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Nurse Education in Practice 12 (2012) 72e76

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Collaborative learning among undergraduate students in communityhealth nursing

Kyeongra Yang a,*, Gail R. Woomer a,1, Judith T. Matthews a,b,2

aDepartment of Health and Community Systems, School of Nursing, University of Pittsburgh, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USAbGerontology Program, University Center for Social and Urban Research, 121 University Place, Rm. 313, Pittsburgh, PA 15260, USA

a r t i c l e i n f o

Article history:Accepted 14 July 2011

Keywords:TeamworkCollaborative learningCommunity healthNursing students

* Corresponding author. Tel.: þ1 412 624 6943; faxE-mail addresses: yangk@pitt.edu (K. Yang), gwoo

jtmatt@pitt.edu (J.T. Matthews).1 Tel.: þ1 412 624 9570; fax: þ1 412 383 7293.2 Tel.: þ1 412 624 3776.

1471-5953/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.nepr.2011.07.005

a b s t r a c t

Teamwork can benefit students, enhancing their ability to think critically, solve problems creatively, andcollaborate effectively. We piloted a collaborative learning project with undergraduate community healthnursing students (N ¼ 83) that entailed working in teams to explore epidemiologic data, synthesize theliterature, and develop an evidence-based plan for nursing intervention and evaluation pertaining toa public health issue. Project evaluation consisted of pre- and post-project surveys by students, peerevaluation, and formative and summative evaluation by faculty. Having students work in teams, whilechallenging both for faculty and students, may be a viable strategy for preparing the next generation ofnurses for inter- and intraprofessional collaboration. Our experience suggests that instituting a collabo-rative learning experience as part of an undergraduate course in community health nursing can be aneffective way to expose students to constructive approaches to teamwork and prepare them forevidence-based nursing practice in the future.

� 2011 Elsevier Ltd. All rights reserved.

Introduction

Sound decision making and implementation of safe and effec-tive community health nursing interventions require clear under-standing of the clinical and scientific evidence that supports thispractice arena. Essential skills include the ability to identifya problem, obtain the most relevant information to solve it, andimplement an intervention tailored to the situation and guided bythe evidence (DiCenso et al., 2005). Developing these essentialskills in undergraduate nursing students requires implementationof learning strategies embedded throughout the curriculum thatpromote evidence-based practice (Burke et al., 2005).

The focus of care in the United States, the United Kingdom, andelsewhere in the world is shifting as nurses increasingly practice inthe community rather than hospital settings. In response tosignificant growth in the delivery of primary care and other healthservices in the community, the Institute of Medicine (2011) hascalled for amore highly educated nursingworkforce in the domainsof community and public health. Similarly, the World Health

: þ1 412 383 7293.mer@pitt.edu (G.R. Woomer),

All rights reserved.

Organization (2010) has identified nurses as frontline serviceproviders who need to be better prepared to assume a greater rolein the design and delivery of people-centered, evidenced basedcare. Nurses are directed to collaborate within and outside thenursing profession to strengthen health systems, ensure provisionof culturally sensitive services, and improve health outcomes acrossthe age spectrum locally and globally.

Nurses in community and public health settings frequently workin teams or serve on committees or task forces charged withdeveloping action plans that are practical and likely to succeed inaddressing emerging public health issues. With limited resourcesand pressing health needs that require appropriate and timelyassessment and intervention, community health nurses must becompetent and comfortable with collaboration. Collaborativelearning involves “an intellectual endeavor in which individuals actjointly with others to become knowledgeable on some particularsubject matter” (Koehn, 2001, p. 160). This approach to learning isknown to benefit students academically, socially, and psychologi-cally (Kinyon et al., 2009; Panitz, 1999). By working together,students enhance their critical thinking skills and become moreinterested in the learning process, often producing an end-productthat is superior to what might have been possible with their indi-vidual effort and resources (Feingold et al., 2008; Panitz, 1999).They develop an appreciation for the wisdom of consideringdiverse perspectives that theymay not have explored on their own,

K. Yang et al. / Nurse Education in Practice 12 (2012) 72e76 73

which in turn may enable the design of more creative solutions(Feingold et al., 2008; Panitz, 1999). Further, collaborative learningincreases self-confidence, reduces anxiety and improves access tofaculty expertise (Clark et al., 2008; Feingold et al., 2008; Panitz,1999; Souers et al., 2007; Yates, 2006). While population healthand interdisciplinary learning are emphasized in all healthprofessional schools (Koh et al., 2011), the ability to function inteams has been identified as a key competency for interprofessionalpractice (MacDonald et al., 2010).

