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FEATURE ARTICLE

A Mobile-Assisted Peer Assessment Approach for Evidence-Based Nursing Education Gwo-Jen Hwang, PhD, Yi-Jung Wu, MSN, Ching-Yi Chang, PhD, RN

Students who learn evidence-based nursing can assist the healthcare team tomake proper medical decisions and pro- vide patients with valuable advice, thus optimizing the quality of patient care in specific situations. In clinical work, nursing staff members participate in decision making by searching for relevant empirical nursing literature, a basic ability re- quired to enter clinical practice. In traditional instruction, nursing students are taught the Problem, Intervention, Com- parison, andOutcomemethod to learn to use library resources and gather empirical nursing knowledge for decision making. However, it is a challenge for most students to have sufficient practice to make decisions correctly and to have opportunities to perceivemedical cases fromdiverse perspectives. Therefore, we propose a peer assessment-based Problem, Intervention, Comparison, and Outcome approach to help nursing stu- dents locate correct evidence and make appropriate deci- sions about patient care. We performed an experiment with our approach in a nursing university training program. The exper- imental results reveal that the subjects learning with the pro- posed approach show better evidence-based nursing knowledge, learning attitude, and critical thinking ability than those learning with the traditional approach.

KEY WORDS: Critical thinking, Evidence-based nursing, Information technology, Mobile learning, Peer assessment, Technology

I n evidence-based nursing courses taught according to tra- ditional approaches, students generally encounter several difficulties, including higher cognition load, lack of com-

prehensive application in using various databases, and un- familiarity with the operation of database interfaces. In addition, it is difficult for students to identify whether the medical or nursing evidence they have found provides sufficient support for clinical cases. Nursing staff who have graduated

Author Affiliations: Graduate Institute of Digital Learning and Education, National Taiwan Univer- sity of Science and Technology (Dr Hwang), Taipei City E-learning Education Center (Ms Wu); and School of Nursing, College of Nursing, Taipei Medical University (Dr Chang), Taiwan.

This study was supported in part by the Ministry of Science and Technology (Taiwan) under contract numbers MOST-106-2511-S-011-005-MY3, MOST-108-2511-H-011-005-MY3, and MOST 109-2635-H-227-001.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Ching-Yi Chang, PhD, RN, School of Nursing, College of Nursing, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan ([email protected]).

DOI: 10.1097/CIN.0000000000000753

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recently have insufficient time to learn evidence-based nursing in clinical settings and to offer appropriate evidence as ref- erences for team decision making. This can be ascribed to new nursing staff members having insufficient grasp of the points of the clinical problems, insufficient searching skills, and, possibly, poor communication with team members. Accordingly, many researchers have proposed learning approaches based on the constructivism theory to create technology-supported activities.1 Constructivism theory emphasizes that learners' experiences are the key for them to construct knowledge and to form meaning.2 For instance, Koohestani et al3 and Carter-Templeton et al4 proposed a clinical mobile learning system for nursing practice. The sys- tem situated the learners in contextual learning scenarios, which enabled them to practice to identify the status of pa- tients. Fertelli5 used a peer assessment (PA) approach in a nursing care activity. The research findings indicate that the proposed approach can effectively articulate and assess teamwork skills for health and reported the positive impacts of using PA on learners' performance. They also indicated that, during the PA process, students who lacked the necessary knowledge and skills could learn from others with good skills.

Many educators and researchers in other fields have indi- cated that PA may lead students to construct domain knowl- edge and skills. Based on the constructivism theory, educators may teach students evidence-based nursing skills by means of searching for empirical literature according to clinical is- sues, identifying real core clinical problems for patients, and finding appropriate evidence for nursing care.6–8 An in- creasing number of studies have emphasized that PA could help students improve patient care, increase their medical knowledge, and enhance their interpersonal communication skills and critical thinking.9–11 Zheng et al12 indicated that students are able to analyze, evaluate, and organize research papers via the PA approach. These research findings are consistent with Lai et al's13 findings in 2020, which also indi- cated that appropriate technology-assisted systems embed- ded in PA can help students integrate learning content and assessment results. In addition, Hsia et al14 stated that educa- tors can analyze students' behaviors in the PA process via computer systems.

