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Collaborative testing as a learning strategy in nursing education: a review of the literature.


Nurses are important members of a patient's interprofessional health care team. A primary goal of nursing education is to prepare nursing professionals who can work collaboratively with other team members for the benefit of the patient. Collaborative learning strategies provide students with opportunities to learn and practice collaboration. Collaborative testing is a collaborative learning strategy used to foster knowledge development, critical thinking in decision-making, and group processing skills. This article reviews the theoretical basis for collaborative learning and research on collaborative testing in nursing education.

Key Words Collaboration--Collaborative Learning--Collaborative Testing--Group Testing--Nursing Education


AS PART OF ITS FINAL REPORT PUBLISHED IN 2000, THE PEW HEALTH PROFESSIONS COMMISSION CITED 21 COMPETENCIES NEEDED BY HEALTH CARE PROFESSIONALS OF THE FUTURE (BELLACK & O'NEIL, 2000). Number 15, work in interdisciplinary teams, is of particular importance. A year later, when the Institute of Medicine outlined a five-step plan for creating a stronger health care system (IOM, 2001), it called for clinicians to collaborate with one another to ensure appropriate sharing of information and coordination of care. * Collaborative working relationships among health professionals are of vital importance in ensuring cost-effective, quality care. Collaborative testing is one learning strategy that is being used in nursing education to enhance knowledge development and provide opportunities to practice the skills of collaboration. THIS ARTICLE REVIEWS THE THEORETICAL BASIS FOR COLLABORATIVE TESTING AND PROVIDES A REVIEW OF PERTINENT NURSING LITERATURE.

What Is Collaborative Learning? In collaborative learning, students work together to learn. Collaborative learning strategies are active and student centered. They include joint intellectual efforts involving groups of students and may include discussions, peer teaching activities, group case studies, study groups, research teams, and testing. The goal of the collaborative learning strategy may be completion of a specific task, such as a group test or presentation, or it may be the process itself, where students reflect on the group process and what could be done to improve it. * A variety of collaborative learning strategies have been used successfully to promote achievement of knowledge and skills at all grade levels and in multiple professions, including nursing (Baumberger-Henry, 2003; Bose, Jarreau, Lawrence, & Snyder, 2004; Glendon & Ulrich, 1992; Gumbs, 2001; Kleffner & Dadian, 1997; Nolinske & Millis, 1999; Richardson & Trudeau, 2003; Slavin, 1991). Johnson, Johnson, and Smith (1998) stated that collaborative learning strategies in the college population increase student achievement, critical thinking, and interpersonal and group processing skills. The development of these skills is an essential element of collaboration for professional practice.

Theoretical Framework Three theoretical frameworks come together to support collaborative learning. While they differ somewhat, each theory predicts that collaboration will promote learning and support growth and critical thinking. These theories, individually and together, provide support for collaborative learning, that is, students working together to learn.

COGNITIVE-DEVELOPMENTAL THEORY This theory, which has its origins with Piaget and Vygotsky (Johnson & Johnson, 1999), points out that social interaction is necessary for human development. Vygotsky (1978) theorized that as individuals communicate, ognitive development is enhanced by verbal discussion and processing of the topic. Cooperation, according to Piaget, is the attainment of goals while coordinating individual feelings and perspectives with the feelings and perspectives of others (Johnson & Johnson).

Smith and MacGregor (1992) stated that learning is the result of social interaction; that learning depends on an individual's ability to reason and solve problems; and that learning has affective and subjective dimensions. Learners are diverse and come to the collaborative experience with a wealth of knowledge from their different backgrounds and experiences. Learning is an active process during which students integrate new knowledge with past knowledge and experience. Students listen to the viewpoints of others and come to understand that they can work with others to learn.

BEHAVIORAL LEARNING THEORY This theory supports that learning is social and brings into play rewards and punishments (Bandura, 1977). Individuals will model behavior if they perceive a benefit or a reward. If individuals do not perceive a benefit, or if a negative consequence results, no change in behavior will be noted. The collaborative learning environment is designed to provide positive incentives for students to collaborate with others.

