Visual Narrative Illustrations Effectiveness

April, 2019

Measuring the Effectiveness of Visual Narrative Illustrations
for Learning Pathophysiology Concepts
Mohamed El Hussein, Mount Royal University,
Vincent Salyers, MacEwan University,
Joseph Osuji, Mount Royal University
Authors’ Contact Information
Mohamed El Hussein, NP, PhD, Associate Professor,
Faculty of Health & Community Studies, School of Nursing,
Mount Royal University, 4825 Mount Royal Gate SW, Calgary, AB. T3E 6K6,
Phone: 403-440.8633 Email: melhussein@mtroyal.ca
Vincent Salyers, EdD, RN, ANEF, Dean & Professor, Faculty of Nursing
MacEwan University, 10700 104 Ave NW, Edmonton, AB T5J 4S2
Email: salyersv@macewan.ca
Joseph Osuji, BsCN, MN, PhD, Associate Professor,
School of Nursing, Faculty of Health and Community Studies,
Mount Royal University, Calgary, AB, Canada,
Phone: 403-440-6559, Email: josuji@mtroyal.ca

Abstract:
Background: Patients’ health needs require detailed knowledge of diseases and the
associated pathophysiology to understand and manage their complex care. Nurses rely
on concepts from anatomy, physiology, microbiology, and pathophysiology to ground
their practice. While knowledge of disease processes is a critical requirements for
competent practice nursing, students often struggle with learning and applying
pathophysiology concepts to clinical practice.
Method: A novel teaching innovation known as “Visual Narrative Illustrations” (VNI)
was piloted in a pathophysiology course. Students (n=75), participated in two phases of
exploratory study that analyzed the impact of VNI on students’ understanding of
pathophysiology concepts and assessed whether VNI is an effective teaching method.
Results: Students taught using the VNI strategy performed significantly better on the
post-test than students taught using a traditional lecture format.
Conclusion: VNI assist students in learning complex concepts through the use of
humor and visual images and facilitate their understanding of pathophysiology
processes.

Key Words:
Visual narrative illustrations, pathophysiology, nursing, education.
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Introduction to Pathophysiology
Background: At an accelerated rate, patients’ health needs are more acute and
require detailed knowledge of diseases, co-morbidities and the associated
pathophysiology in order to understand and manage their complex needs. As a
foundation for this, nurses rely heavily on concepts from anatomy, physiology,
microbiology, and pathophysiology to ground their practice (Christensen, Craft,
Wirihana & Gordon, 2015; Craft, Hudson, Plenderleith, Wirihana & Gordon, 2013; El
Hussein, Salyers, & Osuji, 2016). It is well-documented that science courses such as
pathophysiology are considered strong predictors of students’ success in nursing
programs (Abele, Penprase & Ternes, 2013; Beeman & Waterhouse, 2001). While
knowledge of disease processes is a critical requirements for registered nurses,
students and new nurses often struggle with learning and applying pathophysiology
concepts to clinical practice (Dunn, Osborne & Rakes, 2012; El Hussein, Salyers, &
Osuji, 2016; 2017; 2018; Van Horn, Hyde, Tesh & Kautz, 2014).
Nursing students at the university described in this paper also encounter difficulty
with learning and applying key pathophysiology concepts. The university, situated in
western Canada, has an enrollment of nearly 12,000 students who take a variety of
programs and courses leading to bachelor’s degrees, applied degrees, university
transfer courses, diplomas, and certificates. The baccalaureate nursing program admits
approximately 210 per year. Students are required to take two pathophysiology courses
as part of their program; these two courses are offered in 6-7 week blocks over one
semester and are offered twice each academic year. In order to mitigate some of the
challenges associated with learning pathophysiology concepts, a novel teaching
innovation known as “Visual Narrative Illustrations” (VNI) was piloted and implemented
in the course and findings were published in brief synopsis (El-Hussein, Salyers, &
Osuji, 2018). This paper provides a detailed overview of the findings from this
exploratory study.

