Accepted Manuscript

A qualitative study on using concept maps in problem-based learning

Zenobia C.Y. Chan

PII: S1471-5953(17)30226-3
DOI: 10.1016/j.nepr.2017.04.008
Reference: YNEPR 2215

To appear in: Nurse Education in Practice

Received Date: 29 July 2015

Revised Date: 21 April 2016
Accepted Date: 10 April 2017

Please cite this article as: Chan, Z.C.Y., A qualitative study on using concept maps in problem-based
learning, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.04.008.

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 ACCEPTED MANUSCRIPT
A qualitative study on using concept maps in problem-based learning

Author: Zenobia C. Y. Chan

Post: Associate Professor

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Affiliation: School of Nursing, The Hong Kong Polytechnic University

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Address: School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon,

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Hong Kong

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Phone number: +852 2766 6426
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Fax number: +852 2364 9663
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Email: zenobia.chan@polyu.edu.hk
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Type of paper: Research Paper

Word count: 4,710

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Funding source: This research was financially supported by The Hong Kong Polytechnic
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University (Project Code: A-PM14). The funding source did not involve
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in the entire study.

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A qualitative study on using concept maps in problem-based learning

SUMMARY
Background: The visual arts, including concept maps, have been shown to be effective
tools for facilitating student learning. However, the use of concept maps in nursing
education has been under-explored.
Objectives: The aim of this study was to explore how students develop concept maps and

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what these concept maps consist of, and their views on the use of concept maps as a
learning activity in a PBL class.
Design: A qualitative approach consisting of an analysis of the contents of the concept maps

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and interviews with students.
Settings: The study was conducted in a school of nursing in a university in Hong Kong.

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Participants: A total of 38 students who attended the morning session (20 students) and
afternoon session (18 students) respectively of a nursing problem-based learning class.
Methods: The students in both the morning and afternoon classes were allocated into four

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groups (4-5 students per group). Each group was asked to draw two concept maps based on
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a given scenario, and then to participate in a follow-up interview. Two raters individually
assessed the concept maps, and then discussed their views with each other.
Results: Among the concept maps that were drawn, four were selected. Their four core
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features of those maps were: a) the integration of informative and artistic elements; b) the
delivery of sensational messages; c) the use of images rather than words; and d)
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three-dimensional and movable. Both raters were concerned about how informative the
presentation was, the composition of the elements, and the ease of comprehension, and
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appreciated the three-dimensional presentation and effective use of images. From the results
of the interview, the pros and cons of using concept maps were discerned.
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Conclusions: This study demonstrated how concept maps could be implemented in a PBL
class to boost the students’ creativity and to motivate them to learn. This study suggests the
use of concept maps as an initiative to motivate student to learn, participate actively, and
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nurture their creativity. To conclude, this study explored an alternative way for students to
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make presentations and pioneered the use of art-based concept maps to facilitate student
learning.

Keywords: concept map; nursing; problem-based learning; qualitative study

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INTRODUCTION

In order to cultivate practitioner-leaders, the General Medical Council (GMC)

recommends that a student-driven learning approach be used to develop nursing education

in universities (Cragg and Andrusyszyn, 2004; Iwasiw et al., 2007). Problem-based learning

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(PBL) is a learning and teaching strategy widely used in medical and nursing education to

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nurture in students the ability to apply health care knowledge, develop problem-solving

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skills and clinical reasoning skills, and breadth and depth in critical thinking, as part of the

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process of training professional and ethical nurses in the future (Murphy et al., 2011;
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Niemer et al., 2010). In PBL, students are usually divided into groups, since learning in
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small groups is more efficient than individual learning in prompting students to achieve

(Lou et al., 2001). This study focused on the implementation of concept maps in a nursing
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PBL class. This activity was developed using elements of art education, as the adoption of

arts elements in nursing education can enhance artistry, critical thinking, and creativity in
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students (Chan, 2013a; Leonardo, 2003). Students can express their beliefs through the
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agency of literate subjects or cultural work (Leonardo, 2010), and this educational approach
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is very important in the nursing curriculum, since there is a strong human dimension to the

nursing profession.

Problem-based learning (PBL) is increasingly common in nursing education. The focus

of research on PBL is gradually shifting from comparing the learning outcomes of PBL with

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those of conventional teaching approaches to enhancing the learning efficiency of PBL by

adopting innovative teaching strategies (Chan, 2013a; Chan, 2013b) or to suggesting new

research elements or learning objectives, such as cultural influences (Frambach et al., 2012)

and interprofessional education (Almy et al., 1992; Salvatori et al., 2007).

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The aim of this study was to explore how concept maps were implemented in a PBL

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class, to identify whether these maps had any impact on student creativity.

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LITERATURE
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In this study, concept maps are regarded as a form of the visual arts. The visual arts have
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been shown to be effective tools for facilitating nursing/medical care, especially elderly care

or care in mental health settings. Wikström (2000; 2002) discovered that reproductions of
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pictures of works of art could enhance communication and social interaction among the

elderly, since the clients in the study were encouraged to express their knowledge and
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experience with reference to those artworks. Locsin et al. (2003) revealed that patients’
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drawings could allow readers to gain a deeper insight into the patient’s lived experiences.
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Nanda et al. (2011) investigated how the display of virtual art reduced anxiety and agitation in

patients. Due to their effectiveness in health care services, the visual arts are also becoming

increasingly popular in nursing or medical education. While lecture materials are only plain

texts, drawing can add breadth and depth to the students’ understanding of the clinical world.

