Applied epistemology for community nurses: evaluating the impact of the Patchwork Text

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APPLIED Epistemology for community nurses:

evaluating the impact of the Patchwork Text
Lesley Smith and Richard Winter

In this article we describe how and why a version of the Patchwork Text assessment format was developed for a module called ‘Perspectives on Research in Professional Practice’. This was a module where the teaching and assessment processes were working well but, it was, felt, a more reflective, synthetic, cumulative and open-ended assessment would lead to better learning. We then present comparative material to show how the new format was evaluated by students and how the new format affected the intellectual performance of students. We conclude with a discussion of how far introducing the Patchwork Text met our aims in doing so and what we as tutors learned from the experience.


The module is one of three compulsory theoretical modules taught at the beginning of a post qualifying degree programme for community specialist nurses. Students thus include health visitors, district nurses, community psychiatric nurses, school nurses, general practice nurses and community learning disabilities nurses. The programme seeks to provide already experienced nurses with the specialist skills required when working within the community.

The main aim of the module is to provide students with a theoretical understanding of the different types of knowledge that might inform their practice. The specific learning outcomes which students are required to meet and evidence in their assignment are officially listed as follows:

  1. Develop a critical understanding of the nature of clinical theories and models and their status in contributing to current debates concerning professional knowledge.

  2. Develop a critical approach to the knowledge base of health professionals and its related disciplines through the examination of theoretical problems underlying the nature and structure of knowledge.

  3. Critically analyse the role of the practitioner, researcher and service user in the development of professional knowledge.

  4. Critically examine the differing theoretical underpinnings of qualitative and quantitative research.

The module is based on ten weekly three-hour sessions focusing on topics such as: different conceptions of knowledge and research, comparing qualitative and quantitative methodologies, integrating research in the development of professional practice, action research, research validity and research ethics.

In previous years, before the introduction of the Patchwork Text, students had been required to write a 4,000 word essay submitted on the last day of the module. The guidance notes for the assignment had been as follows:

“This assignment will involve writing about your understanding of the concepts presented during the module and reflected upon in your diary. You should select between two and four of the concepts and refine and develop your material for the assignment. Your chosen topics must evidence that you are familiar with quantitative and qualitative methodologies. You may wish to use headings to discuss the different topics, which you will need to illustrate by reference to one or more work scenarios. Alternatively, you may wish to integrate the material into a general discussion about how the different concepts have informed your practice, but this is by no means intended as a requirement.”

The next section describes how the tutor's sense of dissatisfaction with this assignment led to the development of a Patchwork Text format.

Lesley, who has taught the ‘Perspectives on Research’ module since 1997, had become concerned that her teaching strategies were becoming increasingly didactic. She was committed to a collaborative and constructionist approach to learning (Askew and Carnell 1998; Kasl et al 1993), but as a response to both her own and students’ anxieties about the assignment, she found herself giving more formal lectures. This meant students had less time to explore and debate their own experiences within inter- professional learning groups. Also, although students were urged to keep a reflective diary, few students wrote weekly entries, despite good intentions, perhaps because this did not form part of the summative assessment. Both these factors led her to believe that she was beginning to ‘coach’ rather than facilitate a process of autonomous learning.
These concerns were reflected in students’ written work, where she had a sense that most scripts were similar in content and style of writing, and that the independence of thought, creativity and reflexivity so central to their professional development was not being harnessed. In short, the assignments seemed to reflect what Marton et al (1984) refer to as ‘surface’ rather than a ‘deep’ approach to learning tasks. With these concerns in mind, Lesley decided to work on developing a patchwork text assignment the following year, teaching the module with Richard, with two parallel groups of students.

Evaluation Prior to Introducing the Patchwork Text
We began our curriculum development work by analysing the University’s routine module evaluation forms for the last cohort of 50 pre-patchwork students. 43 students (86%) completed this form and all these students either agreed or very strongly agreed that the learning outcomes and teaching and learning strategies for the module were appropriate. Other community specialist tutors also viewed the module as successful and integral to the degree programme. We therefore decided to leave unchanged the learning outcomes and were indeed heartened by the strength of the positive evaluations, as the data suggested that Lesley’s original anxieties were not reflected in students' or colleagues’ evaluations. This was helpful to our research, because if the module was already in some sense 'working well', there would be less danger that the specific introduction of a new assessment format might be positively evaluated merely as part of a general 'halo' effect, and thereby distort our findings and conclusions.
As the University’s evaluation form gave us little information about how students prepared for writing a 4,000 word essay or indeed how they experienced the assessment process, they were also asked to complete the following questionnaire immediately after handing in their assignment:-

  1. Please outline your thoughts and feelings (positive, negative and ‘general’) about the assignment for this module.

  2. How did you set about preparing yourself to write the assignment?

  3. How far do you feel that writing this assignment has helped you to bring together the various ideas presented in the module?

  4. How far has writing this assignment helped you to develop your own personal response to the module topics?

  5. Any other comments on the assignment process (e.g. Was the timing right? Was it appropriate; Was it too easy / too difficult; too open-ended/ too constraining?).

In addition to the questionnaire two focus groups were held where students were also asked about their experiences of the pre-patchwork text assignment.