In the past 10 years, researchers have used the PA approach in various domains,9,14,15 including science courses in high schools16–18 and English learning courses in universities.19,20

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FEATURE ARTICLE

They have achieved good results. However, few studies in the nursing field have embedded the PA approach into evidence-based nursing activities. This study therefore pro- poses a PA-oriented evidence-based nursing training ap- proach whereby an application (app), combined with an online PA system, is embedded into evidence-based nursing learning activities to guide students to think deeply andmake reflections regarding patient care.

EVIDENCE-BASED NURSING TRAINING Evidence-based nursing knowledge is important in nursing care within nursing clinic settings.21 Researchers have con- ducted relevant studies using computer technologies to im- prove nursing students' ability to search for evidence.22–24

According to previous studies,21–24 evidence-based nursing was developed based on the guidelines of evidence-based medicine. The empirical nursing architecture diagram shows the clarification of a clinical question according to four parts known as PICO: Problem/Population, Intervention, Com- parison, and Outcome, respectively. The PICO model could help nursing students find more appropriate answers to ad- dress clinical issues.25,26 It could also help define clinical ques- tions in terms of the specific patient problem and help the nursing staff find relevant clinical evidence in the literature via the five steps of evidence-based medicine practice: ask a question, find evidence related to the question, assess the ev- idence, combine the evidence with one's own clinical knowl- edge and considering the patient's status, and assess the effectiveness and efficiency of the evidence that has been found.27 Flo et al28 demonstrated that the PICO model can improve communication between medical staff, help track patients' conditions, and ensure appropriate medical care for patients. Thus, the training of evidence-based nurs- ing ability is necessary in nursing education.

From another perspective, researchers have stated that, for most learners, it remains a big challenge to make proper decisions.29,30Without sufficient practice and the opportuni- ties to perceive medical cases from diverse perspectives when making decisions, students' evidence-based nursing learning performance could be disappointing. That is, the adoption of an effective learning strategy to promote students' learning outcomes in PICO is required.

PEER ASSESSMENT Peer assessment is an educational approach whereby stu- dents make judgments or provide comments to peers.

17 It al- lows learners to discuss, collaborate, and reflect with others during the learning process.31 More importantly, students have opportunities to perceive things from diverse perspec- tives during the learning process via seeing peers' work and learning from each other by giving and receiving feedback. Researchers have reported several advantages associated

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with PA, including reducing the teacher's workload,32 im- proving learning outcomes,33 and enabling efficient and ac- tive learning.34 Peer assessment is also a method of formative assessment.35,36 It can be regarded as contributing to a student-centered learning environment and is a learning method that gives students more autonomy, increases their motivation for learning, makes them more responsible for their own learning, and helps them to learn deeply, to take assessment as part of learning, to observe the knowledge that can be applied after learning, to reflect more, and to apply what their have learned to their daily practice.18,37,38

The effectiveness of an assessment relies on whether it is well integrated into the activities.39 It also depends on the quality of the reviewers' evaluation results. The PA approach has been used in different ways in educational apps, includ- ing in the medical and nursing fields. Peer assessment using scaffolding techniques has been shown to have a direct effect on learning performance using problem-based learning.40

As the Internet has advanced and progressed, PA activi- ties have been conducted on the Internet platform.41 This platform has many advantages that enable teachers to mon- itor students' learning and their assessment processes any- time and anywhere. In addition, Lin et al42 developed an interprofessional learning activity through a Wiki platform for improving students' learning performance. The activity allows students from different fields to build knowledge together, observe each other's learning, and conduct PA in groups during the learning process. Several studies have reported that learners generally enjoy PA activities. They have also indicated that PA facilitates students' learning engagement and critical thinking abilities.10,11,43 However, Chang et al22 demonstrated that PA seldom has been investigated in the nursing domain, especially in evidence-based nursing activities. Consequently, in this study, a PA-oriented evidence-based nursing training strat- egy is proposed. The approach is used in an experiment fo- cusing on nursing students' evidence searching ability, evidence quality, and the effectiveness of their online PA.

MOBILE-ASSISTED PEER ASSESSMENT LEARNING SYSTEM In this study, we proposed a mobile-assisted PA learning system, called MAPA. The system was implemented on the Tronclass platform. Using the Tronclass app, nursing students are able to read and critique the PICO articles from the PubMed4Hh database anytime and anywhere (Figure 1). Stu- dents can organize individual PICO articles based on the PICO search form from the PubMed4Hh database (Figure 2).

