013. Judgement, inquiry, engagement, voice: reenvisioning an undergraduate nursing curriculum using a shared decision-making model. J. Prof. Nurs. 29 (6), 407–413. Donnelly, J., 2013. Universal Human Rights in Theory and Practice. Cornell University Press, New York. Gaudet, J., Singh, M.D., Epstein, I., Santa Mina, E., Gula, T., 2014. Learn the game but don't play it: nurses' perspectives on learning and applying statistics in practice. Nurse Educ. Today 34 (7), 1080–1086. http://dx.doi.org/10.1016/j.nedt.2013.05.009. Gottlieb, L.N., 2012. Strengths-Based Nursing Care: Health and Healing for Person and Family. Springer Publishing Company, New York. Hagen, B., Awosoga, O.A., Kellett, P., Damgaard, M., 2013. Fear and loathing: undergraduate nursing students' experiences of a mandatory course in applied statistics. Int. J. Nurs. Educ. Scholarsh. 10 (1), 27–34.
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Identifying student knowledge and perception of what is valuable to professional practice: A mixed method study Judith K. Anderson a,⁎, Lyn Croxon b,1, Denise E. McGarry c,2 a b c
School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Ave., Bathurst, NSW 2795, Australia Undergraduate Program Leader, Bachelor of Nursing School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Tony McGrane Place, Dubbo, NSW 2830, Australia School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Ave., Bathurst, NSW 2795, Australia
a r t i c l e
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Article history: Accepted 14 April 2015 Keywords: Nursing Education Curriculum Students
s u m m a r y Background: Bachelor of Nursing programmes are designed to prepare Registered Nurses for professional practice. The Bachelor of Nursing curriculum under discussion was shaped by the conceptual framework of primary health care philosophy, including themes of social justice, Indigenous health, caring philosophy, and the advancement of the discipline through research, scholarship and application of nursing knowledge and evidence-based practice. Objectives: This study was designed to identify what students and graduates found valuable in a Bachelor of Nursing curriculum conceptual framework and what value they placed on a conceptual framework and underpinning themes. Design: A small study was designed to identify the student perceptions of themes which may be valuable to the new curriculum of the Bachelor of Nursing. A mixed methodology was selected as being appropriate to allow students to indicate the value that previous and completing students placed on each of these items and to explore their perceptions. Settings: The setting for this small study was a regional university in NSW, Australia. Participants: Previous and completing (final year) students were invited to complete the online survey and any who were willing to be interviewed were asked to provide their contact details. Methods: The research was conducted via a questionnaire through Survey Monkey, using a Likert scale and open responses and follow up interviews were conducted with willing participants. Results: A total of 128 responses to the survey were received and ten were interviewed. Overall responses were positive. Students were aware of and valued all aspects of the current and proposed conceptual framework. There were some themes; however which were better understood than others. Conclusions: The majority of graduated students indicated that they were well prepared for the workforce. All aspects of the conceptual framework of the curriculum were valued by the majority of students. © 2015 Elsevier Ltd. All rights reserved.
Introduction When reviewing a curriculum a great deal of discussion takes place about what to include and what can be removed. Many stakeholders have different opinions about the value of some aspects over others and decisions cannot possibly reflect everyone's opinion equally. However, there is a great deal of value in obtaining those opinions. Graduates
are unique in their understanding of current courses and how well it has prepared them for practice. For that reason this study sought their opinions on conceptual frameworks and underpinning themes and their value in structuring a nursing curriculum. Final year students were also involved due to their insight into how well prepared they felt for practice.
