Enhancement of Learning Abilities of Student Nurses: Teaching and Learning Strategies

*Beryl Juliet Sam*

## **Abstract**

The modern era poses a great challenge for students pursuing the baccalaureate program in nursing sciences. The Program requires rigorous hours of learning and clinical exposure. Nursing has now moved into a competency-based curriculum. The global demand for nurses is expected to rise to 9 million in the 2030. Hence, the profession needs a lot of dedicated and inspired minds with sacrifice and accountability. Students in general have a variety of learning styles that aids their learning process. This chapter focusses on the various strategies that nurse educators and faculty should adopt, to help students cope with the demands of the profession. There are a variety of strategies that can be used, however, each one has its own pros and cons. Nursing curriculum is centered on producing professionals who are committed to caring real-life clients. It's the duty of nurse leaders, managers and educationists in sculpting young minds to work towards making a significant difference in the lives of others.

**Keywords:** enhancement, learning abilities, learning strategies, teaching strategies, nursing students

## **1. Introduction**

Nursing is one of the most noble professions in the world. "A nurse is one who opens the eyes of a newborn baby and closes the eyes of the dying". The modern day students need a lot of innovative technologies to enhance their learning. They also have to be exposed to interesting learning strategies that faculty must provide. The competency-based curriculum demands expertise in both the cognitive and psychomotor domains. This chapter will deal with various contemporary methods of teaching and learning.

A study by Gundus and Ozcan on the learning styles of Learning styles of students from different cultures and studying in Near East University found that, cultures of the students affect their learning styles. Arabic students learn more actively than Turkish and Cypriot students. Thus, each student learns in a different way, and to address these learning styles, teachers should use a variety of teaching styles [1].

Students are found to be very passive and disinterested during the traditional teaching methods. There has to be an inclusion of different problem based learning methods that provokes the thought process of students. Nurses are expected to practice in varied settings, and hence the need for equipping them with adequate knowledge to adapt to any situation is the need of the hour [2] Heidgerken explains the fact that, it is not enough if a faculty in nursing poses mere knowledge to teach nursing curriculum to students. They need to possess specialized skills to teach in a variety of settings. Nurses play different roles of caregiving, educating, advocating, and carrying out research. Hence, faculty members should enable the student to have adequate exposure to be effectively equipped to play all these roles [3].

Students also need an exciting experience to learn concepts so that they do not feel bored with traditional system of learning. It is necessary for faculty to update to the latest technology to cater to students in the contemporary era. The teaching process prepares the student nurse to play all the roles that the society expects of her as a fullfledged nurse. Hence, the learning process should be a rigorous period of inculcating necessary skills through several methods.

## **2. Innovative teaching methods in the nursing curriculum**

A wide range of teaching methods are being used by nursing faculty. A few of them will be discussed in this chapter. Some of them are, Flipped Learning, Edpuzzle, Simulation, Virtual Patient Learning, Self-Directed Learning, Problem based learning, Team based Learning and Inter professional education. Innovative approaches will help increase the effectiveness and efficiency of the entire clinical nursing education system that the program offers [4].

### **2.1 Flipped classroom learning**

Flipped learning is new to most students, and it generally takes time to adjust to the pedagogy. Five factors are thought to affect a student's readiness for the flipped classroom. They are perceptions of workload, attitude towards active learning, relevant educational experience, metacognitive skills, and comfort with technology. To help all students benefit from flipped learning at the earliest stages of the class, an orientation is proposed that reduces the potential negative impact of each of these factors. Special advice is provided for first-year students, as they are inexperienced with flipped learning. Freshmen are still adapting to University life. So, there may be low-performing students who may need extra support to fully benefit from the pedagogy [5].

Barbour and Schuessler stated that, though clinical and healthcare settings have grown in complexity over the last several years, the way we educate nursing students remains unchanged. This transformation places a demand on nursing faculty to shift their traditional teaching system to more innovative methods like Flipped Classroom Method (FCM). FCM enhances critical thinking skills of students and enables them to apply this knowledge received outside the class to real-world scenarios and problems within the class [6].

A research on perception of 240 student nurses' on flipped classroom showed a positive attitude towards this type of learning. The use of video and moodle, showed that they had a positive attitude towards FCM. There was also a strong correlation on perceptions of motivation, self engagement, enhanced and effective learning. The

### *Enhancement of Learning Abilities of Student Nurses: Teaching and Learning Strategies DOI: http://dx.doi.org/10.5772/intechopen.110570*

attitudes of low achievers was much more positive as compared to high achievers [7]. The FCM and the virtual experience that students gain out of it helps students learn what cannot be taught through a mere lecture in the physical classroom [8]. Akcayır and Akcayır stated that the challenges faced by students while learning out of the class improved their learning process [9]. FCM uses a system designed with lectures that are pre-recorded, short quizzes and activities. They help increase the motivation level of students and cultivates a better learning environment [10].