Brief Review of the Literature
Nursing students are required to learn complex pathophysiological concepts for
which they often struggle. Furthermore, they enter into the classroom with different
learning styles. This combination of teaching complex concepts and students with
diverse learning styles creates challenges for nursing faculty. In studies evaluating
learning styles among nursing and other students, some researchers have found that
differences in learning styles do exist between and among students (Brady, 2013).
Ideally, instructional strategies would be matched to learning styles and a variety of
teaching methods would be implemented to address individual differences. Researchers
have found that matching instructional strategies to student learning styles yields
positive learning outcomes, while mismatching these may lead to poorer outcomes
(Damrongpanit & Reungtragu, 2013; Fayombo, 2015).
Previous research has identified the need to vary teaching strategies in order to
appeal to different learning styles; and the impact of these teaching strategies on
learning (Liu & He, 2014; Moore & Hansen, 2012. Moore and Hansen (2012) further
suggested that faculty need to use a variety of approaches to help students “embrace
who they are, develop a sense of self, recognize their strengths, and capitalize on
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talents that will strengthen their self-esteem” (Moore & Hansen, 2012, p.28) and further
develop confidence in applying complex pathophysiology concepts in the clinical area
(Craft et al., 2013).
Specific to pathophysiology, different strategies that address multiple learning styles
have been employed. Traditional lecture and face to face (f2f) formats used for teaching
pathophysiology, although widely accepted, have been criticized for their lack of
effectiveness as a teaching method when used in isolation (Isseks, 2011; Herman,
2011). Alternative teaching strategies have incorporated podcasts and video streaming
(McKinney & Page, 2009), problem-based learning, (Mayner, 2013), concept mapping
(Kumar et al., 2011), and a variety of student-centered teaching strategies (e.g. case
studies, creative visual demonstrations, games and small group work, and team based
learning) (Middleton-Green & Ashelford, 2013; Van Horn et al., 2014). Further research
supports supplementing traditional lecture with interactive learning strategies to
enhance students learning and conceptual understanding of pathophysiology (Taylor &
Littleton-Keary, 2012; Van Horn et. al. 2014).
The utilization of illustrations has been implemented in the past as a teaching
strategy, and is emerging again as an effective one that appeals to many learners
(Lapum & St-Amant, 2016; Lake & Jackson, 2013). According to Lowe (2004)
illustrations offer an affective function, by capturing, engaging, and motivating students;
and provide a cognitive function by supporting students’ cognitive processes leading to
a greater understanding of the subject matter. Green and Myers (2010) concluded that
illustrations can facilitate efficient and effective communication of intricate concepts and
have been successfully used to convey ideas and complex concepts in an amusing and
pleasurable manner. Park, Kim and Chung (2011) and Shin, Kim, Park, Jang and
Chung (2013) concluded that illustrations are potent visual messages that communicate
instant visceral meaning in ways that traditional texts often cannot. Bain (2004) further
elaborated on this notion and in his view, when we see, hear, feel, smell, and taste, then
we begin connecting all those sensations in our brain to build patterns of the way we
think the world works. These patterns are used later to understand new sensory inputs.
In health related disciplines such as nursing & medicine, arts-enriched teaching
strategies that include visual images and illustrations actually facilitate critical thinking,
critical inquiry and reflective practice (Lapum & St-Amant, 2016; MacDonnell &
MacDonald, 2011; Schreiner, Wolf- Boldonaro, 2012). For the purpose of this paper,
VNI are brief, narrated stories with images that are used to explain complex scientific,
and physiologic concepts in meaningful and scaffolded ways. By using VNI, students
make associations between the images, stories, and pathophysiology concepts. It is
worth noting that VNI are different from the photos and images typically found in
pathophysiology texts (El-Hussein, Salyers, & Osuji, 2016).

