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Volume 8
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Research and Nursing Education |
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In this Issue Nursing Education Research Teaching Strategies Conversation with a Theorist: A Pedagogical Stragegy for Web Based Graduate Nursing EducationCurriculum Topics Collaborative Change: An Interdependent Model of Nursing Education |
Teaching Writing to Undergraduate Nursing Students: An International Dialog Authors and Affiliations Brazil: Lucila Castanheira Nascimento, RN, PhD Rosalina Aparecida Partezani Rodrigues, RN, PhD Faculties at University of São Paulo at Ribeirão Preto College of Nursing South Africa: Dr.Lyn Middleton Faculty of Health Sciences USA: Ellen B. Buckner DSN, RN University of Alabama School of Nursing
In a globalized world, partnership and collaboration are essential strategies to creatively enhance and share nursing knowledge among professionals from different settings. The ability to establish collaborative relationships provides opportunities for personal and professional growth. This is particularly crucial when we need to respond to the mandate of being designated as a WHO Collaborating Centre, contributing to the development of nursing education, practice, research and leadership, as well as preparing nurses worldwide to successfully deal with global health issues. Motivated to respond to the challenges posed to the nursing discipline in the 21st century,1 an international dialog was established, in order to share experiences of how nursing faculties from three countries, Brazil, South Africa and USA, teach their undergraduate students to write academic articles and disseminate nursing research. Thus, this article aims to describe the main characteristics of the undergraduate programs from three schools of nursing that are PAHO/WHO Collaborating Centres, and to describe strategies used by faculties to develop undergraduates’ writing skills, in order to improve their ability in communicating nursing research. The scholar role is increasingly important for baccalaureate prepared nurses. Nurses must critically evaluate and apply literature to practice, often called evidence-based practice or evidence-informed practice. In the academic literature, authors must communicate their studies results in a succinct and clear fashion. Writing requires authors to formulate ideas, organize thoughts, incorporate and cite published works and draw conclusions relevant for nursing. More importantly, through writing, nurses find their voice, a key element in personal and professional development, and a contributor to the development of the nursing profession. The authors, nurse educators from Brazil, South Africa and the United States, met over a year via electronic means to encourage each other in professional writing andin the submission of manuscripts for publication. This International Virtual Writing Collaborative Project also aims at stimulating international collegial relationships among Sigma Theta Tau International members.2 Along the way, the participants recognized that teaching writing to students was one of our most important educational challenges. What follows is a discussion of teaching writing by faculty from each of the three countries. There are similarities and differences among us but we all share the goal of encouraging effective communication through written expression in our baccalaureate students. We believe that the skill of writing embodies that of professional voice and that, through writing, nurses are better prepared to make a difference in practice. Teaching Writing in Brazil At the University of São Paulo at Ribeirão Preto College of Nursing (EERP-USP), the education process at undergraduate level is guided by the educational reforms established by the Brazilian Ministry of Education. Among other aspects, this process aims to prepare professionals with a critical and reflexive spirit as well as technical-scientific and ethical-political competencies. This involves the construction of new roles for education facilitators and for students, based on a dialogical and partnership relation and mutual learning in the age of knowledge. Thus, the nursing education process at EERP-USP attempts to contribute to the preparation of nurses as citizens, with a view to their participation in the Brazilian socio-cultural, political and economic reality, in a critical and responsible way.3 In line with the institution’s pedagogical project, the nursing professional should be capable, among other skills, to develop and participate in nursing research, as well as to apply it in clinical practice, aiming at the advancement of nursing and health practice.4 This profile highlights the need to work according to current curricular guidelines, which include a collectively constructed pedagogical project. This project must be flexible and able of giving a holistic education, focusing on interdisciplinarity, with predominance of education over information, articulating theory and practice, as well as the interweaving of teaching, research and community services.5 Hence, education facilitators face the challenge of using active methodologies in the teaching-learning process and innovative teaching resources, able to minimize their difficulties to conciliate the different demands of being a faculty. The faculty members’ difficulties mainly refer to keeping up their research productivity and resulting publications, to comply with the university requirements and to achieve the mission of this Collaborating Centre. Strategies used to teach undergraduate students to report research results include the establishment of research groups, the early inclusion of