Nurse Education in Practice 14 (2014) 220e224
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education in practice
Teaching evidence based practice and research through blended learning to undergraduate midwifery students from a practice based perspective Sidebotham Mary a, *, Jomeen Julie b,1, Gamble Jennifer a, 2 a b
Maternity and Family Unit, Centre for Health Practice Innovation, Griffith University, Queensland, Australia Faculty of Health & Social Care, University of Hull, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 October 2013
The international world of higher education is changing with universities now offering students flexible delivery options that allow them to study away from campus and at a time convenient to them. Some students prefer on line learning while others prefer face to face contact offered through a traditional lecture and tutorial delivery modes. The response by many universities is to offer a blend of both. While online and blended mode of delivery may be suitable for some subjects there is little knowledge of the efficacy of blended learning models to teach evidence based practice and research (EBPR) to undergraduate midwifery students. EBPR is a challenging, threshold level subject upon which deeper knowledge and skills are built. This paper describes the design, delivery, and evaluation of an undergraduate EBPR course delivered in blended mode to first year midwifery students. Components of the blended learning innovation included: novel teaching strategies, engaging practical activities, role play, and e-learning strategies to maintain engagement. University-based course evaluation outcomes revealed very positive scores and the course was rated within the top ten percent of all courses offered within the Health Group at the host University. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Teaching Midwives Research Online
Introduction Increasingly, universities are offering students flexible delivery options allowing them to study online, away from campus, and at a time convenient to them (Tanner, 2011). Evidence across international settings demonstrate that online material supported by podcasts results in greater student engagement and overall knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching (Bhatti et al., 2011; Rabe-Hemp et al., 2009). Students irrespective of background have variable opinions about the efficacy of on line learning with some preferring face to face contact offered through a traditional lecture and tutorial delivery modes (Farley et al., 2011). The response by many universities is to offer a blend of both. While online and blended mode delivery may be suitable for some subjects there is little knowledge of the efficacy of this model to teach
* Corresponding author. Tel.: þ61 (0)7 338 21378; fax: þ61 (0)7 338 21277. E-mail addresses: m.sidebotham@griffith.edu.au (S. Mary), [email protected] (J. Julie), j.gamble@griffith.edu.au (G. Jennifer). 1 Tel.: þ44 (0)1482 464618; fax: þ44 (0)1482 464588. 2 Tel.: þ61 (0)7 33821083; fax: þ61 (0)7 338 21277. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.10.001
evidence based practice and research (EBPR) to undergraduate midwifery students. It is well acknowledged that student nurses and midwives find EBPR a challenging subject (Newton et al., 2010; Peckover and Winterburn, 2003). Whilst there is a paucity of literature on teaching this subject to student midwives it can be assumed that issues are similar. EBPR is a threshold level subject upon which deeper knowledge and skills are built to enable midwives to enter the workforce as critical thinkers and reflective practitioners. The disconnect between research active staff and the teaching of undergraduate students that is currently evident in some universities has been cited as problematic, with many students taught by lecturers who are not currently engaged in research, or employed in teaching intensive roles (Strickland et al., 2012). Another challenge includes the lack of engagement with research by clinical staff (Forsman et al., 2009). Student midwives spend up to 50% of their program hours within the clinical environment where program based learning should be embedded through interaction and engagement with clinicians. This interaction across education and practice can be facilitated by the use of e-learning technology which enables the student to be situated in the practice environment, but access learning materials at a time convenient to them (Stewart et al., 2012). The use of e technology also enables research
S. Mary et al. / Nurse Education in Practice 14 (2014) 220e224
active staff to be more readily involved in student teaching. This paper describes the design, delivery and evaluation of an undergraduate evidence based practice and research blended learning course undertaken by students in the first year of their Bachelor of Midwifery program. The paper proposes the benefits of a blended learning environment, but also highlights a number of other important ingredients as seemingly necessary to underpin successful delivery and positive student evaluation. Designing the program The course ‘Research, Evidence and Clinical Practice’ was developed for delivery within a blended learning environment. In designing the course the belief was that the approach to teaching evidence based practice and research (EBPR) within the midwifery programme should be laid down early in the programme and then interwoven and built upon throughout the programme. An understanding of EBPR is important to facilitate the provision of evidence based care (McCurry and Martins, 2010). Hence, the essential requisites of the course were that it would engage students, enabling them to develop an appreciation of the value of evidence based practice/care; to cultivate research knowledge and skills but to stimulate and nurture an interest in and an appreciation of EBPR, which would become embedded in their practice and continue past the point of registration. The underpinning philosophy of the course was that good research emerges from and feeds back into practice, therefore practice experience should be the leading aspect. The course material was developed by the UK author (JJ) in partnership with the Australian course convenor (MS). There is debate about the best time to introduce EBPR within curricula. Ax and Kincaid (2001) found that students disagreed with research methods being taught early in the programme. However, the belief here was that this course should provide a firm foundation for students to consider research and evidence as the foundation of good clinical practice and the development of critical thinking skills. As a consequence, the decision was made to deliver this course to undergraduate midwives in year one, semester two. This enables students to develop a practice focused approach to research early in their programme, critique and reflect on programme content and understand the evolutionary nature of clinical practice. Incorporation of a clinical focus in research has the potential to invigorate nursing students (Rash, 2005) and promote a fuller appreciation of the connection between research and practice (August-Brady, 2005). Students need to consider research skills and knowledge as a tool to be used in order to successfully complete their degree and then guide them through their careers as reflective evidence based practitioners. The design of the course aimed to take the students on journey, beginning the discovery of how generating evidence changes practice and why practitioners resist changes in practice. The programme then addresses all the traditional aspects of research courses but with their own e and others e practice experiences as a constant reference point. This encourages autonomous intrinsic learning by placing the emphasis on the student to distinguish and develop their own areas of research interest. This provides an opportunity for experiential situational learning, which is known to be more effective than surface based learning (Pugsley and Clayton, 2003; Clark et al., 2009), where facts may be retained but students are unable to relate them with meaning and context. This approach is further reinforced by the use of ‘real world’ assessment items. Another key aspect of the curriculum design for this course was the explicit use of the research experiences of lecturers and ‘home grown’ resources such as articles written by faculty or other academics likely to be well known to students, enabling students to contextualise their learning within the course. Adults learn best