SOCIAL INTERDEPENDENCE THEORY Social interdependence theory states that it is the way the task is structured that determines the outcomes (Johnson & Johnson, 1999). In positive interdependence, students facilitate and encourage each other's learning through cooperation toward a shared goal. Because the group goal can only be attained if individual goals are attained, individual members must be successful. Therefore, students are intrinsically motivated to work cooperatively to achieve the goal. In negative interdependence, students compete with each other; in the absence of interdependence, there is no interaction between the students and all efforts are individualistic.

Social interdependence theory provides the strongest theoretical support for collaborative learning. It is the most thorough in that it defines cooperative, competitive, and individualistic efforts and specifies conditions for effectiveness and implementing collaborative learning in the classroom. For collaborative learning to be effective, it must include five elements: positive interdependence, group interaction, individual accountability, interpersonal skills, and group processing skills (Johnson & Johnson, 1999).

Collaborative Testing as a Learning Strategy A large body of research exists to support collaborative learning across disciplines (Baumberger-Henry, 2005; Beeken, 1991; Duncan & Dick, 2000; Gokhale, 1995; Rao & DiCarlo, 2000) and populations, but evidence in support of collaborative testing is sparse. Collaborative testing is defined broadly as a method of collaborative learning in which students work together on a test (Durrant, Pierson, & Allen, 1985; Lusk & Conklin, 2003). Studies of collaborative testing were found in related health care disciplines: exercise physiology (Cortright, Collins, Rodenbaugh, & Dicarlo, 2003), educational psychology (Griffin, Griffin, Warkentin, Quinn, & McCown, 1995; Griffin, McCown, Quinn, & Driscoll, 1994), psychology (Zimbardo, Butler, & Wolfe, 2003), and medicine (Rao, Collins, & DiCarlo, 2002). One study of collaborative testing in business education was found (Nowak, Miller, & Washburn, 1996). All but Griffin et al. (1995) demonstrated positive effects of collaborative testing on student learning.

Collaborative testing has been shown to consistently increase test scores across disciplines (Meinster & Rose, 1993; Nowak et al., 1996; Rao et al., 2002), but the evidence regarding retention of content is inconsistent (Cortright et al., 2003; Griffin et al., 1995; Lambiotte et al., 1987; Lynch, 1984). Student perceptions of collaborative testing have been consistently positive, with students reporting less anxiety (Mitchell & Melton, 2003; Phillips, 1988; Zimbardo et al., 2003); increased learning (Cortright et al., 2003; Durrant et al., 1985; Griffin et al., 1994; Mitchell & Melton, 2003; Nowak et al., 1996); improved student relations (Nowak et al.); improved thinking skills (Griffin et al., 1995); and increased motivation (Zimbardo et al.). Students perceive they learn better in a collaborative testing situation, even if their final course grades do not improve. Positive attitudes regarding the course work, peers, and themselves can be a motivating force to improve study habits.

Collaborative Testing as a Learning Strategy in Nursing Education Research on collaborative testing specifically in nursing yielded only nine studies. Durrant et al. (1985) first compared the effectiveness of group testing and individual testing for short-and long-term retention. The sample consisted of 50 freshmen enrolled in a medical-surgical nursing course. All students took a pretest, followed by content, followed by the group testing experience. Students were assigned to three groups based on past test performance: high (n = 15), medium (n = 22), and low (n = 13) (It is not clear whether the testing groups were homogenous as far as past test ability, or if the groups were heterogeneous with students from different ability groups making up a testing group).

For the group testing experience, students were instructed to discuss the questions among themselves before handing in their own answer sheets; consensus on the answers was not required. New content was then delivered, followed by an individual unit exam. Short-term retention was measured by a midterm examination (individual); long-term retention was measured by a final examination (individual). Comparison of pretest scores to midterm (t(44) = - 9.10, p <.05) and final examination scores (t(44) = -11.65, p < .05) was significant, with better performance noted on the midterm and final exams. Comparison between the experimental and conventional methods on short-term retention (t(44) = 4.08, p < .05) and long-term retention (t(44) = 3.87, p < .05) showed significantly better retention for the experimental method. No significant difference was noted between the ability groups. An attitude questionnaire was administered after the group testing experience; the majority of students favored the group testing strategy. A limitation of this study was that there was no control group. Performance on the individual exam may have been affected by the students' first taking the collaborative exam. The authors recommended replicating the study under experimental conditions.

