Effects of attributional retraining on writing performance and perceived competence of Taiwanese university nursing students

Nurse Education Today 44 (2016) 66–73

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Effects of attributional retraining on writing performance and perceived competence of Taiwanese university nursing students☆,☆☆ Hung-Cheng Tai a, Mei-Yu Pan b, Bih-O Lee c,⁎ a b c

Department of General Education, Chang Gung University of Science and Technology, Chia-Yi Campus, Taiwan Department of Nursing, Chang Gung University of Science and Technology, Chia-Yi Campus, Taiwan Department of Nursing & Nursing Department, Chang Gung University of Science and Technology, Chia-Yi Campus & Chia-Yi Chang Gung Memorial Hospital, Taiwan

a r t i c l e

i n f o

Article history: Received 25 September 2015 Received in revised form 2 May 2016 Accepted 12 May 2016 Available online xxxx Keywords: Attribution theory Attributional retraining Perceived competence English writing proficiency Nursing

a b s t r a c t Background: Attributional retraining (AR) has been applied in various professional fields. The application of AR in nursing education is rarely seen. Objectives: This study explores the effects of AR on university nursing students' writing performance, perceived competence, and the relationship between writing performance and perceived competence using a blended platform of online and face-to-face approaches. Methods: A single-group experimental study was used. A total of 187 students participated in this study. The setting was the two-year vocational nursing course in a university. The Scale for Rating Composition Tasks and the Perceived Competence Scale were used before and after the AR intervention. Results: The students' writing performance showed significant improvement after the intervention. AR had effectively influenced the students' perceived competence. The perceived competence of the students interacted with the writing performance improvements after the AR intervention. Conclusions: The AR intervention suggests an alternative teaching approach that can help enhance students' English writing performance as well as perceived competence. The AR programme may be applied in English language teaching and professional courses. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction In light of increasing globalisation, the advancement of English proficiency in the English as a foreign language (EFL) context has become a prominent issue for nursing students as well as practitioners who are not native speakers of English. In general, nursing students in Taiwanese universities do not study the English language, including writing skills, as intensively as those studying in senior high schools and academically oriented universities. As a result, many nursing students are not confident in their overall English proficiency or their ability to write in English, whether in the classroom or in clinical settings. As written communication skills are critical for all nurses, nurse educators are continually seeking out programmes and strategies ☆ Funding information: This paper, as part of a research project, was funded by ChangGang Memorial Hospital (CMRPF6D0031), and researcher's grant was sponsored by the Institute of Humanities and Social Sciences of the Ministry of Science and Technology. ☆☆ IRB號碼: 101-3241 B. ⁎ Corresponding author at: Department of Nursing, Chang Gung University of Science and Technology, Chia-Yi Campus, No 2, Chia-Pu Road, West Sec., Putz, Chia-Yi County 61363, Taiwan E-mail addresses: [email protected] (H.-C. Tai), [email protected] (M.-Y. Pan), [email protected] (B.-O. Lee).

http://dx.doi.org/10.1016/j.nedt.2016.05.008 0260-6917/© 2016 Elsevier Ltd. All rights reserved.

that will best prepare their students. Oermann et al. (2015) conducted a systematic review of instructional methods for developing nurses' writing skills. The review demonstrates that theoretical frameworks concerned with the learners' psychological traits on top of the pedagogy seem not to have received enough attention. To compensate for the continuing lack of effective English instruction, an alternative to writing instruction may be the adoption of a psychological approach called attributional retraining. Attribution theory was developed by Weiner (2010), and it is one of the most influential psychological theories on motivation. The basic assumption of attribution theory is that individuals strive for a realistic and casual understanding of life events, which leads to functional reactions. Based on this assumption, realistic attributions may lead to appropriate emotional or behavioural reactions. Alternatively, unrealistic attributions may result in dysfunctional emotions or behaviours. However, an individual's reactions to a life event depend on that person's personality, goals, and beliefs. Attributions are divided into three categories: locus of control (internal and external), stability (evaluating whether causes change over time), and controllability (evaluating whether one can control the causes) (Weiner, 2010). Furthermore, an attribution is underpinned by a three-stage process: (a) the individual perceives or observes a behaviour, (b) the individual believes that

