Professional Documents
Culture Documents
Critical Care Nursing, Royal Alexandra Hospital, Edmonton, Canada AB T5G 0B7
University of Alberta, CSB Edmonton Alberta, Canada T6G 2G3
Grant MacEwan University, City Centre Campus, 10700 104 Avenue, Edmonton, Alberta, Canada T5J 4S2
a r t i c l e
i n f o
Article history:
Accepted 9 May 2010
Keywords:
Competencies
Problem-based learning
Non-problem-based learning
Graduate nursing
s u m m a r y
Competence is essential to ensuring safe, ethical and legal nursing practice. Various teaching strategies are
used in nursing education in an effort to enhance graduate competence by bridging the gap between theory
learned in the classroom and professional practice as a nurse. The objective of this comparative descriptive
research was to determine if there was a difference in self reported competence between graduates from PBL
and non PBL (NPBL) nursing programs. A convenience sample of 121 graduate nurses in one Canadian
province, who had been practicing for at least 6 months took part in the study. The researcher designed
questionnaire included both forced choice and open ended questions. There was no statistical signicance
difference between the PBL and NPBL graduates on self reported entry-to-practice competence. However,
several signicant themes did emerge from the answers to open ended questions which asked graduates
how their nursing programs prepared them to meet the entry-to-practice competencies and what program
improvements they might suggest. Unlike the NPBL graduates, the PBL graduates identied the structure and
process of their programs as instrumental in their preparation to meet the entry-to-practice competencies.
PBL graduates associated their abilities to think critically and engage in self-directed evidence-based practice
as key to enabling them to meet the competencies. A common theme for program improvement for both PBL
and NPBL graduates was a request for more clinical time.
2010 Elsevier Ltd. All rights reserved.
Introduction
Graduate competence is a measure of quality assurance that
indicates that professional nurses are prepared to engage in safe,
ethical and legal nursing practice in rapidly changing environments.
Baccalaureate nursing education programs have an obligation to
support learning that prepares nursing graduates to meet professional
entry-to-practice competencies. The issue that continues to challenge
nursing faculty is determining which nursing curriculum and which
teaching methods best prepare graduates for autonomous professional practice in a rapidly changing health care environments. A
predominant challenge in developing such a responsive curriculum is
creating a learning environment that is supported by members of the
educational institution, the community, and the nursing profession
(Iwasiw et al., 2005) and encourages the development of high level
skills in communication and information retrieval, critical thinking
130
Results
Demographics
The ndings of the study reveal a mean age of 27.36 years (SD
7.318 years) for both the PBL and NPBL graduates. This means that
graduates were approximately 23 years of age when they started their
nursing studies and were considered mature students on enrolment
into their nursing programs. This corresponds to their highest level of
academic achievement prior to entering a nursing program. Almost
one-third (31%) of the students had a high school diploma. Another
third had some college (13%) or university (14%) education while the
nal third (31%) had a previous university degree. These ndings
reect the current national trend that more nursing students already
have a degree when they begin their nursing programs (CIHI, 2005).
While 94% of the study participants were female, the remaining 6%
were male. Although this percentage is slightly greater than the
reported percentage (5.5%) of male nurses who worked in Canada in
2005, it suggests that the study sample reects a normal representation based on gender (CNA, 2005).
More NPBL than PBL graduates tend to work in a hospital setting
(NPBL = 84.2%; PBL = 70%) and work in one area of nursing
(NPBL = 60%; PBL = 52%) but these differences were not statistically
signicant. On the other hand, more PBL than NPBL graduates tend to
work full time (PBL = 45%; NPBL = 33%) when they graduate. Of those
who do not work full time, 54.7% of the PBL graduates and 66.7% of the
NPBL graduates work part-time, casual or a combination of part-time/
casual, which also reects current hiring practices in the nursing
workforce (CNA, 2005). Almost twice as many PBL graduates (29.69%)
as compared to NPBL (15.79%). are employed in community health
settings. The fact that 48.4% of the PBL graduates and 40.4% of NPBL
graduates had worked on two or more units in their rst 6 months of
employment indicates a concerning trend in new graduate nurse
work status in the this particular province. The only demographic
variable which indicates a signicant difference between the two
groups of graduates is their previous education. The question of
transferring nursing schools was not an issue as all the participants
indicated they completed their program for all 4 years in the same
nursing program.
The threats to internal and external validity were investigated in
the study, and experimenter bias may have existed in the discourse of
the analysis as a threat to internal validity, but with minimal effect. No
threats to external validity were apparent to this particular study as a
result of the procedures adhered to in the study method. Table 1
highlights the comparatives demographics to support the similarities
and differences in the PBL and NPBL graduates.
131
Table 1
Graduates' demographics.
Characteristic
Dimension
Gender
Female
Male
Age
2131
3241
4255
Environment
Hospital
Community
Work status
Full time
Part-time
Casual
Part-time/
High school
Highest academic
achievement prior to diploma
entering nursing
Post secondary
level courses
Diploma/
certicate
Baccalaureate
degree
Other
certications
PBL
NPBL
n = 64
n = 57
Fisher's
exact
test
Freq. %
Freq. %
61
3
54
4
6
45
19
29
21
12
2
24
95.00
5.00
84.40
6.25
9.37
70.31
29.69
45.31
32.81
18.75
3.13
37.50
53
4
46
8
3
48
9
19
27
7
4
13
93.00
7.00
80.70
14.00
5.26
84.21
15.79
33.33
47.37
12.28
7.02
22.81
0.705
22
34.38 11
19.30
4.69 10
17.54
11
17.19 21
36.84
6.25
0.289
0.086
0.202
0.006
3.51
Table 2
Description of the instruments measuring the four standards.
Standard
Number
of items
Professional
Knowledge
Ethical
Provision of Service
12
16
7
5
95 % condence
interval for the
mean score
Low
Up
4.09
3.72
4.05
3.91
4.26
3.97
4.27
4.13
Cronbach's
alpha
0.774
0.871
0.716
0.703
132
Table 3
Comparison of entry-to-practice competence.