METHODS Study Design Evidence-based nursing ability has become an important competence for nursing students to attain as they enter the

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FIGURE 1. The PubMed4Hh app with PICO.

clinical workplace. To assess the effectiveness of MAPA in critical thinking ability and learning attitude, as well as the PA performance of nursing students, a quasi-experiment was undertaken.

Participants Two classes of second-year university students from a nurs- ing school participated in the study. One class was randomly assigned to the control group, and the other class was the ex- perimental group. The experimental group consisted of 18 students and used the MAPA approach, while the other group of 18 students used the traditional learning approach.

Ethical Considerations This research was reviewed and approved by the university's research ethics committee. Before the experiment, the par- ticipants signed a consent form; moreover, they were permit- ted to withdraw from the study without it affecting their rights. Those who did not want to participate in the experi- ment were scheduled to learn through the conventional ap- proach and did not need to complete the questionnaires.

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Measuring Instruments Based on the purpose of the study, three measuring instru- ments are used to investigate the students' learning perfor- mance and affection.

The questionnaire for critical thinking ability was revised on the basis of the questionnaire proposed by Chai et al44

and included six items with a 5-point scale, with a Cronbach's α value of .85.

The questionnaire for learning attitude was revised on the basis of the questionnaire proposed by Hwang and Chang45

and included six items with a 5-point scale, with a Cronbach's α value of .83.

Experimental Process A quasi-experiment was conducted to investigate the effec- tiveness of the MAPA approach in the evidence-based nurs- ing course.

In the first phase, the two groups took the evidence-based nursing course with the PICO concept and training in evidence-searching skills from the PubMed academic database for 2 hours. After that, the pre-test of learning achievement, critical thinking, and learning attitude was administered for 30 minutes.

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FIGURE 2. The search form for PICO articles in the PubMed4Hh app.

FEATURE ARTICLE

In the next phase, the control group learned with the tra- ditional evidence-based nursing method, in which the stu- dents were asked to search for evidence-based medicine on PubMed, and worked on the PICO articles using PA.

The experimental group adopted the MAPA method, in which each student was asked to search for evidence-based medicine using the PubMed4Hh app, and assessed the PICO articles together on the Tronclass platform with their mobile devices (Figure 3). Thus, the nursing students were able to access and critique the PICO articles based on the Jadad Quality Score46 via MAPA. The Jadad Quality Score enables educators to evaluate PICO articles from three di- mensions, as follows:

1. “Is the study described as randomized?” Zero points are obtained if there is a description of the random al- location method, but the allocation method is not ap- propriate; 1 point is obtained if the study samples were randomly assigned but did not specify how to generate

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random methods; and 2 points are obtained if there are instructions for the generation of random assign- ment, such as a computer-aided random test sequence.

2. “Is the study described as double-blind?” Zero points are obtained if there is a description of how to double-blind, but the method is not appropriate; 1 point is obtained if the experiment is a double-blind experiment, but the double-blind experiment is not explained; and 2 points is obtained if there is a detailed description of how the double-blind experiment was performed.

3. “Is there a clear explanation regarding withdrawals or dropouts?” Zero points are obtained if there is no rea- son to lose tracing, while 1 point is obtained if the rea- sons for losing tracing are clearly explained.

To avoid the Hawthorne effect, students in the control group were asked to join the learning activity with the pro- posed approach after the end of the learning session. Finally,

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FIGURE 3. Illustrative example of the mobile-assisted PA activity.

the post-tests of learning achievement, critical thinking, and learning attitude were administered for 30 minutes.

RESULTS Analysis of Critical Thinking Analysis of covariance (ANCOVA) was used to compare the critical thinking ratings of the two groups. In ANCOVA, the pre-test was the covariate, while the post-test was the depen- dent variable. The homogeneity of regression was examined, showing that the assumption was not violated with F = 3.50 (P = .066 > .05).

Table 1. Results of ANCOVA on Critical Thinking

Group N Mean SD A

Experimental 18 4.20 0.45 Control 18 4.13 0.37 a P < .05.

