Guion técnico

Do nursing students’ approaches to learning impact on their clinical decision making?

To explore the research question, the following two research hypotheses were proposed:

2.19. Research hypotheses

1. There is a correlation between pre-registration Adult Nursing students’ clinical decision-making ability and their approaches to learning.

2. Pre-registration adult nursing students’ clinical decision-making skills can be improved by altering their predominant approach to learning from the surface and strategic approaches to the deep approach.

2.20. Research aim

To ascertain via a mixed method project, whether pre-registration adult nursing students’ clinical decision-making can be improved through a study-specific educational research intervention that aimed to alter their approach to learning from learners who adopt the surface and strategic approaches to learners who adopt the deep approach to learning.

The research question and hypotheses led to the following objectives.

2.21. Research objectives

1. To identify the approaches to learning of final year pre-registration Adult Nursing students enrolled on:

- the Bachelor of Sciences (BSc (Hons) pathway and - the Postgraduate Diploma (PgDip) pathway.

2. To assess the clinical decision-making ability of pre-registration Adult Nursing students on:

- the Bachelor of Sciences (BSc (Hons) pathway

- the Postgraduate Diploma (PgDip) pathway as measured by: 1. a clinical decision-making nursing scale

2. their own self-reported perceptions.

3. To identify whether there are correlations as well as to explore the differences between:

1. the personal demographics, 2. the approach to learning and 3. the clinical decision-making ability

- the Bachelor of Sciences (BSc (Hons) pathway and - the Postgraduate Diploma (PgDip) pathway.

4. To determine whether an educational research intervention specifically designed for this project will encourage learners who adopt the surface and strategic approaches, to adopt the deep approach and affect the clinical decision-making ability of final year pre-registration adult nursing students enrolled on:

- the Bachelor of Sciences (BSc (Hons) and - the Postgraduate Diploma (PgDip) pathway.

2.22. Chapter summary

This literature review has discussed students’ learning specific to the higher education context, beginning with the Cognitive Informing Processing Theory and progressed to the Approaches to Learning Theory. The deep, strategic and surface approaches and studies relating to these approaches are evaluated. Criticisms of the approaches to learning in line with the barriers to students’ learning in higher education that may obstruct the embracing of the deep approach, are also presented. Nursing students’ learning is reviewed parallel to their clinical decision- making. Decision-making models relative to studies exploring critical thinking and clinical judgement are critiqued. From the in-depth engagement with the plethora of literature, it remained unknown whether the approach to learning that nursing students adopt influences their clinical decision-making ability, nor was a relationship between nursing students’ approaches to learning and their CDM identified. This gap in the literature confirmed the research question (Chapter 2, Section 2.18) and guided the methodology, discussed in Chapter 3.

Chapter 3: Methodology

3.1. Introduction

The purpose of this research study is to add to the body of knowledge relating to the approaches to learning (ATL) of student nurses, in relation to their clinical decision- making (CDM) ability. This chapter discusses the procedures and methods used to conduct and analysis the data. The chapter begins with the research question followed by the epistemological stance, the methodological approach and research methods. Strauss and Corbin (1998) definite and compare the methodology as “a way of thinking about and studying social reality” (p. 3), as opposed to the method, which is “a set of procedures and techniques for gathering and analysing data” (p. 3). Therefore, the instruments used to collect data as well as the analysis of the quantitative and qualitative data are explained. Precautions taken to protect the rights of human subjects are also presented.

3.2. Pragmatic epistemology

Methodologically, the guiding paradigm for this research is the pragmatic approach. Whilst it is conceded that the pragmatic approach can be, and is used as a justification for a hybrid of quantitative and qualitative methods (Johnson and Onwuegbuzie, 2004) in pursuit of what works and this study is to an extent, substantively that. In this research it principally accounts for a more general belief system about the nature and purpose of research in the social sciences and the way in which, more specifically, the products of such research are purposively deployed to decide whether certain courses of action are, in practice, actionable (Morgan, 2007). My research is an interventionist study and concerns itself not with the abstract, or the metaphysical, or the philosophy of knowledge but with action and the application of knowledge in real-life contexts. Pragmatism, as Goldkuhl (2012) says, “... is concerned with action and change and the interplay between knowledge and action” (p. 136), which makes the pragmatic approach an appropriate “basis for research approaches intervening into the world and not merely observing the world”

(p. 136). Such is the orientation of the present enquiry, and the pragmatic approach underpins the way in which the research programme has been designed and structured. Goldkuhl (2012) continues:

Methodological pragmatism is concerned with how knowledge is created. Pragmatism emphasises the active role of the researcher in creating data and theories. Experimentation in the world is pivotal. The researcher is participating in practice in order to explore - through own actions or close observations of others’ actions - the effects and success of different tactics (p. 145).

In brief, this research pursues similar, if not the same, goals: firstly, an exploration of how knowledge is created through a comparative study of learners’ approaches to learning; secondly, implementation of a quasi-experimental educational research intervention to ascertain its success in the generation of powerful knowledge; and thirdly, the evaluation of its potential to improve the operationalisation of that powerful professional knowledge in the practice of clinical decision-making.

