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The use of innovative pedagogies in nursing education: an international perspective.

ABSTRACT The purpose of this global study was to explore the types of innovative pedagogies used in nursing education worldwide; transformative learning theory served as the theoretical basis for the study. A descriptive, mixed-method design with a researcher-developed instrument was used to conduct the electronic survey. Respondents were 946 nurse educator A nurse educator is a nurse who teaches and prepares licensed practical nurses (LPN) and registered nurses (RN) for entry into practice positions. Nurse Educators also teach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse  members of Sigma Theta Tau The Honor Society of Nursing, Sigma Theta Tau International exists to improve the health of people by increasing the scientific base of nursing research. It is the second-largest nursing organization in the world with approximately 125,000 active members.  International; more than 93 percent were Caucasian women. Respondents indicated that the conventional teacher-centered approach remains the most prevalent pedagogical ped·a·gog·ic   also ped·a·gog·i·cal
1. Of, relating to, or characteristic of pedagogy.

2. Characterized by pedantic formality: a haughty, pedagogic manner.
 style (56 percent); fewer than 20 percent of respondents used feminist or postmodern post·mod·ern  
Of or relating to art, architecture, or literature that reacts against earlier modernist principles, as by reintroducing traditional or classical elements of style or by carrying modernist styles or practices to extremes:
 approaches. Ninety percent of respondents reported using instruments to evaluate the effectiveness of their teaching. The majority viewed their faculty role as facilitator (88 percent) or information provider (65 percent). Greater efforts are needed to create an evidence base for nursing education through research that focuses on the effectiveness of innovative pedagogical strategies. This study, by describing the current patterns of teaching/learning strategies and approaches used by nurse educators, provides a beginning research base for improving nursing education.

Key Words Nursing Education--Innovative Pedagogies--Transformative Learning--Learner-Centered Approaches--Learning Outcomes


EDUCATION TODAY DOES NOT ALLOW FOR BUSINESS AS USUAL. Nurse faculty are faced with myriad challenges, including transformations brought about by distance education, advances in information technology, and the need for an evidence base in education and practice. Most important, amidst a serious shortage of faculty, educators are tasked with engaging students as active participants in the learning process. Engaging learners in their own self-regulated learning The term self-regulated can be used to describe learning that is guided by metacognition, strategic action (planning, monitoring, and evaluating personal progress against a standard), and motivation to learn  is imperative for education in the 21st century. * Despite the National League for Nursing's curriculum revolution of the late 1980s, which brought about certain innovations, many nurse educators continued to teach as they were taught (Diekelmann, 2002), failing to prepare learners for a reformed health care system (Oesterle & O'Callaghan, 1996; Porter-O'Grady, 2003). But in 2003, with publication of Health Professionals' Education: A Bridge to Quality by the Institute of Medicine and the NLN's Position Statement, "Innovation in Nursing: A Call to Reform," things began to change. Both the IOM IOM

See: Index and Option Market
 and the NLN NLN National League for Nursing.  called for educational reform and support for a worldwide transition from didactic di·dac·tic
Of or relating to medical teaching by lectures or textbooks as distinguished from clinical demonstration with patients.
 education to more nontraditional education. IN HOPES OF IMPROVING PATIENT-CENTERED HEALTH CARE, BOTH GROUPS STRESSED THE NEED FOR HEALTH CARE PROFESSIONALS TO DEMONSTRATE A COMMON SET OF SKILLS: INFORMATICS Same as information technology and information systems. The term is more widely used in Europe. , INTERPERSONAL COMMUNICATION Interpersonal communication is the process of sending and receiving information between two or more people. Types of Interpersonal Communication
This kind of communication is subdivided into dyadic communication, Public speaking, and small-group communication.

The emerging development of a science of nursing education to document the effectiveness and meaningfulness of reform efforts has promised a dramatic change in how students are educated. This article reports on a study designed to determine what innovative pedagogies are being used in nursing education around the world. The goal was to elicit methods used to evaluate the effectiveness of the pedagogies and construct a web workplace from the information obtained.