Phillips (1988) expanded on the Durrant et al. (1985) study to examine the effects of collaborative testing on student anxiety and learning in a population of associate degree nursing students taking Advanced Adult Health II. Data were collected from three classes in the final year of the program; the course was taught three times by the same instructor (fall, winter, spring) with 10, 12, and 12 students. Quizzes were given throughout the semester using a modified group testing approach. Students spent the first 40 minutes working alone and then spent 10 minutes in groups of three to discuss their answers; the groups were homogenous, based on grades from the preceding adult health class (Adult Health I). Consensus on the answers was not required. A final examination was given in the traditional, individual testing format. Comparison of quiz averages and final examination scores was significant for the winter and spring semester groups (p = .05, p = .01, respectively), suggesting increased learning and retention of material. Combining all three semesters to compare quiz averages and final examination scores resulted in significance at the .01 level (p = .01). Students also completed a questionnaire to rate their anxiety level during the course. Ninety-seven percent reported that their anxiety level had been lowered during the course. The authors cited the following limitations to their study: no control group; students were allowed to review their quizzes from the semester the week of finals; and an inability to generalize to other populations of students.

Lusk and Conklin (2003) explored the effects of collaborative testing on student learning and test-taking skills in a Fundamentals of Nursing course. Learning style and test-taking skills were measured using the national Nurse Entrance Test. Unit examinations were taken collaboratively after students worked alone for 40 minutes and then spent 20 minutes in discussion with a randomly assigned partner. Students handed in their own answer sheets; consensus was not required. Scores were compared to previous semester scores where all exams were given individually (control group). Analysis between semesters on unit exam scores showed a significant difference (p = .001), with students testing better using the collaborative approach. Comparison between semesters on final examination scores did not yield a significant difference (p = .33).

Although the students tested better using collaborative testing, retention of material, as measured by final examination scores, did not improve. Analysis of initial test-taking skills and examination scores for the control group yielded a significant correlation (r(24) = .384, p = .029). No significant correlation for the collaborative testing group was noted (r(25) = .089, p = .34). Based on the findings, the authors concluded that a change in test-taking skills occurred for the experimental group. The content between the two semesters was the same, as were the instructor and tests; the only difference reported was the type of testing and the groups of students. Comparison of demographic data revealed no significant differences for age, ethnicity, gender, grade point average, learning styles, or test-taking skills between the groups. There could have been a maturational effect that contributed to the experimental group's performance as well as unmeasured group differences.

Mitchell and Melton (2003) examined the effect of a group test on nursing students' learning of fluid and electrolyte content. After completing and turning in an individual exam sheet, students were randomly assigned to a partner before repeating the exam. Consensus was not required, and each student had a second answer sheet. The average increase in students' scores was one point (range, 1 to 10). While perceptions were positive for the group testing approach, 59 percent of the students expressed concern that unprepared students might be able to earn a higher exam score.

Hoke and Robbins (2005) incorporated group quizzes to explore the impact of active, student-centered learning strategies on nursing students' clinical performance in a licensed practical nurse program. Group quizzes were one of a variety of student-centered learning strategies utilized in the study. Learning strategies included small-group work projects, role-play, take-home quizzes, and group quizzes. Twenty-three students completed a quiz and then were allowed to discuss the answers in a group. After the group discussion, students could change their answers. Higher clinical course grades (mean = 87.03) were found in students utilizing the student-centered learning approach compared to previous semesters, where students were taught by lecture only (mean = 84.19). Qualitative data from course evaluations were overwhelmingly positive for the student-centered approach.