Standard
Professional
Knowledge
Ethical
Provision of service
PBL
NPBL
n = 64
n = 57
SD
SD
4.24
3.87
4.123
3.97
0.466
0.635
0.673
0.637
4.116
3.83
4.20
4.07
0.510
0.753
0.576
0.665
t(df)
Signicance p
1.406(114)
0.292(110)
0.684(119)
.828(116)
0.163
0.771
0.495
0.410
Limitations
The assessment of competence continues to be a key issue in the
nursing literature. Reliability and validity are fundamental measurement issues and need to be rigorously established when measuring
clinical competence (Watson et al., 2002). Watson et al. suggested
that even when reliable and valid instruments for the measurement of
clinical competence are developed, there is still the issue of what level
of performance is associated with competence and at what level a
professional can be identied as incompetent. In addition it is possible
that in self reporting, respondents might have a tendency to present
themselves better than they actually are. In this study the reliability of
the instrument as indicated by Cronbach's alpha (0.7) for the four
standards calculated indicates that the graduates all interpreted the
questions the same way.
A limitation of using a postal survey is the small number of
potential subjects who actually complete and return the survey. A
sample size calculation was used to recruit a convenience sample
from all provincial nursing programs in the province. Although a
sample size of 128 graduate nurses was required to establish
statistical signicance (Cohen, 1997), the sample of 121 was
considered an adequate number to establish an overall moderate
effect for the study. Even though the sample was one of convenience,
there is no clear indication of how the sample could have been biased.
Conclusion
This study involved nursing graduates who had been practicing for
at least 6 months in a graduate role and whose nursing program
utilized either a PBL or a NPBL approach to learning. Regardless of
whether respondents graduated from a PBL or an NPBL program, they
reported that they had the ability to meet the entry-to-practice
competencies established by the Provincial Association of Registered
Nurses (2007). PBL graduates indicated that the structure and process
of their nursing programs were instrumental in their preparation to
meet the entry-to-practice competencies. In addition, they identied
the skills and abilities of critical thinking, self-directed learning,
evidence-based practice, and teamwork that they learned through the
PBL process as key in enabling them to meet the entry-to-practice
competencies. NPBL graduates did not as clearly identify if or how the
structure and process of their nursing programs contributed to them
meeting the entry-to-practice competencies. They also did not
comment on the development related to self-directed learning and
evidence-based practice, which are expected competencies identied
by the professional association. Graduates from both programs
suggested that more clinical hours would further enhance their
ability to meet the entry-to-practice competencies. Additional studies
that compare PBL and NPBL are required to support the ndings in this
study.
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International Medical Journal Vol. 23, No. 4, pp. 331 - 333 , August 2016
331
PUBLIC HEALTH
ABSTRACT
Introduction: Problem Based Learning method is the most advisable method in institutions, but this method may be new to
some university lecturers. Consequently, when it is vital sometimes to agree to the new-fangled method and learn its all new
techniques, it possibly will not be welcomed by the teachers. The purpose of this study is to identify the determinants of univer
sity lecturers intention to adopt Problem Based Learning.
Methods: This was a cross-sectional questionnaire based study with a sample of 112 lecturers of USM, chosen by random
sampling. Theory of Reasoned Action (TRA) model was used to explore the effect of two external variables: knowledge and skill;
three independent variables: attitude, subjective norm and perceived belief control on adoption of PBL by the lecturers.
Multiple Regression analysis was used to find how these two external variables affect these three independent variables.
Discriminant analysis was used to test the effect three independent variables on the dependent variable, adoption.
Results: The findings of the study indicate that, the lecturers knowledge on PBL affect their attitude and perceived belief
control when their skills on PBL affect their subjective norm positively and significantly. Lecturers attitude, subjective norm
and perceived belief control about PBL affect their intention to adopt PBL.
Conclusion: The three independent variables of this study lecturers attitude, subjective norm and perceived belief control
about PBL affect their adoption of PBL positively and significantly.
KEY WORDS
theory of reasoned action, adoption, PBL
INTRODUCTION
PBL is a curriculum development system that recognizes the need to
develop problem solving skills as well as the necessity of helping indi
vidual to acquire necessary knowledge and skills". The nature of effec
tive problems are real-life and authentic not teacher's exercises, lacking
information needed for their resolution and iterative in the way that they
produce further ideas,/hypotheses and learning issues1-2. It challenges
students to "learn to learn" working courteously in groups to seek out
the solutions to the real world tribulations31.
PBL first implemented in McMaster University in Canada in the
mid 1960s. There are variations of PBL implemented at institutions like
University New Maxico, Harvard University, University of Sherbrooke,
and Michigan State University4. Now Problem Based Learning method
is the most advisable method in institutions but this method may be new
to some university lecturers5-6. Consequently, when it is vital sometimes
to agree to the new-fangled method and learn its all new techniques, it
possibly will not be welcomed by the lecturers. This study was mainly
conducted on the issues for example- lecturers' attitude, subjective norm
and perceived belief control towards the PBL to the lecturers adoption
of the PBL method. Thus, this study takes an attempt to develop the
Theory of Reasoned Action (TRA)7 model where the external variables
such as knowledge and skill on PBL are expected to influence the lec
turers' attitude, subjective norms and perceived belief control toward the
adoption of PBL. According to the Theory of Reasoned Action, if peo
ple evaluated the suggested behavior as positive (attitude), and if they
METHODOLOGY
This study is an endeavor to develop a clearer understanding of the
influencing factors in the adoption of PBL by the lecturers of Universiti
Sains Malaysia. Theory of Reasoned Action was based to explore the
influencing factors (Figure 1).
This was a cross-sectional exploratory study. Responses from indi
vidual in natural setting were sought and the variables were neither con
trolled nor manipulated. The unit of analysis in this study was the indi
viduals. Study population was the lecturers from twelve different
schools of Universiti Sains Malaysia (USM), who were aware of
Problem Based Learning in their teaching. Both male and female lectur
ers were the respondents. There was no age limit for these 112 randomly
selected respondents.
The pretested questionnaire for its reliability and validity was used.
The questionnaire was divided into seven sections each to collect data
on different aspect such as personal, knowledge, skill, attitude, subjec
tive norms, personal belief control and adoption of PBL. Personal data
were collected on 9 items, knowledge, skill and attitude on 10, 8 and 6
items respectively. Sections on subjective norms had 7 items and per
ceived belief control had 6 items. Adoption of PBL in teaching was just
332
Barman S. et al.