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the behaviour is intentional, and (c) the individual determines whether they believe others have been forced to perform the behaviour (Weiner, 2010). In an educational context, the learners' perceived competence with regard to their likelihood of success or failure has a significant impact on their motivation, emotions, and academic performance (Weiner, 2010). Thus, based on the attribution theory, attributional retraining (AR) has been developed as a remedial intervention to assist learners by enhancing their internal, unstable, and controllable attributions regarding poor performance, or maladaptive perceptions, through a process of modelling, socialisation, and practice exercises (Chodkiewicz and Boyle, 2014). Previous studies indicate that the effectiveness of AR has been underestimated due to ignorance of its potential for helping university students with a poor sense of control, who perceive themselves to be unable to handle learning activities and/or tasks effectively, or students with learned helplessness, who believe the demands and/or standards of the programme are impossible to meet successfully, leaving them less motivated to learn (Boese et al., 2013). Recent studies have concentrated on the transition from high school to university, since students are considered to be among the groups whose motivation and performance are easily affected by ‘dysfunctional attribution’ patterns (e.g. Hamm et al., 2014:232). A frequently applied strategy for introducing AR is to let university students experience a series of informational sessions followed by a consolidation phase. Informational sessions impart facts/knowledge, while consolidation relates to strategies/activities that enable a learner to practise/bring together learning of knowledge by practical application via authentic learning experiences (Hall et al., 2007). This informational approach may be preceded by supplying the students with handouts prepared by the researchers (Hall et al., 2007) or by allowing them to view a videotaped discussion between graduate students or with a professor to illustrate the benefits of controllable and/or unstable attributions that are successful in cases of academic failure (Perry et al., 2010). Subsequent to this informational presentation, consolidation activities aimed at facilitating the cognitive integration of the attributional principles are recommended (Hall et al., 2006). Consolidation exercises may contain an aptitude or performance test (Menec et al., 1994), group discussion (Chodkiewicz and Boyle, 2014), or a writing exercise (Hall et al., 2006). A comprehensive proposition from Merrell (2008) expands AR into multiple dimensions of cognitive development: environmental enrichment, personal control training, resignation training, and cognitive AR. Thus, AR is not restricted to cognitive training alone but also encompasses environmental enrichment to immerse the students in a multifaceted learning context. 2. Background Nursing students currently in the vocational training system in Taiwan complete a five-year nursing training programme in college after graduating from junior high school (Grade 9) and then go on to complete a two-year advanced learning programme at a nursing university. In general, even those in top nursing universities, such as those who participated in this research, do not study English as intensively as non-nursing students who study at senior high schools and academically oriented universities. Although nursing students study the English language for at least eight years before entering university, many have never learned English composition as such classes were not included in their official curricula. The students can thus be seen as novice writers of English prior to the commencement of writing instruction. In clinical settings, English is a major medium of communication among medical professionals, whether it is used in medical records, on doctors' orders, or in nursing notes. Capability in EFL writing, an ultimate output technique that needs comprehensive instruction and

