Nurse Education Today 60 (2018) 47–55

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Nurse Education Today

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Concept mapping to promote meaningful learning, help relate theory to MARK

practice and improve learning self-efficacy in Asian mental health nursing
students: A mixed-methods pilot study
Daniel T. Bressington⁎, Wai-kit Wong, Kar Kei Claire Lam, Wai Tong Chien
School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: Student nurses are provided with a great deal of knowledge within university, but they can find it
Concept mapping difficult to relate theory to nursing practice. This study aimed to test the appropriateness and feasibility of
student nurse assessing Novak's concept mapping as an educational strategy to strengthen the theory-practice link, encourage
learning self-efficacy meaningful learning and enhance learning self-efficacy in nursing students.
reflective learning
Design: This pilot study utilised a mixed-methods quasi-experimental design.
Setting: The study was conducted in a University school of Nursing in Hong Kong.
Participants: A total of 40 third-year pre-registration Asian mental health nursing students completed the study;
12 in the concept mapping (CM) group and 28 in the usual teaching methods (UTM) group.
Methods: The impact of concept mapping was evaluated thorough analysis of quantitative changes in students'
learning self-efficacy, analysis of the structure and contents of the concept maps (CM group), a quantitative
measure of students' opinions about their reflective learning activities and content analysis of qualitative data
from reflective written accounts (CM group).
Results: There were no significant differences in self-reported learning self-efficacy between the two groups
(p = 0.38). The concept mapping helped students identify their current level of understanding, but the increased
awareness may cause an initial drop in learning self-efficacy. The results highlight that most CM students were
able to demonstrate meaningful learning and perceived that concept mapping was a useful reflective learning
strategy to help them to link theory and practice.
Conclusions: The results provide preliminary evidence that the concept mapping approach can be useful to help
mental health nursing students visualise their learning progress and encourage the integration of theoretical
knowledge with clinical knowledge. Combining concept mapping data with quantitative measures and quali-
tative reflective journal data appears to be a useful way of assessing and understanding the effectiveness of
concept mapping. Future studies should utilise a larger sample size and consider using the approach as a targeted
intervention immediately before and during clinical learning placements.

1. Background lack of understanding may also relate to the necessary mechanism by

Student nurses are provided with a great deal of theory that they are
expected to be able to relate and apply to clinical practice. The se-
paration between classroom and practice placements can make it dif-
ficult to relate theory to nursing practice, resulting in confusion and
potential damage to learning self-efficacy (Wells et al., 2015). Other
studies have also reported that the perceived theory-practice gap is
enlarged due to a mismatch between what is witnessed in the real-
world of the clinical placement and the theoretical ideal practices that
are taught in university (Gray, 1999; Duchscher, 2008). This perceived
which leaners deconstruct and then reconstruct knowledge to develop
their understanding over time in order to be able to relate theory to real
life situations (Kandiko and Kinchin, 2012).
It has been suggested that students fragment large amounts of new
knowledge into lesser parts and then rearrange them as part of the
learning process (Novak and Cañas, 2006). Learners then develop fur-
ther logical connections between these smaller concepts until knowl-
edge is integrated with their existing understanding (D. Hay et al.,
2008; D. B. Hay et al., 2008). Concept mapping is an approach that can
capture a pictorial record of this process, similar to mind mapping

⁎
Corresponding author.
E-mail addresses: Dan.bressington@polyu.edu.hk (D.T. Bressington), Wai.kit.wong@polyu.edu.hk (W.-k. Wong), clairelam15@gmail.com (K.K.C. Lam),
Wai.tong.chien@polyu.edu.hk (W.T. Chien).