Wilks' Lambda
Table 2. Combined effect o f attitude, subjective norm and perceived belief control on the adoption o f PBL.
dfl
DC
Sig.
PerceivedBelief Control
0.84
21.16
110
P<0.01
Test of Function(s)
Subjective norm
0.92
9.37
110
P<0.01
Attitude
0.83
22.91
110
P <0.01
External Variables
Independent Variables
Wilks'Lambda
Chi-square
Df
0.78
26.76
Sig.
P<0.01
Dependant Variable
External Variables
Independent Variables
Dependent Variable
Figure 2. Effects of external variables on independent variables and intern on dependent variable explained by Theory o f Reasoned
Action.
yes/no response.
Data were analyzed by Statistical Package for Social Science (SPSS
17.0) software. Frequencies, means and standard deviations were com
puted for all pertinent items as well as a demographic profile o f all
respondents. Correlation and multiple regression analyses were run to
test the relationship between the two external variables (knowledge and
skill) and attitude, subjective norm as well perceived believed control.
Discriminant analysis was conducted to explore if the Fishbein's
Theory of Reasoned Action model, the intention o f lecturers to engage
in the PBL is influenced by attitude, perceived belief control and subjec
tive norms.
RESULTS
Out of 112 respondents, 63.4% male and 36.6% female who partici
pated in this study, 111 o f them have experiences as PBL facilitator.
Only 29 of them were student of PBL programme. The largest group
that makes up 51.8 percent o f the respondents was lecturer; followed by
associate professor (37.5%) and professor (10.7%) and they were o f the
age group of 36-55 years.
Looking to the theoretical framework drawn based on Theory of
Reasoned Action, it was seen that in case o f PBL, attitude (p =.70,
t( 109) = 2.73 at p < 0.01) and perceived belief control (P = .83, t( 109) =
2.78 at p < 0.01) were significantly influenced by knowledge but not by
skill, whereas subjective norm was influenced by skill (p = .52, t( 109) =
2.57 at p < 0.01) but not by the knowledge of the lecturers.
Second part of the theory, the impact o f teachers attitude, subjective
norm and perceived belief control on adoption of PBL was tested by
discriminant function analysis. It was established that individually atti
tude, subjective norm and perceived belief control positively influence
the adoption o f PBL by the teachers (Table 1). It was also established
the combined positive effect of attitude, subjective norm and perceived
belief control on the intention o f teachers in adopting PBL, but the high
er value o f Wilks' Lambda (0.78) indicated that there were some unex
plained factor(s) in deciding the intention (Table 2).
D IS C U S S IO N
1)
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333
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Bibliography #4
Although PBLs were first implemented in medical education, Walker and Leary (2009) concluded that PBL
students either did as well as or better than their lecturebased counterparts, and they tended to do better when
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they have also found a home in higher education classrooms. The loose structure of the PBL offers opportunities for students to wrestle with complex levels of knowledge through analysis of the problem and synthesis of the
research. PBLs enlighten students as to what they do not
know, whereas lecture and limited hands-on classroom activity promotes the notion that students know more than
13
14
its for a life of learning. This is the key for success in the
classroom.
READING METHODS CLASS
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Appendix A
Luisa is in the third grade at Stonybrook Elementary
School. She came to America last year from Mexico
with her parents who are migrant workers. She speaks
broken English and does not associate with other
children. Luisa loves to draw and paint, but does not
seem interested in reading. There are few books in the
classroom and when she goes to the school library, she
must select books on her Accelerated Reader level.
When she has time on the computer, Luisa likes to visit
virtual art museums and look at paintings.
Facts
List
Possible
Problems
Need to
Know
Reading
Instruction
Needs
How will I
assess?
Reflection/
Next Steps
15
Appendix B
Comprehension Habits: There has been much research on reading comprehension strategies. You are familiar with
the strategies of questioning, clarifying, predicting, and summarizing. Additional strategies that aid in comprehension are building schema, inferencing, synthesizing, and metacognition. Zwiers (2006) synthesized the research
related to comprehension into six comprehension habits for students to internalize in order to monitor their reading
comprehension. The habits Zwiers (2006) recommends are:
1. Organizing text information by sculpting the main idea and summarizing.
2. Connecting to background knowledge.
3. Making inferences and predictions.
4. Generating and answering questions.
5. Understanding and remembering word meanings.
6. Monitoring ones own comprehension.
Practice these habits with the following poem by Robert Frost:
16
Transitioning to the Real World Through Problem-Based Learning:A Collaborative Approach to Teacher Preparation
Appendix C
PBL RDG 4030 Spring 2012
The Tennessee State Board of Education has established learning goals for students. The curriculum coordinator
for the school district that employs you as a fifth-grade teacher notes that the district has been doing a good job
promoting some of the components of a balanced literacy program. Some students come to fifth grade reading
fluently. They are able to summarize what they have read and answer literal questions about fiction and nonfiction readings. The curriculum coordinator has also noted there are some gaps in students reading and thinking
abilities. Students do not dig deeper into what they are reading and vocabulary scores on state tests are somewhat
low. They do not ask questions and are willing to accept things on face value. Students do not offer support for
their viewpoints and have difficulty appreciating other viewpoints. Students believe that reading is for the reading
class. The district administration has decided that there has been too much emphasis on basal readers and covering
the material. The superintendent feels that asking each grade-level team to design a plan that incorporates a
variety of innovative literacy techniques and higher-order thinking skills into classroom instruction will address
this problem. Funds are available for purchasing books and other materials to accomplish these goals. The
superintendent has asked that parents and interested others in the community be well-informed about the changes
because some communities have been reluctant to support school reform.
You are on a team of fifth-grade teachers charged with integrating these goals into the district curriculum
for fifth grade. Such work entails designing a district teaching guide in which you identify aspects of reading
comprehension that need to be developed and how they can be fostered in fifth grade. Explain why the methods
you have selected fill the gaps in students reading and thinking abilities. You should include state standards that
are addressed and how reading is integrated into other subject areas. Explain how you will know if students are
learning and using the processes you identified, and provide a plan for keeping parents informed about the goals,
process, content, and assessments presented in your restructuring.
17
Appendix D
District Teaching Guide PBL
Identifies the problem and four to Identifies the problem; three of less
10
five sub problems.
sub problems are identified.
