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Nurse Education Today 37 (2016) 123127

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Review

Can active learning principles be applied to the bioscience assessments of


nursing students? A review of the literature
Shannon Bakon , Judy Craft 1, Martin Christensen 2, Lisa Wirihana 3
Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland 4510, Australia

a r t i c l e i n f o s u m m a r y

Article history: Objectives: To explore if active learning principles be applied to nursing bioscience assessments and will this
Accepted 25 November 2015 inuence student perception of condence in applying theory to practice?
Design and Data Sources: A review of the literature utilising searches of various databases including CINAHL,
Keywords: PUBMED, Google Scholar and Mosby's Journal Index.
Bioscience Methods: The literature search identied research from twenty-six original articles, two electronic books, one
Assessment
published book and one conference proceedings paper.
Assignment
Student
Results: Bioscience has been identied as an area that nurses struggle to learn in tertiary institutions and then
Nursing apply to clinical practice. A number of problems have been identied and explored that may contribute to this
Teaching poor understanding and retention. University academics need to be knowledgeable of innovative teaching and
assessing modalities that focus on enhancing student learning and address the integration issues associated
with the theory practice gap. Increased bioscience education is associated with improved patient outcomes
therefore by addressing this bioscience problem and improving the integration of bioscience in clinical practice
there will subsequently be an improvement in health care outcomes.
Conclusion: From the literature several themes were identied. First there are many problems with teaching
nursing students bioscience education. These include class sizes, motivation, concentration, delivery mode, lec-
turer perspectives, student's previous knowledge, anxiety, and a lack of condence. Among these inuences
the type of assessment employed by the educator has not been explored or identied as a contributor to student
learning specically in nursing bioscience instruction. Second that educating could be achieved more effectively if
active learning principles were applied and the needs and expectations of the student were met. Lastly, assess-
ment inuences student retention and the student experience and as such assessment should be congruent
with the subject content, align with the learning objectives and be used as a stimulus tool for learning.
2015 Elsevier Ltd. All rights reserved.

Introduction order to produce a nursing practitioner with the critical thinking skills
needed to make autonomous, logical, and safe clinical decisions
Nursing is becoming more self-governing and as such the ability to (Logan and Angel, 2011; Whyte et al., 2011). Bioscience knowledge is
apply theoretical bioscience concepts to clinical practice is essential crucial for nursing competence and should form a substantial part of
(Efstathiou and Bailey, 2012; Taylor et al., 2015). The complexity of the nurse's knowledge base (McVicar et al., 2010; Wissen and
the health care sector is often characterised by a dynamic and evolving McBride-Henry, 2010; Efstathiou and Bailey, 2012). Therefore it is con-
mass of information and research (Mate, 2013). Consequently em- sidered vitally important that nurses are able to comprehend bioscience
ployers expect nursing graduates and students to have not only a content and apply it into their clinical practice (Wissen and McBride-
specialised knowledge base, but to be competently able to apply this Henry, 2010). Research has detailed improved patient outcomes when
knowledge to solve complex health related problems through efcient nurses possess an increased knowledge of bioscience which provides
methods of care (Boud and Falchikov, 2007; McVicar et al., 2010, support to their inclusion in the nursing programme (Davies et al.,
2015). An increased knowledge of the biosciences is fundamental in 2000; Taylor et al., 2015). Facilitating the required level of learning
has proven to be an extensive problem for academics with multiple
Funding: The authors declare no bias in regard to funding. factors that impact on the student learning experience needing consid-
Corresponding author. Tel.: +61 7 5316 7621. eration (Logan and Angel, 2011; McVicar et al., 2015; Taylor et al.,
E-mail addresses: shannon.bakon@qut.edu.au (S. Bakon), j.craft@qut.edu.au (J. Craft),
2015). Facilitating the required level of bioscience education has been
martin.christensen@qut.edu.au (M. Christensen), l.wirihana@qut.edu.au (L. Wirihana).