Introducing nursing students to evidence-based group workthrough collaborative learning experiences is a reasonable startingpoint for developing competencies important for teamwork andthe design of effective public health interventions. In the UnitedStates, community health nursing is typically taught in a baccalau-reate program. It builds upon students’ foundational knowledge ofthe physical and social sciences, human development across the lifespan, and medical-surgical, obstetric, pediatric, and psychiatricnursing of individuals. The course is often part of a capstone senior-year experience designed to expand the notion of “client” toinclude families, aggregates, and communities, while synthesizingrelevant scientific and clinical information and applying it inpractice. Clinical practica enable students to identify challengesfaced by community health agencies, explore their assessmentmethods for quantifying health issues, and learn their interventionand evaluation approaches.

The Essentials of Baccalaureate Education for ProfessionalNursing Practice, published by the American Association of Collegesof Nursing (AACN) in 2008, specifies new competency standards toguide curriculum design and enhance the ability of baccalaureate-prepared nurses to provide safe, high quality patient care withincomplex health care systems. Nine essentials set forth theoutcomes expected of graduates of baccalaureate nursing programs(American Association of Colleges of Nursing, 2008). Essential VIstipulates fostering students’ development in the areas of inter- andintraprofessional communication and collaboration as well astranslation of current evidence into practice, competencies thatseem particularly amenable to a collaborative learning approach.

The purpose of this paper is to describe the collaborativelearning experience that we implemented in our community healthnursing course to address Essential VI. Specifically, we describehow the faculty structured the experience and how students andfaculty responded to our approach. This project received approvalby the University of Pittsburgh Institutional Review Board andfocused on the following research questions:

Among students with prior experiencewith groupwork in othercourses:

� What was most and least favorable about those experiences?What obstacles were encountered? What was considered keyto a successful group project?

Based on the collaborative learning experience in our course:

� Howdid students rate peers in terms of teamspirit, interpersonaldynamics, meeting attendance, and participation in discussion?

� How did students rate other groups in terms of the organiza-tion, clarity, and aesthetic appeal of their presentations andtheir responsiveness to questions?

� How did the faculty rate the quality of each group’s presenta-tion in terms of the evidence provided and the proposedintervention and evaluation plan?

� What did students like most and least about their groupproject? What major obstacles did they encounter and whatsolutions did they try? What would improve the collaborativelearning experience?

Methods

The University of Pittsburgh School of Nursing requires allsenior-level students to take a community health nursing course aspart of the Baccalaureate Program. Though the number of clinicalhours varies based on the student’s academic track (i.e., traditional,second degree, and RN-BSN or RN-MSN), all students attend thesameweekly didactic session. Except for RNswith prior communityhealth nursing experience, all students engage in a clinical prac-ticum that includes placement with a community agency, disastermanagement training, and health promotion activities. Studentshave the opportunity to work alongside a preceptor in one ofseveral community-based settings: schools, public healthprograms, home care and hospice, ambulatory care, community-based health and social service agencies, or health education andoutreach. Successful completion of the course requires passingexaminations, performing clinical activities satisfactorily, andcompleting a collaborative learning experience.

In April of 2008 we established two objectives for a groupproject to enable collaborative learning: helping students synthe-size course content by focusing on a public health issue, andproducing an evidence-based, aggregate-level plan for communityhealth nursing intervention and evaluation. Since Summer Term2008, we incorporated the group project among our courserequirements. Using numbers generated by computer, werandomly assigned students to groups of four. We identifieda public health issue for each group to address and provideda rubric to guide their work. Public health issues included infectiousdisease control, immunizations, teen pregnancy, cancer screening,addiction, environmental contaminants, healthy lifestyle, andinjury prevention.

Students focused on their assigned public health issue as itrelated to at least one group member’s clinical site or population.For example, group members addressing control of environmentalcontaminants might choose to focus their efforts on moldprevention in communities prone to flooding. Each student wasrequired to gather primary data by conducting interviews withhealth professionals and other personnel at their clinical site tolearn the relevance of their group’s public health issue in thatsetting. These interviews involved nurses and nurse practitioners,dentists, physicians, epidemiologists, teachers and their aides,coaches, public health administrators, food safety inspectors, andfood service personnel, among others. In addition, students in eachgroup gathered publicly available secondary data related to theirassigned issue, including agency reports as well as local, regional,and national surveillance summaries.