Narrative as the Theoretical Framework Guiding VNI
Learning is an active process in which learners construct new concepts based on
their current or past knowledge; a premise that is congruent with the narrative notion of
enactive cognition. According to Popova (2014) literary narrative is an intersubjective
process where the instructor and learner make meaning of a subject. The instructor and
the learner bring a myriad of personal, historical, and cultural features that dominate the
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narrative and potentially shape learning. Popova (2014) further added that narratives
are embedded in our thinking, memory and interactions and help organize the human
experience. Learners’ experiences of the world are mediated through narrative
understanding (Coleman-Fountain, 2014; Hoare, 2011), and learners’ interpretation of
reality through memory is guided by narrative principles (Popova, 2014). Therefore the
ability to learn is potentiated when information is presented in a narrative form (Murphy,
Frank, Chatterjee, & Baezconde-Garbanati, 2013).
Tomasello (2014) described a process known as shared intentionality whereby a
story-world is created based on shared experiences of the learners and course
professors. Intentionality is at the core of the learning process where meaning is
generated by using the learner’s mental framework to act as a point of reference or filter
that checks if new details are congruent with the student’s existing mental repertoire.
Narratives describe characters and people who act out events in a particular space and
time through the storytelling process (Bamberg, 2012). Through narratives and stories,
students are able to tie data, facts and information together in meaningful ways (Green,
2004); moreover, storytelling enables recall of details by association, and bring facts to
life through learning contexts (Davidhizar & Lonser, 2003).
VNI are narrated stories with images that are used to explain complex physiologic
concepts in meaningful and scaffolded ways. The illustrations are used to capture the
attention of the student, trigger their imagination, drive their thinking and create a means
by which they can quickly recall complex information. Further, narratives and
illustrations become internalized as part of the students’ learning experience;
associations are made between the images, stories, and pathophysiology concepts (ElHussein, 2017). The narrative stories that are embedded in pathophysiology VNI used
in the pathophysiology course described later: 1) allow the learners to develop a certain
level of understanding that is congruent with their lived experiences; 2) facilitate social
interactions through the construction of meaning based on the stories; 3) emphasize the
active role of learners in building their own understanding of reality; 4) utilize amusing
storylines and, as such, open the door for further discussion and intellectual
engagement. Thus learning becomes an active process whereby students hypothesize,
predict, challenge, engage, resist, and eventually accommodate new information and
construct new knowledge.
There were several principles that guided development of VNI for this study. These
include that learning: 1) must include the shared experiences, understanding, and
organization of knowledge between students and faculty; 2) is potentiated through
narratives that describe key pathophysiologic concepts; 4) must include shared
intentionality of the learning experience; and 5) extends beyond recall of information
and requires associations be made to learn and apply pathophysiology concepts. Figure
1 provides a representation of the theoretical framework by which VNI were framed and
developed.

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Figure 1. Theoretical Framework Guiding VNI Development

Research Objectives
The purpose of this research was to empirically measure the effectiveness of VNI on
nursing students’ knowledge and understanding of pathophysiology concepts; and to
assess the impact of VNI as a teaching method on students learning outcomes. The
following research questions were explored:
1. Do 2nd year baccalaureate nursing students who were taught using VNI perform
better on pathophysiology pre and post-tests than students who were taught using
traditional teaching methods?
2. How do visual narrative illustrations influence 2nd year baccalaureate nursing
students experience with learning complex pathophysiological concepts?

Methods
This exploratory, mixed-methods study elicited perspectives from nursing students
enrolled in two pathophysiology courses regarding their experiences with VNI. The
mixed methods was used for triangulation and to overcome the limitations of the small
sample size (Tashakkori & Teddlie, 2003). Ethics approval was obtained from the
institutional review board to conduct the study. Participants were informed of the
voluntary nature of their participation, right to withdraw, and anonymity of grouped data
in publications.

