Received: 23 December 2022
|
Revised: 9 June 2023
|
Accepted: 12 June 2023
DOI: 10.1002/nop2.1926
E M P I R I C A L R E S E A R C H Q U A N T I TAT I V E
Effectiveness of differentiated instruction on learning
outcomes and learning satisfaction in the evidence-­based
nursing course: Empirical research quantitative
Shwu-­Ru Liou1,2 | Ching-­Yu Cheng1,2
Hsiu-­Chen Liu1
| Tsui-­Ping Chu2 | Chia-­Hao Chang1 |
1
Chang Gung University of Science and
Technology, Puzi, Chiayi, Taiwan
Abstract
Chang Gung Memorial Hospital Chiayi
Branch, Puzi, Chiayi, Taiwan
Aim: Diversified students in higher education and the complexity and difficulty of the
Correspondence
Ching-­Yu Cheng, Chang Gung University
of Science and Technology, Chiayi
Campus, No. 2, Sec. W., Jiapu Rd., Puzi,
Chiayi, Taiwan.
Email: chingyuus@gmail.com
Differentiated instruction can provide students with various opportunities to learn and
2
Funding information
Chang Gung Medical Research Program,
Grant/Award Number: CMRPF6K0051;
Ministry of Science and Technology,
Grant/Award Number: MOST 107-­2511-­
H-­255-­0 02-­
evidence-­based nursing course perceived by students challenge nursing educators.
meet the learning needs of students with different academic abilities and strengths,
which may be a solution. This study aimed to apply differentiated instruction to design
the undergraduate evidence-­based nursing course and evaluate the effects of differentiated instruction on students' learning outcomes and learning satisfaction.
Design: One-­group pretest–­posttest pre-­experimental design was applied.
Methods: Ninety-­eight undergraduate nursing students enrolled in the evidence-­
based nursing course 2020 participated in this study. Students' learning outcomes
including preferred learning styles, classroom engagement, collaborative learning,
attitudes towards evidence-­based nursing, learning satisfaction and evidence-­based
nursing knowledge were measured using validated questionnaires.
Results: The differentiated instruction increased students' learning interests, promoted
focused and independent thinking, and enhanced academic achievement. Students'
classroom engagement, attitudes towards evidence-­based nursing, evidence-­based
nursing knowledge and learning satisfaction were improved after the course. The
course designed with differentiated instruction provided a supportive learning environment and furnished a vivid pedagogical way for the unique nursing profession.
Patient or Public Contribution: Positive results of the study support the application
of differentiated instruction in the evidence-­based nursing course. The study indicates that the application of differentiated instruction in mixed-­ability classrooms in
the evidence-­based nursing course improved students' learning outcomes, attitudes
towards evidence-­based nursing, evidence-­based nursing knowledge and learning
satisfaction. In clinical settings where nurses are even more diverse in academic education, clinical experiences and learning preferences, differentiated instruction can be
a suitable application for in-­service training and education to promote nurses' enthusiasm for professional learning.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.
6794
|

wileyonlinelibrary.com/journal/nop2
Nursing Open. 2023;10:6794–6807.
|
LIOU et al.
6795
KEYWORDS
differentiated instruction, evidence-­based nursing, learning outcomes, undergraduate nursing
students
1
|
I NTRO D U C TI O N
guide to design and evaluate their education programme. One of the
hallmarks emphasizes that teaching/learning strategies should meet
The importance of educating healthcare professionals with compe-
the learning needs of a diverse student population (NLN, 2020).
tency in providing evidence-­based practice (EBP) to enhance quality
Differentiated instruction is teaching strategies that address the di-
and safety care has been declared. The American Nurses Credentialing
verse learning needs of students (Tomlinson, 2001). These teaching
Center Magnet Recognition program stresses hospitals to prepare
strategies can meet the learning needs of students with different ac-
their nurses with the ability to apply EBP to ensure exemplary pro-
ademic abilities and strengths and give various opportunities for stu-
fessional practice (Nelson-­Brantley et al., 2020). The evidence-­based
dents to learn (Boelens et al., 2018; Tomlinson, 2001). Differentiated
nursing (EBN) bridges the gap between research and practice by look-
instruction has been broadly applied in elementary and high schools
ing at the quality of research methods and findings that help nursing
internationally, yet, very little evidence is reported in higher educa-
professionals make appropriate and effective decisions for clinical
tion (Turner et al., 2017). Nevertheless, differentiated instruction is
practice. Nursing students, who are future nursing professionals, are
supposed to be demanded more in higher education since student
naturally expected to have competency in applying the best available
populations in higher education systems are more culturally, socially
evidence and be prepared with the ability of EBP before graduation
and academically diverse (Boelens et al., 2018).
(American Association of Colleges of Nursing [AACN], 2021).
To the best of our knowledge, there is currently no research
With the increasing emphasis on EBN, nurse educators face two
empirically testing the effectiveness of applying differentiated in-
major issues. One is that nursing students regard the EBN course as
struction in nursing students' learning outcomes in an EBN course.
complicated and difficult for them to understand or apply the knowl-
Because of the importance of possessing competency in EBN and
edge and skills in clinical settings (Tlili et al., 2022). The other is the
the diverse student characteristics, the purpose of this study was to
challenge that students are more diversified in higher education due
apply differentiated instruction in designing the EBN course to in-
to their varied educational and life experiences (Trolian & Parker
crease undergraduate nursing students' learning interests in and bet-
III, 2022). Because of the diversified characteristics, students demon-
ter understanding of the EBN. The study also examined the effects of
strate varying learning abilities, learning styles and academic levels in
differentiated instruction on students' learning outcomes and learn-
classrooms (Ramdani et al., 2021). Tomlinson (2001) asserts that stu-
ing satisfaction. Two research questions were set to guide the study:
dents learn best when their teachers accommodate the differences in
their readiness levels, interests and learning profiles. Unfortunately,
1. What are the effects of differentiated instruction on students'
traditional and undifferentiated instruction that does not assist knowledge construction for students with various learning capacities causes
preferred learning styles?
2. What are the effects of differentiated instruction on the degree
problems of inequality and inequity in education (Tomlinson, 2001).
of students' classroom engagement, collaborative learning, atti-
Student-­centred pedagogies, which place learners at the centre of
tudes towards EBN, learning satisfaction and EBN knowledge?
the learning process, can meet learners' individual learning needs and
styles and engage them in the process of learning (An & Mindrila, 2020).
Examples of student-­centred pedagogies include active learning, which
involves students in their own learning process (Nguyen et al., 2021);
collaborative learning, which engages students working together towards the attainment of goals (Lumatauw et al., 2020); and problem-­
2
|
BAC KG RO U N D
2.1 | Theoretical background of differentiated
instruction
based learning, which provides a learning environment for learners to
actively collaborate with others and develop problem-­solving skills
According to differentiated instruction, teachers proactively re-
(Trullàs et al., 2022). These student-­centred pedagogies focus more on
model curricula, teaching methods, resources, learning activities
the process of learning during class time. Differentiated instruction is
and student products to offer a range of learning opportunities that
another student-­centred approach (Gheyssens et al., 2020) that em-
cater to students' individual learning abilities (Tomlinson, 2001).
phasizes flexibility in the areas of content, process and product to pro-
Differentiated instruction can be closely associated with several
vide more opportunities for students to choose appropriate content
adult learning theories, including Humanism, Self-­Determination
and access to content, learning activities that showcase their individ-
Theory, Sociocultural Constructivism and Multiple Intelligences.
ual strengths, and methods that are suitable for them to demonstrate
Humanism places the learner at the centre and emphasizes self-­
their learning outcomes (Tomlinson, 2000).
actualization. It suggests that learning is self-­directed, and adults are
The Hallmarks of Excellence in nursing education proposed by
capable of taking responsibility for their own learning (Mukhalalati
the National League for Nursing (NLN) provides nursing faculties a
& Taylor, 2019). Self-­Determination Theory gives students the
6796
|
responsibility to make choices about their learning, leading to in-
LIOU et al.