http://dx.doi.org/10.1016/j.nedt.2017.09.019
Received 23 February 2017; Received in revised form 10 July 2017; Accepted 30 September 2017
0260-6917/ © 2017 Elsevier Ltd. All rights reserved.
D.T. Bressington et al.
(Buzan and Buzan, 2010). It has its basis in constructivist epistemology
(Kandiko and Kinchin, 2012) and is concerned with the ways in which
people organize and reorder new knowledge based on their past
learning and understanding (Von Glasersfeld, 1984). Concept mapping
has been utilised in a range of educational disciplines (Bressington
et al., 2011, 2013), as a strategy to promote learners' development of an
in-depth understanding (Buzan and Buzan, 1996; Baugh and Mellott,
1998).
The process of repeated concept mapping and subsequent reflection
on the series of maps are thought to help students reconsider in-
formation in order to promote critical analysis (Wheeler and Collins,
2003) and deeper learning. This cyclical process of reflection on their
concept maps helps students engage in further meaning-making by
presenting an opportunity to picture the way they have worked through
trying to understand a complex subject (Gul and Bowman, 2006;
Bressington et al., 2011) and within nursing education the concept
mapping approach has been shown to help effectively link theory and
practice (Hicks-Moore, 2005).
Helping nursing students to become more effective at reflecting on
their understanding is of paramount importance because their abilities
to link theory with practice are closely related to their levels of theo-
retical knowledge and reflective learning skills (Hatlevik, 2012). Other
studies have also shown that reflection and associated critical analysis
can influence the way health professionals conceptualize their clinical
practice and draw attention to related important knowledge or
knowledge deficits (Lowe et al., 2007). Guiding students to reflect in a
structured way on a series of concept maps may strengthen the theory-
practice links because it enables them to visually reorganize, connect,
and assimilate knowledge in different ways which promotes the de-
velopment of an in-depth understanding of important subjects/issues of
a profession (Hicks-Moore, 2005; Kinchin et al., 2008).
Using concept mapping to reflect on understanding has also been
shown in some studies to improve learning self-efficacy by improving
knowledge retention, clarifying concepts and enhancing interest in
learning (Nesbit and Adesope, 2006; Chiou, 2008). Improving learning
self-efficacy is important for the enhancement of academic progress
because students with high learning self-efficacy generally have good
levels of academic achievement and use more effective learning stra-
tegies (Chularut and DeBacker, 2004). The purposeful promotion of
meaningful learning and the improvement of learners' self-efficacy may
be particularly important in Asian students. Research shows that Asian
learners can be comfortable with teaching styles that allow them to
become the passive recipients of knowledge, resulting in superficial rote
learning (Baumgart and Halse, 1999; Hsu, 2004). This is especially
problematic for nursing education because rote learning is rapidly
forgotten (Hsu and Hsieh, 2005), hard to apply in clinical situations and
may reinforce the perceived theory-practice gap (Wells et al., 2015).
1.1. Aims
This pilot study aimed to test the appropriateness and feasibility of
assessing the effectiveness of concept mapping as an educational
strategy to encourage meaningful reflective learning, link theory with
practice and enhance learning self-efficacy in mental health student
nurse education. In order to determine appropriate and feasible
methods of assessment, the specific study objectives were to;
- evaluate the changes in perceived learning self-efficacy in students
who used concept mapping (CM) compared with usual teaching
methods (UTM);
- compare students' opinions of CM or UTM as a reflective learning
strategy;
- examine improvements in the CM students' understanding of ‘the
mental health nursing role’ using concept map series data; and.
- explore experiences of CM for learning enhancement and integration
of theory into practice from their reflective reports.
48
Nurse Education Today 60 (2018) 47–55
2. Methods
2.1. Process
Undergraduate mental health nursing students entering their third
year of study were asked to participate in this project. The duration of
the government funded undergraduate nurse training programme in
Hong Kong is five years. Students entering their first year typically
come from school aged around 17 years. The first two years of the
programme focus on academic development and basic nursing con-
cepts. Students embark on their first mental health clinical placement in
the second semester of their third year.
In order not to deny any students the opportunity of engaging in the
educational intervention randomisation into groups was not carried
out. Instead, students that agreed to take part were able to specify if
they wished to participate in the CM group, or the UTM group. Students
in the UTM group were used as the comparison group. Students in both
groups were required to engage in their usual teaching and learning
activities throughout the study; this included writing a short reflection
on their experiences of practice learning after completing their clinical
placements.
All students completed a Self-Efficacy for Learning and Performance
(SELP) scale (from the Motivated Strategies for Learning Questionnaire
(MSLQ); Pintrich et al., 1993) to assess their perceptions of self-efficacy
in learning at the start of semester 1 (T1), end of semester one (T2) and
when they returned to university after their 3–4 weeks' clinical prac-
ticum (T3). The full MSLQ includes 81 self-reported items; it has been
widely used in educational research and is an important tool to predict
academic performance (Credé and Phillips, 2011). The SELP subscale
contains 8 Likert scale items with a seven-point response option format
(1 = “Not at all true of me” to 7 = “Very true of me”) for each ques-
tion. The subscale has been shown to have good internal consistency
coefficients (Alpha = 0.93) and a significant positive correlation with
final academic grade (r = 0.41).
At T2 and T3, participants were also asked to complete a Student
Opinions Questionnaire (SOQ; Pee et al., 2002) to measure perceptions
of the acceptability and usefulness of CM or UTM as a reflective
learning strategy. The scale contains eight statements rated on a 5-point
Likert scale, ranging from ‘1-strongly disagree’ and ‘5-strongly agree’.
The psychometric properties of the tool as a standalone measure have
not been reported/established, but adequate internal consistency
(Cronbach's alpha = 0.634) was confirmed using the baseline scores in
the current study.
The CM group constructed three concept maps of their under-
standing about mental health nursing at T1, T2 and T3. This involved
asking students to list all the important knowledge concepts they con-
sider are associated with the “role of the mental health nurse”. This
broad concept was chosen because we wanted to avoid limiting the
focus of participants' maps by directing them towards a specific area of
practice or theory. Our earlier studies (Bressington et al., 2011; Wells
et al., 2015) also demonstrated that using similarly broad role-related
topics in concept maps effectively capture a visual record of how stu-
dents make sense of their professional role over time as they acquire
and attempt to integrate new theoretical and practical knowledge. The
individual concepts associated with the mental health nursing role were
then arranged by the student on A3 paper, rearranged as necessary, and
lines were drawn between related concepts. The links should be drawn
with an arrow that indicates the direction of the relationship and each
link should be given a label that explains the relationship between the
two concepts.
All CM students were asked to write a short (500 words) reflective
report about their learning progress during a group session after com-
pleting their final concept map. This was prompted by looking back at
their three concept maps. They were required to reflect on how their
understanding had changed and illustrate this by giving examples from
their maps. They were asked to explain their rationale for the adoption
D.T. Bressington et al. Nurse Education Today 60 (2018) 47–55

Fig. 1. Group reflection prompts.

