A study on Korean nursing students' educational outcomes

The purpose of this study was to describe outcome indicators of nursing education including critical thinking, professionalism, leadership, and communication and to evaluate differences among nursing programs and academic years. A descriptive research design was employed. A total of 454 students from four year baccalaureate (BS) nursing programs and two three-year associate degree (AD) programs consented to complete self-administered questionnaires. The variables were critical thinking, professionalism, leadership and communication. Descriptive statistics, χ2-test, t-tests, ANOVA, and the Tukey test were utilized for the data analysis. All the mean scores of the variables were above average for the test instruments utilized. Among the BS students, those in the upper classes tended to attain higher scores, but this tendency was not identified in AD students. There were significant differences between BS students and AD students for the mean scores of leadership and communication. These findings suggested the need for further research to define properties of nursing educational outcomes, and to develop standardized instruments for research replication and verification.


INTRODUCTION
Nursing education aims to have students acquire the knowl edge, practical skills, and social responsibility necessary to tho roughly assume their role as professional nurses after complet ing a nursing program [1]. Educational outcomes are state ments of the professional abilities that nursing students should achieve during undergraduate study. Outcome statements in corporate philosophical approaches, indicate core curriculum concepts, and describe key professional abilities in a compre hensive, holistic fashion [2].
Since the Korean Council for University Education (KCUE) introduced nursing education accreditation in 1997, arguments have been raised both inside and outside of the circles concern ed. Without devising objective measuring tools to satisfy the parties involved, the accreditation system will not be valid in real terms. Meanwhile, the KCUE tried to adopt evaluation criteria applicable to all educational institutions including nurs ing schools, but it found that more adaptable evaluation crite ria for nursing schools would be necessary. The Korean Ac creditation Board of Nursing (KABON) was established in 2003 under such circumstances as accreditation problems. In 2006, KABON revised the standards and criteria for nursing program based on the studies by Ahn et al. [3] and Kim et al. [1], which identified critical thinking, professionalism, leader ship, communication, skills for nursing practice, and humani ty as core competencies of nursing education. These compe tencies were parallel to Lenburg' s suggested essential core com petencies for students [4]. These included assessment and in tervention, communication, critical thinking, teaching, human caring relationships, management, leadership, and knowledge integration skills, which are found in the Competency Out comes and Performance assessment (COPA) Model. Further, in the US, after already having claimed to consider its profes sionals characteristics in the accreditation system of the fields of public health and medicine [5], in 2002 the National League for Nursing Accrediting Commission (NLNAC), added criti cal thinking, communication, and curative nursing interven tion as a measuring province of educational outcomes. Re cently NLNAC [6] explained those as student learning out comes. Nevertheless, few studies describing the educational outcomes of core competencies have been found in the nurs ing literature. Based on the previously noted literature KA BON core competencies, four cores critical thinking, profes sionalism, leadership, and communication were selected as primary nursing outcome indicators, to evaluate nursing stu dents.
This study aims to describe the critical thinking, profession alism, leadership, and communication of nursing students, and to compare the differences in critical thinking, professional ism, leadership, and communication between types of nursing programs and among academic years.

Research design
A descriptive research design was employed for evaluating critical thinking, professionalism, leadership, and communi cation of nursing students.

Research subjects
This study targeted nursing students from threeyear asso ciate degree (AD) programs and baccalaureate (BS) programs nationwide. Selection criteria for its subjects were as described below. First, considering the regions where nursing schools were accessible, four BS programs and two threeyear AD pro grams located in Seoul, Gangwon, Choongcheong, Jeonra, and Kyungsang Provinces were selected. Second, 1516 stu dents per each year in school in BS programs and 3435 per each year in school in threeyear AD programs were sampled by convenience. The total number of participants was 530 stu dents, including 320 from the BS programs and 210 from the threeyear AD programs. Of these, 454 subjects were included in the final data analysis, after incomplete surveys were elimi nated.

Ethical considerations and human participant protection
Taking the ethical aspect of the procedure into account, sub jects were informed of the purpose of the study and the right to cancel their participation even during the response process. They were informed there would be no penalties for canceling their participation. Subjects agreed to the purpose of this study, voluntarily signed a form, and participated in the survey.