2.3 | Definition of differentiated instruction
creased motivation and a sense of control in the learning process
(Alrabia, 2021). Sociocultural Constructivism proposes that indi-
Differentiated instruction was first proposed as a teaching practice
viduals construct new knowledge based on their existing skills and
by Tomlinson in response to the extensive scope of student discrep-
knowledge. Learning occurs through active social interactions with
ancies in mixed-­ability classrooms. Tomlinson (2000) defines differ-
peers, teachers and engagement in social activities (Mukhalalati &
entiated instruction plainly as tailoring instruction to meet students'
Taylor, 2019). Multiple Intelligences asserts that individuals possess
needs. When teachers vary their teaching in order to fit individuals
different types of intelligence, and effective learning occurs when
or small groups for the best experience, they are differentiating.
instruction is tailored to an individual's strengths and preferences in
relation to a specific task (Magableh & Abdullah, 2020).
Differentiated instruction aligns with these theories in several
2.4 | Description of the differentiated instruction
ways. Firstly, it empowers students to have control over their learning and cater to their individual needs and preferences. Secondly,
Differentiated instruction contains three sections: content and ac-
it promotes collaborative learning and knowledge construction by
cess to content, process and product. It emphasizes a flexible course
creating opportunities for students to engage in meaningful inter-
design that allows curricula for differences in content, process and
actions with others. Thirdly, it recognizes and accommodates the
product sections to provide learners with the excellence of learning
diverse strengths and preferences of students, enabling them to en-
and satisfy their unique learning needs (Tomlinson, 2001).
gage with content in ways that align with their unique intelligence.
These adult learning theories share common characteristics with
differentiated instruction, as they emphasize learner-­centredness,
2.4.1 | First section: Content and access to content
autonomy, active engagement and the recognition of individual
differences.
The content refers to topics, concepts or themes. The differentiating content includes what students are to learn and how students
2.2 | Effects of differentiated instruction
access the material taught. It involves providing students with
various resources and choices that match their readiness, interests and learning profiles to select and access the materials taught
The combing use of differentiated instruction and student-­centred
(Tomlinson, 2000).
teaching strategies provides opportunities for students to trans-
Several ways are proposed for differentiating content. Teachers
form their learning behaviour (Ismail & Allaq, 2019). Studies apply-
may use flexible grouping where students can work in small groups
ing differentiated instruction in mixed-­ability classrooms revealed
or alone to reinforce content; highlight or summarize key portions
that students significantly and positively improved their learning
of content with illustrations or colours; present material in visual,
achievements (Hapsari & Dahlan, 2018).
auditory or kinaesthetic ways; provide lecture videotapes; use
Although differentiated instruction is proposed to be useful at
books, pictures or Internet as a means of developing understanding
all levels of education, not many empirical studies reported its appli-
and knowledge of the topic or concept; use examples that relate to
cation in higher education (Boelens et al., 2018). Published studies
students' experiences or knowledge to practice situations or explain
that applied differentiated instruction among non-­nursing students
contents (Tomlinson, 2001).
reported that students enhanced their learning interests (Sapan &
Mede, 2022), developed independence and autonomy towards their
learning (Chen & Chen, 2018; Sapan & Mede, 2022), grew posi-
2.4.2 | Second section: Process
tive attitudes towards the course (Darra & Kanellopoulou, 2019)
and were satisfied with the classes and course design (Ismail &
The process refers to how students make sense or understand and
Allaq, 2019; Sapan & Mede, 2022). Some studies also reported that
assimilate the information, concepts or skills. The differentiating
differentiated instruction significantly improved students' academic
process involves applying varying activities and techniques which
performance (Darra & Kanellopoulou, 2019) and achievement (Chen
can provide more opportunities for students to learn best and dis-
& Chen, 2018), increased students' cooperation, interaction, class-
play individual strengths (Tomlinson, 2001). It concerns not only how
room engagement (Sapan & Mede, 2022), active learning (Darra &
teachers teach but also involves strategies that teachers encourage
Kanellopoulou, 2019) and learning motivation (Chen & Chen, 2018;
students to use to facilitate exploring the content taught. This can
Sapan & Mede, 2022). Educators using differentiated instruction
be done by tiering the course content and activities that can make
combined with student-­centred learning strategies found positive
students learn step by step; providing guidelines for every step of
outcomes of students' successful learning skills and experiences,
learning; using differentiated tactics to increase student interaction,
classroom engagement, learning interests or social interaction
engagement, higher order thinking and critical thinking during class
(Ismail & Allaq, 2019).
time (Tomlinson, 2000, 2001).
|
LIOU et al.
6797
In addition, educators emphasized that differentiated instruction
According to the concept of patient and public engagement and
places students in the centre, provides opportunities for higher order
involvement (PPEI), the researched population is actively involved in
thinking and group collaboration to solve problems, and changes
the research design, is informed of research information and knowl-
students from passive acquisition of knowledge to an active learn-
edge and participates in the research. The insights provided by these
ing process through student-­centred teachings such as teamwork
participants contribute to the research design and enhance the re-
learning, problem-­based learning or project-­based learning (Ismail &
searcher's understanding of the condition under investigation.
Allaq, 2019). Therefore, in the spirit of this phase, combining the use
In this study, although students were not directly involved in the
of student-­centred teaching methods to design classroom activities
course design, feedback from previous students who had taken the
for the EBN course was considered.
course was taken into consideration during the course design process. Students had the power to choose their preferred methods of
learning under the guidance of the instructor. They had the freedom
2.4.3 | Third section: Product
to select their learning mediums and materials, form groups for collaboration, explore research topics and articles of interest and de-
The differentiating product involves providing various choices of
termine their preferred modes of presentation. Moreover, students
evaluations that permit students to express how much they com-
shared their discussion results throughout the course, presented
prehend and how well they are able to administer their knowledge
their final work in class and participated in evaluating both their own
and skills learned from the content (Tomlinson, 2000). The traits of
and their peers' final presentations.
successfully differentiated products contain providing evident and
proper guides for success, focusing on real-­world application, advancing creative and critical thinking, requiring analysis or synthesis
of information, permitting diverse methods of expression and pro-
3.3 | Development of the EBN course based on the
differentiated instruction
viding opportunities for peer and self-­evaluation (Tomlinson, 2001).
To differentiate product, teachers can encourage students to
3.3.1 | Course description
express what they have learned in varied ways, offer opportunities
for student-­derived topics for projects; allow for varied working
The EBN course was a required, 2-­credit h undergraduate course for
arrangements—­alone or with a group; provide clear guidelines for
nursing students. The course was designed mainly based on the five
independent work that matches individual needs; and use a wide va-
steps of EBN: (1) asking an answerable clinical question, (2) acquir-
riety of assessments or assignments for students (Tomlinson, 2001).
ing the best evidence, (3) appraising the evidence, (4) applying the
evidence and (5) auditing or evaluating the outcomes of the prac-
3
|
M E TH O D S
3.1 | Study design
tice (Melnyk & Fineout-­Overholt, 2019). Since nursing students are
not currently clinical nurses, the course focused more on the first
three steps. The semester lasted 18 weeks. Excluding introduction,
holiday, exam and project report weeks, seven programme units in
11 weeks were designed for the course. Table 1 presents the course
This study used a one-­group pretest–­posttest design to evaluate
objectives and teaching strategies derived from differentiated
students' learning outcomes after the implementation of teaching/
instruction.
learning activities designed based on differentiated instruction.