The FCM is a best example of a learner-centered approach and it is beneficial for both the student and the faculty when compared to traditional lecture methods [11]. The current didactic teaching method does not help nursing students to efficiently apply their theoretical knowledge to clinical situations. The revolution needed in nursing education in the contemporary era poses a need where, educational methods must be designed to apply skills to problem solve [12]. The flipped classroom (FC), was considered to be a novel method of teaching that emphasized Self Directed Learning (SDL) and critical thinking among student nurses in China [13].

A study on the comparison of critical thinking among Second year Iranian nursing students who had traditional vs. flipped classroom learning showed that, those exposed to FC had significant positive effects on their critical thinking when compared to the other group [14]. A mixed methods research was done on the perception of FCL and its impact of learning among undergraduate nursing students from three universities in Sri Lanka. Findings showed that, students perceived it to be highly beneficial and promising [15].

### **2.2 Edpuzzle**

One of the most interesting methods by which students can be attracted to learn concepts in an easy way with their full involvement is edpuzzle. Introducing edpuzzle to students prior to their lab sessions helped in increasing student learning in biochemistry course as reported in a study [16]. This application helps students maximize their learning outcomes while giving teachers an insight into the areas that students perceive as difficult. It will also allow the faculty to readdress the same in the classroom [17].

The current pandemic Covid-19 posed a threat to the traditional teaching methods in nursing education. However, it was augmented with online modules and other applications that enabled students graduate with transformations in the nursing curriculum. The content that must be studied in the classroom was supplemented with youtube educational videos, virtual platforms and other online material. Edpuzzle serves as an interactive as well as an excellent educative online material that helped nurse educators enhance learning [18].

### **2.3 Simulation**

Simulation is a method that involves teaching students by using case scenarios and creating a realistic learning experience. High fidelity simulation is a growing teaching method and has changed to include highly sophisticated and interactive simulators which helps students learn in a non-threatening environment [2].

Students pursuing health care professions are expected to deal with real patients. They often feel very scared, threatened and inadequate when it comes to applying or re-demonstrating clinical skills. Simulation can be explained as an artificially created or man-made replication by which students can learn in order to acquire the necessary clinical skills. They can be manikins or equipment that will enable students to practice on several times, without the fear of harming or endangering the life of the patient. It also helps learners gain expertise and competence [19].

Health science faculty use this as an effective strategy for teaching, learning and training as it gives a near to normal experience for students [20]. Owing to the Covid-19 pandemic, it was practically impossible for learners to gain adequate clinical learning exposure. The simulation labs serve as an atmosphere of actual client centered learning. Many students have a high level of cognition which helps them grasp concepts at a satisfying level. However, when it comes to putting their knowledge into practice, they find it difficult to carryout techniques and demonstrate appropriate clinical skills and manual dexterity [21].

A study regarding Simulation based Learning on Clinical decision making and Communication skills among 88 student nurses revealed that, learning using the SBAR tool helped in precise clinical decision making and professional communication which showed significance at p = <.0001 level [22]. A study on perceptions of Simulation Based Learning (SBL) among students pursuing medicine had majority (90.7%) reporting that, SBL helped in development of their clinical skills. Findings also revealed that the perceptions were higher among female students than males [23].

A study on supporting students through eLearning showed promising results regarding simulation based learning as it helps students learn in a safe and nonthreatening environment without the fear of harming patients. The results also showed enhanced performance, better grades and self efficacy in carrying out nursing procedures [24].

### **2.4 Virtual patient learning**

Virtual Patient cases (VP cases) promote learning, teaching, and assessment of clinical reasoning and can stimulate and motivate active learning experiences in nursing education [25]. A study was conducted among 45 first-year and 31 thirdyear undergraduate nursing students using a case study method with focus groups and individual interviews with the aim of exploring the experience of interaction with a virtual patient in order to develop non-technical skills. Findings indicated that, students at different levels interacted differently with the virtual patients. Four themes were identified in the data (i.e.) how the virtual patients enabled learning non-technical skills, learning regarding the virtual patient encounter, changing the way students perceive practice and the potential limitations to learning [26].

Prelicensure baccalaureate nursing students' perceptions and experiences of using virtual simulation as an alternative to clinical practice during the (COVID-19) pandemic was assessed in South Korea. Findings showed that, Virtual simulation might help pre-licensure nursing students feel more competent and confident [27]. VP cases provided support in translating theoretical knowledge into clinical reasoning, and they facilitated the application of theory in practice and encouraged students to use their clinical reasoning. It also enabled self-evaluation, which was a motivating force and increased awareness of their abilities for clinical reasoning. Learning experiences from VP cases seem to be applicable in higher education and useful in enabling nursing students to apply theory in their clinical practice [28].

