The Effectiveness of Teaching Strategies for Creativity in a Nursing Concepts Teaching Protocol on the Creative Thinking of Two-Year RN-BSN Students

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The Effectiveness of Creative Teaching Strategies in the

Teaching Protocol of Nursing Concepts to RN-BSN Students’ Creative Thinking

Ya-Lie Ku Chi-Hui Kao Lo* Kuei-Min Chen** Jing-Jy Wang*** Jane Lee Hsieh****

Background

Because of the growing complexity of health care system, creative thinking is

essential for delivering and maintaining high quality of nursing care (Biester, Duggan,

Perkins, Powers, & Classick, 1999; Gilmartin, 1999). The professional nurses must

have the ability of creativity to overcome the uncertain health problems of the patients.

Professional nurses also should design problem-solving strategies deliberately by

utilizing creativity in clinical situations (Forrest, 1999; Wood, 1996). However, many

nurses routine work in clinical practice has been changeless so that have wrapped up

the original creativity.

Nursing education plays on crucial role to cultivate the creativity of nurses. It is

imperative to build knowledge and creativity in the process of educating nursing

students as the scholars (Elberson, & Williams, 1996). Curriculum design in the level

of bachelor nursing education should develop the scholarly abilities, such as creativity,

reflection, critical thinking, critical analysis, and openness to new thinking for

students (Ribbons, & Vance, 2001). Although Taiwan has developed the Republic of

Creativity (R.O.C.) 2002 as the foundation for the future education of creativity

(Department of Education, 2002), it has not been encouraged by nursing faculty. The

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nursing concepts by utilizing creative teaching strategies to promote creativity in

RN-BSN students.

Literature Review

The literature in creative thinking is originally started from the field of education.

Guilford (1950s) proposed the first theory of the Structure of Intellect (SI model) for

the creativity. Following Guilford, Parnes (1960s), Williams (1970s) and

Torrance(1980s), are all devoted into the study of creativity. In Taiwan, Chen during

1990s developed the ATDE (asking, thinking, doing, evaluation) model for the

creative teaching. Other researchers such as Wu (1980s), Chang (1999), Mao, Kuo,

Chen, and Lin (2000) are also involved into the area of creative studies. However,

only some teaching strategies of creativity in nursing literature were introduced. A

review of literature on creative thinking is divided into two sections as follows: 一、 General Education

Guilford, a psychologist, first developed the theory of the Structure of Intellect

(SI model) during 1950s. Guilford explained that the SI Model is the process of

integrating with 4 contents (figure, symbol, verbalism, behavior), five operations

(cognition, memory, divergent thinking, convergent thinking, evaluation), and six

products (unit, category, relation, system, transformation, application). Only divergent

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broadly from different perspectives that can derive various problem-solving methods.

Transformation is to reform the original data into the new definition.

Parnes, a behaviorist, during 1960s proposed the factors influencing the

creativity of students. Teachers must help students to remove some internal factors

inhibiting their developing creativity such as habit behaviors, dependent behaviors,

insecurity, and impulse. Also teachers should reinforce students’ actions of creativity

such as improving students’ knowledge background, imagination, critiquing slowly,

and inspire students’ attitudes of exploration. Yang and Chen (1993) also addressed

the factors disturbing the developing of creativity from students. For instance,

students are used to have the standard answers and afraid of having different

responses from teachers. Teachers should prepare a safe, acceptable, and some rules

of environments to enforce the creativity of students.

Williams during 1970s designed a creative plan and proposed the creativity

consisting of cognitive and affective behaviors. Williams developed 18 teaching

strategies to cultivate the cognitive behaviors of students’ creativity such as fluency,

flexibility, and originality and affective behaviors such as curiosity, imagination, and

take adventures. During 1980s, Torrance also provided 16 principles of creative

teaching to train students to aware the problem and design the solving strategies.

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teaching to promote the motivation of students to be creative.

Based on the Guilford’s SI model, Chen during 1990s developed an ATDE

(asking, thinking, doing, evaluation) model to cultivate the divergent thinking of

students. For asking, ten methods of asking questions using “If”, “List”, “Besides”,

“Compare”, “Similar”, “Replace”, “Imagine”, “Possible”, “Constitute”, “6W” can

inspire students to think divergently. For thinking, teachers must allow students to

think at least three seconds for answers. For doing, teachers can choose a guider to

direct group discussion consisting of 5-10 students through brainstorming. For

evaluation, teachers should encourage students to do self-evaluation by following two

principles, “critique slowly” and “accept more”.