Background/Literature ⁎ Corresponding author. Tel.: +61 2 6338 4640; fax: +61 2 6338 4408. E-mail addresses: [email protected] (J.K. Anderson), [email protected] (L. Croxon), [email protected] (D.E. McGarry). 1 Tel.: +61 2 68857325. 2 Tel.: +61 2 6338 4546.
http://dx.doi.org/10.1016/j.nedt.2015.04.007 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
The review of the current Bachelor of Nursing included an appraisal of the underlying conceptual framework which subsequently led to queries about student involvement and interest in a conceptual framework and underpinning themes. Literature related to nursing education
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demonstrates an ongoing interest in and discussion about which conceptual frameworks are most useful to student learning (Benner et al., 2010; D'Antonio et al., 2013; Martyn et al., 2014). In these discussions the ‘voices’ of several groups are heard clearly, including policy makers and lecturers. Student voices, however, are not always so clear. Salyers et al. (2010), describe an evaluation of a pedagogical framework which was used to structure a nursing curriculum and found that both students and academic staff benefit from a framework which reflects the general thinking and learning processes of the discipline. McIntosh et al. (2013, p. 1183) suggest “involving students more deeply in curriculum design, thereby giving them a stake in defining the essential components” of the course. Kumm and Fletcher (2012) in discussing the design of a new bachelor of nursing curriculum do not mention students as stakeholders in the process of designing a new curriculum and although D'Antonio et al. (2013) discuss the value of internal stakeholders (including students) in curriculum design they do not describe students being involved in the undergraduate curriculum renewal process. Naturally most universities survey student satisfaction and perceptions about their courses (Adams and Shearer, 2012). Student feedback has been used to evaluate learning and satisfaction in the clinical environment (Henderson et al., 2012; Loewenson and Hunt, 2011; O'Mara et al., 2014; Papastavrou et al., 2010; Papathanasiou et al., 2014; Roxburgh, 2014; Skaalvik et al., 2011; Sundler et al., 2014) and some literature which relates to preparation for practice examining undergraduate and graduate satisfaction with models of clinical learning and preparation for practice (Hickey, 2010; Milton-Wildey et al., 2014). Other literature relates to evaluation of programmes for nursing students undertaking international experiences (Kulbok et al., 2012), but this does not give them a voice in the conceptual structure of course design. There is also literature around student perception of problem based learning (Cooper and Carver, 2012; Rowan et al., 2009) learning statistics (Hagen et al., 2013) and an increasing focus on simulation (Kelly and Fry, 2013; Reid-Searl et al., 2011) and blended and online learning (Gaudet et al., 2014; Hodges and Cowan, 2012; Lee et al., 2011; Smyth et al., 2012). This literature around nursing education and clinical learning experiences was found across global sources. Methods This study took place at a regional university in New South Wales, Australia. The university has close to 40,000 students in total and approximately 1500 are enrolled in the Bachelor of Nursing. Less than 10% of nursing students come from non-English speaking backgrounds, over 50% are studying part-time and over 50% are mature age students (Charles Sturt University, 2015). A mixed methodology study was implemented to measure the value that previous and completing students placed on different aspects of the current and proposed conceptual framework and underpinning themes and to allow the researchers to explore these results in greater depth. Ethics approval was granted through the School of Nursing, Midwifery and Indigenous Health Human Research Ethics Committee (approval number: 409/2013/04). Links to a survey were emailed to all students who had graduated from the course in the previous 2 years (n = 491) and to current students (n = 256) from a regional university in NSW, Australia. In total the response rate was 23% (n = 111) graduates and 7% (n = 17) current students. The survey used a Likert scale and open responses. Participants who were willing to be interviewed were asked to provide their contact details. A purposive sample of those students who indicated a willingness to be interviewed was then contacted. This sample was representative of age, gender and metropolitan/rural areas. Ten interviews were conducted of approximately 1 hour each, digitally recorded and transcribed verbatim. These were then thematically analysed by a different team member to the interviewer and the themes that emerged were checked by the researcher who conducted the interview. In order to maintain their