A quasi experimental study was carried out to evaluate the effectiveness of VPL on social learning among 40 senior nursing students with 20 in the intervention group and 20 in the non-intervention group. Study results showed that Virtual patients made the learning process more enjoyable and also enhanced the learning of students.

In addition to it, VPL also proved to be effective in improving the communication skills of students [29].

### **2.5 Self directed learning**

Self directed learning (SDL) is another method that enables the nursing student to use his/her critical thinking skills and also increases independence and leads students towards professional competence. An experimental study on SDL with blended learning was carried out among 91 students where the study group and control group had 44 and 47 participants respectively. The intervention group was trained using an SDL program with blended coaching. Those in the experimental group showed a highly significant improvement and were competent in implementation of SDL (F (1,89) = 4.27, p = 0.039). They were also found to have a higher satisfaction with clinical practice at the bedside (t (89) = 3.10, p = 0.003) compared with those in the nonintervention group. Nursing faculty believe that this method increases the students' assertiveness, accountability and makes them develop a sense of responsibility that they need to exercise in their career [30].

A cross sectional comparative study examined the extent of self-directed learning abilities among 1746 nursing students and its possible factors in six European countries. Findings revealed that, the overall SDL abilities were high among students from all countries with statistically significant differences between the countries. It was found that, Spanish nursing students reported the highest level of SDL abilities while students from the Czech Republic reported the lowest. Higher level of self-directed learning abilities was related to several factors, particularly with self-assessed level of competence and geographical location [31].

A study explored the effect of PBL on 12 Iranian students pursuing Masters program in Nursing. The findings indicated that, the students adopted various methods of different SDL for excelling in academics. They also had a lot of perseverance and curiosity that played an important role in their SDL in challenging areas [32].

The readiness for SDL along with learning styles was explored using a cross sectional study among 236 Omani student nurses. Findings showed a low level of SDL and also a negative association between the learning styles and SDL [33]. Students in the health professions education have very limited time to learn vast curriculum and syllabi in the classroom. Hence it is essential that they are encouraged and guided to SDL outside their classrooms. Majority of students reported that, a good lecture led them to SDL [34]. Nursing is a profession in which lifelong learning has to take place. SDL is a very valuable skill that will enable nursing students to adopt SDL and develop these skills. Totally 229 student nurses from South-West Nigeria participated in a study on SDL. The pretest knowledge was assessed followed by 6 weeks interaction by SDL on selected topics in Adult health nursing. A post test was carried out at the end of 6 weeks. The findings revealed a significant improvement in knowledge scores between the pre and post test [35].

A study among 800 student nurses on the associations between SDL and professional nursing values revealed that, male nursing students had higher levels of self-directed learning [36]. Wong, Tang and Chang in their systematic review of 18 studies on SDL reported that, SDL must be encouraged in health professions education because it nurtures self-motivation among students and promotes liability to their own learning. Further more, it is crucial to fostering collaborative skills for multi-disciplinary practice in the contemporary era [37].

### **2.6 Problem based learning**

Problem Based Learning (PBL) is yet another method that promotes teaching and learning among nursing professionals. Nursing curricula is aimed at preparing professionals to deal efficiently with any crisis that they may encounter in patient care and in managing daily challenges as a bedside nurse, patient educator or nurse administrator. Hence problem based strategy which promotes critical thinking is the need of the hour in order to keep in pace and be both confident and competent [38]. Crawford in his article on web-based PBL stated that, PBL is a technique used to discuss clinical case scenarios and it enables students to think deeply towards problem solving, thereby making them aware of the several options and also creating more accountability and responsibility [39].

Critical thinking, problem-solving, and SDL of 90 first year nursing students in two universities receiving PBL vs. traditional lecture, was carried out in South Korea. One group received PBL while the others were given traditional lectures. An initial pretest was given and a post test was done after 16 weeks on aspects like critical thinking, problem-solving, and self-directed learning abilities. There was a significant positive correlation between both groups. The students in the PBL group had an overall improvement across all abilities measured, while students in the traditional lecture group showed a decreased problem-solving ability and lowered levels of selfdirected learning [40].

### **2.7 Electronic learning**

When students are directed to use eLearning in the right way, it can maximize the effects and help in enhancement of knowledge [41]. There is a huge challenge for nursing faculty as they impart education and skills to student nurses. The nursing curriculum is seeking to produce young minds with in-depth knowledge and competence while being equipped with decision making skills [42].

The Covid-19 pandemic posed a threat to on-site learning. A lot of e-learning took place without compromise on nursing education. The satisfaction of nursing students and the perceived barriers to online learning was studied among 219 nursing students. Results revealed that, majority (67.6%) were extremely satisfied with e-learning. Among the perceived barriers which restricted online learning, the highest was a low pitched voice and clarity of language (2.16 ± 0.593). The biological/physical barriers were vision related problems (2.43 ± 0.613) and network issues (2.26 ± 0.534). There was a significant association between the age of nursing students with the extent of satisfaction regarding online learning [43].