Prompts for Mapping Group Reflective Journals

Please describe this map, talk me through the concepts/links?

Any reason why you placed the concepts in the places you did on
Map 1 &2 the page?

Overall, when you look back at this map, what do you think about
your understanding of MH nursing at that point?
This is a snapshot of your understanding when you drew the map;
Map 2 is there anything you would change now? Any other links you
would draw now? Give some examples.

What do you think after looking at all the maps?

How do you think your learning may have changed by looking at
all these maps?
Can you think of anything that may have influenced these
changes? Give can you give me a specific example of (a learning
trigger)?
Map 1, 2 & 3
What may help you to link theory and practice?
What was the most important thing you learnt from
University/Placement about MH nursing over the last year? How
will it influence your next placement/ career?
How do you think you might best prepare yourself for your next
placement?

or rejection of particular concepts and links within their maps. The
students also identified triggers for changes in understanding and wrote
a leaning action plan for the subsequent year. Please see Fig. 1 for
details of the prompts used within the group.
2.2. Ethical Issues
The project was granted ethical approval by The Hong Kong
Polytechnic University (reference: HSEARS20150724001). Students
were informed that they would not be disadvantaged in any way for
declining to take part and were required to provide their written in-
formed consent. The information sheets clearly stated all data would be
anonymized and that they could withdraw their consent at any point
without penalty.
2.3. Analysis Strategies
The impact of using concept mapping as an educational strategy was
evaluated on: the quantitative changes in students' learning self-efficacy
and the structure and contents of three concept maps over three mea-
surements (T1, T2 and T3), and content analysis of students' reflective
reports at T3. Level of significance for all statistical tests was set at
p < 0.05 (2-tailed).
2.3.1. Learning Self-efficacy
Students' self-efficacy measured by the SELP was calculated and
compared within and between the CM and UTM groups across T1-T3,
using repeated-measures ANOVA test; and Friedman test was used for
comparing within-group changes of its individual items. Post-hoc
comparisons to identify significant differences on self-efficacy at follow
up consisted of Mann-Whitney U test for between group comparisons
and Wilcoxon signed-ranks test for within group changes.
2.3.2. Students' Opinions
Analysis of differences between the CM and UTM groups on the
individual item scores of the SOQ at T2-T3 were performed using Mann
Whitney U test and Wilcoxon signed-rank test was used for within
group changes.
2.3.3. Concept Mapping
The 3 maps from each student were analysed by looking at their
overall structures and by describing the differences and changes in
numbers/types of concepts and linking statements in order to quantify
changes and identify types of learning. Analysis of the maps' structures
and numbers of concepts/links was conducted by two members of the
research team (DB and CL) independently. The findings were compared
and then discussed with a third member of the team (WTC) for ver-
ification and to reach consensus. We primarily used the approach ad-
vocated by Kinchin et al. (2000) which highlights changes in map
structures representing different levels of understanding; this involves
classifying each map according to the shape of each student's knowl-
edge structures into spoke, chain or networks (Kinchin et al., 2000;
Hay, 2007; D. Hay et al., 2008; D. B. Hay et al., 2008). Chains suggest a
superficial understanding; spokes indicate a simple relationship be-
tween concepts without interconnectedness suggesting learning-readi-
ness; and networks suggest a complex understanding indicative of ex-
pert knowledge. A comparison of structural and content changes of map
series allows classification of learning development into surface-, deep-
and non-learning outcomes. An absence of increases in concepts/links
and no clear positive changes in map structures are indicative of non-
learning. Surface learning is demonstrated where new concepts and
links are added to previous maps, but the structure has not developed.
Whereas the creation of increasingly complex maps resulting in a net-
work structure is suggestive of deep learning (Hay, 2007; D. Hay et al.,
2008; D. B. Hay et al., 2008).
2.3.4. Students' Reflective Written Accounts
Qualitative analysis of students' reflective accounts was used to
explore their learning trajectories. Data were managed using Nvivo
software and analysed using inductive content analysis (Richards,
2002; Hsieh and Shannon, 2005; Milne and Oberle, 2005). The students'
statements contained within the written accounts were regarded as
individual units of data and were de-contextualized by entering them
into Nvivo before being given initial codes. These initial codes were
reviewed and re-contextualized based on common meanings that
emerged from the data (Richards, 2002). The code sets were revised
until the final codes and relationships between them were identified to
produce a list of themes. The final themes and sub-themes were

49
D.T. Bressington et al. Nurse Education Today 60 (2018) 47–55

Fig. 2. Study flow diagram.