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confidentiality, participants were given pseudonyms and although two males were interviewed, they were also given female pseudonyms. Results A total of 128 responses were received, 111 (86.7%) from previous graduates and 17 (13.3%) from current final year students. Most of the respondents were female (91.4%) which is consistent with gender percentages within the course. Respondents represented fairly evenly those between 19–25 years of age (25.6%), 26–35 years of age (27.1%) and 46–55 years of age (32%). The overwhelming majority of graduate participants were working in the health industry and 95.5% in nursing (the survey included double degree graduates, who may have sought work in other areas). On completion of their degree, 61.2% felt that they were prepared and a further 12.6% felt that they were very prepared for practice. Graduate and student participants were asked about the relevance of current and proposed central themes of the curriculum to their current or future practice. Most graduates were positive about the value of these themes as can be seen in Fig. 1, indicating that current and proposed themes of the curriculum framework were applicable to their practice. These responses are all supportive of the proposed curriculum framework and underpinning themes. Students and graduates were asked to indicate their recognition of the presence of the five themes of the conceptual framework of the current curriculum: Evidence-based practice, person-centred care, primary health care, social justice, and Indigenous health. They were then asked whether the proposed additional themes — cultural competence, strengths based nursing, clinical reasoning and ethical comportment — would be valuable additions to the new curriculum. The responses of ‘agree’ or ‘strongly agree’ are summarised in the following chart, showing responses from graduates and students. As can be seen in the chart, all themes were reasonably equally valued. It was gratifying that these participants did recognise the existence of the conceptual framework and underpinning themes in the curriculum and its application for practice. The focus of the interviews with the participants was around the major themes of the conceptual framework of the current Bachelor of Nursing and the proposed themes of the revised Bachelor of Nursing course. An understanding of the themes that were present in the current curriculum was highlighted in the results. An understanding of three of the proposed themes, strengths based nursing, cultural competence and ethical comportment, was less evident. The themes that were discussed were the value of the conceptual framework; evidence based practice, primary health care, clinical reasoning, person centred care; social justice, Indigenous health, strengths based nursing, cultural competence and ethical comportment. Value of Conceptual Framework All participants in interviews identified the conceptual framework and underpinning themes as being very important. It was seen to offer cohesiveness to the curriculum and to instil overall values within it. Participants confirmed the need to have identified frameworks for curricula and were pleased to have been asked for their opinion about them. Participants stated that it was: I think it's absolutely critical, absolutely critical that there is an overarching framework that everyone is working from. [Toni] Whilst recognising its value, participants also suggested how a conceptual framework acts: It helps to guide us, I think, without one in our course, there are some people who would not actually follow the standards that are set and I think that the nursing board having seen this has also helped to guide our subject and objective delivery and to see that we learn what we need to. [Michelle]
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Fig. 1. Relevance of current and proposed themes to practice. *Proposed curriculum themes.
Many participants were insightful about the role of a conceptual framework and underpinning themes and felt privileged to be asked for their opinion about something they regarded as being so important. The insight gained through asking new practitioners about the conceptual framework and underpinning themes which had impacted so much on their preparation for practice was also highlighted. Participants felt that several aspects of the framework were important and these are dealt with according to the level of importance assigned to them by participants. Evidence Based Practice Evidence based practice (EBP) was seen to be integral to the curriculum and nursing practice. This was the aspect of the conceptual framework and underpinning themes most valued by participants. EBP is defined as interdisciplinary approach to health care practice that bases clinical decisions on research studies that meet rigorous criteria when available (Hoffman et al., 2013). It was evident in the current curriculum especially from second year onward, EBP is related to practice and is evident when on clinical practice. All participants clearly understood the concept of evidence based practice. Participants, particularly those who were now in the workforce regarded evidence based practice as essential to their practice as described by Angie: Evidence based practice, I think is used everywhere, all policy is designed around it, so definitely, people need an understanding of, well nursing IS evidence based practice. [Angie] Evidence based practice was valued by all participants, even current students. However, as Michelle pointed out, this was something that she needed to learn about and did not understand upon entry into the course. It is well covered, it is important. I don't think that I have not had an assignment or a presentation that has not required evidence based practice. At first it was challenging, I thought that what I was presenting