Background To build a science of nursing education, it is critical to examine the effectiveness of alternative pedagogies. Teacher-scholars must share insights in describing the changes made in the teaching/learning environment as new pedagogical strategies are implemented. In 2003, Ironside reported on a pilot study

developed to evaluate the implementation of alternative pedagogical strategies designed to create new partnerships between teachers and students.

A qualitative study conducted in Sweden used a reflective thinking approach (Ekebergh, Lepp, & Dahlberg, 2004) and confirmed the positive effects of both the cognitive and affective affective /af·fec·tive/ (ah-fek´tiv) pertaining to affect.

1. Concerned with or arousing feelings or emotions; emotional.

 aspects of the teaching/learning experience. Both Europe and Australia have used reflective teaching and practice extensively for a number of years (Freshwater fresh·wa·ter  
1. Of, relating to, living in, or consisting of water that is not salty: freshwater fish; freshwater lakes.

2. Situated away from the sea; inland.

 & Johns, 2005; Johns, 2002). However, a critical analysis of data-based studies on reflective practice by Ruth-Sahd (2003) indicates that reflective practice has become more markedly dissimilar based on the teacher's viewpoint. Studies are needed to evaluate the use of reflective teaching approaches and the correlation between these teaching approaches and the use of reflection in practice.

A sound evidence base for the use of a variety of approaches to education has been substantiated. Schoener and Hopkins (2004) found mutual benefits to learners and the service agent alike when they evaluated a service-learning model of education. However, the results were more anecdotal anecdotal /an·ec·do·tal/ (an?ek-do´t'l) based on case histories rather than on controlled clinical trials.
anecdotal adjective Unsubstantiated; occurring as single or isolated event.
 than empirical. A Finnish study (Auvinen, Suominen, Leino-Kilpi, & Helkama, 2004) examined the effects of ethics teaching and practical training on the development of moral judgment in nursing students. The group that had more practical training and teaching showed a statistically significant difference in their moral judgment. But when Evans and Bendel (2004) used a control and experimental group to evaluate whether narrative pedagogy led to increased autonomy in nursing practice, no significant effect was found.

Spector (2006) published a comprehensive, systematic review of educational outcomes in 15 studies by the National Council of State Boards state boards Examinations administered by a US state board of medical examiners to license a physician in a particular state; these examinations play an ever-decreasing role in state medical licensure, as these bodies now rely on standardized national examinations  of Nursing. A qualitative exploratory study conducted by Paniagua-Ramirez, Barone, and Tortes (2004) to review eight pedagogical models provides insights into the types of studies being conducted in nursing education.

Journal articles that disseminate dis·sem·i·nate  
v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates
1. To scatter widely, as in sowing seed.

 educational research are supported by a plethora of books (Bradshaw & Lowenstein, 2007) developed to guide faculty in education reform. For example, Cowan (2006) suggests ways for faculty to become innovative and engage learners as active participants in their learning. A number of books instruct faculty on how to teach using discussion (Bender, 2003; Brookfield & Preskill, 2006; Rabow, Charness, Kipperman, & Radcliffe-Vasile, 1994); reflection (Brockbank, McGill, & Beech, 2002; Freshwater & Johns, 2005); inquiry (Lee, 2006); evidence-based approaches (Lewin & Feldman, 2006); storied approaches (Minden & Gullickson, 2005); and caring (Bevis & Watson, 2000).

The nursing literature is replete re·plete  
1. Abundantly supplied; abounding: a stream replete with trout; an apartment replete with Empire furniture.

2. Filled to satiation; gorged.

 with descriptive examples of innovative teaching/learning approaches designed to involve students and encourage them to become more responsible and engaged as learners (Bowles, 2006; Callister, Bond, Matsumura, & Mangum, 2004; Edwards, 2005; Eide, Hahn, Bayne, Allen, & Swain, 2005; Ellis-Kempner, 2006; Fisher & Riley, 2003; Hegedus & Keneflick, 2006; Kirkpatrick & Brown, 2004, 2006; Kirkpatrick, Brown, Atkins, & Vance, 2001; Lane, 2005; Larew, Lessans, Spunt, Foster, & Covington, 2005; Neuman, 2006; Wilkstrom, 2000).