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learning effort, is thus crucial for healthcare professions. However, in spite of the importance of EFL writing skills, they have long been ignored in the vocational system of nursing education, as relevant instruction is not part of the nursing curricula and sufficient time for such instruction is not provided. This is true in spite of the fact that if nursing students go on to study at a university in an English speaking country, having the ability to write well in English would be of great benefit to them. Nursing students would also need to achieve the minimum standard of English proficiency to gain entry to these universities. The English language course is a compulsory module that all students must complete during their first year of study. Learning to write in English is essential because passing the General English Proficiency Test (GEPT), a popular language test that is widely recognised in Taiwan, is a requirement for graduation. In the context of research, the GEPT policy has been in effect for more than eight years, and proficiency in four language skills—listening, reading, speaking, and writing—is mandatory. The primary goal of the teachers and students in English classes has been for the learners to pass the test at the fundamental level, which is designed for beginners. However, an investigation by a nursing university found that less than 20% of students being admitted every year meet the fundamental proficiency criteria. This result is consistent with the proficiency rates achieved by vocational and technological college students nationwide. Applications of AR in nursing education have become apparent in recent years. For example, Dunn et al. (2013) investigated nursing students' causal attributions in learning pathophysiology. Students who held positive perceptions attributed their academic success to internal, controllable, and unstable causes – primarily ‘effort’ – while those who held negative perceptions attributed failure to external reasons such as task difficulty. In addition, Wu et al. (2015) evaluated the effect of an AR programme on nursing students' perceived career barriers in order to determine if the intervention was effective for fostering positive attributional styles. The nursing students receiving AR training outperformed the control group in terms of vocational knowledge, professional knowledge, and social ability. Based on the support of such increasing evidence, the authors believe that the implementation of AR should be further explored in nursing education. According to the nursing students' perceptions, a lack of practice is always a key attribution for their failure in learning writing, and this situation may persist without a change in educational policy (Tai, 2012). The implementation of an online collaborative writing platform may suggest a feasible solution that can help overcome these obstacles. As writing researchers are increasingly discussing the integration of Computer Assisted Language Learning (CALL), it has become an alternative way of teaching writing since we are now living in a world utilising lots of information technologies (Miyazoe and Anderson, 2010). Guided by the attribution theory, the aim of this study was to examine whether the AR writing intervention would result in better student writing performance and improvements in the students' perceived competence. Additionally, as AR theory speculates that learners with a high perceived competence would result in a better academic performance (Weiner, 2010), the relationship between ‘perceived competence’ and ‘performance’ may need to be tested. The three research questions were as follows. (1) What are the effects of AR on nursing students' writing performance? (2) What are the effects of AR on nursing students' perceived competence regarding writing? (3) What is the relationship between nursing students' writing perceived competence and their actual performance after AR intervention? 3. Method 3.1. Research Design This was a single-group experimental study as all the learners were recruited into the experimental group to learn English writing

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Table 1 The AR writing intervention. AR techniques

Teaching strategies

Procedures

Cognitive AR

Inform Model Persuade Self-instruct Online platform

Supplying AR handouts explaining the research purposes and attributions for nursing students. Providing vicarious learning experiences for the students during the teaching and learning processes. Providing performance feedback in the classrooms regularly. Guiding the nursing students in instructing themselves to have positive perceptions about their learning. 1. Implementing an e-campus online learning platform. 2. Recording all writing processes, collecting the learners' writing portfolios plus the teacher's teaching materials, and sharing writing information with all the participants in the same class. 3. Observing peers' writing freely in this cyber place. 1. Viewing writing as a process of thinking and discovery. 2. Setting goals, generating ideas, organising information, selecting appropriate language, making a draft, reading and reviewing it, and then revising and editing it. 1. A strategy usually accompanies the process approach. 2. Every student needed to write at least 4 versions of each composition, i.e., an initial, second, third, and then final draft, before submitting the final draft for evaluation. 1. Two compositions before midterm and three afterward. 2. The five topics were selected and adopted from mock tests testified by the previous GEPTs. 3. Proficiency level was consistent with validity and reliability. 4. Every writing topic had its teaching focus on genres and grammatical features. 1. Students were grouped into groups of 3 to 4 members each. 2. Every individual had to review their group peers' initial writing drafts and then give feedback and comments by filling out a designed peer review form. 3. Each student received 3 feedback forms from their group-mates, and then modified their compositions after reviewing the comments. 4. Four-hour training sessions: a two-hour face-to-face lecture and another two hours of online tutorials using supplemental reading materials were supplied at the beginning of the semester. 5. A peer review form, with 35 items as a checklist, covered 6 aspects: (a) content; (b) topical & concluding sentences; (c) discourse markers/transitional words; (d) spelling & vocabulary usage; (e) punctuation & capital words; and (f) grammar & sentence structures. 1. The language teacher/TAs supplied written corrective feedbacks between revisions. 2. Indirect comments with code system were given for 2nd drafts; students studied and searched for answers to revise, and then submitted the 3rd drafts. 3. Subsequent direct feedbacks were offered for students to produce more accurate writings, and then they submitted final drafts for assessment.

