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Rethinking Teaching and Assessments

TRANSFORMING NURSING EDUCATION

In their call for radical transformation in nursing education, a must read for all nurse educators, Benner, Sutphen, Leonard, and Day (1984/2010) made four recommendations to accomplish the “integration of knowledge, skilled know-how, and ethical comportment” (p. 82) when educating nurses. These recommendations call for nurse educators to:

Although the site visits that provided the information for their book were done in undergraduate programs of nursing exclusively, eight generic and one RN to bachelor of science in nursing (BSN) program, their findings apply to graduate nursing education as well. Discussing these recommendations in more detail, you will understand how they are grounded in sound educational theory and provide a framework to improve our teaching.

The first recommendation is in reaction to teaching decontextualized content organized in textbook fashion such that students’ only choice was to memorize. Content is presented in such courses as lists of isolated facts and categorized information with little indication of how to use this information. Without applying it to a specific patient’s situation, students cannot extract the important or salient information, understand why it is so, and use it to guide practice. As Brown, Collins, and Duguid (1989) note:

This authentic context provides a backdrop for the theory of situated cognition (Lave & Wenger, 1991) in which learning is enhanced when cognitive activities are embedded in a real-life context of co-participation. Foundational to situated cognition is that knowing cannot be separated from doing, and by giving students opportunities to wrestle with problems common to the role that are complex and unstable, students learn to recognize what is important and what is not when assessing a situation and problem solving. This is what Benner et al. (1984/2010) referred to when they encouraged nurse educators to teach for a sense of salience, or “linking perception and discernment with the ability to use knowledge from a rich knowledge base” (p. 83).

The second recommendation focuses on the separation of classroom and clinical teaching, which applies to online teaching as well. During the site visits that were the basis for their conclusions, Benner et al. (1984/2010) noticed that although students had adequate time to practice skills in a skills lab, for example, doing so was not embedded in a case scenario representing a real-life situation, again referring to the separation of knowing and doing from a relevant context. From an online teaching perspective, lectures are not the main teaching method as they often are in the classroom. Instead, small group discussions become the learning space. Creating engaging discussion questions (DQs), the topic of Chapter 7, allows for the combination of theory and application, content and context.

In the third recommendation, Benner et al. (1984/2010) referred to the term critical thinking, which they feel has become a “catch all phrase” (p. 84) when referring to the various cognitive processes that nurses use to problem solve. They point to the broader need for nursing students to develop skillful critical reflection, clinical and diagnostic reasoning, and “creative, scientific, and formal criterial reasoning” (p. 85) processes. However, what can be taught directly is the theory of these cognitive processes only, which results in knowing. Students then need the opportunity to develop these cognitive skills through practice using these skills (doing) when problem solving in real-life situations without the chance of hurting anyone.

To the online nursing educator, doing refers to using cognitive skills and is best promoted by teaching content within context, either engaging DQs or authentic cases. Although students may know the definition of diagnostic reasoning and the steps of the process, unless they apply that knowledge to a case situation, they are really not doing diagnostic reasoning.

Online discussions provide such opportunities, if the questions asked require higher cognitive functioning. Fact-based questions, the answers to which can easily be found in a textbook, will not suffice, yet this is what 103frequently occurs in online discussions. This not only results in little meaningful discussion, but also in repetitive answers as students struggle to post something that has not already been said. Fact-based questions can increase cognitive load (Chapter 1) when only one correct answer exists. Ill-structured and messy cases that mimic the complex nature of actual nursing practice are necessary to combine theory and practice and allow students to test the waters of the role or do the type of thinking required by the role. How to create ill-structured cases is the topic of Chapter 6.

In addition to and in order for students to use these cognitive skills effectively, developing metacognitive skills is necessary. Recall that metacognition is the executive control and regulation one has over cognition, or thinking. Although the term metacognition is often used interchangeably with reflection, reflection activities are often assigned in nursing as a means to encourage students to review something that occurred in the past. This is different from metacognition, in my view. Although both processes require thinking, the type of reflection often required of students is reflection-on-action, which occurs long after the fact. Metacognition, on the other hand, exerts control over problem solving during the problem-solving activity itself, guiding thinking to consider multiple perspectives and to question understanding (Pintrich, 2002). It is more consistent with Schön’s (1983) view of reflection-in-action, yet this term is seldom heard. Metacognition is the vehicle that sets critical thinking or habits of thought in motion and is a skill that can be learned.

The final recommendation is for nurse educators to expand their focus on socialization to nursing practice and the nursing role to that of formation. The term formation means the process of being formed or “to being constituted by the meanings, content, intents, and practice of nursing rather than merely learning or being socialized into a nursing role in an external way” (Benner et al., 1984/2010, pp. 86–87). Again the authors reiterate the need for this formation to occur in an authentic context. By placing the students in the role they aspire to through messy online case discussions, they begin to think like a professional nurse, for the RN–BSN student, and like a nurse practitioner, educator, administrator, or researcher, for the graduate nurse. Here, modeling and coaching of the role by faculty during these discussions is of utmost importance.