Given these resources, the question remains: Are nurse educators using existing resources and modifying conventional teaching/learning approaches in order to develop a more learner-centered pedagogy? If the answer to this question is yes, we can ask: How is evaluation of the effectiveness of these approaches being managed?

Methodology A thorough, inclusive, and descriptive three-part instrument was designed by the research team. It included closed and open-ended questions related to demographics, pedagogical teaching/learning approaches used, and teaching/learning strategies used. The survey design allowed for multiple answers using check boxes or dropdown lists as well as blank fields for open-ended questions. The survey design allowed for mixed-method analysis using descriptive, quantitative analysis Quantitative Analysis

A security analysis that uses financial information derived from company annual reports and income statements to evaluate an investment decision.

 of the demographic and closed-ended survey items and qualitative content analysis of the open-ended items.

A convenience sample of subjects was elicited from Sigma Theta Tau International's (STTI STTI Sigma Theta Tau International, Inc (Nursing honor society)
STTI Submarine Tactics and Technology, Inc. (naval consultants)
STTI Spatio-Temporal Target Identification
) membership list. An electronic survey weblink was sent to 10,467 STTI members identified as nurse educators. To stay within the allocated budget, the survey was limited to the responses received within a one-week period, which totaled 946.

The majority of the 946 respondents were Caucasian (93 percent), female (96 percent), between the ages of 51 and 60 (50 percent), with more than 20 years of teaching experience (40 percent). The highest level of educational preparation was the doctoral degree (53 percent). Fifty-six percent of the sample were faculty experienced in teaching medical-surgical nursing. Seventy-three percent taught in the classroom, 76 percent taught undergraduates, and 45 percent had attained a senior professorial rank (associate or full professor). Fewer than 2 percent were from outside the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. .

Findings Respondents selected the pedagogical strategies they used in their teaching and then ranked their selections. The pedagogical approaches used most frequently by a majority of the nurse educators in the sample were: conventional, blended or mixed (eclectic), and inquiry. Feminist and postmodern approaches were used by fewer than 20 percent of the respondents. Ninety percent of the sample (n = 853) indicated that they evaluated the teaching/learning approaches used in their teaching (see Table 1).

The qualitative content analysis resulted in two primary themes across all open-ended questions: teacher-centered and learner-centered. Respondents described processes to evaluate both student learning and student satisfaction and described how they themselves or the courses were evaluated institutionally. Faculty failed to describe techniques, instruments/tools, or processes used to evaluate specific teaching strategies or approaches.

From a list of 40 possible teaching/learning strategies, nurse educators used a median of 17, with more than 25 percent of the sample reporting the use of more than 21 different strategies. From the quantitative and qualitative findings, it was revealed that nurse educators pattern teaching strategies and approaches according to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 course content and design courses to meet various learner styles. From the dropdown list of strategies, evidence-based, lecture, discussion, case-based, and multimedia strategies were shown to be used by over 70 percent of the respondents, an indication that active learning strategies are integrated into course design in an attempt to engage the learner. The fact that there was little agreement as to which strategies were most helpful in facilitating student learning further indicates that multiple strategies are used to meet learner needs relative to the educational setting, which may be a traditional classroom, a clinical environment, or an online educational environment.

The strategies identified as most helpful by the largest proportion of the respondents included case-based (36 percent), evidence-based (21 percent), and client/patient (20 percent) care. Interestingly, while 78 percent of respondents used the lecture method, only 17 percent rated it as one of their most helpful strategies for facilitating student learning. (See Table 2.) Case-based, narrative/storytelling, and simulation were considered the most innovative strategies used by respondents. More than half the sample saw critical thinking, knowledge acquisition, and independent learning as important outcomes associated with the use of innovative strategies.