Environmental AR

Process approach

Multiple revisions

Five writing cycles

Peer review

Corrective feedback

skills based on AR techniques. The GEPT policy encouraged all the students to participate in the AR writing teaching programme with little hesitation. 3.2. Participants The study sample included all the nursing students enrolled in their first of two years of vocational training at a Taiwanese university. These students were divided into four classes and consisted of 180 females (96.3%) and seven (3.7%) males, with a total sample size of 187. There were six teaching assistants (TAs) who were trained; they helped give feedback to the nursing students on their written compositions. The teacher/researcher served as an instrument to deliver the AR writing instructions to the learners during the teaching and learning process. 3.3. The AR Writing Intervention The goals of the AR writing intervention were to change the students' perceptions about their writing abilities so that they would be altered for the better in terms of four dimensions: (a) they would change any perception that they would fail to the perception that they could achieve success; (b) they would regard the causes of any failure as external rather than internal; (c) their perceptions of their writing abilities would shift from regarding those abilities as uncontrollable to regarding them as controllable; and (d) their perceptions of their writing abilities would shift from regarding them as stable to regarding them as unstable (see Table 1). Based on attribution theory, the intervention contained two elements: cognitive AR and environmental AR. Cognitive AR suggests that AR should attempt to shift students' attributions of their failure

from lack of ability to a remediable cause of insufficient effort. Environmental AR views the learning from a broader perspective, aiming to create a positive learning environment for the students. An online writing platform, peer review activities, process writing approach, multiple revisions, and a blended mode of corrective feedback, which combined direct and indirect comments and feedback, were all adopted as the teaching strategies. During the period of training, the teacher helped set up a variety of controllable goals and activities for the students to achieve, and emphasised the importance of the students' own effort to make them attribute their success to that internal dimension. One of the controllable goals, for example, consisted of asking the learners to write one-paragraph compositions of approximately 80 words each, informed by one or more pictures and with clear guidance from the teacher/teaching assistants. In addition, the writing cycles gave the teacher opportunities to modify the teaching techniques when necessary, and to inform the students about the unstable possibilities of the learning environment. The crucial point was that all of the activities concentrated on giving instructions based on the students' attributions, and attempted to create a positive learning environment in order to enhance their maladaptive attributions through both cognitive and environmental ARs. 3.4. Instruments 3.4.1. The Scale for Rating Composition Tasks Two written papers were assessed by an experienced writing teacher before and after the teaching intervention. The Scale for Rating Composition Tasks (SRCT) (Chen et al., 1993), a scale developed by the National College Entrance Examination Centre, the official bureau responsible for creating the national examination criteria, was used for making these assessments. It includes five equally weighted

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criteria: (a) content; (b) organisation; (c) grammar; (d) diction; and (e) mechanics. The content section evaluates a writer's logical development of his/ her ideas. The organisation element refers to introductory aspects, such as the topic sentence(s); the main body of the text, including developing sentences; and the conclusion, especially the adequacy of the concluding sentence(s). The grammar criterion is used to assess whether the student can successfully apply grammatical rules such as tenses or parts of speech. The fourth criterion assesses a student's competence in managing aspects of diction, including vocabulary choice and spelling. Finally, the mechanics criterion examines the accurate usage of punctuation, capitalization, abbreviation, and spelling. Based on these criteria, the assessor scored each paper on a six-point scale from 0 to 5 according to the rules of the SRCT. The SRCT has been assessed previously for reliability and consistency in the same context, and demonstrated satisfactory results (Tai et al., 2015). The Cronbach's alpha of the SRCT in this study was 0.91, which means the instrument has high reliability. 3.4.2. The Perceived Competence Scale The Perceived Competence Scale (PCS) was distributed before and after the AR intervention. This scale, which was originally designed by Williams et al. (2004) as an attributional scale consisting of an open-ended question regarding the learner's ‘perceptions’ about their English language ability, was adapted. The researcher made a slight wording modification from ‘language’ in general to ‘writing skills’ specifically. The students' answers to this question were divided into two parts. Statements such as ‘I never do well in English writing’ and/or ‘I seldom do well in English writing’ were seen as failure perceptions, while statements such as ‘I sometimes do well in English writing’ and/or ‘I usually do well in writing’ were categorised as success beliefs. As this study was concerned with attribution theory, the dichotomy of success and failure perceptions was addressed. To simplify the comparison of the PCS, the four points of a four-point Likert scale were effectively converted to indicate a dichotomy between success perceptions (3 or 4) and failure perceptions (1 or 2). An item-level content validity index (I-CVI) for the scale was determined by experienced educators (Polit-O'Hara and Beck, 2006). As items of the PCS were dichotomous, the Kuder–Richardson 20 (KR-20) was conducted to test the reliability of this scale. The coefficient of KR-20 was 0.79 in this study. 3.5. Ethical Considerations Institutional Review Board (IRB) approval was received from the board of a teaching hospital. This study was guided by three essential ethical principles: (1) respect for human dignity, (2) justice, and (3) beneficence (Polit-O'Hara and Beck, 2006). Students were properly informed of the details of the study, and they signed the consent forms distributed and collected by the research assistants without the presence or guidance of the researchers prior to the study. Students were made fully aware of their right to withdraw from the activities at any time during the teaching intervention, and none withdrew from the study. All the research procedures complied with the code of ethics required by the IRB.