Research instruments
The research instruments used in this study were as follows: 1) Critical Thinking Disposition Instrument (CTDI): The CTDI, developed by Yoon [7], was used for measuring critical thinking disposition. Skills in critical thinking can provide the creative solutions and multiple pathways required for success ful qualityimprovement initiatives. CTD describes attributes or habits of the mind integrated into an individual's beliefs or actions that are conducive to critical thinking skills (CTS). The CTD instrument measures intellectual eagerness/curiosity, prudence, selfconfidence, systemicity, intellectual fairness, healthy skepticism, and objectivity. Each item is scored on a fivepoint Likert scale. The range of scores is from 27135 with higher scores indicating higher levels of critical thinking dis position. The reliability of the instrument was Cronbach's al pha 0.89 in the original study [7]. The reliability of the instru ment in this study was Cronbach's alpha 0.88.
2) Nurse SelfDescription Form (NSDF): The NSDF, devel oped by Dagenais and Meleis [8], was used for measuring pro fessionalism. It was validated for nurses and nursing students by the Western Council on Higher Education for Nursing (WCHEN) researchers in a study of the effects of a leadership program in predicting nursing performance [8], and it has demonstrated validity when used to study productivity of RN BSN students in Korea [9]. Each of the 19 items of the Nurse SelfDescription FormKorean version is scored on a fivepoint Likert scale. The range of scores is from 1995 with higher scores indicating higher levels of professionalism. The reliabil ity of the instrument was Cronbach's alpha 0.93 in the original study [8]. Cronbach's alpha was 0.92 in the study of Kim et al. [9]. The reliability of the instrument in this study was Cron bach's alpha 0.88.
3) SelfAssessment Leadership Instrument (SALI): The SALI was developed by Smola [10], and measures leadership behav ior and characteristics in baccalaureate nursing students. The 40item instrument relies on self assessment of critical think ing and decision making skills, interpersonal relationships, group relations, and job relations. Each item is scored on a five point Likert scale. The range of scores is from 40200, with hi gher scores indicating increased occurrence of leadership be havior. The reliability of the instrument was Cohen's K coeffi cient of 0.545 in the original study [10]. Cronbach's alpha was 0.95 in the study of Oh et al. [11]. The reliability of the instru ment in this study was Cronbach's alpha 0.94. 4) Supportive Communication Inventory (SCI): The SCI, developed by Whetten and Cameron [12], was used to assess communication performance for students who majored in management. Supportive communication is communication that seeks to preserve a positive relationship between the com municators while still addressing the problem at hand. Sup portive communication has eight attributes, which include being problemoriented, congruent, descriptive, validating, http://jeehp.org specific, conjunctive, owned, and committed to supportive lis tening [12]. Each of the 20 items is assigned a score with the range from one (never agree) to six (positively agree). The ran ge of scores is from 20 to 120, with higher scores indicating higher communicative skills. The reliability of the instrument was Cronbach's alpha 0.86 in study by Oh et al. [11]. The reli ability of the instrument in this study was Cronbach's alpha 0.94.

Data collection procedure
One student per year in five BS programs and one threeyear AD program was sampled by convenience, resulting in a total of 23 students in the preliminary survey. Since there were no unusual matters concerning the fitness of questions, time, or procedure, the original questionnaires were used without re vision. The data collection involved using selfadministered questionnaires in the main survey. The researchers directly distributed the questionnaires to the students and gathered their responses. It took the students about 2025 minutes to complete the questionnaires.

Data analysis
Data were analyzed with SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were utilized to evaluate gen eral characteristics of the subjects. χ 2 test, ttests, ANOVA, and the Tukey test were utilized to assess differences among nursing programs and academic years.
Cronbach's alpha coefficients were utilized to evaluate the reliability of the instruments.

General characteristics of the subjects
General characteristics of the 246 (54.2%) BS students and 208 (45.8%) AD students are shown in Table 1. Regarding BS students, the average age of the students was 21.2 (± 1.82) years, and most of them were female (94.2%) and single (98.8%). There were 58 (23.6%) in the first year, 62 (25.2%) in the sec ond, 63 (25.6%) in the third, and 63 (25.6%) in the fourth. Like wise the average age of AD students was 21.5 ( ± 2.54) years, and most of them were female (90.9%) and single (98.1%). There were 58 (27.9%) in the first year, 84 (40.4%) in the sec ond, 66 (31.7%) in the third. There were no differences in age or marital status (P > 0.05). The only difference between the BS and AD students was the gender distribution (χ 2 = 8.069, P= 0. 007).