3rd Year students
assessed for eligibility
(n=70)

Students declined to
participate (n=14)
(reasons)
- 500-word reflective
essay commitment

Students recruited (n=56)

Students agreeing to Students agreeing to

participate in Concept participate in Usual
Mapping (CM) group Teach Method (UTM)
(n=13) group (n=43)

Students lost to 3-
Students lost to follow-
month follow-up
up at 3 months (n=8)
(n=2)
(no quantitative
data)

Students unable to
complete concept
Students lost to follow-
map & reflective
up at 6 months (n=7)
report (n=1)
Students lost to 6-
month follow-up
(n=1)

Students analysed (n=10- Students analysed (n=28)

quantitative, n=12 concept Excluded from quantitative
maps) analysis (n=15)
Excluded from
quantitative analysis (n=3)
Excluded from concept
map/reflective report (n-1)

reviewed and debated by the researchers until agreement was reached. 3.1. Students' Learning Self-efficacy

The scores of students' perceived leaning self-efficacy are presented

3. Results
A total of 70 students (whole class of Year 3) were approached to
take part in the study. Of these, 56 (80%) agreed to take part. Thirteen
students volunteered to participate in the CM group, resulting in 43
students in the UTM group. Students were not required to give a reason
for declining participation, but many who chose the UTM group over
the CM group were concerned that writing a reflective account might be
too time consuming. A total of 38 students finished the study with all
quantitative measures completed (10 in the CM group and 28 in the
UTM group). Twelve students in the CM group completed all three
maps and reflective accounts (however, two of these students did not
complete all the quantitative outcome measures). There were 1 male
and 11 females in the CM group, and 9 males and 19 females in the
UTM. All students were aged between 20 and 25 years (see Fig. 2 for the
flow of participants through the study).
in Table 1. A comparison of the two groups at baseline shows that there
were no statistically significant differences in the SELP mean score
(p = 0.899) between the two groups. The SELP score in the CM group
decreased from baseline, and then increased to 32.00 at T3. On the
other hand, the mean total score in UTM increased from baseline, then
further increased to 32.53 at T3. However, there were no statistically
significant within-group changes of the CM (p = 0.158) and UTM
groups (p = 0.346).
3.2. Students Opinions
The SOQ scores are detailed in Table 2. The mean score for Question
1 (The self-reflection provided me with a valuable learning experience) was
significantly higher in the CM group than the UTM at T2 (p = 0.018)
and T3 (p = 0.029), and there was also a significant within group
improvement for this question in the CM group (p = 0.011). The mean
score for Question 4 (I did not like completing the self-reflection activity)
was significantly higher in the UTM group than the CM group at T2

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 D.T. Bressington et al.

Table 1
SELP scores.

Concept mapping (n = 13) Usual teaching method (n = 38) Comparisona

Baseline mean 3-month follow-up 6-month follow-up Within group Baseline mean 3-month follow-up 6-month follow-up Within group p Value f Value
(SD) mean (SD) mean (SD) changeb (SD) mean (SD) mean (SD) changeb

Q1: I believe I will receive an excellent grade in 3.77(1.48) 3.23(0.73) 4.00(1.00) 0.039 3.42(1.10) 3.45(0.92) 3.95(1.09) 0.087 0.34 1.09
this class
Q2: I′m certain I can understand the most difficult 3.54(1.33) 2.92(1.12) 3.69(1.03) 0.094 3.47(1.06) 3.55(0.92) 3.82(1.09) 0.431 0.21 1.58
material presented in the readings of this
course
Q3: I′m confident I can learn the basic concepts 4.38(1.70) 4.62(0.65) 4.62(0.87) 0.928 4.68(0.90) 4.55(0.92) 4.63(0.99) 0.773 0.6 0.51
taught in this course.
Q4: I′m confident I can understand the most 3.69(1.25) 3.62(0.87) 3.69(0.75) 0.973 3.60(1.05) 3.82(0.93) 3.87(0.96) 0.651 0.69 0.37
complex material presented by the instructor

51
in this course.
Q5: I′m confident I can do an excellent job on the 3.46(1.39) 3.15(0.69) 3.54(0.78) 0.261 3.39(0.97) 3.84(0.79) 3.97(0.10) 0.003 0.65 2.81
assignments and tests in this course.
Q6: I expect to do well in this class. 4.38(1.19) 4.23(0.93) 4.31(1.18) 0.905 4.05(0.93) 4.24(0.97) 4.32(1.09) 0.555 0.54 6.22
Q7: I′m certain I can master the skills being taught 3.77(1.36) 3.23(0.83) 4.00(0.91) 0.028 3.97(0.97) 3.89(0.95) 3.94(0.84) 0.990 0.86 2.51
in this class.
Q8: Considering the difficulty of this course, the 3.77(1.24) 3.77(0.83) 4.15(1.07) 0.132 3.95(0.93) 4.13(0.78) 4.03(0.92) 0.466 0.35 1.06
teacher, and my skills, I think I will do well in
this class.
Total Score 30.76(9.96) 28.76(4.69) 32.00(6.18) 0.346 30.55(5.95) 31.47(5.79) 32.53(6.87) 0.158 0.38 0.98