221
when the topic is perceived as being of value (Ramsden, 2003), therefore the presentation of research as a theory based topic with no relevance to the clinical context does not encourage a deep approach to learning (Johnson et al., 2010). The approach taken here aimed to make the content of the module meaningful to students, promote deep learning, and through a reflective framework create an overt relationship between theory and practice. The course structure consisted of seven modules
Evidence based practice Research theory and design Reviewing and critiquing the literature Quantitative research design and methods Qualitative methodologies and methods Ethics From evidence to practice: from practice to evidence
Assessment design The goal of assessment is to foster independent learning and equip students with the skills to situate their learning in the ‘real world’ of practice. The aim was to produce assessment items that used a variety of approaches to assess learning and incorporated the different learning styles used by students. Learning objectives were clearly related to assessment items so students could see the purposeful link of both to their degree (Biggs and Tang, 2007). These strategies not only promote deep learning and understanding around a subject, but also reduce student attrition (Fry et al., 2003; Kiguwa and Silva, 2007; Lizzio, 2011; Norton, 2009; Ramsden, 2003; Sadler, 2009; Stefani, 2009). The assignments within this course were overtly linked to the purpose of the degree and provided early engagement with work-integrated learning, all strategies known to promote success (Lizzio, 2011). The assessment items within the course aimed to build, refine and consolidate skills consistently maintaining a real world focus. Program delivery In line with “blended mode” delivery, students attended two workshop days on campus at the beginning of the semester where they were introduced to the core themes and topics of the course. The aim of the workshops was to motivate and engage students and develop a passion for the subject. This was achieved through the use of a blend of practical activities, role play and engagement with research active faculty. Practical activities One example of this approach was an activity where students worked in groups and looked through an age span of midwifery text books to identify changes that had occurred in practice over the years. The lecturer then introduced the students to key research studies that had prompted the changes they identified. An example would be sleeping position for babies changing in relation to reducing the risk of Sudden Infant Death. In order to contextualise the changes the author (MS) shared with students her personal involvement as a researcher in the Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) cohort studies that led to this change in practice (National Advisory Board, 1996). Students then discussed why changes may be resisted by practitioners who learnt their facts around practice from the older text books. This activity not only encouraged reflection on practice but contextualised the resistance to change they see in practice. Many students shared their own experiences of advice they were given by
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S. Mary et al. / Nurse Education in Practice 14 (2014) 220e224
health care practitioners and family members about the correct sleeping position for their baby. The benefits of using this approach of illustrative storytelling based on faculty and student experience were described as “increased cognitive learning, enhanced role transition, and emotional clarification” by Hunter and Hunter (2006, p273). The link between storytelling, reflection and deep learning is also described by (McDrury and Alterio, 2002). The sharing of previous and current experiences from the professional lives of faculty encourages deeper levels of learning within the student groups by providing them with vicarious experience of relevance (Hodgson, 1997), then actively encourages students to apply the knowledge to practice and construct their own experiences (Fry et al., 2003). These concepts are reflected in the qualitative comments within the end of semester student evaluations for the course: “Mary was good at fleshing out the content and bringing sometimes complex and potentially tedious theory into more tangible real life context which I found helpful and effectively connected theory and practice”. Role play Another activity involved students taking roles within a mock human research ethics committee where they assessed ‘unethical “research applications based on rejected “real cases” assessed previously by members of the academic team who held positions on similar committees. This enabled students to interject humour within the role play but understand the relevance and importance of the key principles of ethics as related to ‘real world” situations.
students with the skills needed to frame their question for assessment item two. Assessment two Writing a research proposal. Students identified an area of practice that interested them, generated a research question, refined the question and identified the best research approach to answering the question. Students were introduced to the concept of assessment item two during the intensive teaching period at the beginning of the semester. Prior to engagement with the modular content students were introduced to a research panel made up of faculty members and doctoral scholars who delivered a short history of their personal research journey describing how they became interested in their particular research area, and how they moved from an idea to a research project that made a difference to practice. Examples heard by students include Professor Jennifer Fenwick talking about her perception from practice that Australian women experienced high levels of fear in childbirth through to her current research project examining whether a counselling intervention can reduce levels of childbirth fear. Students reported feeling motivated by hearing “real life” stories of research that they could identify with and feel enthused and excited about the possibility of discovering and developing their own area of interest. Students were encouraged to discuss their ideas with their practice based preceptors, which diffuses knowledge and enthusiasm and supports the growth of research awareness in the workplace. This promotes experiential situational learning which is known to be more effective than surface based learning where facts may be retained but students are unable to relate them with meaning and context.
