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Student perspectives of learning goals for an undergraduate nursing class Croxen, Hanneke 2009

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STUDENT PERSPECTIVES OF LEARNING GOALS FOR AN IJINDERGRADUATE NURSING CLASS  by Hanneke Croxen  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE  in  The Faculty of Graduate Studies  (Nursing)  The University of British Columbia (Vancouver)  August 2009  © Hanneke Croxen, 2009  Abstract Effective learning is associated with students’ awareness of the importance of learning goals. Currently, the student perspective is not well understood; it is believed there is a disconnect between faculty and students’ perceptions and value of learning goals. The University of British Columbia, School of Nursing, undergraduate leadership course offers students options: an interactive classroom approach (classroom group), or a combination of classroom and a quality and safety practice environment project (the Q&S group). Learning goal surveys at the beginning of the course and end of the course were conducted to gain an understanding of whether these pedagogical strategies were successful or not, with respect to completion of course learning goals from the student perspective. Focus groups with students from both options and observations of students in the learning environment were also conducted. Data showed that Q&S students who received inductive learning reported enhanced appreciation of learning and a deeper understanding of some course learning goals. However, those students in the classroom group (who received less inductive teaching and learning strategies) believed they received a broad understanding of the course content although maybe not as deeply as the Q&S students’ understanding of course content. This study can contribute to the body of knowledge related to nursing education. A pilot study was conducted during Fall semester 2008, and additional data was then collected through summer 2009. This thesis will describe the findings and demonstrate how learning goals can be an effective way for faculty to monitor and adapt courses to facilitate student learning outcomes.  11  Table of Contents Abstract  ii  Table of Contents  iii  List of Tables  viii  List of Figures  x  Acknowledgements  xi  Dedication  xii  1 Introduction  1  1.1 Background  1  1.2 Problem Statement  3  1.3 Purpose  3  1.4 Questions  3  1.5 Significance of Study  4  1.6 Definition of Terms  4  1.7 Assumptions  5  1.8 Summary  5  2 Review of the Literature  6  2.1 Introduction  6  2.2 Importance of the Student Perspective  6 111  2.3 Importance of Learning Goals  .  2.4 Inductive and Deductive Learning  7 9  2.5 Guided Discovery Learning  10  2.6 Project Based Learning  11  2.7 Nursing Education  12  2.8 Learning in the Practice Environment  13  2.9 Learning in the Classroom Environment  14  2.9.1 Small Group Learning in the Classroom Environment  15  2.9.2 Discussion in a Large Class  15  2.10 Summary 3 Methods  16 17  3.1 Research Design  17  3.2 Setting  17  3.3 Sampling Procedure  18  3.4 Measures  19  3.4.1 Surveys  19  3.4.2 Focus Groups  20  3.4.3 Observations  20  3.5 Data Analysis  20 iv  3.6Rigor 3.7 Limitations  .21 .  23  3.8 Ethics  24  3.9 Summary  24  4 Findings  25  4.1 Introduction  25  4.2 Participants  25  4.3 Surveys  26  4.3.1 Beginning of Course Survey: Between Group Comparisons of Perceived Importance of Learning Goals  26  4.3.2 End of Course Survey: Between Group Comparisons of Students’ Perception of how well they Learned the Course Learning Goals  32  4.3.3 End of Course Survey: Between Group Comparisons of Perceived Importance of Learning Goals  39  4.4 Focus Groups  45  4.4.1Q&SGroup  45  4.4.2 Classroom Group  53  4.5 Observations 4.5.1 Communication Behaviors  58 58  v  4.5.2 Student Experiences  .  59  4.5.3 Time  60  4.6 Summary  60  5 Discussion, Implications, and Conclusion  62  5.1 Introduction  62  5.2 The Importance of Learning Goal Attainment  63  5.2.1 Inductive Learning Experiences that Impacted Attainment Learning Goals  63  5.2.2 External Factors that Influenced Learning Goal Attainment  66  5.2.3 Empowerment Influences on Learning Goal Attainment  68  5.2.4 Evaluation Influences on Learning Goal Attainment  69  5.3 Value of Learning Goals from the Student Perspective  70  5.4 Limitations  72  5.5 Implications  73  5.5.1 UBC School of Nursing  73  5.5.2 Post Secondary Education  74  5.6 Conclusion  74  References  77  Appendix 1: Course Description for N453  83  Appendix 2: Course Learning Goals for N453  84 vi  Appendix 3: Beginning of Course and End of Course Learning Goals Surveys  86  Appendix 4: Sample Questions used to Guide the Focus Group Discussions  92  Appendix 5: Consent Letter for Focus Group Participants  93  Appendix 6: Cover Letter for Beginning of Course and End of Course Surveys  95  Appendix 7: The Tn-Council Policy Statement Ethical Conduct for Research Involving Humans Certificate  96  Appendix 8: Ethics Certificate  97  vii  List of Tables Table 4.1: Number of Students who Participated in each Data Collection Method  25  Table 4.2: Differences in Students’ Perceptions of the Course Learning Goals Importance based on the Survey completed at the Beginning of the Course  28  Table 4.3: Ranking (highest to lowest) of Medians for Beginning of Course Survey Results from Classroom and Q&S Groups’ Perception of the Importance of Course Learning Goals  29  Table 4.4: Medians with a score of 4.5 or greater for Beginning of Course Survey Results from Classroom and Q&S Groups’ Perception of the Importance of Course Learning Goals  30  Table 4.5: Key of Learning Goals for Table 4.4  30  Table 4.6: Differences in Students’ Perceptions of how well they Learned the Course Learning Goals based on the Survey completed at the End of the Course  34  Table 4.7: Ranking (highest to lowest) of Medians for End of Course Survey Responses of what Course Learning Goals Q&S and the Classroom Students Thought they Learned  35  Table 4.8: Medians with a score of 4 or Greater for End of Course Survey Results from Q&S Group and 4.5 or Greater from Classroom Groups of Course Survey Responses of what Course Learning Goals they Thought they Learned  36  Table 4.9: Key of Learning Goals for Table 4.8  37  Table 4.10: Difference in Students’ Perceptions of the Course Learning Goals Importance based on the Survey completed at the End of the Course  40  viii  Table 4.11: Ranking (highest to lowest) of Medians for End of Course Survey Responses of what Course Learning Goals Q&S and the Classroom Students Perceived were Important  41  Table 4.12: Medians with a score of 5 for End of Course Survey Results from Q&S and Classroom Groups of Course Survey Responses of what Course Learning Goals they Perceived were Important  42  Table 4.13: Key of Learning Goals for Table 4.12  43  Table 4.14: Learning Goals Identified by Students During the Focus Groups as Having Met or Not Met During N453  47  ix  List of Figures Figure 4.1: Students’ Perceptions of the Course Learning Goals Importance based on the Survey completed at the Beginning of the Course  31  Figure 4.2: Students’ Perceptions of how well they Learned the Course Learning Goals based on the Survey completed at the End of the Course  38  Figure 4.3: Students’ Perceptions of the Course Learning Goals Importance based on the Survey completed at the End of the Course  44  x  Acknowledgements  I would like to thank my supervisor Dr. Maura MacPhee for all her guidance and support throughout the course of this project and my time in the masters program. You were truly a mentor and provided me with opportunities that will stay with me for many years. I would also like to thank committee members Ms. Marion Clauson and Ms. Hilary Espezel for your feedback and support with both the Q&S project and this thesis. I appreciate the time you were able to dedicate to this project. To Kris Gustavson, thank you for being so approachable while I was working on the Q&S project. And to the students of N453, thank you for allowing me to work with you and observe. Your patience and flexibility was very helpful, without your support, this project would not have been possible. To my family, back east, thank you for being behind me and helping me to recognize that this process was well worth it and one that I really wanted to do. I will remember our long talks and the support you all were able to provide. To Matthew, my husband, you have always been behind me and I appreciate all your help. I would not have been able to be here now at the conclusion of this program without you. You helped me to believe that I can do this even when I thought I could not.  xi  Dedication This thesis is dedicated to my father, Peter deRoos. Although I was not able to speak to you in person, I know you were with me throughout the past two years in sprit and will continue to be. I have learned so much from you and you will always be the inspiration that pushes me forward.  xli  1 Introduction 1.1 Background Effective learning is associated with students’ awareness of the importance of course learning goals, while the successful completion of learning goals is deemed significant by instructors (Myers, 2008). For this reason, it is important that the students’ perception of learning goals, and their beliefs about accomplishing these goals are well understood. By studying the student perspective of course learning goals, we will better understand the students’ outlook and will be able to improve the nature of how courses are taught, ultimately enhancing student development. The involvement and feedback of students gives them a voice, allowing their perception to be better understood. Faculty and students may have different learning goals that can cause conflict and can alter the teaching, learning, and student development (Myers). This information will be useful to recognize what students perceive to be beneficial to their learning and what types of learning environments best meet the needs of students. Throughout this thesis, students will refer to university learners, and faculty will refer to university instructors. At the University of British Columbia School of Nursing (UBC SoN), undergraduate nursing students are taught in a variety of ways that include simulation, clinical practicums in healthcare settings, and traditional classroom settings (UBC School of Nursing, 2008a). The Basic Baccalaureate (BSN) Program is consolidated into two years (five semesters) (UBC School of Nursing, 2008a). With intensive programs, teaching and learning activities present different challenges when compared to the traditional four year baccalaureate nursing degree programs (Suplee & Glasgow, 2008). Students in accelerated programs bring previous educational and employment experiences to their nursing program, and their diverse backgrounds present additional challenges to faculty (Oermann, 2004). Teaching strategies that 1  have worked in the traditional four year programs may not be effective for accelerated programs, and faculty are left to explore new options for teaching to help reduce challenges and facilitate better learning.  -  A leadership course in the undergraduate nursing program introduced an opportunity for students to participate in a quality and safety (Q&S) project as part of their course work. This course, N453: Leadership and Management in Healthcare (see Appendix 1 for a course description), was taught in three hour blocks over 12 weeks of a university term. The course was taught in a classroom setting with lectures, group assignments, and discussion that all occurred in class. Those students, however, who selected to participate in the Q&S project, attended five weeks of classroom teaching to obtain an overview of nursing leadership and management theory. For the remaining seven weeks of the course, they worked in teams of three to four students on Q&S projects with nurse leaders in charge of Q&S initiatives in a variety of practice settings. The nurse leaders acted to facilitate students; work in the practice settings, such as arranging for students to interview staff or review, and critique practice policies and procedures related to institutional Q&S initiatives. Because this option was not available to all students registered in the course, students were selected based on their completion of an expression of interest application and their academic standing. This option provided students with the opportunity to learn the course material outside of the classroom by taking part in projects in the healthcare setting. Those students who did not take part in the Q&S option, participated in 12weeks of classroom work that used a variety of pedagogical strategies with a focus on student interaction. The course learning goals were presented to all students in N453 in their course syllabus (see Appendix 2 for course learning goals). Both the classroom and Q&S group were provided 2  with the same learning goals. Because the two cohorts (the classroom and Q&S groups) were presented and taught the material using different techniques, there is question surrounding the students’ perspective of meeting the learning goals and the differences between the cohorts. Inductive teaching and learning practices were used in N453 both in the classroom and in the Q&S option. There was, however, a stronger inductive component with the Q&S option. N453 students were provided with a combination of guided discovery and project based learning. The inductive teaching and learning strategies used for the Q&S students were a combination of guided discovery based learning and project based learning. 1.2 Problem Statement  Currently, the student perspective about learning is not well understood, particularly students’ perspectives of course learning goals. There may be differences in faculty and student perceptions of learning goal attainment. In order to offer alternative learning options to students, such as the Q&S option, it is important to determine whether the course learning goals are sufficiently achieved through alternate approaches. Although those faculty perspectives (of those who teach the course) are understood, it is not clear what the student perspective is. 1.3 Purpose The purpose of this study is to compare the teaching effectiveness of two educational approaches for undergraduate nursing students enrolled in a nursing leadership course at UBC School of Nursing. Comparisons will be based on students’ perceptions of learning goal achievement, as well as the values they affixed to the course’s learning goals. 1.4 Questions The goal of this research study is to answer the following questions: 3  1. What are the differences in students’ perceptions in the attainment of course learning goals by participating in a classroom offering versus a Q&S project option? 2. What are the differences in students’ perceptions in the subjective value of course learning goals when participating in a classroom offering versus a Q&S project? 1.5 Significance of Study Findings from this study will be used to further adapt leadership course offerings at UBC SoN, and will contribute to the body of nursing education literature related to the importance of learning goals that guide student learning as there is a shortage of nursing literature related to this topic. This information will also contribute to how faculty employs student feedback to guide course development and revision. 1.6 Definition of Terms The terms below are defined and commonly understood within the UBC SoN for the purpose for this study. Learning Goals: Course goals developed by the course instructor for N453. These goals should be met by students upon completing the course. These goals help the student to understand what the faculty member expects of them and what they need to understand and know to complete the course (Simon, & Taylor, 2008). Student-Centered Approach: A focus on the student rather than on the instructor. The instructor supports and guides the student, while the student takes control of their own learning (Allen, Crosky, Mcalpine, Hoffman, Munroe, 2008). Practice Environment: A setting outside of the classroom where nursing students have the opportunity to apply concepts, theories, and skills learned in real life situations.  4  Classroom Environment: A setting where teaching and learning takes place outside real-life situations. This can include lectures, seminars, or lab experiences. 1.7 Assumptions Personal beliefs, opinions, and experiences are factors that can prevent objectivity (Pout & Beck, 2008). It is therefore essential that awareness of the assumptions made during the study be identified. The following is a list of assumptions that are relevant to this study: 1. All students in the N453 leadership course have completed the same nursing courses (and the same number of courses) prior to beginning the course. 2. Effective learning is associated with students’ awareness of the importance of learning goals and the successful completion of learning goals deemed significant by the course leaders. 3. The Q&S option will provide students with a practical learning approach that will allow them to meet course learning goals. 1.8 Summary By studying learning goals, we have the opportunity to better understand the students’ perspective and use such findings during course and curriculum development or revision. This will help to ensure that students’ needs are brought forward and understood so that material can be taught in a manner that best suits their needs. The findings from this study have the potential to contribute to the body of knowledge in nursing education as well as other disciplines. This can be used to further understand and improve methods of assessing and evaluating the students’ perspective of their learning.  5  2 Review of the Literature 2.1 Introduction Effective teaching and learning is the result of numerous factors. Some of these factors will be discussed in this review. Benner and Sutphen (2007) reported that best practices are not only necessary in the clinical setting, but are also needed in nursing education. To ensure this occurs, studying teaching and learning theories and techniques can help to create the ideal learning environment for student nurses. Student perspectives (of their learning experiences), learning goals, inductive and deductive teaching and learning methods, and classroom and clinical settings are just some factors that encompass undergraduate nursing education. Understanding these factors will help to provide information to guide and direct nursing programs and courses. This review of the literature will outline the research that has been done related to the topics discussed, and will provide guidance regarding best practices and recommendations for nursing education. 