Study context

The study design was both descriptive and exploratory [31], as it included an analysis of the nursing programme’s course syllabi and a questionnaire addressing aspects of academic and professional literacy in teaching at the nursing programme, completed by nursing students.

This study was approved by the Swedish Ethical Review Authority with (Dnr. 2022-04816-01), and conducted at Karolinska Institutet in Sweden, at the study programme in nursing (SPN), coded as 1SJ18 (Programme syllabus - Sjuksköterskeprogrammet, 180 hp | Karolinska Institutet Utbildning). In Sweden the SPN is a three-year post-secondary education, comprising 180 ECTS, that qualifies for a license to practice as a registered nurse (RN). The SPN awards a Degree of Bachelor of Science in Nursing and a Degree of Bachelor of Medical Science with a major in nursing. The SPN curriculum integrates theoretical courses as well as clinical courses. This allows students to develop knowing-in-action while observing how nurses interact with patients, colleagues, and both linguistic and material resources. A considerable share of the program is dedicated to clinical education that takes place in various health care settings (SFS 1993:100). Learning in nursing education is complex. Undergraduate students must develop both clinical and academic skills, as well as broader professional competences [32].

Object of analysis

The educational plan of the SPN was analyzed according to the two following analytical questions and structured in a table (Table 1). The analytical questions were:

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Table 1. Courses in the Study Programme in Nursing, at Karolinska Institutet, with learning objectives related to academic or professional literacy.

https://doi.org/10.1371/journal.pone.0335166.t001

1. What are the explicit and implicit expressions of writing practices in the SPN?
2. How do the expected learning outcomes and content of the course syllabi align with expressions of academic and professional writing practices in the SPN?

The questionnaire regarding students’ literacy practices

A questionnaire was developed to map students’ note-taking as an aspect of literacy practices during their education. For the development of this we used results from previous inter/national research [18,33,34] for comparative purposes. It included closed questions on how, when and for which purpose students take notes and what tools students use for note-taking (n = 10). The answering format was on an ordinal level with the alternatives, i.e., “always, sometimes, seldom or never”. In addition, open-ended questions (n = 9) with the possibility to comment or explain literacy practices were included. The questionnaire was distributed via Research Electronic Data Capture (REDCap) web application [35,36] to nursing students in their second semester of the SPN during the autumn of 2023, starting 2023-10-01 and ending 2023-12-31 after three reminders (S1 File – Appendix 1a and S2 File – Appendix 1b). The students were informed in written form about their right to withdraw at any time without the need for giving a reason and that their questionnaire answers had no connection with grades or study performance within the SPN [37]. The students were informed about the study through the learning management system and invited to participate, and informed consent was obtained by means of answering the digital questionnaire.

Analytical methods

Descriptive statistics were used to present quantitative data from the digital questionnaire. For closed questions frequency distribution was used, complemented with mean and range for age [38], while for the open-ended questions, a qualitative content analysis [39] was applied to analyze and describe the results on literacy practices. First, all the written answers with free text (displayed in S3 File – Appendix 1c) were collected per question and reviewed several times. Secondly, for each question, the transcripts were grouped according to the content into subcategories. Thirdly, the answers to open-ended questions were reviewed in relation to answers provided by the quantitative questions for any clarifications regarding differences in practices between, for instance, purposes for note-taking. In the last step of analysis, the preliminary results were reviewed and discussed within the research team and categories were determined.

Statements

Ethics approval and consent to participate: This study was approved by the Swedish Ethical Review Authority with (Dnr. 2022-04816-01).

Clinical trial number: Not applicable since it is not a clinical trial.

Consent for participation and for publication: The students were informed about the study through the learning management system and invited to participate, and informed consent was obtained by means of answering the digital questionnaire.

Literacy in the curriculum for the study programme in nursing

The SPN includes courses that specifically address academic or professional literacy in their objectives, based on the idea of a taxonomy, although not specified. There are two dominating taxonomies used in the Western world, the Bloom’s taxonomy for the cognitive domain [40,41], which has also been further developed [42], and the SOLO taxonomy (Structure of the Observed Learning Outcome) [43,44]. These taxonomies are based on different theoretical points of departure. The learning outcomes of these courses are presented in Table 1.

Professional literacy

Based on the analysis of the included courses in the SPN the intended curriculum include professional literacy skills such as: 1) various communication models; 2) oral and written communication with patients in different ages; 3) oral and written communication with patients with different needs; 4) oral and written communication with relatives to patients; 5) oral and written communication with other medical professions; 6) oral and written communication with interprofessional teams; 7) writing patient records; 8) communicate patient care in speech and writing in a patient-safe way; 9) writing assessments, treatment plans, treatment progress and follow-ups and communicate this to interprofessional teams; 10) reading and interpreting patient documentation (records, plans, referrals etc.); 11) calculate, prepare, administer, and evaluate the efficacy of medicines; 12) reading and interpreting the professional meaning of laws and regulations.