IMPLEMENTING THE RECOMMENDATIONS

Teaching Content Within Context

What these four recommendations have in common is teaching in context, or situated in real-life scenarios, similar to clinical experiences. This 104concept was discussed in Chapter 2 in the Situated Cognition section, but is so central to creating engaging online teaching and assessment methods that it is reviewed here. Thus, when creating authentic contexts, we want the scenarios to be true to the specific experiences students will encounter in the role they aspire to. Also important to consider, as we plan for changing the way we teach, is that assessment drives learning (Beattie, Collins, & McInnes, 1997), so the assessments we choose must be congruent with how we teach. Consequently, meeting the call to radical transformation in our teaching will require authentic assessments and authentic teaching methods.

Although the call to transform nursing education and the changes necessary to accomplish this are clearly outlined in these recommendations, operationalizing them has been a challenge for multiple reasons, one of which, I believe, is faculty lacking the know-how. The goal of this chapter is to introduce the notion that teaching methods and assessments are one and the same in online education if (a) the context for learning is authentic, a term that is reviewed in the next section, Authentic Defined, and (b) the questions asked require higher cognitive functioning to answer.

Authentic Defined

One definition of authentic can be something that is real or genuine, not copied or false; that is, true and accurate. Recall from Chapter 2 that situated cognition, a sociocultural learning theory, first introduced the importance of teaching content in context, and it is what Benner et al. (1984/2010) are referring to in their first recommendation, listed at the beginning of this chapter. In education, an authentic context is defined by its characteristics, which are listed in Box 5.1.

The most common teaching methods that meet the criterion of authentic include open-ended, ill-structured DQs, case-based DQs, case studies, unfolding cases, and problem-based learning (PBL). Creating authentic DQs is discussed in Chapter 7 and writing cases is discussed in Chapter 6. Any type of scenario or story that presents a realistic, complex problem or dilemma to be solved or a goal to be achieved that sets the stage for student collaboration in small groups will meet the criteria for authenticity. These types of teaching strategies create context if essential elements are present.

Ill Structured Defined

In addition to providing an authentic context, ill-structured or ill-defined or messy cases, as they are also referred to in the educational literature, are 105used to generate discussion and require the type of thinking that Benner et al. (1984/2010) describe as “multiple ways of thinking, such as clinical reasoning, and clinical imagination as well as critical, creative, scientific, and formal criterial reasoning” (p. 85). Problems in real life, especially in nursing practice, are inherently messy in that information that is relevant, irrelevant, and simply unnecessary is available simultaneously, and it is the nurse’s job to extract the salient data, and use the higher cognitive functions of analysis, synthesis, and evaluation in order to formulate a plan and act.

Barrows and Kelson (1996, para. 25–47) list the essential elements of PBL problems that can be applied to any authentic teaching method (see Box 5.2). Cases or DQs with these characteristics evoke emotions that aid memory (Miller, 2014), are motivating for students, develop the thought processes important for the role, and promote transfer (Norman & Schmidt, 1992).

TEACHING AND ASSESSING AS ONE

Recall from Chapter 3 that the reconceptualized view of Wiggins and McTighe’s (2005) Backward Design process for course development combined determining evidence that the outcomes had been met with choosing learning experiences and teaching methods into one step.

However, can all assessments be used to teach? Although this idea will require a reconceptualization of assessment, I would answer “yes.” The characteristics of assessments that double as methods of teaching include:

In addition, looking at the recommendations from Benner and colleagues (1984/2010), I would add that these methods are authentic and combine knowing that with knowing how and knowing when. So, basically what I am saying is that given the right framework, any assessment can be used to teach. However, in order to maintain the focus on assessing the desired course outcomes, first consider the best methods to assess the objectives and then consider how these methods can also be used to teach.

The process to determine the appropriate assessments and teaching methods begins with a review of the behavioral objectives for the course in order to ground future plans within the prescribed (from the curriculum committee) or faculty-determined learning outcomes. If the objectives have not been written, then doing so becomes the first step. Chapter 4 outlines the objective writing process. If the objectives have been provided, keep in mind that faculty cannot change them. Doing so requires approval 107from the curriculum committee, and oftentimes the entire faculty must vote on any changes.

Recall that the domain and level of verb used in the objective determines the level, but perhaps not the type of assessment. Verbs from the cognitive domain of Bloom’s taxonomy—the application level and higher—are suitable for authentic DQs or case-based learning, either in small group discussions or as the basis for multiple-choice questions (MCQs) on a test. Those written at the lower cognitive levels, knowledge and comprehension, should be assessed with questions that require recall (fill in the blank) or recognition of the content (straightforward MCQs). Note that the knowledge and comprehension levels of Bloom’s taxonomy are not consistent with combining knowing and doing as both levels are about knowing. Although skills assessment based on psychomotor or affective-domain verbs is typically done through simulation, role-playing, or demonstrations—an observation of students’ performance by faculty—high-level DQs and case-based small group discussions that begin with a video clip of the patient or other stakeholder are particularly well suited to assessing objectives written in the affective domain.

