NURSING EDUCATION IS keeping pace with

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1 STUDENT LEARNING WITH CONCEPT MAPPING OF CARE PLANS IN COMMUNITY-BASED EDUCATION SUSAN M. HINCK, PHD,* PATRICIA WEBB, MSN,y SUSAN SIMS-GIDDENS, EDD,z CAROLINE HELTON, MS, KATHRYN L. HOPE, PHD,OROSE UTLEY, PHD,# DEBORAH SAVINSKE, MSN,y ELIZABETH M. FAHEY, MSN,y AND SUE YARBROUGH, MSN** Concept mapping, a learning strategy used to understand key concepts and relationships between concepts, has been suggested as a method to plan and evaluate nursing care. The purpose of this study was to empirically test the effectiveness of concept mapping for student learning and the students satisfaction with the strategy. A quasi-experimental pre- and posttest design was used to examine the content of concept maps of care plans constructed by junior-level baccalaureate students (n = 23) at the beginning and end of a community-based mental health course. Additionally, students completed a questionnaire to self-evaluate their learning and report their satisfaction with concept mapping. Findings indicated that concept mapping significantly improved students abilities to see patterns and relationships to plan and evaluate nursing care, and most students (21/23) expressed satisfaction in using the strategy. This study supported concept mapping as an additional learning strategy and has extended knowledge in communitybased nursing education. (Index words: Concept mapping; Community-based; Baccalaureate nursing education) J Prof Nurs 22:23 29, A 2006 Elsevier Inc. All rights reserved. NURSING EDUCATION IS keeping pace with the changing health-care environment by moving more student practice experiences from the highly structured hospital to the home and community. Community-based nursing necessitates different knowledge and skills to organize nursing care in settings that are less structured and more diverse (American Association of Colleges of Nursing, 1999; Matteson, 2000; Stanley, Kiehl, Matteson, McCahon, & Schmid, 2002). Community-based nursing requires a broad perspective of the client (defined as an individual, family, group, or entire community) and an understanding of *Associate Professor, Department of Nursing, Missouri State University, Springfield, MO. ylecturer, Department of Nursing, Missouri State University, Springfield, MO. zassistant Professor, Department of Nursing, Missouri State University, Springfield, MO. Lecturer and BSN Program Director, Department of Nursing, Missouri State University, Springfield, MO. OAssociate Professor and Department of Nursing Head, Department of Nursing, Missouri State University, Springfield, MO. #Associate Professor and Nurse Educator Graduate Programs Director, Department of Nursing, Missouri State University, Springfield, MO. **Lecturer and FNP Program Director, Department of Nursing, Missouri State University, Springfield, MO. Address correspondence and reprint requests to Dr. Hinck: 1220 West Lakewood Street, Springfield, MO susanhinck@missouristate.edu /$ - see front matter the multiple factors that influence the client s health. Community-based student learning requires a higher level of self-direction, critical thinking, and independent decision-making compared to institutional settings (Kemp, 2003). The focus includes healing the sick, as in hospital-based care, but also a greater emphasis on preventing illness, promoting health, and empowering people to gain greater control over their lives and health (Kemp, 2003). Concept Maps Concept mapping is a means to comprehend multifaceted care. Concept maps (CMs) are diagrams of key concepts and relationships between those concepts. Concepts are visually presented as words or pictures placed in a hierarchical structure, with the most important concepts in the center or on top of the page. Secondary concepts radiate from the central concepts. Lines drawn between the concepts and propositional statements written on the lines graphically show the relationships. Novak and Gowin (1984) recommend six steps in creating a CM: Select a topic, write general concepts, identify more specific concepts, tie general and specific concepts together with propositional words that show how the concepts are linked, make cross-linkages to show connections, and, finally, reflect and revise the CM. CMs have gained widespread acceptance in education as a means for students to learn new information and to Journal of Professional Nursing, Vol 22, No 1 (January February), 2006: pp A 2006 Elsevier Inc. All rights reserved. doi: /j.profnurs