For oral communication, students are expected to use the professional language taught throughout the programme. Additionally, they should demonstrate the ability to adapt to their communication according to the needs of different patients, professional collaborators, and the broader society. Furthermore, students are expected to care for, respond to, and communicate with patients of different ages, with different illnesses, and with different needs based on the principle of health and care on equal terms, ensuring respectful, empathetic, and patient-centered interactions. These skills are trained on throughout the SPN, i.e., every semester, with variations depending on patient age, illnesses, care-situation, etc., i.e., the context, both on campus and in clinical placements.

Academic literacy

Based on the analysis of the included courses in the SPN the intended curriculum include academic literacy skills such as: 1) writing scientific texts including adequate scientific concepts and reference management; 2) planning, writing, presenting and evaluating group projects; 3) formulating a research question in a nursing specific area; 4) writing a degree project in nursing; 5) orally presenting and defending a degree project in nursing.

In contrast to professional literacy that is taught and trained every semester, the academic literacy was visible in the SPN the first two and the last two semesters, mainly with the purpose to be able to plan, write, present a scientific project and evaluate and reflect on scientific publications with an increase in depth the last two semesters where the students are writing their degree project.

Students note-taking

In total, the questionnaire was sent to 166 students, of whom 67 responded (40% response rate). The questionnaire on students’ note-taking practices is presented in Table 2. A majority of the students reported that they always (43%) or sometimes (36%) were taking notes at lectures. During these lectures, the students reported that they always (53%) and/or sometimes (26%) used a pencil, while they always (35%) and/or sometimes (35%) used a computer/tablet. In contrast, students never (59%) and/or seldom (20%) used mobile phones. After lectures students reported that they used a pencil at about a similar frequency (56%) as during lectures, while they used a computer/tablet at a higher frequency (46%) than during lectures. Also, students used mobile phones at about the same frequency (2%). Frequency regarding when students are always and/or sometimes engaged in note-taking was highest during lectures (79%) and before examinations (78%), while the frequency was lower after lectures (49%). The most used tool for note-taking in relation to lectures was pencil, while before examinations pencil and computer were equally used. The highest proportion of students taking notes after lectures were always doing this for themselves (88%), and sometimes for their study group (18%) or friend(s) (15%).

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Table 2. Note-taking practices among 67 undergraduate nursing students, in the Study Programme in Nursing, at Karolinska Institutet, at different learning occasions and tools applied.

https://doi.org/10.1371/journal.pone.0335166.t002

The students described that the reasons for writing these summaries were to enable their own understanding, to clarify concepts and terms, to memorize and to facilitate their preparation for examinations. From the qualitative content analysis on the students’ described reasons for taking notes, two subcategories emerged within an overarching category of Taking notes for facilitating learning. One subcategory was taking notes for the purpose of Summarizing to memorize and understand, as an example that one student wrote:

“Ett sätt att lära och repetera. Många gånger skriver jag anteckningar som jag sedan inte behöver läsa igen, jag lär mig genom att skriva.”

“A way to learn and repeat. Often, I take notes that I do not even need to read again; I learn simply by writing.” [authors’ translation]

The other subcategory emerging from the content analysis was that the students took notes for the purpose of Preparing for the written examination. An example for this subcategory was:

“Kunna få så bred kunskap som möjligt samt se det som ett inlärningstillfälle inför examinationer.”

“To gain as broad a knowledge base as possible and to view it as a learning opportunity in preparation for examinations.” [authors’ translation]

The integration of literacy in professional education

Based on the syllabi, undergraduate nursing education is based on mainly two academic disciplines: nursing and medicine. These two disciplines differ in literacy practices. Nursing courses require reasoning with concepts, diverse epistemological perspectives, and contextual judgement. While the content courses in nursing are related to human encounters (patients, clients, colleagues) and humanistic values, ethics, peoples’ experiences, demanding critical reflection, discussions and the ability to alter perspectives, medical courses are mainly related to content such as anatomy, physiology, pathology and medical calculations, basically demanding knowledge of facts but also judgement specifically related to the nursing profession. A challenge for students is that although the same verbs can be used in learning outcomes and may signal similar types of answers, the differences in expectations are specifically related to what counts as valid answers in nursing sciences as a humanistic discipline versus medical sciences as part of natural science tradition [45]. Whether these differences are made explicit to students or not cannot, however, be answered by merely analyzing documents, other empirical data are needed. The validity of texts is not determined by individual teachers but by the academic discipline itself, with its established traditions for what and how to read and write [2,46,47]. Thus, the students are expected to appropriate a discipline-related practice, and here in the context of nursing [1].