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Table 1 shows the ANCOVA result. The MAPA approach for the experimental group significantly improved the subjects' critical thinking ratingsmore in comparison with the traditional method used for the control group, with F = 0.81 (P < .05). The η2 value is 0.13, revealing a medium effect size.

Analysis of Learning Achievement Peer assessment achievement was evaluated with the Jadad Quality Score, and t test was used to compare the scores of the two groups. The result shows that no significant differ- ence was demonstrated between the pre-test scores of the

djusted Mean SD Error F η2

4.22 0.07 0.81a 0.013 4.12 0.07

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Table 2. Results of the Independent t Test on Learning Achievement

Group N Mean SD t d Experimental 18 3.56 0.98 2.67a 0.035 Control 18 2.75 0.50 aP < .05.

FEATURE ARTICLE

two groups, with t = 0.25 (P = .81 > .05). This implies that the two groups had equivalent prior knowledge before the experiment. Table 2 shows that the experimental group had significantly higher post-test scores than the control group, with t = 2.67 (P < .005, d = 0.35), implying that the MAPA approach improved the subjects' learning achieve- ments more than the traditional approach.

Analysis of Learning Attitude Analysis of covariance was used to compare the learning atti- tude ratings of the two groups. In ANCOVA, the pre-test was the covariate, and the post-test was the dependent variable. The homogeneity of regression was examined, showing that the assumption was not violated with F= 3.06 (P= .06 > .05).

Table 3 shows the ANCOVA result. The MAPA ap- proach for the experimental group significantly improved the subjects' learning attitude ratings more in comparison with the traditional method used for the control group, with F = 1.088 (P < .05). The η2 value is 0.018, revealing a me- dium effect size.

DISCUSSION In this study, the mobile-assisted PA approach was proposed to improve nursing students' evidence-based searching per- formance. The research findings show that theMAPA group had better critical thinking, learning achievements,47 and attitudes than the traditional instruction group in the evidence-based nursing activity according to the ANCOVA analysis result.

These findings echo what was reported by Lai et al,13 who demonstrated that the PA approach embedded in mobile learning activities could enhance students' learning perfor- mance and high-order thinking ability. It can be inferred that students have a chance to reflect during PA sessions. Students' meta-cognitive awareness drove them to construct

Table 3. Results of ANCOVA on Learning Attitudes

Group N Mean SD

Experimental 18 1.67 1.04 Control 18 1.39 1.03 aP < .05.

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PICO knowledge and skills via MAPA.48–50 Wang et al10 in- dicated that the PA approach is an effective method, facilitat- ing the construction of knowledge and skills for individual learning. Students are able to learn how peers think about the learning task via evaluating their peers' work. Carey et al15

also revealed similar findings that PA could stimulate nursing students to become engaged in clinical practice and enhance their collaboration and communication in the co-working contexts. On the other hand, effectively implementing PA in clinical training contexts is challenging.

There are, however, some limitations of this study that should be noted. First, the sample size was not large; therefore, it would be better to be conservative in generalizing the findings to other situations in nursing education. Second, the experi- mental duration was not long; thus, it might be improper to generalize the findings to long-term nursing training.

CONCLUSION Knowledge construction is an important process for stu- dents, especially in expertise domain knowledge. Peer assess- ment helps students construct evidence-searching ability and skill via the observation of peers' work on PICO articles, self- reflection, and improvement of their own work. Such an as- sessment is also called formative assessment; it emphasizes students' assessment and relies on the continuous and timely feedback of teachers. In addition, this study also verifies that PA is an indispensable part of the large-scale online learning context. How to apply technology assistance in clinical settings in the future, how to combine the online teaching process based on educational theories, how to compare the differences among different evaluators, and how to evaluate different types of cur- riculum evaluation methods embedded in evidence-based nursing activities are all worth further investigation.

Educators and practitioners should recognize the benefits of PA and learn to implement it with other learning strategies in nursing training contexts, as suggested by Luaces et al.51

The authors not only reported the benefits of PA for improv- ing learners' performances but also suggested using PA in both experimental and control groups to compare the perfor- mances of various PA approaches.

Acknowledgment The authors thank Ms Catherine Harrington for assistance in editing

the article.

Adjusted Mean SE F η2

1.71 1.88 1.09a 0.018 1.46 1.86

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