2 24 understand prior knowledge in new ways. Construction of CMs provides the opportunity for students to break new knowledge into small parts (concepts), arrange and order concepts to make sense, and make connections between and among concepts (Irvine, 1995; Novak, 1990; Schmid & Telaro, 1990). The process of creating the CM is necessary for maximum learning to take place. Students must prepare their own CMs to reflect on what information is relevant and how it fits together (Novak, 1990). Concept mapping results in meaningful learning that is long-lasting and occurs when the learner consciously relates new knowledge to prior understandings (Ausubel, Novak, & Hanesian, 1986). More importantly, concept mapping is a metacognitive strategy that helps students learn how to learn (Irvine, 1995; Novak, 1990). Rather than traditional learning of memorizing facts in specific contexts, concept mapping helps students recognize how multiple parts result in a cohesive whole. Concept mapping has been discussed in nursing literature as an innovative method of student learning (All & Havens, 1997; All, Huycke, & Fisher, 2003; Beitz, 1998; Irvine, 1995; Kathol, Geiger, & Hartig, 1998; Mueller, Johnston, & Bligh, 2001). Most examples of CMs related to nursing care have presented the identification of and intervention for physiological illnesses (All & Havens, 1997; Daley, Shaw, Balistrieri, Glasenapp, & Placentine, 1999; Irvine, 1995; Kathol et al., 1998; Mueller et al., 2001). The use of CMs in planning and organizing nursing students care, in place of traditional care plans, has been described (All & Havens, 1997; Baugh & Mellott, 1998; Mueller et al., 2001; Schuster, 2000, 2002). CMs offer a more effective way to organize and plan care than traditional care plans that require linear thinking and are often copied from texts with minimal individualization (Schuster, 2000, 2002). Further, concept mapping stimulates students to evaluate what information they still need to gather when in the clinical setting. Nursing diagnoses are derived from the client s pertinent conditions and added to the map. Information on the CM care plan is worded in a similar manner to the traditional care plan, but the structure is more flexible to show the relationships between the information. CMs can be used as visual aids in pre- and postclinical conferences to show application of nursing knowledge and skills (Baugh & Mellott, 1998). Evaluation of the CM usually is based on whether all parts of the nursing process are identified (Mueller et al., 2001) and how well students apply the course content to the clinical situation. However, there are no examples of concept mapping in nursing literature to show the intricate social, cultural, and health dynamics considered when planning and evaluating nursing care in community settings. Measuring the Effectiveness of CMs The effectiveness of CMs in student learning has been indirectly measured by higher scores on multiple-choice HINCK ET AL exams, problem-solving tests, and course grades, as summarized by Novak (1990). Studies have shown that using CMs to outline lecture content and texts have assisted university students to better learn course content and improve exam scores (Francisco, Nakhleh, Nurrenbern, & Miller, 2002; Leauby & Brazina, 1998; Taagepera & Noori, 2000). Few studies have been conducted to examine concept mapping as an effective learning strategy for nursing students (Daley et al., 1999; Rooda, 1994; Wheeler & Collins, 2003). Nurse researchers have reported that concept mapping increases the ability of nursing students to understand massive amounts of content, measured by multiple choice exams (Rooda, 1994), and promotes critical thinking, measured by increased complexity in creating CMs (Daley et al., 1999; Schuster, 2002; Wheeler & Collins, 2003). Nursing studies have investigated the effectiveness of CMs that diagramed physiological aspects of nursing care in highly structured institutional settings only. The use of CMs in learning to create and evaluate the plan of nursing care in community settings has not been empirically tested. Purpose The purpose of this study was to evaluate the effectiveness of concept mapping as a learning strategy for junior-level baccalaureate nursing students to plan and evaluate nursing care during a community-based mental health course. Research Questions 1. Is there a difference in the CMs of care plans at the beginning and end of the course? 2. What are students self-evaluations of their learning and satisfaction with use of concept mapping? Methods Design and Sample A quasi-experimental pre- and posttest design was used to examine the content and differences of CMs of care plans constructed by junior-level baccalaureate nursing students (n = 23) at a Midwest metropolitan university. Students created the CMs at the beginning and end of a community-based clinical experience during a 16-week mental health course in spring This was the third clinical course for students, who had prepared traditional care plans in the prior two courses. In addition, for this study, students completed a questionnaire reporting their self-assessed learning and level of satisfaction with use of CMs. Student and Faculty Training Because concept mapping was a new learning strategy for faculty and students, 11 course and clinical faculty and 23 students took part in a comprehensive training

