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Assessment and instruction to promote higher order thinking in nursing students
Nurse Education Today 34 (2014) 789–794
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Assessment and instruction to promote higher order thinking in nursing students Lina D. Kantar ⁎ Rafic Hariri School of Nursing, American University of Beirut, PO Box 11-0236, Riad El Solh 1107-2020, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Accepted 20 August 2013 Keywords: Assessments Teacher-centered learning Student-centered learning Higher order thinking skills
s u m m a r y Objectives: The dearth of data on the role of assessment in higher education formed the two purposes of this study: first, to explore assessment strategies commonly used in nursing education by analyzing the curriculum documents of three baccalaureate nursing programs in Lebanon against Bloom's Taxonomy of learning, and second to unravel issues of instruction and assessment by categorizing data into teacher- and learner-centered strategies. Design: Content analysis research technique applied to analyze the curriculum documents of three baccalaureate nursing programs in Beirut, Lebanon. Method: After obtaining IRB approval and consent to access the curriculum documents of the programs, data were analyzed using the content analysis research technique. Data on assessments and instruction were categorized into student-centered and teacher-centered. Findings: Data revealed deficiency in employing learner-centered strategies in the assessment and instruction of the three programs. There was evidence that educators of the programs focus on teaching content and examining retention, thus supporting prior notions on teaching to the test and accusations in earnest on adherence to the traditional and behavioral curriculum perspectives. Such curricula leave little room for the development of higher order thinking in learners. Conclusions: Although assessments are believed to be indicators of program and teaching effectiveness, there is relatively alarming information on the incompatibility between current assessment practices and demands of the workplace. There is an urgent need for transforming educators' beliefs, knowledge, and skills on testing, since teaching to pass a test could impede knowledge transfer and deter the development of learners' higher order thinking skills. © 2013 Elsevier Ltd. All rights reserved.
Introduction Despite the rhetoric surrounding the development of real world skills such as reflection, inquiry, self-regulation, and transfer (Silva, 2009), educators still cling to teaching content and assessing knowledge acquisition. Relentless calls for transforming curricula converge on the need to better prepare graduates through the integration of higher order thinking skills (Barnett and Francis, 2012; Fischer et al., 2011; Wagner et al., 2013). Although instruction for higher order thinking has been dealt with a great deal of enthusiasm, assessment of student achievement in higher education remains underexplored (Malik, 2009; Taras, 2008). Precious little work on assessment has resulted in more focus on teaching methods (Nilson, 2010). Current literature on teaching for critical thinking includes changing content-laden curricula to problembased learning, shifting abstract acquisition of knowledge to contextualized knowledge and case-based learning, and transforming the disjointed curriculum to integrative teaching and learning. Although assessment of student performance is crucial to promote the teaching learning loop, ⁎ Tel.: +961 3 684205 (mobile). E-mail address: [email protected]. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.08.013
much of the available work focuses on effectiveness of accountabilitydriven assessments (Wehlburg, 2011), rather than the need to assess thinking skills (Fischer et al., 2011). This study focuses on exploring assessment and instructional strategies used in nursing education and on determining whether these strategies promote critical thinking skills. Background The three pillars of a curriculum are content, instruction, and assessment (Marsh and Willis, 2003). Instruction and assessment are intertwined and reciprocally interconnected, yet very much affected by educators' beliefs. The effectiveness of student assessment is contingent on how educators plan their instruction; instruction that values learner's performance and takes into account learner's thinking and developmental processes. Since “what we assess is what we really value” (Wiggins, 1993, p. 42), student assessment must reflect the inherent tendency of educators to know about how students transfer and use the acquired knowledge in solving the problems of the real world (Janisch et al., 2007). The purpose of this study was to explore assessment and instructional approaches employed in three baccalaureate nursing programs in Lebanon and to describe the possible impact that such approaches
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have on learners' thinking skills. In nursing education, the dearth of data on the role of assessment and instruction in the development of thinking skills has led to the principle inquiry of this study. The research question that guided the inquiry process was: how do the curriculum's structural elements of instruction and assessment influence the development of higher order thinking skills? A thorough analysis of the curriculum documents using the content analysis research technique helped to identify related issues. Since many issues related to the preparation of nurses for the professional role are generic, the study findings could have local and international relevance. Literature Review The calls for curriculum transformation in higher education emerge from the inadequate preparation of graduates (Benner et al., 2010; Wagner et al., 2013). Despite the exhausted literature on identifying the multiple reasons for this under education, queries remain about the effectiveness of instruction and assessment in promoting higher order thinking competencies. Teaching for Higher Order Thinking The concept of thinking and the role of schools in teaching thinking were early introduced in the work of Dewey (1933). Later, Benjamin Bloom provided an illustration of six thinking levels, which, at present, form the framework for developing learning outcomes. Bloom's (1956) cognitive patterns are classified qualitatively into lower and higher order thinking. Lower order thinking encompasses knowledge, comprehension, and application, whereas analysis, synthesis, and evaluation characterize higher order thinking (Barak et al., 2007; Russell, 2011; Wang and Farmer, 2008). Best teaching practice begins with setting learning outcomes, and continues by determining best approaches that help learners achieve those outcomes. With outcomes forming the basis of the educational process, Nilson (2010) categorized instruction and assessment using Bloom's thinking levels. Lower level thinking emphasizes memorization of factual knowledge, and is presented in the form of lectures and teacher-led discussion (Nilson, 2010). These strategies are rampant in higher education (Wagner et al., 2013), and more so in nursing (Benner et al., 2010). Instruction for higher order thinking indicates teaching different ways of thinking, with problem-solving and knowledge transfer as chief outcomes (Wagner et al., 2013). The abundant work in this domain addresses the benefits of higher thinking instruction (Angeli and Valanides, 2009), represented by instructional techniques such as unfolding cases, problem-based and inquiry-based learning, project-based learning, simulation, and integration (Benner et al., 2010; Glasgow et al., 2010; Nilson, 2010). With these techniques, educators integrate skills such as analysis, evaluation, and synthesis. Assessment in Higher Education Assessments incorporate many aspects of the teaching learning process, such as assessment strategies, tools, modes of use, and participants (Giloi and du Toit, 2013). Student assessment remains the focus of attention owing to the impact that such assessments have on accountability of the institution. At present, assessment emphasizes two chief accountability goals: preparing students for the workplace and ensuring effectiveness of educational programs. Accordingly, assessments assume either the ideal or actual form. Ideal assessments provide evidence about teaching effectiveness (Earl and Giles, 2011), whereas actual assessments reflect difficulties of educators in gauging the fit between community demands and accountability systems (Wehlburg, 2011). The incongruence between both assessments has raised a lot of concerns (Stiggins, 2001).