2.2 Importance of the Student Perspective When developing courses, it is important that nursing faculty take into consideration perceptions of students with the understanding that learners develop understanding based on prior knowledge and past experiences (Gallagher, 2007). By understanding student perceptions, faculty has a better understanding of student needs and appropriate learning goals can be developed. If students are excluded from the course development and evaluation process, there will be an incomplete picture of the true reality of the teaching and learning environment (Cook Sather, 2002). By obtaining information from the students’ perspective, teaching practices can be enhanced or altered (Lofmark, & Wikblad, 2001).  6  Throughout the teaching and learning process, faculty may believe that the information was well explained. Because students have a limited background on the topic, they may not have absorbed the information as intended, or understood the concepts in the same way the instructor does (Herpic, Zoilman, & Rebello, 2007). The students, therefore, may not be able to draw the same conclusions that the lecturer or experts in the field intended (Herpic et al.). “Since the aim of teaching is the facilitation of learning, it is suggested that the learner’s perspective must be considered, and that effective teaching can only be understood from the context of the teachinglearning transaction” (Garrison, Andrews, & Magnusson, 1995  ¶ 1). By using the students’  perspective, these gaps in the teaching and learning process can be minimized or prevented. Evaluation of student perceptions is necessary to understand before implementation of new interventions (Jeffreys, 2007). Student opinions can help faculty to understand how the interventions will be perceived by students and if they will be successful from the students’ point of view. Cook-Sather (2002) stated that there are fundamental flaws in building a system without consulting the people it will serve. This too applies to education; the student perspective can help faculty to better understand the situation from all people involved, resulting in better teaching and learning outcomes. 2.3 Importance of Learning Goals Learning goals are often put in place as the backbone to a course. These goals are also believed to be a major academic motivator for students (Miller, Greene, Montalvo, Ravindran, & Nichols, 1996). Students view learning goals as valuable to their learning experience (Simon, & Taylor, 2008) as they can help to inform students on what is expected of them and what they can expect to learn. Students have reported that having clear learning goals and assignments are important elements in their learning (Wolf, Bender, Beitz, Wieland, & Vito, 2004). 7  Having learning goals in place creates accountability for both the student and the course (Marsh, 2007). Harden (2002) further reports that the benefits of having learning goals in place include that: (i) they help the student to learn more effectively, (ii) they create clarity on what students can expect to learn, (iii) faculty can have a template to design their courses and choose appropriate teaching strategies, and (iv) help to ensure appropriate assessment material and methods are used. These goals help the student to be more informed and aware of what they are required to know and do (Simon, & Taylor, 2008; Marsh, 2007). Students who are aware of the course learning goals are more likely to meet the expectations of the course compared to those students who are not aware (Marsh). Students often do not perceive concepts the same as the faculty (Wieman, 2008). Beliefs and understanding change based on the spectrum in which a person lives ranging from novice (the student) to expert (the faculty) (Weiman, 2007). Weiman (2007) discusses that the hope is as students evolve and complete course work, their understanding becomes more expert-like. This may be why students and faculty often have conflicting learning goals (Myers, 2008). Having a better understanding of the student perspective can improve the teaching and learning experience, starting with learning goals (Myers). Students who have learning goals have been shown to have positive correlations to engagement and academic achievement (Miller, et al., 1996). By understanding students’ perceptions of course learning goals, the course can be better tailored to the students’ needs and help to ensure that the goals of the course reflect those of the students.  8  2.4 Inductive and Deductive Learning Teaching and learning can fall under two categories, inductive and deductive. Inductive teaching and learning is a student-centered approach as they require students to assume more responsibility for their own learning (when compared to traditional methods) (Prince & Felder, 2006). Students receive less instruction but learn the material by experiencing and discovering the material by completing the assigned work. Inductive teaching and learning uses different teaching methods such at problem-based learning, project-based learning, discovery-based learning, and inquiry-based learning (Prince & Felder). Deductive learning is perceived as a traditional teaching and learning method, where the faculty member provides the learner the information they are required to know (Prince & Felder). Students often memorize the material and have less control of their learning. Both inductive and deductive learning can provide students with optimal opportunities for successful learning. Deductive teaching methods are best used when learning goals are at a low cognitive level that requires almost exclusive memorization of facts and information (Prince & Felder, 2007). Here, the faculty member provides the information and the student is expected to absorb it (Prince & Felder, 2006). Inductive learning is best done in situations where students require conceptual understanding rather than memorization (Prince & Felder, 2007). One benefit in using inductive learning is that students develop critical, independent thinking skills and self-directed learning skills which are essential in nursing (Prince & Felder, 2006; Kardash & Wallace, 2001). Students, however, have reported feeling confused by some inductive teaching approaches, especially when they are used to more passive, deductive teaching approaches (Kardash & Wallace, 2001). This can lead to resistance with inductive methods as students are expected to take control of their learning with less direction from the 9  faculty (Prince, & Felder, 2007). Despite this, evidence suggests that inductive teaching strategies lead to improved knowledge of the course material and long term outcomes (Church, Elliot, & Gable, 2001; Prince, & Felder, 2006). 2.5 Guided Discovery Learning With guided discovery learning students are given a challenge or question to solve independently with minimal but systematic guidance from the faculty member (Prince, & Felder, 2006; Prince, & Felder, 2007; Mayer, 2004). This technique combines traditional and innovative techniques that result in the opportunity for “deep learning” to occur (Spencer, & Jordan, 1999). Although the faculty provides students with the problem and evaluates their work, the faculty does not direct the process that students take (Prince, & Felder, 2006). Spencer and Jordan (1999) state that “The key features are learning how to learn through the process of discovery and the exploration of knowledge, coupled with the responsibility of the learner to master the content needed for understanding” (p. 1282). Because there is concern that discovery learning will prevent students from learning the course material (due to minimal faculty input) using guided discovery, faculty do provide students with input throughout the process (Prince, & Felder, 2006). Faculty may coach, direct, or provide hints to students throughout the course of their project or challenge while not providing answers (Mayer, 2004). This teaching and learning method has lead to positive outcomes with transfer of knowledge and improved problem solving abilities amongst students (Mayer). With the Q&S group, this was displayed with a half-way meeting check in where students had the opportunity to discuss the progress of their project and were provided with feedback on how to move forward. Students were also encouraged to contact faculty and nurse leaders involved in the projects with questions or concerns they had. 10  2.6 Project Based Learning Similar to discovery learning, project based learning begins with a project or assignments that students are given (Prince, & Felder, 2006). The projects are based on real-world problems or situations (not simulated) and can have an outcome that can be applied in the clinical setting (Thomas, 2000; DeFillippi, 2001). This process challenges students to investigate and seek out solutions to real-world situations by using numerous techniques including, collecting data, developing products (presentations, documents, tools, etc.), asking new questions, communicating with stakeholders, and developing conclusions (Blumenfeld, Soloway, Marx, Krajcik, Guzdial & Palincsar, 1991). This collection of data and information is then used to create a final product. In the Q&S group, the final product may be recommendations or tools that can be used or implemented on the unit(s) to help improve quality and safety. For the classroom group, the end product may be a report or an assignment. Like guided discovery learning, project-based learning allows for faculty input as they help students to fill gaps to ensure learning goals are met (Prince, & Felder, 2006). There are two components to this learning process (Blumdfeld et al, 1991). The first component is a question that is used to guide the activities that are needed to find an answer. The second component is the result of the activities; the end product. The outcomes of project based learning are promising. Mills and Treagust (2003) have reported that project based learning with engineering students have lead to improved motivation, team work and communication skills, and students have a better and realistic understanding of application and knowledge of issues in the practice setting. Although students are not taught the information explicitly, it is taught in the process of completing the challenge(s) and builds on knowledge obtained previously from background information provided to them, previous classes, and practical experiences (Mills, & Treagust). 11  2.7 Nursing Education “Nursing education needs practices and pedagogies of interpretation, formation, contextualization, and performance.” (Benner & Stuphen, 2007, p. 108). Benner and Stuphen believe that, although nurses agree with this statement, this is not practiced in the teaching environment. Instead, they believe that there is a greater focus on a linear problem solving process. Nurses place much emphasis on their patient’s world (their family, community and any other factors that impact their lives), and these factors all influence patients lives as they experience any health care issue (from giving birth to facing death). These complex issues cannot be addressed using narrow linear problem solving concepts (Benner & Stuphen, 2007). Analyzing a variety of studies, Fomeris and Peden-McAlpine (2006) concluded that a variety of nursing education techniques appear to be effective, but they do not adequately prepare nursing students for actual realities in the clinical setting. By providing students with increased time for critical thinking, guidance and time before discussion for joumaling, and creating dialogue, asking critical questions that promote and enhance critical thinking, students demonstrated how their experiences could relate to future practice. Students should be provided with experiences where they can begin a process of combining knowledge obtained from the classroom, the clinical setting, and their own beliefs and opinions (Fomeris & Peden-McAlpine). The goal of teaching becomes the opportunity for nursing students to amalgamate the knowledge they have gained. Young, Urden, Wellman, & Stoten, (2004) stated that (what) “academic leaders must embrace is a continual development of realistic and measurable objectives and critical learning experiences that will transition the new graduate to RN in a smooth and efficient manner.” (p.  12  44) Although there are best practices in patient care, Oermann (2004) stated that best practice guidelines are also needed for teaching in nursing. 2.8 Learning in the Practice Environment Students value teaching methods (Wolf, et al., 2004) that they perceive will benefit their learning experiences and prepare them for practice. Students typically have practice environment learning opportunities during their clinical placements. Practice experiences, such as clinical placements, can help students apply theories and skills taught, working and learning from others students and staff, developing confidence as a nurse, and confirming they made the right career choice (Dunn, Ehrich, Mylonas, & Hansford, 2000). When students use hands-on learning approaches situations where students are provided the opportunity to practice skills and apply -  knowledge and theories in clinical settings they report feeling more competent in their -  attainments of knowledge and skills (Jeffries, Rew, & Cramer, 2007). Working in the clinical setting also provides students with the opportunity to work in and with teams with real world scenarios and problems. This approach, sometimes called team-based learning, promotes cooperative learning, where students have to work together to achieve a solution or outcome. Studeilts are more occupied in the learning process, and they use more communication skills to argue their answers (Clark, Nguyen, Bray, & Levine, 2008). In another example of cooperative learning in the practice environment, a group of nursing leadership students reported how they gained leadership and team work skills by working in (and with) a multidisciplinary team, and participating in change management projects (MacPhee, Espezel, Clauson & Gustavson, 2008). Although there are numerous positive benefits to exposure in the clinical setting, there are also concerns and challenges (Dunn, et al., 2000). Dunn et al. compared nursing student experiences from different ólinical settings. One finding indicated that students stated they 13  observed a hierarchy in the clinical setting where they were expected to “obey” the registered nurses instructions without asking questions, and felt that nurses did not listen to them. Some students also expressed problems when there was lack of adequate preparation prior to clinical placements. Overall, the students’ satisfaction with their clinical experiences was dependent on having a positive learning experience (Dunn & Hansford, 1997). In another study, students also discussed a lack of appropriate learning opportunities for them (Dunn, et al., 2000). Having a lack of opportunity for appropriate learning could be result the result of the complexity of patient care or the lack of opportunities provided by mentors or clinical instructors. The positive experience is created by having staff and management on nursing units recognize the importance of providing students with supports and encouraging positive relationships with clinical faculty, nurses, nurse managers, and patients in the clinical setting (Dunn, et al., 2000). 2.9 Learning in the Classroom Environment The classroom has a vital role to nursing education. This teaching environment can provide students with theoretical knowledge, discussion, and practice before entering the clinical environment; therefore, by placing emphasis on teaching and learning, the classroom setting can help to engage meaningful experiences for nursing students (Schell, 2006). In addition, the classroom environment provides for interaction with other students and faculty that allows students to assess their own level of preparation (Ryan, Carlton, & Au, 1999). This can offer students a safe environment where they can prepare for clinical settings, make mistakes, and ask questions regarding concepts or skills. Some beneficial classroom strategies are described in the following sections.  14  2.9.1 Small Group Learning in the Classroom Environment One method that can be used in the classroom setting is using small groups. There are higher rates of satisfaction amongst nursing students where class participation takes place in small groups compared to lecture format with a large group (Clark, et al., 2008). This method has also shown that students taking part in small group learning have more effective learning experiences and have improved attitudes towards learning (Springer, Stanne & Donovan, 1999). A meta-analysis on small group learning (Springer et al.) showed statistically significant and positive effects on undergraduate students learning outcomes. By using small groups in the classroom, this allowed students to apply knowledge and solve complex clinical problems. Although the large student to faculty ratio cannot be reduced in a large classroom, using small groups can create an environment that adopts the benefits of having a small student to teacher ratio (Clark et al.). 