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For instance, since medical staff have to make judgements according to a patient’s physical

and mental state, Naghshineh et al. (2008), and Wikström (2011) taught visual literacy to help

students develop skills in observing and interpreting the expressions and situations of patients.

Furthermore, the visual arts have been shown to have a significant effect on promoting deeper

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learning (Moulton and McMain, 2004), professional knowledge (Tapajos, 2003), the

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motivation to learn, and emotional control in students (Wikström, 2001).

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The use of the visual arts, especially concept maps, in nursing education in the local
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context has yet to be well explored. The aim of this study was to fill this gap by examining
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how concept maps can be adopted in a nursing problem-based learning (PBL) class and how

the visual arts can be applied in nursing education.

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A concept map is a research and learning tool to help a person visualise how isolated
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concepts are connected. This approach was introduced by Novak and Gowin (1984), who
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aimed to show, through the use of a diagram or a framework, the main concepts involved in a
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study. It was founded on the principle of constructivism, which emphasises the critical role

played by learners in constructing and developing knowledge and meanings from their

experiences and beliefs (Conceição and Taylor, 2007). A concept map is a learning strategy

that provides students with a space to accommodate, by means of a piece of paper, newly

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acquired concepts in their original knowledge base of complex concepts (Revell, 2012). It

also gives faculty members an opportunity to evaluate a student’s progress in learning and to

highlight areas for improvement. Lee et al. (2013) stated that concept maps can help students

to develop their critical thinking skills by encouraging deep learning and a focus on the study

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content instead of on the assessment system. Throughout the process of concept mapping,

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students will pursue the acquisition of additional information using logical reasoning to

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illustrate the links between concepts (Bittencourt et al., 2013).

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The effectiveness of a concept map as a tool to help students organise their knowledge
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can be improved by providing students with instant feedback to revise their work (Wu et al.,

2012). While comparing the concept map to text-based planning about the writing of a photo
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story, students who used the graphic tool, the concept map, demonstrated more creativity in

their photo stories (Simper et al., 2016). It is important to give students an idea of the
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usefulness of concept maps in theoretical and clinical settings(Harrison and Gibbons, 2013).
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Compared with interviews and questionnaire surveys, the unique advantage of a

concept map, namely the visualisation and the co-construction of meanings from the

perspectives and experiences of participants, has recently prompted scholars to adopt it for

use in research on health services and policies (Nalavany et al., 2011; Parsons et al., 2011).

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Ridde (2008) and Burgess-Allen and Owen-Smith (2010) invited stakeholders of a health

policy and service to generate and organise ideas via concept maps. Gortzis (2010) used a

concept map to depict the relationship among various issues relating to electronic clinical

technologies. In addition to research, the concept map is commonly used in teaching PBL

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and group learning (Daley and Torre, 2010). It not only arouses the interest and motivation

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of students to learn (Edwards and Cooper, 2010), but also enhances their critical thinking

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and problem-solving skills (Daley and Torre, 2010). Many scholars have suggested that

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concept maps be used to train students in clinical reasoning, critical thinking, and in the
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application of theoretical knowledge for future clinical practice (Torre et al., 2007; Pottier et
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al., 2010; Atay and Karabacak, 2012). While most studies have concentrated on the

influence of concept maps on critical thinking, Kassab and Hussain (2010) have stated that
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concept maps could also enhance the creativity of students. Since creativity is crucial in

enhancing the spiritual attributes (Hall and Mitchell, 2008) and active engagement
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(Emmanuel et al., 2010) of students, and since the relationship between concept maps and
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creativity has yet to be fully explored, this paper investigated the issue of whether and how
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innovative concept maps supplemented with arts elements improves the creative thinking

abilities of students.

The health professions are an integration of the arts and sciences. When clinical staff

respond to realistic health situations, they need to demonstrate professional care and express

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feelings of empathy when communicating (Markel and Arbor, 1984; Davidoff, 2011). Not

only can the arts facilitate the expression of such feelings in a creative and aesthetic manner

(Wikström, 2003; McCaffrey and Purnell, 2007), but they can also make it easier for a

health professional to visualise the scientific knowledge needed to deal with the situation

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(Ainsworth et al., 2011). In nursing education, where students are usually given images and

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diagrams to interpret, the arts allow them to develop their own inferences in novel

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representations (Ainsworth et al., 2011). As students may not have adequate life experience,

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the arts can reveal their hidden thoughts and understandings of a particular socio-cultural
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issue, such as old age (Roberts et al., 2003; Wikström, 2011) and sexual differences
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(Aronoff and McCormick, 1990). Therefore, for some time now arts-based learning has

been included in nursing education to supplement the non-science contents of the

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curriculum. The subjects that are covered include understanding the sufferings of patients

and their families, providing them with emotional and spiritual support, and fostering
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creativity. The aim is to prepare future nurses with the ability to cope with clinical situations
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and interpersonal relationships (Shapiro et al., 2006a; Casay, 2009; de la Croix et al., 2011;
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Ting et al., 2012). Drawing, dancing, and other arts-based approaches have been explored to

develop the generic skills of the students and to allow the researchers to better understand

the students’ inner world (McLean et al., 2003; Shapiro et al., 2006b; Chan, 2013).

