Implementation of Active Learning Methods in Nursing Undergraduate Study Programs – A Group Interview

Background: Modern and active learning methods form an important part in the education of Nursing students. They encourage the development of communication and critical thinking skills, and ensure the safe health care of patients. Our aim was to obtain naturalistic data from nurse educators regarding the use and effects of implementing active learning methods (Peyton's Four-Step Approach, Mind Mapping, Debrie�ng and Objective Structured Clinical Examination methods) in the study process of students of Nursing after a completed education module, Clinical skills of mentors, as part of the Strengthening Nursing in Bosnia and Herzegovina Project. Methods: Qualitative research was conducted and a group interview technique was used for data collection. Beforehand, research participants were included in a two-day education module, Clinical skills of mentors, as part of the Strengthening Nursing in Bosnia and Herzegovina Project. 14 nurse educators participated. Group interviews were conducted in September 2019. Content analysis of the discussion transcriptions was conducted. Results: The obtained categories form four topics: 1) positive effect on the development of students' communication skills 2) positive effect of learning methods on the development of students' critical thinking skills 3) ensuring a safe learning environment 4) implementation of active learning methods. Conclusions: The use of various active learning methods in simulation settings improves the Nursing students’ critical thinking and communication skills. Therefore, we believe that Peyton’s Four-Step Approach, Mind Mapping and Debrie�ng methods should be included as tools for effective student learning and as preparation for directly performing safe nursing interventions with a patient. Effective approaches to the assessment of Nursing students may ensure quality patient health care in accordance with the vision of the nursing profession.


Introduction
Education of nurses in Bosnia and Herzegovina (BiH) has been undergoing rapid development.In BiH, the emphasis of the health care system and the education of health professionals is mainly on curative care and medical services.This might limit the potential of the nursing staff to react to the population's present and future health needs.To avoid the negative consequences of reduced competencies and practice, nurses developed a project that would strengthen nursing in BiH [1].
Several nursing-related challenges that currently have a negative effect on the nursing profession and which, therefore, hinder health outcomes in BiH, were identi ed in collaboration with major stakeholders in BiH, including faculties of nursing and other important organizations [2].As stated by Francis and O'Brien [3], teaching clinical skills is an important part in educating students of Nursing in an increasingly more complex health care and social environment.As a method of teaching, skills-lab training is viewed as a key component of curricula in the majority of our faculties that offer health-related study programs as it enables a protected training environment where students are permitted to make mistakes and where they can practice their skills on mannequins before working on real patients [4].
In BiH, mentorship at faculties of Nursing is conducted by graduate nurses who are teaching assistants or senior teaching assistants rather than mentors, and are employed full-time or are outsourced.In BiH, there are no additional training options that would equip nurses to work as mentors, either full time or part time, so they only need to meet the general and speci c criteria for an associate/teacher position [5].
That is why in 2017, the Strengthening Nursing in Bosnia and Herzegovina Project developed a training program for BiH clinical skills mentors that comprised seven modules (34 hours in total) and was focused on different aspects of adult education, and teaching tools and methods.In BiH, the faculties offering Nursing courses have been faced with challenges regarding the organization of additional training for clinical skills mentors.In order for mentors to be prepared for this role as best as they can, they use professional literature, the internet and engage in team meetings [6].