2.9.2 Discussion in a Large Class Another technique used in large classroom settings is discussion. “Deep and lasting learning is fostered when students actively engage with the concepts they are learning and construct their own understanding of them” (Boyle & Nicol, 2003, p. 43). Discussion can be held in small groups or with the entire class or both. Incorporating discussion in the classroom, students reported a more effective learning experience in the classroom (Boyle, Nicol, 2003). Students also reported that discussion provided them opportunities to reflect of the topic and understand different perspectives. In addition, students have also reported that class discussion helps them to understand concepts when other students provide an explanation to the topic or problem being discussed (Nicol & Boyle, 2003). Boyle and Nicol also confirmed that faculty 15  share similar beliefs as their students. Faculty felt that discussion promoted engagement in the class and was an essential element to the lesson. Discussion also provided faculty the opportunity to become aware of the students’ understanding of the material being taught. Ryan et al. (1999) have reported that both faculty and students reported that classroom discussion provides students with immediate feedback and even the opportunity to practice speaking in public. 2.10 Summary Regardless of the setting (clinical or classroom), as adult learners, students particularly benefit from inductive teaching and learning techniques such as guided discovery or project based learning (Prince & Felder, 2006). In addition, providing learning goals can also help to achieve optimal classroom or clinical experiences for students as they understand what they can expect to learn and gain from the learning experience (Wolf, et al., 2004). Taking all these factors into consideration can help to create favorable learning experiences from students. To ensure these practices and techniques meet the students needs we must take the student perspective into consideration (Cook-Sather, 2002). These studies support the importance of this research project, as understanding the learner’s perspective is essential to an effective teaching and learning environment.  16  3 Methods 3.1 Research Design To obtain a realistic understanding of the student perspective, a mixed methods approach was used that employed quantitative and qualitative data collection methods (Polit & Beck, 2008). This was an exploratory, descriptive study. There were three methods of data collection that were used: (i) beginning of course and end of course surveys, (ii) observations, and (iii) focus groups. Different forms of data collection provided a variety of means for students to provide study information. Using a mixed methods approach, data were obtained using a variety of methods that can be transformed to create one data set (Sandelowski, 2000). The data sets collected can also complement or depend on each other, and help enhance validity (Polit & Beck). By having numerous methods of data collection, the students’ perspective on learning could be better understood. Numerous comparisons were made with the data that was collected throughout the semester. Beginning of course and end of course survey results were compared for each of the groups (Q&S option and classroom), and comparisons were also made between the two groups. Survey comparisons were reinforced with observations of the two groups, as well as separate focus groups. 3.2 Setting This study was carried out at UBC SoN. Participants were students enrolled in the undergraduate nursing program at UBC. This is an accelerated, 20 month/five term Baccalaureate program where students have completed a minimum of 48 credits prior to entering the nursing program (UBC SoN, 2009b). The undergraduate nursing leadership course, N453, is  17  a required course for completion of the nursing program at UBC, and it is offered to students during their fourth semester in the program. 3.3 Sampling Procedure The sample included all students enrolled in N453 for the winter semester of 2009 at the UBC SoN, a total of 53 students. Students were provided the opportunity to take part in the Q&S option and were selected by the course instructor based on an application filled out by those who were interested. Academic standing was another consideration. There were 16 spots available for students to take part in this option and there were 14 students who enrolled. All students enrolled in N453 were asked to complete a beginning of course and end of course survey. The surveys were accompanied by a cover letter explaining the study, and the instructor and researcher were available to answer questions prior to completion of the surveys. Students had access to the survey questions and the cover letter at least 24 hours before survey collection. The surveys contained no personal identifiers other than whether students were in the Q&S option or the classroom component. Upon completion, students were asked to place their surveys in a research folder. In addition to the surveys, students were asked to volunteer from both Q&S and classroom groups to participate in focus groups. Students received a consent form describing this portion of the study. Interested students contacted the researcher to set up times to participate in focus groups. Students had over 24 hours to read through the forms and contact the researcher prior to the focus groups. Focus groups took place at the UBC SoN in a quiet, private location. The researcher took notes and audio taped all the sessions. Focus group participants received a lunch and a $25 gift certificate as a thank you for their time.  18  Observations were made by the researcher as students worked on interactive exercises during class or on Q&S project work. No specific identifiers were included in the researcher’s observation notes. Permission to observe was obtained by the instructor in advance. Observations were covered by an ethics protocol developed by the UBC Carl Wieman Science Education Initiative. The observations helped to determine efficiency and effectiveness of the activity pertaining to obtaining learning goals. This provided information that can help show the culture in which students learn (Mays & Pope, 1995) and how and if they were meeting course learning goals. Observations can provide information that both surveys and focus groups cannot provide as it can identify behaviors and routines that the students may not be aware of (Mays & Pope). 3.4 Measures 3.4.1 Surveys The goal of the beginning of course survey was to obtain information regarding the students’ perception of the importance of course learning goals with respect to their practice environment experiences during clinical rotations. See Appendix 3 for a copy of the beginning of course and end of course surveys with the 37 course learning goals developed by the instructor. Students were asked to identify if they were in the Q&S option or if they were in the classroom group for both surveys. By differentiating between students in the two options, comparisons were made that provided insights of the differing opinions and perceptions between the two groups. The end of course survey asked the students to repeat the importance ratings for the 37 learning goals at the end of the course, and also asked the students to rate their perceptions of learning goal achievement for each goal. All the beginning of course and end of course survey questions were structured as a five point Likert scale; from not important (1), to very important 19  (5). The structure of the surveys was reviewed with a UBC Educational Psychologist, Dr. Kadriye Ercikan, who specializes in assessment tool development. 3.4.2 Focus Groups Focus groups were conducted with both groups of students at the end of the term once the course work was completed. There were two focus groups that were conducted. One focus group was held with the Q&S group and the other with the classroom group to help ensure a homogenous group. Each of the focus groups had eight participants. Each session was scheduled to last approximately one hour. A series of questions were asked to each group (see Appendix 4 for sample questions) to help guide the discussion. Questions differed slightly between groups based on relevance to the particular group. The questions were pre-approved by the instructor and the thesis committee. 3.4.3 Observations Students in both options were observed. Classroom students were observed throughout the term during lectures, discussions, and while completing in-class group work. Q&S option students were observed as they worked on their projects. A field diary was used to record the estimated time spent on class/option work, as well as the types of student activities, such as group discussion that was held. The researcher’s thoughts and feelings regarding the observations were also recorded in the diary. 3.5 Data Analysis Although the surveys used Likert-like scales, due to small sample sizes, medians were used to make comparisons between the groups. Due to violation that would occur as a result of having a small sample size, the data was treated as ordinal. Medians were used to allow for 20  visual comparisons of the data, using tables and graphic displays. Difference scores were calculated to show differences between the groups. The tables in Chapter 4 also showed rank orders of the learning goals for each group from the highest to lowest. The focus group data were organized according to the questions asked. These were direct and concrete questions that elicited self-explanatory responses from both groups. Observation data were organized into categories for group comparisons according to verbal communications, activities or behaviors, and environmental conditions of the setting. This data were coded based on the notes that were made during observations. The notes were themed and categorized based on comments students made, how students behaved and interacted, the environment where they were learning, and personal perceptions and opinions. From the themes that were created, they were further categorized into the themes discussed in the Findings which include: (i) communication behaviors, (ii) student experiences, and (iii) time. 3.6 Rigor Rigor used in research is put in place to help ensure validity, reliability, appropriate sample size and generalizability (Collingridge & Gantt, 2008). This can help to enhance the inferences made from the study (Polit & Beck, 2008). Triangulation was used in this study as a method to obtain and analyze data using a variety of techniques (Polit & Beck). Because this area of research is not well understood, using triangulation can help to present the full complexity and issues of the student perspective of learning goals (Polit & Beck). This also is a means of ensuring rigor, as using multiple data collection techniques can help to understand and obtain the truth (Pout & Beck). Each source of data complements the other, to provide the “full picture” and to confirm all sources of data.  21  The beginning of course and end of course surveys used were not validated. To ensure that threats to rigor and validity were minimized, the surveys were reviewed by other researchers. Homogeneity was also used to ensure that external factors would not impact the results. Students were asked to complete the survey at the same time and all students in N453 had completed the same requirements. Focus groups were chosen as the optimal method for collecting the qualitative data for this study because it provided participants the opportunity to discuss openly as a group their thoughts and opinions. There was concern, however, that some participants would not feel comfortable discussing the topic with others. This concern was minimized by having small groups in a neutral setting. There was also concern that participants would only express others’ values and opinions, rather than their own. The researcher tried to be aware of this and ask questions to diversify responses to the questions. Although there were specific questions, participants were provided with time to express themselves, and appropriate follow-up questions were asked for clarification or further probing. Focus groups were recorded and notes were taken as well to ensure that data collected were accurate. Focus groups were driven by participants. When observation data were collected, note taking included personal opinions and thoughts and a diary to better understand and identify personal biases. Observations were made in a neutral and non-judgmental fashion to help ensure students that they were not being evaluated. Observations were also conducted in “natural” settings where students completed course work. Observations also continued until data saturation was reached to ensure that the data was complete and true.  22  3.7 Limitations The limitations of this study could impact the results and interpretation of the data. The surveys were not formally validated, although they were reviewed by an educational psychologist and expert educators. These surveys were created for the study because there were no tools available that have been validated to assess student perception of their learning. This data may help to create a validated and reliable tool in the future. Although the majority of students were present for the beginning of course survey, over the course of the term, students did not always attend class. The end of course survey, in particular, may have been influenced by student class attendance during the term. To help maximize student exposure to class content and all the learning goals, the instructor gave intermittent, in-class graded assignments to promote regular attendance and participation. This was a convenience sample of only one class. It will be important to continue surveying students and having focus group discussions to elicit students’ perceptions of the learning goals. The survey and focus group opinions may be based on other factors that were not related to the course learning goals, and repeated administrations in other classes will help identify ongoing issues related to the learning goals. With the focus groups and the observations, there was the possibility of researcher bias, particularly after the researcher did significant background reading on learning goals and inductive teaching strategies. Journaling was done to create awareness of biases and to help reduce the possibility of researcher bias during the focus groups and observations. Because students volunteered to take part in the Q&S option and volunteered to partake in the focus groups, there was the risk of selection bias. With students who took part in the focus groups, selection biases may have resulted in students speaking up about the course based on 23  strong beliefs and opinions. The incentives, a gift card and a free meal, may have also caused bias. To help minimize this, students were signed up to participate on a first come first serve basis. 3.8 Ethics Ethics was obtained through the Behavioral Research Ethics Board of UBC. Approved ethics protocols were used to acquire student approval prior to any data collection. Please see consent forms completed by students taking part in focus groups in Appendix 5 and Appendix 6 for the beginning of course and end of course survey cover letter. The Tri-Council Policy Statement Ethical Conduct for Research Involving Humans was completed by the researcher, and a copy of the certificate can be found in Appendix 7. 3.9 Summary The completion of the surveys, observations and the focus groups helped to determine the students’ perspective of educational effectiveness of the course with a particular focus on the course learning goals. By using the strategies discussed to collect and analyze the data, it was possible to gain a clearer sense of the two student groups’ point of view. A triangulation approach was helpful in drawing conclusions, and these qualitative and quantitative strategies will continue to help faculty develop and design courses with student input.  24  4 Findings 4.1 Introduction Survey, focus group, and observation data were obtained to address and understand how students perceive how well they accomplished the 37 learning goals from N453. The fmdings presented herein identified themes and trends that will provide insight on the students’ experiences and perceptions, ultimately providing insight the teaching and learning experience, and aspects of course learning goals that students’ value. 4.2 Participants Participants of this study were students registered in N453 offered from January 2009 to April 2009. All students were enrolled in the UBC Undergraduate Nursing Program. Students consisted of male (N=7) and female (N=46) who all had previous undergraduate experience prior to entering the nursing program. Participants were in their fourth term (final semester) of the nursing program. Table 4.1 outlines the number of students that participated with each data collection method. Table 4.1: Number of Students who Participated in each Data Collection Method Activity  Q&S Participants  Classroom Participants  Beginning of course survey  10  26  End of course survey  13  22  Focus groups  8  8  Observations  6  33  25  4.3 Surveys The survey data were analyzed using descriptive techniques. Tables and figures were used to help provide a visual display of the data and to indicate differences or similarities in the data. This data compliment the focus groups and observations. 4.3.1 Beginning of Course Survey: Between Group Comparisons of Perceived Importance of Learning Goals To address and compare the classroom versus the Q&S groups’ perception of the value of course learning goals, a survey was provided at the beginning of the course. Table 4.2 gives the medians for each learning goal for the Q&S group and classroom group of what learning goals they believed were important. For both groups, no learning goal had a median less than 3. Every learning goal for both groups was between 3 and 5. Figure 4.2 provides a graphic display of how the two groups rated the importance of each course learning goal. Tables 4.3 and 4.4, show the rankings for course learning goals and the highest medians. Both objectives 20 “Describe effective conflict management strategies.” and 29 “Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting.” had the highest medians for the Q&S and classroom groups as outlined in Table 4.4. Out of the 37 learning goals, 21 had medians that were the same for the classroom and Q&S groups. There were 15 learning goals that were scored higher by the Q&S students compared to the classroom group. One learning goal, 12 “Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel).” had a median that was greater for the classroom group when compared to the Q&S group. There were 12 learning goals that had a difference greater in medians of 1(4, 6, 7, 15, 17, 18, 19, 25, 27, 32, 34, and 37); see 26  Appendix 2 for descriptions of the learning goals. There were no differences higher than 1. Table 4.2 outlines the differences between the two groups for each learning goal.  27  00  —  Ui  C Ui  C C C ‘  C —.  