undergraduate honors students in a research project and integration among researchers and other students at all levels. Educating undergraduates to conduct research and disseminate its results demands multiple skills and attitudes, in combination with expertise. It is a complex process in which the role of research supervisor stands out. Barber and Norman6 define supervision as “an interpersonal process where a skilled practitioner helps a less skilled practitioner to achieve professional abilities appropriate to his role” (p. 56). Thus, including these students in research groups under the coordination of a supervisor aims to give them opportunities to acquire knowledge, skills and attitudes in conducting their own part of a research project. Supervisors need to have experience to help undergraduates and graduate students to conduct their research. Their role is to gather these students in a common research project, define problems, objectives and methods. All research group members should be involved in any discussions related to that project, in a horizontal dialogue that gives everybody the chance to study and discuss different issues and ways of handling them. Supervisors guide their group to jointly find the best way to put that project in practice and show members the potential of research to improve nursing practice. At EERP, as a result of these strategies, students at undergraduate level have been able to present their research outcomes at scientific events and in other settings relevant for nursing practice. In addition, they submit their results for publication in indexed journals, as a final goal in the knowledge dissemination process. The educational process of writing for communicating research results is a complex task. It is part of the preparation of critical and independent individuals, who are able to reflect on reality in its educational, political, economic and cultural dimensions. This process offers liberating instead of dominating education,7 providing nurses with the ability to find creative solutions to the problems they face in clinical practice and use research for evidence-based practice. Moreover, these students get the opportunity to enter graduate programs with the differential of a theoretical background that distinguishes them from others who were not engaged in such strategies. Helping Students to Write (South Africa) Helping students to write means helping them to explore the tension between the rationality of writing and their understanding of the art of writing. It means uncovering a personalized connection between the contents of our uniform pockets or bags, and the contents of the particular nursing praxis paradigm within which students are situated. This connection is given light-heartedly but purposively; its oddness plays an important function in by-passing the intellectual and emotional paralysis that occurs in some students when the idea of developing ideas and writing is raised. The objective of supporting students in emptying the contents of their pockets is to help them to recognize and articulate the ideas they believe are worth pursuing. The justification for this strategy is derived from the findings of a study by Hardey, Payne and Coleman.8 Their study explored the construction and function of personalized recordings of information about clients, which are routinely made on any available piece of paper and kept in uniform pockets. The authors found that these scraps of knowledge were an invaluable source of knowledge about the dynamic process of on-going, personalized nursing care that was not reflected in the formal nursing records and hand-over procedures. Scraps were more likely to reflect “everything”, from information about bodily states, things to do, things to remember to tell clients, to perceptions (both negative and positive) of clients and their nursing care needs. These authors suggest that, while scraps allow nurses to move beyond the medicalized discourse of formal nursing records, they also have the effect of marginalizing the distinctive voice of nursing from formal exchanges and, in so doing, of re-inscribing the dominance of the medical model. Asking students to empty their uniform pockets of scraps means asking them to render their personalized nursing knowledge visible. A post-structuralist justification for rendering the hidden visible might be that what is made visible in a particular context is knowledge/power.9,10 Recognizing an idea (making personalized pieces of nursing knowledge visible) and then increasing and sustaining the idea as a form of knowledge/power are not necessarily contingent. Having personalized ideas about nursing made visible and then having these ideas developed as ideas worth pursuing, all within the ambit of the formal nursing mandate and the educational context’s particular paradigm, is a source of personal and intellectual struggle for most students. On the other hand, this site of struggle is potentially a catalyst for stimulating ideas and, more specifically, for stimulating a passion for pursuing those ideas. Engaging with this site of struggle as a struggle for the visibility of the voice of nursing produces passion for thought and dialogue and may be understood as the art of writing. How then does the School of Nursing (University of KwaZulu-Natal, South Africa) help students to empty their pockets of their accounts of the dynamic on-going process of personalized nursing care and to engage with the public process of nursing, meaning making and writing? The School of Nursing uses a curriculum-as-praxis, problem-based approach to accomplish the person-centered teaching/learning outcomes in its undergraduate nursing curriculum.11 In brief, individual clinical problems are seen as