Critical thinking, professionalism, leadership, and communication of nursing students
The critical thinking, professionalism, leadership, and com munication mean scores of the students are as shown Table 2. The average score for critical thinking was 85.3 out of a possi ble of 135, and the scores tended to be higher for students who had completed more years of education. Scores for seniors  were the highest with an average of 88.2. The average scores for juniors and sophomores were 85.8 and 84.4, respectively. The average score for professionalism was 68.2 out of a total possible of 95. The mean score of seniors was the highest at 70.7, while the score of the freshmen was higher than the scores for sophomores and juniors. The average score for leadership was 149.2 out of a total possible of 200, and the mean score of seniors was the highest as 155. 3, while the score for freshmen was higher than the scores for sophomores and juniors. The average score for communication was 85.2 out of a possible of 120, with increasing scores accompanying more years of edu cation. Senior scores were the highest with an average of 86.2. Junior and sophomore scores were 85.7 and 84.8, respectively. All indicators of critical thinking, professionalism, leader ship, and communication measured a little higher than aver age scores for these testing instruments. Results from Tukey's post hoc test showed that the mean score of seniors were sig nificantly higher when compared to freshmen, sophomores, and juniors in all variables except for communication ( Table 2).

Differences in critical thinking, professionalism, leadership, and communication by nursing programs and academic years
From assessing the differences in critical thinking, profes sionalism, leadership, and communication according to the nursing programs and academic years (Table 3), it was found that the mean score of BS students for critical thinking was 85.7, 0.9 higher than the 84.8 for AD students. However, there was no statistically significant difference between the BS pro grams and threeyear AD programs (t= 1.017, P= 0.310). The ranking of the mean scores by academic year of the BS stu dents showed seniors with the highest scores (88.2), followed by freshmen (85.5), juniors (85.3) and lastly, sophomores (84.0). There were no statistically significant differences among the different years (F= 2.446, P= 0.065). Regarding threeyear AD students, the junior scores were the highest at 86.3, while soph omore and freshmen scores were 84.8 and 83.2, respectively. There were no statistically significant differences among the different years either (F= 1.654, P= 0.194).
The mean score of the BS students for professionalism was 68.3, 0.1 higher than the 68.2 for AD students, but there was no statistically significant difference between the two groups (t= 1.904, P= 0.152). The mean score by academic year for BS students showed that seniors had the highest score (70.8), while freshmen and junior scores were 68.5 and 68.1, respectively. Sophomore scores were the lowest (65.7), indicating a statisti cally significant differences among the academic years (F = 3.255, P= 0.022). Using Tukey's post hoc test significant differ ences between seniors and sophomores were found as well. The mean score by academic year of the AD students was high est for freshman (69.5), while junior and sophomore scores were 68.8 and 66.8, respectively. However, there were no sta tistically significant differences among class years (F = 1.904, P= 0.152).
The mean score of the BS students for leadership was 150.8,  (146.3). Furthermore, there were statistically significant differences among the academic years (F = 3.733, P = 0.012). Significant differences between seniors and sophomores were found as well using Tukey's post hoc test. The mean score per year of the AD students was highest for juniors (148.0), while sophomore and freshman scores were 147.7 and 145.3, respectively, but there were no statistically significant differences among class years (F= 0.467, P= 0.627). The mean score of the AD students for communication was 87.3, 3.6 higher than the 83.7 for BS students, and it indicated statistically a significant difference between two groups (t = 4.175, P< 0.001). The mean score by academic year of the BS students was highest for seniors (86.2), while junior and fresh man scores were 83.5 and 83.2, respectively. The sophomore scores were the lowest (81.6). However, these scores revealed statistically significant differences among the academic years (F= 3.052, P= 0.029). In Tukey's post hoc test, significant dif ferences between senior and sophomore years were found as well. The mean score per year of the AD students was highest for juniors (87.8), while sophomore and freshman scores were 97.5 and 86.3, respectively. There were no statistically signifi cant differences among class years (F= 0.381, P= 0.684).
Results comparing the average scores focused on the last year of the two types of degree programs (Table 4). For critical thinking the mean score of BS seniors was 88.2, 1.9 higher than the 86.3 for threeyear AD juniors. However, there was no sta tistically significant difference between the two groups (t= 1.135, P= 0.259). In terms of professionalism, the mean score of BS seniors was 70.7, 1.9 higher than the 68.8 for threeyear AD juniors, but there was no statistically significant difference be tween the two groups (t= 1.393, P= 0.166). For leadership, the mean score of BS seniors was 155.3, 7.3 higher than the 148.0 for threeyear AD juniors. This indicated statistically a signifi cant difference between the two groups (t = 2.540, P = 0.012). For communication, the mean score of the threeyear AD ju niors was 87.8, 1.6 higher than the 86.2 for BS seniors, but this difference was not statistically significant (t= 1.112, P= 0.268).