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Phase I: Pre-Study Instrument Validation
One semester prior to the study, a convenience sample of second year nursing
students taking the pathophysiology course were invited to evaluate fifteen VNI
developed for the pathophysiology course. These VNI were utilized to teach various
pathophysiology concepts such as oncotic pressure, HbA1c, acute and chronic renal
failure among others.
At the end of the course, students completed a survey composed of 19 Likert items
indicating agreement (1=strongly disagree; 5 strongly agree) with statements about the
VNI, as well as 4 Likert items regarding the effectiveness of the VNI for teaching key
pathophysiology concepts. Students were also asked to provide qualitative comments
regarding their perceptions of the effectiveness of VNI as a teaching strategy. Student
feedback informed revision of some VNI for use in phase two of the study. Findings
from the VNI instrument validation process are described in the Results section of this
paper.

Phase II: Pre and Post-VNI Knowledge Gains
In phase two of the study, students enrolled in the pathophysiology course were
invited to consent and participate in the study. Two sections of the course were offered
and taught by different course professors. In the control group (CG) section, students
were taught pathophysiology concepts using a traditional lecture-discussion approach,
while students in the intervention group (IG) learned pathophysiology concepts using
VNI. Once consent was obtained, a pretest of pathophysiology knowledge was
administered to CG & IG students. The pretest consisted of 42 multiple choice
questions that were conceptually based on the VNI used to teach pathophysiology
concepts during the course. At the end of the semester, CG & IG students took a posttest equivalent to the pretest. Using SPSS 23.0, tests of reliability, normality,
homogeneity, and hypothesis testing were conducted.

Results
Phase I: Pre-Study VNI Validation

Fifteen VNI were developed and pilot tested with a convenience sample of second year
nursing students (n=63; 90% response rate) one semester prior to full implementation
within the pathophysiology course. Faculty with pathophysiology expertise evaluated the
VNI prior to the pilot study and confirmed construct validity. At the end of the course,
students were asked to rate their agreement with 19 VNI statements. The following
Likert scale was used: 1 = strongly disagree; 2 = disagree; 3 = neither agree nor
disagree; 4 = agree; 5 = strongly agree. Table 1 highlights z-score statistics for the VNI
that were evaluated. The alpha coefficient for the pre-study VNI was 0.91 and
demonstrates high construct validity (Nunnally, 1978).

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Table 1 - Z-Score Statistics for VNI Pilot Study

VNI – Specific Concepts

Mean (SD)

The Cancer VNI helped me understand the characteristics of
cancer cells.
The Renal VNI helped me understand the difference between
acute and chronic renal failure.
The Diabetes VNI helped me appreciate the significance of
chronic hyperglycemia of blood vessels.
The Diabetes VNI helped me understand the effects of
chronic hyperglycemia on immunity.
The HbA1c VNI helped me understand the impact of chronic
hyperglycemia on different body organs and tissues.
The HbA1c VNI helped me understand the function of Hba1c
and its importance in monitoring blood glucose control.
The Lipids VNI helped me understand and differentiate
between LDL and HDL.
The ABG VNI helped me in developing a systemic approach
to arterial blood gas analysis (ABG’s).
The D-Dimer VNI helped me understand the clotting cascade
and associated diagnostics tests.
The Hypertension VNI helped me understand the
significance of chronic hypertension on the heart and blood
vessels.
The Oncotic/hydrostatic pressure VNI helped me
understand the pathophysiology of edema.
The Liver VNI helped me understand the clinical
manifestations of liver cirrhosis.
The Circulation VNI helped me understand the process of
atherosclerosis and thrombus formation.
The Immunity VNI helped me understand the reaction of the
body to harmful invaders and the functions and actions of
different immune cells.
The Airway/String VNI helped me understand
pathophysiology of emphysema and its relation with chronic
bronchitis.
VNI General Comments
1. Overall, learning pathophysiology concepts using VNI
had a high impact on my understanding of
2. VNI helped me to readily recall and apply knowledge.