the starting point for the process of developing nursing knowledge within the evolving nurse-client interaction.11-14 It commonly requires students to move through a series of steps to a final outcome.15 These steps include searching the nurse-client interaction for problems overtly and covertly expressed by the client; identifying possible theoretical paradigms for underlying problems; developing a series of nursing actions consistent with client needs and theoretical frameworks; exploring the ethical and creative meanings underpinning client behaviors and nursing actions in practice; and finally, implementing and evaluating the outcome of nursing actions.14,16-17 (Phillips, Fawns & Haynes, 2002; Pierson, 1998; Scanlan, Care & Udod, 2002). The value of this approach in developing nursing practitioners who are able to competently solve clinical problems in practice is illustrated in the study by Uys, Van Rhyn, Gwele, McInerney and Tanga.18 These authors explored and compared the clinical problem solving abilities of nurses who had graduated from problem-based and non-problem based programs in nursing schools in South Africa. The study found that those who graduated from problem-based programs were generally more competent in solving complex clinical problems than those who graduated from non-problem based programs. Whereas the former were able to integrate past experience with similar situations and to adapt their responses accordingly, the latter tended to respond to clinical problems as if for the first time and therefore, drew extensively on institutional rules to moderate their responses. On the other hand, anecdotal comments from students suggest that there may be a tension between the philosophical assumptions of this knowledge generating approach and the medical paradigm at work in clinical practice. The possibility of this client-oriented approach becoming normalized within the direction of the dominant medical paradigm underlying public health practice settings cannot be underestimated.19 This may in part be why PBL has been variously criticized for its linear and a-contextual approach to meaning making and its solution-oriented knowledge base.20 It may be a catalyst for understanding that there are potentially many different and equally valid systems or methodologies for developing, pursuing and implementing ideas about nursing in clinical encounters and, thus, for developing nursing knowledge.21-23 Coming to terms with the idea that there are different ways of constructing nursing knowledge and then engaging with these different ways speaks to the rationality of writing. How then are the art and rationality of writing made visible (and invisible) in our undergraduate nursing curriculum? One concrete example of this is the strategy the mental health nursing module uses to provide these students with a route of entry into the psychiatric and personal world of mental illness and distress. Students are introduced to the world of mental health/illness through a case study that details both the psychiatric and personal experiences of mental illness for a hypothetical person and his family. Students’ personal responses to the case study and to the idea of psychiatric nursing in general serve as one of the starting points for reflective learning.24-26 Pockets are emptied and experiences are articulated, explored and clarified in class as rich and diverse sources for developing nursing knowledge. Potential theoretical knowledge constructs, embedded within each student’s description of their personalized responses to the case study, are identified and discussed. The students then use their “personalized” knowledge constructs as a basis for a literature search and review, wherein they attempt to show how different theoretical data supports, explains, contradicts or develops their understanding of the dynamics of the described experience, and how this understanding might be transferred to other situations. Once students enter the clinical field, this same framework is used in response to the clinical and intrapersonal issues they encounter in their clinical work with clients. And it is here that the paradigm tension between nursing’s client-oriented understanding of PBL and the public health settings’ bio-medical approach to health problems becomes evident as both a source of and resource for the art and rationality of writing. The caution here is that, for experience to be constructed as meaningful knowledge, the processes through which this knowledge is constructed and the knowledge itself must be rigorous and clearly evident.27 This is the hard part – what is described below as the “nuts and bolts” - helping students to locate their own ideas within the context of the vast body of already developed knowledge; to use this knowledge to refine and dispute their ideas and to show how different knowledge generating systems might produce different but equally plausible forms of knowledge for clinical practice; and finally, to transform this process into readable text and useable nursing knowledge. Finding an idea and placing in context through writing (USA) Teaching writing to nursing students has always been a part of nursing education, with “writing across the curriculum” being a benchmark of curricular organization at the University of Alabama School of Nursing. In our institution, it has reached a higher plane with our initiation in 2000 of a nursing honors program. Through honors seminars students develop a clinical project, writing an introductory paper, a proposal and a final paper. In many cases, these papers go on to be submitted and accepted for a peer-reviewed national publication.28 The steps in this process are integral to that success. Although many of the examples