However, after reviewing a series of studies, Perry et al. (2011) concluded that the

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evaluations that have been conducted of the learning effectiveness of arts-based

interventions in the nursing curriculum lack soundness. Therefore, this study investigated

the nature of concept maps and their representations from the perspective of students, based

on a PBL case scenario.

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METHODS

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This study was one arm of a major educational study. In this study, a qualitative design

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was adopted consisting of an analysis of the contents of both concept maps and interviews

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with students. The intention was to present a holistic and detailed picture of the contextual
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realities of learning in a PBL class (Dempsey and Dempsey, 2000; Hansen, 2006). The
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concept maps produced by the students were examined, since the process of making the

concept maps allowed the participants to express their perspectives in a more innovative,
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active, and autonomous manner than usual (Clayton, 2006; Conceição and Taylor, 2007;

Edwards and Cooper, 2010).

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Participants
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The participants were 38 nursing students from two PBL classes (18 in the morning

class and 20 in the afternoon class) from a nursing school at a university in Hong Kong.

They were randomly distributed into four groups per class, each containing four or five

students, to participate in drawing two concept maps during one PBL class. The ethical

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approval was obtained prior to collect the data with the consent forms were collected from

the participants.

Data Collection

In the case scenario below, they were asked to collaboratively draw a creative concept

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map on poster paper in about 30 minutes. They tended to start drawing up the concept maps

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by analysing the key points of the case and investigating the context of the patient’s case.

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Then, they discussed the presentation and did a sketch. Finally, they refined the concept

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map and wrote the keywords on it. When they were satisfied with the result they took
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photographs of the concept maps. Six out of the eight groups produced two concept maps
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while another two groups only produced one concept map. Ultimately, total of 14 concept

maps were collected. Through a consensus reached between the author and the students and
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through a vote among the students on the best and most representative concept maps, the

following four concept maps were ultimately selected for analysis.

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Case Scenario Description

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The four selected concept maps were based on the following case adopted from the
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author’s school, with each group focusing on a particular issue based on a consensus

reached among the members of the group on the need to maximise the use of lesson time:

Mrs Law, 43 years old and overweight, has four children. One day, Mrs Law

experienced nausea and right upper quadrant abdominal pain. On the following day, her

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urine became dark brown, the stool appeared pale yellow, and she emitted some

foul-smelling gas. Through a series of investigations, the medical practitioner diagnosed her

condition as cholelithiasis. After undergoing a surgical operation, Mrs Law was given an

intravenous (IV) infusion Mrs Law’s daughter was worried about her mother, especially

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when she saw the drain, the IV line, and the nasogastric (NG) tube. Mrs Law was not

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satisfied with her recovery process, since she continued to suffer from pain and nausea and

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was not informed about the self-caring process.

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Data Analysis
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All of the 14 concept maps were first screened by two raters (one was the author and

the other was the research assistant). A consensus was reached on the selection of four
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concept maps, which were deemed to be the most representative. These were then assessed

based on techniques for assessing comprehensiveness, proposed by Urban (2004) and Chen
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et al. (2002). Urban’s Test of Creative Thinking – Drawing Production (TCT-DP) was
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developed using two commonly adopted instruments, namely the Test for Divergent
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Thinking and the Verbal Creativity Test, and refining their weaknesses of range. Using this

assessment technique, this study evaluated the students’ concept maps according to

differences in the design and composition of the product, whether the maps gave evidence

of thinking outside of a given frame, and on whether innovative use had been made of the

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space provided. Since the above assessment technique was contextualised in a German

setting, to prevent cultural bias this study also referred to another assessment tool suggested

by Chen et al. This assessment tool is particularly suitable for investigating the cultural

elements involved in the drawing of different shapes, by assessing creativity and appeal as

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judged by subjective reactions to the drawings, the uniqueness of the presentation, and

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artistic ability. To conclude, the four concept maps were assessed according to the

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following dimensions using a five-point scale and overall comments: (i) differences in

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design, (ii) the composition of the map, (iii) thinking outside a given frame, (iv) innovative
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use of the space provided, (v) creativity, (vi) appeal, (vii) uniqueness of the presentation,
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and (viii) artistic ability. To enhance the trustworthiness of the research results, the two

raters analysed the concept maps individually, and then held regular meetings to discuss the
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issue of inter-rater reliability and to compare similarities and differences in their analyses.
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RESULTS
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The groups of students in the PBL class designed concept maps (Figures 1–4) to
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summarise the main themes of the given case. The four selected concept maps shared

common elements with regard to the diagnosis and treatment of the case, such as

cholelithiasis, cholecystectomy, and the amount of IV infusion. Another main theme shown

in the concept maps was the suffering of the patient and her family members. Two concept

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maps (Figures 1, 4) illustrated this point using the words “pain” and “right upper quadrant

abnormal pain”, while the other two concept maps (Figures 2, 3) depicted it using facial

expressions to represent the feelings of the patient and family members. Groups 1 to 3 drew

the concept maps on poster-sized paper (Figures 1–3), and Group 4 folded the piece of

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paper to form a flower of the kind used in a traditional paper game known as Pakupaku,

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also called “East, South, West, North” (Figure 4). Details of the characteristics of each

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concept map are given below.