C C C C  C — Ui  .  C  C  4 .I .I Ui Ui Ui Ui .I Ui  Ui  -  Ui  .I Ui .I .I 4 .1 Ui .4 Ui .l .f  C C  .  -  Ui  Ui  .I .I 4 .4 .  CJi -  C3  Ui  Ui  C  .  .  —  -  CD  Cl)  C C C  -‘  CD  0  CD  -  0 C  l-  Cl)  IC) o Cl) ts)  CD  C/)  C) o  CD  —t  — cJQ o  CD  CAD  -  CD CD  CD CD  o o  CD  CD Cl)  II  C  -“  )c  CD  i—  444mS  .l 4 Ui 4 Ui 4  00  C C C C• C C C  .  -  )J—--———————— C k) — C C 00 L3 — 3 CJ O CJ — C (J C C 00  —_1  r CD  o  I  CD  Cl)  C  CD  Cl)  C  CD C) CD  Cl)  CD  -  -.  C) CD  CD  H  k)  Li) )  Li. IN) INJ I’J t’J INJ — C 00 ON U. C) ) I— ON 4  Li)  Li)  Li)  k) t’-)  Li  Li)  00  U.U.  )  -  Li  Li)  -1 -  -  —. C 00  -.  (M  Li3  t’J  -  —.-  .  Li)  -I -I 4 -I  ON U  ‘  4 4 4 4 4  C C 00  4 4 4  L’J  ON Li) L’-)  -  i)  4 -i -i -1 -I -l -1 -I -l -I  ON U. -1 Li) C 00  Li)  4 4 4 4 4 4 4 4 4 4 4 4 4 4  L’J Li.) LJ -I ON C-f.  -  —  -  •  —a C D 00 —.I U.  •  a -  -  -f -1 4 4 -I -l -1  D ON U. -I Li) t’J  —‘  U. U. U. U. U. U. U. U. U U. U.  —a  L’J -i C Li)  C,  CD  -  -#  .  CD  CD  -*  0  ON  CD  0  ‘E  CD  )  C) —  0 O  ‘.—  —  C2  ,I  d? CI)  c)z  CD  H  Cl)  0  •  CD  CD  -* ((1  0  o  p C) CD  o  CD  0  0  i-..  CD C) CD  (I)  0  0  C,)  Cl)  CD  CD  CD Cf)  0  (Th  0  —.  .  CD  0  i-.  _,  CD  0  -  CD  CJ9  .  ii  CD O  —  C’  (•)  Table 4.4: Medians with a score of 4.5 or greater for Beginning of Course Survey Results from Classroom and Q&S Groups’ Perception of the Importance of Course Learning Goals Rank 1 2 3 4 5 6 7 8 9 10 11  Learning Goal for Q&S 4 6 15 17 18 19 20 27 29 34 37  Q&S Median 5 5 5 5 5 5 5 5 5 5 5  Learning Goal for Classroom 29 12 20  Classroom Median 5 4.5 4.5  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  Table 4.5: Key of Learning Goals for Table 4.4 Learning Learning Goal Description Goal 4 Identify examples of effective nursing leadership in the practice environment. 6 Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations. 12 Make an appropriate patient assignment for RNs, LPNs, care aides (non licensed personnel). 15 Design an ideal care delivery model for today’s practice settings. 17 Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. 18 Describe the components of an effective healthcare team. 19 Provide examples from practice settings of effective and ineffective healthcare teams. 20 Describe effective conflict management strategies. 27 Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment). 29 Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting. 34 Provide examples of how new nurses can function in leadership roles in the practice environment. 37 Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting? 30  o  Cl  0  I  (01  OIl  011  (0’  —  00  01  — --..-.  (0  —  (0  I  —  —  i  q  ____—  I  • 01  --...-—---..  — —  I  (0 (0  ..__—  _i  U)  _— — — —  (0  Medians (Not Important-i to Very Important-5) 01  —-1  CD  Cl)  o  .  CD  CD  o  ‘-  I  •1  0  C)  CD  0  0  -;1 CD -s C)  CD  ‘.1-i  4.3.2 End of Course Survey: Between Group Comparisons of Students’ Perception of how well they Learned the Course Learning Goals To address and compare the classroom versus the Q&S groups’ perception of how well they achieved course learning goals, a survey was provided at the end of the course. Table 4.6 shows the medians for each learning goal for the Q&S and the classroom groups regarding which learning goals they believed that they learned in N453. For the Q&S group, the lowest median was 2.5 for learning goal 24 “Critique the effective and ineffective qualities of healthcare organizations’ Vision/Mission statements”. For the classroom group, the lowest medians were scored 3 for learning goal 15 “Design an ideal care delivery model for today’s practice settings”, 20 “Describe effective conflict management strategies”, and 36 “Identify the key steps related to the professional responsibility process (i.e., professional responsibility form)”. The learning goals for the Q&S group had medians that ranged from 2.5-4 and classroom group had medians that ranged from 3-5. Table 4.7 and 4.8 show the rankings of the course learning goals and the highest medians for both groups. Both objectives 6 “Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations” and 9 “Describe the styles and competencies associated with effective leaders” had the highest medians for the Q&S and classroom groups as outlined in Table 4.8. The medians for the Q&S group were scored equal or less when compared to the classroom group. Figure 4.2 provides a graphic display of how the two groups rated their perception of how well they learned the course learning goals. Out of the 37 learning goals, there were 13 learning goals with the same medians. There were 24 learning goals that the classroom group scored higher than the Q&S group, and none that the Q&S group had scored higher than 32  the classroom group. Table 4.6 shows that there were numerous differences in medians of 1 or greater. There were 3 learning goals that had a difference greater than 1. They included learning goal 24 “Critique the effective and ineffective qualities of healthcare organizations’ VisionlMission statements.” (a difference of 2), 27 “Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment).” (a difference of 1.5), and 32 “Provide examples from practice settings of horizontal violence” (a difference of 2).  33  Ui  L’J ‘—‘  0 00  C  --‘JC  ‘  Ui  Ui  c-”  C Ui  CC—  0 00 Ui  -I L) k) C  Ui  ‘-‘  CD  C C  I-  C/)  I’) ‘J C,)  II  I  I  CD  CD  CD  R rj  C  •-t  C  (11  C  C) CD  CD  c,J  CD  rf)  CD  CD 4  H  o  (-)  Ct’  o  LI -  CD  c  pz  -  CD  CD  CD  -  c,  ‘-v  LJ,C  ‘  ,—  444ThS:.  C —--CCCC-C• CC--  C  CD  —-g) —.  Q•’  •d)  0  Vi  CD  CD  CD  1Q  D  o  C  Cl) Cl) I-i  I—  (_)  0  Cd)  CD  Cl)  0  CD  CI)  CD  0  c:  CD  Cl)  CD  0 cL  CD  0  Cl)  CD  CD  H  )  (.1)  Cl)  0  I  CD  Th  Table 4.8: Medians with a score of 4 or Greater for End of Course Survey Results from Q&S Group and 4.5 or Greater from Classroom Groups of Course Survey Responses of what Course Learning Goals they Thought they Learned Rank 1 2 3 4 5 6 7 8 9 10 11 12  Learning Goal for Q&S 4 5 6 7 9 11 12 13 21 23 35 37  Q&S Median 4 4 4 4 4 4 4 4 4 4 4 4  Learning Goal for Classroom 9 32 6 24 27  Classroom Median 5 5 4.5 4.5 4.5  -  -  -  -  -  -  -  -  -  -  -  -  -  -  36  Table 4.9: Key of Learning Goals for Table 4.8 Learning Learning Goal Description Goal 4 Identify examples of effective nursing leadership in the practice environment. Perform an analysis of healthcare settings using evidence-based quality 5 practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice 6 environment positively influences outcomes for: a) patients, b) nurses, c) organizations. 7 Identify the key components of an organization’s structure using an organizational chart. Describe the styles and competencies associated with effective leaders. 9 11 Identify the similarities and differences between scopes of practice for RNs and LPNs. 12 Make an appropriate patient assignment for RNs, LPNs, care aides (nonlicensed personnel). 13 Describe the difference between licensed healthcare professionals and unlicensed professionals. 21 Explain the relationship between effective communications and safe and effective teamwork. 23 Describe the relationship between effective leadership and effective change management. Critique the effective and ineffective qualities of healthcare organizations’ 24 VisionlMission statements. 27 Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment). 35 Describe the key functions of the CRNBC and the BCNU. 37 Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  37  00  C.)  —  —  —  I  — . — . — I  — .  —  —  q  -  .?wMg  *S!  — —  -  -  Medians (Did Not Leam-O to Learned WelI-5  CD  o  CD  l.)  0  tn  -. CD  -  CD  ‘  -,  C)  o  CD  .  CD 1D  I:  CD  CD  0  0  ; 0  C) CD  CD  -  CD -I  jQ  4.3.3 End of Course Survey: Between Group Comparisons of Perceived Importance of Learning Goals To address and compare the classroom versus the Q&S groups’ perception of the value of course learning goals, a survey was provided at the end of the course. Table 4.10 gives the medians for each learning goal for the Q&S and the classroom groups regarding which learning goals they believed were important. For the Q&S group, the lowest median was 4 for 22 learning goals. For the classroom group, the lowest median 3.5 for learning goal 25 “Appropriately utilize change management tools, such as Lewin’s force field analysis and SWOT analysis to determine whether a healthcare setting is ready for change”. The learning goals for the Q&S group had medians that ranged from 4-5 and the classroom group had medians that ranged from 3.5-5. Table 4.11 and 4.12 show the rankings of the course learning goals and the highest medians for both groups. Objectives 4, 6, 9, 11, 12, 13, 16, 17, 21, 34, and 35 had the highest medians for the Q&S and classroom groups as outlined in Table 4.12; see Appendix 2 for descriptions of the learning goals. The medians for the Q&S group were scored equal or less when compared to the classroom group with the exception of learning goals 22 and 31. There were 20 learning goals that were the same for both groups. The classroom group had 13 medians that were higher than the Q&S. The Q&S group had 4 learning goals that had higher medians than the classroom group. Figure 4.3 provides a graphic display of how the two groups rated their perception of course learning goals they believed were important. Table 4.10 shows the differences in medians of 1 or less. Learning goals that had a difference of 1 were 8, 10, 18, 20, 27, 29, 32, 33, and 37; see Appendix 2. 39  -  (J  CJ  cj .I tji  4  .  t’) 0 00  U 4 4 4 .I .1  C  -  U.  -  -  .I (J  L) L’J -  O U 4  J  -  U. -I .1 .I (J (Ji -l .I U. U. U. .l U.  C  - 0 00 00  4 U.  4  U. .1 .I .1  CD  CD  ‘—,  k)  CD  0 0  Cl)  L’J  IIc-  CD  Cl)  CD  II  cQ  k) — 0  CD  -t Cl)  o  CD  0  rn  CD  o  C)  CD Cl)  o  I:  0  (-)  CD  0  Cf)  0  (1)  C) CD  CD  •‘•)  H  )  k) ) L’J C 00 - ON CJ 4 (.) D 00 (Ji  .  oo —  c ‘—  ON ON -I D C-ti .i  C-ti  -  ‘  k)  —a -) I  00  C-J t’J ‘-  C-’  4 C-k) ‘J  -1 -I - -I - -L -I .1 4 -1 -1 -1 .1 4 -I -I -I - - -I -I -l  ON  CJJ  CJ  C-ti  cl-i 4  t’J ‘  —. ON C13  C  ‘  ON  Cl)  t’J  —  I-  r CD  CD  0 I  CD  JL’)  II 0  CD  o  CD  -  -  C-J  C/)  CD  C)-  0 00 ON C-ti - 0  C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti C-ti  —  ‘  CD  c,  Cl)  CD  (I)  C •.-  (Th  C C  Cl)  CD C-  Cl)  CD  0  CD  0  Cl)  CD  41  CD C-  ‘•  Cl)  CD  -  Cl)  o  0  P  CD  c  Cl)  IC  o  H  P Q_ CD  Ii  CD  o  (j  L’J  ( C  Ui  CJ  Ui  4  C  k) k) k) •  —  —  — — L) k) —  —  0 00 0  Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui  t) k) k) — — k) D -.I 00  U  C)  Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui Ui  Ui -I  C.i)  I  I  I  ..-  —  -  0C) 00  -i  1  CD  l-  .  -  CD  Cl)  -  D  d  I  CD CD  I  0  0  C/) C,)  H  Table 4.13: Key of Learning Goals for Table 4.12 Learning Goal 4  5 6 8 9 10 11 12 13 16 17 18 20 21 22 27 29 31 32 33 34 35 37  Learning Goal Description Identif’ examples of effective nursing leadership in the practice environment. Perform an analysis of healthcare settings using evidence-based quality practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations. Describe practice environment outcomes resulting from restructuring. Describe the styles and competencies associated with effective leaders. Provide evidence from the research literature of how effective nursing leadership positively influences outcomes for: a) patients, b) nurses, c) organizations. Identify the similarities and differences between scopes of practice for RNs and LPNs. Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel). Describe the difference between licensed healthcare professionals and unlicensed professionals. Describe the roles and responsibilities of all members of a healthcare team. Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. Describe the components of an effective healthcare team. Describe effective conflict management strategies. Explain the relationship between effective communications and safe and effective teamwork. Provide examples from practice settings of nursing leaders using effective and ineffective conflict_management_approaches. Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment). Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting. Describe the benefits of different types of networking. Provide examples from practice settings of horizontal violence. Describe strategies for effectively managing horizontal violence in the practice environment. Provide examples of how new nurses can function in leadership roles in the practice environment. Describe the key functions of the CRNBC and the BCNU. Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  43  ‘  ,  — I_  — — __f —  —  —  —  —  — —  —  —  —  —  —  —  _____  F  • •  I  —  —  —  I  I  .-  — — — — — — — — —  _—.  —  — — —  .— —  —  —  —  ,  —  —  —  -  — — — — — — — — — — — ,-  —  — — — — — —  —  0  I  0  2  LI)  0  0  p  —  -  c 0  0  rn  —  —  I  -  — —  —  -  0  —_ — — __ .i_ •i-i — — ___•.  — — — — — — I — — — — — — — —r — — — — — — ii I • — — — _.. _. — — — — — — — —I— — — — — — — — — — — — — — — i_I.  — —  —  —  — — — — — — — — — — —  — — — — — — — — —  —  —  —  Median (Not Important-i to Very Important-5  4.4 Focus Groups Although there were some common themes observed during the focus groups with the Q&S and classroom groups, there were also themes that were unique to each group. During both focus groups students discussed the pros and cons of their group and of the other group. These findings will be identified based on the responses students provided for each question that was asked during the focus groups (see Appendix 7). There were slight differences in the questions asked to the Q&S and classroom groups. This is because the teaching and learning techniques were different and therefore, some questions would not apply to both groups. 4.4.1 Q&S Group 4.4.1.1 Review learning goals and discuss which ones you met and did not meet. Why or why not? During the focus groups students addressed the questions and highlighted some learning goals that they believed that they did and did not meet. Table 4.14 compares the learning goals that students identified in the focus groups that they had and had not met in N453. Although Q&S students did not identifr meeting some of the course learning goals, they believed that they still understood the underlying concepts of them. One student in the Q&S group stated: “...the networking showed its self as really important because by having the connections we could get things done.” The Q&S group believed that their experience in completing the project allowed them to observe examples of some learning goals, despite being unable to give an actual definition. One student stated:  45  “I learned it, and I learned how to do it more effectively but if you asked me what are the components of conflict management I’d probably guess communication, respect.” Q&S students reported not meeting 10 of the 37 learning goals: 14, 15, 24, 25, 26, 27, 28, 29, 32, and 33. Students believed that this was a result of missed class time while they worked on their Q&S project. One student also believed that numerous learning goals were met previously from other classes and clinical experiences. In addition, there were 5 learning goals (4, 9, 20, 22, and 23) that students believed that they had met. Students felt that these 5 learning goals were well learned because of their exposure and experiences to them during their project. Students especially believed that the Q&S project provided them with exposure to different leadership styles as students were able to observe, meet, and work with numerous nurse leaders. Learning goal 20 “Describe effective conflict management strategies” was unique as classroom students believed that they did not achieve this goal, while Q&S students identified this learning goal as one that they learned well. Q&S students agreed that they could not provide a definition of conflict management (learning goal 20), they believed this is something that they dealt with frequently. “Whether or not we actually learned it, we learned it, whether or not it was actually done in a power point slide or not, we definitely got a lot of that from this”  46  Table 4.14: Learning Goals Identified by Students During the Focus Groups as Having Met or Not Met During N453 #  1 2 3 4  5 6 7 8 9 10  11 12 13 14 15 16 17 18 19 20 21  Learning Goal  Provide examples of current quality and safety trends in healthcare. Provide examples of healthcare innovations from practice settings. Describe the necessary components of effective innovation. Identify examples of effective nursing leadership in the practice environment. Perform an analysis of healthcare settings using evidence-based quality practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations Identify the key components of an organization’s structure using an organizational chart. Describe practice environment outcomes resulting from restructuring. Describe the styles and competencies associated with effective leaders. Provide evidence from the research literature of how effective nursing leadership positively influences outcomes for: a) patients, b) nurses, c) organizations Identify the similarities and differences between scopes of practice for RNs and LPNs. Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel). Describe the difference between licensed healthcare professionals and unlicensed professionals. Describe the positive and negative attributes of different nursing care delivery models. Design an ideal care delivery model for today’s practice settings. Describe the roles and responsibilities of all members of a healthcare team. Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. Describe the components of an effective healthcare team. Provide examples from practice settings of effective and ineffective healthcare teams. Describe effective conflict management strategies.  Classroom Group Met Did Not Meet  Q&S Group Met Did Not Meet  *  *  *  *  *  *  * *  *  *  *  *  *  *  *  *  Explain the relationship between effective communications and safe and effective teamwork. 