States how each identified deficien- States how each identified deficy will be addressed. Research sup- ciency will be addressed. Research 30
ports some decisions.
is missing.
Includes a few state standards that Includes a few state standards that
are aligned with the strategies.
are not aligned with the strategies.
18
Is creative, but not all team memLacks creativity and not all team
bers participate. A visual aid is part
members participate. There is no 10
of the presentation, but there is no
visual aid, nor handout.
handout.
Copyright of Journal of Learning in Higher Education is the property of JW Press and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
APA
(American Psychological Assoc.)
References
Barron, L., & Wells, L. (2013). TRANSITIONING TO THE REAL WORLD THROUGH PROBLEM-BASED LEARNING: A COLLABORATIVE
APPROACH TO TEACHER PREPARATION. Journal Of Learning In Higher Education, 9(2), 13-18.
Bibliography #1 Article
Im
Salam A".
ABSTRACT
Objectives: Regular problem ba.sed learning (PBIJ workshops are to be conducted in order to know the
laciiniie of the PBI, facilitators and improve on various aspects.
Materials and Methods: A total of 20 workshops ( with duration of 2-days) were conducted between the year
2005 and 200S, One hundred and ninety one participiints registered for the workshop. However, only 173
individuals fully attended the workshops. Nine attended hut were unable to complete the workshop for various reasons. The rest nine registered hut still did not turn up. The 2 day training .session ended with an overall feedback from trainers to participants and b> evaluation of the workshop by participants. A 15-iteni questionnaire was distributed which covered each of the workshop activities as well as the facilities provided during tbe training sessions. Satisfaction was rated as '0' to '5' where *0' was 'disastrous' and '5' was considered
as 'excellent'
Results: Of the 173 participants, 155 completed the 2-day workshop and returned tbe feedback forms
(response rate of 89.6^/( ). Feedback from participants was obtained based on the activities as well as facilities
provided during the workshops.
Conclusion: The 2-day FItL tacilitator training session exposed teacbers to a new way of condueting student centered small group learning. Tbe results obtained from the study might be helpful in proper conductance of FIL at all medical institutions.
KEY WORDS
facilitation, problem based learning, small group learning. statT development
INTRODUCTION
Itnplemcntution of any PBL curriculum involves three
itnportiitit elements, i.e. the stitdents. the lacilitators and the
resources. Students as stake holders should develop skills
in conductitig (i.e. learning through) PBLs. Studetil's functioning correspond closely to the teacher's efforts to facilitate ihe student's scientific literacy, initiative. respiMisibility. and motivation'.
An earlier study on facilitators was supported by sufficient resources that would ensure the successful implementation of a PBL curriculutir . Changing roles from teachers
to tutors create discomtOrt and insecurity atnong PBL
tutors". The challenges faced by the tutors ranges from handling of group dynamics to ensuring that the learning out-
104
Nabishah M. et al.
20
2 days
6-12
191
173
9
9
20
Day 1
All participants went through the PBL session playing
the role as students while the trainer acted as the facilitator.
Each workshop was conducted by 2 trainers. Each day was
conducted in two sessions. During the first session, participants experienced the PBL process by reasoning through a
PBL problem using the hypothetical deductive reasoning.
Participants then performed their self-directed learning
(SDL) for 2 hours, answering the learning issues generated
during that first session. This was followed by the second
session.
In the second session, participants discussed their newly
acquired knowledge whilst the trainer (facilitator) guided
thetn to integrate the new knowledge into their reasoning,
to reach an understanding and to solve the problem. The
first day of the workshop ended with an interactive lecture
on PBL process aimed to consolidate participants experiences in Day 1 and to he able to apply the skills acquired
during the subsequent training session conducted on the
following day.
Day 2
The second day began with a lecture on the roles of the
facilitator in PBL. This was followed by the first part of
facilitator ttaining session. During this session participants
took turns for about 15 minutes each to tacilitate the group,
siinilar to as how it was conducted in the Day 1 session.
whilst the remaining participants played the role of students.
This was followed by feedback from the trainer focusing on
his/her Cacilitation skills and handling of group dynamics.
This session ended when all participants have had opportunity to conduct the I ' part of the PBL session.
The second session followed the self-directed learning
period, similar lo how it was conducted in Day 1. In this
session, again participants worked in a student group while
one of them took turns to be the facilitator every 15 minutes. This was again followed by constructive feedback
from the trainer.
The 2 day training session ended with an overall feedback from trainers to participants and by evaluation of the
workshop by participants. Questionnaires were distributed
RESULTS
One hundred and ninety one participants registered for
the workshop: however only 173 fully attended the workshops. Nine attended but were unable lo complete the
workshop for various reasons. The other nine registered but
did not turn up (Table 1). Of the 173 participants, 155 completed the 2-day workshop and returned the feedback
forms, giving a response rate of 89.6%. Feedback from participants was obtained based on the activities as well as
facilities provided during [he workshops. Results were presented in percentages (Figure 1)
The facilitator training sessions were rated from good to
excellent by 82.9 of the participants. Feedback from
trainers to participants following their performances as
facilitators were rated as good to excellent by 85.8'^;i of the
participants. The self-directed leatning (SDL) resources,
audio-visual and cotnputer equiptiient i-eceived relatively
poor ratings. These two iiems were interrelated. The SDL
sessions were held during the lunch hour. The easiest and
fastest way of getting information for their learning issues
would be by accessing the internet. An internet line was not
available at the venue where the workshops were cotiducted. Even though the library was situated in the same building, due to the very short period of time provided for participants to conduct their SDLs, it was difficull to complete
all their SDL goals.
The lectures entitled "The Facilitation Process', 'The
Role of Facilitators" and "The PBL Group Assessment'
were rated as "good' to "excellent' by 809^. 77.4% and
76.8% of participants, respectively. While none of the participants rated the PBL training experience as "disastrous'
and 'poor', 0.6% of participants rated the facilitator training as "poor".
Regarding the length or duration of the workshop.
52.3% of participants rated the 2-day session as "good" to
"excellent'. In terms of overall usefulness of the workshop,
85.2% of participants rated as "good" and 'excellent', while
a smaller percentage (14.8%) rated as "poor", 'fair' and
'adequate'.