The overall learning objectives of the course were first estab-
The one-­group pretest–­posttest design is proposed to be useful for
lished and proposed for students. Each unit also had unit objectives
discovering the effectiveness of an intervention in a homogeneous
that guided students to learn from that unit. The overall goal of the
group (Norwood, 2000). The research design, therefore, is suitable
course was that nursing students learned how to search health-­
for this study because participants in the study were nursing stu-
related literature with empirical findings based on their answerable
dents in the same age group and university.
questions or topics of interest and assess the quality of evidence
from the studies. A pre-­assessment to assist the understanding of
3.2 | Participants and setting
individuals' readiness, interests and learning styles was provided to
students before the class began.
The participants were students in a 2-­year Registered Nurse-­to-­
Bachelor of Science nursing programme who enrolled in the EBN
3.3.2 | Strategies for differentiated instruction
course at the primary investigator's serving university in southern
Taiwan in 2020. All students that enrolled in the EBN course taught
According to differentiated instruction, after understanding how
by the researcher (a total of 100 students) were invited to participate
students learn best, a course can be developed with differentiating
in this study. Of them, 98 students completed and returned both the
content and access to content, differentiating process and differ-
pre-­and post-­test questionnaires with a response rate of 98%.
entiating product. Information from the pre-­assessment guided the
1. Understand the importance of applying evidence-­
based knowledge to practice.
2. Understand the process of transferring evidence into
practice.
1. Understand the concept of transdisciplinary care.
2. Understand the importance of transdisciplinary care
for quality patient care.
Asking PICO questions
Acquiring the best evidence
Research design and level of
evidence
Appraising critically the
quality of healthcare-­
related research
Speech:
Evidence translation and
clinical nursing practice
Speech:
Trans-­disciplinary EBP and
quality of patient care
2 and 3
4 and 5
6
7–­9
10 and
11
1. Understand tools for appraising different study
designs.
2. Understand critical appraisal principles of quantitative
studies.
3. Critically appraise the study design of the selected
research articles.
1. Understand the levels of evidence pyramid.
2. Understand types of research designs.
3. Understand study types and biases.
4. Identify the research design and level of evidence of
the selected research articles.
1. Understand the types of PICO questions.
2. Understand the 6S Pyramid.
3. Understand the search strategy for the best evidence.
4. Understand the PRISMA flow diagram.
5. Search evidence based on the scenario and PICO
question.
1. Understand the main concepts in the unit:
foreground/background problem, PICO and types of
PICO questions
2. Understand how to ask a PICO question
3. Establish a topic for EBN and ask a PICO question
based on scenarios.
1. Understand the definition of EBN
2. Understand the importance of EBN
3. Understand the steps of EBN
Introduction to EBN
1
Unit objectives
Unit topic
Week
Content and access to
content
Process
1. Flexible grouping: Students decide on group size (alone, in pairs or
in small or large groups) for all classroom activities.
2. Flexible class time proportion: based on unit topic and instructional
instruction.
3. Literature search: A 2-­h laboratory session guided by the school
librarian.
4. Flexible topic and article selection: Students select the article to
read from searched literature based on their own interests.
5. Hands-­on practice: students demonstrate their abilities in
accessing electronic databases and searching for publications.
6. Guided reading: Students are guided to read research articles
based on the unit.
7. Literature circle: Students read and answer the guiding questions
based on their selected article, and decide the way to share in
class.
8. Learning sheets: Contain different question types and vivid
illustrations in a variety of styles for each unit.
9. Independent study: Allow students to work with whomever they
felt comfortable.
10. Clinical expert speeches: sharing the role and application of the
EBN in clinical.
Section
1. Teaching aids development:
-­Non-­electronic materials: Books, supplemental articles in English
and Chinese, reading and assignment guidelines
-­Electronic materials: Videos with PowerPoint slides embedded with
highlighted key portions of content and vivid illustrations, colours
or graphs
-­C ase scenarios related to EBN steps
2. Materials uploaded onto the school's electronic platform
Strategies designed in the study
Overall goal: Nursing students will be able to search health-­related literature with empirical findings based on their answerable questions or topics of interest. Students will also be able to assess the
quality of evidence from the studies.
TA B L E 1 Course objectives, sections of differentiated instruction and teaching strategies designed in the study.
6798
|
LIOU et al.
|
6799
instructor to appropriately differentiate the content, process and
product of the EBN course throughout the semester.
students with various learning resources and choices to select and
Product
Section
The first section differentiating content involves providing
access the materials taught (Tomlinson, 2000). To differentiate
content and access to content, teaching aids were developed as
1. Allow flexible grouping for all evaluations.
2. Research article reading test using the article selected by students
themselves.
3. Complete a mini-­project using the guideline and appraisal tool.
4. Self-­determine the topic of interest for the project.
5. Present the mini-­project publicly in ways preferred.
6. Both the instructor and all students evaluate all presentations.
Strategies designed in the study
electronic and non-­e lectronic materials. For non-­e lectronic materials, books, extra supplemental articles in English and Chinese
and reading and assignment guidelines were prepared and used
in response to varied learning levels of complexity. When developing textual materials, we highlighted key portions of content in
PowerPoint slides for each unit and used vivid illustrations, colours or graphs to help students to understand more about the
content and made the contents more attractive to students. Case
scenarios related to EBN steps were developed as examples for
students to practice and explain contents.
For electronic materials, videos with PowerPoint slides for each
unit lecture were made. All these materials were uploaded onto the
school's electronic platform for courses, the E-­C ampus, to allow students to access and learn the subject in a self-­paced format. The
design of these materials can make the conceptual abstraction of the
content more concrete and practical to students, provide opportunities for independent study, help and stimulate students to stay focused and clarify the content. In addition, supplemental instruction
outside of the scheduled class times was offered for individuals or
Evaluate students' knowledge and skills gained from the
course.
Unit objectives
groups to reinforce contents.
The second section differentiating process encompasses using
diverse activities and techniques which can furnish more chances for
students to learn best (Tomlinson, 2001). To differentiate the process, we first applied flexible grouping for all classroom activities.
Students decided the size of the group, such as working alone, in
pairs or in small or large groups. Flexible grouping was also applied to
the term project, oral presentation and final exam. Arranging appropriate class time proportions for various instructional strategies was
then planned based on the unit topic. Combining the use of differentiated instruction and student-­centred teaching strategies which
were proposed by researchers to transform students from passive
learners to active learners and promote students' learning interests
were also administered (Ismail & Allaq, 2019). In addition, 4 h of the
class were arranged as independent study hours. Students could use
the 4 h to work with whomever they felt comfortable.
The classroom activities designed for the EBN course included
first, a 2-­h laboratory session for literature search was arranged.
Project report
and online library resources. Students were asked to specify a topic
13 and
14
Final examination
12
Unit topic
The school librarian was invited to guide students to use physical
Week
Overall goal: Nursing students will be able to search health-­related literature with empirical findings based on their answerable questions or topics of interest. Students will also be able to assess the
quality of evidence from the studies.
TA B L E 1 (Continued)
LIOU et al.
of interest and turn in one searched research article based on the
topic to demonstrate their ability to search for and access publications. Second, two clinical experts were invited to give speeches to
share the role and application of the EBN in clinical to foster students' learning interests in EBN. Third, to provide information to the
instructor and students about students' understanding of the core
concepts and contents taught in the unit, learning sheets were developed and used at the end of each class. The items in the learning
6800
|
LIOU et al.
sheet were designed in various styles to meet the learning needs of
negligible (or negative) preference. Major means the learners' pre-
students of varying levels. These item styles included single choice,
ferred learning style; minor indicates learners who do not prefer to
multiple choice, fill-­in-­the-­blank, connecting the dots, short answer
learn in such a way but can still function using such learning method,
or essay questions that were helpful to cultivate students with dif-
whereas negligible means they may have difficulty learning in that
ferent thinking abilities. These learning sheets were also designed
way. The cut-­off points for each of these categories are as follows:
with vivid illustrations to attract students' attention and interest.
