Creative Education
2013. Vol.4, No.2, 160-164
Published Online February 2013 in SciRes (
Copyright © 2013 SciR e s .
The Assessment Methods and Learning Approaches in
Nursing Students of Kerman University of
Medical Sciences in Iran
Sakine Sabzevari, Abbas Abba szade *, Fa riba Bor hani
Department of Nursing, Kerman University of Medical Sciences, Kerman, Iran
Email: *
Received November 27 th, 2012; revised December 30th, 2012; accepted January 15th, 2013
The purpose of this paper is to gain insight into the relationship between the conventional methods of as-
sessment in medical surgical courses and students’ approaches to learning. In this descriptive correlational
study; the sample consisted of 198 undergraduate and postgraduate students studying nursing. Data were
obtained using the revised two-factor study process questionnaire (R-SPQ-2F) and the Assessment pref-
erence inventory including personal characteristics and assessment methods. The results showed that
mean grade for deep learning approaches were a bit higher than surface learning approaches. (Mean ±
Standard error [SE] 34.27 ± 5.006 versus Mean ± Standard error [SE] 31.21 ± 5.52). The deep and surface
approaches were proposed each with a motive and strategy subscale. In this regard; grades of 16.51 ± 2.73,
17.75 ± 3.28 and 14.6 ± 3.72, 16.61 ± 2.74 were obtained for deep motive and strategy and surface motive
and strategy respectively. Regarding the relationship between learning approaches and clinical assessment
methods; the results of ANOVA test showed significant differences only on surface learning strategy (p <
0.05) and between clinical, oral and practical group project assessments. In respect to the relationship
between learning approaches and written assessment methods; there were also strong and significant cor-
relations between True-False questions and a combination of tests groups in deep motive subscale and
between project assessment and a combination of tests groups in surface strategy subscale (p < 0.05).
Suggestions are offered for mixed and new assessment methods and techniques in medical education. In
case of some new debates on evaluation, workshops and training courses are recommended.
Keywords: Assessment Methods; Learning Approaches; Medical Surgical Nursing Courses; Nursing
Students; Student Evaluation
During the past decades it has been evidenced that new
graduated nurses are not prepared to do their duties properly.
Effective assessment of nursing students during university
education would ensure their competency, professional satis-
faction as well as their patients’ safety (Shipman et al., 2012).
Learners’ performances are different due to differences of sev-
eral affecting factors including their learning and training styles,
how learners encounter with subjects and use their knowledge
(Seif, 2008). In recent years various learning approaches are
introduced by learning psychologists and educational experts.
According to individuals’ differences and their special style
of receiving and organizing new information, it can be expected
that if teaching methods are consistent with the learner’s learn-
ing style, learning process is improved and educational failures
are prevented (Bourbonnais et al., 2008). Learning approaches
are mental activities that learners use in their study and these
approaches guide them in understanding subject organizing and
reminding (Park, 1995). According to the studies on learning
approaches, there are two basic approaches (deep and surface)
in higher education (Duff et al., 2004) and (Diseth, 2007). Deep
learning approach leads to real understanding of the subject,
and deep and stable learning but surface approach focuses on
memorizing information and results in incomplete understand-
ing. Each approach has been formed of two elements: motiva-
tion and strategy. The motive tells why the individual decides
to learn; while the strategy is about how to improve the learning
process (Shokri et al., 2006). In deep approach, students like the
subjects and try to understand the subjects with high motive.
They have deep strategy in doing their assignments, find the
assignments interesting, emphasize on the deep meaning of the
subject rather than the surface meaning and investigate the
relationship between the subjects. For applying deep learning
approach, students’ teachers should utilize deep approach in
teaching and encourage students to have deep approach and
strategy in learning (Parsa & Saketi, 2006).
As one of the main objectives of the education system is to
improve the learning process, teachers should recognize and
apply the teaching methods which can lead the student to achieve
that goal (Houston et al., 2004, Khomeiran et al., 2006).