3 CONCEPT MAPPING 25 program. To help students and faculty develop skills in concept mapping, the faculty initiated a 2-phase education plan. First, in the semester prior to student use, an expert on concept mapping presented a half-day seminar to nursing faculty about the theoretical underpinnings and purpose of concept mapping in nursing education. Faculty then devised a plan for student preparation, course expectations, and evaluation of concept mapping. Second, to further meet the need for knowledge and skill development, a nationally recognized expert in concept mapping within communitybased nursing education presented a 1-day workshop for students and faculty at the beginning of the course. The workshop provided the opportunity to learn about and practice creating CMs. As an in-class activity after the workshop, students practiced concept mapping to identify nursing diagnoses and supporting subjective and objective data, nursing interventions, including teaching, client outcomes, and evaluation of nursing care. Case studies of familiar, common client situations were presented to determine the student s baseline knowledge of the complex components influencing the client s health. Students were divided into groups of three or four, and each group was given a case study of a mental health client, a large sheet of paper, and colored pencils. Students worked together to illustrate the relevant information from the case study. Instructions to students were to do the following: c Identify the client as the central concept in the middle of the page. c Add the client s main health concern or reason for seeking help. c From the main health concern, add two relevant nursing diagnoses. The concepts can be contained within circles or other shapes to differentiate them from each other. c For each nursing diagnosis, list the subjective and objective data, identified from the case study, that are associated with the diagnosis. c List current information about medical diagnosis, risk factors and etiologies, diagnostic tests, treatments, and medications under the appropriate nursing diagnoses. c List nursing interventions for each diagnosis. Interventions include key areas of assessment, procedures, teaching, and therapeutic communication. c Add expected outcomes associated with the nursing interventions for each nursing diagnosis. c Finally, draw lines between concepts to indicate relationships. Link the concepts and related data by different types of lines (e.g., arrows, bolded lines, direct lines, or broken lines), depending on the nature of the relationship. On each line, use words (such as related to, contributes to, is necessary for) to explain the relationship between linked concepts. Illustrations and shapes can be used to clarify concepts. Develop a map key with codes to explain what each color and illustration represent. Students Use of CMs During the Course During the course, students cared for clients from an assigned community setting such as an adolescent behavioral health center, substance abuse counseling center, older adult day care center, and others. Students each created eight CMs to identify the complex situations and relationships of mental health clients in the community, prioritize client needs, develop and implement interventions to meet the needs, and evaluate the effectiveness of their nursing care. Because students were not able to have prior contact with their clients, they began developing the CMs the day of their clinical experience. Students spent the day with their clients to learn of clients concerns, difficulties, strengths, and adaptive strategies. Students also reviewed written records to determine information about the client s health problems, medical history, family relationships, and community resources used. They gathered information on relevant medications, treatments, and medical diagnoses. Then students analyzed the assessment data and identified two nursing diagnoses and interventions related to those diagnoses. During pre- and postclinical conferences, students discussed their CMs with faculty and peers. This activity provided all students the opportunity to think out loud about the accuracy and completeness of the relationships depicted on their CMs. Students used diagrams, shapes, and color to code the parts of the nursing process and included a key to explain their coding. Students had several days after the clinical experience to Table 1. CM Grading Criteria A maximum of 20 points will be given for each CM. The points will be awarded using the following criteria: Item Maximum Points Possible The client s main health concern is present. 1 Two clearly stated nursing diagnosis 2 (NANDA) are present. Nursing diagnoses are prioritized for 2 the client. Subjective and objective data support the 2 nursing diagnosis. Short- and long-term goals for each 4 diagnosis are behaviorally stated with time frames that are measurable and realistic (NOC). Nursing interventions relate to the nursing 2 diagnosis and are individualized to the client (NIC). Evaluation addresses if the short- and 4 long-term goals were met. Additionally, indicate if the goal should be continued, deleted, or replaced with another goal. Teaching was relevant to the nursing 2 diagnosis and realistic. Cross-links are present. 1