Higher thinking assessments assess the ability to transfer knowledge to the real world where learners need to think critically (Silva, 2009). Like most competencies of higher education, thinking skills cannot be developed with the content-laden curricula (Benner et al., 2010; Silva, 2009), nor improved with clinical training alone (Barak and Dori, 2009). Educators assume a great responsibility in promoting thinking skills by conceptualizing how, what, where, and when to assess these skills and use the data to improve learning (Wehlburg, 2011). Recent work on the impact of instruction and assessment on learning has revealed that instruction is crucial for the development of higher order thinking (Barak et al., 2007). Similarly, assessments could persuade learners to focus on thinking skills throughout the learning process (Barak and Dori, 2009). A recent study by Barnett and Francis (2012) supports the role of assessments in promoting higher order thinking. Assessment in Nursing Education Thinking in nursing involves training in analysis, synthesis, and evaluation. The reality is that undergraduate programs rarely instruct and assess past the analysis level (Russell, 2011). Critics of accountability test-driven programs contend that assessments are structured at lower order thinking levels, thus compel educators to teach-to-the test (Au, 2007). The findings from a survey conducted by the National League for Nursing (NLN) revealed that nurse educators continue to rely on teacher-centered tests to safeguard success of students on state board exams (Oermann et al., 2009). In the NLN's study, learnercentered assessments were emphasized by nurse educators, yet teacher-centered tests were assigned more weight in the curriculum. Findings revealed that teaching-to-the-test remains the chief means to prepare nurses for practice (Oermann et al.). Three assumptions underpin current assessment practices in nursing. First, it is believed that the primary purpose of assessment is assessing content that appears on board exams (Oermann et al., 2009). With this approach, learners get preoccupied with what to learn, rather than how to learn subject matter. Second, assessment data are associated with accountability measures for the sake of demonstrating program and instructional effectiveness. This assumption leads to an obvious divide between imparting content and developing the learner's habit of mind (Silva, 2009). The separation of instruction from learning by standards-driven assessments tends to underpin the theory practice gap (Brunt, 2005). The third assumption emanates from the belief that continuous assessments increase exposure to test items that may appear on registration examinations, thus ensuring success on first attempt. The debate continues since such tests lack thoroughness in assessing thinking skills, thus defeating the needs of constituencies for a better preparation of graduates for practice. Method The qualitative content analysis research technique was employed in this study. This research method helped to gain an in-depth understanding of the curriculum structure by exploring the various instructional and assessment strategies used in the three programs. In this respect, Posner's (2004) criteria for curriculum analysis and Neuman's (2006) coding system were incorporated in the analysis process. Posner's criteria included curriculum theory and approach to purpose and content, which formed the unit of analysis in this study. For the curriculum theory, data were obtained from documents that solicit the mission, purpose, philosophy, or conceptual framework of the program (Wiles and Bondi, 2007). Since the four most commonly used curriculum theories in the discipline of nursing are traditional, behavioral, experiential, and constructivist perspectives (Benner et al., 2009), the curriculum documents were assessed against these theoretical perspectives. To better understand curriculum purpose and content,
L.D. Kantar / Nurse Education Today 34 (2014) 789–794
the syllabus for each nursing course in the participating programs was assessed. Neuman's (2006) manifest and latent coding represented the analysis procedure. Through manifest coding, the content of each of Posner's criteria was made visible and explicit, whereas latent coding provided the means to surface themes and messages hidden in the curriculum (Neuman). The coding procedure was based on an extensive literature review resulting in terminologies or phrases that helped categorize assessments and instruction. The categorization procedure was based on both the theoretical perspective of the programs and Bloom's (1956) cognitive pattern. Data gleaned from the curriculum documents were categorized into teacherand learner-centered strategies. Teacher-centered represents the traditional curriculum which emphasizes recall, comprehension, or application of knowledge (Bloom, 1956; Janisch et al., 2007; Zohar and Dori, 2003). This category's instruction and assessment are teacher-driven, thus requiring low student effort and less engagement (Nilson, 2010). Two types of learning underpin the teacher-centered perspective: declarative and procedural. Instruction and assessment targeting declarative learning focus on knowledge and comprehension, whereas procedural learning focuses on application (Nilson, 2010). Terms in the curriculum reflecting either declarative or procedural learning are categorized as teacher-centered. The learner-centered category reflects the constructivist curriculum, thus higher order thinking pattern. In this category, learners are expected to construct knowledge through analysis, synthesis, and evaluation (Bloom, 1956; White, 2007), and to execute moderate to high effort (Nilson, 2010). Learner-centered assessment and instruction employ conditional or reflective learning, thus enabling learners to know where, when, and how to use knowledge. In conditional learning, learners apply, analyze, and synthesize knowledge when engaging them in case discussion, ill-structured problems, simulation, project, research, and role play (Nilson). Reflective learning prompts learners to analyze, synthesize, and evaluate knowledge, especially when reflecting and journaling.