Students met with their groups during class on four to sixoccasions over a two-month period. During each meeting, thegroup designated a facilitator, a recorder, and a time keeper, witheach member expected to assume these various roles at least once.For each meeting our faculty stipulated a task: identifying the topicand the population of interest; setting at least one goal and cor-responding objective; developing a plan for gathering primary andsecondary data; reviewing pertinent clinical and research litera-ture; or proposing strategies for intervention and evaluation.Specific guidelines for the group work were provided, with eachgroup required to specify an accessible population for their plannedintervention; how, when, where, and by whom the interventionwould be implemented; and how formative and summative eval-uation of the intervention would occur. Students recorded meetingnotes in a notebook provided by faculty, summarizing theirdiscussion and the resulting action plan. Our faculty reviewed thesenotes and provided feedback before the next class session.

One week after the final groupmeeting, students made a formalpresentation of their evidence-based project to classmates and

K. Yang et al. / Nurse Education in Practice 12 (2012) 72e7674

faculty. The 20-min presentation required discussion of the clinicaland scientific evidence (including a summary table of the researchliterature) thatsupported the group’s proposed nursing interven-tion, their specific action and evaluation plan, and what had beenlearned through collaboration. Table 1 lists the required compo-nents of the presentation.

Evaluation methods

We evaluated this collaborative learning experience in a varietyof ways: pre- and post-project survey, peer evaluation, and forma-tive and summative evaluation by faculty. Prior to beginning thegroup project during Summer Term 2008 and Spring Term 2009,students completed a brief survey indicatingwhether theyhaddealtwith group projects in other courses and what they liked most andleast about those experiences. They were asked open-ended ques-tions about obstacles they had encountered and their views aboutthe keys to successful group work.

Grading rubrics guided peer and faculty evaluation. Studentsrated fellow group members’ team spirit (0 ¼ obstructive;5 ¼ compliant; 10 ¼ cooperative), interpersonal dynamics(0 ¼ critical; 5 ¼ neutral; 10 ¼ supportive/respectful), meetingattendance (0 ¼ more than one absence; 5 ¼ one absence;10¼ perfect attendance), and participation in discussion (0¼ poor;5¼moderate; 10¼ verywell), whichwhen summed and divided byfour yielded a maximum score of 10. Students also evaluatedpresentations made by other groups, rating them on a scale from0 (poor) to 3 (excellent) in terms of organization, clarity of textualand visual content, aesthetic appeal, and responsiveness to ques-tions, for a possible total score of 15.

Faculty evaluated how well each group described its topic andpopulation of interest using primary and secondary data and howwell it reviewed pertinent literature, proposed an evidence-basedintervention, and articulated an evaluation plan. To ensure

Table 1Required components of the group project presentation.

Component Description

A. Identified Public HealthIssue/Topic and PopulationWarranting NursingIntervention

Summary of primary data such asobservations during clinical practicum,windshield surveys, and key informantinterviewsSummary of secondary data drawnfrom existing reports such asmorbidity, mortality, andnatality rates

B. Review of the Literature Synthesis of the clinical and researchliterature pertaining to the identifiedpublic health issue and topic,including known efficacy andeffectiveness of interventions

C. Planned Nursing Intervention Development of a plan forevidence-based interventionwith an accessible population,specifying at least one goal andobjective and the details ofimplementation (i.e., who, what,where, when, how, and resourcesneeded)

D. Evaluation Plan Description of methods for evaluatingthe planning and implementationprocess (formative evaluation) andthe extent to which expectedoutcomes are achieved (summativeevaluation)

Note: Each team compiles a table summarizing research literature relevant to thetopic and population of interest. The summary table includes author, year ofpublication, sample, research question(s), study design, description of the inter-vention (if applicable), study variables, and findings.

students’ exposure to a variety of public health issues and inter-ventions, faculty deducted 10 points from the final grade for thegroup project when a student was absent for other groups’presentations. The group project contributed 30% to the final coursegrade, weighted so that 35% of the points earned derived from peerevaluation and 65% from faculty evaluation.

After delivering their group presentation students completeda brief post-project survey, indicating what they liked most andleast about their group project. They identified major obstaclesencountered, the solutions they tried, and their recommendationsfor improving the group project assignment. On a scale from 0% to100%, students also rated their comfort with peer evaluation andtheir general satisfaction with the group project.

Results

Eighty three students (12 male and 71 female) who engaged inthis collaborative learning experience completed the pre- andpost-project surveys. The majority of these students had beentraditional undergraduates (n ¼ 56; 67.5%), with the remaindereither second degree (n ¼ 20; 24.1%) or returning RN students(n¼ 7; 8.4%). The findings we report here pertain to the 83 studentswho completed both surveys.

