Service Learning Experience on Health Habits in High School Students Conducted by Nursing Students: A Qualitative Design

Round 1

Reviewer 1 Report

I thank the authors for the opportunity to review this article; however, it presents important methodological deficiencies and therefore it was considered that it is not suitable for publication.

• The objectives in the study are not adequately formulated according to the qualitative methodology. Evaluating an intervention through a service-learning program is more typical of quantitative studies; while qualitative studies focus more on knowing/describing perspectives and/or experiences of subjects.

• Does not describe the type of qualitative study developed

• It does not detail how informed consent was reached when dealing with minors, regarding the use of data for research purposes.

• The data collection tools for high school students are not described, and in the case of nursing students the reflective journal is mentioned, but not the areas of interest to be explored, the use of a question script.

• The statement of the results is scarce, little elaborated and irrelevant

• No details are given of the quality criteria followed in preparing the study.

All the best

Author Response

1-The objectives in the study are not adequately formulated according to the qualitative methodology. Evaluating an intervention through a service-learning program is more typical of quantitative studies; while qualitative studies focus more on knowing/describing perspectives and/or experiences of subjects.

Thank you for this comment and your suggestion. We have now changed the objective of the study to adequately address qualitative research.

“This paper aims to explore learning about healthy habits and standards of nursing professional practice through a service learning activity between nursing students and high school students”

2-Does not describe the type of qualitative study developed

Thank you for this observation. We have now added information about the generic qualitative design used in this research. We have also added three new references regarding this design [20-22].

“A generic qualitative design [20] based on a constructivist naturalistic approach was adopted. A qualitative methodology offers the possibility of understanding the complexity of a phenomenon from the differing points of view of informants [21]. Generic studies offer an opportunity for researchers to play with boundaries, use the tools provided by established methodologies, and develop research designs that fit their epistemological stance, discipline, and particular research questions [22].”

 

 

-20-Caelli, K.; Ray, L.; Mill, J. ‘Clear as mud’: toward greater clarity in generic qualitative research. Int J Qual Methods. 2003;2,1–13.

-21-Taylor, S.J.; Bogdan,R.; De Vault, M. Introduction to Qualitative Research Methods: A Guidebook and Resource. 4th ed. Hoboken: Wiley Publications; 2015. p. 34

-22-Kahlke, R.M. Generic Qualitative Approaches: Pitfalls and Benefits of Methodological Mixology. Int J Qual Methods. 2014;13,37–52.

 

3-It does not detail how informed consent was reached when dealing with minors, regarding the use of data for research purposes.

All high schools participating in the Health and School Program [10], must inform parents about the program, and before attending they must give consent to their children to participate in all the sessions held in this program. The session led by this project is part of the activities of the Health and School Program, therefore the parents had already consented to the high school student’s participation. In addition, before starting the sessions on health habits carried out by nursing students, the nurse of the Health and School Program explained the activity to secondary school students and also asked for oral consent to participate in the proposed activity.

We have now clarified this point in the following sections or the text: Sample and Ethical considerations

 Sample:

“As it is an activity developed through the Health and School program [10] [7] the informed consent of the parents of high school students was already obtained when the parents received the information about the program and which activities are included in it. In addition, before starting the sessions on health habits carried out by nursing students, the nurse of the Health and School Program explained the activity to high school students and also asked again for oral consent to participate in the proposed activity.”

 

Ethical considerations:

“Informed consent of the nursing students was obtained. Regarding informed consent of high school students, being an activity developed through the Health and School program the parents of high school students had already consented to their participation in the activity. In addition, before starting the session on health habits carried out by nursing students, the nurse of the Health and School Program explained the activity to secondary school students and also asked for oral consent to participate in the proposed activity.”