4 26 reflect and evaluate the effectiveness of their nursing care before the CMs were due. Students constructed eight CMs, but chose only two CMs to receive grades. A tool was developed by the nursing clinical faculty to evaluate the CMs based on the presence of required elements of the care plan, as well as whether the plan was appropriate for the client (Table 1). Human Subjects Concerns The university s institutional review board approved the study prior to data collection. Students were told that the purpose of the study was to evaluate the effectiveness of concept mapping on student learning and that neither participation nor nonparticipation would affect their grades. Students signed a consent form granting permission for their CMs and comments to be evaluated and included in publications. All students in the course were required to take part in the class activity of concept mapping. However, those who did not wish to participate in the study would not have their CMs and comments included in data analysis. Course instructors did not know which students agreed or declined to participate. All students in the course chose to participate in the study. An instructor removed student names from papers and assigned codes, therefore investigators did not have knowledge of which students created the CMs. Additionally, students were asked to not place names on the self-assessment of learning and satisfaction questionnaires. HINCK ET AL Measurement and Data Analysis Scoring CMs The first (n = 23) and seventh (n = 23) CMs for each student were scored. These CMs will be referred to as CM1 and CM7. The CMs scored by investigators may or may not have been the same as the two CMs chosen by students to receive grades. The investigators did not have knowledge of which CMs were graded by instructors. Investigators scored CMs by assigning points for the presence of nine items: main health concern, two nursing diagnosis, prioritization of diagnosis, supporting data, short- and long-term goals, interventions, teaching, evaluation of care, and cross-links (see Table 1). The number of maximum points varied per item from 1 to 4 for 20 total points for the CM. Because the investigator scoring the CMs did not know the clinical situations, the investigator did not make judgments about the appropriateness of the care plan. An example of a CM, based on student work and minus identifying information, is included in Figure 1. To establish reliability of findings, two investigators scored all CMs, and the level of agreement was determined by number of agreements divided by number of possible agreements. For this process, the two investigators randomly chose and independently scored the same three CMs. The investigators discussed identification and scoring of unlabeled items and the minimum acceptable level of detail for acceptance of items, and agreement was reached. Then, three additional CMs were Figure 1. CM of care plan.

5 CONCEPT MAPPING 27 randomly chosen, independently scored by both investigators, and discussed. Agreement on individual items of the six CMs ranged from.44 to.70. The remaining 40 CMs were independently scored with an agreement on items ranging from.41 to 1.0 (mean of.84 for all items). Lower agreement ratings on the items identification of goals (CM1 =.53, CM7 =.87) and evaluation of care (CM1 =.41, CM7 =.83) were a result of continued differences in recognition of unlabeled items. In addition, identification of cross-links (CM1 =.59, CM7 =.59) had lower rater agreement because of differences in interpretation of whether a line was a link or cross-link. Two investigators scored all CMs; however, only one investigator s scores were used in data analysis. Student Satisfaction and Self-Assessment of Learning Questionnaire A questionnaire to evaluate students satisfaction with the presentation of CMs and their learning was administered during class time at the end of the course. Based on the Student Assessment of Learning Gains Instrument (Wisconsin Center for Education Research, 1997), the investigators developed a 21-item questionnaire consisting of 20 five-point Likert scale items that determined amount of learning (5 = great amount, 4 = moderate amount, 3 = fair amount, 2 = minimal amount, 1 = none). In addition, an open-ended question asking if there was anything else about learning with the use of concept mapping they would like to say. Three doctorate-prepared investigators, who were not involved in data collection and analysis, reviewed a draft of the questionnaire for clarity, appropriateness of the