47  #  Learning Goals  22  Provide examples from practice settings of nursing leaders using effective and ineffective conflict management approaches. Describe the relationship between effective leadership and effective change management. Critique the effective and ineffective qualities of healthcare organizations’ Vision!Mission statements. Appropriately utilize change management tools, such as Lewin’ s force field analysis and SWOT analysis to determine whether a healthcare setting is ready for change. Describe the social-emotional outcomes related to change in the workplace. Identif,’ strategies that nurse leaders use to empower their staff (structural and psychological empowerment). Provide examples from practice settings of nurse leader empowerment and nurse staff empowerment. Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting. Describe how shared governance/shared leadership can be an effective nurse empowerment strategy. Describe the benefits of different types of networking.  23 24  25 26 27 28 29 30 31 32 33 34 35 36 37  Classroom Group Did Not Met Meet  Q&S Group Met Did Not Meet *  *  Provide examples from practice settings of horizontal violence. Describe strategies for effectively managing horizontal violence in the practice environment. Provide examples of how new nurses can function in leadership roles in the practice environment. Describe the key functions of the CRNBC and the BCNU. Identify the key steps related to the professional responsibility process (i.e., professional responsibility form). Identifkj examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  *  *  * *  *  *  *  * *  *  4.4.1.2 Do you think this approach was worthwhile? Do you think this was quality learning time for you? Students had different opinions regarding this experience but indicated that they believed that with some learning goals, such as those they outlined in Table 4.14 as goals they learned well, this option was valuable. Students reported that despite their belief that they did not meet numerous learning goals, those that they did meet, they leant a lot about.  48  “I felt like the ones that I did meet I met much more effectively than I ever would have in class, whereas if I had gone to class... I probably wouldn’t have met many of them that were there.” The Q&S group felt that their experience provided them a learning environment that was conducive to their learning. One student stated that: “I much prefer to do hands on application of the material then sit in a lecture.” And another student then followed by saying: “I just don’t learn when it’s the PowerPoint and lecture.” One Q&S student, however, reported that having more structure would have been helpful. “I’m the kind of learner that... I need more structure than less structure... if you want me to do something I will do it but just tell me what you want....” The Q&S students felt that although the classroom group was likely able to meet more learning goals, and did not spend as much time on school work as they had, they reported that the learning that they experienced was more meaningful to them. “I really enjoyed applying theory... I will remember this project in 2 or 3 years time as opposed to a lot of other projects that we have done.” Overall, students appeared to value this type of learning experience. Students stated that they liked having the freedom to decide how to organize their project while reporting that the mentor should be there to guide students through. The Q&S groups expressed different opinions regarding empowerment. Some students identified this experience as very empowering, while others felt that they were not given respect, or felt that their project would not be used, which were both disempowering experiences for them. 49  “It is... empowering cause you feel like you are really.., implementing change.” “Sending out email after email after email and making phone calls, people were just not.., willing to talk to you. Maybe it’s part of being a student but I also... worry... when I’m a new nurse maybe trying to do that, is that going to be the same situation? If I don’t know that person, are they even going to bother to return my phone call?” 4.4.1.3 How do you think you should be evaluated? The Q&S group agreed that they wanted a greater percentage of their final mark on their work, results, and recommendations of their project or the process of their work. They also suggested that defining the scope of the project could be worth marks (which could be done at the beginning of the project). Students agreed that marking their project deliverables may be difficult. Students indicated that the work they put into their project should be given greater value in their course evaluation as they spent much more time on the project than on assignments “We spent... so much time on them (the projects)... the 5 pg paper is worth 30%... I felt I didn’t put nearly enough effort into that as I did in this whole thing (the project).” 4.4.1.4 What went well? Students stated that having time dedicated to work on the project (Monday mornings when the classroom group was in class) was very helpful. Students also reported that they had a halfway “check-in meeting” which they thought was helpful. “I did like that check in mid way through, it... gave us a chance to chat with them and say this is the problem that we are currently having and this is how many hours we’re at approximately, do you think this is reasonable?”  50  Q&S students were assigned a mentor, a nurse leader (a registered nurse in a leadership role including a manager or nurse educator) who was there to provide guidance and support throughout their project. Having a good mentor really helped students with their project. Students also reported that mentors who were committed to the project and who made themselves available to students were a valuable asset to them. “We knew who everyone was, if we were contacting other hospitals we’d mentioned her name, she’s already contacted them, letting them know that we’re going to be in touch with them so it was a breeze getting in touch with everybody which was fantastic.” “I thought our mentor was great too. I know some people had really poor experiences with their mentors. But for us, we had a mentor who was genuinely interested in having students work on this project and I think that’s really important.” 4.4.1.5 What were the challenges you experienced? Students identified that one major challenge that they experienced was the amount of time that they were allotted to work on the project as it was difficult to complete the project within the allotted 30 hours. It was also expressed that the classroom group did not work as much as they had. “You feel like you need a lot more time... it took us quite a while even to just get to a stage where we could start making recommendations” Students also reported that there was much work to do outside the allotted Monday mornings that they were provided to work on the project. Despite these difficulties, one student discussed how 51  having limited time to work on the project helped develop time management skills that would be necessary for practice. “Being efficient is really important for a project like this so if you were working at a hospital and you went to them and said I want to do this and they said ok I’m going to give you 30 hours pay to do this and then we’re going to stop and then... you have to get it done within 30 hours or you work for free after that and so we need to be able to really manage our time well and be efficient and don’t waste time...” There were some experiences where students reported that they did not have a mentor who was able to provide them with the support that they anticipated. Students discussed that having a mentor who was not accessible to them, caused them to spend more time on their projects, and felt that they were not given adequate direction needed to work on their project. “With our mentor... she was all over the map and then we were confused because of the list that we had been given about what we were going to do and what she was going to do and we were confused... for... two or three weeks.” 4.4.1.6 Is there anything you would change about the program? It was suggested that all students be provided with the opportunity to complete a Q&S project. In addition, students recommended that having a “condensed course” prior to doing the Q&S option would help students to meet the course learning goals. “Maybe have 3 lectures, condensed lectures and then go out and do a project and then... they would also do a better job in trying to ensure that we meet goals.” 52  The students also recommended that their mentors be provided with information about the UBC nursing program or N453 so that they are aware of what is expected of the students for N453. Because students were not aware of the communication that occurred between their mentors and the nurse leaders, they thought it would be helpful if they were included with these communications as much as possible. 4.4.2 Classroom Group 4.4.2.1 Review learning goals and discuss which ones you met and did not meet. Why or why not? The classroom groups identified numerous learning goals that they believed they met and did not meet (see Table 4.6). The learning goals that they believed they did not meet were 1, 11, 12, 13, 17, 18, 20, and 35. Students reported that classes with guest lecturers, made the learning goals difficult to achieve as the topic of discussion did not always match the intended goal. One student described: “A lot of the times they would have the guest lecture come in to teach us about these, but I was never really sure which objectives we were meeting.” Students did, however, appear to be very satisfied with their experience indicating: “I learned more than I thought I would.” Students also reported learning goals that they believed they achieved, such as goals 4, 5, 9, 10, and 23. Students reported that, by achieving these goals, they felt more prepared for the practice setting and felt like that they were provided with valuable information. One student stated:  53  There were numerous learning goals that students did not address during the focus groups. Both Q&S and classroom groups reported meeting learning goal 4, 9, and 23 as outlined in Table 4.14. Although students were in different teaching and learning settings, both groups reported that they had a good understanding of these learning goals. The classroom group discussed that meeting the conflict management learning goal (learning goal 20) was difficult to achieve in the classroom setting and felt that this was one example where the Q&S students were at an advantage. “Comparing.., our class with the quality and safety group... I think with them working out hospitals, they got more practical experience in learning how to do... conflict management.” “They... had conflicts, where as... it’s really hard to sort of create that real atmosphere which the Q&S group is getting. I mean, I don’t know, I just I don’t even know how you could teach this class.” 4.4.2.2 Do you like this approach of teaching and learning? Was coming to class quality learning time for you? The classroom group reported that N453 provided them with the confidence and perception that they could all achieve their goals in their nursing careers and be successful. Students also felt this course empowered them to share what they were taught with leaders in the clinical setting and that they could affect change regardless of their role as a student or new graduate. “. .  .empowering us to believe that we can be actively involved in our... student  position or new nurse position and not high up in management to effect change.” 54  “I think the course provided us with some pretty useful tools for going into practice for when we first start out, and... knowing what our expectations should be.” The classroom group reported that this course provided them with confidence and helped them to understand what they want from their work place and how to support their co-workers with events that may occur. Students also felt that they now had a better vision for their career, and some even reported that this course inspired them to pursue graduate school in the future. The classroom students also discussed the time spent in small groups. Students reported this time was valuable learning as they enjoyed working on the assignments in class with multiple people, and finishing it home on their own. There were, however, different opinions about the productivity level of the group work. “We always goofed off... we would just go waste time completely so I think that is... a little bit group specific.” Students also reported that they were very happy not having done the Q&S project as they stated they did not have the time. They also believed that they received more information than students in the Q&S option. “You’d have to be crazy to do the quality and safety in terms of the workload, I think it was probably a great experience.” “We got a broader scope of what we learned and that we maybe got some things that might be more applicable to our practice initially. And I think quality and safety is important but... I think we just got a little bit of a lot of things where as they focused on one project.”  55  4.4.2.3 How do you think you should be evaluated? The classroom group agreed that their evaluation was reasonable and found the small assignments fun and educational. Students preferred this method of evaluation as opposed to doing a long paper. “It helped you... integrate knowledge throughout the semester.” “As opposed to one big paper on one small piece of the course, yeah this was great.” Students in the classroom also discussed the format of their midterm and agreed that the short answer and multiple choice questions were appropriate for N453. “I don’t think it’s a course that can just be marked by multiple choice. Multiple choice is often recognition like I think the short answer is another type of understanding and I think it’s relevant for this course.” 4.4.2.4 What did you like/dislike about the course? There was consensus within the focus group that the time allotted for group work was longer than needed. Students felt that this was one aspect about group work that they did not enjoy. However, it appeared that most students stayed on task until their work was finished. “Maybe a little too much time was allotted for it cause eventually you do end up just talking... ok we’ve answered the questions, we’re just gossiping now.” Course readings were discussed, and although students believed that they benefited from some articles, they felt that others were not helpful to understanding the course content. Students also reported they were confused with some articles as they did not see a connection between the article, the class content, and the course learning goals. 56  “I would read the articles and we would sometimes not refer to the article and they seemed disjointed from what the objectives were a little bit.” “I felt like you were doing reading to do it and then didn’t really see how it fit into the course content.” Another teaching and learning technique that was used incorporated guest lecturers in the course. Students said that they had positive experiences with some guests. However, there were many experiences that students felt did not aid in their learning. “I really disliked the disjointed nature of a lot of the guest lectures and how it wasn’t really integrated very well into the course objectives.” The learning environment was also addressed. Students reported the room where there classes were held was not ideal. They did, however, indicate that having desks that can be picked up and move around was very useful for doing group work. “The space really.., is not optimal for learning.” “It’s like an invitation to zone out to me, to have such a big space and so few people.” 4.4.2.5 Is there anything you would change about the course? The classroom group appeared content with their overall experience. They did recommend incorporating role play or seminars to be taught for some lectures. “People getting together in small groups, in little rooms like this and someone being in charge and presenting us with an organized format for how to meet the objectives for conflict management and horizontal violence.”  57  Students believed that this format would help to improve their understanding and help to prepare them for real word scenarios they may face upon entering the workforce. 4.5 Observations Observations were made of classroom group during two class sessions and with two Q&S groups. Two entire classroom sessions were observed lasting three hours each. Two Q&S project meetings were also observed for a total of three hours. Observational notes were kept for all observations that were made. With the completion of the observations, there were common themes that developed that were used to describe and compare and contrast both the classroom and Q&S groups. Themes were used to organize, compare and contrast the groups’ experiences. These themes included: communication behaviors, student experiences, environmental conditions, and time and are further discussed below. 4.5.1 Communication Behaviors Classroom students participated in small group discussions (2-5 students peer group) and large class discussions (held with the entire class and faculty members). In both situations, students had the opportunity to ask the faculty member questions or receive feedback. The inclass small group discussion often had an “unofficial leader”, where one student would lead the discussion and guide the group through the assignment. Small-group work was designed to accentuate concepts pertaining to that day’s learning goals, and students were typically given 1530 minutes to work on these exercises together. The faculty would end the small group work if she noticed students straying from the task or signaling completion of the task, such as social conversations, texting, et cetera.  