This research aimed to clarify the relationship between nursing students’ levels of structural knowledge and assessment skills. Participants were 17 third-year university students majoring in nursing who participated individually in the experiments. The experiments included a nursing-scene task, free-recall task, and sorting task. Experiments were conducted before and after their clinical practice. Each student’s level of structural knowledge was calculated from the free-recall and sorting task responses, and each student’s assessment skill was calculated from the nursing-scene task responses. Levels of structural knowledge were significantly higher in post-examination compared with pre-examination ( p < 0.01). Assessment skills scores were also significantly higher in post-examination compared with pre-examination ( p < 0.001). When comparing assessment skills in relation to levels of structural knowledge, the high-structured group ( n = 5) had significantly higher scores for their conclusions and reasons than the low-structured group ( n = 5) ( p < 0.001). Information-collecting scores in the task case did not differ between the low- and high-structured groups, although the high-structured group tended to mention information that was not included in the task case ( p < 0.10). Well-structured knowledge of students in the high-structured group seemed to enable them to acquire and activate highly related information during assessment. Students in the high-structured group apparently made assessments not only by using information given but also by over viewing information comprehensively.
Recently, nurses are required to have a high level of clinical judgment due to changes in the types of diseases of aged patients and advances in medical technology. The thinking process that a nurse goes through when caring for patients is called the “nursing process” which includes the processes of “assessment”, “nursing diagnosis”, “planning”, “implementing” and “evaluation” [
In clinical practice, nursing students are required to care for patients and provide needed nursing care as licensed nurses do even though they are students. Therefore, even students in clinical practice are expected to have high-level assessment skills. However, Sasabe et al. reported that at graduation, students’ self-evaluations of their assessment skills were low [
Yura and Walsh [
For example, Chi et al. [
When considering ways to improve student assessment skills, the relationship between students’ structural knowledge and assessment skills must be understood because the amount and structure of knowledge affect the ways of problem-solving. However, there is little research on assessment skills in relation to structural knowledge despite the abundant research on nursing-process education. Both in the United States and in Japan, standardized patients or students’ self-assessments by the Objective Structured Clinical Examination (OSCE) are used in assessment education (e.g., Hemming and Jennrich [
Therefore, this study aims to clarify the relationship between the structural knowledge of nursing students and their assessment skills.
In this study, we organized the structural knowledge of nursing students through a measure of category clustering. Measurements were made by free recall of verbal materials in experiments. Various measures were developed to clarify the development of memory or structural knowledge. Adjusted-ratio-of-clustering-S (ARCS; Inoki [
Participants were 17 third-year university students majoring in nursing. The purpose of this research was explained to 35 students who were randomly sampled from the students enrolled in Basic Nursing Practice in the 2014 academic year. Of these students, 17 volunteered to participate in this study.
Participants were individually interviewed and participated individually in the experiments. Three tasks were administered: a nursing-scene task, free-recall task, and sorting task. One experiment took approximately 60 to 90 min. Experiments were conducted before and after each participant’s clinical practice, during the period from July to November 2014.
The originally conceived case was about a patient who had increased energy demand five days after lobectomy for lung cancer but who lacked sufficient energy intake (see
Fifteen pairs of 30 terms were chosen from a textbook used by the participants. The terms were related to the nutritional-metabolic pattern in Gordon’s functional health patterns, which is knowledge needed for assessment. Participants had studied the terms prior to the experiments. Two researchers engaged in nursing education chose the terms so that the terms could be paired with complementary terms. Examples of terms used in the free-recall test are shown in
The case was presented on paper to the participants and they were asked to answer orally.
Participants were asked to discuss the problems and factors of the issues in the case. They were asked not only to give conclusions but also to think about how they thought about the case. Participants were asked to assess the problems related to the nutritional-metabolic pattern.