Web based learning has assisted students to a great extent. Nowadays the use of electronic learning has become unquestionable among students in the health professions education. The advancement and utilization of information technology even when all educational institutions were shut during the pandemic brought a solution and enhanced uninterrupted learning. An online survey on web based learning among 490 nursing students revealed that, only 34% of them found that e learning was as effective as face to face learning. More than half (58.9%) of them had a favorable attitude towards e-learning. Majority (81.7%) of them had issues with internet connections followed by technical issues (65.5%). If these barriers can be reduced, online learning will be the best method for educating nursing students [44]. An integrative review on attitudes of nursing students towards learning using the mobile specified that, majority of nursing students have a positive attitude and willingness

towards mobile learning, but practically, the actual use rate was low. This was thought to be due to unstable network connectivity and technical problems [45].

### **2.8 InterProfessional education**

Interprofessional education (IPE) is an emerging method where team based learning takes place among students from various health related professions. It enables students to learn together and also to learn from each other. A planned IPE program was offered to students from two universities in Hong Kong. Students who belonged to various healthcare disciplines like medicine, nursing, pharmacy, biomedical science, and Chinese medicine programs were included in the study. Anonymous questionnaires were given to 40 nursing students in order to gauge their IPE experience. There was a statistically significant improvement in the knowledge level (p < 0.001), attitude towards readiness for IPE, team based learning, and perceived group efficacy (p < 0.001) [46].

A mixed method design was used to measure the interprofessional competencies and attitudes among students pursuing health professions education on virtual patient cases. Students participated and worked together as a team in developing virtual case based patient learning modules on family planning. The changes in perception of students belonging to various health care professions was assessed before and after the project work. Results revealed a statistically significant increase in the students' self-assessment competency scores. An improvement in interprofessional collaboration skills was observed among students from various disciplines at the end of the study [47].

IPE is thought to advance learning among students in the health professions and also promote the quality of health care delivery [48]. When students from various health professions meet and work together on a case, it allows collaboration of health care. It involves a lot of thought processes and helps cater to the needs of clients. IPE enables knowledge and skills that are essential for collaborative working to be learnt [49].

### **2.9 Team based learning**

One of the most innovative strategy that nursing faculty can plan for their students is Team based learning (TBL). It helps in imparting knowledge and skills that students will find easy to understand. This could prove to be very effective because it is very well structured, thus enhancing a student-friendly learning environment [50].

A study helped determine the factors that influenced satisfaction of nursing students in regards to Team based Learning (TBL) in Korea. Team-based learning sessions consisting of preparation, readiness assurance, and application were given to a cohort of 139 second year nursing students in 2010 and 263 students in 2011 respectively. At the end of the learning sessions, participants completed a self-administered questionnaire regarding their learning experience. Nursing students were generally satisfied with team-based learning. Multiple regression analysis revealed that the learning process significantly affected learner satisfaction compared to pre-assignment, course content, peer evaluation, and team activity [51].

A study was undertaken in order to apply TBL in four nursing courses and to assess its effect on the learning outcomes and behaviors among 387 Registered Nurse-Bachelor of Science in Nursing students (RNBSN) and Bachelor of Science in Nursing (BSN) students at a University in Taiwan. Medical Surgical nursing, Obstetrics and Pediatric nursing, Public health nursing, and Adult nursing were the four courses chosen for the study. Results revealed that the TBL significantly improved the learning behaviors of students in both the nursing programs, including self involvement in the classroom (p < .001) and SDL (p < .001). The study concluded that TBL generally improves academic performance and learning among students [52].

TBL is considered to be one of the most effective method of small group learning where the student nurse is benefitted to a great extent. The TBL can be a faculty led learning experience with a student – faculty ratio as less as 7:1 without comprise on the course delivery in a group even as large as 200:1. A study that sought to assess the efficacy of TBL in regards to involvement and engagement of students in the process, found it to be very effective [53].

A study was conducted on the impact of TBL on first year undergraduate nursing students in relation to their knowledge, application and attitude on integration of concepts learnt in the process. Majority of students (70%) reported an increase in knowledge, skills and satisfaction in working together as a team [54]. The effect of TBL on the critical thinking, problem solving ability and SDL of students was carried out among 167 junior student nurses working with clients suffering from disorders of the respiratory system. The study design was a one-group pretestposttest design. The students had TBL sessions for 2 hours a week for a period of six weeks. Findings showed a significant improvement in critical thinking disposition (t = 5.02, p < .001), problem solving ability (t = −6.04, p < .001), and self-directed learning (t = 5.96, p < .001). There was a significant positive correlation among problem solving ability, critical thinking skills and SDL among the undergraduate students [55].