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Figure 1 mainly illustrates the various treatments given to a patient suffering from
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cholelithiasis. The top left shows cholelithiasis, with a pair of scissors depicting the cutting
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of the gallbladder from the liver. The bottom left is a loudspeaker, which depicts the use of

shock waves to remove gallstones via lithotripsy. On the right is an image of an IV infusion
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1/2:1/2 solution. Although most of the elements shown on this concept map are related to

the treatments, at the centre of the map is a word in capital letters: “pain”. An adhesive
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bandage placed on the cholelithiasis demonstrates the students’ creativity competence and
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caring attitude. On this concept map, the students demonstrated both their professional
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knowledge and their understanding of the patient’s condition.

[Insert Figure 1 here.]

The concept map in Figure 2 consists of two parts. The left refers to cholelithiasis and

the right refers to cholecystectomy. The liver and gallbladder placed at the middle of the

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concept map are also separated in half to show the influence of cholelithiasis and

cholecystectomy before and after the surgery. The elements depicted on the left include the

symptoms (stool and gas) and the drugs (ibuprofen and tramadol). Several gallstones are

also present in the gallbladder. The right part illustrates the characteristics of the IV infusion

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and the removal of the gall bladder. The bottom of the concept map draws the attention of

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readers, with the facial expressions and the remarks from the four girls showing changes in

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the emotions of the patient’s daughters. The four girls on the left look worried, anxious, and

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frustrated, while the girls on the right are holding hands and looking happy.
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[Insert Figure 2 here.]
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Of the four the concept maps, Figure 3 was the only one to use only images to express

the main themes. The image on the left focuses on the sufferings of the patient and her
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family. The top left shows the patient undergoing IV infusion and experiencing frequent

nausea, while the bottom left shows expressions of pain on the faces of the patient and her
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daughters. The middle of the concept map depicts the surgical operation and post-operative
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nutritional care. The right shows the colour of the patient’s stool changing from pale yellow
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to black and red.

[Insert Figure 3 here.]

Figure 4 presents a three-dimensional concept map. A piece of paper was folded to

form a flower, the school logo was cut into the shape of two leaves for decoration, and the

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petals were a toy with origins in a traditional paper game called Pakupaku or “East, South,

West, North”. The players could choose one of four positions, labelled “diagnosis”,

“assessment”, “planning and implementation”, and “evaluation”. The players then randomly

choose a position. Each position consists of two faces, which represent the main themes of

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two scenarios. The faces of the position marked “diagnosis” are: (i) cholelithiasis; and (ii)

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fluid loss. The faces of “assessment” are: (i) right upper quadrant abnormal pain, nausea

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two days ago, dark brown urine, pale yellow stool, and yellow cast of skin; and (ii) intake

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and output, electrolyte imbalance, and complications after an operation. The faces of
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“planning and implementation” are: (i) an operation is scheduled; and (ii) IV infusion
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1/2:1/2 solution, drain, and NG tube. The faces of “evaluation” are: (i) assess Mrs Law’s

pre-operation condition and prepare for the operation; and (ii) amount and characteristics of
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drainage, and wound healing.

[Insert Figure 4 here.]

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In short, three concept maps used simple images to summarise the surgery and
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post-operational caring process, and to describe the facial expressions of a patient and the

emotional state of the patient’s family members. One of the maps contained only images

without words. The fourth map far exceeded the usual expectations of a concept map. It was

a three-dimensional flower used in a traditional paper game, with the petals showing the

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main contents of the map.

DISCUSSION

The two raters assessed the four concept maps separately using the abovementioned

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five-point scale (Chen et al., 2002; Urban, 2004) (Please refer to Table 1 below). The mean

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score of the concept maps was 3.66 and the inter-rater reliability was 0.88. Figure 4

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received the highest scores from both raters, while Rater 1 rated Figure 2 the lowest and

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Rater 2 rated Figure 3 the lowest. The maps gained higher scores for “thinking outside a
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given frame” and “appeal”, and lower scores for “composition of the map” and “artistic
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ability”.

*Insert Table 1 here.

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The two raters’ comments were generally similar. Both were concerned about the

informativeness of the presentation, the composition of the elements, and the

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comprehensibility of the presentation. They especially appreciated the three-dimensional

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presentation and effective use of images. The differences in rating were due to the fact that
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Rater 1 emphasised the connection among themes and the use of actual objects, while Rater

2 focused on the use of colour and space. Four features of concept maps were discerned

based on the analysis of the four concept maps, namely: a) the integration of informative

and artistic elements; b) the delivery of sensational messages; c) the use of images rather

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than words; and d) three-dimensional and movable.