Assessment methods might have an effect on nursing stu-
dents’ learning approaches. If the assessments are designed
based on deep understanding they can lead to deep learning
(Morrison, 2003). Assessment is not appended to curriculum
but it is one part of it. After determining educational needs,
learning outcomes should be defined and assessment objectives
must be cleared and linked to the outcomes. Not only assess-
ment is more effective when the learners have comprehensive
*Corresponding autho r.
assessment of their learning and understand their own learning
style but also having continuous and comprehensive under-
standing of their performance is a matter of consideration
(Watkins et al., 2007).
To educate competent nurses, teachers should pay attention
to learning approaches. In this regard, teaching methods, teach-
ers’ roles and assessment have considerable effects on the
learning process (Akinsanya & Williams, 2004); therefore some
experts recommend that student assessment process should
provide adequate information to students and their teachers to
be able to improve students’ progress especially in aspect of
moral and professional responsibility (Bourbonnais et al., 2008).
Although clinical assessment is of great importance but it is
often subjective and confusing. (Scouller, 1998) and some tea-
chers and students aren’t satisfied with clinical evaluation.
Teachers can improve students’ critical thinking through as-
sessment methods (Narenji et al., 2010). Assessment methods
can influence the learning approaches of nursing students. As-
sessments are designed to assess student’s understanding rather
than their rote learning. Assessments should target students’
understanding of knowledge, their use of critical thinking, and
their application of knowledge (Leung et al., 2008). Hessler and
Humpherys (2008) suggested that student assessment is a
valuable method for changing educational methods and cur-
riculum planning in nursing; and also an important source of
information to determine the quality of education. Universities
and schools have too much responsibility in students’ educa-
tional progress and student assessments.
Literature Review
In a study conducted by Harlen (2007) about student assess-
ment criteria, three main paradigms were mentioned: behavior
change, merit and making data summary. The assessment of
students is used for various different purposes which will have
an impact on education process and the curriculum thus it is
necessary to emphasize on criteria of validity, reliability and
good use of resources and apply them to assessment for forma-
tive and summative purposes. According to Leung (2008) based
on her study on the impact of assessment methods on learning
approaches of nursing students, it was noted that excessive
workload of nursing students would decrease their deep learn-
ing scores and increase their surface learning scores. There is a
negative relationship between students’ academic achievements
and their surface learning approach. On the other hand, students
believed that assessments which were designed based on sce-
nario-based questions, simulated role-play situations and case
studies could lead to better critical thinking and knowledge
application. Some studies showed that students’ assessment re-
sults and their educational performance are inversely correlated
with surface approach and directly correlated with deep learn-
ing approach and indeed assessment methods might have an ef-
fect on learning approaches (Parsa & Saketi, 2006). Some as-
sessment methods tha t emphasize on data recalling and do not
pay enough attention on knowledge application would en-
courage students to have surface learning approach (Magnus-
sen, 2001).
Nursing Education Issues in Iran
In Iran, nursing students are selected by National University
Entrance Examination after they finish high school. In nursing
school, students can study their Bs degree and if they pass fur-
ther entrance examinations, they can tailor a master or a Ph.D.
degree. All these programs are currently taught in Razi School
of Nursing in Kerman, Iran. Due to the importance and intrinsic
nature of clinical assessments which enable students to obtain a
qualification to continue their career in a number of health pro-
fessions, these tests should be designed and implemented accu-
rately. The most commonly used assessment methods to evalu-
ate medical and surgical nursing courses are listed as multiple
choice questions (MCQs), true-false questions, Extended mat-
ching Questions (EMQs) for pen and paper testing, work sam-
ples, question answering, Objective Structured Clinical exami-
nation (OSCE), portfolio, log book, written practical tests and
simulation based situations for clinical evaluation. Based on
our experiences, students aren’t highly qualified and compe-
tent in their courses and some of them ask their teachers about
the assessment methods of the final examinations and choose
their studying style according to the assessment methods only
to pass the exams and based on their little knowledge, poor
attitude and weak performance would face some problems in
clinical situations. Currently, traditional clinical assessments
are frequently used for assessments. It is important to determine
whether assessment methods lead to deep learning approach or
Study Aims
Due to the importance of medical surgical courses in nursing
education, we aimed to investigate the assessment methods of
medical surgical courses and their relationship with learning
approaches in nursing students of Kerman University of Medi-
cal Sciences.
It was a descriptive correlational study that evaluated the
conventional assessment methods of medical surgical nursing
courses and students’ learning approaches.