content, format, and style. Data Analysis Analysis was conducted with SPSS 12.0 (SPSS, Chicago, IL). A paired samples t test was used to compare CM mean scores at the beginning and end of the course (CM1 = CM7). Student self-evaluation of learning and satisfaction questionnaires were evaluated by calculating the means and standard deviations of each of the 20 Likert items. Students qualitative written responses on the final questionnaire item were analyzed for common themes. Results Students CM scores improved (CM1: M = 17, range 8 20; CM7: M = 19, range 16 20), with no students decreasing scores. Means of the first (CM1: M = 15.35, SD = 2.95) and the second set (CM7: M = 17.39, SD = 1.12) of CMs were calculated, out of 20 possible points. A significant increase in comprehensiveness of CMs over the course was found (t = 3.01, df = 22, P =.006), with less variation among student scores, as evidenced by the standard deviation. Select results of the questionnaire are reported, with higher scores (1 5 range) indicating greater satisfaction. Students rated in-class practice (Item 3: M = 3.78, SD = 0.74; Item 4: M = 3.74, SD = 0.81) most favorably and least favored reading assignments (Item 5: M = 2.65, SD = 1.34) to learn how to create CMs. Satisfaction with grading of maps was high (Item 8: M = 3.96, SD = 0.93), and feedback was appreciated (Item 9: M = 3.96, SD = 0.71). Students said CMs improved thinking ability (Item 12: M = 3.08, SD = 1.09), preparation for the real world (Item 13: M = 3.04, SD = 0.83), and ability to understand complex situations in the community (Item 14: M = 3.17, SD = 0.98). Students believed that CMs helped them create their care plan for clients in the community (Items 16 19: M range = , SD range = ) and enhanced their overall learning (Item 20: M = 3.26, SD = 1.06). Four students wrote comments on the questionnaire (two were in favor of concept mapping and two did not like the activity). Students positive comments about concept mapping included: bi really liked the concept map and feel I benefited from doing them. I think they should be continuedq and bi liked the concepts. The feedback we got on them was very useful.q Two of the students struggled with CMs as evidenced by these comments: bit is difficult to get what I m thinking into a concept mapq and bconcept maps were a hassle and a burden. I learned from the process of writing things down but not from putting it into a concept map and connecting things. I would prefer to go back to care plans.q An additional recommendation by students was to allow adequate time for concept mapping. Many students said they spent 3 hours or more preparing the CMs. Discussion This study supported concept mapping as a learning strategy for nursing students in community settings and extended knowledge in community-based nursing education. As with all studies with small samples, generalization of findings must be made cautiously. However, this study adds to the growing body of knowledge that suggests concept mapping improves students abilities to see patterns and relationships. Prior research suggested that CMs may help nursing students prepare for clinical experiences in hospital settings (Daley et al., 1999; Wheeler & Collins, 2003), settings in which the focus of care is often on physiological symptoms and medical treatments, many of which can be gleaned or at least confirmed with the medical record. Community settings require different nursing skills because resources may be more varied and the solutions to problems abstract. A greater number of factors may affect the response to teaching and other interventions in the community. An instructor attested to the practical value of concept mapping in community settings when she said, bthe CMs gave a holistic picture of the clients and the complexity of their life circumstances. It became clear why many of the clients problems were so difficult to resolve.q

6 28 Students had stronger preferences when rating their satisfaction with how CMs were presented and scored in class, than when self-assessing how much CMs improved their learning. This may possibly suggest students are either unsure of how to self-assess learning or unaware that learning occurred. However, their skills in creating CM care plans significantly improved during the course. Overall, students did not have difficulty identifying the components of the nursing care plan, probably because they had prepared traditional care plans for two prior courses. This was an advantage for students because they knew the elements of a nursing diagnosis, appropriate interventions, and how to write behavior and time specific outcome goals. It is notable that the students ability to see relationships improved after only one course using concept mapping although students had created care plans for two prior courses. Concept mapping expanded students knowledge beyond what they learned during two courses using traditional care plans. Investigators