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were adopted to confirm the results of McNemar test; and repeated measure one-way ANOVA served as the post-hoc analysis of each group (cell) categorised by the McNemar tests. The interactions after the AR writing intervention between the perceived competence and performance were tested by the repeated measure MANOVA again. Post-hoc analyses of each performance dimension were further examined by checking for the moderating effect (Aubé et al., 2007; Baron and Kenny, 1986). 4. Results 4.1. Nursing Students' Writing Performance The students' writing performance improved significantly after the writing AR intervention. The results of the repeated-measure MANOVA reached statistical significance between the pre-test and post-test periods: F(6,177) = 5.04, p b 0.001, partial eta squared = 0.15, observed power = 0.99. Post-hoc comparisons demonstrated that there were statistically significant differences between the students' pre- and post-test performance levels for five out of six elements of performance, with the exception being the diction dimension. Descriptive statistics of the five dimensions of the SRCT demonstrated a trend of improvement from the means for every dimension (see Table 2). There were also outcome differences among four classes comparing any two classes with the two times of pre-test and post-test results. 4.2. Changes in Perceived Competence The students perceived competence in terms of their beliefs (or attributions) of success or failure changed significantly from the pre-test (Mean = 1.73, S.D. = 0.71) to the post-test (Mean = 2.49, S.D. = 0.64) according to a paired sample t-test: t(186) = 13.92, p b 0.001. The McNemar test results for the PCS were also significant (p b 0.001), and a similar conclusion was obtained: the number of students expressing failure perceptions declined from the pre-test (n = 160; 85.6%) to the post-test (n = 83; 44.4%), while the number expressing success perceptions increased from the pre-test (n = 27; 14.4%) to the post-test (n = 104; 55.6%) (Table 3). The perception patterns of the students were further categorised into four groups (which are mixed from the four classes) as follows: group 1 consisted of those with failure perceptions at both the pre-test and post-test stages (n = 79; 42.3%); group 2 expressed failure perceptions at the pre-test but improved to success perceptions at the post-test (n = 81; 43.3%); group 3 expressed success perceptions at the beginning but then expressed failure perceptions at the post-test (n = 4; 2.1%); and group 4 expressed success perceptions at all the time points (n = 23; 12.3%). As to the perceived competence levels of the four existing classes, the ANOVA test results indicated that there were no significant differences among the classes either at the pre-test (F(3,183) = 0.32, p = 0.810 (ns)) or at the post-test (F(3,183) = 0.05, p = 0.986 (ns)). 4.3. Writing Performance Differences among the Four Learner Groups

3.6. Data Analysis Statistical analyses were performed with SPSS version 21 (SPSS, 2012), including descriptive and interpretive statistics. The preand post-SRCT data were analysed using Repeated-Measure Multivariate Analysis of Variance (MANOVA) (O'Brien and Kaiser, 1985). The PCS data were calculated by performing the McNemar tests (Eliasziw and Donner, 1991), which compared the correlations between the two dichotomous variables, and generated four cells of a 2 × 2 matrix (i.e., pre-test–post-test × success–failure). In addition, paired sample t-tests and analysis of variance (ANOVA)