Instruction: Please discuss the problems and factors of the issues in this case. Please discuss how you thought about the case as well as your conclusions. The problems are related to the nutritional-metabolic pattern. | ||||
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65-year-old man treated with a lobectomy for lung cancer on February 8. His situation on February 13 is given below. | ||||
Activity level | Although the patient can walk around the ward freely, he is usually found in a supine position on the bed when nurses visit his room. He said “There is nowhere I want to go to”. | |||
Eating | A meal of gruel (1600 kcal) was served for lunch on February 10. From February 10 to 13, he consumed half of every meal. The daily energy requirement for this patient is 1600 kcal calculated by age, physique, and activity level. After breakfast on February 13 he said “I might not be hungry because I do not walk”. | |||
Cleanliness | Showering is not allowed yet. Bed-bath is conducted with some assistance. When a nurse hands him a towel, he can maintain a sitting position and independently wipes his body. Wiping his back and lower extremities requires assistance. | |||
Excretion | He can walk to the restroom and self-excrete. After surgery, there was a little stool on only the 10th. He said he has no desire to defecate but voiced that “My stomach feels heavy”. | |||
Blood test | WBC RBC Hb TP ALB CRP | Admission day 5500/μl 4.7 million/μl 14.0 g/dl 6.7 g/dl 3.5 g/dl 0.203 mg/dl | February 12 8080 μ/l 4.5 million/μl 11.2 g/dl 5.8 g/dl 2.5 g/dl 1.543 mg/dl | Baseline 3600 - 9300/μl 4.3 - 5.54 million/μl 13.8 - 16.9 g/dl 6.6 - 8.1 g/dl 4.1 - 4.9 g/dl Under 0.6 mg/dl |
Meals / Appetite Exercise / Sleep Height / Weight TP / Alb Infection / CRP Intention / Scar Bed-bath / Foot-bath Hydration / Dehydration Bedsores / Wet Compression / Friction Assessment / Nursing process Information gathering / Communication Constipation / Bloating Basal metabolism / Calorie intake Nutritional condition / Vital signs |
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Experimental procedures were explained to the participants before the task. Terms were visually presented on a personal computer screen for 3 each. To prevent rehearsal using short-term memory, participants were asked to do a calculation task (i.e., adding 10 adjacent numbers for 30 s). After the calculation task, participants were asked to recall memorized terms in free order for 120 s. Participants’ responses were recorded with an IC recorder. One trial consisted of visual presentation of the terms, the calculation task, and free recall. Six trials were carried out for each participant.
A white board (58 cm width × 43 cm height) and 30 cards (6 cm width × 1.5 cm height) each displaying a term were presented to the participants, who were asked to categorize these cards into groups using their own thinking.
We created a checklist to evaluate assessment skills for the nursing-scene task. The checklist’s validity was checked by four researchers including two teachers and two clinical experts. The checklist comprised three assessment categories and 34 items: “conclusions and reasons” had 8 items and “information paid attention to” had 26 items, of which 13 items were included in the case and 13 items were not included in the case (
ARCS scores were used to measure levels of structural knowledge. ARCS scores were measured based on free-recall responses. When two words from the same category were recalled together, the two words were evaluated as well structured by the participant. In this case, the “same category” would mean that the participant sorted the two terms into the same group in the sorting task. ARCS scores ranged between the numerical values of 0 and 1, and a higher score indicates a higher level of structural knowledge.
Participants were divided into two groups based on their post-examination ARCS score in the sixth trial: Participants who scored over 0.90 points were assigned to the high-structured group and participants who scored less than 0.80 points were assigned to the low-structured group. We compared the mean scores of the assessment skills of two groups.
Data analysis was performed using the statistical program ANOVA4 on the Web. The level of significance was set at p < 0.05.
Items | Assessment categories | ||
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Information included in the case | Information not included in the case | Conclusions and reasons | |
Nutrition | Low TP | Height/weight | |
Low ALB | Skin | ||
Low Hb | Intravenous drip | ||
Eating half of a meal | Patient’s perception of nutrition | ||
Calorie intake is half | |||
Saying “I might not be hungry because I do not walk” | |||
Activity level | Usually in a dorsal position on the bed | Scar pain | |
Patient can walk around the ward freely | |||
Constipation | No stool for 3 days | Liquid intake | |
Problems and factors of the issues | Loss of appetite | ||
Low activity level | |||
Constipation | |||
Imbalanced nutrition: less than body requirements | |||
Bedsores | Pressure on the same parts of the body for a long time | Bedsores skin around sacrum | He can walk by himself |
Low nutrition | Low risk of impaired tissue integrity/progress surveillance | ||
Infections | High CRP | Infection | He was treated with lung lobectomy 5 days ago |
Low nutrition | Vital signs | ||
Red/flushed | Normal reaction for surgery | ||
Scar pain | |||
Scar intention | |||
Score | 13 | 13 | 8 |
The Ethics Committee of Hirosaki University Graduate School of Medicine gave ethical approval for this study. Participants were provided with a complete explanation about the objective and process of the study. Written consent was obtained from each participant. All participants voluntarily participated and were free to withdraw from the study at any time.
We analyzed the data of the 13 participants who participated in both pre- and post-examinations (before and after clinical practice). The data of 4 participants who participated in only the pre-examination were excluded.
ARCS scores as indices for levels of structural knowledge were calculated for the six trials of each participant. Mean ARCS scores of trials 1 to 6 and mean ARCS scores of pre- and post-examinations were compared (
As a result of analysis of variance, mean ARCS scores increased with each trial in both pre- and post-exami- nations. The score of the sixth trial became the peak value (F[5, 60] = 102.54, p < 0.001). Also, mean ARCS scores were significantly higher post-examination compared with pre-examination (F[1, 12] = 11.14, p < 0.01). There were no interactions between the trials and pre- and post-examinations (F[5, 60] = 0.363, p > 0.10).