1
Tel.: +61 7 5316 7451.
identied as a global problem in tertiary institutions as nursing students
2
Tel.: +61 7 5316 7508. question their competence in bioscience, they report failing to see its
3
Tel.: +61 7 5316 7412. relevance to practice, experience anxiety, and have poor condence in

http://dx.doi.org/10.1016/j.nedt.2015.11.030
0260-6917/ 2015 Elsevier Ltd. All rights reserved.
124 S. Bakon et al. / Nurse Education Today 37 (2016) 123127

appropriately applying concepts to patient conditions (Wissen and teach the nursing bioscience curriculum (Craft et al., 2013; McVicar
McBride-Henry, 2010; Birks et al., 2011). Students detail that the lack et al., 2015). This has promoted surface or rote learning of bioscience
of applied learning in the bioscience curriculum has led to difculties content due to the high volume of concepts (Logan and Angel, 2011;
in their role as a registered nurse (Davis, 2010; Logan and Angel, Craft et al., 2013). These factors may have led to decreased comprehen-
2011; Taylor et al., 2015). Therefore academics are challenged to incor- sion levels of the intrinsic relationship between bioscience and the clin-
porate active teaching and learning strategies that reect the diversity ical interventions utilised in nursing practice (Logan and Angel, 2011;
in student demographics and ensure that they produce safe competent Christopher et al., 2013; Craft et al., 2013). Scientists may never have
practitioners (Meehan-Andrews, 2009; McVicar et al., 2014). been exposed to the clinical environment and this lack of context can
lead to the student's poor integration of bioscience theory into the clin-
Problems ical setting (Logan and Angel, 2011, 2014; Craft et al., 2013; Christopher
et al., 2013). Research details a theory-practice gap where the theory
Teaching bioscience presents a multifactorial problem, and can be that should guide nursing practice is unable to be understood to be ap-
challenging due to, students differing academic entry levels, large class plied (Wissen and McBride-Henry, 2010; Logan and Angel, 2011).
sizes, length of classes, allocated time motivation, and, concentration
(Efstathiou and Bailey, 2012; McVicar et al., 2015; Taylor et al., 2015). Methods
Due to the current Australian government marketing initiatives and
widening participation agendas, universities have increased access to Aim
the Bachelor of Nursing degree (Koch et al., 2010; Taylor et al., 2015).
Subsequently there has been an increase in the educational diversity Therefore taking into consideration the problems detailed above this
of students enrolling in the course, with some of these students having literature review will explore if active learning principles be applied to
no science or nursing background (Koch et al., 2010; Efstathiou and nursing bioscience assessments and will this inuence student percep-
Bailey, 2012). Bioscience is reported to be an intense subject with a tion of condence in applying theory to practice?
heavy study load that is conceptually challenging (Davies et al., 2000;
McVicar, 2009; Johnston et al., 2015). Students have found that many Search Strategy
of the concepts are not familiar and the binomial nomenclature is dif-
cult to grasp (McVicar, 2009; Logan and Angel, 2011). Mature aged stu-
The search process utilised four databases, namely CINAHL, PUBMED,
dents may have not entered a learning environment for a substantial
Google Scholar and Mosby's Journal Index. The citations of the identi-
amount of time, and younger students nd that the mode of content de-
ed papers were also manually reviewed to identify studies that could
livery is substantially different from secondary school (McVicar et al.,
be of relevance to our literature search.
2010; Efstathiou and Bailey, 2012; Johnston et al., 2015).
The keywords utilised included bioscience, assessment, assignment,
The large class sizes for lectures, particularly in rst year where most
student, nursing, and teaching. These keywords identied from the
bioscience units are taught pose a problem as complex systems need to
research theme were integrated with Boolean operators and and
be explored and the students may lack condence in the learning process
or to create appropriate search phrases.