given below are personal strategies from the honors context, most are applicable to general nursing curricula as well. First, students must find something to say—the topic, area or issue they will compose. Second, students must support their ideas with literature. Third, they must begin to write ideas, in black & white, actual printed words on a piece of paper! Fourth, they must assimilate and respond to feedback in the form of revisions to the written manuscript. Through these steps, they differentiate their idea and their ideas about their idea, and integrate those with the “nuts and bolts” of writing it down. Once we begin talking about the written product, the words on paper, we have made a major leap. Objectivity begins to be defined as what is or is not “there” and the possibility exists for the craftsmanship of writing to emerge. Strategies for improvement can follow. Adding to definitions in the introduction will tell the reader what parameters are in force. Adding to the review of literature strengthens the place for the student’s ideas in the context of the works of others. Writing should keep the passion and involve the reader in how the idea brings reality to it. These skills are sorely needed in our profession to keep it current and engaging. They are essential to clinical judgment and changing practice. They constitute an underlying cognitive process of evidence-based practice. The First Step: Looking for Ideas Invariably the students come with some experience, either personal or from educational background, which has captured their interest. Sometimes, it is a desire to work in a particular field and, in other cases, an experience of health care received or a need unmet. Recent students’ topics in honors courses have included moral distress in nurses, parent waiting room support behaviors, family issues across a surgery, ethical concerns in elders, protection of fertility following chemotherapy, nursing theories applied to care, international nursing research collaboration, and others. The most important element at this stage is students’ selection of their own topic, albeit as a novice in the content area. Individual discussion with faculty is the key as the idea begins to have words. Often, the faculty member’s familiarity with common keywords in nursing will help the student express the idea. For example, one student identified an interest in new mothers’ bonding with their newborns and, through discussion with faculty, was able to separate the concepts of attachment developing over time from that of acquaintance immediately at birth. The student went on to develop her honors papers on the earlier period. The Second Step: Placing in Context and Citing Primary Sources The initial formulating of an idea leads the student into the literature. One cannot write without something to say and that must be developed in context. For us, the context is nursing practice and nursing literature. In the second step, the students are taught to search through the library (including remote access from their home), using the nursing database the Cumulative Index of Nursing and Allied Health Literature (CINAHL). Again, faculty input can be very beneficial in assisting the student to find good search strategies. Each cohort of students receives a general introduction to using CINAHL and other resources as part of the initial seminar. These are conducted by the reference librarians, initiating a relationship which can support future literature search. Meetings with faculty are critical to guide the student through focusing their idea and finding professional sources to support these. Students can use general search techniques with keywords and subject headings and combine searches with specific nursing roles, age groups or methodological approaches. For example, to assist the student to find specific articles, one can ask if they are more interested in physiological or psychosocial aspects of a problem, if they have a favorite nursing theory that they would like to apply or if they prefer to look at the topic as affecting a particular age group, such as children or elderly. To further define their idea through this process, an initial search is made from CINAHL, and then read through the titles and abstracts of recent articles it identifies. The goal at this stage is not a comprehensive review of available articles, but to separate those of interest from those more distant. The student makes decisions as to what is “in” and what is “out”, choosing what is immediately relevant and what can be saved for a later date. As we work through approximately ten selected titles and abstracts, I also watch their eyes and their facial expressions—I watch for the spark of excitement, the flicker of curiosity or the surprise of awe. This becomes the criterion for their subsequent pursuit on their own, developing the idea more fully. Through this second stage, a remarkable thing happens—students find there are others with interests similar to theirs. They find that the nurse researchers and nurse clinicians, perhaps thousands of miles away, are interested in the same phenomena and have developed articles, research and programs on these topics. The student receives confirmation and validation of the worth of their work and their thinking. The light comes on! As students begin to access literature, they are encouraged to find research-based literature to keep their work grounded in primary sources, specifically single-study and collective evidence sources. Ability to appraise data-based scientific works is a skill itself. In our classes, we use a small handbook by Sarah Jo Brown entitled “ Knowledge for Health Care Practice: A Guide to Using Research Evidence."29 This text and others like it