was evidence based practice and then I learned about peer review articles and receiving information from .org or .au websites and learning that research is completed and then implemented into hospitals and that then becomes the culture of research based practice … definitely should not be introduced later, it could be brought in earlier, it might have been, but I might not have paid enough attention. [Michelle] Evidence based practice was perceived by participants to be central to their course, assessments and their practice. It was the theme most valued by participants. This reinforces the connection between theory and practice which the majority of nursing courses are aiming for. Primary Health Care Primary health care (PHC) is defined as universally available health care that is based on evidence and provided in a culturally competent manner in collaboration with the communities serviced (McMurray and Clendon, 2011). It is viewed as the most important trend or direction in health care in the literature and by participants. It has been the overarching concept for the current and the proposed curriculum and participants agreed that it was regarded as very relevant to nursing practice. Participants described primary health care as involving: I think that primary health care is something that we as nurses can actually do a lot of, it is not necessarily medical officer based, necessarily, you know the simple things that we can do that advocate for that … you know that nursing is not just hospital based, so there are other options out there for people, not just ordinary things. [Angie] Participants also recognised the changing role of nursing in primary health care. Some acknowledged that as students perhaps they were not aware of it as much as they were now, but they also described an increased role for nurses in this area, which they described as: It is more prevalent now than when I graduated … only the last few years that I really noticed … from memory the focus of primary health
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care was on allied health, maybe community and mental health services, child and family health … but I think that is changing now to more nurse specific roles, popping up out there. You had the district nurses, but now you have a bigger proportion of people out there. [Sarah]
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All participants valued this highly and graduates indicated that it was a significant part of their continuing practice. This theme was very strong and very much valued by all participants as being significant in curriculum development and in nursing overall. Social Justice
Overall, participants agreed that primary health care was an important aspect of their curriculum and relevant to health care in general. They felt that its inclusion was essential for the progression of nursing into future roles and addressing health care needs as they continue to evolve. Clinical Reasoning Clinical reasoning is defined as a process of collating cues, understanding problems, planning interventions, evaluating outcomes and reflection and learning from the process (Levett-Jones and Lapkin, 2013). The development of clinical reasoning is seen as area of strength in the current curriculum, but was not previously articulated as a theme of the conceptual framework. It is highly valued and linked to evidence based practice. It is theme that is proposed to carry into curriculum renewal. Angie described it as:
Social justice is defined as valuing human rights and recognising the dignity of every individual and based on principles of equality (Donnelly, 2013). Participants demonstrated a sound understanding of the importance of equity and access in terms of health care and the roles of nurses in this area. I think nurses could be at the very front line of that and probably are in some respects, especially in rural and regional areas. It's not that there's many nurses out there either but I think that nurses are more sympathetic maybe to that and trying to bridge gaps between service access. Accessing services for us in public hospitals is a central theme, and part of our business plan as surrounding access to services. I think there's a great opening for nurses in the community to be gap fillers, if you like for want of a better word. [Sarah]
For me would be using evidence based practice and our knowledge to put it into our practice and to work out what we are actually going to achieve, what would we do in that situation, how we can best help our patient … definitely a useful theme. [Angie]
This concern for equity and access was not limited to graduated students, but also reflected in the comments of current students. As Toni, a mature age student, pointed out, one of the reasons that this theme was so important was that not all students came into the degree with the same background and understanding, so it was necessary to ensure that everyone understood the concept.