(McVicar et al., 2010; Efstathiou and Bailey, 2012). Content delivery mo-
Eligibility criteria were applied to further narrow down the selection
dalities have been criticised as not appropriate or favourable in regard to
of studies and suitable papers were identied by removing duplicates
student learning approaches (Davis, 2010; McVicar et al., 2015). Students
and reviewing the title and abstract. Inclusion parameters were
have conveyed that there is insufcient time allocated for the large
applied further to narrow the list to documents published in the last
amount of content they are required to learn (Davies et al., 2000;
fteen years (20002015), with the full text available, from peer
Meehan-Andrews, 2009; Taylor et al., 2015). There has been discussion
reviewed publications in English. This prevented any translational
that more curriculum time and teaching content in smaller groups may
problems and preserved the authenticity of the papers.
be more benecial (McVicar, 2009; McVicar et al., 2015; Taylor et al.,
From the literature 26 journal articles of various methodology includ-
2015). The delivery of bioscience content through a lecture series is
ing qualitative discursive and review articles were found to meet the
favoured by students and universities as this didactic approach is often
inclusion criteria. A critical analysis of the methodology of the remain-
viewed as efcient and economical (Meehan-Andrews, 2009; Efstathiou
ing papers established validity with various congruent themes identi-
and Bailey, 2012). It is viewed as a method to present concepts to a
ed utilising an inductive strategy detailed in the results.
large group of students and stimulate topic interest (Meehan-Andrews,
2009) though it is heavily criticised as outdated, and ineffective to learn-
ing as the students remain passive and can experience stress from the
surplus of information (Meehan-Andrews, 2009; Efstathiou and Bailey, Results
2012). It has further been demonstrated that students can only concen-
trate for 2030 min at a time and as such there is a limited amount of ac- From the literature several themes with additional concerns were
tual information exchange occurring (Davies et al., 2000; Efstathiou and identied. Firstly there are many problems with teaching nursing stu-
Bailey, 2012). Therefore due to their time length lectures are criticised dents bioscience education (Taylor et al., 2015). These include: student
as being a poor mode of content delivery that may compromise student academic entry level, motivation, concentration, length and size of class,
learning (Meehan-Andrews, 2009; Efstathiou and Bailey, 2012). Lectures a lack of congruency in teaching depth between institutions, insufcient
if utilised should incorporate a combination of visual, aural, kinaesthetic time allocated for classes, a lack of condence in the learning process,
and reading processes with question time encouraged to facilitate active ineffective teaching modalities and the types of assessment utilised by
learning ideals and maintain student participation and concentration educators (Efstathiou and Bailey, 2012; McVicar et al., 2015; Taylor
(Meehan-Andrews, 2009). et al., 2015). Secondly that educating could be achieved more effectively
An ensuing problem associated with the teaching of bioscience if active learning principles were applied and the needs and expecta-
includes that there is no congruency in the level and depth of teaching tions of student were met (Al-Modhefer and Roe, 2009; Koch et al.,
between units and institutions (Efstathiou and Bailey, 2012; Taylor 2010). These needs and expectations include: utilising tutorials, practi-
et al., 2015). This may be because bioscience educators may be ill cal and lab based learning, providing feedback, innovative teaching and
equipped and unprepared to teach the complex subject matter assessment strategies, anonymity in the marking process and a learning
(Efstathiou and Bailey, 2012; McVicar et al., 2015; Taylor et al., 2015). focus (McVicar et al., 2015). Assessment that employs active learning is
Additionally there is a trend in Australian universities for scientists to congruent with the subject content and aligns with the learning
S. Bakon et al. / Nurse Education Today 37 (2016) 123127 125

objectives can be used not only for assessment purposes but also as a assessment pieces such as case studies has been identied as a valuable
stimulus tool for additional learning (Boud and Falchikov, 2007). tool for increasing the learning of nursing students (Lavelle et al., 2013).
Nursing students can develop increased insight into their own strengths
Teaching Principles and Assessment Strategies and weaknesses by engaging in academic writing which will conse-
quently assist in developing their problem solving skills (Lavelle et al.,
Learning is achieved more effectively if the approach through which 2013). Literature has detailed that writing is linked to the reective pro-
a concept is taught embodies active learning principles such as reec- cess, increases critical thinking, and both personal and professional de-
tion, interaction, and engagement (Al-Modhefer and Roe, 2009; Koch velopment (Lavelle et al., 2013). Critical thinking is an integral concept
et al., 2010). Learning involves the internalisation of new data into an in nursing literature and writing assignments allows the student to cor-
existing mental schematic; creating new pathways that permit the relate content with increased development in their cognitive abilities
retainment of this new information (Al-Modhefer and Roe, 2009). This (Lavelle et al., 2013). PBL with an embedded bioscience focus such as
networking occurs more prociently if the methods utilised involve case studies is gaining support as a method to encourage applied learn-
the active participation of the student (Al-Modhefer and Roe, 2009; ing and address the theory-practice gap (Logan and Angel, 2011, 2014).