Concept maps consist of informative and artistic elements

Most of the concept maps had a balance of informative and artistic elements. The

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students demonstrated creative skills by visualising the processes of surgical treatments

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using simple shapes (Ainsworth et al., 2011; Parsons et al., 2011). The use of an adhesive

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bandage successfully drew the raters’ attention, as actual objects are seldom placed on

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concept maps. The composition of the elements showed that the students gave careful
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consideration to the drawing (Gortzis, 2010).
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Rater 2 appreciated the unique design and composition of Figure 2. It made clear the

changes in the patient before and after the surgery. The contents were brief and the images
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were interesting and simple. Rather than occupying the space with the branches of a

complicated tree structure, this map left some visual space for the readers’ imagination.
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Rater 2 stated that this concept map demonstrated the adage of “simple is beautiful”, which
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is the advantage of using a concept map (Burgess-Allen and Owen-Smith, 2010). The
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fluorescent colours attracted the readers’ attention, and the concise content fulfilled the

requirements of the PBL facilitator while demonstrating the students’ familiarity with

medical knowledge.

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Concept maps deliver sensational messages

Figure 1 successfully emphasised the topics of pain and sadness by using simple words and

dark colours. It showed that the students sincerely empathised with the patient in her

sufferings (Nalavany et al., 2011). This concept map consisted of the images of a wound, a

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liver, and an infusion, which was informative and reflected an understanding of professional

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treatment (McLean et al., 2003).

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Rater 1 stated that Figure 2 clearly presented the situation of the patient before and

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after the surgery. The images depicting the emotional changes in the patient’s family were
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particularly appreciated (Ridde, 2008).
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Of the four concept maps, Figure 2 illustrated the sufferings of the patient’s family in

the most detail, which demonstrated the students’ empathy. Rater 1 suggested that this
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concept map could be improved by replacing the curves with clearer labels to indicate the

connection among keywords (Gortzis, 2010).

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Concept maps use images rather than words

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Rater 1 mentioned that it is a challenge to express professional knowledge in images

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only, and that Figure 3 successfully met the challenge. This concept map used drawings to

depict the physical and emotional suffering involved, and the nutritional care and surgical

treatment required (Shapiro et al., 2006a, b). By using creative images, the professional

contents became comprehensible to a non-specialist. Rater 2 commented that Figure 3

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consisted of several colourful images and the knowledge that was delivered was easy to

comprehend (Wikström, 2011). Although Figure 3 conveyed a certain amount of

information on nursing care, the construction of the design did not fully demonstrate the

outcome of knowledge translation.

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Concept maps can be three-dimensional and movable

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According to Rater 1, Figure 4 exceeded the expectations of a concept map. The idea of

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using a three-dimensional paper game to connect the main themes was innovative. However,
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since the composition of this map was restricted by the game, the theoretical connection
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among the concepts was not fully elaborated (Torre et al., 2007). The students could show

more of their artistic ability by drawing images on the faces of the positions. Rater 2 stated
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that this concept map went beyond her expectations. It was in three dimensions and

consisted of motion elements suitable for educational purposes (Daley and Torre, 2010).
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The students made full use of the paper to produce different parts of the flower. This
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concept map systematically showed an understanding of nursing processes (Conceição and

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Taylor, 2007). However, the students should have employed more critical thinking and

digested the contents of the case.

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Students’ thoughts on concept maps

The participants were invited for a follow-up interview after the PBL class, conducted

by the research assistant. The students’ thoughts on concept maps were as follows.

Regarding concept maps as a learning activity, half of them agreed that concept maps

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enhance the efficiency with which a clinical case is analysed, while the other half stated that

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presenting the information in words is more efficient than using concept maps. Two

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representative quotes from the students are given below:

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One student from the morning class said:
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Drawing concept maps is a good way to enhance the comprehensiveness of an

analysis of a patient’s background. We (students) can remember the materials

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through the concept map memory method, and it is an interesting and fun way of

learning. In addition, it may not be easy to present some information, such as the
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structure of the human body, in words; in such cases, concept maps are a more
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efficient learning tool.

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Another student from the afternoon class held a different opinion:

I can express myself more clearly in words than in drawing a concept map, and

different people may perceive concept maps differently. Furthermore, drawing a

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concept map may not facilitate a more systematic analysis. I think that concept

maps may help with understanding abstract concepts, but may not be as efficient

for conveying concrete information.

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The above excerpts are an indication of the opposing perspectives of students on the

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effectiveness of using concept maps in learning. Those who did not prefer concept maps,

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suggested other alternatives, such as listing keywords, and setting out the priorities for

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patient care plan.
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Over half of the students thought that there was a connection between concept maps
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and nursing care, and some of them stated that concept maps were not an efficient way of
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learning. Others mentioned that drawing is an interesting approach to learning, and stated
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they were able to memorise complicated information more easily through pictures.
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Therefore, we should challenge the general understanding of nurses as care providers who

approach their work in a structured and organised manner and who lack artistry and
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imaginative ability, and embrace the importance of artistry in nursing training. Furthermore,

to fulfil society’s expectations of current nursing graduates, namely that they should have

the ability to think in an innovative and abstract manner (Ball et al., 2010), according to

Wikström (2001), and Moulton and McMain (2004) we should develop a comprehensive

nursing programme with elements of artistry.