E-learning component Evaluation Once the intensive workshops were completed students undertook the interactive modules loaded on the learning platform Blackboard 8 (Blackboard, 2012). Students accessed readings, podcasts, and contributed to discussions boards as they worked their way through the modular content. Engagement with the lecturer and each other was maintained through the use of course announcements and bi weekly on line classroom sessions delivered via the WIMBA classroom platform (WIMBA, 2012). The classroom sessions focussed on discussion around assessment items and enabled the students to share ideas and follow exemplar papers for critique with the lecturer. They also engaged in discussion and debate around their own emerging research questions. All classroom sessions were archived to enable students to access the content at a time convenient to them. Assessment Assessment one Critique of a qualitative and quantitative research paper. Papers written by members of faculty were included for selection by students to review. This assessment provided students with skills to effectively critique the literature. This is vital if we are to move students from a position of mere description to that of informed critical thinker. Students used a template to deconstruct and critique two papers from a choice of four. They completed the task following the online modules and group completion of exemplar papers facilitated through WIMBA classroom sessions. This engaged students in debate, and tested their understanding of the module content. The use of exemplar papers established the standard of work expected, enabling students to have a better understanding of what is required of them, a factor known to increase student success and satisfaction (Sadler, 2002). The structured critique of contemporary papers builds confidence and provides
Students traditionally expect to find research to be a difficult subject and this was confirmed when we surveyed student expectations prior to commencing the course in 2011. Thirty nine (75%) students completed the survey and only 38% were looking forward to undertaking the course, additionally 33% of students reported being anxious that they would fail the course. Despite these pre course fears, the end of semester student evaluations were extremely positive. At the host University students are encouraged to complete an on line course evaluation at the end of each semester for each course. They have the opportunity to rate their response to standard questions using a likert scale with responses ranging from 1 ¼ strongly disagree [SD] to 5 ¼ strongly agree [SA]. Additionally they have the opportunity to add qualitative comments. Course evaluation was completed online by 30 students (58%). Students were very positive in their evaluation of the course which in that year was rated within the top ten percent of all courses offered within the Health Group at the host University (see Table 1). Students commented that the course gave them a good overview of the subject and provided them with the skills to build on their knowledge and apply it in practice. “It gave me a good overview of a subject that I would have otherwise avoided. I learned useful skills that I will use as a student as well as a practising midwife”. Students enjoyed participating in the assessment items and found them to be useful in situating the subject into the world of practice, ‘this course showed me why research is so important in the medical field. It also showed what goes into getting a research project off the ground and what is involved”. Students also demonstrated their ongoing commitment to developing their research awareness skills by becoming engaged in current research projects within the school where they are
S. Mary et al. / Nurse Education in Practice 14 (2014) 220e224 Table 1 Student evaluation of course. Question
Scale
%
Question
Scale
%
This course was well-organised.
SA A N D SD
51.7% 37.9% 10.3% 0% 0%
SA A N D SD
65.5% 27.6% 3.4% 3.4% 0%
The assessment was clear and fair.
SA A N D SD SA A N D SD SA A N D SD
72.4% 17.2% 10.3% 0% 0% 72.4% 17.2% 10.3% 0% 0% 55.2% 34.5% 6.9% 3.4% 0%
The teaching (lecturers, tutors, online etc) on this course was effective in helping me to learn. Overall I am satisfied with the quality of this course.
SA A N D SD SA A N D SD EX VG G A P
51.7% 41.4% 3.4% 3.4% 0% 41.4% 44.8% 10.3% 3.4% 0% 31% 37.9% 24.1% 3.4% 3.4%
I received helpful feedback on my assessment work.
This course provided feedback on my work that I could learn from during the course.
This course engaged me in learning.
Overall, how effective was this course in helping you to learn?
employed as research assistants. Three students have since gone on to work as research assistants within the school and presented their journey from research novice to research groupie following engagement with the course at the recent Australian College of Midwives National Student Midwife Conference (Force et al., 2012). Conclusion Evidence highlights that students traditionally find EBPR courses challenging and fail to engage effectively. This can have a number of negative consequences beyond academic outcome, including a failure to appreciate the necessity to practise within an evidence based framework to assure safe, high quality care and fulfil the legal and professional obligations of a midwife. The positive student evaluations and outcomes of this course demonstrate that it is possible to effectively engage students in research courses when the right ingredients are combined. The tangible and lucid link to practice throughout this course is clearly a key element in its success. The ability to make research relevant and ‘real’ to students underpins both a recognition and understanding of its value but also an enthusiasm in some for becoming actively involved in research. An outcome which can only be beneficial for the future development of midwifery practise and the growth of a clinical research culture. The mode of delivery through a blended approach in this course enabled students to develop a relationship with the lecturer and their peers within the intensive teaching workshops and retain their practice focus without any perceived sense of disengagement. The evaluation comments confirmed that students felt supported and there was clear acknowledgement of ‘the presence’ of the lecturer throughout the course, which underpinned both effective learning and seemingly high levels of satisfaction. As universities internationally move away from the traditional lecture/tutorial model this paper provides both evidence and reassurance that a blended learning model can provide good results in a threshold knowledge subject. This opens numerous possibilities for course development and delivery for the future within an internationalised context. Students no longer need to be located at their university of choice and cohorts can become much more demographically and geographically diverse. This also presents opportunities and possibilities for collaborative teaching which brings together international lecturers and experts in the field and