McVicar et al., 2015). Fundamental aspects of active teaching and PBL requires self-motivated, and self-directed students as the content
learning need to be applied to nursing bioscience education to encour- builds on their previous experiences to provide clear relevance of biosci-
age students to become engaged, maintain enthusiasm, and encourage ence content to clinical scenarios (Logan and Angel, 2011, 2014). This
participation (Efstathiou and Bailey, 2012). Studies demonstrate that can remove the feeling of being overwhelmed by bioscience content,
students that are actively involved in their learning are associated and provide a context for information transference thus addressing
with advancement in educational achievement (Efstathiou and Bailey, the theory practice gap (Logan and Angel, 2011, 2014). Practice in ap-
2012). plying bioscience content can provide an opportunity for a nexus be-
As new modalities of teaching are explored and implemented there tween bioscience units and practical clinical experience (Logan and
is a necessity to examine and reconceptualise the current methods for Angel, 2014). Academic writing can present a challenge for students
assessing and testing students (Boud and Falchikov, 2007; Logan and with English as a second language (ESL), though it is also heralded as
Angel, 2014). Generally there is a divide in how assessment can focus a method to assist in comprehension, language development and aca-
on and be used as a tool for learning that will assist students to apply demic success (Salamonson et al., 2010). It may be prudent to ensure
the theory in practice (Boud and Falchikov, 2007; McVicar et al., student access to further academic writing support mechanisms
2015). It can be argued that when there is alignment between new (Salamonson et al., 2010).
effective learning modalities, and methods utilised for assessment an Reective writing can also be used as a method which assists to fos-
improved learning environment may be experienced (Boud and ter analytic thinking (Lavelle et al., 2013). This is a method through
Falchikov, 2007). There is continued support for assessments that incor- which the student can engage in self-appraisal and critique their per-
porate active learning process and academic merit for the representa- sonal responses to assessment tasks (Lavelle et al., 2013). It is a process
tion of assessment as a learning tool; this encourages the student to through which students can assimilate theoretical content and reect
become an active participant in their study (Boud and Falchikov, upon their application of content with practice (Lavelle et al., 2013).
2007; Logan and Angel, 2011). This can also be used as a method to enhance continuous dialogue and
Learning is recognised as an active process and the views of students interaction between the educator and student (Lavelle et al., 2013).
are increasingly being considered in the formation of unit assessments
(Clouder, 2012). Students have found bioscience learning more under- Student Expectations
standable when active learning principles were applied and the learning
was related to their practice either through simulation or placement Research has identied several key features that students expect in
(Fell & James, 2010). This paper highlights that theoretical bioscience their assessment items (Clouder, 2012). These include feedback, inno-
concepts must be related to practice and reinforced through clinical ex- vation, anonymity, a learning focus, and ease of submission (Clouder,
amples and experiences that incorporate self-evaluation, reection and 2012). In regard to feedback students request comments that are pro-
collaboration (Fell and James, 2012; Boud and Falchikov, 2007). vided with clear time frames, access to face to face feedback if required,
The type of assessment provided to students can also assist to facil- and constructively written comments on their exam pieces (Clouder,
itate and encourage learning (Meehan-Andrews, 2009; Taylor et al., 2012). Students further report the usefulness of exam feedback in the
2015). There are many different types of assessments incorporated in form of prep sessions with information regarding where students strug-
the tertiary curriculum (Smales, 2010; Taylor et al., 2015). These include gled in the past, key learning points and exam techniques (Clouder,
both formative and summative assessments (Falchikov, 2005). Several 2012). Written feedback on assessment items is most useful to students
methods are available that can be utilised to assess student learning in when it is individualised, understandable, timely, focused on both
biosciences (Smales, 2010; Taylor et al., 2015). strengths and weaknesses, constructive and expressed positively
Multiple choice questions (MCQs) are a popular choice for use in (Iqbal et al., 2014). Feedback should be consistent with graded marks
exams (Smales, 2010; Taylor et al., 2015). These are convenient because and stimulate student thought processes (Iqbal et al., 2014). Despite
they are able to be taken online, but there is debate over whether MCQs how invaluable students nd feedback as a learning tool and stimulus
promote a deep understanding of the topic or if they can assess high it is not uniform among teachers even within the same disciplines
cognitive functioning such as application, synthesis of knowledge and (Iqbal et al., 2014).