Background
In order to improve nursing education, various teaching methods have been introduced to assist students in gaining knowledge, skills and attitudes that are relevant for nursing practice.The use of simulationbased learning contributes to the development of students' sense of safety when they perform various tasks [7].The skill laboratory functions as a transitional setting between a classroom and clinical venues [8].
The implementation of active learning methods into the study process might result in students' improved motivation for learning, encourage their critical thinking skills and independent learning [9].Rather than continuing with employing traditional teacher-centered educational approaches, faculties should introduce an active student-centered learning environment since creating learning experiences that encourage re ection, knowledge building, problem-solving, inquiry, and critical thinking are highly signi cant [10].
Peyton's Four-Step Approach is a learning method that comprises four steps and is highly effective in the learning process of nursing interventions.The rst step is demonstration, in which the teacher demonstrates the intervention at their normal pace without giving any additional verbal explanations.The second step is deconstruction, in which the teacher performs the intervention by giving detailed descriptions of all the phases of the intervention.In the third step referred to as comprehension, the teacher performs the intervention according to the student's instructions of each step of the intervention.In the nal, fourth step called intervention, students perform the intervention by themselves without the help of the teacher [11].In the research on the effectiveness of the method, the authors found that the Peyton's Four-Step Approach method enables students' active involvement in the process of learning about nursing intervention [12].The process of self-explanation, which Peyton's Four-Step Approach contains when a student is thinking aloud, enables an improved learning process and the development of critical thinking skills [13].
The Mind Mapping method is an excellent pedagogical tool used to help students achieve positive learning outcomes [14] that may be successfully implemented in the education process as it ensures a creative environment and is an effective tool for teachers, mentors, students and researchers [15].The Mind Mapping method encourages students to obtain relevant information and develops critical thinking skills, which in turn, has positive effects on the provision of safe health care for patients [16].There are several reasons why using the Mind Mapping method in learning and teaching is recommended.Firstly, there is no long text.Also, it enables learning through synthesizing, as well as clari cation and better reorganization of ideas.Furthermore, it assists with revision, encourages visualization of the content that had been learnt before, enables cooperation via studying in groups, which has positive consequences for everybody involved, and nally, mind maps that are submitted to the group result in a better experience because more participants are involved, which produces more ideas and stimulates the use of critical thinking skills [17][18][19].
A guided discussion is also quite signi cant in teaching Nursing students as it enables very authentic simulations of reality since a mentor asks students to critically evaluate their knowledge and skills that they had demonstrated while performing the scenario.Despite much research conducted on educating with simulation, the guided discussion has not yet been su ciently de ned [20].The use of scenarios with debrie ng constitutes a strategy facilitating the teaching-learning process in the undergraduate nursing course [21].
The assessment of clinical skills is also highly signi cant in nursing education.Therefore, the Objective Structured Clinical Examination (OSCE) may be considered to be a sound assessment tool whose objective is the assessment of nursing students' clinical competences in a safe and controlled environment, which enables simple assessment of the knowledge and performance of clinical skills that are important in nursing practice.Also, the assessment tool may serve to better prepare students for their profession [22,7].
A higher education teacher is one of the key factors for a nursing student to be successful in their studies [23], so teachers should be familiar with effective teaching methods [24].A teacher's primary task is to ensure a creative environment and a learning path that engages a student [25].A suitable learning method may encourage nursing students to learn, improve students' communication, and motivate and inform them about effective learning [26].

Aim of the study
After conducting the educational module Clinical skills of mentors as part of the Strengthening Nursing in Bosnia and Herzegovina Project, our aim was to obtain naturalistic data from nurse educators regarding the use and effects of introducing active learning methods (Peyton's Four-Step Approach, Mind Mapping, Debrie ng and Objective Structured Clinical Examination methods) in the study process of Nursing students.

Design
The qualitative method of a formal group interview was used [27].The group interview was conducted in pre-existing "natural" groups of nursing educators in a region of Bosnia and Herzegovina.Invited participants attended a two-day education module: Clinical skills of mentors as part of the Strengthening Nursing in Bosnia and Herzegovina Project that was hosted by two higher education senior lecturers of Nursing from Slovenia, where higher education and clinical mentorship in Nursing is developed in accordance with international [28, 29] and national guidelines for Nursing education [30].
A group interview allows group members to in uence each other with their comments and experience, and to form an opinion regarding the issue currently discussed after re ecting on it as a group [31], which results in obtaining more information than with face-to-face interviews [32].

Setting and participants
The environment in which the research was conducted impacted the format of the group [27] that was invited to participate for research purposes.14 nurse educators that are employed at the faculty (n = 6) and/or in a clinical setting (n = 8) participated in a group interview.12 women and two men participated, the average age of the participants was 35.7 years (SD = 0.7), the average length of service was 15.1 years (SD = 11.1).One participant had completed doctoral studies, nine held master's degrees in Nursing and four held bachelor degree in Nursing.

