Design and tuning
The design used in this quantitative research was a quasi-experimental approach with a pre- and a post-design. In Iran, a Bachelor of Science in Nursing lasts 4 years. Students complete two semesters each year and complete 130 credits over four years. Each theoretical, practical and workshop/course unit is equivalent to 17, 34 and 51 hours respectively. Students in the first semester of the fourth year take the Adult and Elderly Nursing Internship course (8 credits) and the Oncology Nursing Internship course, both scheduled for a total of 6 days (0.5 credit). In Tabriz School of Nursing and Midwifery, Oncology Nursing Internship Program is provided for 7th semester students. The research setting was Shahid Ghazi Hospital, affiliated to Tabriz University of Medical Sciences. The first author of this article developed the intervention protocol in collaboration with the research team. The protocol was implemented during the oncology nursing internship for undergraduate nursing students in 2019-2020 by the first author.
In this research, 107 undergraduate nursing students in the 7th semester formed the research population. A total of 55 students between September 2019 and December 2019, who entered this internship program, formed the control group, and another 51 students, who entered this program between January 2020 and May 2020, were selected for the intervention group. The reason for this choice was to prevent the dissemination of information about the intervention from the intervention group to the control group and to be able to collect data from the control group before the intervention group (Fig. 1).
Participants in the intervention group learned using the integrated teaching-learning method, while the control group learned using the conventional method. In the conventional method, students assessed their patients after assigning them 1-2 patients and cared for their patients under the supervision of an instructor based on their nursing diagnoses and care plan. Participants in the two groups were comparable in terms of demographic characteristics after being assigned. Students were included in the study if they had passed a theory course in nursing for hematology and oncology diseases during the Adult and Elderly Nursing-3 course unit. Inability to complete classes and absence from classrooms for at least one day served as exclusion criteria.
Data collection tools
Data collection tools included a sociodemographic form, a clinical decision support scale, and a cognitive learning test that students completed before and after training. Age, sex, marital status, nursing experience and GPA were among the sociodemographic variables obtained.
The Clinical Decision Making in Nursing Scale (CDMNS) was developed by Jenkins (1985). It assesses nurses’ clinical decision-making skills and has four subscales: (1) Seeking alternatives or options (2) Prospecting goals and values (3) Assessing and reassessing consequences (4) Finding information and impartial assimilation of new information. It comprises 40 items to which participants’ responses (based on their understanding of the clinical decision-making situation) are scored on a Likert scale as follows: 5 – always; 4 – most of the time; 3 – occasionally; 2 – rarely; 1 – never; 0. The range of scores is between 40 and 200, with higher scores indicating higher clinical decision-making abilities. This tool was found to have favorable internal consistency with a Cronbach’s alpha of 0.83 . Lotfi et al. previously confirmed the scientific validity of this scale in a study to determine the effect of integrated simulation training and critical thinking strategies on the clinical decision-making ability of nurses . The validity and reliability of the CDMNS was also confirmed in this present study after translation by three bilingual nursing specialists using the Forward method and following tests on a group of ten nursing students not enrolled in this present study, using the face validity method and the scale was found to have a Cronbach’s alpha value of 0.89, indicating good internal consistency.
The cognitive learning test, which was a teacher-designed test, was developed for the study. The teacher test is an important tool used by teachers to assess the teaching method of the class for which they are prepared. . The test for this study consisted of 25 multiple-choice questions designed to determine the extent to which course objectives were met. Each question has a stem with four answer options (distractors) from which the respondent must select the correct/best option. Based on the lesson plan, course content and objectives, the test was designed to assess high levels of cognitive learning. Each correct option received a score of one and the range of possible scores was between 0 and 25. A Table of Requirements (TOS) approach was used to ensure the content was relevant and inclusive. A TOS is defined as a test plan that helps teachers align objectives, instruction, activity and assessment [18, 19]. The reliability coefficient using the Kuder-Richardson-21 formula was calculated at 0.92.
Analysis of statistical data
After data collection and coding, analysis was performed using SPSS Statistics 16.0 (2008). An independent t-test and a paired t-test were used to compare the mean scores of the intervention and control groups on the cognitive learning test and the CDMNS before and after the integrated teaching-learning method. Comparison of baseline parameters was performed with independent t-test and analysis of variance. Since the intervention and control groups had significant differences in GPA before the intervention, and the intervention group had a significantly higher GPA, an analysis of covariance (ANCOVA) was used.
The intervention protocol
The first author of the article, who was also the instructor of the internship course, explained the integrated teaching-learning method to the students of the intervention group and guided the students during the course. The intervention groups were divided into 9 groups. Each internship course lasted two weeks (three morning shifts per week) and was attended by six to seven students in each group. On the first day of the internship, common hematology and oncology diseases were selected as cases for example: acute myeloid and lymphoid leukemia, Hodgkin’s and non-Hodgkin’s lymphoma, multiple myeloma, aplastic anemia and others bleeding disorders. Since each student was introduced to one disease case in hematology and oncology, the entire group was exposed to 6-7 different cases in hematology and oncology.
In addition to routine nursing care, the students began their case study on the second day of the internship. The students needed basic knowledge and previous experience to carry out the case study and set up the scenario. The students had completed 5 blood and cancer theory credits during the semester, and on the first day of the internship, they were told to study their cases and be prepared to assess patients. Data on each case was collected by the students using a health survey form designed by the first author and based on reputable oncology nursing books. During the second day of the internship, the students carried out two essential tasks: the creation of a case study in the form of a scenario and the realization of the first stage of the nursing process (evaluation and development of a database of information). It took 2 hours to assess, recognize and set up the scenario. This was a crucial step that needed to be completed correctly. To this end, the instructor guided the students through the case study and ensured that the students gained valuable insights from the patient.
The material written in the script was considered a learning tool, and some additional essential information was needed, which the students had to acquire in order to know more about the case. To this end, after the student created the scenario, the instructor reviewed it and created appropriate patient questions that were tailored to the student’s learning needs. For example, if a bone marrow biopsy was performed on a patient, the instructor would inquire about nursing care before and after the biopsy, or if the patient’s treatment regimen included Taxoter and Cisplatin, the instructor would inquire about the diet, as well as its medications and side effects. The content of the case study questions came from the patients themselves, and the case was taken as an index of student learning. After designing useful questions, the instructor would guide the students, so that they can get answers to questions and complete information about the case. The learning was exploratory in nature.
On the third day of the course, students were expected to summarize their patient’s situation and, with guidance from the instructor, describe the illness, present assessment results, develop nursing diagnoses and a holistic care plan. The cases were then presented to the rest of the clinical group. So that during the second week of the internship, two of the case studies were presented for about 15 to 20 minutes by the students. Selected questions about the case were asked for 30 minutes, and other students in the group expressed their opinions. The nursing diagnoses and the care plan were then discussed as a group, and the teacher finally provided the comments necessary to achieve the learning objectives and the care plan. So, in the second three days, all the students in the group were given good information about 6-7 different cases and familiarized with those cases that they would most likely face in their future careers as nurses and provide nursing care quality and safe.
It should be noted that during the six days of the course, cognitive skills were taught alongside clinical skills. In addition to clinical care, students improved their cognitive abilities. The trainer tried, as much as possible, to have the students take care of the patients and observe, step by step, the progress and recovery of the patient, as well as the state of the treatment, so that a meaningful, deep and lasting learning has been created. A summary of the intervention protocol for the intervention group is provided in Supplementary File 1.