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Table 1 Teacher-centered assessment strategies and weights of theoretical courses. Program
Frequency of tests
Weight
A B C
9 16 14
≥70% N80% ≥70%
Findings revealed that assessments in theory courses were mainly based on ‘tests’. The use of testing to assess learners' knowledge acquisition is categorized as a teacher-centered strategy. Structuring of tests remains the chief function of teachers, with no input on part of students in this strategy. The frequency of tests in a program and the weight allotted for this strategy were tabulated.
assessments in a program and the weight allotted for each strategy were tabulated. The assessment categories employed to analyze the theory courses were used to analyze the clinical courses. The teachercentered category included evaluations based on performance of learners from the perspective of ‘tutor’ or ‘preceptor’ and by ‘clinical examinations’ (see Table 3). Assessments reflecting learnercentered were: ‘case presentation’; ‘case study discussion’; and ‘written submissions’ in the form of reports, summary, care plans, and papers; ‘simulation’; ‘patient education’; and ‘reflection’. The frequency of occurrence of each category was tabulated (see Table 4). Curriculum Analysis: Instructional strategies Instructional strategies were categorized into teacher- and learnercentered. In this study, traditional teaching is teacher-centered and content-laden (Posner, 2004), and information is presented using either the ‘lecture’ format or ‘teacher-led discussion’ (see Table 5). Data on learner-centered strategies were: ‘case presentation’, ‘evidence-based’ teaching, ‘case discussion’, ‘simulation’, ‘reflection’, and ‘team-learning’ (see Table 6). Data on instruction were coded to each of the categories. Results
Sample A purposeful, homogeneous sampling was used to select three baccalaureate nursing programs in Lebanon with similar characteristics. The programs operate within reputable tertiary institutions in a geographical area that is accessible and feasible for conducting the study. The purposeful selection of Programs A, B, and C minimized “extraneous variation and clarified the domain of the findings as large corporations operating in specific types of environment” (Huberman and Miles, 2002, p. 12). Data Collection The study was reviewed and approved by the significant Institutional Review Board. After obtaining permission to access the curriculum documents of three nursing programs, the data collection process commended. Posner's (2004) curriculum principles guided the process. Curriculum Analysis: Assessment Strategies Assessments in this study were categorized depending on whether the nursing courses had a clinical or theoretical focus. For the theory courses, ‘tests’ were classified as teacher-centered (see Table 1), whereas learner-centered had the following strategies integrated in the courses: (a) ‘presentations’; (b) assignments in the form of ‘research, project, or online discussion’; and (c) ‘report writing’ (see Table 2). Evaluation tools for every nursing course in the program were coded to each of the categories in the coding hierarchy. Sometimes courses used both categories and were attributed to each applicable code. The frequency of
The theoretical framework of the three curricula is traditional in nature, and all programs used ‘tests’ as the means to assess learning. In this study, tests are considered teacher-centered and of lower order thinking category. Program A used ‘tests’ as the means to assess learners, whereas learner-centered strategies appeared with a higher frequency in the curriculum. In Program B, testing was the chief assessment strategy used in the program. Theory courses for Program C had nearly equal occurrence of teacher-centered and learner-centered assessments. Although the frequency of learner-centered assessments in programs A and C was higher compared to teacher-centered strategies, yet the weight allotted to each of the identified teacher-centered strategies was higher (see Table 1). For assessments of clinical courses, Program A used both teacherand learner-centered approaches. Most of teacher-centered assessments in the program depended on evaluations by clinical tutors (see Table 3), whereas learner-centered approaches focused on ‘case presentation’, ‘case study’ discussion, ‘written submissions’, and ‘patient education’ at Table 2 Learner-centered assessment strategies and weights of theoretical courses. Program Case Weight Research Weight Report Weight presentation (%) project/online (%) (%) A B C
9 2 4
10% b10% 10%
4 2 6
10% b10% 5–35%
2 2 7
Total
10% 15 b10% 6 10–30% 17
Table 2 illustrates the various learner-centered assessment strategies applied to the theory courses in the three programs. Three major learner-centered strategies were captured in each nursing curriculum. The frequency of these strategies in the program and the weight allotted for each strategy are presented in this table.
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Table 3 Frequency of teacher-centered assessment strategies in clinical courses.
Table 5 Frequency of teacher-centered instructional strategies.
Program
Evaluation by tutor
Evaluation by preceptor
Clinical exam
Total
Program
Lecture
Teacher-led discussion
Total
A B C
6 5 7
3 9 0
6 6 0
15 20 7
A B C
9 17 7
4 1 6
13 18 13
Table 3 reflects the teacher-centered assessment strategies for the clinical courses of the three programs. The teacher-centered category included evaluations based on performance of learners from the perspective of ‘tutor’ or ‘preceptor’ and by ‘clinical examinations’. Only the frequency of occurrence of each strategy is tabulated without considering its weight, since the clinical courses in two of the programs use the pass and fail criteria.
nearly equal frequency (see Table 4). Program B's clinical assessments were mostly teacher-centered, with the focus on evaluations by preceptors, yet to a lesser extent the clinical tutor. Program C depended solely on evaluations by the clinical tutor with higher occurrence of learnercentered strategies. The weight allotted for learner-centered assessments in program A clinical courses ranged between 40% and 50%, whereas Program B and C's learner-centered strategies had a weight of less than 30%, except for three senior nursing courses in Program C with a weight reaching 70% in one of them. ‘Simulation’ and ‘reflection’ were not used in any of the three programs. Findings on instructional strategies revealed the emphasis on teacher-centered instruction rather than learner-centered ones, specifically in Programs A and B respectively (see Table 5). Program A used direct instruction in the form of ‘lectures’ or ‘teacher-led discussions’ with ‘case presentations’ as the only learner-centered strategy. ‘Simulation’ and ‘reflection’ were omitted from the curriculum. Program B had similar findings, with ‘teacher-led discussion’ as the main strategy employed in the theory courses, whereas learner-centered instruction was employed to a lesser extent. For Program C, findings revealed that both types of instructional strategies occurred with nearly equal frequency (see Table 6). ‘Case presentation’ appeared as a commonly used strategy in both instruction and assessment of the three programs. Discussion The study findings revealed the high use of ‘tests’ to assess student achievement in the theory courses of the three programs. The emphasis on testing in the three programs was presented in the curriculum documents in two forms. The first form was the high frequency of testing which was prominent in Program B, resulting in lesser use of learnercentered assessments in the curriculum. The second was the obvious use of learner-centered strategies in Programs A and C, yet the weight allotted for each strategy was negligible compared to weights on ‘tests’. These findings support prior work by Oermann et al. (2009), which revealed the high weight that educators allot to ‘tests’ to assess learning and to determine the ability of learners to transfer knowledge from the classroom to the real world of practice. The frequency of teacher-centered assessments in the practicum courses varied between programs, with ‘evaluation’ and ‘examination’ as dominant strategies. The highest frequency of this assessment category was detected in Program B. Programs A and C used ‘written Table 4 Frequency of learner-centered assessment strategies of clinical courses.
