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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 members of Sigma Theta Tau International; more than 93 percent were Caucasian women. Respondents indicated that the conventional teacher-centered approach remains the most prevalent pedagogical style (56 percent); fewer than 20 percent of respondents used feminist or postmodern 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

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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 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 and the NLN called for educational reform and support for a worldwide transition from didactic 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, INTERPERSONAL COMMUNICATION SKILLS, INTERDISCIPLINARY TEAMWORK, QUALITY IMPROVEMENT, CRITICAL/REFLECTIVE THINKING, CULTURAL COMPETENCY, AND EVIDENCE-BASED PRACTICE.

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 aspects of the teaching/learning experience. Both Europe and Australia have used reflective teaching and practice extensively for a number of years (Freshwater & 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 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 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 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 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 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) 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.

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 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, attitude change in learner, information literacy, adaptive learning, lifelong learning, cooperative learning, and moral reasoning.

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 in nursing education that, in effect, represents deconstruction 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 www.nursing2.ecu.edu/ 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 literacy of educators.

References

Auvinen, J., Suominen, T. Leino-Kilpi, H., & Helkama, K. (2004).The development of moral judgment during nursing education in Finland. Nurse Education Today, 24(7), 538-546.

Bender, T. (2003). Discussion-based online teaching to enhance student learning: Theory, practice and assessment Sterling, VA: Stylus.

Bevis, E. O., & Watson, J. (2000). Toward a caring curriculum: A new pedagogy for nursing. Sudbury, MA: Jones and Bartlett.

Bowles, D. J. (2006).Active learning strategies ... not for the birds! International Journal of Nursing Education Scholarship, 3(1),Article 22, 1-11.

Bradshaw, M.J., & Lowenstein, A.J. (2007). Innovative teaching strategies in nursing. Sudbury, MA: Jones & Bartlett.

Brockbank, A., McGill, I., & Beech, N. (2002). Reflective learning in prance. Brookfield, VT: Gower.

Brookfield, S., & Preskill, S. (2006). Discussion as a way of teaching: Tools and techniques for democratic classrooms. San Francisco: Jossey Bass.

Callister, L. C., Bond, A. E., Matsumura, G., & Mangum, S. (2004).Threading spirituality through out nursing education. Holistic Nursing Prance, 18(3), 160-166.

Cowan, J. (2006). On becoming an innovative university teacher. (2nd ed.). Buckingham, UK: Open University Press.

Diekelmann, N. (2002). "Too much content" ... epistemologies grasp and nursing education. Journal of Nursing Education, 41, 469-470.

Edwards, P.A. (2005). Impact of technology on the content and nature of teaching and learning. Nursing Education Perspectives, 26(6), 344-347.

Eide, P.J., Hahn, L., Bayne, T., Allen, C. B., & Swain, D. (2005). The population-focused analysis project for teaching community health. Nursing Education Perspectives, 27(1), 22-25.

Ekebergh, M., Lepp, M., & Dahlberg, K. (2004). Reflective learning with drama in nursing education: A Swedish attempt to overcome the theory praxis gap. Nurse Education Today, 24(8), 622-628.

Ellis-Kempner, B. (2006). Caring from our bodies: Using dance performance to give voice to silences in nursing. International Journal for Human Caring, 10(3), 47-55.

Evans, B. C., & Bendel, R. (2004). Cognitive and ethical maturity in baccalaureate nursing students: Did a class using narrative pedagogy make a difference? Nursing Education Perspectives, 25(4), 188-195.

Fisher, E. M., & Riley, T.A. (2003). Fostering the scholarship of discovery and integration for advanced practice education. Nursing Education Perspectives, 26(6), 348-350.

Freshwater, D., & Johns, C. (2005). Transforming nursing through reflective practice. Oxford: Blackwell.

Greiner, A. C., & Knebel, E. (2003). Health professionals' education: A bridge to quality. Washington, DC: National Academies Press.

Hegedus, K. S., & Keneflick, A. L. (2006). Strategies for teaching aesthetics to undergraduate nursing students. International Journal for Human Caring, 10(3), 66-69.

Ironside, P. M. (2003).Trying something new: Implementing and evaluating narrative pedagogy using a multi-method approach. Nursing Education Perspectives, 24(3), 122-128.