have suggested that an increase in complexity in CMs indicates an increase in conceptual and critical thinking (Daley et al., 1999; Wheeler & Collins, 2003) and may be an indirect measure of clinical performance. Students are more adept at creating CMs with practice and feedback; however, further research is warranted to examine how and to the extent that concept mapping may improve clinical practice. Additional strategies to directly and indirectly measure the effectiveness of CMs are needed. Some students dissatisfaction with concept mapping may be related to the learning style of the students. Mueller et al. (2001) suggested that concept mapping may be more difficult for persons who are linear thinkers, and their CMs will appear as a flowchart form. In addition, because concept mapping is a graphic technique, students with visual learning styles may prefer this method more than do students with strong auditory or kinetic learning styles. Therefore, concept mapping is only one of the multiple learning techniques that can be employed. Further study may explain why some students prefer the visual diagramming of care plans, and others prefer the more linear presentation of information. Students commented that the CMs took a large amount of time, often more than 3 hours, to construct. Others also received feedback that concept mapping was time-consuming (Daley et al., 1999; Schuster, 2000) and overwhelming at first (Baugh & Mellott, 1998; Wheeler & Collins, 2003). Concept mapping may become easier and faster with practice. This was the first time the students had created CMs and their abilities may continue to increase. Novak (1990) suggested that skill in use of CMs may develop over 1 2 years. He reported that for 2 4 weeks after CMs were initiated with university students, a decline in learning was seen as measured by standard written exams, and then, test scores increased. Concept mapping skills may initially develop over one semester, HINCK ET AL as found in our study and others (Daley et al., 1999; Rooda, 1994; Wheeler & Collins, 2003), and then improve. Longitudinal studies may show whether improvements in identifying pertinent factors in situations continue or increase in months and years. Instructors recommended placing the client, rather than the client s main health concern, in the center of the CM to more accurately show relationships. The main concern, health history, family, environment, and other concepts flow from the client. Some information that is important to understanding the client may not be related to the main health concern. Therefore, CMs with the client as the focus may show a more complete picture of assessment. An instructor commented, bafter reading the CM, I felt like I really knew this client instead of just knowing a diagnosis about the client.q Whether and how to grade CMs is controversial. CMs are a visual way students demonstrate learning, making CMs attractive as a method of measurement. However, some educators caution against grading CMs because it can inhibit creativity and learning. Students may structure their maps to meet the grading criteria and, thus, not expand their thinking to the greatest extent possible. To encourage students to try out different representations, students may be given few instructions and full freedom in mapping their perceptions of a client (All & Havens, 1997). Conversely, if students are given guidelines and examples, they may have a better understanding of how to view the client from a holistic nursing perspective. Many nursing students have a good understanding of anatomy, physiology, and pharmacology learned in prior coursework and, therefore, may emphasize these concepts. Because students are novices in nursing care, they need guidance about what elements to include in the care plan. Instructor feedback can then draw attention to any undeveloped areas. It can be demoralizing to students if instructors give few instructions and then extensive feedback of what should have been included. Methods of grading CMs include assigning points for the number of concepts, hierarchies, and cross-links (Daley et al., 1999; Rafferty & Fleschner, 1993), and as in our study, the elements of the care plan. Evaluating the quality and appropriateness of a care plan is a subjective process. Achieving consistency in grading is difficult, as evidenced by our low interrater agreement of some items, and may contribute to why some educators prefer not to grade CMs. Standardizing scoring with multiple clinical instructors is a challenge. In this study, the three clinical instructors worked together closely to achieve consistency. Weekly discussions provided the opportunity to share how they evaluated CMs. Areas of concern for them included the level of acceptable detail and wording of CMs. For example, instructors required that students provide the detail of specific client behaviors rather than simply stating that the goals were met.