acquaint students with a structure for appraisal of evidence, including evaluating the credibility of the report, the feasibility of applying the research in a clinical practice setting and the value and relevance for changing practice. The process of placing their ideas in context includes critical appraisal of usefulness of their idea to practice in the context of available evidence. Also, in this stage is using software to manage formatting. How often has the fear of red ink sent the student into overt writers block? Today, this fear can be obsolete through use of bibliographic management software such as Endnote®. Students should purchase or obtain access through their libraries at the beginning of the process of scholarly writing, so that, as articles are found to support their writing, these may be entered into the database format. As relevant articles are found in CINAHL, these can be saved with complete formatted bibliographic detail (authors, journal, volume, pages, etc.) in a software “library” for future retrieval. Thereafter, the program allows selected references to be listed in any format instantaneously. No red ink circling a missed comma! The manager software also provides a template for the specific format and a feature “cite while you write” to insert the reference with one click. Writing is made much less laborious! Instead of being paralyzed by the mechanics with writing, the student may focus on the effectiveness of the idea presentation, the clarity of expression, the concepts, the meaning of the text and the substance of the writing content. An interim requirement that facilitates writing is an annotated bibliography. The annotated bibliography on approximately five articles requires the student to summarize the author’s procedures and findings, and go on to discuss these and how they relate to their idea. Students may not use the published abstract but must summarize, developing their technical skills in accurately paraphrasing. They must then write a critique, specifically addressing how the author’s ideas support their own (or raise questions about the topic). The provision for several articles means they have used some better and some worse, which gets them a good start on an appropriate bibliography for an undergraduate paper. In the next step, the annotated bibliography can be put in narrative form, with transitional sentences becoming the review of literature or background section of a formal paper. The Third Step: Writing It Down The requirement of a scholarly paper cannot be underestimated—an idea, passion or flickering curiosity rarely finds being beyond the imagination without such requirement. The requirement of a written paper gives the idea form and substance. It is in writing one’s ideas on paper that the idea becomes real, communicable to others. In this stage, the single most valuable teaching strategy is the provision for writing drafts. The first draft is the hardest, as the student crystallizes concepts, organizes the document logically, selects literature and presents an arguable thesis. One approach is for the student to choose a few key resources and apply these in the definition of the problem. At the undergraduate level, a comprehensive review or exhaustive search is not warranted. The students’ ideas and the literature chosen should converge, forming a focus concept within the context of background knowledge and evidence. The sources should be critically applied, noting strengths and weaknesses for application in the new inquiry or thesis. The organizational flow of this written work should be from what is known (review of literature) to what is unknown—the clinical or research question. This step of writing the first draft of the idea, context and future direction, sets the process of scholarly inquiry in motion. For students in honors, the output at this point is the well-defined clinical question. Other strategies for “writing it down” have been used to encourage students to find their voice and communicate with the written word. These include journal writing,30 writing in groups or with a collaborative team,31,32 and writing shorter pieces such as letters to the editor.33 Whatever form is chosen for the instructional strategy, the draft provides some safety for the student, where tentative ideas can be stated without fear of absolute failure. The quiet, small voice can begin to be heard. Writing often, in smaller pieces, can support idea development and emerging voice. The Fourth Step: Feedback and Revision Feedback can include peer-review in addition to instructional comments from faculty. Stowell34 reported a study of the use of peer-review in a writing-intensive honors course. Students submitted a draft by a deadline and then received a structured peer-review by a classmate. Peer reviewers were required to give feedback, using the formal grading rubric (maximum 20 points for a clear well-supported idea, down to 0 for an unclear idea with random or absent support) with comments on strengths and weaknesses. He found students benefited from the process of evaluating others as well as improved their own works in the revision process. Positive reinforcement of the quality of the idea, the appropriateness of the literature, the effectiveness of the application of that literature should be documented by faculty. Instructor comments must include positive feedback, noting elements that are “good”, “excellent”, and “outstanding”. Without the positive feedback, students will not get the message of their accomplishment in the first draft. Reinforcement of the good is also critical support for nurturing the nascent student voice. The flame of personal development and the voice of the emerging scholar is the objective of the educational