40 or above for major, 25–­39 for minor and 24 or less for negligible.
Fourth, the literature circle activity was applied to help students
The reliability of the original scale was confirmed by the split-­half
integrate what they have learned in the module content with real
reliability. In the study, Cronbach's alpha for the six subscales of the
hands-­on practice and to increase students' understanding of the
PLSPQ were 0.73, 0.66, 0.71, 0.67, 0.89 and 0.89 for visual, auditory,
content. The instructor first guided students to read the section in
kinaesthetic, tactile, individual and group learning respectively.
the selected research article in accordance with the course unit for
The Value of Teams (VT) developed by Levine et al. (2004) was
that week. Using flexible grouping, students were then instructed to
used to measure students' value of collaborative learning. The VT
choose a research article they preferred, read the article and answer
consists of 17 items scored on a 5-­point Likert scale from 1 (strongly
the guiding questions based on the chosen article. Finally, students
disagree) to 5 (strongly agree). A higher score indicates greater
decided on a way to share in class what they have discovered from
agreement about the value of collaborative learning. The validity
the article.
of the scale development study was confirmed by a factor analysis
The third section differentiating product involves providing
that showed two subscales: the value of group work and the value
various ways of evaluations for learners to exhibit their compre-
of working with peers. Cronbach's alphas for these two dimensions
hension of the course and ability to apply the gained knowledge
were 0.79 and 0.81 respectively (Levine et al., 2004). In this study,
and skills learned from the content (Tomlinson, 2000). According
Cronbach's alpha was 0.85. Exploratory factor analysis showed that
to differentiated instruction, the teacher may combine tests with
the VT explained 48.46% of the variation in the value of collabora-
product options so that students have more opportunities to pon-
tive learning. The first factor (value of group work) explained 37.67%
der, apply and display what they have learned from the content
of the variation while the second factor (value of working with peers)
(Tomlinson, 2001). In the EBN course, project-­b ased learning with
added another 10.79%.
a presentation was designed to meet the general goal of the course
The Classroom Engagement Survey (CES) developed by O'Malley
so that students were able to evaluate the quality of evidence.
and colleagues (O'Malley et al., 2003) was used to measure stu-
Students were requested to finish a mini project by following a
dents' level of classroom engagement. The CES is a 9-­item scale with
provided project guideline and a critical appraisal tool. Students
Likert-­t ype response options ranging from 1 (strongly disagree) to 5
were allowed to work on the project alone or in a group with two
(strongly agree). A higher score indicates a higher level of agreement
or more people. In addition, students decided on the topic of the
in classroom engagement. Reliability (Cronbach's alpha was 0.84)
project by themselves. At the end of the semester, students were
and validity were confirmed by factor analysis in the original study.
asked to present their project publicly in ways they preferred. The
In this study, Cronbach's alpha was 0.92. Exploratory factor analysis
class instructor and all students were responsible for the presen-
showed that the CES as a single factor explained 41.35% of the vari-
tation evaluation. For the test, an academic article reading test
ation in classroom engagement.
was used. Students first decided to take it alone or in a group and
The short form of Individual Development and Educational
the group size. They were allowed to find a health-­related research
Assessment (IDEA) developed and validated by the IDEA Center was
article in English or Chinese in accordance with their own interests
used to evaluate students' satisfaction with the course learning. The
before the test. Eight short answer questions were developed for
scale, which contains 18 items and uses a 5-­point Likert scale (item
students to answer based on the research article they selected.
score ranges from 1 to 5), has been utilized at a variety of universities
Two hours were scheduled for the test.
in the USA with confirmed reliability and validity (Benton & Li, 2015).
A higher score indicates a higher level of satisfaction with the des-
3.4 | Outcome variables and measurements
ignated course. In the study, Cronbach's alpha was 0.90. Parallel
analysis resulted in two factors and exploratory factor analysis was
done by requesting two factors. Results showed that the IDEA could
Preferred learning style was measured by the Perceptual Learning-­
explain 58.44% of the variation in learning satisfaction. The first fac-
Style Preference Questionnaire (PLSPQ) created by Reid (1987,
tor (12 items), named knowledge and skills gained, explained 47.45%
1995). The PLSPQ consists of 30 items with six learning styles (five
of the variation in learning satisfaction while the second factor (six
items for each learning style) including visual, auditory, kinaes-
items), named perceived course quality, added another 10.99%.
thetic, tactile, individual and group learning. The scale is rated on
The 15-­item Attitudes Towards Evidence-­based Nursing scale
a 5-­response Likert scale scoring from 1 (strongly disagree) to 5
(ATEN) was used to rate nursing students' attitudes towards EBN.
(strongly agree). Since individuals may utilize a combination of senses
The ATEN was developed by the researchers based on literature and
to optimize their learning outcomes while preferring one particular
rated on a 5-­response Likert scale scoring from 1(strongly disagree)
sensor mode, each learning style is categorized into major, minor or
to 5 (strongly agree). In the study, Cronbach's alpha for the scale
|
LIOU et al.
6801
was 0.85. Parallel analysis resulted in two factors and exploratory
values for measured variables. Before doing inferential statistics,
factor analysis was done by requesting two factors. Results showed
all measured variables were tested for normality using the Shapiro–­
that the ATEN explained 54.83% of the variation in attitudes to-
Wilk test. Results showed that except for learning style-­visual at the
wards EBN. The first factor (nine items), named importance of EBN,
pretest and attitudes towards EBN at the pretest and posttest, all
explained 36.49% of the variation in attitudes towards EBN while
other variables were not normally distributed. Therefore, to test the
the second factor (six items), named perceived competence in EBN,
effects of differentiated instruction, the Friedman test and Wilcoxon
added another 18.34%.
signed-­rank test were used to compare differences before and after
The 16-­item Concept Inventory (CI) was developed by the re-
the differentiated instruction on classroom engagement, collabo-
search team to measure students' level of EBN knowledge and was
rative learning, learning satisfaction, preferred learning styles and
used to assess students' academic performance. The CVI validity of
EBN knowledge. Paired t-­test was used to compare differences be-
the Concept Inventory was confirmed (CVI = 0.94) in this study.
fore and after the differentiated instruction on attitudes towards
A demographic sheet was used to understand individual characteristics such as age, grade level, learning experiences and achieve-
EBN. All tests were two-­sided and p-­values of less than 0.05 were
considered to be statistically significant.
ment, and educational and career plans. Questions about the role of
differentiated instruction in facilitating students' EBN learning were
also asked.
3.5 | Ethical considerations
4
|
R E S U LT S
4.1 | Descriptive results
The mean age of the participants was 20.81 (SD = 1.06) years and
We began to conduct the study after obtaining approval from an
94.9% were females. As shown in Table 2, most students expressed
Institutional Review Board in Taiwan (REDACTED). In the first
that their academic performance was either fair or good at their
class, the course syllabus, the purpose and procedures of this study
previous college and current school, and considered their current
and participants' rights were verbally explained to the students.
academic performance improved. More than half of the students
Participants were assured that they had the right not to fill out the
planned to obtain a bachelor's as their last academic degree and
questionnaires or answer any questions that they did not feel com-
had a moderate or strong willingness to work as clinical nurses after
fortable answering and that such a refusal would not influence their
graduation. Over 70% of the students expressed that they had a
academic grades. All participants signed a consent form before data
great sense or sense of academic accomplishment in the EBN course
collection. Since the EBN course is a required course, all students
learning and agreed or strongly agreed that the differentiated in-
in the course were required to participate in all designed activities.
struction was worth applying to other courses.
