Examining test performance, a common practice in nursing education, is often done in class with faculty providing the correct responses. This practice may lead to grade groveling or fighting for points, setting up an adversarial power differential between students and faculty. Furthermore, providing students the answers does not cultivate a climate for metacognition. On the other hand, using exams as learning tools, not merely assessment tools, and allowing students to reflect on their performance and effort develop the skill for lifelong learning and metacognition. This metacognitive assessment process skill is referred to as calibration, the ability to discern what one knows along with one's knowledge deficiencies.
Many beginning students overestimate their knowledge, resulting in poor test results (Sanchez & Dunning, 2018). Moreover, fixed mindset learners -those who do believe they can learn new things but are not able to modulate their cognitive ability - often overestimate their knowledge (Ehrlinger, Mitchum, & Dweck, 2016). This article describes a metacognitive exam review exercise known as cognitive wrappers or exam wrappers, which can be effective with nursing students.
LITERATURE REVIEW
A review of the literature (CINAHL, PubMED, and ERIC) for the period 2013 to 2018 with keywords nursing and exam wrappers yielded two articles. Cross-referencing those articles led to four additional articles. It is important to note that cognitive or exam wrappers have been in practice in other disciplines since they were first developed for a nutrition course (Achacoso, 2004). Nursing has been slow in accepting these exam review techniques.
Two nonnursing articles detail the benefits of exam wrappers in the classroom (Gezer-Templeton, Mayhew, Korte, & Schmidt, 2017; Soicher, & Gurung, 2017). Gezer-Templeton et al. discussed how the use of exam wrappers in a nutrition course highlighted students' overestimation of their content knowledge prior to the exam. Over half the class (56 percent in the first wrapper and 72 percent by the second exam) completed the exercise because they saw how beneficial it was to their grades and test scores. Nearly three quarters of the class (72 percent) either strongly agreed or agreed that wrappers helped them improve their study habits; only 2 percent of the students disagreed. Many students independently applied wrappers in other courses as well. Soicher and Gurung (2017) examined the use of exam wrappers by first-year psychology students. They did not find an increase in grades, but they did report increases in metacognitive abilities in their students. Citing former studies, the researchers hypothesized that, for cognitive wrappers to boost grades, they must be conducted regularly across courses and semesters.
Butzlaff, Gaylle, and O'Leary-Kelley (2018) reported grade increases (80 percent to 91 percent) in 120 undergraduate medical-surgical nursing students. Students utilizing the exam wrappers became aware of the difference between memorization and understanding, and that understanding leads to deeper learning and better grades. The researchers found that students began to attend exam reviews and study in groups rather than alone, a preferred learning strategy (Brown, Roediger, & McDaniel, 2014). Poorman and Mastorovich (2016) detail a review of the use of exam wrappers as well as lecture and homework wrappers.
THE STRUCTURE OF COGNITIVE WRAPPERS
The cognitive wrapper is, for the most part, meant to be done by students independently. At first, nurse faculty may need to assist students to develop their own wrappers and regularly complete the process, fostering automaticity and eventual agency in the process. A cognitive wrapper consists of three distinct segments or mental processes. Students complete the first segment before seeing their exam grade, the calibration phase. The next segment begins in exam review, examinining testing errors. Lastly, students develop a success plan for the next exam (see Supplemental Digital Content at http://links.lww.com/NEP/A154 for a sample exam wrapper).
The first segment begins the process of calibration, with students predicting their exam score. Students must then assess their effort, usually in a Likert-type or visual analog scale indicating low effort, moderate effort, or high effort, with low effort being the lower score. To calibrate closely, students must begin to see the relationship between their actual grade correlated with effort or performance. Typically, high scholastic achievers can more accurately calibrate their grades with performance or effort than lower scholastic students (Ehrlinger et al., 2016). Faculty should then list the various learning strategies they feel are most effective for learning course content, such as read the assigned reading, attend class, participate in class, routinely set aside time for study versus cramming, and engage in a study group. Students then decide which of the strategies they used (or not) and weigh these with percentages to add up to 100 percent.
The second segment begins at exam review, as it assesses test-taking skills. Many students do one of the following actions that contribute to low exam scores: 1) I changed my answer; 2) I added a "what if scenario" to the test question; 3) I misread the question; 4) I misunderstood the question; 5) I did not know the content. This explicit checklist makes it quite clear to students where they need to improve their test-taking skills while learning to trust the content they feel they do know.
During the third and final segment, students, having reviewed the example, need to make a plan for the next exam. Ehrlinger et al. (2016) highlight how students who believe their cognitive ability is nonmalleable (fixed mindsets) are often overconfident and overestimate their knowledge. Fixed mindsets, in particular, do not like to review information they answered incorrectly. They prefer to avoid difficult feedback which may show signs their learning is limited. Students with fixed mindsets often just move on to the next exam, failing to make a plan or remediate (Williams, 2018). On the other hand, students who believe their cognitive ability is malleable through effort and persistence (growth mindsets) do remediate and do so by developing learning goals (Williams, 2018). Gezer-Templeton et al. (2017) found that students utilizing exam wrappers began to establish and carry out effective learning goals for study.
To make a plan for the next exam, students must develop a list of three things they could do better (goals) and list anything nursing faculty could do to assist on the next exam. At this point, students should be encouraged to meet with course faculty and develop mutual goals for success. Often students need extrinsic motivation to begin a new strategy. Gezer-Templeton et al. (2017) assigned free points to complete the wrappers. However, over time, as students used them more often and saw their grades improve, the free points were less of a motivator.
The final segment provides an opportunity for mutual review. Students have an opportunity to evaluate the process of teaching by stating ways they think their learning could be enhanced. Nurse faculty may be oblivious to ineffective student learning and seemingly nonhelpful teaching strategies. Exam wrappers have documentated grades increasing from 80 percent to 90 percent (Butzlaff et al., 2018) and the need to use them in more than one course (Soicher & Gurung, 2017). Perhaps then it is time for nursing education to adopt exam wrappers as a best practice within departments and across nursing curricula.
CONCLUSION
The "illusion of knowing," or overconfidence with inaccurate calibration, is fostered by students relying upon old, conventional, and ineffective learning strategies, such as memorization over understanding, and reading and rereading textbooks with abundant highlighting (Brown et al., 2014). Students who do poorly on an exam often bring faculty their color-coded books to demonstrate their hours of learning. Brown et al. (2014) found that many students have not been taught how to learn. This author has confirmed that in three prior studies.
Exam wrappers are an excellent tool for nurse faculty to objectively view students' performance, effort, and study habits. The process encourages effective remediation in all students (fixed and growth mindsets) and teaches enduring lifelong skills in metacognition necessary beyond the classroom. Research on the adoption of exam wrappers as an effective learning strategy is needed in nursing education.
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