process. Positive feedback (green ink) is the key to progress. Specific recommendations can be given for refocusing, adding, defining or taking the next logical step. Feedback can also be given to identify errors or omissions of logic, to recommend articles or information to fill in gaps in supporting literature, to redirect the emphasis to a nursing model or framework, and to suggest ways to tighten the written text. At this point, the primary target is the written manuscript draft, what will make it more effective. Students must use the feedback, incorporating both major recommendations (conceptual shifts, completeness, logic) and minor recommendations (grammar, word choice, sentence structure). This step produces a draft that is approaching effectiveness of communication of the idea with its substance, content, and structure. Over the next semester, the Honors in Nursing student will take the clinical question, developing the methodological approach, establishing the feasibility through the clinical mentor, securing IRB and agency approvals, collecting data through surveys, observations and interviews, and writing a research paper. Further refinement may actually result in the student’s work being published. These activities are beyond the scope of this discussion. There are numerous possibilities for undergraduates to turn the student paper, a “diamond in the rough,” into a published paper in undergraduate journals, online journals, clinical journals or research applications sections.35-37 Four steps of teaching writing are described here, each with student and faculty roles and responsibilities, and the mutual goal of a well-written, engaging manuscript. From idea generation through literature support of the context to a well-written product, the process is as much about the individual’s development as it is about the creation of a scholarly work. Use of databases (CINAHL and others), searching techniques, software (Endnote® and others) makes the tasks of writing manageable. The provision for drafts, feedback and revisions allows early tentative student efforts to be confirmed and strengthened by peer and faculty input. The end result is a scholarly paper, which can make a genuine contribution to the nursing literature and development of nursing practice. Summary—Evidence-Based Practice and Nursing Voice Nursing students in the 21 st century must base their practice on the critical appraisal of evidence, applied in complex clinical and community settings. The Honor Society of Nursing, Sigma Theta Tau International, has defined evidence-based nursing practice as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities served".38 This assumes that nurses are able to exercise their judgment to bridge the gap between the evidence and the individuals’ needs.39 Pierce40 summarizes the steps of evidence-based nursing (EBN) as follows: a) Developing a researchable practice question to guide the search for research-based evidence; b) Designing and implementing a search for the best available, current evidence; c) Retrieving and appraising the credibility, clinical significance and applicability of the evidence; d) Making a decision based on the appraisal of the evidence and implementing the decision; and e) Evaluating the effects of the decision and the application of the EBP process. The three writing approaches described in this paper all rely on these steps, both for understanding the essentials of research applied to practice and for designing new ways to express what is unique to nursing. Chandler, Roberts and Demarco31 describe finding a positive identity in the nursing role, one which liberates from the oppression of the solely medically-based model and the avoidance pattern of communication (silence) to learn a new language and find a new voice. Their model values reflection, connection and the receipt of support from other nurses. That support can also come from peers and faculty willing to accept non-traditional roles of nursing and creative approaches to care. The three pieces linked in this paper discuss the efforts of nursing faculty to teach and encourage writing in their students. Drs. Nascimento and Rodrigues from Brazil have introduced use of nursing research process as a way of structuring students’ expression and validation of ideas. Dr. Middleton from South Africa has expanded on that approach with a philosophical description of the cognitive processes of students in discovering what is in their pockets, taking their informal observations and understandings to the more formal level through writing. Dr. Buckner from the United States of America has given a practical approach to getting students involved in utilizing available software and databases, and the essential element of the faculty-student interaction to encourage students to find their voice. These three approaches to teaching writing to undergraduate nursing students are as disparate as three continents, but as similar as three faculty operating in adjacent classrooms. Through an electronic writing collaboration, three continents have been drawn together on these pages. If that feat is possible, what are the potential accomplishments of our students? Acknowledgements The authors would like to thank the three sponsoring chapters of the Honor Society of Nursing, Sigma Theta Tau International, Rho Upsilon (Brazil), Tau Lambda (South Africa) and Nu (USA), for support of the International Writing Collaborative. We would like to particularly express our appreciation to Dianne M. Richmond, Dr. Lynda L. Harrison and Dr. Maria Helena Larcher Caliri, whose expertise and enthusiasm have been instrumental to the group’s formation and productivity. References
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