4-The data collection tools for high school students are not described, and in the case of nursing students the reflective journal is mentioned, but not the areas of interest to be explored, the use of a question script

Thank you for this recommendation. We have now added information about both tools, the mind-map and the reflective journals. On one hand, regarding mind-map we have clarified how we collected high school impressions about which health habits should be improved. On the other hand, we have now added more information about the areas of interest explored using the reflective journals, as well as the model we used to evaluate those reflective journals. This model was Gibbs’ Reflective Cycle, which was developed by Graham Gibbs in 1988 to give structure to learning from experiences.  It offers a framework for examining experiences, and given its cyclic nature lends itself particularly well to repeated experiences, allowing you to learn and plan from things that either went well or didn’t go well. It covers 6 stages: description of the experience; feelings and thoughts about the experience, evaluation of the experience, analysis to make sense of the situation, conclusion about learning and action plan. We have also included a new reference to justify Gibbs Reflective Cycle [23]

“The mind map tool was designed to allow high school students to identify through a notes wall the health habits they thought it needed to be improved. After the session, this healthy habits mind map was collected for analysis. and Nursing students recorded their experience using a reflective journal, which explored areas of interest, such as:  global satisfaction with the activity, perception of learning about health behaviors and other learnings regarding standards of nursing professional practice.  In addition, to examine the nursing students' experience related to the activity we reviewed the reflective journals using the Gibbs Reflective Cycle, which encompasses 6 stages: description of the experience; feelings and thoughts about the experience, evaluation of the experience, analysis to make sense of the situation, conclusions about the learning and action plan [23].”

-23-Gibbs, G. Learning by doing: A guide to teaching and learning methods. 1998. London: Further Education Unit.

 

5-The statement of the results is scarce, little elaborated and irrelevant

Thank you very much for this consideration. According to your recommendations and with suggestions of the other reviewer, we have now made some changes and have added some information in this section.

-First of all, we have clarified the standard deviation by using SD.

“The average age of the participants was 14 years (SD=0.7), and “the average age was 19 (SD=1.2)”

 

-We have also added information about what high school students stated regarding their tobacco use.

“Although during the session some high school students stated that they used tobacco, no intention of changing his habits was pointed out through the mind-map.”

-In the nursing students section we have added a new idea from how service learning methodology could help nursing students improve their knowledge about all the topics studied in the healthy persons throughout the life cycle subject. To reflect this idea we have also added a new verbatim

“Most of the participants pointed out that by service learning they should learn other topics closely related to the nursing profession.”

 

“I think it’s a very good way to learn all the topics presented in this subject, but I suppose it should be very difficult to organize…”

 

Finally, we added information about the phases students reached in their reflective journals. This assessment was made according to the Gibbs Reflective Cycle

“Finally, all the nursing students who participated in this activity completed the 6 stages encompassed in the Gibbs Reflective Cycle [23] in their reflective journals. “

 

 

6-No details are given of the quality criteria followed in preparing the study.

Thank you for this observation. We have now added information about the Standards for Reporting Qualitative Research (SRQR) checklist we used to ensure the rigor of the research. We have also added the reference of SRQR [27]

“Standards for Reporting Qualitative Research (SRQR) checklist was used to ensure the rigor of the research [27]”

 

-27-O’Brien, B.C.; Harris, I.B.; Beckman, T.J.; Reed, D.A.; Cook D.A. Standards for reporting qualitative research: A synthesis of recommendations. Acad. Med. 2014;89,1245–1251.

 

 

 

Reviewer 2 Report

This manuscript describes the experiences of nursing degree students (and their pupils) in a 1-hour teaching/learning session, carried out in one high school. The study involved 12 nursing degree students and 127 first-year high school students. The design of the study and the results are clearly described, but some improvements are possible.

