With advances in genetics and genomics transforming health care, it is important to address the American Nurses Association's (2012)Essential Genetic and Genomic Competencies in advanced practice nursing (APN) curricula. However, many nursing students have little or no exposure to this material, challenging educators to incorporate the fundamentals of genetics in doctoral level courses. Because most advanced practice nurses work collaboratively with other professionals in the clinical setting to provide comprehensive care that includes genomic-based treatment, nurse educators must also strive to develop effective ways to teach communication skills and encourage teamwork among doctoral APN students, especially in blended or online formats.

BACKGROUND

Collaborative learning strategies have been used in higher education for a number of years (Martin, Friesen, & DePau, 2014). Collaborative learning is supported by the social interdependence theory, where outcomes for students are impacted by their own or other students' actions (Johnson & Johnson, 2009). Students strive for individual goal attainment, after which they can collaborate with a group.

One form of collaborative learning, consensus testing (CT), is also known as group test-taking, cooperative testing, collaborative testing, double testing, and dyad testing (Centrella-Nigro, 2012; Green, Worthey, & Kerven, 2018). With CT, students work together in small groups, learning or refining the art of collaboration and teamwork when solving problems. Exposure to CT helps improve communication techniques in nursing professionals (Burgess & Medina-Smuck, 2018; Sandahl, 2009, 2010; Wiggs, 2011). It has also been shown to have a positive effect on confidence in collaborating with others (Green et al., 2018; Martin et al., 2014; Meseke, Nafziger, & Meseke, 2010; Sandahl, 2009). These outcomes are in keeping with the Institute of Medicine's (2011) call to improve quality and safety in health care through increased collaboration among health care providers. Collaborative learning, specifically CT, is an effective assessment strategy for enhancing learning in the blended or online classroom (Bjornsdottir, Garfield, & Everson, 2015).

Doctor of nursing practice (DNP) programs use the American Association of Colleges of Nursing's (2006)Essentials as a guideline for curricular development. DNP Essential IV, "Interprofessional Collaboration for Improving Patient and Population Health Outcomes," can be addressed through the use of CT. However, after an extensive search, no published research articles were found related to CT use in doctoral level nursing education. The aim of this study was to use CT as a teaching/evaluation strategy to increase doctoral students' understanding of genomic content and provide practical experience with teamwork and collaboration in a blended course. Three research questions were addressed: 1) Does CT increase students' perceptions of understanding genomic content? 2) Does CT increase students' experiences with collaboration and team communication? 3) What were students' personal experiences with CT?

METHOD

A descriptive survey design was used to evaluate CT as an innovative assessment strategy in a blended course, "Genetics, Ethics and Innovations in Advanced Nursing Practice." Institutional review board approval was obtained from the university. Prior to testing, students spent three weeks in online and face-to-face classes learning genomic concepts and teamwork essentials important to APN practice. Concepts included pedigree development and analysis, patterns of inheritance, pharmacogenetics, genetic testing, teamwork, and counseling.

Mastery of content was assessed using a 25-question multiple-choice and short-answer examination. Students completed the written exam individually and were then assigned to groups of three to four to work through the same examination collaboratively. Consensus was required for each question, and each group turned in one examination. Students had up to eight points added to their individual test score if the group score was higher than their individual score. The course had postmaster's DNP students as well as students in a BS to DNP program; groups were structured to include students from both programs.

Following the collaborative testing, students were asked to evaluate their experience using a researcher-developed 12-item Likert evaluation tool (1 = strongly disagree, 5 = strongly agree). To gain insight into how students experienced CT, two open-ended questions asked about the positive and negative aspects of participation. Evaluations were analyzed using descriptive statistics for demographics and Likert questions and content analysis for open-response questions.

QUANTITATIVE FINDINGS

Thirty-eight students from three cohorts participated in the study. Most were BS to DNP students (74 percent) with no previous experience with CT (89 percent). Participants reported little previous exposure to genetics and genomic content (mean score = 1.51, with 1 = no previous exposure/5 = extensive previous exposure).

To answer the first question on perceptions of understanding genomic content, responses to four items were analyzed. Mean scores ranged from 4.43 to 4.72, supporting CT as an effective strategy for increasing students' perceptions of understanding genomic content. To answer the second question, on whether CT increases experiences with collaboration and team communication, responses to five items were analyzed. Mean scores ranged from 4.02 to 4.60, supporting increased student experiences with collaboration and communication.

Three questions provided insight into students' personal experiences with CT. Asked if CT "helped me get to know my classmates better" and "decreased my test-related anxiety," mean scores were positive, 4.01 (SD = 0.3) and 4.73 (SD = 0.41), respectively. Participants responded positively to the question about whether they enjoyed participating in CT, with a mean score of 4.81 (SD = 0.26).

QUALITATIVE FINDINGS

Students reported increased confidence in their understanding of the material after CT, and their comments on the open-response questions were supportive, for example, "I realized I actually knew the answer and could explain it to my peers, it made reviewing and learning the material more enjoyable." Students commented that CT allowed them to talk through the problem or case study and helped them see "why the answer was the answer." Others commented that working with their peers gave them the opportunity to see the whole picture from different perspectives: "I could see the situation more holistically after discussing it with my group."

Students identified teamwork as the main facilitator of learning: "[CT] allowed brainstorming together and building on what I already knew" and "it helped to confer with my peers and work through the problems together." Another response highlighted the redirection of learning that CT can offer: "By comparing my answers and rationales with the groups, it helped guide me to the material that I needed to go back and revisit."

CT was also effective at providing students with practical experience with teamwork and collaboration. By completing case studies online in discussion boards, developing written responses to others' posts, and then solving problems face-to-face during CT, students gained practical experience with collaboration, communication, and leadership and negotiation skills. Comments included: "The activity made me think by listening to the other people's point of view" and "The positive feedback from peers was worth as much as the points."

Most students (68.5 percent) felt CT reduced test-related anxiety; however, responses indicated that some students felt anxious when their answers differed from those of their peers, fearing "that my peers would think I didn't know what I was doing." Teamwork and collaboration were challenging, with students noting, "It was sometimes difficult to get everyone to participate." Negotiating was also difficult: "When all the answers were different than yours, it was hard to get your point across."

DISCUSSION AND CONCLUSION

These qualitative findings highlight the importance of establishing a positive learning environment that is safe for solving problems and taking chances before implementing CT. Although CT was effective for providing experiences with conflict resolution and difficult conversations, strategies to achieve consensus should be taught in advance of this activity to ensure best outcomes and enhance team communication. The social interdependence theory proposes positive interdependence, group interaction, individual accountability, interpersonal skills, and group processing skills as necessary characteristics for CT to be an effective learning strategy (Johnson & Johnson, 2009). The study findings support this theory and suggest that collaborative learning was most effective when these individual and group characteristics were present and reinforced. Future nursing studies may explore how to enhance these characteristics to increase learning with CT.

While collaborative learning has been used with undergraduate and some master's level students for decades, using CT with doctoral level students has not been documented in the literature. The findings of this study indicate that teaching genomic content to APN students in a blended format supports collaborative learning strategies as an effective approach for improving learning outcomes in this student population. Nurse educators are encouraged to broaden the use of CT with doctoral students to additional content areas.

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