Instructional strategies were categorized into teacher- and learner-centered. Table 5 reflects the frequency of occurrence of the traditional teaching format in the programs, which appeared in the form of lectures and teacher-led discussion. The frequency of occurrence of each strategy reflects the level of emphasis in the curriculum.
submissions’ and ‘patient education’ as learner-centered assessments. Although writing improves content acquisition and thinking (Emerson et al., 2006), professional practice stresses the role of the curriculum in acquainting students with knowledge and skills related to knowledge transfer, interpretation, response, and reflection (Tanner, 2006). Reflective practice and simulation are essential strategies for the development of these skills (Kantar and Alexander, 2012), yet neither strategy was captured in the clinical courses of the programs. Findings gleaned from instructional data support prior work regarding the central role of teachers in the educational process (Rupani and Bhutto, 2011). The study's results revealed that direct instruction in the form of ‘lectures’ and ‘teacher-led discussion’ were dominant in the theory courses of the programs. Although one of the programs had nearly equal occurrence of learner- and teacher-centered instruction, teacher-centered assessments were given higher weight in that curriculum. This finding reflects the absence of an alignment between the curriculum, assessment, and instruction. The situation is likewise with higher education (Malik, 2009), where the alignment issue is attributed to the advent of innovative curricula with inadequate exploration of new assessment practices (Taras, 2008). Teaching practices in the three programs were test-driven and teacher-led. The shy use of learner-centered assessments and instruction in the three programs and the minimal weight assigned for this assessment category manifests itself for four distinct reasons: educators' knowledge about means to nurture higher order thinking skills in learners, beliefs regarding diffusion of content, preparation on best grading practices, and clarity on modes of knowledge transfer. In nursing education, substantial attention has been given to content–practice continuum. Nevertheless, there exists a need to consider thinking skills and knowledge transfer as major educational outcomes of a curriculum. It is strongly believed that instruction and assessment help in the development of higher order thinking skills (Jones, 2012) and in knowledge transfer (Leberman et al., 2006). Instruction must be contextual since classroom knowledge cannot resemble the setting in which graduates function (Brooks et al., 2010), and assessments geared for learning and transfer (Illeris, 2009; Taras, 2008). Implications for Educators Learner-centered assessments, tailored to elicit learner performance, can inform both teachers and learners about achievement and improvement. Effective assessments emanate from differentiated instruction which, in effect, appreciates modes of knowledge acquisition. Assessing Table 6 Frequency of learner-centered instructional strategies.
Program Presentation Case Writing Simulation Patient Reflection Total study education
Program Case Evidence- Case Simulation/ TeamTotal presentation based discussion reflection learning frequency
A B C
A B C
4 2 4
4 2 1
5 2 6
0 0 0
5 0 5
0 0 0
20 6 17
The learner-centered category of Table 3 pertains to the assessment of clinical courses in the three programs. Based on the use of the pass–fail criteria in the clinical courses, the frequency of occurrence of each category was all that can be captured from the curriculum documents.
6 1 5
0 2 1
1 5 3
0 0 2
1 2 4
8 10 15
This table presents the learner-centered instructional strategies. The strategies reflect student involvement in the teaching learning process. Five instructional strategies were captured in the curriculum documents and tabulated accordingly. The frequency of occurrence of each strategy reflects the level of emphasis in the curriculum.
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learning must be on-going for the sake of monitoring progress and maximizing learner's potentials. Teachers need to conceptualize assessments as an interactive process which builds on learners' engagement and motivation (Taras, 2008). In practice, assessment for learning requires curriculum integration of the following strategies: reflective practice (Epp, 2008), learning logs (BergstrÖm, 2010), program-workplace projects (Illeris, 2009), simulation (Shepherd et al., 2010), and journaling (Barak and Dori, 2009). The development of thinking skills is central to the aforementioned methods (Maniotes, 2010). Development of cognitive skills to solve problems of the future mandates the integration of problem-solving skills in the program's instruction and assessment system. Assessments using ill-structured problems help to augment learners' ambiguity level and activate cognitive processes (Zane, 2009). The processes commence with formulating hypotheses and conclude with an action plan to solve the problem (White, 2007). Assessment for transfer is deemed essential to prepare graduates for practice. Transfer can be strengthened by exposing learners to experiences of three salient features: “participant direction, problem orientation, and exemplarity” (Illeris, 2009, p. 143). Through project work, students are prompted to select a problem from the immediate environment, and exercise efforts to construe the situation and present solutions. This approach enhances metacognition through questioning learners' ability in forming constructs that fit different contexts, thus enhancing knowledge expansion, application, reconstruction, and connection (Shepard, 2006). Teaching for transfer influences how students learn. Implications for Curriculum Leaders Amid the calls for transforming assessment practices in higher education, the development of an assessment system must be at the forefront. The system must be based on a framework to carefully ground any practical decision about the curriculum in clear and well-informed thought. Curriculum leaders can elicit the momentum for change and enhance buy into the change process through professional development initiatives. With such initiatives, teachers could be prompted to reflect on their assessment practices and explore beliefs about teaching and learning. Any change in teaching practice is contingent on creating an appropriate balance between mandated standards and curriculum goals. Limitations Three limitations were inherent in the study. First was the small sample size drawn from three nursing programs confined to a geographical area in Lebanon. Another limitation relates to the quantity of information provided by the available curriculum documents, which could have been inadequate for a comprehensive content analysis. The third limitation relates to language, since one of the programs uses French as the medium of instruction. The program documents were translated to English and checked by the program director, thus ensuring validity of the document content. Conclusions The emphasis of this study was on the assessment for the development of higher order thinking skills in nursing students. Instruction was included as well since assessment and instruction form the framework of a curriculum, thus assessment cannot be independently studied. Although assessments are believed to be indicators of program and teaching effectiveness, there is relatively alarming information on the incompatibility between current assessment practices and aspirations of constituencies. There is an urgent need to transform educators' beliefs, knowledge, and skills on assessing student achievement, since teaching to pass a test could impede knowledge transfer and deter the development of learners' higher order thinking skills.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Assessment and instruction to promote higher order thinking in nursing students Lina D. Kantar ⁎ Rafic Hariri School of Nursing, American University of Beirut, PO Box 11-0236, Riad El Solh 1107-2020, Beirut, Lebanon
a r t i c l e
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Article history: Accepted 20 August 2013 Keywords: Assessments Teacher-centered learning Student-centered learning Higher order thinking skills
s u m m a r y Objectives: The dearth of data on the role of assessment in higher education formed the two purposes of this study: first, to explore assessment strategies commonly used in nursing education by analyzing the curriculum documents of three baccalaureate nursing programs in Lebanon against Bloom's Taxonomy of learning, and second to unravel issues of instruction and assessment by categorizing data into teacher- and learner-centered strategies. Design: Content analysis research technique applied to analyze the curriculum documents of three baccalaureate nursing programs in Beirut, Lebanon. Method: After obtaining IRB approval and consent to access the curriculum documents of the programs, data were analyzed using the content analysis research technique. Data on assessments and instruction were categorized into student-centered and teacher-centered. Findings: Data revealed deficiency in employing learner-centered strategies in the assessment and instruction of the three programs. There was evidence that educators of the programs focus on teaching content and examining retention, thus supporting prior notions on teaching to the test and accusations in earnest on adherence to the traditional and behavioral curriculum perspectives. Such curricula leave little room for the development of higher order thinking in learners. Conclusions: Although assessments are believed to be indicators of program and teaching effectiveness, there is relatively alarming information on the incompatibility between current assessment practices and demands of the workplace. There is an urgent need for transforming educators' beliefs, knowledge, and skills on testing, since teaching to pass a test could impede knowledge transfer and deter the development of learners' higher order thinking skills. © 2013 Elsevier Ltd. All rights reserved.