SELP - Self-efficacy for Learning and Performance subscale from the Motivated Strategies for Learning Questionnaire (MSLQ) for college students.
(Scores range from 1 to 7, with 1 being “Not at all true of me”, to 7 being “Very true of me”).
p Values < 0.05 are indicated in bold.
a
Tested by repeated-measures analysis of variance (ANOVA) tests.
b
p Value, tested by Friedman's ANOVA Test.
Nurse Education Today 60 (2018) 47–55
D.T. Bressington et al. Nurse Education Today 60 (2018) 47–55

(p = 0.007) and T3 (p = 0.004). Similarly, the mean score for question

Between group comparisonb

T3 p value
7 (I think that this self-reflection activity is not useful in my training) is
significantly higher in the UTM group than the CM group at T3

0.029

0.004

0.001
0.132

0.702
0.842

0.151
0.552
T2 p value (p = 0.001).

0.018 3.3. Concept Map Data

0.007
0.938
0.261

0.651
0.659

0.367
0.577
The numbers of concepts, links, map structures and learning out-
comes for all concept maps are shown in Table 3. Analysis of within
group changes on numbers of concepts and links showed statistically
significant improvements.
UTM within group

At T1 (start of semester 1) almost all students (11) drew a map with

a spoke structure indicating being “learning ready”. One student con-
T2-T3 p value

structed a map consisting of linear chains, suggesting superficial un-

changesa

derstanding. Many students presented a holistic view of mental health

0.038
0.197
0.218

0.682
0.502
0.224

0.144
0.115

nursing, but this was text-book type knowledge. Most links were weak,
suggesting overall that students found areas of knowledge difficult to
relate together. This indicates that they were in a “learning ready”
T3 Mean (SD)
Usual Teaching Method (UTM)

3.76(0.49)
3.79(0.53)
3.76(0.49)
2.82(0.61)
2.71(0.65)
2.18(0.46)

2.63(0.67)
3.37(0.67)

stage. Given that the students had yet to complete any mental health
clinical placements their “learning ready” state is probably under-
standable at this stage of the programme.
At T2 (end of semester one) nine students drew maps with a spoke
T2 Mean (SD)

structure, whilst three constructed networks. As with map 1, most

3.89(0.45)
3.92(0.43)
4.00(0.46)
2.87(0.66)
2.82(0.80)
2.34(0.78)

2.37(0.82)
3.61(0.59)

concepts related to nursing theory and the links were superficial. The
average number of concepts and links reduced from T1. Most students
had learnt new knowledge from the classroom, but rejected some
concepts present in their initial maps, made less links and still found it
problematic to relate areas of knowledge together. This illustrates a
constructivist process of de-constructing existing knowledge in order to
CM within group

reorganize and assimilate new knowledge into existing understanding.

T2-T3 p value

The final maps (T3- after clinical practicum) had more concepts and
changesa

links than the earlier maps. Seven students constructed networks, four
Student Opinion Scale - Scores range from 1 to 5, with 1 representing “Strongly Disagree” to 5 representing “Strongly Agree”.
0.011
0.366

0.739
0.357
0.589

0.317
0.157
1.00

drew spokes and one created a map resembling a series of linear chains.
The concepts were comprehensive, including a range of theories,
T3 Mean (SD)

mental health nursing principles and the practical concepts of nursing.

4.08(0.28)
4.08(0.64)
3.77(0.60)
2.23(0.60)
2.38(0.77)
2.38(0.87)

1.92(0.49)
3.31(0.63)

Many maps were very patient-focused reflecting the recent patient care
Concept Mapping (CM)

experience and concepts were self-reflective. There was an increase in

ability to connect concepts and apply theory to nursing practice. Some
links were highly developed, in longer phrases and were often in a
T2 Mean (SD)

questioning form, showing curiosity for the nursing process. Overall,

3.46(0.45)
3.85(0.69)
3.77(0.60)
2.31(0.63)
2.69(0.75)
2.23(0.60)

2.15(0.69)
3.62(0.77)

the final maps suggest that many students had further developed by
assimilating knowledge acquired through practice learning with their
previous understanding.
Q8: The self-reflection activity helped me communicate with my clinical teacher.
The self-reflection activity provided me with a valuable learning experience.

The self-reflection activity did not help me to communicate with my peers.

The self-reflection activity made me realize the importance of target-setting.