Johns, C. (2002). Guided reflection: Advancing practice. London: Blackwell.

Kirkpatrick, M., & Brown, S. (2004). Narrative pedagogy: Teaching geriatric content with stories and the "Make a Difference" project (MADP). Nursing Education Perspectives, 25(4), 183-187.

Kirkpatrick, M., & Brown, S. (2006). Leadership development through the Intergeneration Make a Difference Project. Nursing Education Perspectives, 2 7(2), 89-92.

Kirkpatrick, M. K., Brown, S.T., Atkins, A. J., & Vance, A. R. (2001). Education innovations using popular culture to teach nursing leadership. Journal of Nursing Education, 40(2), 90-92.

Lane, M. R. (2005). Creativity and spirituality in nursing: Implementing art in healing. Holistic Nursing Practice, 19(3), 122-125.

Larew, C. Lessans, S., Spunt, D., Foster, D., & Covington, B. G. (2005). Innovations in clinical simulation: Application of Benner's theory in an interactive patient care simulation. Nursing Education Perspectives, 2 7(1), 16-19.

Lee, V. S. (2006). Teaching and learning through inquiry: A guidebook for institutions and instructors. Sterling, VA: Stylus.

Lewin, D., & Feldman, D. R. (2006). Teaching evidence-based practice in nursing. New York: Springer Publishing.

Minden, P., & Gullickson, C. (2005). Teaching nursing care of the chronic illness: A storied approach to whole person care. New York: Springer Publishing.

National League for Nursing. (2003). Innovation in nursing education: A call to reform. [Position statement]. Retrieved from: www.nln.org/aboutnln/ PositionStatements/index.htm

Neuman, L. H. (2006). Creating new futures in nursing education: Envisioning the evolution of e-nursing education. Nursing Education Perspectives, 27(1), 12-15.

Oesterle, M., & O'Callaghan, D. (1996).The changing health care environment: Impact on curriculum and faculty. Nursing & Health Care: Perspectives on Community, 17, 78-81.

Paniagua-Ramirez, C.T., Barone, C. R, & Torres, I. (2004, May). Making the paradigm shift: A review of nursing pedagogical models and approaches. Enfermeria Global, 4, 1-17. Retrieved from www.um.es/eglobal

Porter-O'Grady, T. (2003). A different age for leadership. Journal of Nursing Administration, 33, 105-110.

Rabow, J., Charness, M.A., Kipperman, J., & Radcliffe-Vasile, S. (1994). William Fawcett Hill's learning through discussion (3rd ed.). New York: Waveland Press.

Rogers, E. M. (1995). Diffusions of innovations. New York: Free Press.

Ruth-Sahd, L.A. (2003). Reflective practice: A critical analysis of data-based studies and implications for nursing education. Journal of Nursing Education, 42(11), 488-497.

Schoener, L., & Hopkins, M. L. (2004). Service learning: A tuberculosis screening clinic in an adult residential care facility. Nurse Educator, 29(6), 242-245.

Spector, N. (2006, April). Systematic review of studies of nursing education outcomes: An evolving review. Retrieved November 13, 2006, from www.ncsbn.org/Final_Sys_Review_04_06.pdf

Wilkstrom, B. M. (2000). Nursing education at an art gallery. Journal of Nursing Scholarship, 32(1), 197-199.

Sylvia T. Brown, EdD, RN, CNE, is a professor and acting dean, East Carolina University College of Nursing, Greenville, North Carolina. 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, RN, CNE, is a nursing instructor and Nursing Department head, Coastal Carolina Community College, Jacksonville, North Carolina, 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 brownsy@ecu.edu.
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)
approaches)

Table 2. Teaching/Learning Strategies and Outcomes

STRATEGIES/OUTCOMES RESPONSE OPTIONS N (%)

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)
 Collaborative/
 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)
 Collaborative/
 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)
 Scholarly
 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)
 Learning/
 Self-responsibility 118 (13)

Table 3. Strategies Used by Pedagogy

STRATEGY PEDAGOGY

(Ranked most CONVENTIONAL BLENDED/MIXED INQUIRY
helpful by at
least 10 N (%) N (%) N (%)
percent of
respondents)

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

Client/
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)

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

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

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

Collaborative/
Cooperative
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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Title Annotation:NURSING EDUCATION RESEARCH
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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