Introduction Despite the rhetoric surrounding the development of real world skills such as reflection, inquiry, self-regulation, and transfer (Silva, 2009), educators still cling to teaching content and assessing knowledge acquisition. Relentless calls for transforming curricula converge on the need to better prepare graduates through the integration of higher order thinking skills (Barnett and Francis, 2012; Fischer et al., 2011; Wagner et al., 2013). Although instruction for higher order thinking has been dealt with a great deal of enthusiasm, assessment of student achievement in higher education remains underexplored (Malik, 2009; Taras, 2008). Precious little work on assessment has resulted in more focus on teaching methods (Nilson, 2010). Current literature on teaching for critical thinking includes changing content-laden curricula to problembased learning, shifting abstract acquisition of knowledge to contextualized knowledge and case-based learning, and transforming the disjointed curriculum to integrative teaching and learning. Although assessment of student performance is crucial to promote the teaching learning loop, ⁎ Tel.: +961 3 684205 (mobile). E-mail address: [email protected]. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.08.013
much of the available work focuses on effectiveness of accountabilitydriven assessments (Wehlburg, 2011), rather than the need to assess thinking skills (Fischer et al., 2011). This study focuses on exploring assessment and instructional strategies used in nursing education and on determining whether these strategies promote critical thinking skills. Background The three pillars of a curriculum are content, instruction, and assessment (Marsh and Willis, 2003). Instruction and assessment are intertwined and reciprocally interconnected, yet very much affected by educators' beliefs. The effectiveness of student assessment is contingent on how educators plan their instruction; instruction that values learner's performance and takes into account learner's thinking and developmental processes. Since “what we assess is what we really value” (Wiggins, 1993, p. 42), student assessment must reflect the inherent tendency of educators to know about how students transfer and use the acquired knowledge in solving the problems of the real world (Janisch et al., 2007). The purpose of this study was to explore assessment and instructional approaches employed in three baccalaureate nursing programs in Lebanon and to describe the possible impact that such approaches
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have on learners' thinking skills. In nursing education, the dearth of data on the role of assessment and instruction in the development of thinking skills has led to the principle inquiry of this study. The research question that guided the inquiry process was: how do the curriculum's structural elements of instruction and assessment influence the development of higher order thinking skills? A thorough analysis of the curriculum documents using the content analysis research technique helped to identify related issues. Since many issues related to the preparation of nurses for the professional role are generic, the study findings could have local and international relevance. Literature Review The calls for curriculum transformation in higher education emerge from the inadequate preparation of graduates (Benner et al., 2010; Wagner et al., 2013). Despite the exhausted literature on identifying the multiple reasons for this under education, queries remain about the effectiveness of instruction and assessment in promoting higher order thinking competencies. Teaching for Higher Order Thinking The concept of thinking and the role of schools in teaching thinking were early introduced in the work of Dewey (1933). Later, Benjamin Bloom provided an illustration of six thinking levels, which, at present, form the framework for developing learning outcomes. Bloom's (1956) cognitive patterns are classified qualitatively into lower and higher order thinking. Lower order thinking encompasses knowledge, comprehension, and application, whereas analysis, synthesis, and evaluation characterize higher order thinking (Barak et al., 2007; Russell, 2011; Wang and Farmer, 2008). Best teaching practice begins with setting learning outcomes, and continues by determining best approaches that help learners achieve those outcomes. With outcomes forming the basis of the educational process, Nilson (2010) categorized instruction and assessment using Bloom's thinking levels. Lower level thinking emphasizes memorization of factual knowledge, and is presented in the form of lectures and teacher-led discussion (Nilson, 2010). These strategies are rampant in higher education (Wagner et al., 2013), and more so in nursing (Benner et al., 2010). Instruction for higher order thinking indicates teaching different ways of thinking, with problem-solving and knowledge transfer as chief outcomes (Wagner et al., 2013). The abundant work in this domain addresses the benefits of higher thinking instruction (Angeli and Valanides, 2009), represented by instructional techniques such as unfolding cases, problem-based and inquiry-based learning, project-based learning, simulation, and integration (Benner et al., 2010; Glasgow et al., 2010; Nilson, 2010). With these techniques, educators integrate skills such as analysis, evaluation, and synthesis. Assessment in Higher Education Assessments incorporate many aspects of the teaching learning process, such as assessment strategies, tools, modes of use, and participants (Giloi and du Toit, 2013). Student assessment remains the focus of attention owing to the impact that such assessments have on accountability of the institution. At present, assessment emphasizes two chief accountability goals: preparing students for the workplace and ensuring effectiveness of educational programs. Accordingly, assessments assume either the ideal or actual form. Ideal assessments provide evidence about teaching effectiveness (Earl and Giles, 2011), whereas actual assessments reflect difficulties of educators in gauging the fit between community demands and accountability systems (Wehlburg, 2011). The incongruence between both assessments has raised a lot of concerns (Stiggins, 2001).