Critical thinking
The average score on the CTDI in this study was lower than the study of Oh et al. [11] using the same tool, which was 102.3 for RNBSN students and 103.7 for graduates. One explana tion for this result could be that students and graduates from RNBSN programs are expected to acquire a more critical ori entation through professional nursing activities.
Regarding the differences in nursing programs in this study, BS students showed a higher disposition toward critical than the AD students, but it was not statistically significant. How ever, compared to the study of Cho [13], and that of Bae et al. [14] on threeyear AD students using the same tool, the mean score for AD students in the previous study was little higher than that of the BS students in the current study. More detailed research on critical thinking is needed because while educa tion for critical thinking has been emphasized in 4year nurs ing education, it is unclear whether the curriculum is making a measureable difference. Considering differences by class lev el, both BS students and AD students revealed statistically sig nificant differences by year in Yoon's study [7]. However, nei ther AD nor BS student mean scores revealed statistically sig nificant differences by academic year in this study. Those in the last year of each programs attained higher scores. There fore, a critical thinking disposition can apparently developed as nursing students advance through school. Also, in the case of BS programs, it is probable that freshmen attained higher critical thinking disposition scores than sophomore because of exposure to subjects such as philosophy and introduction to nursing. This is supported by the study results of Yang and Jung [15] which revealed that taking philosophy courses re sulted in statistically significant different critical thinking dis position scores. Using Turkey's post hoc test as well, that the critical thinking disposition showed no differences by class year is a similar result to that of the study of Yang and Jung [15]. It is possible that encouraging students to choose rele vant liberal arts courses and designing a nursing education curriculum with the principles of sequence, continuity, and integration will lead to the development of critical thinking skills and a critical disposition. The critical thinking process is interactively operated cognitive skills and affective skills in cluding attitude and disposition traits. Therefore, Facione ex plained that critical thinking appears by interactions between critical thinking skills and disposition, so in order to measure critical thinking, both skill and disposition should be measured [16]. The study of Shin et al. [17] showed that there was a sig nificant correlation between a disposition toward critical think ing and critical thinking skills in Korea. Research related to critical thinking in nursing has focused on definition [18,19], and, more recently, on teaching strategies [20,21]. However, the mutual understanding among nursing scholars of its use in educational outcomes lacks depth. Considering all these re sults, the experiences of learning to have a disposition toward critical thinking in nursing education needs to be analyzed in detail, and critical thinking skill measurement and compari son is required as well.

Professionalism
Professionalism is a basic requirement for a Registered Nur se, so it is natural that there is no difference between BS and AD nursing programs in this study. For example, the two types of programs would provide similar education in professional ethics and the core values of nursing. However, compared to the studies by Oh et al. [11] and Kim et al. [9] on educational outcomes of RNBSN students using the same tool, students in the present study attained lower scores than RNBSN stu dents and graduates of the other studies. This result could be due to the idea that students and graduates from RNBSN programs are expected to acquire deeper professional values and attitudes through professional nursing activities in vari ous health care settings. The score on professionalism in BS programs in this study increases as students progress through their four years of school. Students' learning experiences relat ed professionalism in nursing education and practices need to be identified by academic year in the future because profes sionalism is increased as students continue to learn. Profes sionalism gives a framework for the criteria of nursing activity and a guide for the evaluation of nurses' behavior [22]. There fore, research on professionalism showed that it was related to job satisfaction, organizational commitment, and professional selfconcept [23,24]. It is indeed meaningful to measure pro fessionalism as one of the outcome indicators of nursing edu cation.