After categorising the four different groups of students according to their changes in perceived competence, their writing performances were then compared. The repeated measure one-way ANOVA results revealed that the group 1 students had the most significant improvements in terms of every dimension: Content F(1,78) = 34.86, p b 0.001; Organisation F(1,78) = 28.98, p b 0.001; Grammar F(1,78) = 22.29, p b 0.001; Diction F(1,78) = 9.40, p = 0.003; Mechanics F(1,78) = 54.44, p b 0.001; Holistic F(1,78) = 40.77, p b 0.001. For those students who consistently perceived negative beliefs about their competence, their actual performances had nonetheless significantly

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Table 2 Changes in writing performances (n = 187). Class

Content Organisation Grammar Diction Mechanism Holistic

Partial eta2

Observed power

.001⁎⁎⁎

.06

.94

5.51

.020⁎

.03

.65

6.31

.013⁎

.03

.71

2.76

.098

.02

.38

19.37

.000⁎⁎⁎

.10

.99

11.32

.001⁎⁎⁎

.06

.92

A (n = 47)

B (n = 49)

C (n = 45)

D (n = 46)

Total (n = 187)

Post-hoc

Time

Mean (S.D.)

Mean (S.D.)

Mean (S.D.)

Mean (S.D.)

Mean (S.D.)

F(1182)

Sig.

Pre-test Post-test Pre-test Post-test Pre-test Post-test Pre-test Post-test Pre-test Post-test Pre-test Post-test

3.06 (1.24) 3.17 (.96) 3.28 (1.16) 3.19 (1.06) 2.49 (1.12) 2.49 (.88) 2.64 (1.22) 2.62 (.90) 3.04 (1.25) 3.68 (.84) 2.98 (1.26) 3.17 (.99)

2.55 (1.24) 3.10 (1.12) 2.76 (1.42) 3.12 (1.11) 2.16 (1.14) 2.22 (1.01) 2.39 (1.12) 2.27 (1.00) 2.61 (1.26) 3.51 (.98) 2.45 (1.24) 3.10 (1.12)

3.36 (.83) 3.76 (1.13) 3.44 (.92) 3.47 (1.08) 3.02 (.89) 2.89 (1.03) 3.27 (.89) 3.18 (1.05) 3.27 (.89) 3.42 (1.14) 3.33 (.88) 3.49 (1.14)

2.78 (1.11) 3.98 (1.15) 2.63 (1.24) 3.76 (1.03) 2.26 (.91) 3.15 (1.10) 2.72 (1.00) 3.20 (.91) 2.83 (1.02) 3.72 (.98) 2.74 (1.00) 3.76 (1.18)

2.93 (1.16) 3.49 (1.15) 3.02 (1.24) 3.38 (1.09) 2.48 (1.07) 2.68 (1.06) 2.74 (1.11) 2.80 (1.04) 2.93 (1.14) 3.58 (.99) 2.87 (1.15) 3.37 (1.13)

12.25

Note: ⁎ p b .05. ⁎⁎⁎ p b .001.

improved after the writing training sessions. In effectiveness contrast, the other three groups did not exhibit any significant changes in their writing performances according to an analysis using the same procedure. These results for the group 2 students were especially contradictory to our expectation that nursing students who had enhanced their perceived competence would improve their writing competence correspondingly. 4.4. Perceived Competence and Performance The pre-test perceived competence had no significant interactions with their performance progress: F(6,177) = 0.66, p = 0.69 (ns; Time × Pre_PC), partial eta squared = 0.02, observed power = 0.26. However, Students' post-test perceived competence had significant interactions with their performance improvement. The results of the repeated measure MANOVA analysing the interactions between the two dependent variables demonstrated a significant relationship among them: F(6,177) = 2.32, p b 0.05 (Time × Post_PC); partial eta squared = 0.07, observed power = 0.79. Appendix 1 details the results for each dimension. 5. Discussion According to the results, the AR intervention seems to be an effective teaching intervention for students' writing performance. The mean holistic score, which improved from 2.87 to 3.37, is a key indicator of the learners' writing performance. Since the GEPT requires a score of at least 3.0 in this section, it can be concluded that the AR was able to help a larger proportion of students to achieve the standard (higher than 3.0: 115/187 in pre-test; 153/187 in post-test). However, this