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allows students to link with and benefit from experiences of their peers on a global scale. The belief that research courses should not be delivered early in the curriculum is not supported by the early experience of running this course. High levels of satisfaction and overall student success appears to validate the decision to introduce this subject early on. The qualitative comments confirm that students recognise the value of the course and where it ‘fits in’ in relation to ongoing theory and practice requirements as well as current and future practice as a midwife. This ongoing commitment to EBPR will be measured in a follow up study of the original graduates from this course to measure application of research principles in practice. References August-Brady, M., 2005. Teaching undergraduate research from a process perspective. J. Nurs. Educ. 40 (4), 174e180. Ax, S., Kincaid, E., 2001. Nursing students’ perceptions of research: usefulness, implementation and training. J. Adv. Nurs. 35 (2), 161e170. Bhatti, I., Jones, K., Richardson, L., Foreman, D., Lund, J., Tierney, G., 2011. E-learning vs lecture: which is the best approach to surgical teaching? Colorectal Dis. 13 (4), 459e462 http://dx.doi.org/10.1111/j.1463-1318.2009.02173.x. Biggs, J., Tang, C., 2007. Teaching for Quality Learning at University, third ed. Open University Press, Maidenhead. Blackboard, 2012. Blackboard for Higher Education. Retrieved November 18th 2012, from: http://www.blackboard.com/Markets/Higher-Education-%281%29/Overview. aspx. Clark, K., Stanforth, D., Humphries, M.P., 2009. Teaching undergraduate nursing research: a collaborative approach. Nurse Educ. 34 (1), 9e11. http://dx.doi.org/ 10.1097/01.NNE.0000343392.96200.9b. Farley, A., Jain, A., Thomson, D., 2011. Blended learning in finance: comparing student perceptions of lectures, tutorials and online learning environments across different year levels. Econ. Pap. 30 (1), 99e108. http://dx.doi.org/10.1111/j.17593441.2010.00094.x. Force, R., Glasgow, A., Pattie, K., 2012. The dreaded “R” word.... or is it? Our journey as student midwives into the world of research via the BELIEF study. In: Paper Presented at the Australian College of Midwives Queensland National Student Midwife Conference, Gold Coast Queensland. Forsman, H., Gustavsson, P., Ehrenberg, A., Rudman, A., Wallin, L., 2009. Research use in clinical practice e extent and patterns among nurses one and three years postgraduation. J. Adv. Nurs. 65 (6), 1195e1206. Fry, H., Ketteridge, S., Marshall, S., 2003. Understanding Student Learning, second ed. Kogan Page, London. Hodgson, V., 1997. Lectures and the Experience of Relevance: the Expereience of Learning: Implications for Teaching and Studying in Higher Education. Scottish Academic Press,, Edinburgh. Hunter, L.P., Hunter, L.A., 2006. Storytelling as an educational strategy for midwifery students. J. Midwifery Womens Health 51 (4), 273e278 doi:1016/ j.jmwh.2005.12.004. Johnson, N., List-Ivankovic, J., Eboh, W.O., Ireland, J., Adams, D., Mowatt, E., Martindale, S., 2010. Research and evidence based practice: using a blended approach to teaching and learning in undergraduate nurse education. Nurse Educ. Pract. 10 (1), 43e47. Kiguwa, P., Silva, A., 2007. Teaching and learning: addressing the gap through learning styles. South Afr. J. Psychol. 37 (2), 354e360. Lizzio, A., 2011. Succeeding@ Griffith: Next Generation Partnerships across the Student Lifecycle. Griffith University, Queensland, Australia. McCurry, M.K., Martins, D.C., 2010. Teaching undergraduate nursing research: a comparison of traditional and innovative approaches for success with millennial learners. J. Nurs. Educ. 49 (5), 276e279. http://dx.doi.org/10.3928/ 01484834-20091217-02. McDrury, J., Alterio, M., 2002. Learning Through Storytelling in Higher Education: Using Reflection & Experience to Improve Learning. Dunmore Press Ltd., London. National Advisory Board, 1996. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI), 3rd Annual Report. Department of Health, London. Newton, J., McKenna, L., Gilmour, C., Fawcett, J., 2010. Exploring a pedagogical approach to integrating research, practice and teaching. Int. J. Nurs. Educ. Scholarsh. 7 (1), 1e13. Norton, L., 2009. Assessing student learning. In: Fry, H., Ketteridge, S., Marshall, L. (Eds.), A Handbook for Teaching and Learning in Higher Education, third ed. Routledge, New York, pp. 132e149. Peckover, S., Winterburn, S., 2003. Teaching research to undergraduate community nursing students: reflections upon curriculum design. Nurse Educ. Pract. 3 (2), 104e111. Pugsley, K.E., Clayton, L.E., 2003. Traditional lecture or experiential learning: changing student attitudes: 1. J. Nurs. Educ. 42 (11), 520e524. Rabe-Hemp, C., Woollen, S., Humiston, G.S., 2009. A comparative analysis of student engagement, learning, and satisfaction in lecture hall and online learning settings. Q. Rev. Distance . 10 (2), 207e218, 250e252.
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Rash, E., 2005. A service learning research methods course. J. Nurs. Educ. 44 (10), 477e481. Ramsden, P., 2003. What Students Learn. LEarning to Teach in Higher Education, second ed. Roultedge Falmer, London. Sadler, D.R., 2002. Ah so thats quality. In: Schwartz, P., Webb, G. (Eds.), Case Studies of Teaching in Higher Education. Kogan Page, London, pp. 133e135. Sadler, R.D., 2009. Grade integrity and the representation of academic achievement. Stud. Higher Educ. 34 (7), 807e826. doi.org/10.1080/03075070802706553. Stefani, L., 2009. Planning teaching and learning: curriculum design and development. In: Fry, H., Ketteridge, S., Marshall, S. (Eds.), A Handbook for Teaching and Learning in Higher Education. Routledge, New York, pp. 40e57.