The pragmatic researcher recognises that researching at the interface of the natural sciences and the human sciences aims to reconcile the differences between statistically or data-driven on the one hand and ideationally or thematically-derived enquiry on the other. There are dimensions, or facets, of the mental adaptation to deep approaches to learning and of the cognitive processes involved in decision- making in the context of nursing praxis that defy the natural gravitation of the empiricist working primarily in the physical sciences towards an exclusively deductive-objective-generalizing approach (Morgan, 2007). This is where the pragmatist grasps the nettle, so to speak, namely, the issue of commensurability, and recognises the compatibility and complementarity of inductive-subjective- contextual approaches in the research process (Morgan, 2007), especially where impact evaluation may be concerned. However, the idea that commensurability must be taken at face-value and that “proportionate” and “coextensive” (Oxford, 2010) should be the overriding guiding principles in the mix of methods within the research design is not consistent, as I see it, with a pragmatist approach. Where the relative contribution of quantitative and qualitative methods is concerned, commensurate and

complementary, do not necessarily mean always in equal proportions: the weighting must be determined by what best works towards the actualisation of the aim and purpose of the research. Pragmatically, I stand by Symonds and Gorard’s (2008) argument:

Drawing on Hammersley’s perspective, we would argue that researchers should focus more on designing studies that best suit their research topic, no matter what types of methods are used, rather than making the assumption that triangulating qualitative and quantitative data as currently defined will necessarily be most effective (p. 15).

Triangulating qualitative and quantitative data in equal measure was not my primary goal. Whilst the value of capturing the impact of the research intervention on the participants is acknowledged in the qualitative phase of this research, I acknowledge that the extent to which it assumes importance in the research design in achieving the objectives of the research is to a lesser degree and is dependent on the approach in this inquiry. Working in the applied field of nursing professional practice and clinical decision-making as well as testing a research intervention for its efficacy, the substantive element of this research is firmly located in the area of applied research. Applied research employs predominantly empirical methods and statistical data. The relaxation of strict empirical methodological protocols is a matter of pragmatic consideration and the qualitative data is admitted as a relatively small, though credible source of useful supplementary data.

Epistemologically, this research paradigm is founded on pragmatism. The essence of the research question and the core of the hypothesis directed the focus of understanding the problem that this study intends to investigate. Therefore, I felt it was essential to understand the research question and accompanying objectives before the philosophical and the methodological implications were considered. In line with Onwuegbuzie and Leech (2005), the “research question should drive the method/s used” (p. 377). Kuhn (1962) cited in Feilzer (2010) asserts that a paradigm is an “accepted model or pattern” (p. 23), that directs the research. When reviewing significant research paradigms, the positivist notion of a single reality with the truth being the only and absolute truth that is expected and is confirmed by objective

investigation, underpins the quantitative research method. In contrast, the subjective enquiry rejects the single objective reality and based on this rationale; constructivists support qualitative research methods (Creswell and Plano Clark, 2011). However, between the measurable, objective, positivism, quantitative position to the subjective, constructivist/interpretivism, qualitative approach; it is agreed that the research paradigm directs the recommended research methods (Albright et al, 2013). It is also worth acknowledging that the paradigmal stipulation to follow a specific research method may in fact restrain a researcher’s scholarly curiosity. This may inadvertently result in obscuring key components of the phenomena from being explored. It was also considered that although the research question and the chosen methodology may reflect a researcher’s epistemological stance; should the method be mono- focused, for instance, follow either the quantitative or alternatively the qualitative framework without any consideration of the co-existence of both paradigms in a single study, then besides, this imposing a constraint on a researcher, it may prevent the emancipatory impact of research and unconsciously reject significant findings from emerging (Johnson and Onwuegbuzie, 2004). Researchers (Guba and Lincoln, 1994) advocate that the quantitative and qualitative research paradigms and methodologies should remain separate entities and not be integrated, as mixing the methodologies would antagonise the methods and research findings. Nonetheless, despite the emergence of Howe’s (1988) Incompatibility Thesis, where incompatibilitists assert that the combining of methods is epistemologically incoherent; the expanding literature defending the mixing of the quantitative/qualitative paradigms, reassures that the benefits of its use outweighs the limitations.

Pragmatism on the other hand, offers a contrasting paradigm by circumventing the concern for truth and reality, thereby recognising that singular as well as numerous realities can mutually be open to empirical exploration (Creswell and Plano Clark, 2011). Thus, pragmatism aims to solve practical issues in the ‘real world’ (p. 20). A fundamental component of pragmatism is the process of ‘knowing’ or ‘determining’ the current situation and through intervention, allows for the restructure of a new, revised reality (Denscombe, 2008). Although in the past two decades, extensive discussion in social science research, epistemology has centred on the pragmatic

influential philosophers of the 20th century, William James, John Dewey and Richard Rorty, all acknowledged Pragmatists. Based on this acceptance, the underpinning approaches to learning philosophy of this research integral to a pragmatic approach, is to gain an understanding of the learning behaviours adopted by nursing students and find possible solutions to the obstacles that impede the transition of the knowledge taught when making clinical decisions. Pragmatism as viewed through Dewey’s perspective is an action-oriented philosophy of science that examines the association between theory and practice without identifying a dualism between the two concepts (Peters, 2007). Although they appear as two separate entities, they are instead noted to be closely related as opposed to being disassociated (Peters, 2007, p. 356). In line with Dewey’s viewpoint, this study explores the mechanism by which nursing students approach their learning, in addition to correlating these findings with how these students perceive their decision-making in the clinical patient-care environment. The unique aspect of this research examines the relationship between the students’ engagement with the theoretical components and the demonstration of this transmission into the real world of clinical practice.