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When the students were given more freedom to create concept maps, rather than

simply using a conventional tree structure they made use of kinetic movement and energy in

learning (Burgess-Allen and Owen-Smith, 2010; Edwards and Cooper, 2010; Frambach et

al., 2012). They produced a comic or even a three-dimensional figure to convey the

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messages and to construct and internalise the knowledge that they needed to learn

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(Conceição and Taylor, 2007). In addition, the method of analysis, namely a qualitative

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approach of examining overall comments, supplemented by a quantitative approach of

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rating them, balanced the subjective and objective components of an evaluation. Since this
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study is a one-time assessment performed by independent raters, it is recommended that
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future studies include students’ self-assessments of concept maps.

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Limitations
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There are two limitations in this study. First, students whose talents lie elsewhere or
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who dislike concept maps may not enjoy the process of producing concept maps. Second,
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although the students could state the basic visual elements shown in the concept maps, they
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found it difficult to discuss more sophisticated health issues based solely on the concept

maps. Third, the students needed to finish drawing within a short period of time and with

limited resources. In a future replication of this learning activity, it is suggested that some

examples of previous student concept maps be shown for reference and brainstorming

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purposes, that the students be allowed more time (such as one hour) to prepare the concept

map, or that students be allowed to produce the map at a time of their choosing, even if this

is outside of class time.

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CONCLUSIONS

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In evaluating the creativity of students through art-based concept maps, this study is a

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pioneer in nursing education. Through an analysis of the students’ artworks, this study
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revisited the definition of concept maps and explored alternative ways of expressing the

connections among key terms on a visual platform, which could help to enhance the
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students’ creativity in future clinical practice. This study found that including the arts,
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especially the visual arts, in nursing education, can cause students to develop better clinical
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observation skills and better critical thinking skills, to engage in deep learning, and to be
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more creative. The results suggest that the visual arts could play a pivotal role in nursing
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education.
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REFERENCES

Ainsworth, S., Prain, V., Tytler, R., 2011. Science education: drawing to learn in science.

Science 333 (6046), 1096-1097.

PT
Almy, T.P., Colby, K.K., Zubkoff, M., Gephart, D.S., Moore-West, M., Lundquist, L.L.,

RI
1992. Health, society, and the physician: problem-based learning of the social sciences

SC
and humanities. Eight years of experience. Annals of Internal Medicine 116 (7),

U
569-574.
AN
Aronoff, D.N., McCormick, N.B., 1990. Sex, sex role identification, and college students'
M

projective drawings. Journal of Clinical Psychology 46 (4), 460-466.

Atay, S., Karabacak, U., 2012. Care plans using concept maps and their effects on the
D
TE

critical thinking dispositions of nursing students. International Journal Nursing Practice

18 (3), 233-239.
EP

Ball, C.G., Sutherland, F., Kirkpatrick, A.W., Dixon, E., Maclean, A.R., Mack, L.A.,
C

Feliciano, D.V., Rajani, R.R., Karmy-Jones, R., Buie, W.D., Temple, W.J., Rozycki,
AC

G.S., Simeone, A., 2010. Dramatic innovations in modern surgical subspecialties.

Canadian Journal of Surgery 53 (5), 335-341.

23
 ACCEPTED MANUSCRIPT

Bittencourt, G.K.G.D., Nóbrega, M.M.L., Medeiros, A.C.T., Furtado, L.G., 2013. Concept

maps of the graduate programme in nursing: experience report. Revista Gaúcha de

Enfermagem 34 (2), 172-176.

Burgess-Allen, J., Owen-Smith, V., 2010. Using mind mapping techniques for rapid

PT
qualitative data analysis in public participation processes. Health Expectations 13 (4),

RI
406-415.

SC
Casey, B., 2009. Arts-based inquiry in nursing education. Contemporary Nurse 32 (1-2),

U
69-82.
AN
Chan, Z. C. Y., 2013a. Exploring creativity and critical thinking in traditional and innovative
M

problem-based learning groups. Journal of Clinical Nursing 22 (15-16), 2298-2307. doi:

10/1111/jocn.12186
D
TE

Chan, Z.C.Y., 2013b. Drawing in nursing PBL. Nurse Education Today 33 (8), 818-822.

Chen, C., Kasof, J., Himsel, A.J., Greenberger, E., Dong, Q., Xue, G., 2002. Creativity in
EP

drawings of geometric shapes. Journal of Cross-cultural Psychology 33 (2), 171-187.

C

Clayton, L.H., 2006. Concept mapping: an effective, active teaching-learning method.

AC

Nursing Education Perspectives 27 (4), 197-203.

Conceição, S.C.O., Taylor, L.D., 2007. Using a constructivist approach with online concept

maps: relationship between theory and nursing education. Nursing Education

Perspectives 28 (5), 268-275.

24
 ACCEPTED MANUSCRIPT

Cragg, C.E.B., Andrusyszyn, M.A., 2004. Outcomes of master's education in nursing.

International Journal Nursing Education Scholarship 1 (1), 1-18.

Daley, B.J., Torre, D.M., 2010. Concept maps in medical education: an analytical literature

review. Medical Education 44 (5), 440-448.

PT
Davidoff, F., 2011. Music lessons: what musicians can teach doctors (and other health

RI
professionals). Annals of Internal Medicine 154 (6), 426-429.