637.5 (103.59)

Test
Statistic
4.66*

473.0 (82.82)

3.67*

715.5 (112.96)

3.99*

612.5 (100.53)

4.87*

430.5 (77.17)

3.17*

588.0 (97.50)

4.36*

612.5 (100.53)

3.09*

564.0 (94.50)

4.03*

588.0 (97.50)

3.39*

410.0 (74.40)

3.68*

588.0 (97.50)

2.71*

715.5 (112.96)

4.53*

715.5 (112.96)

4.60*

689.0 (109.81)

3.96*

612.5 (100.53)

4.74*

715.5 (112.96)

3.59*

540.5 (91.53)

2.67*

3. VNI boosted my confidence to understanding client
conditions in clinical settings.

517.5 (88.59)

2.41*

4. VNI made complex pathophysiology concepts easier
to understand.
*p < 0.05

637.5 (103.59)

4.75*

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Effectiveness of VNI as a Teaching Strategy
In addition to the quantitative questions regarding VNI, students were asked to
respond to the following items: Please tell us about your experience with Visual
Narrative Illustrations. Sixty-three students replied to this item and their responses were
analyzed. The overall approach to data analysis followed the method outlined by Miles
and Huberman (1994); data collection is followed by data reduction, display of findings,
and drawing and verifying conclusions. Each member of the research team
independently reviewed the narrative responses obtained at the end of the course. The
principal investigators then examined the themes and categories, identified inferences
and discerned meanings from the responses, and then agreed on final themes to
ensure reliability. Generally, perceptions regarding the VNI were positive although there
was a distinct preference for them by self-identified visual learners. Table 2 highlights
perceptions of VNI made by students at the end of the course.
Table 2 Student Perceptions of VNI

Theme
The VNI are good leaning resources but
require some refinement.
The VNI are humorous, entertaining,
and helped break up complex content.

Representative Student Comments
I believe VNI have great potential as teaching
tools but be sure to create standout images
to make them more appealing and
understandable.
Provided some laughs and helped breaking
up the heavy lectures; these were an
awesome way to grasp confusing concepts.

The VNI are particularly helpful for
students who are visual learners.

Good for visual learners. My experience with
them was a good one. They helped me
destress and learn easier.

The VNI furthered my understanding of
pathophysiology concepts and solidified
my learning.

Definitely a helpful tool to visual harder
concepts and understand them later.

Be sure to provide VNI at the beginning
of the course and make them
accessible.

I would say that these would help future
students if added on a permanent basis to
the lecture. I wish we had access to view
these images again.

The VNI created confusion and did not
facilitate my learning.

I don’t feel they vastly increased my
understanding; I am an auditory learner and
generally visuals and drawings don’t help
much.

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Phase II: Pre and Post-VNI Knowledge Gains
Seven students participated in the control group (58.3%) while five students were in
the intervention group (41.7%). More than 95% of the students were female, between
the ages of 20 and 25, and were taking the course for the first time. The alpha
coefficient for the VNI pre and posttests was 0.94 and demonstrated high construct
validity Nunnally (1978). Table 3 displays the mean scores, standard error and standard
deviations on the pre and posttest by group. A low standard deviation shows that the
data points are near the average, whereas high standard deviation shows that much
variation exists from the average (Creswell, 2011).
Table 3 Pre and Posttest Scores by Group

Pretest
Posttest

Mean

Std. Error

Std. Deviation

Control

24.29

1.30

3.45

Intervention

24.80

.80

1.79

Control

29.71

1.38

3.64

Intervention

34.20

.58

1.30

Normal Distributions

The skewness and kurtosis for “posttest”, “VNI”, and “satisfaction” were within the
values range of minus two through plus two. The skewness and kurtosis for “pretest”
and “group” were outside the values range of minus two through plus two. The
assumption of normality is not satisfied. Thus, the researchers used the nonparametric
alternative to a repeated measures ANOVA to evaluate pre and posttest scores.