Major remarks:

1. The manuscript appears to have a somewhat ‘double purpose’. Although the title and the Introduction give the impression that the main focus is on the design and evaluation of the nursing degree students’ teaching/learning session, a large part of the both the Results (page 4, line 4 from bottom – page 5, line 16 from bottom) and the Discussion (page 6, line 11 from bottom – page 7, line 20 from bottom) section is devoted to describing and discussing the opinions of their pupils. In fact, a larger part of the manuscript is devoted to the experience of the pupils than to the experience of the nursing students (i.e. their teachers). Although having a ‘double purpose’ in a research paper is usually discouraged, it is understandable that the authors want to combine both aspects, but this should be reflected in the Title, the Abstract and the Introduction. Some (extensive) rewriting of the Introduction appears to be necessary. Moreover, the authors should provide a rationale to include both aspects in one paper. Alternatively, this article could concentrate on the nursing degree students’ experience, and a second paper could be dedicated to the impact of the learning experience on the high school students’ opinions about health habits.

2. A main limitation appears to be the sample size. The study was carried out in 5 classes of one high school, out of potentially 70 schools (page 3, mid-page). The study should, therefore, be clearly labelled (and discussed) as a ‘case study’.

3. The role of different authors in the Data analysis (page 4) can be described in more detail. Who are the researchers (first two authors?) doing the initial analysis and have they both analysed all transcripts independently? Did they solve discrepancies before consulting others? Who ‘discussed and clarified until a consensus was reached’ (remaining authors)?

Minor remarks:

4. With respect to ‘smoking’ it is not described what the smoking habits of first-year high school students (age?) are. The results of having ‘no intention to improve habits’ (page 7) has no meaning, therefore. The literature data referred to appear the be marginally relevant.

5. The paper could benefit from spelling checking and/or having a native English speaker correcting the manuscript, e.g.:

·       Page 2, mid-page: ‘Teenager hood’ or ‘Teenagerhood’ ?

·       Page 3, line 16 from bottom: ‘lectures’ or ‘lecturers’ ?

·       Page 4, line 4 from bottom: ‘stated necessary’ ?

·       Page 5, bottom line: ‘many information’ ?

·       Page 7, line 17 from bottom: ‘to impact into’ ?

6. The structure of the Discussion could benefit from having separate sections for the discussion of pupil and student experiences (as in the Results section).

7. Page 4, line 8 from bottom: ‘(0.7)’ probably represents the standard deviation, but this should be indicated explicitly.

Author Response

1. The manuscript appears to have a somewhat ‘double purpose’. Although the title and the Introduction give the impression that the main focus is on the design and evaluation of the nursing degree students’ teaching/learning session, a large part of the both the Results (page 4, line 4 from bottom – page 5, line 16 from bottom) and the Discussion (page 6, line 11 from bottom – page 7, line 20 from bottom) section is devoted to describing and discussing the opinions of their pupils. In fact, a larger part of the manuscript is devoted to the experience of the pupils than to the experience of the nursing students (i.e. their teachers). Although having a ‘double purpose’ in a research paper is usually discouraged, it is understandable that the authors want to combine both aspects, but this should be reflected in the Title, the Abstract and the Introduction.

Thank you very much for this valuable suggestion. Our purpose was to explore the experience of participating in an activity about health habits using the service learning methodology in both, nursing students and also high school students. We completely agree with you saying that title, abstract and also introduction don’t reflect this objective and we have now made changes in all these sections to clarify the study purpose.

-In regards to the title we have changed from Assessing Learning-Service Experience on Health Habits of Nursing Degree students in a High School to “Service learning experience on health habits in high school students conducted by nursing students. A qualitative design”. In this point, and according to the editor’s suggestions we have also added in the title the study design.

-We have also clarified the objective in the abstract and in the last paragraph of the introduction.

“This paper aims to  evaluate an activity on healthy habits developed by nursing students and applied to high school teenagers, while using a service learning methodology explore learning about healthy habits and standards of nursing professional practice nurses competencies through a service learning activity between nursing students and high school students.”