Table 3 summarizes the teaching/learning strategies found to be most helpful by faculty who used a conventional, blended, or inquiry approach to teaching and learning in nursing education. For those who used a conventional pedagogy most often, case based, lecture, and client/patient care strategies were reported to be most helpful in facilitating student learning. For those who used inquiry pedagogy most often, case-based, evidence-based, inquiry-based, and client/patient care strategies were found most helpful. In the blended pedagogical approach, case-based and evidence-based strategies were found most helpful.

Table 4 summarizes the most prevalent faculty roles, faculty perceptions of the learner's role, and faculty expectations of student outcomes. The majority of the respondents viewed their faculty role as either facilitator (88 percent) or information provider (65 percent). The two roles used least were initiator (14 percent) and partner (11 percent). The student role identified by the majority of faculty was the active learner role (87 percent), with partner and team member a distant second (25 percent). More than 80 percent of faculty identified academic skills, inquiry, and independent learning as their expected student outcomes. More than half identified additional desired student outcomes: values, scholarly communication Scholarly Communication is an umbrella term used to describe the process of academics, scholars and researchers sharing and publishing their research findings so that they are available to the wider academic community (such as university academics) and beyond. , attitude change in learner, information literacy Several conceptions and definitions of information literacy have become prevalent. For example, one conception defines information literacy in terms of a set of competencies that an informed citizen of an information society ought to possess to participate intelligently and , adaptive learning (algorithm) adaptive learning - (Or "Hebbian learning") Learning where a system programs itself by adjusting weights or strengths until it produces the desired output. , lifelong learning Lifelong learning is the concept that "It's never too soon or too late for learning", a philosophy that has taken root in a whole host of different organisations. Lifelong learning is attitudinal; that one can and should be open to new ideas, decisions, skills or behaviors. , cooperative learning cooperative learning Education theory A student-centered teaching strategy in which heterogeneous groups of students work to achieve a common academic goal–eg, completing a case study or a evaluating a QC problem. See Problem-based learning, Socratic method. , and moral reasoning Moral reasoning is a study in psychology that overlaps with moral philosophy. It is also called Moral development. Prominent contributors to theory include Lawrence Kohlberg and Elliot Turiel. .

Implications for Nursing Education According to Rogers (1995), innovation is a different way of doing things, or thinking outside the box. Respondents to this study described using multiple teaching/learning strategies and approaches in combinations that were innovative to them. Respondents demonstrated a paradigm shift A dramatic change in methodology or practice. It often refers to a major change in thinking and planning, which ultimately changes the way projects are implemented. For example, accessing applications and data from the Web instead of from local servers is a paradigm shift. See paradigm.  in nursing education that, in effect, represents deconstruction deconstruction, in linguistics, philosophy, and literary theory, the exposure and undermining of the metaphysical assumptions involved in systematic attempts to ground knowledge, especially in academic disciplines such as structuralism and semiotics.  of old ways of teaching and practicing and challenges nurse educators to develop new ways to measure the impact of their teaching. Research that differentiates the outcomes of teacher- and learner-centered strategies and approaches and takes into consideration content application, synthesis, and course design is essential to the development of a science of nursing education. Because objective assessments of specific outcomes is vital to building a sound framework for nursing education, the establishment of measurement tools is essential.

Evidence that educators are using a variety of teaching/learning approaches and strategies suggests the further need for faculty development in the use of contemporary teaching methods, as well as skill development in the application of evaluative measures to determine learning outcomes. Clearly, additional research is needed that will benchmark innovative teaching methods against the more traditional approaches. Research that studies the application and evaluation of teaching methods across various levels of nursing education in multiple settings would help refine the validity of findings. By correlating teaching/learning strategies with pedagogical approaches identified, and comparing the student outcomes to these strategies and approaches, a better defined, research-based science of nursing education will evolve. A secondary data analysis of the qualitative data from this study has served as the foundation for a doctoral dissertation and will he reported in the literature.