As shown in Table 3, at posttest, students regarded differ-
3.6 | Procedures
entiated instruction played an important role in facilitating their
EBN learning, such as increasing learning interests, helping them
to think independently and improving concentration on learning
Before the class began, the EBN course syllabus that outlined course
and learning aggressively. As a result, their acceptance of the
objectives, unit contents, classroom activities, project guidelines
EBN course augmented and they agreed that the EBN course was
and methods of performance evaluation, supplementary reading ar-
worth taking. The number of passive learners decreased while ac-
ticles, learning sheets, PowerPoint slides and lecture videos of the
tive learners increased. More students considered that the nurses
EBN course were all uploaded to the school's online learning plat-
with a bachelor's degree need to do EBN; this percentage was
form, the E-­campus. Students who were willing to participate in the
higher than the percentage of nurses with a master's or doctoral
study received a packet containing a cover letter, a set of question-
degree.
naires and a set of multiple-­choice test questions at the beginning
of the first and last class days. Students could choose to answer the
questionnaires at any place they felt comfortable with and send the
completed questionnaires back to the research assistant using the
4.2 | Preferences of learning styles among
nursing students
prepared envelope.
At the pretest, the percentage of students owning more than one
3.7 | Statistical analysis
major or preferred learning method was: 23.5% for two, 23.5%
for three, 20.4% for four, 10.2% for five and 7.1% for six methods.
Other 11.2% of the students had only one and 4.1% did not have
All data were entered and analysed using the Statistical Package for
any major or preferred learning methods. At posttest, the percent-
the Social Sciences (SPSS) version 23.0. Demographic information
age changed to 18.4% for two, 24.5% for three, 30.6% for four,
was summarized using descriptive statistics. There are no missing
9.2% for five and 9.2% for six methods. Other 5.1% of the students
6802
|
LIOU et al.
TA B L E 2 Demographic information of the participants.
Variables
n
%
TA B L E 3 Differentiated instruction course design in facilitating
students' learning.
Pretest
Performance at previous school
Posttest
Poor
4
4.1
Variables
Fair
53
54.1
EBN course design can increase my learning interests
Good
34
34.7
Disagree
4
4.1
1
1.0
Excellent
7
7.1
Neither agree nor disagree
36
36.7
18
18.4
Agree
58
59.2
79
80.6
Performance at current school
n
%
n
%
Poor
1
1.0
Fair
64
65.3
Disagree
0
0
0
0
Good
29
29.6
Neither agree nor disagree
22
22.4
9
9.2
Excellent
4
4.1
Agree
76
77.6
89
90.8
Performance improvement at current school
EBN course design can help me think independently
EBN course design can help me concentrate on learning and learn
aggressively
Significant
14
14.3
Some improvement
69
70.4
Disagree
0
0
1
1.0
15.3
Neither agree nor disagree
30
30.6
12
12.3
Agree
68
69.4
85
86.7
About the same
15
Last academic degree plan to obtain
Level that I accept the EBN course
Bachelor
56
57.2
Master
41
41.8
Low
0
0
2
2.0
1.0
Median
54
55.1
34
34.7
High
44
44.9
62
63.3
Doctoral
1
Willingness to be a nurse after graduation
EBN course is worth taking
Strong
15
15.3
Medium
41
41.8
Disagree
0
0
2
2.0
Neither agree nor disagree
21
21.4
14
14.3
Agree
77
78.6
82
83.7
Fair
42
42.9
Weak
0
0
I prefer just following instructor's direction (passive learning)
Learning experience in the EBN course gives me
Greatest accomplishment
22
22.5
A sense of accomplishment
50
51.0
Fair
21
21.4
No sense of accomplishment
4
4.1
Worst accomplishment
1
1.0
Differentiated instruction is worth applying to other courses
Strongly agree
27
27.6
Agree
56
57.1
Fair
14
14.3
Disagree
1
1.0
Strongly disagree
0
0
Yes
70
71.4
64
65.3
No
28
28.6
34
34.7
I prefer to have more time and space to learn by myself and will seek
teachers' help if needed (active learning)
Yes
72
73.5
83
84.7
No
26
26.5
15
15.3
Who needs to perform EBN (select all that apply)
Bachelor's degree nurses
74
75.5
77
78.6
Master's degree nurses
73
74.5
66
67.3
Doctoral degree nurses
65
66.3
53
54.2
while the group learning style had a higher score than visual, auditory,
kinaesthetic and individual learning (Chi-­square = 240.23, p < 0.001).
had only one and 3.1% did not have any major or preferred learning
methods. The number of students who had unimodal or no major
or preferred learning method decreased from pretest to posttest.
As shown in Table 4, according to the mean cut-­off points stated
4.3 | Effects of differentiated instruction on
measured variables
by Reid (1995), at both pretest and posttest, the learning styles of kinaesthetic, tactile, and group fell into the major category of learning
As shown in Table 5, the scores of group and tactile preferred learn-
styles whereas the visual, auditory and individual learning styles fell
ing styles increased significantly from pretest to posttest whereas
into the minor category. At the pretest, the Friedman test showed
the score of individual learning style decreased (p < 0.05). The score
that scores of visual and individual learning styles were lower than
for classroom engagement, collaborative learning, learning satisfac-
scores of the other learning styles (Chi-­square = 155.64, p < 0.001).
tion and attitudes towards EBN and EBN knowledge increased sig-
At posttest, the score of the individual learning style was the lowest
nificantly from pretest to posttest.
|
LIOU et al.
6803
TA B L E 4 Students' preferred learning styles.
Pretest
Variables
Posttest
n (%)
1. Visual
M
SD
n (%)
M
SD
34.24
6.03
34.51
5.92
Major
20 (20.4)
43.10
2.79
22 (22.5)
41.82
2.30
Minor
74 (75.5)
32.51
3.66
69 (70.4)
33.54
3.31
Negligible
4 (4.1)
22.00
2.31
7 (7.1)
21.14
2.80
39.24
4.95
39.10
6.22
Major
47 (48.0)
43.23
3.43
55 (56.1)
43.13
3.59
Minor
50 (51.0)
35.80
2.30
38 (38.8)
35.53
2.35
Negligible
1 (1.0)
24.00
0.00
5 (5.1)
22.00
2.00
41.12
5.22
42.96
3.83
2. Auditory
3. Kinesthetic
40.49
4.31
Major
66 (67.3)
42.67
3.13
75 (76.5)
Minor
32 (32.7)
36.00
2.59
22 (22.5)
35.91
2.86
Negligible
0
—­
—­
1 (1.0)
18.00
0.00
4. Tactile
40.88
4.56
41.94
5.02
Major
69 (70.4)
42.96
3.46
77 (78.6)
43.53
3.97
Minor
29 (29.6)
35.93
2.65
20 (20.4)
36.90
1.77
Negligible
0
—­
—­
1 (1.0)
20.00
0.00
32.57
7.82
29.88
8.36
5. Individual
Major
22 (22.5)
43.36
3.87
17 (17.4)
43.29
3.80
Minor
54 (55.1)
32.22
3.92
50 (51.0)
30.92
3.57
Negligible
22 (22.4)
31 (31.6)
20.84
3.00
42.65
5.35
6. Group
22.64
1.68
40.88
6.06
Major
74 (75.5)
43.27
3.74
86 (87.8)
43.86
4.07
Minor
22 (22.5)
34.91
3.69
11 (11.2)
35.27
3.61
Negligible
2 (2.0)
18.00
0.00
1 (1.0)
20.00
0.00
Note: The cut-­off point for major: 40 or above, minor: 25–­39 and negligible: 24 or less.
TA B L E 5 Effects of differentiated instruction on measured variables.