Each participant’s assessment protocol was derived from the nursing-scene task responses. We evaluated each participant’s assessment skills using the checklist and calculated the average score of each assessment category for each participant. We then compared the mean average scores of the pre- and post-examinations (
The main effect of the pre- and post-examinations was significant based on variance analysis (F[1, 12] = 27.64, p < 0.001). Assessment skill scores of the post-examination were higher than those of the pre-examina- tion. Also, the main effect of the category was significant (F[2, 24] = 42.48, p < 0.001). Multiple comparisons by Ryan’s method were conducted. As a result, there were significant differences between “information included in the case” and “information not included in the case” (t[
Participants were divided into two groups based on their post-examination ARCS scores in the sixth trial. Five participants who scored over 0.90 points were assigned to the high-structured group, and 5 participants who scored less than 0.80 points were assigned to the low-structured group. Participants who scored 0.81 - 0.89 points were excluded from this analysis.
Mean average scores of each category were compared between the low-structured group and high-structured group (
First, an overview of the memory model and structural knowledge in cognitive psychology will be followed by a discussion of the structural knowledge of the nursing students. In cognitive psychology, a memory model is considered an operation of acquiring new information. According to Baddeley [
Next, we will discuss the relationship between levels of structural knowledge and assessment skills. Assessment is the collection and interpretation of information. Its purpose is to decide whether or not a problem exists, such as a problem requiring nursing intervention or a potential problem [
“information paid attention to” and “conclusions and reasons” based on responses to a nursing-scene task. In “information paid attention to”, we found no difference between students with low and high levels of structural knowledge in the percentage who mentioned information that was directly provided in the task case. The high-structured group tended to mention necessary information that was related to but not directly provided in the task case. The percentage who mentioned a decision made along with its reasons was also significantly higher in the high-structured group.
Benner [
These above-mentioned assessment characteristics will be discussed from the perspective of cognitive psychology. In one study, Gobband Chi [
Here, we discuss the mechanism of structural knowledge after clinical practice according to characteristics of the students’ structural knowledge before and after clinical practice. In this study, the nurses’ knowledge was well-structured after their clinical practice. During clinical practice, students collected information from primary patients, assessed the type of nursing needed, and actually provided the needed nursing. When learning new information, being conscious of how the information will be used in actual nursing serves to facilitate structuring of knowledge. Murayama [
Experience in clinical practice improves students’ structural knowledge for its effective utilization in making assessments in a clinical setting. Knowledge required to make assessments is utilized to facilitate structural knowledge, which makes it possible to make assessments through comprehensively understanding the situation. It was clarified that well-structured knowledge facilitates the development of the assessment skills. Therefore, promoting education that facilitates the structuring of knowledge is important for improving students’ assessment skills.
1) Scores of structural knowledge regarding nutrition evaluation were significantly higher after clinical practice.
2) Scores of assessment skills after clinical practice were raised significantly compared with those before clinical practice.
3) Regarding the relationship between levels of structural knowledge and assessment skills, information-col- lecting scores did not differ between the low- and high-structured groups, although the “conclusions and reasons” score was significantly higher in the high-structured group. The high-structured group tended to mention information that was not stated in the task case.
4) Through clinical practice, students develop structural knowledge that can be utilized in a clinical setting to improve assessment skills.
In this study, we compared assessment skills and levels of structural knowledge using randomly chosen data from students before and after their clinical practice without controlling the content of clinical practice. Therefore, whether the content of clinical training actually promoted structural knowledge remains uncertain. Discussions were based on clinical practice experience and past studies. Future research should investigate teaching strategies for acquiring structural knowledge that can be utilized in a clinical setting, and its effects on assessment skills must be tested. In addition, the number of participants in this study was low because the experiments took a long time and few students volunteered. Consequently, our analyses were based on a small amount of data from a limited sample. Further studies with larger sample sizes and more diverse populations (e.g., other schools, other grades) are needed.
This study was supported by JSPS KAKENHI Grant-in-Aid for Young Scientists (B) Grant Number 25862099. The authors are grateful to the participants of this study, who provided us with invaluable information.
KeikoAizu,KasumiMikami,RyokoTsuchiya,MayumiShimizu,NanaeKojima,NaokiOka,YoshikoNishizawa, (2015) The Relationship between Assessment Skills and Nursing Knowledge. Open Journal of Nursing,05,1072-1081. doi: 10.4236/ojn.2015.512114