Prior collaborative learning experiences

Only two students reported not having prior experience withgroup work. With these prior experiences, students mostfrequently reported having difficulties with communication(n ¼ 19), coordinating meeting times (n ¼ 40), and being penalizedin grading based on other group members’ poor work (n ¼ 52).Nevertheless, many students liked group work because it offeredthe opportunity to share responsibility and ideas with others(n ¼ 33), thereby lessening their own workload and enabling themto consider different perspectives (n ¼ 35). Fifteen students indi-cated that nothing was good about past group work, but 17students appreciated collaborating with other students. Schedulingconflicts (n ¼ 27), difficulties in communication (n ¼ 26), anduneven distribution of workload (n ¼ 25) were most frequentlycited as past obstacles to successful group work (Table 2).

Not surprisingly, students identified good communication(n ¼ 39) and the ability to cooperate (n ¼ 32) as essential toteamwork, and they endorsed collaborative learning when thework was equally distributed among team members (n ¼ 18).Students also considered honesty, patience, flexibility, and open-ness to others’ ideas to be the most important attributes needed forsuccessful group projects (Fig. 1).

Table 2Perceived obstacles to successful group work before and after collaborative learningexperience (N ¼ 83).

Obstacle Pre-ProjectSurvey

Post-ProjectSurvey

n % n %

Conflicting schedules 27 32.5 17 20.5Difficulty achieving consensus/poor

communication26 31.3 7 8.4

Uneven distribution of work 25 30.1 5 6.0Inadequate time for group meetings 11 13.3 8 9.6Differing work styles and work ethics 8 9.6 0 0Unproductive group meetings 1 1.2 5 6.0None 2 2.4 17 20.5No response 9 10.8 6 7.2

Note: The total number of perceived obstacles is greater than 83 due to multipleresponses provided by some students.

Fig. 1. Attributes perceived as important to successful teamwork. Note: The totalnumber of perceived obstacles is greater than 83 due to multiple responses providedby some students.

K. Yang et al. / Nurse Education in Practice 12 (2012) 72e76 75

Current collaborative learning experience

Post-project surveys revealed that most students enjoyedworking with their peers in our course, and they valued learningthrough the group process and presentations. They also valueddiscovering evidence-based interventions that were feasible andapplicable to current public health issues and topics. Though somestudents appreciated having structured group time within the classperiod to organize and plan their projects, others did not, eventhough theywere permitted tomeet anywhere at school during thein-class meeting time. Those who preferred self-scheduling indi-cated that their time would have been used more effectively ina less distracting environment or in a setting with access theInternet and other resources.

Compared to their assessment of obstacles encountered duringprior group work (Table 2), students at post-project survey lessfrequently reported difficulties with scheduling (n ¼ 17), commu-nication (n ¼ 7), and distribution of work (n ¼ 5). Though 17students reported no obstacles in completing their group projects,several reported difficulty interpreting project guidelines (n ¼ 6),agreeing upon a topic (n ¼ 4) and target population (n ¼ 2),obtaining primary and secondary data (n ¼ 4), and designing theintervention plan (n ¼ 2). Approaches taken by students to over-come these challenges were many: revisiting the guidelines toclarify expectations and refine the topic; seeking input frompreceptors and other experts; collaborating to find, interpret, andsynthesize information from various sources; holding membersresponsible for delegated tasks; compromising to accommodateschedules, alternate meeting locations, and assignments; and per-sisting in efforts to communicate clearly. Given that our studentshad fewer schedule conflicts and communication challenges andconsidered their work to be more evenly distributed among groupmembers than had been the case in the past, we surmise that theseapproaches contributed to a more positive experience.

Most students graded fellow team members leniently (range:9.38 to 10 out of a possible 10), despite frequent comments thatsuggested displeasure with others’ commitment to the project andthe quality of their work. They also tended to grade other groups’presentations generously (range: 13.23 to 14.86 out of a possible15). Of the78 students who rated their comfort with peer evalua-tion (mean � SD: 73.08 � 32.08%), 15.4% (n ¼ 12) were less thanmoderately comfortable including seven (9.0%) who were not at allcomfortable.

Students were moderately satisfied with their project(mean � SD: 65.77 � 23.16%). In general, the faculty was wellsatisfiedwith the progress each groupmade throughout the course.All groups did a good job describing their public health issue

relevant to a particular topic and population, gathering primary andsecondary data, reviewing pertinent literature, proposing anevidence-based intervention, and articulating an evaluation plan.The mean score from faculty evaluation of projects was 61.7 (�2.6)out of a possible 65.