 

2-Some (extensive) rewriting of the Introduction appears to be necessary. Moreover, the authors should provide a rationale to include both aspects in one paper. Alternatively, this article could concentrate on the nursing degree students’ experience, and a second paper could be dedicated to the impact of the learning experience on the high school students’ opinions about health habits.

Thank you for this suggestion. We have now rewrite the introduction to better integrate all the aspects studied in our research. That is why we have removed the section titles from the introduction, we have changed the order in which the information was presented and also we have added more information to provide a rationale to include both aspects in our paper. For that we have also added 9 new references [1-9]

3- A main limitation appears to be the sample size. The study was carried out in 5 classes of one high school, out of potentially 70 schools (page 3, mid-page). The study should, therefore, be clearly labelled (and discussed) as a ‘case study’.

Thank you for this observation.

The objective of this study was to explore the learning about healthy habits andstandards of nursing professional practice through a service learning activity between nursing students and high school students in both populations.  The nursing students involved in this study were those who had the best qualifications in the activity of preparing a practical session about healthy habits (within Health Person Care throughout the Life Cycle subject), with a final number of  12 nursing students. 

In our region the Health and School program encompasses 70 high schools. As researchers we randomly selected one high school for developing this activity.  In addition, our sample was both nursing students and high school students.  Therefore, we considered that the participation of 124 high school students and 12 nursing students was sufficient to give a response to our objective. 

 To clarify this point, we have also changed how the information regarding the number of high school centers in the manuscript was written. 

“To develop this activity we only need highschool students from one high school. Therefore, the high secondary school where the activity was carried out was randomly selected by a nurse from the Health and School program from among more than 70 centers.”

 

4-The role of different authors in the Data analysis (page 4) can be described in more detail. Who are the researchers (first two authors?) doing the initial analysis and have they both analysed all transcripts independently? Did they solve discrepancies before consulting others? Who ‘discussed and clarified until a consensus was reached’ (remaining authors)?

Thank you for this suggestion. We have now added information regarding the role of different authors in the data analysis section.

“Both the data obtained from the healthy habits mind map and the reflective journals were analyzed by two different researchers using content analysis. These two authors analyzed all the data independently. Afterwards, all the themes were discussed and clarified until a consensus was reached [24] [13].

Krippendorff [25] [11] defined content analysis as “a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use”. The process followed in conducting qualitative content analysis is composed of four stages: decontextualization, recontextualization, categorization and compilation [26]”

 

Moreover, to ensure the rigor of the research we used the Standards for Reporting Qualitative Research (SQRS) checklist. We have now added information about this in the manuscript. We have also added the SQRS reference.

“The Standards for Reporting Qualitative Research (SRQR) checklist was used to ensure the rigor of the research [27]”

 

-27-O’Brien, B.C.; Harris, I.B.; Beckman, T.J.; Reed, D.A.; Cook D.A. Standards for reporting qualitative research: A synthesis of recommendations. Acad. Med. 2014;89,1245–1251.

 

5-With respect to ‘smoking’ it is not described what the smoking habits of first-year high school students (age?) are. The results of having ‘no intention to improve habits’ (page 7) has no meaning, therefore. The literature data referred to appear the be marginally relevant.

Thank you for this observation. We have now changed how the information regarding tobacco consumption is presented. 

“Although during the session some high school students stated that they used tobacco, no intention of changing his habits was pointed out through the mind map .  But in this case, there was no intention to improve it. “

 

Moreover, we have discussed more about tobacco consumption among adolescents in the discussion section.

“According to WHO the tobacco epidemic is one of the biggest public health threats the world has ever faced, and its use often begins in early adolescence [1]. The initiation and establishment of smoking behavior frequently occurs during adolescence, and 9 of 10 children have started smoking by the age of 18 years old [41] [27], being 10% of 13–15 year olds worldwide smokers [1].  In addition, the prevalence of tobacco consumption among teenagers retrieved from Global Health Observatory was 19,33%, especially in high-income countries [42] [28]. The initiation and establishment of smoking behavior frequently occurs during adolescence, and 9 of 10 children start smoking by the age of 18 years old [27]. The prevalence of tobacco consumption among teenagers retrieved from Global Health Observatory was 19,33%, especially in high-income countries [28].  However, our study results didn’t show any intention to improve habits related to tobacco consumption.