Jane confirmed the usefulness of this theme and the valuable role that she believes clinical reasoning plays in nursing:
I think it's really important because I mean how many 17 or 18 year olds are coming in whose entire understanding of the world is what they've seen over the back fence or what their parents have told them over dinner? I think that I'm across to a small degree over these issues, but I think it's absolutely important, I think that, yeah, it's absolutely fundamentally critical. [Toni]
Being able to use your judgement and justify why you have performed a procedure or why you're going to do something or why you need to do something for a patient using your clinical judgement as reasoning to why you're going to do something. [Jane] Both Angie, now a registered nurse and Jane in her final year of the programme felt that clinical reasoning was important to their careers. They agreed with the findings of the survey that this theme was an important part of the conceptual framework and underpinning themes and should be strengthened in the new curriculum. Person-Centred Care Person-centred care, arising from aged care paradigms, refers to a way of caring that treats each as a unique individual whose behaviour is meaningful. The concept emphasizes appreciating the other's pointof-view and how they may be feeling (White et al., 2008). This is viewed as a top priority to guide practice by Sarah: It's what I was taught that everything is person-centred care, it didn't get lost along my career … it's a top priority … actively re-introduced, not that its ever gone, but actively re-introduced … it's always been important, but now it's starting to make its way into our [health service] structure and business. [Sarah] This focus on person-centred care was reinforced by Angie, who felt that it was a useful component of the curriculum. I think it is relevant because no two individuals are ever the same and the way we deal with people, we don't even realise that we are doing it. You have to treat them as an individual, it's not about what the doctors' want, it's what they want, and it enhances the curriculum. [Angie]
Participants in the focus groups reinforced the results of the survey, indicating that social justice was an important concept within the Bachelor of Nursing. Not only did they recognise the concept of social justice within the curriculum, but they also identified their roles and how they were implementing this concept in the everyday practice. Indigenous Health All participants viewed Indigenous health as an important theme in the conceptual framework. The general term Indigenous health was used to refer to the health needs of Aboriginal and Torres Strait Islander peoples. Participant discussion often mentioned the clinical placement for this subject, which they did not always find relevant to Indigenous health. Most participants felt that this theme was threaded throughout the subjects in the Bachelor of Nursing curriculum and made relevant to rural nursing practice. Indigenous health was described by participants as being very important to their studies: They [Indigenous Health concepts] were threaded throughout the curriculum … especially relevant to practice out here, certainly in our practice out here. [Michelle] As Michelle pointed out Indigenous health concepts were not only considered to be an important part of the curriculum, but were also directly relevant to her current practice now that she had graduated. This relevance was not lost on other participants, who also pointed it out: It is very important; we all know the sad statistics on the health of Aboriginal people in this country and working for the X health service.
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It is, it would be in the top 3 priorities, if not the top priority for our business plan is to close the gap, Indigenous Health. We've got, we have employed a lot of Aboriginal Identified positions within our hospital, educational officers, and liaisons, bridges hopefully to the Aboriginal community. Our new CE is really passionate about the health of our Indigenous people. [Sarah] The university that these participants were recruited from is a regional university with a large rural and remote catchment area. This could have influenced the relevance of Indigenous health to their practice when they graduated, as these students frequently stay in the catchment area after they have completed their courses.
Other Themes Interview participants did not have clear understandings of strengths based nursing, cultural competence or ethical comportment as individual themes. As these were not existing themes within the current curriculum, this was not surprising. They recognised their value, but identified their similarities with other themes within the existing curriculum. Strengths based nursing which encourages nurses to focus on a client's strengths when dealing with their problems and deficits (Gottlieb, 2012), were linked by some participants with PHC and they could see aspects of the theme currently in place in their subjects of chronic care, mental health and care of the older person. As Angie pointed out: The strengths of the individual and using them to their advantage … it's a bit of primary health care, empowering them to take control of their own health care … that's one of the biggest challenges to deal with a lot of different personalities. [Angie] Cultural competence was also not seen to require an individual theme by participants, who felt that it was covered by the theme of Indigenous health. I think to be honest I remember them talking about it because I didn't have the exposure I think back then. I thought, oh this is really relevant and da, da, da but that was all recapped again in our training our mandatory type training and obviously the Area Health has to tick boxes as far as their staffing, their commitment to Indigenous health. So I think it all came back to me when I was talking to them in terms of how they perceive things you say, your actions as does other cultures as well so they spoke about other cultures as well but particularly Indigenous health was a big one. [Frances] Most participants related the ethical comportment to ethics. However several students saw a relationship to professionalism and professional role. As Sarah commented: … professional conduct brings its own challenges, we have all these mandatory components we have to deal with … if you want to be identified as a professional you have to behave like a professional … they are all so focussed on tasks and getting things done. [Sarah] Overall, participants valued a conceptual framework and underpinning themes, other issues emerged that did not directly relate to the conceptual framework but rather the course in general. They are beyond the scope of this paper. Overall the graduates felt that they were as prepared as they could be to enter practice after completing the Bachelor of Nursing course.