Leadership
The mean leadership score of all subjects was 149.2 out of a possible of 200, and by nursing programs, BS students scored higher than AD students. The score of seniors was the highest, followed by that of the freshmen, which in turn was higher than the scores of sophomores and juniors. This positive chan ge reflected a major nursing educational goal and curriculum of BS programs in training leaders to contribute to society. However, compared to the study of Oh et al. [11] using the same tool and researching RNBSN students, students of this current study attained lower scores than the RNBSN students (154.7) and graduates (160.8) of the other study. Leadership behaviors tended to increase in the later academic years both in threeyear AD programs and BS programs. Through deep er theoretical and practical education in major nursing sub jects, the importance of leadership is also emphasized. In ad dition, in comparison with the results of Oh et al. [11], the students' leadership scores were higher than graduates, indi cating that leadership in nursing students is increasingly streng thened by learning. Therefore, in order to fully display leaders' capacities at work sites after graduation, leadership education should be consistently provided. On the other hand, the in strument used in this study measured a selfassessment of lea dership traits, and was utilized as a tool for integrating com ponents of outcome measurement necessary to leadership de velopment. However, from the viewpoint of leadership theory this instrument focused on behavior theory as opposed to bro adly including other sciences, so there are limits to its compre hensiveness. Leadership skills are needed that emphasize ethi cal and critical decisionmaking, initiating and maintaining effective working relationships, using mutually respectful com munication and collaboration within interprofessional teams, care coordination, delegation, and developing conflict resolu tion strategies [25]. Leadership in the nursing profession is important for students at diverse levels, from preparing for the role of nursing leadership to eventually being the leaders in nursing practice.

Communication
The mean communication score in this study (85.2 out of 120) was higher than the average score for this instrument. The score of the AD students was significantly higher than that of the BS students. This is because freshman in threeyear AD programs begin clinical practice during their first year, which provides learning by practical experiences. By class year, the score of seniors (86.2) was the highest, followed by that of the freshman, which in turn was higher than the score of sopho more and juniors in BS programs. The score of seniors (87.8) was higher than that of the other students, revealing that com munication gradually improved as a result of learning by aca demic years in threeyear AD programs. However, compared to the study of Oh et al. [11], scores from this study were low er when compared to RNBSN students (88.9) and graduates (90.1) measured by the same tool. Subsequently, a detailed analysis regarding communication content and experiences in nursing education is needed. Effective communication among health professionals is imperative to providing clientcentered care, and is an essential professional competency that is con ceptualized and developed during undergraduate education [26]. Communication skills of nursing students can be mea http://jeehp.org sured as a core indicator of final educational outcomes.
There are some limitations to this study. The sampling by convenience may limit generalization of the findings. Another limitation is that only four core concepts were delineated, and there was no instrument for appropriately measuring students' ability to think critically.
This study investigated the levels of critical thinking, profes sionalism, leadership, and communication of nursing students as outcome indicators of nursing education, and compared and analyzed the differences by nursing programs and aca demic years. Nursing students in BS programs and threeyear AD programs were sampled using the convenience method and a total of 454 surveys were analyzed. Data collection was performed with four instruments: the CDTI, NSDF, SALI, and SCI. All scores for critical thinking disposition, professional ism, leadership, and communication of nursing students were slightly above the average scores for these instruments. There were statistically significant differences in the BS program and threeyear AD programs leadership and communication scores. This indicated that leadership development in BS programs was greater than in threeyear AD programs. Conversely, in communication, threeyear AD students' scores were higher than those of BS students. The mean scores for leadership, com munication, and professionalism tended to increase as students progressed through the program, while scores of critical think ing disposition did not. Based on these findings, recommen dations are as follows: 1. Properties of the nursing educational outcomes must be defined.
2. Standardized instruments for research replication and ver ification are needed.