Regarding the definitions of creativity, Guilford has defined creative thinking as

fluency, flexibility, originality, sensitivity, and elaboration (Guilford, 1956). In 1970,

Williams addressed that creativity should include fluency, flexibility, originality, and

elaboration. Demetrulias and Shaw (1985) later work supported inclusion fluency,

flexibility, associative thinking, and originality in creativity. Then Dowd (1995)

proposed that creativity should consist of fluency, flexibility, and originality. Finally,

Chen (1998) and Chang’s (1999) definition of creativity was fluency, flexibility,

originality, and elaboration.

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the components of creativity. Because Torrance’s (1974) Tests of Creative Thinking

(TTCT) are the most popular instrument used to test the creativity in the field of

education, Wu (1985) has applied the Torrance’s definition of creativity into the

research of general education. According to Torrance (1974), fluency is the total

number of responses students report, flexibility is the number of different categories

of responses students report. Originality is defined as the numbers of responses that

occurred with a frequency of 5% or more among the total responses in the data set

were scored 0 for originality; those with a frequency of 2% to 4.99% were scored 1,

and those with a frequency less than 2% were scored 2. 二、Nursing Education

Recent nursing literature has continuously emphasized the innovation and

creativity because nurses must have creativity, flexibility, independence, critical

thinking, and collaboration to meet the demands in the healthcare (Lewis, Brand,

Duckett, & Fairbanks, 1997; Potgieter, 1999). Also, it is imperative to build

knowledge and creativity in the process of educating nursing students as the scholars

(Elberson, & Williams, 1996). The University education is to develop the scholarly

abilities of nursing students such as creativity, reflection, critical thinking, critical

analysis, and openness to new thinking (Ribbons, & Vance, 2001). Creativity in the

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In the clinical practice, a study by Berg and Hallberg (1999), twenty-two nurses

in a general psychiatric ward were tested before, during, and after one year of

systematic clinical supervision. Results identified that systematic supervision of

clinical nursing care can improve the creativity of nurses and the organizational

climate (Berg, & Hallberg, 1999). Titchen and Binnie (1995) suggested three

supervision strategies such as using a clinical story to demonstrate each demand from

the supervisor and the offers from the nurses that can nurture the creativity of nursing

staffs.

Except for the systematic supervision, Webster (1998) introduced an innovative

process to teach adult nursing staff and spur their creativity, team working, and

individual accountability. The use of creative teaching strategies in nursing staff

development can inspire enthusiasm for learning (Geyer, & Korte, 1990). Anderson

(1998) also suggested that matching the teaching style of nursing preceptors with the

learning style of new nursing staffs with the orientation creatively can maximize their

job satisfaction. The factors for job satisfaction has been ranked by the directors of

nursing staff as the intrinsic variables such as creativity, moral values, social service,

ability utilization and responsibility (Rehtz, 1995).

Besides, Robbins (1997) suggested nurses to use Nursing Interventions

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the creative teaching strategies. Through NIC with using creative teaching strategies,

the clients with multiple sclerosis (MS) can use open communication and creativity to

deal with the problems of fatigue, impotence, decreased vaginal lubrication,

dysfunction of bladder and bowel (Weiss, 1992).

For clinical teaching, the central essential elements of nursing students’

expectations of faculty guidance activities in the clinical laboratory are critical

thinking, professional judgement, application of knowledge, and fostering creativity

(Heims. 1991). Gross, Aysse, and Tracey (1993) designed a creative education model

for the first-semester students’ clinical practicum. Students are paired in a one to one

relationship with a staff nurse who will be served as a role model. Responses to this

model from students’, nursing staffs’ and faculty’s perspectives indicate that the

paired model has worked in improving creativity of beginning nursing students in a

clinical setting.

Anthony (1998) utilized an artistic expression model by teaching Haiku (an

ancient Japanese poetry) to encourage the nursing beginning students to verbiage their

perceptions in relation to the clients through writing an ancient Japanese unrhymed

form of poetry. Through the poems, the nursing beginning students can create the

different kind of writings to identify their major concerns about their clients. Mueller,

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care plans to stimulate creativity of the nursing students.

In the educational studies, nursing education literature emphasizes the

importance of teaching students to think creatively to meet the challenges of 21st

century health care delivery (Le Storti et al., 1999). Creativity is the character of

teaching resulting in empowerment between students and teachers (Chally, 1992). For

instances, Greiner and Valiga (1998) have proposed that nurse educators can use some

creative teaching strategies such as stories, analogies, parables, and metaphors

(Trunnell, Evans, Richards, Grosshans, 1997) to fulfill students’ health promotion

responsibility.

Also, a nursing portfolio is a creative way for traditional nursing or RN students

to document their achievements, past works, and life experiences without taking a

standardized test (Alexander, Graft, Baldwin, Beers, & McDaniel, 2002). Besides,

individualization as the creative teaching strategy for mater’s prepared nursing

students to develop the home health care experiences of creativity (Alley, Donckers,

King, 1992).