Instrument
One-group pretest-posttest nonexperimental design Semi-structured guiding questions that were being updated throughout the discussion were used in the group interview.The semi-structured interview contained eight basic questions: What is your opinion regarding the signi cance of the quali cations of nurse educators to work with Nursing students?What skills should nurse educators have in order to teach students of Nursing effectively?How useful do you think the Peyton's Four-Step Approach method is for teaching Nursing students?
What is your opinion on the usefulness of the OSCE stations as a method of assessing Nursing students?
How do you assess the usefulness of the Mind Mapping method in the learning process?What is your attitude towards using and implementing the Debrie ng method in the process?Which presented method do you think is most suitable for teaching the students of Nursing?
What is your attitude towards the impact of the presented learning methods and assessment on the development of critical thinking skills of Nursing students?
The reliability of the research was ensured by considering the homogeneity of the group, an appropriate number of participants in the interview, by giving instructions before the start of the interview emphasizing that everyone has the possibility to participate in the discussion and by encouraging them with questions when guiding the group interview [33].

Data collection
The group interview took place in September 2019 and was guided by a moderator and a semi-structured questionnaire.There was also an administrator who recorded the discussions.The research participants attended a two-day education module, Clinical skills of mentors, as part of the Strengthening Nursing in Bosnia and Herzegovina Project.The purpose of the module was to inform and educate nurse educators about active learning methods and assessment of students of Nursing: Mind Mapping, Debrie ng, Peyton's Four-Step Approach methodology and the OSCE stations.We presented the purpose of the research and topics before conducting the group interview.The average time of the group interview was 90 minutes.Discussions were recorded upon obtaining a written permission by the participants.To ensure anonymity we added randomly selected letters to the interviewers.

Data analysis
For qualitative data, the method of thematic content analysis was employed.All recordings were transcribed verbatim and the texts were read several times.After coding units were identi ed, coding was conducted and categories and key topics were de ned.Each participant in the group interview was ascribed a corresponding code.The nominal identity of a transcription was lost while the traceability of content was ensured.

Results
Based on an analysis of the text, 47 codes were designed alongside 14 umbrella categories.The obtained categories fall into four nal topics: 1) a positive effect on the development of students' critical thinking skills 2) a positive effect of learning methods on the development of students' critical thinking skills 3) providing a safe learning environment 4) implementation of active learning methods (Table 1).andragogy, and active teaching methods.
Table 2 presents topics that are substantiated by representative quotes, their effects on the education of students of nursing, the obstacles and consequences that nurse educators have observed, and suggestions regarding improvements based on the presented topics and statements.

A positive effect on the development of students' communication skills
Participants in the group interview believed that various active methods have a positive effect on the development of Nursing students' communication skills, and on achieving professional competencies in communication.They emphasize the importance of feedback exchanged between a student and a nurse educator that should be given at a time when a student is still thinking about their work and there is still time to improve the process itself.They think that feedback has an impact on the active role of a student and on achievement of the set goals.The research participants believe that showing nursing interventions several times during the learning process has positive effects on students' memorizing skills and results in less errors when providing health care to patients.

The effect of learning methods on the development of critical thinking
In their statements, the participants of the group interview most often stated that using various innovative methods in a simulation setting encourages critical thinking skills of nursing students, impacts the development of students' self-con dence and motivates them to work and study.Active participation and critical thinking lead students to successful problem solving.Participants believe that teaching by means of actively solving problems results in students' re ecting and encourages them to show and say what they know.The participants emphasize that using certain methods of learning also depends on external resources.

Ensuring a safe learning environment
The participants of the group interview all thought that methods such as the Peyton's Four-Step Approach method, the OSCE stations and Debrie ng contribute to a safe clinical environment since students revise their knowledge and skills several times in simulated conditions and in this way strengthen their knowledge.They believe that preparing students to perform safe nursing intervention is connected to safe and quality patient health care in a clinical setting.

Implementation of active learning methods
The nurse educators included in the research found the presented methods highly suitable for use in the education process of Nursing students, but emphasized that a suitable venue should be provided, and that teachers or clinical mentors should be suitably prepared.They think that nurse educators neither have enough pedagogical and andragogical experiences and skills, nor knowledge on active learning methods.