SC
de la Croix, A., Rose, C., Wildig, E., Willson, S., 2011. Arts-based learning in medical

U
education: the students' perspective. Medical Education 45 (11), 1090-1100.
AN
Dempsey, P.A., Dempsey, A.D., 2000. Using Nursing Research: Process, Critical
M

Evaluation, and Utilization, 5th ed. Lippincott, Philadelphia; New York.

Edwards, S., Cooper, N., 2010. Mind mapping as a teaching resource. Clinical Teacher 7 (4),
D
TE

236-239.

Emmanuel, E., Collins, D., Carey, M., (2010). My face, a window to communication: using
EP

creative design in learning. Nurse Education Today 30 (8), 720-725.

C

Frambach, J.M., Driessen, E.W., Chan, L.C., van der Vleuten, C.P.M., 2012. Rethinking the
AC

globalisation of problem-based learning: how culture challenges self-directed learning.

Medical Education 46 (8), 738-747.

25
 ACCEPTED MANUSCRIPT

Gortzis, L.G., 2010. Selecting healthcare information systems provided by third-party

vendors: a mind map beyond the manuals. Informatics for Health & Social Care 35 (1),

1-9.

Hall, J., Mitchell, M., 2008. Exploring student midwives creative expression of the meaning

PT
of birth. Thinking Skills and Creativity 3 (1), 1-14.

RI
Hansen, E.C., 2006. Successful qualitative health research: a practical introduction. Open

SC
University Press, Maidenhead, England; New York.

U
Harrison, S., Gibbons, C., 2013. Nursing student perceptions of concept maps: from theory
AN
to practice. Nursing Education Perspectives 34 (6), 395-399.
M

Iwasiw, C.L., Andrusyszyn, M.A., Goldenberg, D., 2007. Fostering future nursing

professionals: it's a matter of values. International Journal of Nursing Education

D
TE

Scholarship 4 (1), 1-2.

Kassab, S.E., Hussain, S., 2010. Concept mapping assessment in a problem-based medical
EP

curriculum. Medical Teacher 32 (11), 926-931.

C

Lee, W., Chiang, C.H., Liao, I.C., Lee, M.L., Chen, S.L., Liang, T., 2013. The longitudinal
AC

effect of concept map teaching on critical thinking of nursing students. Nurse

Education Today 33 (10), 1219-1223.

Leonardo, Z., 2003. Interpretation and the problem of domination: Paul Ricoeur's

hermeneutics. Studies in Philosophy & Education 22 (5), 329-350.

26
 ACCEPTED MANUSCRIPT

Leonardo, Z., 2010. Critical empiricism: reading data with social theory. Educational

Researcher 39 (2), 155-160.

Locsin, R.C., Barnard, A., Matua, A.G., Bongomin, B., 2003. Surviving Ebola:

understanding experience through artistic expression. International Nursing Review 50

PT
(3), 156-166.

RI
Lou, Y., Abrami, P.C., Apollonia, S., 2001. Small group and individual learning with

SC
technology: a meta-analysis. Review of Educational Research 71 (3), 449-521.

U
Markel, H., Arbor, A., 1984. Charles Dickens and the art of medicine. Annals of Internal
AN
Medicine 101 (3), 408-411.
M

McCaffrey, R., Purnell, M., 2007. From experience to integration: the arts in nursing

education. Nursing Education Perspectives 28 (2), 72-76.

D
TE

McLean, M., Henson, Q., Hiles, L., 2003. The possible contribution of student drawings to

evaluation in a new problem-based learning medical programme: a pilot study.

EP

Medical Education 37 (10), 895-906.

C

Moulton, E.A., McMain, S.S., 2004. An iceberg in Springfield: using the humanities to
AC

explore and challenge the attitudes of general practice (GP) educators towards the

management of GP registrars with substance abuse problems. Medical Education 38

(2), 218-222.

27
 ACCEPTED MANUSCRIPT

Murphy, S., Hartigan, I., Walshe, N., Flynn, A.V., O'Brien, S., 2011. Merging

problem-based learning and simulation as an innovative pedagogy in nurse education.

Clinical Simulation in Nursing 7 (4), e141-e148.

Naghshineh, S., Hafler, J.P., Miller, A.R., Blanco, M.A., Lipsitz, S.R., Dubroff, R.P.,

PT
Khoshbin, S., Katz, J.T., 2008. Formal art observation training improves medical

RI
students' visual diagnostic skills. Journal of General Internal Medicine 23 (7), 991-997.

SC
Nalavany, B.A., Carawan, L.W., Rennick, R.A., 2011. Psychosocial experiences associated

U
with confirmed and self-identified dyslexia: a participant-driven concept map of adult
AN
perspectives. Journal of Learning Disabilities 44 (1), 63-79.
M

Nanda, U., Eisen, S., Zadeh, R.S., Owen, D., 2011. Effect of visual art on patient anxiety

and agitation in a mental health facility and implications for the business case. Journal
D
TE

of Psychiatric and Mental Health Nursing 18 (5), 386-393.

Niemer, L., Pfendt, K., Gers, M., 2010. Problem-based learning in nursing education: a
EP

process for scenario development. Nurse Educator 35 (2), 69-73.

C

Novak, J.D., Gowin, D.B., 1984. Learning How to Learn. Cambridge University Press, New
AC

York.