Data Collection
We used a questionnaire for assessment of students’ learning
approaches which included the followings: personal character-
istics, assessment methods and the revised two-factor study
process questionnaire (R-SPQ-2F) that consists of twenty items
scored on a five-point Likert scale (from “completely agree” to
“completely disagree”) (Leung, 2008). It is suitable for teachers
to assess the learning approaches of their students. The revised
questionnaire which uses fewer items categorizes students into
two different approaches to learning. These are “surface learn-
ing approaches” (referring to student intentions in learning by
memorizing and reproducing the factual contents of the study
materials) and “deep learning approaches” (associated with
student intentions in understanding and constructing the mean-
ing of the content to be learned). Both deep and surface ap-
proach scales have motive and strategy subscales (Biggs et al.,
Because our students study in Persian language, we trans-
lated the questionnaire to Persian and then to English (back-
ward and forward). For content validity, we emailed the trans-
lated questionnaire to some experts and requested them to
evaluate it. After they approved the questionnaire, we asked 30
Copyright © 2013 SciRe s . 161
students to complete the questionnaire. Then we evaluated its
reliability which was confirmed by alpha = 0.7. Moreover, the
questionnaire’s validity and reliability have been also con-
firmed by Shokri et al. (2006) with alpha = 0.85 for the deep
approach and 0.73 for the surface approach (Shokri et al.,
The sample consisted of 240 undergraduate and postgraduate
nursing students. A total of 198 students completed the ques-
tionnaire, among them, 144 and 54 were undergraduate and
postgraduate students respectively. All participants were in-
formed about the purpose of the study and agreed with its pro-
Data Analysis
All tests were conducted using SPSS version 18 Software.
Variables’ normality was tested with Kolmogrov-smirnov test;
then we used descriptive statistics (frequency distribution, mean,
and standard deviation) as well as analytical tests (T test,
ANOVA) and Pearson correlation test for data analysis.
This study was approved by the University of Kerman
Medical Sciences Committee for Ethics. All students were in-
formed of the purposes of the study and agreed on sharing of
their views.
Most students were female (52.5%), undergraduate (72.7%)
and single (64.1%). The average age was 23.42 ± 5.38. Most
written tests were MCQs (32.3%), projects (13.1%) and a com-
bination of methods (42.9%). For clinical assessment, the most
commonly used test formats were bed-side examination
(30.3%), practical projects (31.3%), oral tests (15.7%) and a
combination of these methods (21.7%).
Analysis of students’ responses showed that item 8 (I some-
times learn topics by rote learning and going over and over
until I learn them by heart even if I do not understand them)(x =
3.96), item 2 (I think that I have to work on a topic adequately
so that I can make my own conclusions before I am satis-
= 3.92) and item 10 (I test myself on important topics
until I understand them completely)(
= 3.82) had the highest
average scores. On the other hand, item 7 (I do not find my
courses very interesting so I don’t work on them adequately)
= 2.59), item 17 (I attend most of my classes with ques-
tions in mind that I want answers to them) (
= 2.69) and
item 3 (My aim is to pass the courses by doing as little work as
possible) (
= 2.71) had the lowest average scores.
Regarding learning approaches, deep approach score was
34.27 ± 5.006 and surface approach score was 31.21 ± 5.52.
The deep and surface approaches were proposed each with a
motive and strategy subscale. In this regard; grades of 16.51 ±
2.73, 17.75 ± 3.28 and 14.6 ± 3.72, 16.61 ± 2.74 were obtained
for deep motive and strategy and surface motive and strategy
respectivel y (Table 1).
With regard to the learning approaches and personal charac-
teristics, there was an inverse relationship between students’
age and surface learning approach (p < 0.05) and also between
motivation and strategy subscales. Conversely, there were sig-
nificant differences between mean grades of surface learning
approach, motivation and strategy. Post-graduate students’
scores in deep approach was more than those of undergraduate
students (p < 0.05).
Besides, there was no significant difference in learning ap-
proaches scores of two genders, but we found significant dif-
ferences in surface learning approach and motivation scores of
student with different marital status as the married students had
higher average scores in surface learning approach (p < 0.05).