Table 3 Changes in perceived competence among four student groups (n = 187). % (n)

Pre-test

Post-test

Failure Success Total

Failure

Success

Group 1 42.3% (79) Group 3 2.1% (4) 44.4% (83)

Group 2 43.3% (81) Group 4 12.3% (23) 55.6% (104)

Total 85.6% (160) 14.4% (27) 100.0% (187)

study did not track the final passing rate in the GEPT due to many practical concerns, including, for instance, ethical issues, the students' willingness to take the test, and the nursing students' competence in other language skills (e.g., listening). In addition to the variations between individual learners, the four classes exhibited differences in writing performance among each other, too. Moreover, while all students received the same teaching intervention, each class developed its own learning atmosphere and classroom culture according to its specific context. In the long term, these contextual or cultural factors may have led to the learning outcome differences among the different classes (e.g. Ke and Hsu, 2015). Diction was the only dimension for which obvious learning progress could not be observed. This result was not completely consistent with AR theory, as one of the objectives of the AR intervention in this context was a focus on the teaching and learning of vocabulary, a focus that was chosen because a major attribution the learners made regarding their writing failures consisted of attributing them to their lack of vocabulary competence. This issue involves vocabulary acquisition: it took time to memorise and accumulate the necessary number of words, and to master the use of various aspects of diction (Coady, 1997). Another reason for this result may be that because the GEPT elementary level requires EFL writers to draft a rather simple composition of only 50 words, it does not require a good command of diction. As measured by the PCS, students' perceived competence improved significantly after a semester of writing instruction. At the pre-test, over 85% of the nursing students lacked confidence in their writing abilities. This may have been due to the fact that most of the students were novice writers who had never learned writing before. However, the proportion was reduced to 44.4% at the post-test, and we may reasonably postulate that this improvement came from the introduction of the writing teaching and learning activities. The results may also have been related to the students' level of insight into their performance, and they indicate an increase or improvement in confidence and competence. The McNemar test computed and grouped the students' perceived competence patterns into a 2 × 2 matrix. The first group of students (42.3%) believed that they were failures as writers both before and after the training sessions. This result is consistent with the performance measurement indicating that most of the students' post-test holistic scores were 3.37, although the safest passing standard should be better than 4 points (3 points may not be good enough should there be a poor performance in the previous section of translation). This group of students was apparently still thinking that they should be