Parsons, J.A., Mamdani, M., Bhattacharyya, O., Fortin, C.M., Melo, M., Salmon, C., Raptis,

S.R., Bain, D., O'Campo, P., 2011. Narcotic analgesic utilization amongst injured

28
 ACCEPTED MANUSCRIPT

workers: using concept mapping to understand current issues from the perspectives of

physicians and pharmacists. BMC Health Services Research 11 (Suppl. 1), 280-280.

Perry, M., Maffulli, N., Willson, S., Morrissey, D., 2011. The effectiveness of arts-based

interventions in medical education: a literature review. Medical Education 45 (2),

PT
141-148.

RI
Pottier, P., Hardouin, J.B., Hodges, B.D., Pistorius, M.A., Connault, J., Durant, C., Clairand,

SC
R., Sebille, V., Barrier, J.H., Planchon, B., 2010 Exploring how students think: a new

U
method combining think-aloud and concept mapping protocols. Medical Education 44
AN
(9), 926-935.
M

Revell, S.M.H., 2012. Concept maps and nursing theory: a pedagogical approach. Nurse

Educator 37 (3), 131-135.

D
TE

Ridde, V., 2008. Equity and health policy in Africa: using concept mapping in Moore

(Burkina Faso). BMC Health Services Research 8 (1), 90.

EP

Roberts, S., Hearn, J., Holman, C., 2003. Using drawing to explore student nurses'
C

perceptions of older age. Nursing Older People 15 (5), 14-18.

AC

Salvatori, P.S., Berry, S.C., Eva, K.W., 2007. Implementation and evaluation of an

interprofessional education initiative for students in the health professions. Learning in

Health and Social Care 6 (2), 72-82.

29
 ACCEPTED MANUSCRIPT

Shapiro, J., Rucker, L., Beck, J., 2006b. Training the clinical eye and mind: using the arts to

develop medical students' observational and pattern recognition skills. Medicine

Education 40 (3), 263-268.

Shapiro, J., Rucker, L., Robitshek, D., 2006a. Teaching the art of doctoring: an innovative

PT
medical student elective. Medical Teacher 28 (1), 30-35.

RI
Simper, N., Reeve, R., Kirby, J.R., 2016. Effects of concept mapping on creativity in photo

SC
stories. Creativity Research Journal 28 (1), 46-51.

U
Tapajos, R., 2003. HIV/AIDS in the visual arts: applying discipline-based art education
AN
(DBAE) to medical humanities. Medical Education 37 (6), 563-570.
M

Ting, S., Chen, Y., Ho, M., Gaufberg, E., 2012. Using hospital art in medical student

reflection. Medical Education 46 (5), 505-506.

D
TE

Torre, D.M., Daley, B., Stark-Schweitzer, T., Siddartha, S., Petkova, J., Ziebert, M., 2007.

A qualitative evaluation of medical student learning with concept maps. Medical

EP

Teacher 29 (9), 949-955.

C

Urban, K.K., 2004. Assessing creativity: the test for creative thinking - drawing production
AC

(TCT-DP). Psychological Science 46 (3), 387-397.

Wikström, B.M., 2000. Visual art dialogues with elderly persons: effects on perceived life

situation. Journal of Nursing Management 8 (1), 31-37.

30
 ACCEPTED MANUSCRIPT

Wikström, B.M., 2001. Works of art: a complement to theoretical knowledge when teaching

nursing care. Journal of Clinical Nursing 10 (1), 25-32.

Wikström, B.M., 2002. Social interaction associated with visual art discussions: a controlled

intervention study. Aging & Mental Health 6 (1), 82-87.

PT
Wikström, B.M., 2003. A picture of a work of art as an empathy teaching strategy in nurse

RI
education complementary to theoretical knowledge. Journal of Professional Nursing 19

SC
(1), 49-54.

U
Wikström, B.M., 2011. Works of art as a pedagogical tool: an alternative approach to
AN
education. Creative Nursing 17 (4), 187-194.
M

Wu, P.H., Hwang, G.J., Milrad, M., Ke, H.R., Huang, Y.M., 2012. An innovative concept

map approach for improving students' learning performance with an instant feedback
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mechanism. British Journal of Educational Technology 43 (2), 217-232.

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FIGURE CAPTIONS

Figure 1. Concept map of group 1

Figure 2. Concept map of group 2

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Figure 3. Concept map of group 3

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Figure 4. Concept map of group 4

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Table 1: Ratings of concept maps

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Difference Composition Thinking Innovative Creativity Appeal Uniqueness Artistic Mean
in design of the map outside a use of space presentation ability Score

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given frame provided

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Figure 1
Rater 1 4 4 4 4 4 5 4 4 4.13
Rater 2 3 4 3 4 3 3 3 3 3.25

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Figure 2

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Rater 1 3 3 4 3 3 4 3 3 3.25
Rater 2 5 5 4 3 4 4 4 4 4.13

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Figure 3
Rater 1 4 2 4 3 4 4 4 3 3.50

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Rater 2 2 2 2 2 2 2 2 2 2.00

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Figure 4
Rater 1 5 3 5 5 4 5 5 3 4.38
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Rater 2 4 3 5 5 5 5 5 5 4.63
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