Discussion Participants were able to recognise the major themes of the existing Bachelor of Nursing curriculum and had a greater understanding of their application to nursing than was anticipated by the researchers. They valued the idea of a conceptual framework and underpinning themes as an organising structure to ensure that linkages occurred throughout. Overall the majority of participants were aware that Primary Health Care was the basis of the existing curriculum. There was a sound understanding of the philosophy and of the relevance to nursing practice. This focus was based on the acknowledgement of a need to provide a skilled workforce which strengthens and improves how primary health care is provided in order to address current and emerging factors in the health care system (Australian Government Department of Health and Ageing, 2009a,b; World Health Organization, 2008). This framework supports the trends that are emerging in the health sector toward strengthening and expansion of primary health care services as health care is moved from hospitals to the community. Not only did participants value this overarching framework, but they identified the trends in healthcare both theoretically and in their current practice (for graduated participants). In applying this framework the focus for student learning was on families, communities and individuals and on health rather than illness. A strengths based approach is based on the underlying assumption that a community or individual can address its or their own problems, the community or individual knows best and uses an asset model (Lind and Smith, 2008; Gottlieb, 2012). This supports the overall philosophy of Primary Health Care and was a theme that both graduates and students saw as being very relevant to practice and was in their opinion sufficiently linked to primary health care for this theme to be subsumed rather than to gain its place as a stand-alone theme. Another theme which may be considered in future curricula revisions is solutionfocused nursing, which emphasizes change at several levels — client, nursing and society (McAllister, 2007). Several themes were valued by participants to continue to be included in future curricula. Evidence Based Practice was appreciated as the underlying basis for nursing practice. It was recognised as having a strong presence in the curriculum and teaching strategies and its presence is supported by other research on curricula (Brown et al., 2010; Cronje and Moch, 2010; Zhang et al., 2012). Brown et al. (2010) found that attitude toward evidence based practice improved with higher academic level among undergraduate nursing students in America. This may be a bias within the sample in this study as such students may have had more pleasant memories of the course and thus been more likely to respond. Similarly clinical reasoning, person centred care and social justice were recognised by participants as having the same presence and sense of importance in the existing curriculum and participants supported their continued inclusion in the curriculum. Indigenous health was seen to be integrated throughout the subjects in the existing curriculum. It was seen to be very relevant to practice in the rural footprint of the university. Due to the regional demographics, a focus on Indigenous health was seen to be an important part of the curriculum. A subject dedicated to Indigenous health was seen to be a strength of curriculum design in 2008 and was still seen in that light by the participants of this study. Hunt et al. (2015) confirm the need for such a subject and identify improved attitudes among students toward indigenous peoples after its completion. The participants in this study identified cultural competence to be part of learning around Indigenous health and were not seen by the participants as being worthy of becoming a stand-alone theme. The results of this study are limited by it being completed at a single university, at a single point in time and due to limited numbers of participants. The results cannot be generalised broadly, but did indicate a distinct interest and willingness of graduates to have a voice about the conceptual framework of a Bachelor of Nursing course. Some of the changes recommended by the participants have been identified by the BN curriculum development team and implemented