Discussion

Feedback from students regarding the group project in ourundergraduate community health nursing course suggests thatworking in teams, while challenging, may be a viable strategy forpreparing the next generation of nurses for collaboration. Indeed,our findings support the call by Mennenga and Smyer (2010) toincorporate team-based learning into nursing education as a meansof enriching the learning environment. Our students demonstratedwillingness to work together, gather salient information abouta public health issue, learn about available resources, and devisea feasible plan for evidence-based intervention.

Most students had experienced group work in other courses,which may have dampened their enthusiasm for our group projectat the outset. Whether those prior experiences were in nursingcourses in our curriculum is unknown, so we can only surmise thattheymight have been nursing-related or involved other students inan earlier stage of professional development. Nevertheless, by theend of the term the majority of students in our course viewed theirgroup project favorably, acknowledged learning much about theirselected topic and population, and expressed appreciation for theopportunity to work with fellow students. Their solutions toobstacles demonstrated howour approach to collaborative learningfacilitated communication and set the stage for optimizing theirtime and talent to reach a common goal.

Exploring students’ views about past group projects and initi-ating formative evaluation early in the process helped us torespond in a timely manner to students’ concerns. For example,students desired greater flexibility when conducting group work inclass. Our original guidelines had stipulated that students wouldmeet with their groups on four to six occasions during class timeand as needed outside the classroom. Students found that meetingin the classroom limited their access to resources. Though theclassroom was equipped for wireless access to the Internet, fewstudents brought laptops to class and they were unable to print oremail relevant documents to one another. In response, we relaxedthese restrictions and permitted them to meet in a location of theirchoosing within our school, with the requirement that they submita summary of their progress and planned next steps. In addition tothe students appearing more contented, their meeting notes andcomments reflected greater productivity.

This collaborative learning experience successfully addressedEssential VI of the Essentials of Baccalaureate Education (AmericanAssociation of Colleges of Nursing, 2008) by fostering studentdevelopment of inter- and intraprofessional communication andcollaboration skills and enabling them to begin the process oftranslating current evidence into practice. Our findings furthersuggest that this experience also helped students with otheressential elements of their nursing education. While engaged ingroup work, students honed their teamwork skills (Essential II)including conflict resolution and collaboration. They engaged in theprocess of retrieving, appraising, and synthesizing clinical andresearch evidence in collaboration with peers (Essential III). More-over, this experience provided students with the opportunity topropose an evidence-based plan of intervention that would enabletranslation into practice. The Affordable Care Act of 2010 calls forteam-based approaches to health care delivery among advancedpractice nurses and physicians, for example, and this undergrad-uate exposure to collaborative learning gives students a glimpse at

K. Yang et al. / Nurse Education in Practice 12 (2012) 72e7676

the challenges inherent in defining common goals, developinga coherent plan of care substantiated by available evidence, andmanaging conflicts among collaborators’ views (Gardner, 2010).

Students have been shown to reliably evaluate their peers(Arnold et al., 1981), with such evaluations significantly promotingteam effectiveness in terms of workload sharing, cooperation, andproducing constructive suggestions for change (Erez et al., 2006).Peer evaluation can also be used to develop teamwork skills andhelp students become active learners (Topping, 1998). Peer evalu-ation is being introduced to health care settings because it has beenshown to improve the quality of care (Welch, 2001) and to promotenurses’ professional development (Vuorinen et al., 2000).

Though evaluating the collaborative learning experience in ourcourse enabled us to better understand group dynamics and facil-itate learning, we also found that students were uneasy with peerevaluation. They often contradicted their generous numericalratings of peers by verbally criticizing the uneven distribution ofwork that occurred in their groups. Our findings suggest the needfor greater attention to preparing undergraduate nursing studentsin the process of peer evaluation and the value of sharingconstructive feedback. Instructional strategies to promote collab-orative peer evaluation need to include clear description of theevaluation purpose and process, creating tailored evaluation toolsand criteria, and having ongoing formative evaluation in placeduring the process (Gueldenzoph & May, 2002). Instituting thesestrategies must be tempered by sensitivity to societal and culturalnorms that may influence hownurses respond to offering as well asreceiving feedback regarding their performance.

Conclusions

All nursing students may not eventually practice in communitysettings, since at present only 34% of nurses are employed innonhospital clinical settings (Institute of Medicine, 2011). But thevast majority is likely to assume positions that require professionalcollaboration, whether dealing with health at the local level orbeyond. Our experience suggests that instituting a collaborativelearning experience as part of an undergraduate course incommunity health nursing can be an effective way to exposestudents to constructive approaches to teamwork and to preparethem for evidence-based nursing practice in the future.

Conflict of interestThere is nothing to disclose.

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