A comparison of the changes in map structures from time 1 to time 3

indicates that 7 students learnt in a deep and meaningful away, four
The self-reflection activity helped me to determine my learning needs.

students learnt superficially and one student seemed to have struggled

to acquire a new depth or level of understanding.
Q7: I think this self-reflection activity is not useful in my training.
The self-reflection activity did not help me to identify my

3.4. Reflective Accounts

Comparison results between groups on Student Opinions Scale.

I did not like completing the self-reflection activity.

Two themes with three subthemes each emerged from analyses of

the reflective reports. A few examples of verbatim data illustrating the
themes/subthemes are presented in Table 4. The first (Text book or real
world?) consisted of three subthemes: “Knowledge I didn't grasp”,
“Learning that was unrealistic and rejected” and “I need to go back to
Tested using Wilcoxon sign-rank test.
p Values < 0.05 are indicated in bold.

the books”. The second main content theme (Maps as learning) also
Tested by Mann Whitney U test.

included three subthemes: “This is where I am”, “Recognizing my

limitations” and “Questions I ask”.
strengths & weaknesses.

Theme A: Textbook or Real World?

All students reported notable changes in their understanding of
mental health nursing after beginning their clinical placement in the
third year, noting discrepancies with knowledge gained purely from
academic settings and those obtained in the ‘real world’ during
Table 2

placement.
Q1:
Q2:
Q3:
Q4:
Q5:
Q6:

b
a

A1) Knowledge I didn't grasp

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D.T. Bressington et al. Nurse Education Today 60 (2018) 47–55

Table 3
Concept map data.

Number of concepts Number of links Structure type Learning outcome

T1 T2 T3 T1 T2 T3 T1 T2 T3 From T1-T3

Student 1 32 39 22 9 6 39 Spoke Spoke Network Deep learning

Student 2 19 11 42 9 0 3 Spoke Spoke Chain Non learning
Student 3 22 16 28 15 20 21 Spoke Network Network Deep learning
Student 4 15 24 27 16 0 10 Spoke Spoke Spoke Surface learning
Student 6 13 15 20 16 3 24 Spoke Spoke Network Deep learning
Student 7 33 17 36 0 2 1 Chain Spoke Spoke Surface learning
Student 8 21 20 25 3 1 6 Spoke Spoke Spoke Surface learning
Student 9 28 27 32 13 0 5 Spoke Spoke Spoke Surface learning
Student 10 32 32 61 2 8 10 Spoke Spoke Network Deep learning
Student 11 15 38 44 11 11 24 Spoke Spoke Network Deep learning
Student 12 51 18 14 4 13 13 Spoke Network Network Deep learning
Student 13 20 17 18 25 15 40 Spoke Network Network Deep learning
Total mean (SD) 25.1 (10.8) 22.8 (9.3) 30.8 (13.3) 10.3 (7.3) 6.6 (6.8) 16.3 (13.3) 11 Spoke 9 Spoke 1 chain 7 Deep
1 Chain 3 Network 4 spoke 4 Surface
7 network 1 non-learning
Within group changes for total scorea 0.031 0.016 – – – –

Note: Student 5 lost to follow-up.

a
Tested using Friedman's ANOVA Test.

Table 4
Main themes, subcategories and example statements.

Main theme Subcategory Example

Theme A: Textbook or Real
World?
Theme B: Maps as Learning
A1) Knowledge I didn't grasp
A2) Learning that was unrealistic
and rejected
A3) I need to go back to the books
B1) This is where I am
B2) Recognizing my limitations
B3) Questions I ask
“I think the map is more like recitation of lecture notes. I don't think I understand much about mental health
nursing but just superficial and brief impression.” (Female, 004)
“What I know towards these subjects is too little and incomplete so I haven't written any details or further
developed these items. Maybe, this map can cover a lot of aspects, as subjects I have taken cover a lot of aspects,
but it doesn't mean that I understand a lot.” (Female, 010)
“In Map 1, I wrote stuff which are not practical or relevant to my nursing role. I did not hold any bits of insight
into my job. The knowledge of that map comes from lectures and textbooks, mainly without thorough critical
thinking. All those points seem legit and sensible, but they are not helping me to do my job well.” (Female, 004)
“[Map 1 was] based on the knowledge I obtained from teachers and different lessons. Not really related to the
practical skills I need in ward… Several things written down were not really useful in practical settings, like the
nursing models.” (Female, 001)
“I′ve ignored that knowledge from textbooks. [But] They're important as well. Maybe, we don't need to remember
a lot of knowledge in the ward. But I do believe that I need those messages when I′m not just doing the routine,
but also making some decision”. (Female, 009)
“I have increased my practical skills, yet it seems that I might forget what I learnt before. Thus, next year I would
like to revise what I have learnt in Year 1 & 2 which related to mental health nursing.” (Female, 001)
“Comparing Map 3 with Map 1, the categorization and linkage improved so the understanding presented was
much easier for creating the links.” (Female, 011)
“There were increased aspects in the second map, but still were without explanation and details. I would not say
that I understood about mental health well at this point…” (Female, 008)
“I found I haven't mentioned my expectation to how can I be a good nurse. I never think about it but staff in
hospital always ask me this question. Usually I muted [be]cause I was blank and found nothing to say. These
3 years studying, I only absorb knowledge but neglect my attitude which is also very important.” (Female, 012)
“After the ward practicum, I realize that my knowledge is not enough to apply in the workplace, especially in
those medication dosage, and the doctor's regime (those are not often mentioned in the lecture), my
understanding of the pharmacology of Mental Health is not sufficient.” (Female, 007)
“In map 3, most of the linkages are questions. I question about it is the practice really can help the recovery of
mental illness. What I have done such as the routine job are really beneficial to the patients? Is it really helping
patients? How can I apply the knowledge in practice?” (Female, 013)
“Also, in map 3, I′ve written how to improve mental health nursing. I think this is because I have a great
reflection towards mental health nursing after placement. What is good and bad practice? How to balance?
Sometimes, we can't just care for patients [and] not consider efficiency. So how to strike a balance and improve
our service while considering efficiency and managing a ward? I bear this question in my mind.” (Female, 009)