Higher thinking assessments assess the ability to transfer knowledge to the real world where learners need to think critically (Silva, 2009). Like most competencies of higher education, thinking skills cannot be developed with the content-laden curricula (Benner et al., 2010; Silva, 2009), nor improved with clinical training alone (Barak and Dori, 2009). Educators assume a great responsibility in promoting thinking skills by conceptualizing how, what, where, and when to assess these skills and use the data to improve learning (Wehlburg, 2011). Recent work on the impact of instruction and assessment on learning has revealed that instruction is crucial for the development of higher order thinking (Barak et al., 2007). Similarly, assessments could persuade learners to focus on thinking skills throughout the learning process (Barak and Dori, 2009). A recent study by Barnett and Francis (2012) supports the role of assessments in promoting higher order thinking. Assessment in Nursing Education Thinking in nursing involves training in analysis, synthesis, and evaluation. The reality is that undergraduate programs rarely instruct and assess past the analysis level (Russell, 2011). Critics of accountability test-driven programs contend that assessments are structured at lower order thinking levels, thus compel educators to teach-to-the test (Au, 2007). The findings from a survey conducted by the National League for Nursing (NLN) revealed that nurse educators continue to rely on teacher-centered tests to safeguard success of students on state board exams (Oermann et al., 2009). In the NLN's study, learnercentered assessments were emphasized by nurse educators, yet teacher-centered tests were assigned more weight in the curriculum. Findings revealed that teaching-to-the-test remains the chief means to prepare nurses for practice (Oermann et al.). Three assumptions underpin current assessment practices in nursing. First, it is believed that the primary purpose of assessment is assessing content that appears on board exams (Oermann et al., 2009). With this approach, learners get preoccupied with what to learn, rather than how to learn subject matter. Second, assessment data are associated with accountability measures for the sake of demonstrating program and instructional effectiveness. This assumption leads to an obvious divide between imparting content and developing the learner's habit of mind (Silva, 2009). The separation of instruction from learning by standards-driven assessments tends to underpin the theory practice gap (Brunt, 2005). The third assumption emanates from the belief that continuous assessments increase exposure to test items that may appear on registration examinations, thus ensuring success on first attempt. The debate continues since such tests lack thoroughness in assessing thinking skills, thus defeating the needs of constituencies for a better preparation of graduates for practice. Method The qualitative content analysis research technique was employed in this study. This research method helped to gain an in-depth understanding of the curriculum structure by exploring the various instructional and assessment strategies used in the three programs. In this respect, Posner's (2004) criteria for curriculum analysis and Neuman's (2006) coding system were incorporated in the analysis process. Posner's criteria included curriculum theory and approach to purpose and content, which formed the unit of analysis in this study. For the curriculum theory, data were obtained from documents that solicit the mission, purpose, philosophy, or conceptual framework of the program (Wiles and Bondi, 2007). Since the four most commonly used curriculum theories in the discipline of nursing are traditional, behavioral, experiential, and constructivist perspectives (Benner et al., 2009), the curriculum documents were assessed against these theoretical perspectives. To better understand curriculum purpose and content,
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the syllabus for each nursing course in the participating programs was assessed. Neuman's (2006) manifest and latent coding represented the analysis procedure. Through manifest coding, the content of each of Posner's criteria was made visible and explicit, whereas latent coding provided the means to surface themes and messages hidden in the curriculum (Neuman). The coding procedure was based on an extensive literature review resulting in terminologies or phrases that helped categorize assessments and instruction. The categorization procedure was based on both the theoretical perspective of the programs and Bloom's (1956) cognitive pattern. Data gleaned from the curriculum documents were categorized into teacherand learner-centered strategies. Teacher-centered represents the traditional curriculum which emphasizes recall, comprehension, or application of knowledge (Bloom, 1956; Janisch et al., 2007; Zohar and Dori, 2003). This category's instruction and assessment are teacher-driven, thus requiring low student effort and less engagement (Nilson, 2010). Two types of learning underpin the teacher-centered perspective: declarative and procedural. Instruction and assessment targeting declarative learning focus on knowledge and comprehension, whereas procedural learning focuses on application (Nilson, 2010). Terms in the curriculum reflecting either declarative or procedural learning are categorized as teacher-centered. The learner-centered category reflects the constructivist curriculum, thus higher order thinking pattern. In this category, learners are expected to construct knowledge through analysis, synthesis, and evaluation (Bloom, 1956; White, 2007), and to execute moderate to high effort (Nilson, 2010). Learner-centered assessment and instruction employ conditional or reflective learning, thus enabling learners to know where, when, and how to use knowledge. In conditional learning, learners apply, analyze, and synthesize knowledge when engaging them in case discussion, ill-structured problems, simulation, project, research, and role play (Nilson). Reflective learning prompts learners to analyze, synthesize, and evaluate knowledge, especially when reflecting and journaling.