Homogeneity
In order to assess equality of variances between the CG & IG samples, a Levene’s
test was conducted with results reported in Table 4. The Levene’s test examined the
null hypothesis that the population variances are equal (O’Neill & Mathews, 2002). If the
p value is greater than .05, then the null hypothesis that the population variances are
equal is accepted (O’Neill & Mathews, 2002). A p-value of < 0.05 (i.e., posttest) did not
validate this assumption.
Table 4 Levene's Test of Equality of Error Variances

Pretest
Posttest

F
.63
6.10

df1
1
1

df2
10
10

Sig.
.44
.03

Hypothesis Testing

Research Question 1:
Do 2nd year baccalaureate nursing students’ who receive the VNI
intervention perform better on pathophysiology pre and post-tests than
students who were taught using traditional teaching methods?
The following hypothesis was tested:

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H0: There is no difference in 2nd year baccalaureate nursing students’ pre and
posttest scores using visual narrative illustrations as a contemporary pedagogy when
compared to traditional teaching methods.
H1: There is a difference in 2nd year baccalaureate nursing students’ pre and
posttest scores using visual narrative illustrations as a contemporary pedagogy when
compared to traditional teaching methods.
A Kruskal-Wallis Test was conducted for between-subject differences. On the
pretest, the p value was equal to .459, which is greater than .05 (α), therefore the null
hypothesis was accepted. The intervention group who received instruction using VNI did
not differ from the control group, taught using traditional teaching methods, on the
pretest. On the post-test, the p value was equal to .011, which was less than .05 (α),
therefore the null hypothesis was rejected. The intervention group taught using VNI
were significantly different from the control group on the post-test. Table 5 highlights pre
and post-test scores and significance by group.
A Friedman's 2-Way ANOVA by ranks was conducted for within-subject evaluation
of the group mean scores. The p value equaled .001, which was less than .05 (α),
therefore the Friedman's 2-Way ANOVA by ranks revealed a main effect of time. The
combined CG/IG group average on the pretest was 24.50 before the VNI treatment,
while the combined CG/IG group average on the post-test was 31.58 after the
treatment. Therefore, the null hypothesis that there was no difference in pre and posttest scores was rejected.
Table 5 Kruskal-Wallis Test

Group
Pretest Control
Intervention
Posttest Control
Intervention

Mean
Rank Sum of Ranks
7
5.86
5
7.40
7
4.29
5
9.60

P-Value
.459
.011

A Friedman's 2-Way ANOVA by ranks was conducted for within-subject evaluation
of the group mean scores. The p value equaled .001, which was less than .05 (α),
therefore the Friedman's 2-Way ANOVA by ranks revealed a main effect of time. The
combined CG/IG group average on the pretest was 24.50 before the VNI treatment,
while the combined CG/IG group average on the posttest was 31.58 after the treatment.
Therefore, the null hypothesis that there was no difference in pre and posttest scores
was rejected.

Discussion
Research Question:
Do 2nd year baccalaureate nursing students who were taught using VNI
perform better on pathophysiology pre and post-tests than students who
were taught using traditional teaching methods?