The majority of students reflected on concepts that illustrated ‘idealized’ textbooks.

knowledge they were not able to fully grasp at the moment,
recalling that many concepts were recited directly from lecture
notes without any in depth understanding.
A2) Learning that was unrealistic and rejected
All students reported that the most significant change and trigger
for learning came from their ward placement experience, pointing
to knowledge acquired from lectures they now rejected as a result
of discrepancies they found between the ‘real world’ and the
A3) I need to go back to the books
Students were asked to describe their action plan for the remainder
of academic year and many highlighted their realization of how
important it is to bridge the gap between knowledge and practice,
in particular emphasizing the need to go back to the books they
may have first rejected at the start of their ward placement.
Theme B: Maps as Learning
When asked to reflect on their learning, all students found their

53
D.T. Bressington et al.
concept maps to be a useful tool for self-reflection, providing an
opportunity for them to pinpoint the gaps in their knowledge as well
as confront their personal limitations.
B1) This is where I am
Students showed an overwhelming sensitivity to remark upon their
changes (or lack thereof) in learning from maps 1 to 3, reflecting an
accurate self-account of their current understanding and how they
arrived at it.
B2) Recognizing my limitations
In addition to reflecting on what they know now, students also
reflected on personal shortcomings as a mental health nurse.
Students found it useful to identify knowledge they may have in-
cluded in one map and not the other, as well as concepts that were
not on their maps that they now wished to include.
B3) Questions I ask
When students were prompted to consider concepts that were
missing, many posed further questions towards the nursing role on
their own accord.
4. Discussion
The main aim of this pilot study was to determine appropriate and
feasible methods for assessing the effectiveness of concept mapping as
an educational strategy for mental health student nurses. The first ap-
proach towards assessing the effectiveness of concept mapping was to
measure changes in students' perceived learning self-efficacy compared
with usual teaching methods using a self-report quantitative measure.
Unfortunately, due to the small numbers of participants we are unable
to assert that one group was superior to the other (due to the few sta-
tistically significant results found). However, it is clear from the data
that the levels of learning self-efficacy in the CM group dropped after
completing their maps prior to the clinical placements, but these re-
bounded to levels in excess of baseline scores once the placement was
complete, and the final scores suggest that learning self-efficacy was
similar in both the CM group and the UTM group. This is a very in-
teresting finding, and suggests that the concept mapping exercise made
them more aware of their limitations in understanding and/or that they
had some trepidation prior to their first clinical learning placements.
Despite the lack of power, the use of a quantitative measure of learning
self-efficacy seems appropriate and sensitive enough to capture changes
in self efficacy over time.
Combining and triangulating the different forms of data collected
over the study was an effective way to add greater depth of under-
standing to the quantitative findings. For instance, the reductions in
numbers of concepts and links in the maps drawn prior to placement
supported the idea that the students were finding it very difficult to
integrate newly acquired knowledge into their existing understanding.
The concept mapping data also highlighted that many students went
through a process of deconstructing and reconstructing their under-
standing as a result of classroom-based and clinical learning experi-
ences. Similarly to other studies (Bressington et al., 2011; Wells et al.,
2015) knowledge deconstruction is most evident after they acquire
knowledge from the classroom, and seems to be associated with a drop
in learning self-efficacy just prior to starting their clinical placements.
The qualitative data from the reflective accounts shows that at this
stage many students are unable to see how the theoretical knowledge
relates to their role as a mental health nurse.
The challenge of bridging the theory-practice divide within nursing
education has long been identified as an important issue (Bendall,
1976; Benner, 1984); unfortunately, our study demonstrates that this
problem persists for some students some forty years after it was first
written about. It seems essential that further support should be offered
to try and help them integrate this new knowledge with their existing
understanding at this critical stage of learning. As knowledge decon-
struction is most pronounced just prior to embarking on clinical
54
Nurse Education Today 60 (2018) 47–55
learning placements we hypothesize that a concept mapping interven-
tion would be particularly effective at this point. Similarly, because
students reported a shift in their understanding whilst on placements it
may also be useful to use concept maps mid-way through in order to
facilitate greater connections between concepts, visually reinforce
learning progress and identify areas for further development.
A further objective of this study was to ascertain students' percep-
tions of the acceptability and usefulness of concept mapping to en-
courage reflective learning and compare these with students' views of
the usual teaching methods. The results from the SOQ highlight that
UTM students felt increasingly negative about the reflective learning
they had experienced in the programme's routine teaching and learning
activities, indicating that the students in the CM group on the whole felt