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Table 1 Teacher-centered assessment strategies and weights of theoretical courses. Program
Frequency of tests
Weight
A B C
9 16 14
≥70% N80% ≥70%
Findings revealed that assessments in theory courses were mainly based on ‘tests’. The use of testing to assess learners' knowledge acquisition is categorized as a teacher-centered strategy. Structuring of tests remains the chief function of teachers, with no input on part of students in this strategy. The frequency of tests in a program and the weight allotted for this strategy were tabulated.
assessments in a program and the weight allotted for each strategy were tabulated. The assessment categories employed to analyze the theory courses were used to analyze the clinical courses. The teachercentered category included evaluations based on performance of learners from the perspective of ‘tutor’ or ‘preceptor’ and by ‘clinical examinations’ (see Table 3). Assessments reflecting learnercentered were: ‘case presentation’; ‘case study discussion’; and ‘written submissions’ in the form of reports, summary, care plans, and papers; ‘simulation’; ‘patient education’; and ‘reflection’. The frequency of occurrence of each category was tabulated (see Table 4). Curriculum Analysis: Instructional strategies Instructional strategies were categorized into teacher- and learnercentered. In this study, traditional teaching is teacher-centered and content-laden (Posner, 2004), and information is presented using either the ‘lecture’ format or ‘teacher-led discussion’ (see Table 5). Data on learner-centered strategies were: ‘case presentation’, ‘evidence-based’ teaching, ‘case discussion’, ‘simulation’, ‘reflection’, and ‘team-learning’ (see Table 6). Data on instruction were coded to each of the categories. Results
Sample A purposeful, homogeneous sampling was used to select three baccalaureate nursing programs in Lebanon with similar characteristics. The programs operate within reputable tertiary institutions in a geographical area that is accessible and feasible for conducting the study. The purposeful selection of Programs A, B, and C minimized “extraneous variation and clarified the domain of the findings as large corporations operating in specific types of environment” (Huberman and Miles, 2002, p. 12). Data Collection The study was reviewed and approved by the significant Institutional Review Board. After obtaining permission to access the curriculum documents of three nursing programs, the data collection process commended. Posner's (2004) curriculum principles guided the process. Curriculum Analysis: Assessment Strategies Assessments in this study were categorized depending on whether the nursing courses had a clinical or theoretical focus. For the theory courses, ‘tests’ were classified as teacher-centered (see Table 1), whereas learner-centered had the following strategies integrated in the courses: (a) ‘presentations’; (b) assignments in the form of ‘research, project, or online discussion’; and (c) ‘report writing’ (see Table 2). Evaluation tools for every nursing course in the program were coded to each of the categories in the coding hierarchy. Sometimes courses used both categories and were attributed to each applicable code. The frequency of
The theoretical framework of the three curricula is traditional in nature, and all programs used ‘tests’ as the means to assess learning. In this study, tests are considered teacher-centered and of lower order thinking category. Program A used ‘tests’ as the means to assess learners, whereas learner-centered strategies appeared with a higher frequency in the curriculum. In Program B, testing was the chief assessment strategy used in the program. Theory courses for Program C had nearly equal occurrence of teacher-centered and learner-centered assessments. Although the frequency of learner-centered assessments in programs A and C was higher compared to teacher-centered strategies, yet the weight allotted to each of the identified teacher-centered strategies was higher (see Table 1). For assessments of clinical courses, Program A used both teacherand learner-centered approaches. Most of teacher-centered assessments in the program depended on evaluations by clinical tutors (see Table 3), whereas learner-centered approaches focused on ‘case presentation’, ‘case study’ discussion, ‘written submissions’, and ‘patient education’ at Table 2 Learner-centered assessment strategies and weights of theoretical courses. Program Case Weight Research Weight Report Weight presentation (%) project/online (%) (%) A B C
9 2 4
10% b10% 10%
4 2 6
10% b10% 5–35%
2 2 7
Total
10% 15 b10% 6 10–30% 17
Table 2 illustrates the various learner-centered assessment strategies applied to the theory courses in the three programs. Three major learner-centered strategies were captured in each nursing curriculum. The frequency of these strategies in the program and the weight allotted for each strategy are presented in this table.
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Table 3 Frequency of teacher-centered assessment strategies in clinical courses.
Table 5 Frequency of teacher-centered instructional strategies.
Program
Evaluation by tutor
Evaluation by preceptor
Clinical exam
Total
Program
Lecture
Teacher-led discussion
Total
A B C
6 5 7
3 9 0
6 6 0
15 20 7
A B C
9 17 7
4 1 6
13 18 13
Table 3 reflects the teacher-centered assessment strategies for the clinical courses of the three programs. The teacher-centered category included evaluations based on performance of learners from the perspective of ‘tutor’ or ‘preceptor’ and by ‘clinical examinations’. Only the frequency of occurrence of each strategy is tabulated without considering its weight, since the clinical courses in two of the programs use the pass and fail criteria.
nearly equal frequency (see Table 4). Program B's clinical assessments were mostly teacher-centered, with the focus on evaluations by preceptors, yet to a lesser extent the clinical tutor. Program C depended solely on evaluations by the clinical tutor with higher occurrence of learnercentered strategies. The weight allotted for learner-centered assessments in program A clinical courses ranged between 40% and 50%, whereas Program B and C's learner-centered strategies had a weight of less than 30%, except for three senior nursing courses in Program C with a weight reaching 70% in one of them. ‘Simulation’ and ‘reflection’ were not used in any of the three programs. Findings on instructional strategies revealed the emphasis on teacher-centered instruction rather than learner-centered ones, specifically in Programs A and B respectively (see Table 5). Program A used direct instruction in the form of ‘lectures’ or ‘teacher-led discussions’ with ‘case presentations’ as the only learner-centered strategy. ‘Simulation’ and ‘reflection’ were omitted from the curriculum. Program B had similar findings, with ‘teacher-led discussion’ as the main strategy employed in the theory courses, whereas learner-centered instruction was employed to a lesser extent. For Program C, findings revealed that both types of instructional strategies occurred with nearly equal frequency (see Table 6). ‘Case presentation’ appeared as a commonly used strategy in both instruction and assessment of the three programs. Discussion The study findings revealed the high use of ‘tests’ to assess student achievement in the theory courses of the three programs. The emphasis on testing in the three programs was presented in the curriculum documents in two forms. The first form was the high frequency of testing which was prominent in Program B, resulting in lesser use of learnercentered assessments in the curriculum. The second was the obvious use of learner-centered strategies in Programs A and C, yet the weight allotted for each strategy was negligible compared to weights on ‘tests’. These findings support prior work by Oermann et al. (2009), which revealed the high weight that educators allot to ‘tests’ to assess learning and to determine the ability of learners to transfer knowledge from the classroom to the real world of practice. The frequency of teacher-centered assessments in the practicum courses varied between programs, with ‘evaluation’ and ‘examination’ as dominant strategies. The highest frequency of this assessment category was detected in Program B. Programs A and C used ‘written Table 4 Frequency of learner-centered assessment strategies of clinical courses.