105
5: Excellent
4: Good
3: Adequate
m 2: Fair
.#
-if
l:P(K>r
0: Disastrous
^ ^ / , /
Figure 1. valuation of the 2-day PBL facilitation training by the participants. A total of 155
respondents rated 0-5, where 0 is 'disastrous' and 5 is 'excellenit\
DISCUSSION
Prohlem based learning (PBL) demands medical educators to rethink and change Iheir edticational role Irom predominantly tran-sniit facts, to facilitating and guiding students to achieve their learning goals". As per an earlier
study, while conducting the PBL tutorials, tutors must
allow students to determine on their own what they need to
know, und to learn through sourcing varied resources on
their own"'. The same study emphasized that faeilitaiion
skills are crucial for students' learning"'. As such, faculty
members in m institution that uses PBL as a teaching and
learning method or one who plans to implement a PBL curriculum must be trained properly in the PBL facilitation
skills as a prerequisite for the suecessful implementation of
its PBL curriculum.
As part of the preparation in implementing a hybrid
I'BL curriculum, this institution conducted a series of staff
development programmes to provide faculty members with
basic skills in conducting small group learning focusing on
PBL facilitation. Altending ihis 2-day workshop was made
mandatory to all tutors before they were allowed to conduct
any PBL sessions. However, 9.4% of the registered participants either did not attend or if attended then did not stay
for the entire 2-day training programme. Failure to attend
the workshop could be due to other competing interests or
due to their disinterest in the PBL teaching and learning
process.
Harden and Crosby (2000) related this to professionalism and selt-development of the individual as a teacher".
Another study Stone el al, (2002) argued that underlying
humanitarianism. familiarity with adult learning principles,
understanding of the benefits and drawbacks of teaching
ami the image of self as a teacher might influence faculty's
teaching identity which potentially determined their readiness to attend any staff development programmes"".
This staff development programme took the principle of
experiential learning as the method to train the facilitators.
The PBL experience exposed partieipants to the PBL
process. In this session participants played the role as students and it was intended to make the teachers experience
the PBL process from students" perspectives. This was considered as very important as most of teachers did not have
the chance to experience PBL during their student days.
An earlier study had found that most teachers only
remember either lectures or bedside teaching or both when
asked to rclTcct on their experience as learners". This fresh
experience as learners might help the teacher to shape their
teaching particularly their facilitation styles. Participants
had mixed feeling about this experience.
Following were the participants" comments reflecting
on their role as students.
1. "
It is not easy to role-play as a medical student."
2. "A very good workshop where role play was the main
essence. The participant's role changed from being
Student * Scriber ' Facilitator
'"
3. "
good experience to be in a student's shoe."
4. "Getting medical student involvement would provide
"true-to-life" situation of PBL."
5. "The facilitation training should be with "real student' instead of among us to make it more beneficial
"
6. "Having our own colleagues "act" as students tend to
lead us to take for granted that the students' already
have the knowledge and this leads to lack of probing."
Facilitator training on the second day took about 27:
hours for simulating PBL session I and 2. Though it was
rated as 'good" and 'excellent' by most of partieipants,
there was one participant who rated it as "poor' and 7 participants {4.5*>} rated it as "fair". This was probably due to
the limited time available for individual participants to
practice. The dissatisfaction could also be attributed to the
participants need to play the role as 'students' while the
other participant played the role as the 'facilitator' and this
allowed for only limited experience to act as the facilitator. This was reflected by sotTie of the participants' eonv
106
Nabishah M. tal.
ments:
1. "Not enough time to experience the 'facilitator' rolebut on the whole, gave the feel of the true life
situation"
2. "
need more time to practice facilitating"
Duration of the workshop scored the lowest satisfaction
rate. A total of 52*)?^ rated as "good' and 'excellent". Most
participants voiced that the 2-day training was too short.
Distlehorst et al (2005) conducted their PBL facilitation
ttaining for 1 week which gave enough time to practice and
improve the skills after receiving feedback from the trainers'' . Receiving feedback was highly valued by the participants with 81.3% rated as "good" and "excellent"; however,
there wasn't enough time for them to improve their skills
following the feedbacks.
Lengthening the duration would definitely improve the
facilitation skills; but it would also demand more time on
the trainers as well as the participants who are mostly busy
clinicians. Therefore this workshop may have served as a
starting point before one start facilitaiing a PBL group,
Johnston and Tinning (2001) developed a two-phase discussion among the PBL facilitators instead of a usual way
of training facilitation techniques". In the first phase, the
aim of ihe discussion was to establish group dynamics and
set collaborative learning environment. In the second
phase, the group critically analyzed their experiences in
dealing with various problems while conducting the PBL,
The authors used group reflection as a means to improve
skills in PBL facilitation.
CONCLUSION
This 2-day PBL facilitator training session exposed
teachers to a new way of conducting student centered small
group learning. The overall impressions on the training sessions were expressed by participants as:
/. "
received valued tips and suggestions. Can'i
wait to apply it a.s soon a.s possible. "
2. "I am glad to have attended this workshop. There is
more tofacilitute a PBL group than ! thought
"
3. "Overall. I find this workshop very useful and helpful. We got some useful tips on how to conduct an
effective PBL session. "
The 2-day duration was not enough to acquire the facili-
tation skills, but with practice in real-life situations combined with constructive feedback from students tnight help
to further improve tutors" facilitation skills. Limitation of
this training session: The "PBL Group Assessment"" session
was delivered in the form of a lecture. Participants did not
have the opportunity to practice assessing students* performance during the workshop. The other limitation was thai
the workshops were conducted among teachers. Facilitating
group of students may pose different challenges as compared to facilitating a group of teachers.
REFERENCES
1) Zion M and Slczak M. It lakes two to tango: In dynamic inquiry, the
self-directed student acts in association with ihe f;iciiitating leacher.
Teach Tciifli Bduc 2005; 21: 875-94,
2) Yee HY. Radhakrishnan A. Ponnudunii G, Improving PBLs in the
Iniernaliunal Medical University; defining the 'goitd' PBL racililator,
Med Teach 2006: 28(6): 558-(iO,
3) Mpiiiu DJS. Das M. Stewart T. Dunn E. Schmidt H, Perceptions of
gmiLp dynatiiics in prob lern-ha sed learning sessions: a lime lo reflect
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facilitalinn- Med Teach 2005: 27: 676-81.