Once the level of assessment required by the objectives is understood, the key question becomes: How will meeting these outcomes play out in the students’ future role? This question will serve to maintain focus on the desired learning outcomes and specific understandings students must acquire as course planning continues. The ideal situation is for students to learn by wrestling with real-world problems that connect specific content in the course and prior knowledge to their future role. If they are given the opportunity to think like a _____________ (fill in the blank with the student’s desired role), what they are learning will be encoded in long-term memory as cases in a similar fashion to how it will be retrieved, thus making retrieval easier when the information is needed in practice. To accomplish this, authentic teaching methods situated in real-life contexts that combine knowing (content) and doing (skillful manipulation of that content and the habits of thought of the role) that promote collaborative constructivist learning can be used as the foundation for both teaching and learning. This can be accomplished with any content using cases or questions for discussion that mimic situations a student may encounter in the role.

The final aspect of assessment to consider is which assessments will be formative (assessment for learning) and which summative (assessment of learning). Again, most, if not all, types of assessment used in the online environment can be used for both. However, considering what is known from cognitive science research regarding the benefits of the testing effect and spaced study, the role of multiple-choice tests in learning and assessment has changed. Traditionally used as summative assessment in nursing 108education, their role as formative assessment and self-assessment is now well established.

Small group discussions have the potential for both formative and summative assessments if the DQ is ill structured, does not have one right answer, and requires students to employ multiple ways of thinking. To be used as formative assessment, faculty must be active in the discussion and provide feedback and guidance in order for students to meet the learning outcomes. Discussions of this type can subsequently be graded as summative assessment.

OPTIONS FOR ONLINE TEACHING AND ASSESSMENT

Given the research-based value of online group discussions, it is not surprising that they are included in the course design of most online nursing courses. A well-designed online course with authentic assessments and well-thought-out DQs is, by far, the best way to decrease faculty workload and make learning for students engaging and meaningful.

In a constructivist, learner-centered paradigm, learning should occur in a context that reflects how students will encounter the content, issues, or problems in their future roles. Ideally, this is done through group discourse in which knowledge is co-created with facilitation from faculty. The entire continuum from knowledge to evaluation in Bloom’s cognitive domain, the affective domain, and the knowledge behind learning in the psychomotor domain can be learned within a context, such as that provided by a case study or well-written DQ. The discussions or assignments that fulfill these criteria are considered authentic.

Additional assignments appropriate for the online environment, such as quizzes or lessons to support if–then thinking, may be considered authentic, but this depends on how the questions are written. Quizzes can be used to support learning of knowledge and facts and, while useful to help scaffold learning, may not be considered authentic. These assignments can be used for either formative or summative assessment, or both. It depends on how they fit into your course design and the main purpose you have decided they will serve.

Small Group Discussions

Discussion boards are equivalent to classroom discussion, but hold additional benefits in that they allow time for reflection and composition of an evidence-based, well-thought-out response. They are also beneficial for shy or less verbal students, those who do not think fast on their feet, or who 109prefer not to speak up as they are afraid their responses will be incorrect. The benefit of online group discussions is that all students must participate and their responses can be objectively graded based on a rubric. Before deciding on the type of discussion to include in your course, it is important to consider the desired outcomes.

Pedagogical Benefits of Discussions

A misconception many faculty have, most likely held over from the days when lecture was used exclusively as the teaching method, is that students must be taught basic facts, concepts, and principles before they can apply them. Experience with PBL in the basic science courses during the initial 2 years of medical school has refined what is known about how and when students are capable of learning what. Medical students are a heterogeneous lot in that their educational preparation at the bachelor’s level ranges from biology to business. Few are familiar with medical jargon, yet PBL is successful in engaging these students in the process of thinking like a physician and approaching problems with an inquisitive mind, taking responsibility for their learning. Although the problem presented may be a mystery to them initially, the process facilitated by an expert tutor encourages them to continually question what they really know and understand, identify what they need to learn to understand better and in greater depth, and the curiosity to find the answers. In other words, experience with case-based learning has brought to light that the lower levels of Bloom’s taxonomy (knowledge, comprehension, and application) can be uncovered in the process of working through more complex cases requiring higher order thinking. Time need not be spent teaching facts, as students will inadvertently learn the basic information through independent study as they assimilate what they have read. The same is true for a non-case-based DQs. Perhaps Ross (1997) says it best when referring to problem-based curricula and how readings are not assigned; instead the task is for students to locate and evaluate what resources they need to work on the problem:

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