58  Large class discussions often began by a question asked by the faculty member which was followed by an answer(s) from a student(s). This sometimes led to further discussion with student comments or questions. Although the class members seemed engaged, large group discussions were typically limited to a few interchanges between the faculty and a select group of students. With the Q&S students, no one seemed to be in charge of directing group work. In each observed group, all the members seemed to participate equally in verbal exchanges. Each Q&S group was responsible for organizing its own meeting agenda, length of time to meet, and goals or objectives for future meetings. The contexts of the observed exchanges were focused on specific components of the project. The Q&S students had access to faculty and nurse leaders working with them on their projects, but not immediate access or feedback on their work. They often had to arrange special meetings or engage in e-mail exchanges to address project issues and concerns. 4.5.2 Student Experiences The classroom group did not receive any direct clinical experience, although the small group exercises and large discussions were frequently organized around students’ experiences from clinical settings. The Q&S students were able to do most of their project work off-site, but whenever necessary, were able to arrange through their nurse project leaders to do work on-site in clinical settings. Some Q&S students, for instance, did a nursing staff survey on-site with assistance from their nurse project leader. While working in on-site, students were observed accommodating staff. Students waited in the halls and then would move out of people’s why way when they were conducting surveys. 59  The classroom group met in a large lecture room and sat in desks facing the front of room. Small group work usually required shifting of tables and chairs to facilitate face-to-face discussions. The Q&S groups had flexibility with respect to when and where to meet. They often chose to meet at each other’s houses or in a designated space in the clinical settings set aside for them by their respective nurse leaders. 4.5.3 Time The classroom group spent their time listening and participating in the lecture and discussion during three-hour blocks each Monday morning. Lecture, discussion, and small group work was arranged by the faculty to offer some diversity among learning methods during the long block of time. The Q&S students managed their own time, but they typically met for one to two hours at a time to complete a specific agenda. To be as time-efficient as possible, it was noted that Q&S students often chose to work in pairs on project components. 4.6 Summary The findings have identified key components to understanding the student perspectives. The key finding from the surveys show that all students in N453 had medians of 3.5 or higher at the beginning of the course and end of the course as Figures 4.1 and 4.3 shows. The surveys at the end of the course also showed that students in the classroom group had higher medians overall for their perception of meeting the course learning goals when compared to the Q&S group as there were 24 of the 37 learning goals that had higher medians for the classroom group compared to the Q&S group as outlined in Table 4.6 and Figure 4.2.  60  The focus groups showed that students had different experiences. The classroom students felt empowered and prepared for practice. Those students also reported liking their course experiences. The Q&S students reported that they will remember their experiences from the project, and that this was a valuable experience for them. They did, however, feel that they were not empowered in situations where they were required to contact and speak with staff or health care professionals from other organizations. The observations showed that the classroom students were guided by faculty and that they engaged in a variety of teaching and learning strategies. In contrast, the Q&S students were observed guiding their own work with minimal instruction from faculty. The classroom students had an environment that they could focus entirely on their learning, while the Q&S students were observed having to adapt to different settings in the clinical environment.  61  5 Discussion, Implications, and Conclusion 5.1 Introduction Having an awareness of course learning goals can help promote learning by providing students with a guide of what they are expected to know (Myers, 2008). Because teaching and learning is an interactive process involving students and faculty, it is essential that the student perspective is well understood. By recognizing how students perceive learning goals and use them, the teaching and learning process can be enhanced. The data obtained in this study strived to understand the student perspective regarding the differences in the attainment and the subjective value of course learning goals when two different teaching and learning strategies were used. Both groups of students in the classroom and Q&S group reported that they enjoyed their learning experiences in N453. They believed that this course helped to prepare them for practice. Students in both groups discussed their opinion of the teaching and learning approaches for the course. All students agreed that they felt that the course was valuable to their future as a nurse. Regardless of the learning option chosen, all students said they were happy with their respective choices. There were, however, distinct differences that emerged from the surveys, focus groups, and observations. The results from this study have provided information that can be used to better understand the student perspective. By focusing on their understanding of the course learning goals, their beliefs of meeting these goals, and their learning experiences, students’ needs can be better met to ensure that optimal teaching and learning occurs. Based on triangulation of the  62  surveys, focus groups, and observations, this chapter will cover the significance of the key findings from the surveys, focus groups, and observations. 5.2 The Importance of Learning Goal Attainment 5.2.1 Inductive Learning Experiences that Impacted Attainment Learning Goals Both groups of students indentified liking benefitting from their learning experiences from N453, which showed that both teaching and learning environments were valuable, but for different reasons. Because the Q&S group experienced guided discovery and project based learning techniques, students had the opportunity to apply theory and concepts and then make decisions for their project. This was one aspect of the project, that Q&S students discussed in the focus group that they thought benefited them. In addition to the results from the end of course survey, during the Q&S focus group, students discussed that they did not meet the learning goals as well as the classroom group. Q&S students did, however, report in the focus group that that they would remember this experience for a longer period of time compared to other learning activities from other courses. Therefore, they believed that what they learned, they learned well, and perhaps better than if they had been in the classroom group. These comments suggest that inductive teaching and learning methods can enhance learning for students. The observation data revealed that students in the Q&S group worked independently from faculty. Students had to apply knowledge and information they obtained, and were observed having minimal guidance as they problem solved questions they encountered on their own. This is likely the reason why students in the focus group believed that this would be memorable. Prince and Felder (2007) confirmed this as they found that inductive teaching and learning strategies resulted in better and deeper learning for students. These strategies have also been shown to produce relevant and 63  authentic learning (Farrell, Henderson, & Boutilier, 2008). Prince and Felder (2007) and Farrell et a!. (2008) reported similar results, and that inductive teaching and learning strategies do result in deeper learning because learning is enhanced compared to deductive methods. Because students were practicing and applying the course material, they were likely better able to comprehend the course material outlined in the learning goals compared to the classroom group. The focus group and observations with the classroom group displayed that students gravitated towards inductive learning. The classroom students liked teaching and learning strategies such as the group work. The success of using these techniques in the classroom could be the result of having the appropriate amount of guidance and support necessary when the strategies were introduced. This was also noticed during the observations. Although students were asked to work on an assignment as a group, they had faculty available to ask for help and clarification. Prince and Felder (2006) have identified that these are key elements for success when implementing inductive teaching and learning strategies. Although classroom students believed that some concepts, such as conflict management, were better learned by the Q&S group, they felt that they had a broader overview of nursing leadership. This could be the result of having also experienced deductive learning as it is beneficial for introduction of basic principles related to nursing leadership (Prince & Felder, 2006), in addition to the support and guidance students had when deductive strategies were used. Focus group and observations showed that Q&S students were excited, motivated, and eager to learn and accomplish the goals that they set for their project. During the focus group, Q&S students discussed how they were excited to work on their project that could promote change in the clinical setting. The observations showed this motivation as students were efficient with their time and stayed on tasks while having to manage their learning. This finding 64  contradicts the finding discussed by Kardash and Wallace (2001) as they reported that students preferred having their expectations spelled out for them by the faculty member. However, inductive learning processes are believed to better motivate students (Prince & Felder, 2007), which proved to be true for the Q&S students. There were, however, examples where not all students appeared to value their independence in their learning as one student discussed wanting more guidance and felt lost without it. This could be related to resistance some students express when they are introduced to inductive teaching and learning methods (Prince & Felder, 2006). On the other hand, Q&S students all agreed that they learned leadership concepts and techniques better than they would have in a classroom setting. This is the result of inductive learning as it promotes “deep learning” (understanding meaning rather than memorization), intellectual development, and critical thinking (Prince & Felder, 2007). Therefore, despite the differences between the classroom and Q&S groups in the end of course survey, the Q&S students will likely remember what was taught for a longer duration, and have a deeper understanding for the learning goals that they met. The observations showed that students in the classroom group were provided with the course learning goals that applied to the lesson at the beginning of each class. The Q&S students did not seem as aware of learning goals over the course of their project. The observations did not identify the Q&S students discussing or using learning goals, but students were observed using skills that apply to nursing leadership such as communication strategies. In addition, the course learning goals may not have catered to the learning that the Q&S students were doing. Observations illustrated that classroom students were focused on the course work and completing course requirements. This created a concrete structure for the classroom students as they were aware of what was expected of them. Simon and Taylor (2008) found that students valued 65  learning goals, and that the goals helped them to understand what they were required to know. The results from the classroom group agree with Simon and Taylor’s findings. The classroom groups rated the course learning objectives high at the end of course survey, indicating that students valued their importance. The end of course survey showed that 36 of 37 learning goals had medians of 4 or more. The Q&S students did not have learning goals discussed with them in the same manner, which could have prevented them from identifying when or if they met the learning goals. Learning can be hampered because students do not have the “intellectual scaffolding” and organizational structure that learning goals provide (Simon & Taylor). As a result, Q&S students may have scored their understanding lower (36 of the 37 learning goals had medians of 3 or higher and ranged from 2.5 to 4) on the end of course survey (when compared to the classroom group), because concepts they learned may not have appeared as clear as they were for the classroom students. The classroom group was observed being guided by faculty who outlined what they needed to do, and when they had to do it. Once they completed one task, they waited for further instruction before moving on. Although inductive strategies were used, classroom students were not expected to take control of their learning experience in the same manner as the Q&S students. Rather than relying on faculty to guide them through tasks, assignment, or activities, Q&S students chose what they would do next and had discussions and activities based on what they learned and were learning with each other. 5.2.2 External Factors that Influenced Learning Goal Attainment The environment in which Q&S students were learning was very different from the classroom setting that was experienced by the classroom group. By working in numerous settings 66  as the observations indicated, Q&S students likely had to adjust to the setting and accommodate to staff and patients, in addition to completing their project work. Lofmark and Wikblad (2001) reported that students found their time in the clinical setting was more stressful than in the classroom, and had limited time in the practice setting, ultimately obstructing learning. Although the Q&S students were not directly working with patients in the clinical setting, this could have distracted Q&S students from their project due to the stress Lofmark and Wilblad describe, and may have taken valuable learning time away. Students in the clinical setting are concerned about the reaction of nursing staff, in addition to their learning (Campbell, Larrivee, Field, Day, & Reutter, 1994). Relationships students have with people that they work with, in the clinical setting, impact their perception of the clinical learning environment (Dunn & Hansforcl, 1997). Because Q&S students were expected to work in numerous setting and had to adjust to the clinical environment, students could have been distracted from their learning as they were more focused on relationships and reactions of staff. This could have changed the students’ perspective of their learning, which may have impacted the results of the end of course survey. This was also observed when students were collecting data from nurses on nursing units. Although the focus group data identified that the classroom students did not like their classroom, the observations showed that the environment provided them a space where they could learn concepts of nursing leadership without the stressors experienced in the clinical setting. This space was dedicated to them for their learning, where they could ask questions, make mistakes, and use the time to their advantage.  67  5.2.3 Empowerment Influences on Learning Goal Attainment Empowering experiences for nursing students include: continuity, time, and mentorship (Bradbury-Jones, Sambrook, & Irvine, 2007). Because Q&S students discussed in the focus group not having these factors available to them during their project, they sometimes felt disempowered. Having these perceptions could have impacted on Q&S students’ learning experiences. Q&S students discussed that they felt that their work was not valued and felt that their treatment could reflect how they will be treated as new nurses. This could have resulted in Q&S students feeling discouraged, perhaps altered their learning, and impacted the end of course survey results. Rather than focusing on learning goals and nursing leadership, Q&S students learned that they were undervalued. This also is reflected in the literature as Bradbury-Jones et al. (2007) reported that students who were empowered were able to learn. Having resources available to the Q&S students proved to be very valuable, and appeared to be a predictor for students’ success and enjoyment of their experience. Campbell, et al. (1994) agreed with this finding as they found that students who had instructors that had positive attitudes, were knowledgeable, and had good communication skills, improved students experiences in the clinical setting. Regardless of support that the Q&S students believed they received from their nurse mentor, all students appeared to value their experience and believed that it helped to prepare them for practice. This was identified in the focus groups. Although the medians for the Q&S students in the end of course survey of student perspective of how well they learned the learning goals were lower than the classroom students, the Q&S students’ medians were 3 (somewhat learned) or above for 36 of the 37 learning goals, which indicated that they did feel they learned portions of the learning goals.  68  Students in the classroom group felt empowered from N453. The focus group data indicated that classroom students felt prepared to help influence change and believed that they could have a voice in the clinical setting as new nurses. This was very different from how the Q&S group felt, and could be related to the exposure Q&S students had to the clinical setting. Because Q&S students gained experience regarding the processes of creating change and improving the workplace, they also experienced resistance and the hierarchy that exists in clinical settings. This was also experienced by other nursing students (Dunn & Hansford, 1997), as they indicated that the hierarchy they experienced in the clinical setting created limitations. This left students feeling frustrated as they were expected to follow orders and not ask questions. To ensure students feel empowered and experience a positive experience in the practice environment, they need to feel valued (Hartigan-Rogers, Cobbett, Amirault, & Muise-Davis, 2007). By being empowered, classroom students could have developed more confidence in their learning and therefore, scored higher on the end of course surveys than the Q&S students. 