5) Farmer. E.A. Faculty developnieni lor problem-based learning. Kur J
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6) N A/ah MN. M Shah ME, Juwita S. S Bahri I. WM Rtishidi WM. M
Jamil Y. Validation of tht^ Malay version hriel paticnl health ijuestitinnaire. Iniernalional Medical Journal lIMJl 2005; 12(4): 259-63.
7) Maudsley G Roles and responsibilities of the problem based learning
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fi) Barrows HS. 1992. Revised edition. The lulorial process. Illinois:
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9) Harden RM, Crosby J. AMEE Guide No 20: The good teacher is more
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10) Stone S, Ellers B, Holmes O, Qualiers D, Thompsons J, Idenlifying
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11 ) MacDougall J, Drummond MJ. The development of medical teachers:
an enquiry inlo ihe learning hislorie of 10 experienced medical teachers. Med Educ 2005: 39: 1213-20,
12) Distle LH, Dawson E, Randall S, Barrows HS. Problem-based learning
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Copyright of International Medical Journal is the property of Japan International Cultural Exchange Foundation
and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.
APA
(American Psychological Assoc.)
References
Mohamad, N., Chen, R., Isahaki, I., Salam, A., Siraj, H., & Das, S. (n.d). Developing Skills in Problem Based Learning Facilitation: An
Insight. International Medical Journal, 17(2), 103-106.
APA
(American Psychological Assoc.)
References
Barman, S., & Barman, A. (2016). Theory of Reasoned Action in Exploring Factors Affecting Lecturers' Intention to Adopt PBL.
International Medical Journal, 23(4), 331-333.
Bibliography #2
student-teacher interactions
Conducting the symphony: a qualitative study of
facilitation in problem-based learning tutorials
Tracey Papinczak1, Terry Tunny2 & Louise Young1
APA
(American Psychological Assoc.)
References
Papinczak, T., Tunny, T., & Young, L. (2009). Conducting the symphony: a qualitative study of facilitation in problem-based learning tutorials.
Medical Education, 43(4), 377-383. doi:10.1111/j.1365-2923.2009.03293.x
377
T Papinczak et al
INTRODUCTION
378
RESULTS
METHODS
When sensitive material arose within PBL discussions, some tutors were clearly more able to deal
with the information in an open manner without
discomfort. Thus, some tutors were able to model a
way of dealing with awkward information and
potential embarrassment, which students found
supportive and helpful:
Some sensitive issues arose during our group discussion and the consensus was that our tutor handled
these expertly and confidentially and with aplomb...
379
T Papinczak et al
When tutors were unable to provide a framework for
handling sensitive issues, students were critical of the
failure of the scaffold they had anticipated would
exist under those circumstances. One Year 1 student
noted that, when faced with a situation in which
potentially embarrassing material was being
discussed, the tutor reacted inappropriately:
This tutor made many inappropriate comments that made the group as a whole and individuals
uncomfortable not helpful for our learning!
Tutor style
The majority of responses focused clearly on tutors
facilitation styles. These respondents had unmistakable preferences for the manner in which PBL tutorials
were to be conducted. Three themes were apparent:
the degree to which scaffolding was provided for
learning, the manner in which group processes were
managed, and the provision of tutor input and
information to provide structure for discussion.
Scaffolding of learning
[The tutor should] be a facilitator, not a dictator...
The first (and most abundant) category arose from a
number of responses focused on the directive (or
non-directive) approaches taken by tutors to guide
consideration of the problem or case, generation of
hypotheses and learning objectives, and consideration of mechanisms. Preference for a much more
directive approach was apparent among some
respondents:
If [the tutor] could take more control of what our
group should be focused on, it would be better...
[The tutor] did not encourage us to consider the
mechanism behind the symptoms in the PBL cases. I
did not feel like we were getting everything we could
out of the triggers...
[The tutor should be] leading the group more
actively instead of sitting back and watching...
We are quite autonomous but still like to be
challenged, and an individual shouldnt have to guide
group learning while trying to learn themselves.
An in-depth interview with a Year 2 student provided
insight into the student experience under a
marshmallow tutor:
The marshmallow tutor only steps in to guide the
group if asked questions directly, often allows the
380
381
T Papinczak et al
Students were not satisfied with clinical facilitators
who did not guide group discussions by using their
expert knowledge in any way, or who allowed their
groups to go off on tangents and miss relevant facts
and opportunities to reflect on important information. The following comment highlights this omission:
With her medical knowledge and experience I would
encourage her to contribute more during sessions.
DISCUSSION
CONCLUSIONS
Findings highlight the link between tutors scaffolding skills and students perceptions of overall tutor
effectiveness. When given carte blanche to comment on
the effectiveness of their PBL tutors, students gave
feedback that focused predominantly on scaffolding
experiences. Within its wider definition (as used
within the MBBS programme), scaffolding of learning includes all aspects of learning experiences in
PBL.4
382
REFERENCES
1 Vermetten YJ, Vermunt JD, Lodewijks HG. Powerful
learning environments? How university students differ
in their response to instructional measures Learn Instr
2002;12:26384.
2 Mayo WP, Donnelly MB, Schwartz RW. Characteristics
of the ideal problem-based learning tutor in clinical
medicine. Eval Health Prof 1995;18:12436.
3 King A. ASK to THINK-TEL WHY: a model of transactive tutoring for scaffolding higher level complex
learning. Educ Psychol 1997;32:22135.
4 Albanese MA, Mitchell S. Problem-based learning: a
review of the literature on its outcome and implementation issues. Acad Med 1993;68:5280.
5 Vygotsky LS. Mind in Society. Cambridge, MA: Harvard
University Press 1978;7991.
6 Barrows H. The Tutorial Process. Springfield, IL: Southern Illinois University School of Medicine 1988;142.
7 McInerney DM, McInerney V. Education Psychology,
Constructing Learning. Sydney, NSW: Prentice Hall
1998;1448.
8 Maudsley G. Roles and responsibilities of the problembased learning tutor in the undergraduate medical
curriculum. BMJ 1999;318:65761.
9 Margetson D. Current educational reform and the
significance of problem-based learning. Stud High Educ
1994;19:519.
10 Dahlgren M, Castensson R, Dahlgren L. PBL from the
teachers perspective: conceptions of the tutors role
within problem-based learning. High Educ 1998;36:437
47.