Pretest
Variables
Posttest
Range
M
Visual
20–­48
34.24
6.03
34.00
16–­48
34.51
5.92
36.00
−0.39
0.70
Auditory
24–­50
39.24
4.95
38.00
20–­50
39.10
6.22
40.00
−0.03
0.98
SD
Median
Range
M
SD
Median
Z or t
p
Preferred learning styles
Kinesthetic
28–­50
40.49
4.31
40.00
18–­50
41.12
5.22
40.00
−1.57
0.12
Tactile
26–­50
40.88
4.56
40.00
20–­50
41.94
5.02
40.00
−2.33
0.02
Individual
20–­50
32.57
7.82
32.00
12–­50
29.88
8.36
30.00
−3.34
0.001
Group
18–­50
40.88
6.06
40.00
20–­50
42.65
5.35
40.00
−2.39
0.02
Classroom engagement
24–­45
34.14
4.47
34.00
17–­45
35.63
4.38
35.00
−3.53
<0.001
Collaborative learning
42–­8 4
69.30
7.42
67.00
50–­85
70.69
8.01
69.00
−2.16
0.03
Learning satisfaction
52–­90
72.91
8.51
72.00
18–­90
76.13
10.53
73.00
−3.19
0.001
Attitudes towards EBN
42–­73
55.33
6.85
55.50
38–­75
60.37
7.54
59.50
7.96
<0.001
0–­75
42.86
13.82
43.75
31–­100
71.36
14.80
68.75
−8.16
<0.001
EBN knowledge
Note: Paired t-­test was used to compare scores of attitudes towards EBN, whereas Wilcoxon signed-­rank test was used to analyse all the rest
variables at pretest and posttest.
|
6804
5
|
LIOU et al.
DISCUSSION
More surprisingly, at the end of the course, more nursing students
agreed that nurses with a BSN degree needed to perform EBN when
The purposes of this study are to apply differentiated instruction
compared to nurses with a master's or doctoral degree. Two reasons
for an EBN course presented to nursing students in Taiwan and test
might explain this result. One is that while students might not un-
the effects of differentiated instruction on students' learning out-
derstand the master's and doctoral programmes, they gained learn-
comes. Although not many studies reported the application of dif-
ing interests in the subject designed with differentiated instruction.
ferentiated instruction in higher education, research findings from
The other might be that healthcare-­related institutions have as-
this study provided meaningful evidence for the contribution of dif-
serted that healthcare professionals should use the most validated
ferentiated instruction to undergraduate nursing students' learning
research findings as evidence to make decisions for patient care
in the EBN course. Generally, students demonstrated positive stand-
(AACN, 2021). Therefore, students were aware that the EBN is a
points towards the role of differentiated instruction in facilitating
growing trend and momentum in clinical nursing practice.
their EBN course learning and gained substantial growth at the
The learning styles preferred by students in the study were kin-
end of the semester. Most of the students said that they benefited
aesthetic, tactile and group learning. These results indicated that
from the EBN course designed with differentiated instruction and
nursing students preferred to learn through hands-­on practices,
believed that the strategies employed in the three sections of dif-
physical and active involvement in classroom, and valued group work
ferentiated instruction increased their learning interests, promoted
and interaction with teammates. These findings were quite different
their focused and independent thinking and gave them a sense of
from previous studies with nursing students. Mckenna et al. (2018)
academic achievement. In addition, nursing students' acceptance of
found that students in the Master of Science in Nursing programme
the EBN course was enhanced. The number of passive learners de-
preferred kinaesthetic learning to auditory learning, whereas under-
creased while active learners increased.
graduate nursing students preferred either auditory (Soliman, 2017)
The study's positive results support the use of differentiated
or visual learning style (Alharbi et al., 2017). Some other studies
instruction in the EBN course. These findings align with the prin-
found that dental students preferred an auditory learning style
ciples of student-­centred pedagogies, emphasizing flexibility,
(Akhlaghi et al., 2018). Different cultural backgrounds might be the
choice, collaboration and active participation in the learning pro-
reason for this difference.
cess, all of which are key traits of differentiated instruction (An &
Researchers proposed that embedded use of differentiated
Mindrila, 2020). Moreover, the study's results are congruent with
instruction with various teaching strategies could develop oppor-
some adult learning theories such as Self-­Determination Theory
tunities for students to maximize individual growth and success
(Alrabia, 2021) and Sociocultural Constructivism (Mukhalalati &
in learning (Gheyssens et al., 2020; Ismail & Allaq, 2019; Ramdani
Taylor, 2019) that emphasize student autonomy and motivation.
et al., 2021). Our study found that the individual learning style
Students take responsibility for their own learning and choose how
score significantly decreased but the group learning style score sig-
they learn and knowledge is constructed collaboratively by collabo-
nificantly increased at the end of the semester. The combining use
rating with others.
of differentiated instruction and other teaching strategies such as
Similar to the results of previous studies with non-­university
collaborative learning with flexible grouping in this study created a
students, differentiated instruction provides students with op-
more supportive learning environment for students to meet their
portunities to choose learning methods that meet their learning
multiple learning needs. Collaborative learning constructs a learn-
styles and progress their learning at a pace suitable for their needs
ing environment that offers opportunities for students to work with
and abilities (Iqbal et al., 2020). When students are offered mean-
peers who own different learning styles. This environment enables
ingful opportunities to select learning methods and demonstrate
individuals to experience and learn different learning styles from
their abilities, strength, or talents, they relish learning more, be-
group members and promote individuals' performance achievement
come more self-­directed and turn into focused thinkers (Darra
from the newly gained learning styles and from the help of higher
& Kanellopoulou, 2019; Sapan & Mede, 2022). All the benefits
achievers in the team (Ismail & Allaq, 2019). Our study also found
of differentiated learning lead students to positive outcomes in-
that at the end of the semester, the number of preferred learning
cluding academic achievement, active learning, group interaction
styles used by students increased.
and cooperation, self-­confidence and satisfaction with the class
We found in the study that differentiated instruction had pos-
(Chen & Chen, 2018; Darra & Kanellopoulou, 2019; Gheyssens
itive effects on students' classroom engagement, and attitudes
et al., 2020;Ismail & Allaq, 2019; Sapan & Mede, 2022).
towards EBN and EBN knowledge. These results were congruent
In addition, in this study, nursing students regarded the EBN
with previous studies that differentiated instruction positively im-
course designed with differentiated instruction as worth taking
pacted students' learning process and academic performance by
and considered differentiated instruction worth applying to other
improving student engagement and learning attitude towards the
courses. These results are congruent with previous studies that
lessons (Darra & Kanellopoulou, 2019; Haelermans, 2022; Ismail &
students generally responded favourably to differentiated instruc-
Allaq, 2019). In other words, the learning environment influences
tion and preferred to experiment with applying the course design
students' learning experiences. A learning environment that pro-
in other classrooms (Ismail & Allaq, 2019; Sapan & Mede, 2022).
vides students with insufficient motivation to learn might lead to
|
LIOU et al.