Stewart, S., Sidebotham, M., Davis, D., 2012. The virtual international day of the midwife: social networking for continuing professional development. Nurse Educ. Pract. 12 (5), 248e252. Strickland, K., Gray, C., Hill, G., 2012. The use of podcasts to enhance research-teaching linkages in undergraduate nursing students. Nurse Educ.Pract. 12 (4), 210e214. Tanner, L., 2011. Universities must adapt or die in the e-learning world. The Australian. WIMBA, 2012. Wimba Classroom for Higher Education. Retrieved November 18 2012, from: http://www.wimba.com/solutions/higher/education/wimba_ classroom_for_higher_education/.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education in practice
Teaching evidence based practice and research through blended learning to undergraduate midwifery students from a practice based perspective Sidebotham Mary a, *, Jomeen Julie b,1, Gamble Jennifer a, 2 a b
Maternity and Family Unit, Centre for Health Practice Innovation, Griffith University, Queensland, Australia Faculty of Health & Social Care, University of Hull, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 October 2013
The international world of higher education is changing with universities now offering students flexible delivery options that allow them to study away from campus and at a time convenient to them. Some students prefer on line learning while others prefer face to face contact offered through a traditional lecture and tutorial delivery modes. The response by many universities is to offer a blend of both. While online and blended mode of delivery may be suitable for some subjects there is little knowledge of the efficacy of blended learning models to teach evidence based practice and research (EBPR) to undergraduate midwifery students. EBPR is a challenging, threshold level subject upon which deeper knowledge and skills are built. This paper describes the design, delivery, and evaluation of an undergraduate EBPR course delivered in blended mode to first year midwifery students. Components of the blended learning innovation included: novel teaching strategies, engaging practical activities, role play, and e-learning strategies to maintain engagement. University-based course evaluation outcomes revealed very positive scores and the course was rated within the top ten percent of all courses offered within the Health Group at the host University. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Teaching Midwives Research Online
Introduction Increasingly, universities are offering students flexible delivery options allowing them to study online, away from campus, and at a time convenient to them (Tanner, 2011). Evidence across international settings demonstrate that online material supported by podcasts results in greater student engagement and overall knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching (Bhatti et al., 2011; Rabe-Hemp et al., 2009). Students irrespective of background have variable opinions about the efficacy of on line learning with some preferring face to face contact offered through a traditional lecture and tutorial delivery modes (Farley et al., 2011). The response by many universities is to offer a blend of both. While online and blended mode delivery may be suitable for some subjects there is little knowledge of the efficacy of this model to teach
* Corresponding author. Tel.: þ61 (0)7 338 21378; fax: þ61 (0)7 338 21277. E-mail addresses: m.sidebotham@griffith.edu.au (S. Mary), [email protected] (J. Julie), j.gamble@griffith.edu.au (G. Jennifer). 1 Tel.: þ44 (0)1482 464618; fax: þ44 (0)1482 464588. 2 Tel.: þ61 (0)7 33821083; fax: þ61 (0)7 338 21277. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.10.001
evidence based practice and research (EBPR) to undergraduate midwifery students. It is well acknowledged that student nurses and midwives find EBPR a challenging subject (Newton et al., 2010; Peckover and Winterburn, 2003). Whilst there is a paucity of literature on teaching this subject to student midwives it can be assumed that issues are similar. EBPR is a threshold level subject upon which deeper knowledge and skills are built to enable midwives to enter the workforce as critical thinkers and reflective practitioners. The disconnect between research active staff and the teaching of undergraduate students that is currently evident in some universities has been cited as problematic, with many students taught by lecturers who are not currently engaged in research, or employed in teaching intensive roles (Strickland et al., 2012). Another challenge includes the lack of engagement with research by clinical staff (Forsman et al., 2009). Student midwives spend up to 50% of their program hours within the clinical environment where program based learning should be embedded through interaction and engagement with clinicians. This interaction across education and practice can be facilitated by the use of e-learning technology which enables the student to be situated in the practice environment, but access learning materials at a time convenient to them (Stewart et al., 2012). The use of e technology also enables research
S. Mary et al. / Nurse Education in Practice 14 (2014) 220e224
active staff to be more readily involved in student teaching. This paper describes the design, delivery and evaluation of an undergraduate evidence based practice and research blended learning course undertaken by students in the first year of their Bachelor of Midwifery program. The paper proposes the benefits of a blended learning environment, but also highlights a number of other important ingredients as seemingly necessary to underpin successful delivery and positive student evaluation. Designing the program The course ‘Research, Evidence and Clinical Practice’ was developed for delivery within a blended learning environment. In designing the course the belief was that the approach to teaching evidence based practice and research (EBPR) within the midwifery programme should be laid down early in the programme and then interwoven and built upon throughout the programme. An understanding of EBPR is important to facilitate the provision of evidence based care (McCurry and Martins, 2010). Hence, the essential requisites of the course were that it would engage students, enabling them to develop an appreciation of the value of evidence based practice/care; to cultivate research knowledge and skills but to stimulate and nurture an interest in and an appreciation of EBPR, which would become embedded in their practice and continue past the point of registration. The underpinning philosophy of the course was that good research emerges from and feeds back into practice, therefore practice experience should be the leading aspect. The course material was developed by the UK author (JJ) in partnership with the Australian course convenor (MS). There is debate about the best time to introduce EBPR within curricula. Ax and Kincaid (2001) found that students disagreed with research methods being taught early in the programme. However, the belief here was that this course should provide a firm foundation for students to consider research and evidence as the foundation of good clinical practice and the development of critical thinking skills. As a consequence, the decision was made to deliver this course to undergraduate midwives in year one, semester two. This enables students to develop a practice focused approach to research early in their programme, critique and reflect on programme content and understand the evolutionary nature of clinical practice. Incorporation of a clinical focus in research has the potential to invigorate nursing students (Rash, 2005) and promote a fuller appreciation of the connection between research and practice (August-Brady, 2005). Students need to consider research skills and knowledge as a tool to be used in order to