While the researchers desired to have a sample that included a global perspective, only 2 percent of respondents were from outside the United States. Additional research is needed to obtain a more global and diverse view of innovative pedagogies used in nursing education worldwide.

Enhancement of the pedagogical literacy of faculty assures a future for nursing education that will result in meaningful learning for students. By identifying current patterns used by nurse educators, this study provides a beginning research base for improvements in nursing education. Nurse educators with an interest in traditional and contemporary pedagogies and the teaching/learning strategies described in this study may obtain additional information from a website created by the researchers. The website (located at sonprojects/researchl/index.html), is based on the findings of this study and describes innovative pedagogies, provides literature sources for review, and ultimately enhances the pedagogic ped·a·gog·ic   also ped·a·gog·i·cal
1. Of, relating to, or characteristic of pedagogy.

2. Characterized by pedantic formality: a haughty, pedagogic manner.
 literacy of educators.


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(1) A pen-shaped instrument that is used to "draw" images or select from menus. Styli (the plural of stylus, pronounced "sty-lye") come with handheld devices that have touch screens, such as PDAs and video games.

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n. pl. prax·es
1. Practical application or exercise of a branch of learning.

2. Habitual or established practice; custom.
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1. pertaining to elderly persons or to the aging process.

2. pertaining to geriatrics.

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MADP Medicinal, Aromatic and Dye Plants
MADP Materiel Acquisition Decision Process
MADP Mission Area Development Plan
MADP Memory Address and Data Path
MADP Managing the Application Development Process
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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
: Springer springer

a North American term commonly used to describe heifers close to term with their first calf.

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Sylvia T. Brown, EdD, RN, CNE (Certified NetWare Engineer) See Novell certification. , is a professor and acting dean, East Carolina University East Carolina University is a public, coeducational, intensive research university located in Greenville, North Carolina, United States. Named East Carolina University by statue and commonly known as ECU or East Carolina  College of Nursing, Greenville, North Carolina

For other places with the same name, see Greenville.

Greenville, one of the fastest growing cities in North Carolina, is the county seat of Pitt County, and is the principal city of the Greenville, North Carolina Metropolitan Statistical Area.
. Mary K. Kirkpatrick, EdD, RN, is a professor and international coordinator, East Carolina University College of Nursing. Annette Greer, PhD, RN, is the co-director of the Office of Interdisciplinary Health Sciences Education, East Carolina University. April D. Matthias, MSN (1) (MicroSoft Network) A family of Internet-based services from Microsoft, which includes a search engine, e-mail (Hotmail), instant messaging (Windows Live Messaging) and a general-purpose portal with news, information and shopping (MSN Directory). , RN, CNE, is a nursing instructor and Nursing Department head, Coastal Carolina Community College, Jacksonville, North Carolina Jacksonville, North Carolina, is a city in Onslow County, North Carolina, United States. As of the 2000 census the city had a total population of 66,715. It is the principal city of and is included in the Jacksonville, North Carolina Metropolitan Statistical Area. , and a PhD student at East Carolina University College of Nursing. Melvin S. Swanson, PhD, is a professor and statistician, East Carolina University College of Nursing. The authors are grateful to the NLN for support through the Nursing Education Research Grant Program. For more information, contact Dr. Brown at
Table 1. Teaching/Learning Approaches

APPROACH                         RESPONSE OPTIONS      N (%)

Pedagogical                          Conventional    525   (56)
teaching/learning                  Blended, mixed    511   (54)
approaches identified as                  Inquiry    492   (52)
one of the top three                       Caring    306   (32)
most frequently used                   e-Pedagogy    233   (25)
(multiple options selected)              Critical    221   (23)
                                 Phenomenological    203   (22)
                                         Feminist    160   (17)
                                       Postmodern    75    (8)
                                        Uncertain    22    (2)
                                            Other    21    (2)