Students reported using note-taking mainly to memorize information and prepare for exams, suggesting that their practice is strongly shaped by teaching and assessment. Thus, note-taking is most plausibly related to an organized activity by the university, that is, teaching and assessment. Second-semester students showed no signs of connecting note-taking to professional needs, focusing instead on academic learning and exam preparation. Instead, there is a clear focus on the present situation, that is, the academic context in terms of learning and passing exams. This may also be a signal that students, early on the SPN, have not yet become aware of the demands of professional literacy. Indeed, the students’ experience in the nursing context comprised a week of field studies of observing nursing care, which may not provide adequate preconditions for understanding the aspect of literacy. This has also been highlighted in a previous study where there was a discrepancy between students’ preparedness for academic and professional literacy practices at the time for graduation and five years into their professional careers [22].

According to previous research there are dual goals within professional education, where teaching integrates both academic literacy and professional literacy, that in principle may equip students for both academic and professional success [21,24]. Also, it has been shown that academic literacy promotes critical thinking which is essential for the nursing profession [13]. In the course syllabi of this SPN, academic literacy is in the form of scientific writing and as preparation for the Bachelors’ thesis. While previous studies have acknowledged the crucial role of teaching in helping students recognize this connection, the kind of professional programmes that involve knowledge from two or more different disciplines require further investigation [8]. This SPN features similar vocabulary regarding expected learning outcomes, due to taxonomical formulations, but differ in their criteria for what counts as valid written answers [48]. In a previous study, nursing students’ academic writing included learning and using an academic writing style, which required time and effort to learn [49]. When two academic literacy practices (nursing, medicine) are involved, it can be surmised that this requires attention from teachers in order for students not to experience these as differences in individual teachers’ demands. Since students must also adopt a third literacy practice, the professional one, they cannot be expected to manage all three without guidance. According to a study that investigated college students’ note-taking, most students report that their note-taking is self-regulated. Those who report teacher guidance, refer to middle school or high school [50]. Whether this support is offered to them or not is, however, an empirical question.

Students’ reported forms of note-taking

This study showed two forms of note-taking, pen and paper, and digital forms of note-taking, such as computers, tablets and mobile phones. A surprising result was that pen and paper was the dominating form of note-taking reported by the students, followed by note-taking on a computer/tablet.

Although digital tools for note-taking are widely available, studies show that they have not significantly changed the amount nor the quality of students’ notes [50]. It is the student that makes the choice of how and what to write. Also, in line with the practice of the academic context, this study showed that the frequency of note-taking was higher during teaching and before examinations [50].

As a further illustration that the academic context plays a crucial role in the practice of note-taking, a previous study surveyed nursing students about their chosen method of note-taking during a semester [51]. The majority of students (71.2% of 217 participants) reported using electronic note-taking, while the remaining students (28.8%) used handwritten note-taking. A common reason for choosing electronic note-taking was speed, that is, the ability to keep up with the lecturer and the pace of teaching. However, students also reported downsides, such as distractions from social media and web surfing. This indicates that note-taking is strongly tied to the academic context, although individual factors may also influence students’ choice of tool. However, that is another empirical question.

Strengths and limitations

This study was conducted by a research team that represented three disciplines, and that has collaborated in the “preparation, organization, and reporting of results” [39]. This has demanded reciprocal exploration of how the concepts and theories used are understood, what counts as valid ways of analyzing and describing previous research as well as results. This concerns specifically the analysis of the course’s syllabi.

The response rate of the questionnaire was relatively small (40%) despite reminders. The small sample (n < 100) allows us only to regard the quantitative result as indications. However, the size of 20–50% of responders is a common response rate of, e.g., course evaluations and other non-mandatory and anonymous evaluations at our university. There are two possible risks: 1) that the students interpret the questionnaire as yet another evaluation within the SPN, although they were informed of the purpose; and 2) that the content and purposes of the questionnaire are of little interest to the students although of great interest to the teachers. Although we followed recommendations for increasing the response rate, such as informing of the purpose in advance, using a mixture of open ended and closed questions and directing the questions to a specific group [52,53] this was obviously not enough for motivating the students. Thus, the results must be interpreted with caution. Another contributing factor to the response rate might also have been that the questions in the questionnaire were limited to note-taking in relation to lectures and examinations. This can be seen as a weakness of the study. Furthermore, the choice of the group of students and the course during the period of data collection was mostly based on teacher-led activities. Furthermore, in this article, the clinical context was not included.

Further studies

This article is the first one in a series of longitudinal study concerning literacy in the nursing programme. Future studies should include larger samples, follow students longitudinally, and address literacy practices in clinical and interprofessional contexts. This is particularly relevant given the growing concerns with documentation and patient safety [25–27]. Regarding this specific group of students, we have already conducted interviews based on the questionnaire on the one hand, and on their individual notes on the other. The results of this study can broaden the understanding of students’ note-taking with concrete examples and patterns, which may support development of teaching and nursing programmes.