Additional writings support case method, seminar format, and workshop were

good ways to improve nursing students’ creativity. Wade (1999) utilized the case

method approach to help nursing students understand the complexity of patients’

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providing care. Seminar format teaching increased the skills of traditional RN

students in creativity, autonomy, and flexibility (Rains, Richardson, & Fowler, 1999).

A group of nursing students have developed creativity workshops for the parents with

the preterm babies under risk at the University of Sao Paulo Hospital (Brunherotti,

Pereira, de Souza, Nogueira, & Scochi, 2000).

Finally, the assignments nursing faculty designed can inspire nursing students’

creativity. Slaninka (1999) applied creative teaching strategies in a course of nursing

theory and derived the outcomes of the students’ presentation and term paper

assignments creatively. Also, Olivet and Jones (1997) used the telecommunication

technology for innovation and creativity in nursing graduate education. Besides,

nursing instructors designed the assignments with technology-assist can encourage

students to collaborate with one another to promote their abilities of solving problems

creatively (Mastrian, & McGonigle, 1999). Additionally, nursing educators have used

television games as effective teaching strategies to help students to develop

imagination and creativity (Youseffi, Caldwell, Hadnot, Blake, 2000).

Definition of Terms

1. Fluency: The total number of problem-solving strategies in clinical situations

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2. Flexibility: The number of different categories of problem-solving strategies in

clinical situations reported by the students.

3. Originality: The number of novel, elegant, or unusual problem-solving strategies

in clinical situations reported by the students. Responses that occurred with a

frequency of 5% or more among total responses in the data set were scored 0 for

originality; those with a frequency of 2% to 4.99% were scored 1, and those with a

frequency less than 2% were scored 2.

Design

This study design is a time series and two groups experiment utilized multiple

institutions of treatment to measure the creativity of 52 two-year and 69 three-year

RN-BSN students at four different points in time. The research protocol consists of

three semester courses including 12 credits lectures and 9 credits practicum. A

teaching model of creativity with various strategies included the process of asking,

thinking, doing, and evaluation are applied into each of teaching protocol of nursing

concepts to improve both groups of RN-BSN students’ fluency, flexibility, and

originality.

Sample

The purposive sample includes 52 two-year and 69 three-year RN-BSN students

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setting. It was assumed that one year’s experience after completing a junior college

program would enable them to think conceptually about patient’s problems. Both

groups of RN-BSN students have completed the courses in the teaching protocol of

Nursing Concepts within three semesters and the teaching strategies of creativity are

applied into each of teaching units.

Instrument

一、Creativity in the application of the Nursing Process Tool

The instrument “Creativity in the application of the Nursing Process Tool

(CNPT)” integrating the nursing process designed by Emerson (1988) was used in this

study. The steps in nursing process as defined by Marriner (1983) include assessment,

planning, implementation, and evaluation. The content validity of English-version

CNPT was .83 including eight major questions. The question number one, for instance,

is “List all the consequences to health care if people have only black and white

vision.” In this study, the CNPT was translated into Chinese. Five experts who have

involved in the research of creativity assessed the content validity of Chinese-version

CNPT. As a result, question number 3 was irrelevant for measuring the fluency,

flexibility, and originality and was deleted. Finally, the content validity index of

Chinese-version CNPT approached at 0.79. 二、Coding Guide

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questions. Narrative answers from the randomly selected 5 questionnaires were read

and classified into the different categories by two nursing researchers. Ten nursing

education experts were invited to assess the relevance of each category in the clinics

as well as the accurate and appropriate items under each category. The coding guides

were modified following the process of coding when two nursing researchers have

found the new categories. Within 20 open-ended questions, 6 to 19 categories were

developed as coding guides.

Data Collection and Analysis

Fifty-two two-year and 69 three-year RN-BSN students of a southern University

were invited to participate in this study. Due to various scheduling problems, only 30

two-year and 44 three-year RN-BSN students have completed the four times tests,

giving a 58% and 64% returned rate. Both groups of RN-BSN students were

measured by their fluency, flexibility, and originality before the first semester and the

end of each semester from March, 1999 to May, 2001.

The investigator explained the purpose of this study to 52 two-year and 69

three-year RN-BSN students while collecting data. Also, each student was given a

small gift as an incentive for participating in this study. Two researchers coded the

data by following the coding guides. Inter-coder reliability between the two

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compare the fluency, flexibility, and originality from pretest to test III.