7 CONCEPT MAPPING 29 Conclusion Based on a review of the literature, this study is the first to examine the effectiveness of CMs to plan and evaluate nursing care in community settings. The comprehensiveness of students care plans improved when they diagramed the main concepts and relationships between concepts. Further, most students were satisfied with this strategy to learn how their clients health existed in context to a situation. Because nursing care in the community is often complex and changes in each setting, students are best served if they are helped to learn how to process new information rather than memorize care required in a specific setting. With concept mapping, the focus is on facilitating learning rather than teaching facts. Concept mapping is an effective learning strategy to help students apply new knowledge and skills to clients with complex health-care needs. Acknowledgments The research and development activities undertaken in this project were part of the Teaching Fellowship Program hosted by the Academic Development Center at Missouri State University. References All, A. C., & Havens, R. L. (1997). Cognitive/concept mapping: A teaching strategy for nursing. Journal of Advanced Nursing, 25, All, A. C., Huycke, L. I., & Fisher, M. J. (2003). Instruction tools for nursing education: Concept maps. Nursing Education Perspectives, 24, American Association of Colleges of Nursing. (1999). Essential clinical resources for nursing s academic mission. Washington, DC: Author. Ausubel, D. P., Novak, J. D., & Hanesian, H. (1986). Educational psychology: A cognitive view (2nd ed.) New York: Holt, Rinehart & Winston. Baugh, N. G., & Mellott, K. G. (1988). Clinical concept mapping as preparation for student nurses clinical experiences. Journal of Nursing Education, 37, Beitz, J. M. (1998). Concept mapping: Navigating the learning process. Nurse Educator, 23, Daley, B. J., Shaw, C. R., Balistrieri, T., Glasenapp, K., & Placentine, L. (1999). Concept maps: A strategy to teach and evaluate critical thinking. Journal of Nursing Education, 38, Francisco, J. S., Nakhleh, M. B., Nurrenbern, S. C., & Miller, M. L. (2002). Assessing student understanding of general chemistry with concept mapping. Journal of Chemical Education, 79, Irvine, L. M. C. (1995). Can concept mapping be used to promote meaningful learning in nurse education? Journal of Advanced Nursing, 21, Kathol, D. D., Geiger, M. L., & Hartig, J. L. (1998). Clinical correlation map: A tool for linking theory and practice. Nurse Educator, 23, Kemp, C. E. (2003). Community health nursing education: Where we are going and how to get there. Community Health Nursing, 24, Leauby, B. A., & Brazina, P. (1998). Concept mapping: Potential uses in accounting education. Journal of Accounting Education, 16, Matteson, P. S. (2000). What is community-based education? In J. Stanley (Eds.), Implementing communitybased education in the undergraduate nursing curriculum (pp. 5-12). Washington, DC: American Association of Colleges of Nursing. Mueller, A., Johnston, M., & Bligh, D. (2001). Mindmapped care plans: A remarkable alternative to traditional nursing care plans. Nurse Educator, 26, Novak, J., & Gowin, D. B. (1984). Learning how to learn. New York: Cambridge University Press. Novak, J. D. (1990). Concept maps and Vee diagrams: Two metacognitive tools to facilitate meaningful learning. Instructional Science, 19, Rafferty, C. D., & Fleschner, L. K. (1993). Concept mapping: A viable alternative to objective and essay exams. Reading, Research, and Instruction, 32, Rooda, L. A. (1994). Effects of mind mapping on student achievement in a nursing research course. Nurse Educator, 19, Schmid, R. F., & Telaro, G. (1990). Concept mapping as an instructional strategy for high school biology. Journal of Educational Research, 84, Schuster, P. M. (2000). Concept mapping: Reducing clinical care plan paperwork and increasing learning. Nurse Educator, 25, Schuster, P. M. (2002). Concept mapping: A critical-thinking approach to care planning. Philadelphia: F.A. Davis. Stanley, J. M., Kiehl, E. M., Matteson, P. S., McCahon, C. P., & Schmid, E. S. (2002). Moving forward with communitybased nursing education. Washington, DC: American Association of Colleges of Nursing. Taagepera, M., & Noori, S. (2000). Mapping students thinking patterns in learning organic chemistry by the use of knowledge space theory. Journal of Chemical Education, 77, Wheeler, L. A., & Collins, S. K. R. (2003). The influence of concept mapping on critical thinking in baccalaureate nursing students. Journal of Professional Nursing, 19, Wisconsin Center for Education Research. (1997). Student Assessment of Learning Gains Instrument. Retrieved December 16, 2003, from