Length of time                > 10 academic years    393   (42)
pedagogical approaches        6-10 academic years    263   (28)
were used                      2-5 academic years    253   (27)
                              < = 1 academic year    23    (2)

Evaluate effectiveness                        Yes    853   (90)
of teaching/learning                           No    85    (9)

Table 2. Teaching/Learning Strategies and Outcomes


Teaching/learning                         Case-based    336   (36)
strategies identified as              Evidence-based    201   (21)
one of the top three             Client/patient care    191   (20)
most helpful in                              Lecture    165   (17)
facilitating student                   Problem-based    147   (16)
learning                      Narrative/Storytelling    147   (16)
                                       Inquiry-based    137   (15)
                                          Reflection    124   (14)
                                Cooperative learning    119   (13)
                                          Discussion    115   (12)
                                          Multimedia    110   (12)
                                          Simulation     95   (10)
Single most innovative                    Case-based     98   (10)
strategy of top three         Narrative/Storytelling     79    (8)
strategies selected                       Simulation     64    (7)
                                      Evidence-based     61    (6)
                                Cooperative learning     53    (6)
Five most important                Critical thinking    849   (90)
learner outcomes associated    Knowledge acquisition    644   (68)
with the use of                 Independent learning    630   (67)
innovative teaching/                     Empowerment    375   (40)
learning strategies                  Self-motivation    345   (37)
(multiple options selected)           Self-discovery    340   (36)
                              Collaborative learning    339   (36)
                                       communication    283   (30)
                                          Creativity    251   (27)
                                 Cultural competence    212   (22)
                                     Moral reasoning    176   (19)
                                       Self-reliance    163   (17)
Most frequent learner              Critical thinking    373   (39)
outcome                        Knowledge acquisition    162   (17)
                                 Self-responsibility    118   (13)

Table 3. Strategies Used by Pedagogy

STRATEGY                           PEDAGOGY

helpful by at
least 10          N (%)          N (%)           N (%)
percent of

Case-based        212   (40)     181   (35)      182   (37)

Patient care      127   (24)     91    (18)      101   (21)

Evidence-based    95    (18)     113   (22)      108   (22)

Inquiry-based     55    (11)     65    (13)      101   (21)

Lecture           137   (26)     79    (16)      77    (16)

Problem-based     79    (15)     76    (15)      82    (17)

Storytelling      84    (16)     77    (15)      55    (11)

Reflection        48    (9)      66    (13)      62    (13)

Simulation        63    (12)     49    (10)      46    (9)

learning          55    (11)     68    (13)      56    (11)

Discussion        60    (11)     65    (13)      70    (14)

Table 4.
Roles and Outcomes of Teaching/Learning Approaches

ROLE / OUTCOME                       RESPONSE OPTIONS       N (%)

Top three most prevalent                  Facilitator    829   (88)
faculty roles                    Information provider    616   (65)
                                               Mentor    426   (45)
                                            Motivator    402   (43)
                                                Coach    304   (32)
                                            Initiator    151   (14)
                                              Partner    106   (11)

Primary classification of              Active learner    824   (87)
learner's role                                Partner    239   (25)
(multiple options selected)               Team member    235   (25)
                                          Independent    146   (15)
                                            Initiator    102   (11)
                                      Passive learner    65    (7)
                                                Other    5     (1)

Expected student                      Academic skills    864   (91)
outcomes                                      Inquiry    838   (89)
(multiple options selected)      Independent learning    791   (84)
                                               Values    698   (74)
                              Scholarly communication    605   (64)
                                      Attitude change
                                           in learner    603   (64)
                               Informational literacy    518   (55)
                                    Adaptive learning    508   (54)
                                    Lifelong learning    507   (54)
                                 Cooperative learning    503   (53)
                                      Moral reasoning    494   (52)
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Author:Brown, Sylvia T.; Kirkpatrick, Mary K.; Greer, Annette; Matthias, April D.; Swanson, Melvin S.
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:May 1, 2009
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