43 students (86%) completed this questionnaire and these together with the transcripts of the focus groups were analysed in terms of positive and critical attitudes about the assignment (i. e. the final essay). We were also interested in the way students had set about writing the essay and whether the experience was a collaborative and insightful one. On the whole, as we now expected, most students expressed positive attitudes towards the assignment, saying that although the module was difficult the assignment was nevertheless interesting, enjoyable and challenging, and 32 students (64%) felt that writing the essay had led to a deeper understanding of the module content:
However alongside these positive comments, students were also articulating more critical experiences, and their concerns provided useful insights into the limitations of the existing assessment format and helped us in clarifying what it was we were trying to achieve by introducing the Patchwork text. For example, some students complained about lack of time to complete the assignment, about an initial sense of being overwhelmed and daunted by the prospect of the assignment, and about feeling constrained to leave out some of the topics (especially those presented later) in their work, so that there were aspects of the course and learning outcomes which they still felt they didn't understand as well as they ought:-
It is a shame that the way the course is designed meant that the assignment has to be written before the taught element is complete. I was tempted to use ‘action research’ but felt that as this was not covered until the end I would be disadvantaged time wise by doing so.’
I was unable to bring in all the ideas and reflective thoughts following lectures and unable to be creative and bring in the various ideas that I would liked to have followed through.’
There wasn’t time to consolidate the knowledge gained in the weekly sessions…. I would liked to have been writing my assignment in line with the taught sessions but this wasn’t possible.’
Writing a 4,000 word essay is an enormous pressure- the pressure and the expectation (perceived) is that there must be a correct way to answer the assignment question. This reduces options for self learning and development of own ideas.’
Students' responses to the question concerning how they set about preparing themselves for the assignment suggested that the process was a rather individual and instrumental one, involving reading relevant articles and handouts but little in the way of what Barnett (1998, p77) refers to as ‘critical self reflection’. Only 5 students (12%) mentioned exchanging ideas with their peers or work colleagues and there was a sense in which the linking of theory to practice was an academic exercise rather than an illuminating process in which new meanings and understandings were being developed:-
I found the most difficult part was relating theory to practice. I spent most of my time trying to understand the concepts and then tried to fit my practice scenarios into the concepts. More time was needed to discuss our different practice experiences.’
The focus group discussions illustrated perhaps even more clearly how for some students writing the assignment had become a kind of ‘academic game’, where independence of thought was being sacrificed to the perceived need (often fostered by tutors) that the most important thing was assembling a plethora of references: -
I felt like I’ve got to stop this sentence, because I’ve got to find a reference ….you interrupt your train of thought, and you can’t say it all because you haven’t got the theory that you need to put in there.’

Aims for the Patchwork Text Project
The conclusion of our analysis of the above material seemed to confirm our original suspicion that the essay assignment format had a number of drawbacks. It seemed that students’ anxieties about the subject matter meant that trying to represent the views of different writers (including those of the lecturers!) left little scope for reflexivity. Additionally, students often responded to the constraints of having to present a time-consuming essay at the end of the module by beginning the essay before the module had finished and by adopting a rather selective and instrumental approach to the module content. Arising from these interpretations of students’ experiences, then, we formulated the following statement of what we hoped to achieve by introducing the Patchwork Text: -
We want to encourage a form of writing which :-

1) Is more 'reflective', i.e., which presents a more personal interpretation of students', understanding of the topics, of their own development, of their own learning process.

2) Places more emphasis on creating a 'synthesis' of their learning.

3) Places more emphasis on the relationship between the concepts, rather than exploring each one separately.

4) Includes all the topics presented in the course and addresses all of the learning outcomes.

5) Presents ideas more tentatively, with a greater sense of questioning and exploring issues.

6) Displays more individual variety of approach and theme.

7) Starts out from students' own experience and uses theory to question and explore their experience, rather than simply using theories to categorise their experience.

8) Draws on a variety of writing styles.
We also hope that the patchwork text process will enable us to identify and support 'invisible weak' students, i.e. those who respond to uncertainty by adopting a low profile, so that their lack of understanding only emerges at a late stage in the course.

THE PATCHWORK TEXT: activities, Learning Outcomes and Guidance Notes for Students

As described in the previous section, our aims in introducing the patchwork text were to address the shortfalls of the essay as identified by student evaluations. We were also concerned that the teaching and learning process should provide students with the opportunity to discuss their pieces of writing in small learning groups (see Winter et. al., 1999, Chapter 3). The Patchwork Text format had originally been developed for a 'Reflective Writing' module in which students know in advance that they are signing up for a relatively ‘open’ experience and will be expected to share their writing. However, this is not the case for the ‘Perspectives on Research’ students, whose expectations concerning the assessment process and methods of learning we predicted as being fairly conventional. We therefore reproduce below the notes we gave students to prepare them for this quite different assessment. Also included in the notes is the list of activities for the Patchwork Text, cross-referenced with the list of learning outcomes (see page 1, above) that the patches were seeking to assess.

Guidance Notes for Students
Your assignment will be assembled gradually during the progress of the module through a series of written tasks, which you will share with each other in small groups. There are several reasons for this:-

  • to avoid the last minute rush of having to write the whole assignment at the end of the teaching, when time is short;

  • to enable you to use a variety of different ways of writing, and thus to increase your opportunity to demonstrate your own particular abilities;

  • to enable you to give each other early constructive feedback as to how clearly you have presented your ideas and how they might perhaps be developed;

  • to enable you to write about all aspects of the module content (instead of having to select just a few aspects for a specific essay topic).

Before you submit your assignment, you will be asked to write a final piece, to be added to what you have written already. This is designed to give you the opportunity to revisit (edit and revise) the ideas you have presented in your earlier pieces and to discuss what you have gained from the work as a whole. (This is the only task that will need to be completed after the end of the teaching.)

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