11 Woods DR. Problem-based Learning: How to Gain the Most
from PBL. Waterdown, ON: Donald R Woods 1994;317.
383
Bibliography #5
ORIGINAL RESEARCH
ABSTRACT
tinue to increase in the radiologie sciences, it is imperative for educators to re-examine their roles in
preparing radiologie science graduates for the workplace. Radiologie science graduates must be able to
seek answers to challenges they face in the clinical
environment as a result of the increased complexity of
healthcare delivery and the rapid technologic changes
inherent in the professions. This requires graduates to
be self-directed learners throughout their careers. The
development of critical-thinking skills is a mandate
for educational programs programmatically accredited by the Joint Review Committee on Education
in Radiologie Technology (JRCERT) (2001) and a
recommendation from the Pew Health Professions
Commission's Twenty-one Competencies for the
Twenty-first Century (2000). Problem-based learn-
ing (PBL) group techniques are the preferred educational method for bridging the gap between theory
and practice (Kowalczyk, 2011; Rideout, 2001).These
learning strategies have been used in medical education since the 1960s and in nursing and other allied
health professions since the 1980s. However, a review
of literature demonstrates that the radiologie science professions lag behind other health professions
in incorporating critical-thinking strategies into the
educational curricula (Kowalczyk, 2011). Research
has shown that utilization of a traditional lecture in
the classroom results in little transfer of learning to
the clinical setting, as students lose their motivation
and do not understand the relevance of the material
(McLoda, 2003). Also, many of the assessment tools
currently in use only measure lower levels of thinking.
A 2009 survey of program directors of JRCERT-accredited radiography and radiation therapy programs
assessed the directors' perception of the benefits and
barriers to the incorporation of critical-thinking activities in their educational programs (Kowalczyk,
Hackworth, & Case-Smith, 2012). Results of this
survey suggest educators lack the skills and resources necessary to implement PBL. The respondents
identified a need for assistance in PBL curriculum
Review of Literature
A systematic review of the literature was conducted
to identify the best educational methods for developing critical-thinking skills in students within the
health sciences (Kowalczyk, 2010). The review adhered to the A Measurement Tool to Assess Reviews
(AMSTAR) evaluative framework to examine problem-based learning strategies utilized in medicine,
nursing, physical therapy, and occupational therapy
programs. The review was conducted using an "a priori" design and strict inclusion criteria, which resulted
in the analysis of 19 research studies. Of the 19 studies meeting the inclusion criteria for the systematic
review, 79% were conducted on educational strategies
used in nursing programs, and all but one of the most
rigorous studies at the highest levels of evidence were
conducted in nursing. These results suggest that educational strategies used in nursing education should
serve as examples to inform educators in the radiation
sciences. Additionally, all of the teaching-learning
strategies included in the systematic review involved
active learning methods, with the majority of the research (68%) focused on problem-based learning. Of
the 13 studies relating to PBL, 6 demonstrated significant differences in student critical-thinking scores,
thus suggesting that problem-based learning is an
effective teaching method that should be utilized in
radiologie science education.
From a constructivist theoretical perspective, adult
learners actively create their own knowledge through
lived experience. This experiential learning is accomplished through interaction with the environment,
not by passively absorbing facts and concepts from
a lecturer. Therefore, in this type of learning environment, the educator must focus on each student's
unique experience, taking into consideration his
body, mind, emotions, and social relationships (Fenwick, 2003). Problem-based learning, as described
in the literature, is a specific, self-directed learning
activity in which learners must solve a problem. In
this context, a problem is defined as any situation
or circumstance in a particular setting where specific knowledge and understanding must be applied
Problem Statement
According to Rideout (2001), transitioning to a PBL
method requires a fundamental shift in the assumptions and primary beliefs about learning; thus the faculty plays an essential role in PBL. An understanding
Methods
A qualitative study was conducted at McMaster University, Hamilton, Ontario, in May 2010, including
course observations and interviews vwth nine skilled
educators in the nursing and health sciences faculty.
McMaster University is a worldwide leader in conducting PBL and in training educators in the process
of PBL. The institutional review board of The Ohio
State University approved the study.
The overreaching goal of this study was to identify, observe, and describe successful PBL teaching/
learning strategies which can be incorporated into
the radiologie sciences curricula. Interviews were
audio taped, transcribed, and analyzed utilizing use
the constant comparative method of qualitative data
analysis (Glaser & Strauss, 1967) and standard techniques to code the data (Constas, 1992; Miles c Huberman, 1994). This iterative approach enabled the
exploration of emergent themes to ensure saturation
in data collection (Glaser 6c Strauss, 1967). Atlas.ti
5.0 software package (Scientific Software Development, 2004) was utilized to facilitate coding and data
analyses, including the formal exploration of patterns
and themes within the data. Although a wealth of
data was obtained during the observations and interviews, this article will only focus on the issues pertinent to the role of the educator.
Findings
Philosophy and Curriculum Design
The McMaster University School of Nursing was
established in the 1940s and currently resides in the
College of Health Sciences, which was established
when the medical program began in the 1970s. At
that time, inter-professional education was prevalent,
v\dth nursing faculty teaching in medicine and medical faculty teaching in nursing. Since its inception,
the College has added programs in rehabilitative sciences, physician assisting, and midvwfery. The leaders within the College of Health Sciences adopted
It is important to note that not all faculty members will facilitate the process in the same manner.
Although the overall learning outcomes are achieved
in each group, facilitator variation is common and
must be understood before implementing a PBL format. One informant suggested that this level of comfort resides with the educator's awareness of her/his
own limitations.
So the whole challenge is around, "Do you need to be
an expert in the content or do you need to be an expert
in the PBL process?" We incorporate critical thinking
and criticaljudgment and so the debate is that you
probably need both. Students need to be exposed to
differences. When students complain that the tutors are
not consistent, I say, "well, in fact, patients are NOT
consistent. " We are using the same cases, we are using the
same strategy, it is very experiential in each group, and
how we go about that is different with differentfaculty.
We are not all identical; we all comefrom very different
backgrounds.
Lastly, one important area of interest regarding curriculum design is the integration of theory
to practice. Nursing education, both traditional and
PBL, have a strong history of utilizing nursing theory and various models as a basis for learning. This
is an inherent weakness in the radiologie sciences.