6805
students' disengagement with the classroom. The EBN course was
bachelor's degree or 5-­year diploma programme or inviting a variety
developed based on the spirit of differentiated instruction, which
of other nursing schools, are encouraged to increase the strength of
has been considered as contributing to the creation of a comfort-
the generalizability of the results.
able learning environment and the formation of positive motivation
to learn (Iqbal et al., 2020; Sapan & Mede, 2022). In addition, differentiated instruction is a student-­centred approach that has been
7
|
I M PLI C ATI O N FO R PR AC TI C E
suggested as conducive to behaviourally, emotionally or cognitively
engaging students in learning through participation in classroom
Nurses demonstrating competence in providing EBN is emphasized
activities, and interaction with teachers and classmates (Ismail &
in current clinical practice. Nursing students, the future nurses, need
Allaq, 2019; Sapan & Mede, 2022). The student-­centred learning en-
also to have the EBN ability to seamlessly connect to future clinical
vironment also offers opportunities for students to transform their
nursing practice. This study indicates that the application of differ-
learning behaviour from passive to active (Ismail & Allaq, 2019).
entiated instruction in mixed-­ability classrooms in the EBN course
Nursing students' attitudes towards EBN were significantly
improved students' learning outcomes, attitudes towards EBN and
more positive at the end of the course. The result is similar to
EBN knowledge and learning satisfaction. These results are different
one previous research finding that the differentiated instruc-
from the previous findings that students consider the EBN course
tion approach had a positive effect on non-­nursing undergrad-
as complicated and difficult since courses designed with differenti-
uate students' attitudes towards course learning (Darra &
ated instruction meet the learning needs of students with different
Kanellopoulou, 2019). Students' EBN knowledge significantly im-
academic abilities and strengthen and give various opportunities for
proved at the end of the semester as well was supported by other
students to learn. In clinical settings where nurses are even more di-
studies that used differentiated instruction. These previous stud-
verse in academic education, clinical experiences and learning pref-
ies exhibited results of improvement in academic performances
erences, differentiated instruction can be a suitable application for
among non-­university students such as greater gains in calculus
in-­service training and education to promote nurses' enthusiasm for
or mathematical understanding (Chen & Chen, 2018), and outper-
professional learning.
formance in the course examination (Haelermans, 2022). Learning
satisfaction for the EBN course among nursing students also significantly increased at the end of the course. Differentiated in-
8
|
CO N C LU S I O N
struction that furnishes students with diverse learning methods
to choose from can meet individuals' learning needs and is con-
Differentiated instruction has been popularly applied in elementary
ducive to students' learning (Iqbal et al., 2020), motivation (Chen
and secondary schools internationally. Yet, limited empirical study
& Chen, 2018; Sapan & Mede, 2022) and performance (Chen &
has been reported about this approach applied in higher educa-
Chen, 2018; Haelermans, 2022). When students' learning needs
tion, especially for nursing education. Moreover, there is a paucity
are satisfied, naturally, they are satisfied with the course.
of literature reporting the application of this pedagogy, specifically,
the outcome evaluations of application in EBN courses. The study
6
|
S T U DY LI M ITATI O N S
designed the EBN course based on differentiated instruction for
undergraduate nursing students in order to provide a supportive
learning environment and to furnish a vivid pedagogical way for the
Although differentiated instruction exhibits positive effects on
unique nursing profession. The findings indicate that implement-
nursing students' learning outcomes, the results of differentiated
ing differentiated instruction in the EBN course improved students'
instruction designed for the EBN subject are still preliminary. The
classroom engagement, group learning style, learning satisfaction,
study findings are limited because of the incapability to build a sub-
attitudes towards EBN and EBN knowledge. The positive results of
stantial, causal relationship test between the effectiveness of differ-
the study contribute to the existing body of knowledge by providing
entiated instruction and the learning outcomes. The major limitation
evidence of the positive effects of differentiated instruction in the
of this study is the single-­group research design, which is suscepti-
EBN course. Differentiated instruction has the potential to be ben-
ble to threatening the effectiveness of the intervention. Without a
eficial not only in academia but also in clinical in-­service training and
comparison group, it is challenging to confirm whether the interven-
education, by addressing the diverse academic backgrounds, clinical
tion can be successfully performed in other contexts. The study is
experiences and learning preferences of nurses. Further research in
also limited due to the insufficiency of generalizability of its study
this field can expand upon these findings and establish a stronger
population, such as few samples and a homogenous cultural back-
foundation for effectively implementing differentiated instruction in
ground in the study participants. Therefore, further studies are rec-
nursing education, both in academic and clinical contexts.
ommended for researchers to include a comparison group to furnish
more vigorous experimental evidence for the effectiveness of dif-
AU T H O R C O N T R I B U T I O N S
ferentiated instruction. Including more study participants as nursing
Conceptualization: SRL, CYC, CHC and TPC; Data curation: SRL, CYC
students in other nursing programmes, such as the regular 4-­year
and CHC; Formal Analysis: CYC and CHC; Funding acquisition: SRL
6806
|
LIOU et al.
and CYC; Investigation: SRL and HCL; Methodology: SRL, CYC and
HCL; Project administration: SRL, CYC, HCL and TPC; Supervision:
SRL and CYC; Validation: SRL, CYC and TPC; Writing—­original draft:
SRL, CYC and TPC; Writing—­review and editing: SRL, CYC, CHC,
TPC and HCL.
AC K N O​W L E D
​ G E ​M E N T S
The authors thank all funders for financial support and students for
their participation.
F U N D I N G I N FO R M AT I O N
This research was funded by the Chang Gung Medical Research
Program, grant number CMRPF6K0051 and the Ministry of Science
and Technology (MOST 107-­2511-­H-­255-­0 02-­) in Taiwan.
C O N FL I C T O F I N T E R E S T S TAT E M E N T
The authors have no conflict of interest to declare.
E T H I C S S TAT E M E N T
Ethical approval for the study was obtained from the Institutional
Review Board of the investigator’s serving institution. Written consent was obtained from all participants, ensuring confidentiality,
anonymity, and the option to participate. The participants were assured that refusal to participate or answer certain questions would
not affect their academic grades.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available
in Mendeley Data at http://doi.org/10.17632/​7fmsw​nmyft.1.
ORCID
Ching-­Yu Cheng
https://orcid.org/0000-0002-1872-0896
REFERENCES
Akhlaghi, N., Mirkazemi, H., Jafarzade, M., & Akhlaghi, N. (2018).
Does learning style preferences influence academic performance
among dental students in Isfahan, Iran? Journal of educational
evaluation for health professions, 15, 8. https://doi.org/10.3352/
jeehp.2018.15.8
Alharbi, H. A., Almutairi, A. F., Alhelih, E. M., & Alshehry, A. S. (2017).
The learning preferences among nursing students in the
King Saud University in Saudi Arabia: A cross-­sectional survey. Nursing Research and Practice, 2017, 3090387. https://doi.
org/10.1155/2017/3090387
Alrabia, F. (2021). The influence of autonomy-­supportive teaching on
EFL students' classroom autonomy: An experimental intervention.
Frontiers in Psychology, 12(728657), 1–­15. https://doi.org/10.3389/
fpsyg.2021.728657
American Association of College Nursing (AACN). (2021). The essentials:
Core competencies for professional nursing education. https://
www.aacnn​u rsing.org/Porta​l s/42/Acade​m icNu​r sing/​p df/Essen​
tials-2021.pdf
An, Y., & Mindrila, D. (2020). Strategies and tools used for learner-­
centered instruction. International Journal of Technology in Education
and Science (IJTES), 4(2), 133–­143.
Benton, S. L., & Li, D. (2015). Validity and Reliability of IDEA Teaching
Essentials (IDEA Research Rep. No. 8). The IDEA Center. https://
www.ideae​d u.org/Porta​ls/0/Uploa​ds/Docum​e nts/Resea​rch%20
Rep​orts/Resea​rch%20Rep​ort%208.pdf
Boelens, R., Voet, M., & De Wever, B. (2018). The design of blended learning in response to student diversity in higher education: Instructors'
views and use of differentiated instruction in blended learning.
Computers & Education, 120, 197–­212. https://doi.org/10.1016/j.
compe​du.2018.02.009
Chen, J. H., & Chen, Y. C. (2018). Differentiated instruction in a calculus
curriculum for college students in Taiwan. Journal of Education and
Learning, 7(1), 88–­95. https://doi.org/10.5539/jel.v7n1p88
Darra, M., & Kanellopoulou, E. M. (2019). The implementation of the
differentiated instruction in higher education: A research review.