5.2.4 Evaluation Influences on Learning Goal Attainment Evaluation helped to enhance the learning experience for the classroom group. “The information to be tested has the greatest influence on guiding students’ learning” (Bransford, Brown, Cocking, 2000, p. 245). By having numerous small assignments, students reviewed the contents as necessary for the assignments, which resulted in less cramming of the material. This may have impacted on their understanding of the learning goals, and how well they met them. By having concrete assignments that clearly related to what was taught, the observations and focus groups showed that students were aware of the evaluation process. This was reflected in the results of the end of course survey on classroom students’ perspective of how well they learned 69  the learning goals. Q&S students discussed in the focus groups that they were evaluated quite differently. Therefore, Q&S students may not have had the same confidence and beliefs of meeting course learning goals because they were not as aware of what goals they were meeting and how well they had met them. In addition, observations displayed how Q&S students did not refer to learning goals to complete their projects or assignments. During the focus group, Q&S students did not discuss using the learning goals as a guide, unlike the classroom students who did use the learning goals in this manner. 5.3 Value of Learning Goals from the Student Perspective Students in both the Q&S and classroom groups identified the course learning goals as valuable to their nursing career. The differences between the Q&S students and the classroom students, based on the beginning of course survey results, indicated that Q&S students perceived the learning goals to be slightly more important than the classroom students. This may be related to the group of students who opted to do the Q&S option. At the beginning of the course, these students could have scored the learning goals higher and chosen to do the Q&S option based on perceptions and beliefs of experiences that could provide them with optimal methods for teaching and learning essential information. This assumption would need to be further researched to confirm a correlation. The highest medians for both groups at the beginning of the course surveys were for the value of learning goals 20 “Describe effective conflict management strategies” and 29 “Provide examples from practice settings of nurse leader empowerment and nurse staff empowerment”. The results from the end of course survey completed by the classroom students also showed that these learning goals had the highest medians. In the focus groups, students in both groups re enforced their belief of the importance of these goals. This indicates that these were aspects of 70  the course that students believed were important facets of nursing leadership that could help to prepare them for practice. The results of the end of course survey for the Q&S group showed that the value of learning goals changed slightly. Three learning goals that they identified as important that classroom students did not, were learning goals 22 “Provide examples from practice settings of nursing leaders using effective and ineffective conflict management approaches”, 31 “Describe the benefits of different types of networking”, and 37 “Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?”. This change is likely the result of what students were exposed to during their project and what they observed to be necessary for success in leadership roles (e.g. the Q&S project). These results were reinforced in the focus groups, and students identified these topics and why they were valuable. The Q&S students discussed how networking was helpful in obtaining the information that they needed. When classroom students discussed what they liked about N453, they identified that conflict management is important and wanted more information on this. During the focus group, the classroom group discussed using the learning goals to determine if they had met the goals, and if they felt that they understood what they were expected to know. It appeared that the students therefore, used the learning goals to help determine what they were expected to learn, which was also found by Simon and Taylor (2008). Having learning goals may be a valuable tool for students as it can help to create a framework for the course. The classroom students were able to use the learning goals to help evaluate their understanding of the course material and their class experience. The Q&S group did not have the same experience. They were observed working on their projects without the guidance of learning 71  goals. This could be why they did not believe that they learned the material as well as the classroom group, which the focus groups and end of course survey both identified. 5.4 Limitations There were limitations in this study that could have impacted the results. This study was done with one group of students during one semester. Because the sample size was small, it was not possible to do parametric statistical testing, which was why medians were used instead of means and a descriptive approach was used allowing for visual trends from the survey data to be identified. Another limitation was that the study did not include data beyond the semester. If the study focused on the perspectives after students had graduated and entered practice, additional information could have been obtained that would help understand the success of students’ learning in N453. This would be an interesting follow up study to ascertain the sustainability of learning. This would better determine course content retained and valued learning experiences beyond nursing school. Although this study focused on understanding the student perspective, there was not a comparison made to evaluate the differences and similarities with faculty or grades. This information could help to clarify and validate perspectives, as having additional information (i.e. faculty perspectives, class averages for assignments or mid terms) could provide a more complete picture of the N453 learning experience. Because there is no validated survey tool on learning goals, the survey used was not validated. It was, however, reviewed by an educational psychologist and expert educators, but further research must be done to validate a survey that can be used to understand the student perspective of course learning goals. The survey data was used to help enhance the data from the focus groups and observations due to the lack of validity of the tool. 72  The sample used was a convenience sample. This limitation could impact the results as this may not reflect the opinion of all nursing students in the UBC SoN program, or other nursing programs. Students were also asked to volunteer for the focus groups. Students may have volunteered because they have strong feelings about the course, which could alter the information obtained as the results may not accurately reflect the true perspective of all students in N453. Another limitation is the variability of the Q&S projects. Students worked in different locations, health care program, and settings. All Q&S students had different mentors and they projects were all unique. Because the variation in project, students were required to completed different activates (such as conducting surveys versus interviews). There was less variability with the classroom group. Classroom students were all provided with the same assignments, course work, and were expected to come to the same classes. 5.5 Implications 5.5.1 UBC School of Nursing The implications of this project can help to provide information to the UBC SoN undergraduate nursing program. This information can help guide faculty to make decisions related to ongoing curriculum revisions. The results of this research project may also help identify the strengths and weaknesses students experience in learning at UBC, and offer guidance for changes to specific courses within the UBC SoN to better meet student learning needs. Further research is necessary to evaluate students’ understanding of what they learned in N453 to determine the effectiveness of what they learned. This could be a longitudinal study to follow students after they have entered their nursing careers. 73  5.5.2 Post Secondary Education The information from this study can also be used to help guide other programs and courses outside of nursing. The teaching and learning techniques used in N453 can be applied in many programs, especially those programs that allow students to complete hands-on or practical experiences inductively in or outside the classroom. This study can offer guidance to post secondary educators with respect to student perspectives on learning methods, and learning goals that are necessary to understand when designing and implementing a course. The findings of this study may also provide insights on how different inductive teaching and learning strategies can be used, and how successful they could be for a particular course or student group. This study confirmed that learning goals are valuable to students. This information can help educators in nursing and beyond to use learning goals in ways that students identified can help them and their learning. In addition, results of this study have the potential to assist educators with understanding which teaching strategies can be best used to accomplish specific learning goals. 5.6 Conclusion Providing students with time and a safe environment to ask questions and learn concepts, and developing inductive teaching and learning strategies such as the Q&S project can enhance the student learning experience. Students require time and the opportunity to learn basic concepts, skills and definitions that can be taught in the classroom setting. Using inductive teaching and learning techniques appear to provide valuable learning experiences for students and students agree that these techniques help them to remember course content. Students taught in the classroom setting believed that N453 provided them with a broad introduction to nursing leadership. Students felt that they accomplished the course learning goals  74  by using the teaching and learning strategies selected by the faculty member teaching the course. This group of students valued their experience and the course learning goals. The students in the Q&S group also valued the course learning goals but did not use them to guide their learning throughout their time spent working on the project. The Q&S students understood, experienced, and practiced concepts outlined in the course learning goals, although they may not always have been aware of the related learning goals. Q&S students also believed that the course learning goals were important, and were able to identify examples from the practice setting of why and how they could be used in nursing leadership. However, the connections between the learning goals and their experiences were not explicit, which led to a belief that they did not accomplish the learning goals as well as the classroom group. Q&S students believed that this method of inductive teaching and learning was beneficial as it provided them with additional practice experiences and exposure. Course learning goals are a necessary ingredient for students. Students can organize their learning and can be better prepared to meet the requirements of the course as they know what they are expected to learn from each class. Students working in the classroom setting are learning in an environment where they can easily refer to learning goals and evaluate their learning. In the clinical setting, this could become more difficult. The instructor must make explicit emphasis on the learning goals that the students are learning. Both groups of students indicated that their experience was favorable. By providing students with the opportunity to obtain course content that can provide a foundation for learning in the clinical setting, students can learn the basic concepts and definitions or theories that they will then experience in the clinical setting as they complete projects or assignments. Inductive learning from the student perspective appears to be very valuable to learning, although students 75  may require time to adjust to inductive (versus deductive) approaches and the roles required of students when using these approaches. Learning goals are an essential element to teaching and learning (regardless of the teaching and learning environment). 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Through an understanding of organizational structures, functions, and concepts, you will develop knowledge and skills that will support you as a new graduate and as a nurse with practice experience. Key leadership and management competencies will be highlighted throughout the course. It is intended that the course will enhance your leadership potential and prepare you to function as an effective member of the health care team in various practice environments. A key thread throughout the course is supporting quality professional practice environments, which is an important issue in nurse recruitment and retention.  83  Appendix 2: Course Learning Goals for N453 Upon completion of Nursing 453 you will be able to: 1.  Provide examples of current quality and safety trends in healthcare.  2.  Provide examples of healthcare innovations from practice settings.  3,  Describe the necessary components of effective innovation.  4.  Identify examples of effective nursing leadership in the practice environment.  5.  7.  Perform an analysis of healthcare settings using evidence-based quality practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations Identify the key components of an organization’s structure using an organizational chart.  8.  Describe practice environment outcomes resulting from restructuring.  9.  Describe the styles and competencies associated with effective leaders.  6.  Provide evidence from the research literature of how effective nursing leadership positively influences outcomes for: a) patients, b) nurses, c) organizations 11. Identify the similarities and differences between scopes of practice for RNs and LPNs. 10.  12. Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel). 13. Describe the difference between licensed healthcare professionals and unlicensed professionals. 14. Describe the positive and negative attributes of different nursing care delivery models. 15.  Design an ideal care delivery model for today’s practice settings.  16. Describe the roles and responsibilities of all members of a healthcare team. 17. 18.  Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. Describe the components of an effective healthcare team.  19. Provide examples from practice settings of effective and ineffective healthcare teams. 20. Describe effective conflict management strategies. 21.  Explain the relationship between effective communications and safe and effective teamwork. 84  22. 23.  Provide examples from practice settings of nursing leaders using effective and ineffective conflict management approaches. Describe the relationship between effective leadership and effective change management.  24.  Critique the effective and ineffective qualities of healthcare organizations’ Vision/Mission statements. 25. Appropriately utilize change management tools, such as Lewin’s force field analysis and SWOT analysis to determine whether a healthcare setting is ready for change. 26. Describe the social-emotional outcomes related to change in the workplace. 27.  31.  Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment). Provide examples from practice settings of nurse leader empowerment and nurse staff empowerment. Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting. Describe how shared governance/shared leadership can be an effective nurse empowerment strategy. Describe the benefits of different types of networking.  32.  Provide examples from practice settings of horizontal violence.  33.  Describe strategies for effectively managing horizontal violence in the practice environment. Provide examples of how new nurses can function in leadership roles in the practice environment. Describe the key functions of the CRNBC and the BCNU.  28. 29. 30.  34. 35. 36. 37.  Identify the key steps related to the professional responsibility process (i.e., professional responsibility form). Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  85  Appendix 3: Beginning of Course and End of Course Learning Goals Surveys  N453 Learning Survey Background  This survey will be given to you now, and at the end of the class, a similar survey will be used to determine what you think about the importance of the course’s learning objectives. The information will be strictly used for educational purposes. There are no names or personal identifiers on this survey. Permission has been obtained from UBC Ethics to conduct pre-post course educational surveys. Directions During your time in the School of Nursing, you have been in a number of different practice environments. Based on the experiences you have had to date, indicate (on a scale of 1-5) how important you believe each of the following objectives is to you as a student nurse preparing for entry to practice. In the space provided alongside each objective, please indicate your importance rating for that objective. 1 (not important)C—*2 *—*3 (somewhat important)c—* 4  Course Objective  1  Not Important  1 2 3 4  5  6  2  -*  5 (very important) 3  Somewhat Important  4  5  Very Important  Provide examples of current quality and safety trends in healthcare. Provide examples of healthcare innovations from practice settings. Describe the necessary components of effective innovation. Identify examples of effective nursing leadership in the practice environment. Perform an analysis of healthcare settings using evidence-based quality practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations  86  Course Objective  1  2  Not Important  7 8 9  10 11 12 13 14 15 16 17 18 19 20 21  22 23 24  25  26 27  28 29  Identifj the key components of an organization’s structure using an organizational chart. Describe practice environment outcomes resulting from restructuring. Describe the styles and competencies associated with effective leaders. Provide evidence from the research literature of how effective nursing leadership positively influences outcomes for: a) patients, b) nurses, c) organizations IdentifS’ the similarities and differences between scopes of practice for RNs and LPNs. Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel). Describe the difference between licensed healthcare professionals and unlicensed professionals. Describe the positive and negative attributes of different nursing care delivery models. Design an ideal care delivery model for today’s practice settings. Describe the roles and responsibilities of all members of a healthcare team. Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. Describe the components of an effective healthcare team. Provide examples from practice settings of effective and ineffective healthcare teams. Describe effective conflict management strategies. Explain the relationship between effective communications and safe and effective teamwork. Provide examples from practice settings of nursing leaders using effective and ineffective conflict management approaches. Describe the relationship between effective leadership and effective change management. Cntique the effective and meffective qualities of healthcare organizations’ Vision/Mission statements. Appropriately utilize change management tools, such as Lewin’s force field analysis and SWOT analysis to detennme whether a healthcare setting is ready for change. Describe the social-emotional outcomes related to change in the workplace. Identify strategies that nurse leaders use to empower their staff (structural and psychological empowerment). Provide examples from practice settings of nurse leader empowerment and nurse staff empowerment. Identify ways, that you, as a new nurse, can empower yourself and others in the practice setting.  4  3  5  Somewhat Important  Very Important  I  I  . S  ‘--•  .  *  ij .  -  . S  87  Course Objective  1 Not Important  30 31 32 33 34 35  36  37  2  3 Somewhat Important  4  5 Veiy Important  Describe how shared governance/shared leadership can be an effective nurse empowerment strategy. Describe the benefits of different types of networking. Provide examples from practice settings of horizontal violence. Describe strategies for effectively managing horizontal violence in the practice environment. Provide examples of how new nurses can function in leadership roles in the practice environment. Describe the key functions of the CRNBC and the BCNTJ. Identify the key steps related to the professional responsibility process (i.e., professional responsibility form). Identify examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  Please indicate if you were in the Q&S option. Yes  No  88  N453 Learning Survey Background There are two parts to this learning survey. The first part asks you to rate how well you learned each course objective during this term in N453. The second part is similar to the survey we gave you at the beginning of the term. During your time in the School of Nursing, you have been in a number of different practice environments. Based on the experiences you have had to date, rate how important you believe each of the objectives is to you as a student nurse preparing for entry to practice. The information will be strictly used for educational purposes. There are no names or personal identifiers on this survey. Permission has been obtained from UBC Ethics to conduct pre-post course educational surveys. Thank you for your time and consideration! Directions First part: Based on your N453 experience, rate how well you learned about each course objective. 1 (did not learn) +-* 2 *—*3 (somewhat learned)  i—*  4  —*  5 (learned well)  Second part: Based on the experience you’ve had to date, rate how important you believe each of the objectives is to you as a student nurse preparing for entry to practice. 1 (not important)*—*2 *—*3 (somewhat important)4—* 4  4—*  5 (very important)  89  How well did you learn each objective? .  .  .  Learning Objective  1 2 3 4  5  6 7 8 9  10 11 12 13 14 15 16 17 18 19 20 21  (1-5 scale) 1-did not learn 3=somewhat learned 5=learned well  How important is each objective to you as a student nurse preparing for entry to practice? (1-5 scale) 1=not important 3=somewhat important 5= very_important  Provide examples of current quality and safety trends in healthcare. Provide examples of healthcare innovations from practice settings. Describe the necessary components of effective innovation. Identif’ examples of effective nursing leadership in the practice environment. Perform an analysis of healthcare settings using evidence-based quality practice environment indicators (such as the CRNBC Quality Practice Environment tool). Provide evidence from the research literature of how a quality practice environment positively influences outcomes for: a) patients, b) nurses, c) organizations Identifj the key components of an organization’s structure using an organizational chart. Describe practice environment outcomes resulting from restructuring. Describe the styles and competencies associated with effective leaders. Provide evidence from the research literature of how effective nursing leadership positively influences outcomes for: a) patients, b) nurses, c) organizations Identif’ the similarities and differences between scopes of practice for RNs and LPNs. Make an appropriate patient assignment for RNs, LPNs, care aides (non-licensed personnel). Describe the difference between licensed healthcare professionals and unlicensed professionals. Describe the positive and negative attributes of different nursing care delivery models. Design an ideal care delivery model for today’s practice settings. Describe the roles and responsibilities of all members of a healthcare team. Differentiate between roles and responsibilities of nurse leaders at different levels of an organization. Describe the components of an effective healthcare team. Provide examples from practice settings of effective and ineffective healthcare teams. Describe effective conflict management strategies. Explain the relationship between effective communications and safe and effective teamwork.  90  • Learning Objective  22 23 24  25  26 27 28 29 30 31 32  33 34 35 36  37  How well did you learn each objective?  How important is each objective to you as a student  (1-5 scale) 1-did not learn 3=somewhat learned 5=learned well  nurse preparmg for entry to practice? (1-5 scale) 1=not important 3=somewhat important 5= very_important  Provide examples from practice settings of nursing leaders using effective and ineffective conflict management approaches. Describe the relationship between effective leadership and effective change management. Critique the effective and ineffective qualities of healthcare organizations’ Vision/Mission statements. Appropriately utilize change management tools, such as Lewin’s force field analysis and SWOT analysis to determine whether a healthcare setting is ready for change. Describe the social-emotional outcomes related to change in the workplace. Identi1 strategies that nurse leaders use to empower their staff (structural and psychological empowerment). Provide examples from practice settings of nurse leader empowerment and nurse staff empowerment. Identifj ways, that you, as a new nurse, can empower yourself and others in the practice setting. Describe how shared governance/shared leadership can be an effective nurse empowerment strategy. Describe the benefits of different types of networking. Provide examples from practice settings of horizontal violence. Describe strategies for effectively managing horizontal  violence in the practice environment. Provide examples of how new nurses can function in leadership roles in the practice environment. Describe the key functions of the CRNBC and the BCNU. Identifi the key steps related to the professional responsibility process (i.e., professional responsibility form). Identit,’ examples of quality/safety initiatives in practice settings, and provide a rationale for them: Why are they important in that practice setting?  Please indicate if you were in the Q&S option. Yes  No  91  Appendix 4: Sample Questions used to Guide the Focus Group Discussions Focus Group Questions for Q&S Students: 1. Review learning goals and discuss which ones they met and did not meet. Why or why not? What didyou learn about leadership and management bypartic4ating in the Q&S option? 2. Do you think this approach was worthwhile? Do you think this was quality learning time for you? 3. How do you think you should be evaluated (what types of assignments)? 4. What went well? 5. What were the challenges you experienced? 6. Is there anything you would change about the program? 7. Any other comments, ideas, suggestions?  Focus Group Questions for the Classroom Students: 1. Review learning goals and discuss which ones they met and did not meet. Why or why not? What did you learn about leadershzp and managementfrom N453? 2. Do you like this approach of teaching and learning? Was coming to class quality learning time for you? 3. How do you think you should be evaluated (what types of assignments)? 4. What did you like/dislike about the course? 5. Is there anything you would change about the course? 6. Any other comments, ideas, suggestions? 92  Appendix 5: Consent Letter for Focus Group Participants THE UNIVERSITY OF BRITISH COLUMBIA  J Jø  School of Nursing T20 1-2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel (604) 822 2891 Principle Investigator (MacPhee) Fax (604) 822-7466  A Collaborative Model to Introduce Healthcare Quality and Safety to Nursing Students Funding: TLEF Principal Investigator: Maura MacPhee, RN, PhD, Assistant Professor, UBC, School of Nursing Contact Information: 604-822-2891 (Work phone) The University of British Columbia (UBC) School of Nursing has been partnering with Providence Health Services Authority’s (PHSA) Quality, Safety and Risk Management Department to provide unique learning opportunities for UBC nursing students at Children’s and Women’s Hospitals of BC. In order to continue this partnership, it is important for us to determine whether requisite learning objectives are being met by students participating in this initiative. This study is also part of a graduate student’s thesis project. The student, Hanneke Croxen, is comparing the effectiveness of two teaching methods: classroom  participation versus classroom participation plus project work. The student will be comparing learning goals survey answers between students who participate in the two, different options. As a student of N453, you are being invited to participate in a focus group to discuss the learning advantages and disadvantages the educational approaches you experienced during the course. This focus group will consist of your peers other students who participated in this UBC-PHSA initiative. The focus group session will last no more than two hours. As a thank you for your participation, you will receive a $25 Chapters coupon at the end of the focus group session. If you agree to participate in the focus group, a breach of confidentiality is an identified risk to you. Precautions are in place to protect your confidentiality, but due to the nature of the group format, only limited confidentiality can be provided. If you participate in the 93  focus group, please respect the privacy and confidentiality of other participants’ comments and opinions. Focus groups will be audio taped, and the audiotapes will be transcribed at a later time. Specific names and/or personal identifiers will be XXed out of the transcripts. The transcripts will not include any names or features that might identify individuals. The transcripts will be analyzed for general themes. The final written report from the focus groups will contain no identifying information. The audiotapes and transcripts will be stored in a secure location for a period of five years as per research protocol. Only the researchers will have access to the passwordprotected computer files and the locked file cabinet where electronic and hard copies of research materials will be stored. At the end of the required 5-year storage period, any written records, such as transcripts and consent forms, will be shredded for disposal. Computer files will be erased. There is no actual or potential conflict of interest on the part of the investigator or the funding agency. You may choose to withdraw from the focus groups or the study at any time without concern for adverse consequences. Please feel free to contact Dr. Maura MacPhee, Principle Investigator, at 604-822-2891, or Han neke Croxen, graduate student, at 604-630-8051, if you have any questions about the research study. If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 CONSENT Your signature below indicated that you have received a copy of this consent form for your own records. Your signature indicated that you consent to participate in this study.  Printed Name of the Participant  Signature of the Participant  Date 94  Appendix 6: Cover Letter for Beginning of Course and End of Course Surveys  —fla • ta  THE UNIVERSITY OF BRITISH COLUMBIA Dear N453 Student, You are being invited at the beginning of the semester to complete a survey on your perceptions of the importance of the learning goals for this course. At the end of the semester, we will invite you to complete a similar survey about the learning goals. The end-of-year survey will ask you your perceptions about the importance of the learning goals and your perceptions of how well you met these goals by attending N453. This will help us make a comparison of your perceptions about the learning goals over the course of the semester. This information will be used for educational purposes to develop course goals that are significant to you and guide your learning. This study is also part of a graduate student’s thesis project. The student, Hanneke Croxen, is comparing the effectiveness of two teaching methods: classroom participation versus classroom participation plus project work. The student will be comparing learning goals survey answers between students who participate in the two, different options. The survey will have no personal identifiers on it. The survey asks you to identify whether you are participating in the classroom option or the classroom plus project work option. The survey will take you approximately 15 minutes to complete. Your participation is voluntary. There are no benefits associated with completing the survey. A potential benefit is course enhancement resulting from what we learn from the survey responses. There are no known risks associated with participation in this survey. The completed survey questionnaires will be stored in a locked filing cabinet. The graduate student will code the survey data and store it in a password-protected computer. Only the Principal Investigator and the graduate student will have access to the survey data. If you have any questions or would like further information about this study, you may contact the Principal Investigator (Maura MacPhee) or the graduate student (Hanneke Croxen). If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line at the UI3C Office of Research Services at 604-822-8598 of e-mail RSTh@ors.ubc.ca. Your participant is entirely voluntary and your may refuse to participate or withdraw from the study at any time without jeopardy to your class standing. Your completion and return of the survey indicates your willingness to participate in the study. Thank you for your time and assistance, Principal Investigator Hanneke Croxen, RN Maura MacPhee, RN, PhD Master of Nursing Student Ph:604-822-289 1 hannekec(interchange.ubc.ca Maura.macpheenursing.ubc.ca  Version 1: 01/04/09 95  Appendix 7: The Tn-Council Policy Statement Ethical Conduct for Research Involving Humans Certificate  Certflcate of Comp(etion ‘This is to cert!f) that  Hanneke Croxen  has completed the Interagency ,4d’icory Pane[on Rsearcfi Ethics Introfuctory ‘Thtoria (for the Tri-(’ounci(’Po&y Statement: ‘EtliwalConéuctfor Rçarcfi Involving Jlitmans f7t)1 Issued On: November-2-2008  96  Appendix 8: Ethics Certificate The University Of British Columbia Office of Research Seivices Behavioural Research Ethics Board Suite 102, 6190 Agronomy Roa Vancouver; B. C. V6T 123  CERTIFICATE OF APPROVAL MINIMAL RISK AMENDMENT -  RINCIPAL INVESTIGATOR 1  EPARTMENT LJBC/Apphed SciencelNursing NSTrrUTION(S)WHERERESEARCH.WILLBECARRIEDOUT:: auraMacPhee  Institution  LJBC BREB NUMBER jHO7415O4 te  350 hildrens and Women s Health Centre of BC (md unny HiH) ther locations where the research will be conducted  Vancouver (excludes UBC Hospital) Chfldren s and Wom’* Health Centre of BC (mci Sunny Hill)  hA:  O4NVESTIGATOR(S)  Aarlon C{auson (ris GustavsOn  PONSORING AGENCIES: University of British Columbia Please find below the PG and account information for your TLEF allocation for 008/2009: 110900, CAN S5683 11S36628 JMBA Applied Science. School of Nursing ‘Enhanced Learning )ptons for Undergraduate Nursing Students’.” ROJECT TITLE: collaborative model to introduce healthcare quality and safety to nursing stidents -  Expimy Data Approval of an amendment does not change the expiry date on the current UBC BREB approval of thIs Itudy.Mappllcatlon for renewal Is required on or before: July 14, 2009 -  NPMIT(S)  I  .  rmnaIieItlenne  cpyer Letter. Tpte;  ewnkiggoal.surveypre goals swvey cover letter goals survey post  IAMENOMENT APPROVAL DATE: IFemy 4, 2009 Date I Version I 1 1 1  Januaryl3,2009 January 13, 2009 January 13, 2009  he amendment(s) and the document(s) listed above have been reviewed and the procedures were found to be icceptable on ethical grounds for research involving human subjects. Approval is issued on behalf of the Behavioural Research Ethics Board and signed electronically by one of the following:  Dr. M. Judith Lyriam, Chair Dr. Ken Craig. Chair Dr. Jim Rupert. Associate Chair Dr. Laurie Ford, Associate Chair Dr Daniel Saihani. Associate Chair Dr. Anita Ho, Associate Char  97  

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