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in the curriculum revision process. One of the most significant features of the interviews was the recognition by graduated students that they had not been aware of the significance of many aspects of the course and underlying conceptual framework until they had been in practice for some time. Conclusion This project confirmed that graduate and students' knowledge of the conceptual framework was at a high level and exceeded initial expectations. Further it affirmed value for the conceptual framework as a significant part of curriculum development. The results confirmed the participants' knowledge of and value of existing and proposed themes and the conceptual framework. All aspects of the conceptual framework of the curriculum were valued by the majority of students. The majority of graduated students indicated that they were well prepared for the workforce. From the survey data evidence based practice, primary health care and clinical reasoning were perceived to be the most important. It is gratifying that evidence based practice and primary health care were the most highly valued themes to emerge from the survey data. Themes which were ranked at lower levels (strengths based nursing, cultural competence and ethical comportment) were often described by interview participants as being incorporated into other themes and already well covered, rather than requiring individual focus. Although previous literature calls for student consultation very little demonstrates that this is in the practice of curriculum development. Further research would be beneficial into how best to support student involvement in curriculum development in the future. Providing more structure for student feedback on curriculum design may ensure that their responses have greater clarity. This study demonstrates the capacity, willingness and interest of students in contributing to this process. The students were attuned with the curriculum and underpinning themes. Involving students in future curriculum development may ensure that their needs are considered and assist in their voices being heard in the development of curricula which better meet their needs. References Adams, J., Shearer, D., 2012. Evaluating an advanced nursing practice course: student perceptions. Nurs. Stand. 26, 35–41. Australian Government Department of Health and Ageing, 2009a. Building a 21st Century Primary Health Care System: A Draft of Australia's First National Primary Health Care Strategy: Commonwealth of Australia. Australian Government Department of Health and Ageing, 2009b. Primary Health Care Reform in Australia: Report to Support Australia's First National Primary Health Care Strategy: Commonwealth of Australia. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical Transformation. Jossey-Bass, United States of America. Brown, C.E., Kim, S.C., Stichler, J.F., Fields, W., 2010. Predictors of knowledge, attitudes, use and future use of evidence-based practice among baccalaureate nursing students at two universities. Nurse Educ. Today 30 (6), 521–527. http://dx.doi.org/10.1016/j. nedt.2009.10.021. Charles Sturt University, 2015. Planning and audit website. Accessed: 14/3/15. http://www.csu.edu.au/division/plandev/. Cooper, C., Carver, N., 2012. Problem based learning in mental health nursing: the students' experience. Int. J. Ment. Health Nurs. 21 (2), 175–183. http://dx.doi.org/ 10.1111/j.1447-0349.2011.00788.x. Cronje, R.J., Moch, S.D., 2010. Part III. Reenvisioning undergraduate nursing students as opinion leaders to diffuse evidence-based practice in clinical settings. J. Prof. Nurs. 26 (1), 23–28. http://dx.doi.org/10.1016/j.profnurs.2009.03.002. D'Antonio, P., Brennan, A., Curley, M., 2013. Judgement, inquiry, engagement, voice: reenvisioning an undergraduate nursing curriculum using a shared decision-making model. J. Prof. Nurs. 29 (6), 407–413. Donnelly, J., 2013. Universal Human Rights in Theory and Practice. Cornell University Press, New York. Gaudet, J., Singh, M.D., Epstein, I., Santa Mina, E., Gula, T., 2014. Learn the game but don't play it: nurses' perspectives on learning and applying statistics in practice. Nurse Educ. Today 34 (7), 1080–1086. http://dx.doi.org/10.1016/j.nedt.2013.05.009. Gottlieb, L.N., 2012. Strengths-Based Nursing Care: Health and Healing for Person and Family. Springer Publishing Company, New York. Hagen, B., Awosoga, O.A., Kellett, P., Damgaard, M., 2013. Fear and loathing: undergraduate nursing students' experiences of a mandatory course in applied statistics. Int. J. Nurs. Educ. Scholarsh. 10 (1), 27–34.
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