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While the sample was small for this phase of the study, the results are promising.
Like at many universities, student participation in research studies are impacted by
multiple competing demands. In the School of Nursing and Midwifery in which this study
took place, depending on their year in the program, students are asked to complete
surveys, questionnaires, and other program evaluation documentations. This may have
influenced their willingness to participate in the current study. Students taught using the
VNI strategy did perform significantly better on the posttest than students taught using a
traditional lecture format. Students commented that the VNI assisted them in learning
complex concepts through the use of humor and visual images that created
understanding of processes. This reinforces the notion that narratives are embedded in
our thinking, memory and interactions and help organize our experiences (Popova,
2014); is potentiated through shared understanding (Coleman-Fountain, 2014; Hoare,
2011); and that storytelling enables recall of details by association and brings facts to
life (Davidhizar & Lonser, 2003). While VNI were the means by which learning and
understanding of pathophysiology concepts occurred in this course, the authors wish to
emphasize the importance of developing scaffolded teaching approaches such as VNI
for deconstructing complex concepts with which students often struggle.
Ideally, students in both sections of the course would have been exposed to both
traditional and VNI approaches in a quasi-experimental study to further elicit whether
VNI had a greater impact on knowledge and understanding of pathophysiology
concepts. If there had been more time, it would have been useful to collect data
regarding the various learning resources beyond the VNI that students utilized as a
means for learning pathophysiology concepts. Based on this study, it was unclear how
much the VNI specifically impacted learning outcomes.
Research Question:
How do visual narrative illustrations influence 2nd year baccalaureate
nursing students experience with learning complex pathophysiological
concepts?
The qualitative data gathered and analyzed in this research project suggested that,
overall, students perceived the benefit of VNI as a learning tool. There was unanimous
agreement that VNI facilitated their understanding of, and served as a catalyst for
learning, complex concepts. Moreover, considering the intensity of the pathophysiology
course and the tension and anxiety it created for students, VNI provided a humorous
outlet and mental breaks from the difficult material to be learned. However, the students’
preoccupation with course grades and their primary focus on passing the course may
have influenced their willingness to participate in the study and may have also impacted
their responses.
Frequently students commented that VNI were effective for self-identified visual
learners, while the non-visual learners had mixed feelings about them. Consistent with
the findings of others (Taylor & Littleton-Keary, 2012; Van Horn et. al. 2014), student
comments supported the notion that VNI, when used simultaneously with other teaching
strategies, would appeal to multiple learning styles and increase opportunities to learn
pathophysiology concepts. There were also consistent comments that each VNI could
be revised and fine-tuned to make them more understandable and provide even greater
links to the concepts learned. Again, these comments supported the importance of
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shared knowledge construction, development and understanding (Coleman-Fountain,
2014; Hoare, 2011) described in the theoretical framework. The researchers have
begun to incorporate feedback specific to each VNI and redevelop them based on
student comments with the intention of further strengthening their potential as a
teaching tool.

Limitations
There were several limitations the authors wish to acknowledge. The study was
carried out at one academic institution with a small convenient sample of students,
therefore results cannot be generalized beyond this population. Two faculty members
facilitated the lectures which may have impacted the internal validity of the design and
whether post-test scores were exclusively due to the VNI (intervention). An additional
factor that may have impacted results relate to the teaching styles and personalities of
the two faculty members who taught the course. This may have introduced unconscious
bias into the results. Moreover, using the same test material in a repeated fashion for
the same cohort of students may have introduced a testing effect (sensitized the
student). Demographic factors, such as previous knowledge of pathophysiology,
preferred learning style, and resources used to learn course content should have been
compared with scores on pre and post-tests to further validate whether VNI were the
reason that students in the intervention group performed better on the post-test. Finally,
the instruments (e.g. questionnaires, pre and post-tests) used may not have been
sensitive enough to identify differences between groups. Standardized instruments
might be a more powerful means of determining differences.

Conclusions & Recommendations
Nursing students often struggle to grasp concepts surrounding sophisticated and
complex pathophysiological concepts for which they are required to understand.
Furthermore, they enter into the classroom with different learning styles. This creates
challenges for faculty and individuals who teach them. Ideally, instructional strategies
would be matched to learning styles and a variety of teaching methods would be
implemented to address individual differences. Applying VNI principles to lectures
delivered to nursing students helps to improve knowledge and understanding of
pathophysiology concepts and provides a means by which humor, mnemonics, and
storytelling can offset the stress and anxiety that often comes with studying
pathophysiology.

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