interpretation (Smales, 2010; Taylor et al., 2015). The use of clinical Innovation in the design of assessment items and in teaching strate-
simulations has also become a popular assessment tool in nursing gy includes involving the students in the process of assessment devel-
education. These assessments allow the student to actively respond to opment (Clouder, 2012). Research details that in this process the
physiological changes in the patient's condition (Smales, 2010). This assessment that the students had designed was more complex than
practice based learning (PBL) has been debated as a possible method the previous form utilised (Clouder, 2012). Students reported feelings
of employing active learning in assessment (McVicar, 2009; Logan and of engagement and ownership and felt as if they were an active partic-
Angel, 2014). While PBL should not completely diminish university ipant in their learning and course (Clouder, 2012). There are several
based styles of educating it may assist by providing nursing students ways that students can become involved in the assessment process.
with experiences of applied learning (McVicar, 2009). These include through peer assessment, self-assessment, feedback pro-
Students reported a view of exams as harder than other forms of vision, self or peer testing, and collaborating with assessors on particular
assessment pieces (Craft et al., 2013). Therefore utilising written aspects of the project (Falchikov, 2005).
126 S. Bakon et al. / Nurse Education Today 37 (2016) 123127

An innovative strategy that has been demonstrated to assist student sizes, length of classes, allocated time, motivation, concentration, un-
learning is the use of a web interface (Koch et al., 2010; Clouder, 2012). derstanding terminology, content delivery methods, lack of academic
Web based learning activities and materials have the ability to provide skills, congruency in level and depth of teaching and lecturer perspec-
further educational support to the increasing number of students with ex- tives and background (Efstathiou and Bailey, 2012; McVicar et al.,
ternal commitments and the large portion of diverse ESL students (Koch 2015; Taylor et al., 2015). The type of assessment utilised can directly
et al., 2010). This will enable students to study at home and at their inuence student academic achievement and attrition. As students are
own pace thus assisting the student to achieve a balance between work, consumers in regard to their education an inclusive approach to incor-
study, and life (Koch et al., 2010). Students reported this extra resource porating their views, expectations, and participation in assessment de-
as helpful in assisting them to comprehend content and meet learning ob- velopment should be encouraged (Efstathiou and Bailey, 2012).
jectives (Koch et al., 2010). Researchers have found that students Assessment should be viewed as a tool to increase and facilitate learning
responded favourably to the use of technology with the main noted lim- (McVicar et al., 2015). Therefore it should incorporate active learning
itation identied as a lack of internet access at home (Koch et al., 2010). principles and development should be an iterative process constantly
Anonymity in the marking process was detailed as an important evolving to remain innovative and applicable (Clouder, 2012). Students
method to remove any perceptions of bias and to provide reassurance have discussed a range of aspects that they feel are needed in assess-
to the students (Clouder, 2012). Anonymous marking is not encouraged ments (Clouder, 2012). These include feedback, innovation, anonymity
to accuse academics of discrimination but is advocated as a method to al- in marking, and a learning focus. There are various methods that can
leviate student's perceptions of bias (Clouder, 2012). This process is rec- be utilised to incorporate these methods including PBL such as simula-
ommended for all forms of summative assessment items (Clouder, 2012). tions, case studies, written assessments, and formative assessments in
Learning focussed refers to assessment that is part of the learning tutorials, labs, and reective essays (McVicar, 2009; Meehan-Andrews,
process, including the use of formative assessment pieces (Clouder, 2009; Logan and Angel, 2011, 2014; Lavelle et al., 2013). Clearly further
2012). Formative assessment allows the student to reect on their research is needed on the relationship between type of assessment
own learning process and level of comprehension and can allow the utilised and their efcacy in encouraging learning that facilitates the in-
student to identify the standards required by the marker (Clouder, tegration of bioscience knowledge into the clinical setting.