more positively about the reflective learning activities than their peers
in the UTM group. This instrument was useful in some respects as it
provided a general idea of how satisfied the students felt about their
reflective learning activities, however these are purely subjective views
which are prone to social desirability bias. Future studies may benefit
from using a validated objective measure of students' reflective learning
abilities in order to more effectively measure how reflective learning is
related to concept mapping.
The qualitative journal data also show that most students in the CM
group perceived that the concept mapping intervention was a useful
reflective learning activity, which helped them to link theory with
practice. The action of looking back over the maps series was reported
to be very helpful in terms of students being able to see their progres-
sion over time, and was perceived as being a valuable exercise to help
them reflect upon and identify significant triggers for learning and
areas for future development. Many authors have previously reported
the difficulties students experience when trying to engage in reflective
learning and whilst attempting to develop the associated meta-cogni-
tive skills (Tomlinson, 1999; Eraut, 2000; Clegg, 2004; Clegg and
Bradley, 2006). The results of our study seem to support earlier ob-
servations that reviewing a series of concept maps effectively slows
down and directs the meta-cognitive processes, resulting in structured
and meaningful reflections on the process and outcomes of learning
(Kinchin et al., 2008; Jankowska, 2010; Bressington et al., 2011). This
suggests that concept mapping is worthy of further study because it may
provide a partial solution to the reflective learning difficulties experi-
enced by some students.
4.1. Study Limitations and Directions for Future Research
By nature, this pilot study has a number of limitations which should
be considered when interpreting the results. Given the educational
nature of the intervention and a wish to avoid potentially disadvanta-
ging students by excluding them from the mapping exercise, we decided
not to randomly allocate them to the concept mapping or teaching as
usual groups. This self-selecting allocation approach is likely to have
introduced bias, and it is quite possible that the most enthusiastic and
able students, or those whose learning styles were more suited to the
approach, volunteered to join the concept mapping group. Students in
the UTM group were not required to write a reflective report of their
learning progress, we chose not to do this because we viewed the
writing of the reports as an inherent aspect of the concept mapping
intervention, and wanted to compare the intervention with usual
teaching (i.e. not adding anything additional to the UTM group). It is
therefore possible that similar benefits in linking theory with practice
may have resulted from the writing of reports without the concept map
triggers. This pilot study involved a small sample of Asian nursing
students and it is not possible to generalise the results beyond the study
population. The small numbers of participants have also likely resulted
in a lack of power to detect statistically significant changes in the self-
reported quantitative measures between and within groups. Although
the student opinions questionnaire has been previously used effectively
and demonstrated reasonable internal consistency in the current study,
D.T. Bressington et al.
it's psychometric properties have not been evaluated and it was not
specifically validated for our study population. Finally, students'
learning outcomes as indicated by the concept maps were not in-
dependently verified by an external person and this may have in-
troduced some interpretation bias.
Despite the limitations, the results from this pilot study provide
useful directions for future research. Subsequent studies should aim to
include larger groups of students from different ethnic backgrounds
that are randomly allocated to the concept map intervention and
comparison groups. In addition, it would be interesting to investigate
potential relationships between students' preferred learning styles, level
of engagement with concept mapping activities and learning outcomes.
Future studies should also compare concept mapping with an alter-
native reflective learning activity, obtain external verification of con-
cept map learning outcomes, utilise a validated objective outcome
measure of students' reflective abilities and consider extending the
study population by involving students from different nursing dis-
ciplines or other professional health-related programmes.
5. Conclusions
Overall, the findings from this pilot study provide preliminary evi-
dence that the concept mapping approach may be useful to help mental
health nursing students evaluate their learning, promote reflective
learning and encourage the integration of theoretical knowledge with
clinical knowledge to develop a deeper level of understanding.
Combining longitudinal data from concept maps with quantitative
outcome measures and qualitative reflective journal data appears to be
an appropriate and useful way of assessing and understanding the ef-
fectiveness of concept mapping as an educational strategy for mental
health student nurses. Concept mapping may be most effective if used
immediately prior to and during student nurses' clinical placements.
Conflicts of Interest
None.
Funding
This research was supported by the Overseas Scholarship Scheme
(Teaching Development) Implementation Fund, Teaching and Learning
Committee at The Hong Kong Polytechnic University. The funders had
no role or involvement in study design; in the collection, analysis and
interpretation of data; in the writing of the report; and in the decision to
submit the article for publication.
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