Group consensus testing, an alternate form of collaborative testing, requires students to come to agreement on answers to the test questions. Three studies found in the literature explored this phenomenon in baccalaureate nursing education (Gaskins & VanderMeer, 1992; Rossignol, 2004; Wink, 2004). In each study, students completed two exams, first individually and then in a group. In two of the studies students were randomly assigned to groups. In the third study, groups were formed based on a student's clinical group. Consensus on the group exam was required. In each study, group mean scores were higher than individual mean scores. Student perceptions of the collaborative experience and its effects on their anxiety, learning, peer relationships, and thinking skills were overwhelmingly positive (Gaskins & VanderMeer; Rossignol). Wink reported that the majority of students (71 percent and 54 percent) earned the same grade they would have earned had they taken the exams individually. This finding addresses the concern that collaborative testing would allow low-achieving students to be carried along by their high-achieving peers. No one passed the course who would not have passed if only individual exam scores were used. Retention was not addressed in any of the three studies.

A fourth study, by Hickey (2006), explored nursing students' responses to group consensus testing. For each unit exam, students initially completed the exam individually. After all students had completed the individual exam, students reconvened according to clinical groups and repeated the exam in a group. Consensus was required on the group exam. Points were added to the student's individual exam score based on the group's exam score. These were minimal; groups remained consistent throughout the semester. At the beginning of the next semester, students were asked to complete a questionnaire about their collaborative testing experiences. Eighty-eight student surveys (86 percent) were returned (in addition to four faculty surveys). Student responses were positive with regard to collaborative testing and its effects on learning (76 percent, n = 67), thinking (79 percent, n = 71), and confidence (70 percent, n = 62). Although 89 percent of the students reported that they liked collaborative testing, student responses regarding collaborative testing and its effect on communication skills were mixed; only a slight majority reported a positive impact (57 percent, n = 50). Students reported that collaborative testing had no effect on their study habits. In contrast to previous research (Gaskins & VanderMeer, 1992; Phillips, 1988; Rossignol, 2004), the majority reported that collaborative testing did not reduce their anxiety (74 percent, n = 66). A group size of three to four students was considered optimal for collaborative testing (72 percent, n = 63). Exposure to differing viewpoints and hearing explanations from peers were described as helpful; disadvantages cited by students included second-guessing oneself, weak groups, increased anxiety, and arguing when there was no agreement on an answer.

Faculty responses were also positive; faculty cited a more pleasant exam review. No change was noted in student grades compared to previous semesters when collaborative testing was not used. Hickey (2006) reported exam averages of 81.73 and 82.67 for two sections with collaborative testing, in contrast to an average of 82.73 in previous semesters. Faculty reported continued use of collaborative testing with changes based on student feedback. One area of specific concern was the stability of the group over the entire semester. Hickey concluded that random assignment to groups might encourage students to study, as students will not know who will be in their group. Changing groups for each collaborative exam was recommended.

Conclusion In today's evolving health care environment, nurses are important members of a patient's interprofessional health care team. As such, they must be prepared to be effective collaborators with patients and interdisciplinary team members. Learning is a social experience, and nursing education must provide opportunities to learn and practice collaboration, first with peers and then with members of other health care disciplines. Collaborative testing is a learning strategy that can be used to foster learning, critical thinking, and group process skills.

While research on collaborative testing as a collaborative learning strategy in nursing education is meager, increased exam scores are shown consistently; however, findings on long-term retention, as measured by final cumulative examinations, are inconsistent. The few studies conducted have consistently used unit exam scores, final exam scores, and/or final course grade as the dependent variable(s). None of the studies used a control group during the same semester. Group size and formation were also not consistent.

Future research needs to focus on retention of material, preferably with a control group. Group size and formation should also be addressed, along with the stability of the group over time and its effect on student learning, critical thinking skills, and group process skills. Utilization of collaborative testing within the curriculum should be explored to include clinical and core courses, as well as different levels of students.


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Sheryl S. Sandahl, DNP, MPH, RN, CNP, is an assistant professor, School of Nursing, College of St. Scholastica, Duluth, Minnesota. For more information, contact Dr. Sandahl at
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Author:Sandahl, Sheryl S.
Publication:Nursing Education Perspectives
Date:May 1, 2009
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