In application of clinical assessments and based on ANOVA
and post hoc tukey results, we found significant differences
only between surface strategy scores of bed-side exams, oral
and practical projects (p < 0.05) (Table 2). Moreover, in appli-
cation of written tests and based on ANOVA and post hoc
tukey results, we found significant differences between deep
motive scores of true-false tests and combined tests and also
between surface strategy scores of projects and combined tests
(p < 0.05) (Table 3).
In this contribution, the multiple-choice questions (MCQs)
and project presentations were the most common type of writ-
ten test items used in postgraduate nursing examinations.
Teachers used various types of tests including MCQs, Extended
matching questions (EMQs) and essays for students’ evalua-
In addition to written tests, the most commonly used test
formats regarding practical tests were bed-side exams and
practical projects. 21.7% of respondents stated that their teach-
ers used a combination of methods (bed-side exams, oral tests
and practical projects) for their evaluation. On the contrary,
none of the respondents reported using OSCE and logbooks
despite their pivotal role in assessment of nursing students and
teachers’ awareness of their importance. Magnussen (2001)
posed that the traditional clinical assessment methods cannot
lead to meaningful and deep learning (Magnussen, 2001).
Because assessment methods are based on teaching methods,
so it is expected that teachers change their curriculum planning
to conduct more effective clinical assessments and shift from
subjective conditions to more serious ones. No study has been
conducted about common assessment methods in Iran. Regard-
ing students’ learning approaches, the deep approach has been
used more than the surface approach. Haggis (2003) reported
that administration of surface approaches for gaining achieve-
ment and success at the end of the semester, predicts poor
In this study, the scores of deep approach (34.27 ± 5.006)
and surface approach (31.21 ± 5.52) were more than the study
Table 1.
Mean and standard deviation of learning approaches and strategies
Learning approaches and subscales
24 10 2.73 16.51 Deep motive
24 6 3.28 17.75 Deep strategy
23 5 3.72 14.60 Surface moti v e
24 9 2.74 16.61 Surface strategy
48 20 5.006 34.27 Deep approach score
45 16 5.52 31.21 Surface approach score
Copyright © 2013 SciRe s .
Copyright © 2013 SciRe s . 163
Table 2.
Mean and standard deviation of learning approaches scores according to practical tests.
Deep mot Deep str Sur mot Sur str Deep AS Sur AS
Test types
3.0615.933.66 17.19 3.5614.742.7515.385.8633.124.80 30.12 Oral test
3.1216.663.08 17.65 3.9515.302.5717.455.3534.905.82 32.75 Bed side procedure
3.5317.502.82 19 3.5310.500.7016.506.3636.504.24 27 OSCE
2.2716.092.45 18.72 3.3514.252.6916.084.2833.755.23 30.33 Practical project
2.3717.273.22 17.66 3.9614.202.7117.094.7235.255.71 31.30 Mixed of oral, procedure and project
F = 1.68
p = 0.15
F = 0.40
p = 0.80
F = 1.40
p = 0.23
F = 4.08
p = 0.003
F = 1.15
p = 0.33
F = 2.19
p = 0.07
Table 3.
Mean and standard deviation of learning approaches scores according to Written tests.
Deep Mo Deep Str Sur mot Surstr Deep AS surAs
Test types N
MCQ 64 16.42 3.02 16.92 3.47 14.95 3.84 16.23 2.97 33.34 5.61 31.18 5.82
True false 10 14 2.49 19.1 3.10 12.40 2.59 15.80 1.331 33.10 4.70 28.20 2.85
Essay 13 16.30 2.28 17.15 4.23 15.76 4.22 16.38 3.53 33.46 6.26 32.15 5.98
Project 26 16.38 2.53 18.07 3.29 14 3.07 15.65 1.93 33.46 3.12 29.65 4.19
Mixed of above 85 16.95 2.53 18.22 2.89 14.60 3.79 17.31 2.80 35.17 4.00 37.91 5.69
2.811 = f
0.027 = p 2.93 = f
0.08 = p 1.51 = f
0.19 = p 2.83 = f
0.02 = p 1.49 = f
0.20 = p 1.72 = f
0.14 = p
performed by Nejat (2011) in which she used the same
R-SPQ-2F for evaluating nursing students. In a similar study
conducted by Shokri (2006), the scores of deep learning ap-
proach and surface learning approach were 35 ± 7.68 and 26.90
± 8.78 respectively. So there was a similarity between his re-
sults and that of ours on deep approach. However, this impact
was not significant on surface approach (31.21 versus 26.90).