Discussion
With qualitative research, we obtained the views and opinions of nurse educators from some nursing faculties and clinical settings in BiH on the effects of active learning methods on students of nursing.
Participants in the group interview believed that various active methods have a positive effect on the development of Nursing students' communication skills, and on achieving professional competencies in communication.They emphasized the importance of feedback exchanged between a student and a nurse educator.Other research [34][35][36] also emphasizes the importance of communication skills, giving feedback and providing quality in nursing care.In our study the participants of the conducted research thought that active learning methods contribute to a more effective learning of nursing interventions, provide an active approach to learning about nursing interventions and enable a more con dent performance of nursing interventions in a clinical setting with a patient, and provide a safe environment either for the patient or for the student.
We have found that the use of innovative methods in a simulation environment encourages students' critical thinking, motivation, development of self-con dence and problem-based learning.Christianson Krista [37] puts great importance on the connection between emotional intelligence and critical thinking in nursing education.A study [38] demonstrated that critical thinking education improves problem-solving skills.A good relationship between a nurse educator and a student brings positive results in students' education and motivates them for work in a clinical setting [39].In addition, a teacher's professional knowledge and their organizational and communication skills also have an effect on successful learning [40].Baksi et al. [41] researched the effects that clinical preparatory education provided before the rst clinical experience had on anxiety.
The opinions of the participants regarding the Debrie ng method mostly refer to the importance of feedback.In researching debrie ng practices in interprofessional simulation with students from the sociomaterial perspective, the ndings have shown how debrie ng intertwines with, and is shaped by social and material relationships.Two patterns of enacting debrie ng were identi ed.First, debrie ng as an algorithm was enacted as a protocol-based, closed inquiry approach and secondly, laissez-faire debrie ng was enacted as a collegial conversation with an open inquiry approach that has a loose structure [42].
In their statements, the participants of the group interview most often stated that using various active methods in simulation settings improve critical thinking skills of students of Nursing, which is why we think that Peyton's Four-Step Approach method, Mind Mapping and Debrie ng should be included as a tool for successful learning of students and preparation for working directly with patients, which has already been pointed out by previous research conducted by Janicas and Narchi [21] and Francis and O'Brien [3].The use of Mind Mapping helps students to understand their thinking process, obtain basic knowledge that they will upgrade with in-depth professional knowledge [15], and encourages them to learn independently, be independent and think critically [43].While students were developing mind maps, they were also exploring the critical thinking concept by re ecting on how they make patient care decisions in a clinical setting [19].The re ection resulted in the students being better able to describe their critical thinking process and demonstrate the concept graphically.Mind Mapping may be used to illustrate the pathways that encourage re ection on patient care [44].
The participants of our research believe that the methods that were presented and demonstrated with examples contribute to a safe clinical setting.Clark [22] also emphasizes that one of the more challenging tasks of faculties of health sciences is to educate students with competencies that will secure safe and effective nursing and patient care.In the research, nurse educators believe that active methods are very useful in the education process of Nursing students, but emphasize that an appropriate location should be provided and that nurse educators should be suitably trained.They also believe that nurse educators must have pedagogical and andragogical knowledge, so that they can implement active and quality teaching methods in the pedagogical process.The challenges in the training of nursing educators are in the transition from traditional education to simulated learning environment [45].
Addressing nurse educator challenges and empowering them with the means, opportunity and skills to utilize student-centered teaching and learning strategies may contribute to the development of undergraduate student nurses' clinical reasoning skills.Raising awareness of the challenges that nurse educators experience in implementing student-centered facilitation of learning can assist in developing the strategies to ensure nurse educators become more student-centered in their teaching [46].
Based on the conducted research, we propose an implementation of active teaching methods in the educational process of nursing students.Recommendations relate to regular monitoring of learning objectives, evaluation, updating teaching methods and the transition from traditional forms of learning to innovative forms.

Conclusions
The results of the qualitative research were used to present the meaning and understanding of implementing active learning methods in undergraduate study programs of Nursing.The use of active Limitations and StrengthsNurse that had previously been included in the training on active teaching methods in Nursing were included in the research.An advantage of the research is that we have obtained the views and opinions of nurse educators regarding the usefulness and effectiveness of the presented methods in the undergraduate study program of Nursing immediately after the conducted theoretical and practical training.An important limitation is also the local context of nursing development in BiH.The convenient sampling does not always allow us to select the best representatives related to the research question.It is likely that the members included in the group are more motivated for improvements in nursing education than other nurses at faculties and clinical settings.Further research should focus on two areas.Firstly, it should be researched how often active learning methods are used in the education process and secondly, the opinions of students on how active learning methods impact the understanding and learning of nursing intervention could be obtained.The limitation of the research is the time span of the education on active teaching methods and the selection of guiding questions.It may be supposed that a different selection of guiding questions might result in different opinions of nurse educators.

Table 1
The results of the discussion on the use of active learning methods in Nursing undergraduate study programs