Result

一、Demographics

The average age of the sample is from 21 to 30 years old; however, the

three-year RN-BSN students were older than the two-year students’ significantly. The

majority of both groups (89% and 78%) were not married and graduated from 5-year

nursing program (65% and 68%). Almost half of two-year RN-BSN students were

either nurses or registered nurses (48% and 48%); however, the majority of three-year

RN-BSN students were registered nurses (54%). In working experiences, three-year

RN-BSN students (6-10 years) worked longer than the two-year students’ (1-5 years)

significantly. The majority of both groups (67% and 81%) worked either in the

medical unit or surgical unit. The demographics of two-year and three-year RN-BSN

students were indicated in the Table 1. 二、 Fluency、Flexibility、Originality

The results indicated that the creativity of both groups in the fluency and

flexibility tend to be improved after the second semester and the improvement had

become significantly in the third semester. The fluency and flexibility of two-year

RN-BSN students tend to be better than the three-year students’. However, originality

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better in the originality than the two-year students’. The study findings were indicated

in the Table 2.

Discussion

According to the literature, no research has done about the creativity including

fluency, flexibility, and originality in nursing students. Only some teaching strategies

have been introduced for nursing faculty to help students to develop the creativity.

This study has applied the definition of fluency, flexibility, and originality from the

Torrance’s (1974) and transformed them into the nursing. Also, Chen (1990)’s ATDE

model was used in this study to cultivate RN-BSN students’ creativity.

The fluency and flexibility of both groups tended to decline after the first

semester that indicate RN-BSN students may have the difficulties to take the teaching

protocol of Nursing Concepts at the initial time. As Anthony’s (1998) Haiku and

Johnston and Bligh’s (2001) mind mapping, nursing faculty have requested students

to write the daily journals to express their opinions about the teaching protocol of

Nursing Concepts. Through various ideas from the daily journals, nursing faculty can

understand inhibits from the RN-BSN students to develop the creativity in the

teaching protocol of Nursing Concepts. As Parnes’ (1960s) suggestions, teachers must

help students to remove internal factors inhibiting them to develop the creativity.

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(1993) advices to encourage students to have different opinions from the teachers.

Not until the third semester, have the fluency and flexibility of both groups

improved significantly. The study of Berg and Hallberg (1999) has emphasized the

function of systematic supervision to improve nurses’ creativity. Similarly, this study

has spent three semesters to supervise RN-BSN students’ creativity systematically.

The results indicate that the fluency and flexibility of both groups have declined after

the first semester; however, the improvement of fluency and flexibility started from

the second semester and continue to become significantly after the third semester. The

cultivation of RN-BSN students’ creativity does take time.

Since the originality of both groups has declined, nursing faculty may design

teaching strategies more special on the originality. Trunnell, Evans, Richards, and

Grosshans (1997) have suggested to use stories, analogies, parables, and metaphors to

improve nursing students’ creativity. Also, nursing portfolio was introduced as the

creative way for RN-BSN students to record the past experiences (Alexander, Graft,

Baldwin, Beers, & McDaniel, 2002). Nursing faculty can create the unusual clinical

situations within the analogical concepts during case analysis and lead students

brainstorming by using metaphors. In addition, nursing faculty can suggest students to

inquiry experts from the other field for the ideas of different nursing interventions

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In compared with both groups, the fluency and flexibility of 2-year students was

better than the 3-year students’. On the other hand, the originality of 3-year students

performed better than the 2-year students’. Because three-year students were older

and work longer than the 2-year students’, three-year students may think special and

unique ideas often. However, the 2-year students were younger and had less working

experiences so that they have more chance to inspire the imagination. Therefore,

two-year students may report many ideas.

Limitation

Five limitations are explored in this study. First, this study was lack of two

pretests as compared to the posttests within the second and third semesters so that

maturation existed to affect the internal validity of this study. Also, this study did not

have a control group to compare to in terms of research results. Besides, a teaching

protocol of nursing concepts is used in this study by applying critical, creative,

problem-solving, integrate teaching strategies to improve RN-BSN students’ four

abilities of critical and creative thinking, problem-solving, and integration. This study

did not have control group and used mixed teaching strategies so that research results

could not be explained exclusively from the effect of creative teaching strategies.

In addition, subjects in this study were purposively selected from two-year and

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nursing student populations. Finally, the returned rate in this study is only 58% and

64% that a small sample size (N=30 and N=44) might impact the results of statistical

analysis.

Acknowledgements

Upon completing this study, I would like to give special thanks to our National

Science Council to support this study, Kuei-Lan Yang and Shih-Tau Hwang have

developed the proposal, Ling-Huang Wang and Huey-Shyan Lin worked on the data

coding and analysis, Yu-Chu Yeh and ten nursing education experts have helped to

revise the questionnaire as well as built the coding guides.

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