Students with higher scores in deep learning are motivated by
an interest to have higher internal motive and an intention to
use an appropriate approach for learning. Oppositely, students
with higher scores in surface learning show an extrinsic moti-
vation, which is accompanied with rote memorization in their
learning process.
The quality of learning is related to the students’ learning
approach and if teachers identify students’ characteristics and
their learning approach, they can improve the quality of learn-
ing. Those students, who only use memorization, do not have
deep learning approach and cannot increase their knowledge. A
notable proportion of students adopt learning approaches ac-
cording to assessment methods and the subjects which they
think they would be tested in the final examination. If assess-
ment methods emphasize only on recalling facts and data and
not on knowledge application and higher order thinking, they
can lead to surface learning approach (Seif & Khayer, 2007).
Assessment is an important component of the learning proc-
ess in nursing students. It is also a powerful motivator for
learning. Students’ experiences of assessments can affect their
learning styles (Leung et al., 2008). Seif and Khayer’s (2007)
study on medical and engineering students in Shiraz, Iran,
showed high scores for deep learning approach in both groups.
High expectation of success leads to deep learning approach.
Students, who believe that they would be successful, pay more
attention to their lessons and are eager to learn new topics even
they take much time to learn. In the light of conclusions, sur-
face learning strategy score in bed-side exams was higher in
comparison to other assessment methods. On the other hand,
deep motive score in mixed assessment methods was higher in
contrast to written tests; which demonstrates higher students’
deep motive in these conditions. There weren’t any significant
differences between deep and surface learning approach scores
except between the subscales. The results support the sugges-
tion, by Seif and Khaier (2007) that students with deep learning
approach, try to investigate the relationship and integration of
different parts of the lessons and assignments. Teachers are
expected to encourage students to have deep learning approach.
Students can adopt different approaches in different situations.
Students, who have surface approach, have surface motive and
think of higher education as only a means of finding a good job.
It seems that students are not being encouraged to have a de-
sired learning approach at universities.
Analysis of students’ characteristics offered that students’
age is inversely correlated with surface learning and its motive
and strategy subscales. Undergraduate and married students
adopt surface approach more often than post-graduate and sin-
gle students but there weren’t any significant correlations be-
tween their scores. In addition we couldn’t find any significant
differences between the results of male and female students in
our study. Nonetheless from the research of Shokri et al. we
derived that there was a significant relationship between gender
and surface approach score which was higher for male students
(2006), whereas the study of Parsa and Saketi (2007) showed
that deep approach and deep motive scores were higher in fe-
According to the results of our study, because postgraduate
students are older than other students, they have stronger inter-
nal motive and intention for deep approach; while married stu-
dents have surface learning approach due to their endeavors and
lack of free time. Explanations for these interesting results
could lie in other contextual elements, alongside the cultural
factors and educational disciplines which affect learning ap-
proaches and styles. (Seif & Khaier, 2007)
Limitation of the Study
This research was conducted only on a small size of popula-
tion. Therefore, research studies with much larger sample size
would be required to ensure appropriate generalization of the
findings of the study.
Assessment is a basic component of curriculum planning but
despite its importance, many teachers believe that it is often a
time-consuming and confusing process. Learning approaches
influence students’ academic achievements thus deserve special
considerations and more investigations. We recommend teach-
ers to use the assessment methods which can encourage stu-
dents towards deep understanding and critical thinking.
Applying mixed assessment methods in written tests lead to
deep learning approach but taking technical examinations
without focusing on reflective thinking, problem solving and
critical thinking lead to surface learning approach; therefore the
aim of students in those circumstances would be only on pass-
ing the exams. We recommend teachers to use mixed assess-
ment methods for clinical assessments. Holding special work-
shops on new assessment methods would be beneficial for
clinical teachers.
The authors acknowledge all the students for collaboration in
conducting this research. We also acknowledge the Research
Council Center of Kerman Medical University for their Support
and dedicated work. This paper is part of a Ph.D. dissertation.
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