International Journal of Education, 11(3), 151–­172. https://doi.
org/10.5296/ije.v11i3.15307
Gheyssens, E., Struyven, K., & Griful-­Freixenet, J. (2020). Differentiated
instruction as a student-­centered teaching approach in teacher education. In S. Hoidn, & M. Klemenčič (Eds.), The international handbook
of student-­centered learning and teaching inhigher education (1st ed.
pp. 254–­268). Routledge. https://doi.org/10.4324/97804​29259371
Haelermans, C. (2022). The effects of group differentiation by students'
learning strategies. Instructional Science, 50, 223–­250. https://doi.
org/10.1007/s11251-021-09575-0
Hapsari, T., Darhim, & Dahlan, J. A. (2018). Understanding and responding the students in learning mathematics through the differentiated instruction. Journal of Physics: Conference Series, 1013 12136.
https://doi.org/10.1088/1742-6596/1013/1/012136
Iqbal, J., Khan, A. M., & Nisar, M. (2020). Impact of differentiated instruction on student learning: Perception of students and teachers.
Global Regional Review, V(I), 364–­375. https://doi.org/10.31703/​
grr.2020(V-I).40
Ismail, S. A. A., & Allaq, K. A. (2019). The nature of cooperative learning
and differentiated instruction practices in English classes. SAGE
Open, 9, 1–­17. https://doi.org/10.1177/21582​4 4019​856450
Levine, R. E., O'Boyle, M., Haidet, P., Lynn, D. J., Stone, M. M., Wolf, D. V.,
& Paniagua, F. A. (2004). Transforming a clinical clerkship with team
learning. Teaching and Learning in Medicine, 16(3), 270–­275. https://
doi.org/10.1207/s1532​8 015t​lm1603_9
Lumatauw, L., Wollah, M., & Tulangow, R. (2020). Application of student
centered learning (SCL) method through discovery strategies in
vocational educations. Open Journal of Social Sciences, 8, 82–­90.
https://doi.org/10.4236/jss.2020.811008
Magableh, I. S. I., & Abdullah, A. (2020). On the effectiveness of differentiated instruction in the enhancement of Jordanian students' overall achievement. International Journal of Instruction, 13(2), 533–­548.
https://doi.org/10.29333/​iji.2020.13237a
Mckenna, L., Copnell, B., Butler, A. E., & Lau, R. (2018). Learning
style preferences of Australian accelerated postgraduate preregistration nursing students: A cross-­s ectional survey. Nurse
Education in Practice, 28, 280–­284. https://doi.org/10.1016/j.
nepr.2017.10.011
Melnyk, B. M., & Fineout-­Overholt, E. (2019). Evidence-­based practice in
nursing & healthcare: A guide to best practice. Wolters Kluwer.
Mukhalalati, B. A., & Taylor, A. (2019). Adult learning theories in context: A quick guide for healthcare professional educators. Journal of
Medical Education and Curricular Development, 6, 1–­10. https://doi.
org/10.1177/23821​20519​8 40332
National League for Nursing (NLN). (2020). Hallmarks of excellence.
https://www.nln.org/docs/defau​l t-sourc​e /uploa​d edfi​l es/defau​
lt-docum​e nt-libra​r y/hallm​a rks-of-excel​l ence-2019.pdf?sfvrs​
n=7d92a​60d_0
Nelson-­Brantley, H. V., Beckman, D., Parchment, J., Smith-­Miller, C. A.,
& Weaver, S. H. (2020). Magnet® and pathway to excellence®:
Focusing on research and evidence-­based practice. The Journal of
Nursing Administration, 50(5), 245–­247. https://doi.org/10.1097/
NNA.00000​0 0000​0 00877
|
LIOU et al.
Nguyen, K. A., Borrego, M., Finelli, C. J., DeMonbrun, M., Crockett,
C., Tharayil, S., Shekhar, P., Waters, C., & Rosenberg, R. (2021).
Instructor strategies to aid implementation of active learning: A systematic literature review. International Journal of STEM Education,
8(9), 1–­18. https://doi.org/10.1186/s40594-021-00270-7
Norwood, S. L. (2000). Research strategies for advanced practice nurses.
Prentice-­Hall, Inc.
O'Malley, K. J., Moran, B. J., Haidet, P., Seidel, C. L., Schneider, V., Morgan,
R. O., Kelly, P. A., & Richards, B. (2003). Validation of an observation instrument for measuring student engagement in health professions settings. Evaluation & the Health Professions, 26(1), 86–­103.
https://doi.org/10.1177/01632​78702​250093
Ramdani, Z., Amri, A., Hadiana, D., Warsihna, J., Anas, Z., & Susanti, S.
(2021). Students diversity and the implementation of adaptive
learning and assessment: A systematic literature review. Advances
in Social Science, Education and Humanities Research, 639, 157–­161.
https://doi.org/10.2991/assehr.k.220203.025
Reid, J. M. (1987). The learning style preferences of ESL students. TESOL
Quarterly, 21(1), 87–­111. https://doi.org/10.2307/3586356
Reid, J. M. (1995). Preface. In J. M. Reid (Ed.), Learning styles in the ESL/EFL
classroom (pp. viii–­x vii). Heinle & Heinle.
Sapan, M., & Mede, E. (2022). The effects of differentiated instruction
(DI) on achievement, motivation, and autonomy among English
learners. Iranian Journal of Language Teaching Research, 10(1), 127–­
144. https://doi.org/10.30466/​ijltr.2022.121125
Soliman, S. M. (2017). Learning style preferences and perceptions of undergraduate nursing students upon applying web-­based learning
modules. IOSR Journal of Nursing and Health Science, 6(2), 68–­74.
https://doi.org/10.9790/1959-06020​96874
Tlili, M. A., Aouicha, W., Tarchoune, S., Sahli, J., Dhiab, M. B., Chelbi,
S., Mtiraoui, A., Ajmi, T., Rejeb, M. B., & Mallouli, M. (2022).
Predictors of evidence-­based practice competency among Tunisian
6807
nursing students. BMC Medical Education, 22(421), 1–­9. https://doi.
org/10.1186/s12909-022-03487-4
Tomlinson, C. A. (2000). Differentiation of instruction in the elementary
grades. ERIC Digest. ERIC Clearinghouse on Elementary and Early
Childhood Education. https://files.eric.ed.gov/fullt​ext/ED443​572.
pdf
Tomlinson, C. A. (2001). How to differentiate instruction in mixed-­ability
classrooms (2nd ed.). Association for Supervision and Curriculum
Development.
Trolian, T. L., & Parker, E. T., III. (2022). Shaping students' attitudes toward diversity: Do faculty practices and interactions with students
matter? Research in Higher Education, 63, 849–­870. https://doi.
org/10.1007/s11162-021-09668-2
Trullàs, J. C., Blay, C., & Pujol, R. (2022). Effectiveness of problem-­based
learning methodology in undergraduate medical education: A
scoping review. BMC Medical Education, 22(104), 1–­12. https://doi.
org/10.1186/s12909-022-03154-8
Turner, W. D., Solis, O. J., & Kincade, D. H. (2017). Differentiating instruction for large classes in higher education. International Journal of
Teaching and Learning in Higher Education, 29(3), 490–­500.
How to cite this article: Liou, S.-R., Cheng, C.-Y., Chu, T.-P.,
Chang, C.-H., & Liu, H.-C. (2023). Effectiveness of
differentiated instruction on learning outcomes and learning
satisfaction in the evidence-­based nursing course: Empirical
research quantitative. Nursing Open, 10, 6794–6807. https://
doi.org/10.1002/nop2.1926