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struggling with enhancing their writing skills, and so they perceived failure even though they might have experienced some learning progresses. Nevertheless, according to their actual performance, they had achieved significant improvement that went beyond their expectations. Their attitude of viewing their performance as unsatisfactory and always believing that there were further opportunities for improvement might have resulted in their learning progresses. However, the characteristics of these students' perceptions may be context-specific insofar as the traditional Confucian culture, which teaches students to be humble and more reserved about their competence, might have had a strong influence on the girls. Furthermore, there were still a few students who may not have devoted themselves to improving their writing skills for various reasons, and so, they would not have sensed any changes in their competence. The second group (43.3%) exhibited failure perceptions regarding their writing at the beginning but then exhibited success perceptions after learning. This result should have been encouraging whether in regard to language teaching or learning, and it was what the teaching intervention was designed for. However, their real performances demonstrated a contradictory direction in that they did not make a significant improvement in writing even as they exhibited more positive self-evaluations. Two major reasons may help explain this conflict: first, they might have sensed some aspects of learning progress in their writing; for example, they had at least learned what effective EFL writing should be. In such a short period of learning (about 16 weeks), however, to be able to perform significant improvement in writing was not an easy task. Second, it might also be possible that they did not answer the perceived competence questionnaires objectively for the sake of reporting some progress in their own learning. They understood that the AR teaching design had devoted precious resources to their learning, and so they may have sought to show appreciation toward the system. Without the AR writing teaching, they would have had to find external learning resources such as private language schools to obtain writing skills training. Again, then, the nursing students' responses may be context-specific, and more evidence would be required to support the conclusion that the pattern shown in this study is replicable in other contexts. The third group (2.1%), though small in number, were confident in their capabilities prior to the writing course but the exhibited negative beliefs after the semester. These four students were interviewed afterwards, and almost every one of them stated that they had overestimated their English writing capabilities based on previous English language learning experiences. They then realised their EFL writing skills were not as good as they expected at the pre-test. One student even admitted that she did not answer the questionnaire seriously at the pre-test. Finally, the fourth group (12.7%), also a minority group, expressed success perceptions regarding their writing competence at both time points. These 23 students were categorised as successful writers as they had already been equipped with the ability before entering the class, and they continued to sharpen the skills in benefiting from the instruction. The analysis of interactions implied that learning progress served as a moderator (Frazier et al., 2004) of post-test perceived competence. In fact, students were continuously receiving information from the feedback, and were self-evaluating their own competence during the teaching and learning process. Nursing students who sensed a greater improvement in their writing abilities exhibited more positive perceptions of their writing capabilities after the AR intervention. Therefore, their perceived competence was strongly correlated with their actual performance, and the two measures had significant interactions with each other. This phenomenon is well recognised in the field of educational psychology, and researchers have reported similar results for the variables of perception and academic performance (Perry et al., 2010). The finding indicates that AR intervention has potential for application in nursing education.

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Apart from guidance regarding AR interventions, educational researchers provide a few more valuable suggestions when applying AR. First, it may take a long time for the students to establish their attributions, and thus a longitudinal study may be required to follow up the change of their attributions. Second, it may be more important for students to learn how to face their possible failures rather than experience their successes. Third, teachers and peers play crucial roles in forming nursing students' attributions. The teachers may need to be more aware of their own behaviour and perceptions in order to provide their students with good models. Based on the findings, a teaching implication may be proposed that educational practitioners should pay more attention to their students' perceptions in learning subjects or skills instead of focusing solely on the outcomes. Beliefs regarding self-perceptions in learning and locus of control (two features underpinning attribution theory) can help educators develop learning and teaching strategies that build confidence through scaffolded success and feedback. The traditional EFL context in Taiwan, which overemphasises students' performances, has created a rather competitive learning environment and has brought some detrimental effects to those students with lower competence levels (Anderman and Dawson, 2011). With a slight shift in teaching focus, the whole classroom atmosphere may become different, and a more friendly and supportive culture can eventually be formed without harming the learning outcomes. 6. Limitations This study has four limitations. First, the study did not design a comparison group due to ethical concerns and the complex components of AR techniques. Thus, the effectiveness of the AR instruction could not be further investigated through experimental manipulation. Second, we conducted the study at only one university, which could be a potential hazard with regard to the external validity. Third, students might have enrolled in other English classes outside the campus although they were taught by traditional teaching methods, and this might be a confounding factor of the outcomes. Lastly, little can be said about the males in the cohort because they constituted a very small minority of the participants and so did not make a significant statistical contribution to the study. 7. Conclusions The findings of this study indicated that the nursing students' EFL writing proficiency was significantly improved after the students received the AR writing intervention. The AR intervention also effectively influenced the nursing students' perceived competence, such that they expressed more success perceptions and fewer failure perceptions. The perceived competence had moderating effects on the writing performance as well. As Weiner's attribution theory emphasises that an individual's causal attributions of achievement can affect subsequent behaviours and motivation, results from this study may support partial assumptions of this theory to understand how nursing students interpret their learning environment in such a way as to maintain a positive self-image. We would suggest that nursing educators may extend the application of the attribution theory from EFL to other professional subjects, and test its effectiveness in more nursing education settings. We also suggest that the AR programme may be applied not only in teaching EFL but also for teaching ESL both domestically and internationally to help nursing students work worldwide. Conflict of interest The authors declare no conflicts of interest.

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Appendix 1. Interactions between post-test PCS and learning progress of the SRCT in six subsets

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