successfully complete their degree and then guide them through their careers as reflective evidence based practitioners. The design of the course aimed to take the students on journey, beginning the discovery of how generating evidence changes practice and why practitioners resist changes in practice. The programme then addresses all the traditional aspects of research courses but with their own e and others e practice experiences as a constant reference point. This encourages autonomous intrinsic learning by placing the emphasis on the student to distinguish and develop their own areas of research interest. This provides an opportunity for experiential situational learning, which is known to be more effective than surface based learning (Pugsley and Clayton, 2003; Clark et al., 2009), where facts may be retained but students are unable to relate them with meaning and context. This approach is further reinforced by the use of ‘real world’ assessment items. Another key aspect of the curriculum design for this course was the explicit use of the research experiences of lecturers and ‘home grown’ resources such as articles written by faculty or other academics likely to be well known to students, enabling students to contextualise their learning within the course. Adults learn best
221
when the topic is perceived as being of value (Ramsden, 2003), therefore the presentation of research as a theory based topic with no relevance to the clinical context does not encourage a deep approach to learning (Johnson et al., 2010). The approach taken here aimed to make the content of the module meaningful to students, promote deep learning, and through a reflective framework create an overt relationship between theory and practice. The course structure consisted of seven modules
Evidence based practice Research theory and design Reviewing and critiquing the literature Quantitative research design and methods Qualitative methodologies and methods Ethics From evidence to practice: from practice to evidence
Assessment design The goal of assessment is to foster independent learning and equip students with the skills to situate their learning in the ‘real world’ of practice. The aim was to produce assessment items that used a variety of approaches to assess learning and incorporated the different learning styles used by students. Learning objectives were clearly related to assessment items so students could see the purposeful link of both to their degree (Biggs and Tang, 2007). These strategies not only promote deep learning and understanding around a subject, but also reduce student attrition (Fry et al., 2003; Kiguwa and Silva, 2007; Lizzio, 2011; Norton, 2009; Ramsden, 2003; Sadler, 2009; Stefani, 2009). The assignments within this course were overtly linked to the purpose of the degree and provided early engagement with work-integrated learning, all strategies known to promote success (Lizzio, 2011). The assessment items within the course aimed to build, refine and consolidate skills consistently maintaining a real world focus. Program delivery In line with “blended mode” delivery, students attended two workshop days on campus at the beginning of the semester where they were introduced to the core themes and topics of the course. The aim of the workshops was to motivate and engage students and develop a passion for the subject. This was achieved through the use of a blend of practical activities, role play and engagement with research active faculty. Practical activities One example of this approach was an activity where students worked in groups and looked through an age span of midwifery text books to identify changes that had occurred in practice over the years. The lecturer then introduced the students to key research studies that had prompted the changes they identified. An example would be sleeping position for babies changing in relation to reducing the risk of Sudden Infant Death. In order to contextualise the changes the author (MS) shared with students her personal involvement as a researcher in the Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) cohort studies that led to this change in practice (National Advisory Board, 1996). Students then discussed why changes may be resisted by practitioners who learnt their facts around practice from the older text books. This activity not only encouraged reflection on practice but contextualised the resistance to change they see in practice. Many students shared their own experiences of advice they were given by
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health care practitioners and family members about the correct sleeping position for their baby. The benefits of using this approach of illustrative storytelling based on faculty and student experience were described as “increased cognitive learning, enhanced role transition, and emotional clarification” by Hunter and Hunter (2006, p273). The link between storytelling, reflection and deep learning is also described by (McDrury and Alterio, 2002). The sharing of previous and current experiences from the professional lives of faculty encourages deeper levels of learning within the student groups by providing them with vicarious experience of relevance (Hodgson, 1997), then actively encourages students to apply the knowledge to practice and construct their own experiences (Fry et al., 2003). These concepts are reflected in the qualitative comments within the end of semester student evaluations for the course: “Mary was good at fleshing out the content and bringing sometimes complex and potentially tedious theory into more tangible real life context which I found helpful and effectively connected theory and practice”. Role play Another activity involved students taking roles within a mock human research ethics committee where they assessed ‘unethical “research applications based on rejected “real cases” assessed previously by members of the academic team who held positions on similar committees. This enabled students to interject humour within the role play but understand the relevance and importance of the key principles of ethics as related to ‘real world” situations.
students with the skills needed to frame their question for assessment item two. Assessment two Writing a research proposal. Students identified an area of practice that interested them, generated a research question, refined the question and identified the best research approach to answering the question. Students were introduced to the concept of assessment item two during the intensive teaching period at the beginning of the semester. Prior to engagement with the modular content students were introduced to a research panel made up of faculty members and doctoral scholars who delivered a short history of their personal research journey describing how they became interested in their particular research area, and how they moved from an idea to a research project that made a difference to practice. Examples heard by students include Professor Jennifer Fenwick talking about her perception from practice that Australian women experienced high levels of fear in childbirth through to her current research project examining whether a counselling intervention can reduce levels of childbirth fear. Students reported feeling motivated by hearing “real life” stories of research that they could identify with and feel enthused and excited about the possibility of discovering and developing their own area of interest. Students were encouraged to discuss their ideas with their practice based preceptors, which diffuses knowledge and enthusiasm and supports the growth of research awareness in the workplace. This promotes experiential situational learning which is known to be more effective than surface based learning where facts may be retained but students are unable to relate them with meaning and context.