Although some high school students of this study stated that they consume tobacco, they did not express any intention to change this habit. Therefore, in our territory strategies are necessary to raise awareness about the harmful effect of tobacco on health among adolescents. In this line, a Health and School program could be a good scenario to promote these strategies. School health programmes have been demonstrated to be the most cost-effective way to influence health behaviors in young people [43]. “

 

 

6-The paper could benefit from spelling checking and/or having a native English speaker correcting the manuscript, e.g.:

 

Thank you for your suggestion. The article has now been reviewed by a native English

speaker to improve your spelling and grammar. We have corrected all the examples you

have given us and also other problems detected.

 

• Page 2, mid-page: ‘Teenager hood’ or ‘Teenagerhood’ ?

We have changed from teenagerhood to adolescence.

• Page 3, line 16 from bottom: ‘lectures’ or ‘lecturers’ ?

We have corrected it.

• Page 4, line 4 from bottom: ‘stated necessary’ ?

We have changed from stated necessary to felt it was necessary to

• Page 5, bottom line: ‘many information’ ?

We have changed from many information to much information

• Page 7, line 17 from bottom: ‘to impact into’ ?

We have changed from to impact to to but also to impact the community’s health.

 

 

7- The structure of the Discussion could benefit from having separate sections for the discussion of pupil and student experiences (as in the Results section).

Thank you very much for this suggestion. We have now separated the discussion section, as we had done previously in the results section, in high school students and nursing students. We hope this modification will make this section clearer.

Moreover, to give a better discussion we have added new information in the discussion section, supported by 5 new references [1,28,41,42,43]

 

1-World Health Organization. Life Skills education school handbook. Prevention of noncommunicable diseases. 2020. Available online: https://apps.who.int/iris/bitstream/handle/10665/331948/9789240004849-eng.pdf?sequence=1&isAllowed=y (accessed 12 October 2022)

-28-Myers-Lipton, S.J. Effect of a comprehensive service-learning program on college students’ civic responsibility. Teaching Sociology. 1998; 26,4, 243–258.

-43-Monitoring and evaluation guidance for school health programs. Thematic indicators, supporting FRESH (Focusing Resources on Effective School Health). Paris: United Nations Educational, Scientific and Cultural Organization; 2013 Available online: http://www.unesco.org/new/ fileadmin/MULTIMEDIA/HQ/HIV-AIDS/pdf/ENGLISH_M_E_Guidelines_for_web.pdf. Accessed: 12 October 2022.

-47- Bulot, J.J.; Johnson, C.J.  Rewards and costs of faculty involvement in intergenerational service-learning. Educational Gerontology. 2016;32,8, 633–645.

-48-Bush, K.; Edwards, M.; Jones, G.; Hook, J. Service Learning for Social Change: Raising Social Consciousness Among Sport Management Students. SMEG. 2016; 10,2,127-139.

 

8-Page 4, line 8 from bottom: ‘(0.7)’ probably represents the standard deviation, but this should be indicated explicitly.

Thank you for this observation. We have now added the abbreviation SD to represent the standard deviation.

“The average age of the participants was 14 years (SD=0.7), and “the average age was 19 (SD=1.2)”

 

Round 2

Reviewer 1 Report

Dear authors

After the changes introduced, the article could be published

Kind regards

Reviewer 2 Report

The authors have chosen to keep the ‘double purpose’ of the manuscript but have adapted the title, the abstract and (most important) the introduction of the paper. This brings the paper in balance with the obtained results and makes the paper suitable for publication.

In addition, the other (relatively minor) remarks were handled adequately.