Instructional strategies were categorized into teacher- and learner-centered. Table 5 reflects the frequency of occurrence of the traditional teaching format in the programs, which appeared in the form of lectures and teacher-led discussion. The frequency of occurrence of each strategy reflects the level of emphasis in the curriculum.
submissions’ and ‘patient education’ as learner-centered assessments. Although writing improves content acquisition and thinking (Emerson et al., 2006), professional practice stresses the role of the curriculum in acquainting students with knowledge and skills related to knowledge transfer, interpretation, response, and reflection (Tanner, 2006). Reflective practice and simulation are essential strategies for the development of these skills (Kantar and Alexander, 2012), yet neither strategy was captured in the clinical courses of the programs. Findings gleaned from instructional data support prior work regarding the central role of teachers in the educational process (Rupani and Bhutto, 2011). The study's results revealed that direct instruction in the form of ‘lectures’ and ‘teacher-led discussion’ were dominant in the theory courses of the programs. Although one of the programs had nearly equal occurrence of learner- and teacher-centered instruction, teacher-centered assessments were given higher weight in that curriculum. This finding reflects the absence of an alignment between the curriculum, assessment, and instruction. The situation is likewise with higher education (Malik, 2009), where the alignment issue is attributed to the advent of innovative curricula with inadequate exploration of new assessment practices (Taras, 2008). Teaching practices in the three programs were test-driven and teacher-led. The shy use of learner-centered assessments and instruction in the three programs and the minimal weight assigned for this assessment category manifests itself for four distinct reasons: educators' knowledge about means to nurture higher order thinking skills in learners, beliefs regarding diffusion of content, preparation on best grading practices, and clarity on modes of knowledge transfer. In nursing education, substantial attention has been given to content–practice continuum. Nevertheless, there exists a need to consider thinking skills and knowledge transfer as major educational outcomes of a curriculum. It is strongly believed that instruction and assessment help in the development of higher order thinking skills (Jones, 2012) and in knowledge transfer (Leberman et al., 2006). Instruction must be contextual since classroom knowledge cannot resemble the setting in which graduates function (Brooks et al., 2010), and assessments geared for learning and transfer (Illeris, 2009; Taras, 2008). Implications for Educators Learner-centered assessments, tailored to elicit learner performance, can inform both teachers and learners about achievement and improvement. Effective assessments emanate from differentiated instruction which, in effect, appreciates modes of knowledge acquisition. Assessing Table 6 Frequency of learner-centered instructional strategies.
Program Presentation Case Writing Simulation Patient Reflection Total study education
Program Case Evidence- Case Simulation/ TeamTotal presentation based discussion reflection learning frequency
A B C
A B C
4 2 4
4 2 1
5 2 6
0 0 0
5 0 5
0 0 0
20 6 17
The learner-centered category of Table 3 pertains to the assessment of clinical courses in the three programs. Based on the use of the pass–fail criteria in the clinical courses, the frequency of occurrence of each category was all that can be captured from the curriculum documents.
6 1 5
0 2 1
1 5 3
0 0 2
1 2 4
8 10 15
This table presents the learner-centered instructional strategies. The strategies reflect student involvement in the teaching learning process. Five instructional strategies were captured in the curriculum documents and tabulated accordingly. The frequency of occurrence of each strategy reflects the level of emphasis in the curriculum.
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learning must be on-going for the sake of monitoring progress and maximizing learner's potentials. Teachers need to conceptualize assessments as an interactive process which builds on learners' engagement and motivation (Taras, 2008). In practice, assessment for learning requires curriculum integration of the following strategies: reflective practice (Epp, 2008), learning logs (BergstrÖm, 2010), program-workplace projects (Illeris, 2009), simulation (Shepherd et al., 2010), and journaling (Barak and Dori, 2009). The development of thinking skills is central to the aforementioned methods (Maniotes, 2010). Development of cognitive skills to solve problems of the future mandates the integration of problem-solving skills in the program's instruction and assessment system. Assessments using ill-structured problems help to augment learners' ambiguity level and activate cognitive processes (Zane, 2009). The processes commence with formulating hypotheses and conclude with an action plan to solve the problem (White, 2007). Assessment for transfer is deemed essential to prepare graduates for practice. Transfer can be strengthened by exposing learners to experiences of three salient features: “participant direction, problem orientation, and exemplarity” (Illeris, 2009, p. 143). Through project work, students are prompted to select a problem from the immediate environment, and exercise efforts to construe the situation and present solutions. This approach enhances metacognition through questioning learners' ability in forming constructs that fit different contexts, thus enhancing knowledge expansion, application, reconstruction, and connection (Shepard, 2006). Teaching for transfer influences how students learn. Implications for Curriculum Leaders Amid the calls for transforming assessment practices in higher education, the development of an assessment system must be at the forefront. The system must be based on a framework to carefully ground any practical decision about the curriculum in clear and well-informed thought. Curriculum leaders can elicit the momentum for change and enhance buy into the change process through professional development initiatives. With such initiatives, teachers could be prompted to reflect on their assessment practices and explore beliefs about teaching and learning. Any change in teaching practice is contingent on creating an appropriate balance between mandated standards and curriculum goals. Limitations Three limitations were inherent in the study. First was the small sample size drawn from three nursing programs confined to a geographical area in Lebanon. Another limitation relates to the quantity of information provided by the available curriculum documents, which could have been inadequate for a comprehensive content analysis. The third limitation relates to language, since one of the programs uses French as the medium of instruction. The program documents were translated to English and checked by the program director, thus ensuring validity of the document content. Conclusions The emphasis of this study was on the assessment for the development of higher order thinking skills in nursing students. Instruction was included as well since assessment and instruction form the framework of a curriculum, thus assessment cannot be independently studied. Although assessments are believed to be indicators of program and teaching effectiveness, there is relatively alarming information on the incompatibility between current assessment practices and aspirations of constituencies. There is an urgent need to transform educators' beliefs, knowledge, and skills on assessing student achievement, since teaching to pass a test could impede knowledge transfer and deter the development of learners' higher order thinking skills.
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