E-learning component Evaluation Once the intensive workshops were completed students undertook the interactive modules loaded on the learning platform Blackboard 8 (Blackboard, 2012). Students accessed readings, podcasts, and contributed to discussions boards as they worked their way through the modular content. Engagement with the lecturer and each other was maintained through the use of course announcements and bi weekly on line classroom sessions delivered via the WIMBA classroom platform (WIMBA, 2012). The classroom sessions focussed on discussion around assessment items and enabled the students to share ideas and follow exemplar papers for critique with the lecturer. They also engaged in discussion and debate around their own emerging research questions. All classroom sessions were archived to enable students to access the content at a time convenient to them. Assessment Assessment one Critique of a qualitative and quantitative research paper. Papers written by members of faculty were included for selection by students to review. This assessment provided students with skills to effectively critique the literature. This is vital if we are to move students from a position of mere description to that of informed critical thinker. Students used a template to deconstruct and critique two papers from a choice of four. They completed the task following the online modules and group completion of exemplar papers facilitated through WIMBA classroom sessions. This engaged students in debate, and tested their understanding of the module content. The use of exemplar papers established the standard of work expected, enabling students to have a better understanding of what is required of them, a factor known to increase student success and satisfaction (Sadler, 2002). The structured critique of contemporary papers builds confidence and provides
Students traditionally expect to find research to be a difficult subject and this was confirmed when we surveyed student expectations prior to commencing the course in 2011. Thirty nine (75%) students completed the survey and only 38% were looking forward to undertaking the course, additionally 33% of students reported being anxious that they would fail the course. Despite these pre course fears, the end of semester student evaluations were extremely positive. At the host University students are encouraged to complete an on line course evaluation at the end of each semester for each course. They have the opportunity to rate their response to standard questions using a likert scale with responses ranging from 1 ¼ strongly disagree [SD] to 5 ¼ strongly agree [SA]. Additionally they have the opportunity to add qualitative comments. Course evaluation was completed online by 30 students (58%). Students were very positive in their evaluation of the course which in that year was rated within the top ten percent of all courses offered within the Health Group at the host University (see Table 1). Students commented that the course gave them a good overview of the subject and provided them with the skills to build on their knowledge and apply it in practice. “It gave me a good overview of a subject that I would have otherwise avoided. I learned useful skills that I will use as a student as well as a practising midwife”. Students enjoyed participating in the assessment items and found them to be useful in situating the subject into the world of practice, ‘this course showed me why research is so important in the medical field. It also showed what goes into getting a research project off the ground and what is involved”. Students also demonstrated their ongoing commitment to developing their research awareness skills by becoming engaged in current research projects within the school where they are
S. Mary et al. / Nurse Education in Practice 14 (2014) 220e224 Table 1 Student evaluation of course. Question
Scale
%
Question
Scale
%
This course was well-organised.
SA A N D SD
51.7% 37.9% 10.3% 0% 0%
SA A N D SD
65.5% 27.6% 3.4% 3.4% 0%
The assessment was clear and fair.
SA A N D SD SA A N D SD SA A N D SD
72.4% 17.2% 10.3% 0% 0% 72.4% 17.2% 10.3% 0% 0% 55.2% 34.5% 6.9% 3.4% 0%
The teaching (lecturers, tutors, online etc) on this course was effective in helping me to learn. Overall I am satisfied with the quality of this course.
SA A N D SD SA A N D SD EX VG G A P
51.7% 41.4% 3.4% 3.4% 0% 41.4% 44.8% 10.3% 3.4% 0% 31% 37.9% 24.1% 3.4% 3.4%
I received helpful feedback on my assessment work.
This course provided feedback on my work that I could learn from during the course.
This course engaged me in learning.
Overall, how effective was this course in helping you to learn?