2012). Formative assessment should be integrated in the curriculum
in a strategic way that facilitates the educational growth and develop- Implications for Further Research
ment of the student (Clouder, 2012). This can occur through various
methods such as tutorials of laboratory based learning. Tutorials can Despite evidence regarding the best principles to apply to teaching
be described as learning sessions in smaller groups that provide the assessment there remains the question of what type of assessment in
student with the opportunity to engage with and learn content in the eld of nursing bioscience education is the most appropriate to uti-
more detail (Meehan-Andrews, 2009; Davies et al., 2000). Tutorials pro- lise to encourage student learning and address the theory practice gap.
mote an increased comprehension of course concepts, and permit the Therefore the implications for further research should include studies
student to learn actively by engaging with the tutor and their peers that focus on:
(Meehan-Andrews, 2009; Davies et al., 2000). The success of tutorials
is dependent on the size of the class, as larger class sizes diminish the re- Understanding better the needs of nursing students in regard to
quired interaction necessary to facilitate an interactive and engaged integrating bioscience theory to practice.
learning environment (Meehan-Andrews, 2009). The dynamic of the What type of assessment can assist in facilitating bioscience
tutorial group is important and student led tutorials can foster greater integration?
participation, improve tutorial atmosphere, and increase student How can nursing bioscience units incorporate active learning
leadership (Meehan-Andrews, 2009). principles into their curriculum and assessment items as they relate
Practicals or laboratory based learning incorporates the themes pre- to clinical nursing practice?
sented in lectures and tutorials and allows the student to learn
kinaesthetically (Meehan-Andrews, 2009). The students can develop
condence and practical skill, exploring the concepts that were present-
ed in theory (Meehan-Andrews, 2009). Literature discusses the success Conclusion
of practicals in reiterating and emphasising bioscience concepts and
encouraging interest (Meehan-Andrews, 2009). Practicals encourage As nursing becomes more autonomous the need to produce nursing
active learning and critical thinking with the smaller class sizes advocat- practitioners that are safe, competent, and able to appropriately apply
ed (Meehan-Andrews, 2009). It is important for academics and educa- bioscience concepts to practice is paramount. The ability to integrate bio-
tors to provide multiple types of learning/assessing modalities to cater science theory to practice correlates with improved patient outcomes
to the various types of learners in their student cohort that employ and as such it is vital to ensure and facilitate this integration in nursing
the attributes of active learning (Meehan-Andrews, 2009). This ap- education. This is a major problem as students and established registered
proach of teaching in multiple modalities further provides the student nurses report difculties in learning and applying bioscience content.
with several opportunities to form connections and comprehend con- There are numerous reported difculties in the teaching and assessment
tent material (Meehan-Andrews, 2009). modalities utilised which indicates the need for innovative active teach-
Submission of assessments should be through a mode that has an ing and learning strategies to be researched and applied to the bioscience
ease of accessibility and exibility (Clouder, 2012). Electronic submis- curriculum to foster an encouraging student driven learning environ-
sion has been advocated though there are practical limitations such as ment. Active learning and teaching methods include involving students
ensuring materials have been received (Clouder, 2012). In regard to in assessment design and development. Furthermore noting what stu-
submission a reliable integrated electronic method of submitting dents expect from assessments such as feedback, innovation, anonymity,
work, then receiving results and feedback should be implemented and a learning focus will allow educators to form assessments that align
where possible (Clouder, 2012). with student needs and assist in addressing the theory practice gap by
ensuring students can apply the theory to clinical situations.
Discussion
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