employed as research assistants. Three students have since gone on to work as research assistants within the school and presented their journey from research novice to research groupie following engagement with the course at the recent Australian College of Midwives National Student Midwife Conference (Force et al., 2012). Conclusion Evidence highlights that students traditionally find EBPR courses challenging and fail to engage effectively. This can have a number of negative consequences beyond academic outcome, including a failure to appreciate the necessity to practise within an evidence based framework to assure safe, high quality care and fulfil the legal and professional obligations of a midwife. The positive student evaluations and outcomes of this course demonstrate that it is possible to effectively engage students in research courses when the right ingredients are combined. The tangible and lucid link to practice throughout this course is clearly a key element in its success. The ability to make research relevant and ‘real’ to students underpins both a recognition and understanding of its value but also an enthusiasm in some for becoming actively involved in research. An outcome which can only be beneficial for the future development of midwifery practise and the growth of a clinical research culture. The mode of delivery through a blended approach in this course enabled students to develop a relationship with the lecturer and their peers within the intensive teaching workshops and retain their practice focus without any perceived sense of disengagement. The evaluation comments confirmed that students felt supported and there was clear acknowledgement of ‘the presence’ of the lecturer throughout the course, which underpinned both effective learning and seemingly high levels of satisfaction. As universities internationally move away from the traditional lecture/tutorial model this paper provides both evidence and reassurance that a blended learning model can provide good results in a threshold knowledge subject. This opens numerous possibilities for course development and delivery for the future within an internationalised context. Students no longer need to be located at their university of choice and cohorts can become much more demographically and geographically diverse. This also presents opportunities and possibilities for collaborative teaching which brings together international lecturers and experts in the field and
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allows students to link with and benefit from experiences of their peers on a global scale. The belief that research courses should not be delivered early in the curriculum is not supported by the early experience of running this course. High levels of satisfaction and overall student success appears to validate the decision to introduce this subject early on. The qualitative comments confirm that students recognise the value of the course and where it ‘fits in’ in relation to ongoing theory and practice requirements as well as current and future practice as a midwife. This ongoing commitment to EBPR will be measured in a follow up study of the original graduates from this course to measure application of research principles in practice. References August-Brady, M., 2005. Teaching undergraduate research from a process perspective. J. Nurs. Educ. 40 (4), 174e180. Ax, S., Kincaid, E., 2001. Nursing students’ perceptions of research: usefulness, implementation and training. J. Adv. Nurs. 35 (2), 161e170. Bhatti, I., Jones, K., Richardson, L., Foreman, D., Lund, J., Tierney, G., 2011. E-learning vs lecture: which is the best approach to surgical teaching? Colorectal Dis. 13 (4), 459e462 http://dx.doi.org/10.1111/j.1463-1318.2009.02173.x. Biggs, J., Tang, C., 2007. Teaching for Quality Learning at University, third ed. Open University Press, Maidenhead. Blackboard, 2012. Blackboard for Higher Education. Retrieved November 18th 2012, from: http://www.blackboard.com/Markets/Higher-Education-%281%29/Overview. aspx. Clark, K., Stanforth, D., Humphries, M.P., 2009. Teaching undergraduate nursing research: a collaborative approach. Nurse Educ. 34 (1), 9e11. http://dx.doi.org/ 10.1097/01.NNE.0000343392.96200.9b. Farley, A., Jain, A., Thomson, D., 2011. Blended learning in finance: comparing student perceptions of lectures, tutorials and online learning environments across different year levels. Econ. Pap. 30 (1), 99e108. http://dx.doi.org/10.1111/j.17593441.2010.00094.x. Force, R., Glasgow, A., Pattie, K., 2012. The dreaded “R” word.... or is it? Our journey as student midwives into the world of research via the BELIEF study. In: Paper Presented at the Australian College of Midwives Queensland National Student Midwife Conference, Gold Coast Queensland. Forsman, H., Gustavsson, P., Ehrenberg, A., Rudman, A., Wallin, L., 2009. Research use in clinical practice e extent and patterns among nurses one and three years postgraduation. J. Adv. Nurs. 65 (6), 1195e1206. Fry, H., Ketteridge, S., Marshall, S., 2003. Understanding Student Learning, second ed. Kogan Page, London. Hodgson, V., 1997. Lectures and the Experience of Relevance: the Expereience of Learning: Implications for Teaching and Studying in Higher Education. Scottish Academic Press,, Edinburgh. Hunter, L.P., Hunter, L.A., 2006. Storytelling as an educational strategy for midwifery students. J. Midwifery Womens Health 51 (4), 273e278 doi:1016/ j.jmwh.2005.12.004. Johnson, N., List-Ivankovic, J., Eboh, W.O., Ireland, J., Adams, D., Mowatt, E., Martindale, S., 2010. Research and evidence based practice: using a blended approach to teaching and learning in undergraduate nurse education. Nurse Educ. Pract. 10 (1), 43e47. Kiguwa, P., Silva, A., 2007. Teaching and learning: addressing the gap through learning styles. South Afr. J. Psychol. 37 (2), 354e360. Lizzio, A., 2011. Succeeding@ Griffith: Next Generation Partnerships across the Student Lifecycle. Griffith University, Queensland, Australia. McCurry, M.K., Martins, D.C., 2010. Teaching undergraduate nursing research: a comparison of traditional and innovative approaches for success with millennial learners. J. Nurs. Educ. 49 (5), 276e279. http://dx.doi.org/10.3928/ 01484834-20091217-02. McDrury, J., Alterio, M., 2002. Learning Through Storytelling in Higher Education: Using Reflection & Experience to Improve Learning. Dunmore Press Ltd., London. National Advisory Board, 1996. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI), 3rd Annual Report. Department of Health, London. Newton, J., McKenna, L., Gilmour, C., Fawcett, J., 2010. Exploring a pedagogical approach to integrating research, practice and teaching. Int. J. Nurs. Educ. Scholarsh. 7 (1), 1e13. Norton, L., 2009. Assessing student learning. In: Fry, H., Ketteridge, S., Marshall, L. (Eds.), A Handbook for Teaching and Learning in Higher Education, third ed. Routledge, New York, pp. 132e149. Peckover, S., Winterburn, S., 2003. Teaching research to undergraduate community nursing students: reflections upon curriculum design. Nurse Educ. Pract. 3 (2), 104e111. Pugsley, K.E., Clayton, L.E., 2003. Traditional lecture or experiential learning: changing student attitudes: 1. J. Nurs. Educ. 42 (11), 520e524. Rabe-Hemp, C., Woollen, S., Humiston, G.S., 2009. A comparative analysis of student engagement, learning, and satisfaction in lecture hall and online learning settings. Q. Rev. Distance . 10 (2), 207e218, 250e252.
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