Theoretical models provide a standardized framework on which to build knowledge, which translates
to evidence-based clinical practice. Throughout all 4
years of PBL at the McMaster University School of
Nursing, theoretical models are interwoven throughout all aspects of nursing process and practice. The
PBL units are designed to encompass specific concepts including both nursing concepts and associated
"soft skills" required for clinical practice. In addition
to nursing practice theory, resources are provided to
help students understand group dynamics, conflict
resolution, diversity, advocacy, and leadership. Thus
students are actually developing multiple skills and
Facilitators are very important in helping students develop the skills required for group learning
and team work. Students are assigned specific roles
in the first year of PBL, and the group openly discusses conflict management. The group sessions are
videotaped and reviewed as a group activity to selfassess the group dynamics in terms of individual
contribution to the group activities. This helps each
member grow and learn how to be a valuable group
participant. It is critical for the facilitator to keep the
student groups on focus without taking control ofthe
PBL process. If conflict arises, it is addressed by the
entire group and not relegated to the facilitator to
intervene with the individual students in a parentchild conversation. Students are required to actively
engage in adult-adult conversations to resolve their
own group conflicts. All graduates will be working in
teams in the clinical environment, and learning to be
a productive team member is an important skill for
success. Comments were made by multiple nursing
faculty members during the interview process:
In the real world, we know that conflict is present in
professionalpractice, andpatients get poor care because
of it. So we have to teach our practitioners, in school,
how to do this, not wait until they are graduates. So
those are some ofthe things I think are important, like
teaching students how to manage conflict, dealing with
a difficult student.
When there are small groups, they cannot hidefrom one
another. When they are working after they graduate,
veryfew are going to be a solo practitioner; they are
going to work in groups and teams. So they need to learn
how to negotiate, how to get that vocabulary, how to
seek and state the knowledge rather than just think the
knowledge. I think that is a really important process.
One ofthe things PBL does is that it promotes that
reflection knowledge, the overt knowledge, the covert or
tacit knowledge. How do your experiences influence how
you view new knowledge? How do you link it to the
context of another environment?
8 Radiologie
Science
& Education
17{I)\u\y20n
Faculty members are introduced to the background and process of problem-based learning with
an over-arching goal of understanding that PBL is
not about the educator, it is about the student. The
first session includes observations of mock PBL sessions, as observation and role-playing are important
components of the training workshops. The following
References
Constas, M. (1992). Qualitative analysis as a public event:
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de Gruyter.
Knowles, M. S. (1970). The modern practice ofadult education:
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Vygotsky, L.S. (1978). Mind in society: The development of
higher psychologicalprocesses. Cambridge, MA: Harvard
University Press.
Copyright of Radiologic Science & Education is the property of Association of Educators in Radiological
Sciences (A.E.I.R.S.) and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
APA
(American Psychological Assoc.)
References
Kowalczyk, N. (2012). Facilitating the Integration of Problem-Based Learning in Radiologic Science Education: The Role of the Educator. Radiologic
Science & Education, 17(1), 3-9.
a r t i c l e
i n f o
Article history:
Accepted 18 February 2013
Keywords:
Problem-based learning
Critical thinking
Problem-solving
Self-directed learning
s u m m a r y
Background: Problem-based learning (PBL) is a method widely used in nursing education to develop students'
critical thinking skills to solve practice problems independently. Although PBL has been used in nursing
education in Korea for nearly a decade, few studies have examined its effects on Korean nursing students'
learning outcomes, and few Korean studies have examined relationships among these outcomes.
Objectives: The objectives of this study are to examine outcome abilities including critical thinking,
problem-solving, and self-directed learning of nursing students receiving PBL vs. traditional lecture, and to
examine correlations among these outcome abilities.
Design: A quasi-experimental non-equivalent group pretestposttest design was used.
Participants/Setting: First-year nursing students (N = 90) were recruited from two different junior colleges
in two cities (GY and GJ) in South Korea.
Methods: In two selected educational programs, one used traditional lecture methods, while the other used
PBL methods. Standardized self-administered questionnaires of critical thinking, problem-solving, and
self-directed learning abilities were administered before and at 16 weeks (after instruction).
Results: Learning outcomes were signicantly positively correlated, however outcomes were not statistically
different between groups. Students in the PBL group improved across all abilities measured, while student scores
in the traditional lecture group decreased in problem-solving and self-directed learning. Critical thinking was
positively associated with problem-solving and self-directed learning (r = .71, and r = .50, respectively,
p b .001); problem-solving was positively associated with self-directed learning (r = .75, p b .001).
Conclusion: Learning outcomes of PBL were not signicantly different from traditional lecture in this small
underpowered study, despite positive trends. Larger studies are recommended to study effects of PBL on critical
student abilities.
2013 Elsevier Ltd. All rights reserved.
Introduction
Problem-based learning (PBL) helps students develop critical
thinking to solve problems in their clinical settings, and bridges the
gap between theory and practice (Rogal and Snider, 2008). PBL is a
student-centered method of instruction; it is an educational strategy
in which students take responsibility for their own learning and it
appears to enhance self-directed learning skills (Dolmans et al.,
2005; Lekalakla-Mokgele, 2010). The self-directed learning aspect of
PBL encourages the development of nursing students' ability to
think critically, and critical thinking enhances the nurses' abilities to
Corresponding author at: Kyungpook National University, College of Nursing, 101
Dongin-dong, Jung-gu, Daegu 700-422, South Korea. Tel.: +82 53 420 4978; fax: +82
53 421 2758.
E-mail addresses: eychoi@cnc.ac.kr (E. Choi), lindq002@umn.edu (R. Lindquist),
asansong@knu.ac.kr (Y. Song).
1
Tel.: +82 62 231 7368; fax: +82 62 232 9072.
2
Tel.: +1 612 624 5646; fax: +1 612 625 7180.
0260-6917/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.02.012
53
group's responses were more often at the novice level. Cooke and
Molye (2002) reported that students felt more pressure to learn and
to actively solve problems when instructed with PBL strategies. These
two studies support that there is an increase in the problem-solving
ability when PBL is used.
Self-directed learning is an outcome in which individuals take the
responsibility for one's own learning; self-directed learning has been
shown to be facilitated by PBL (Yuan et al., 2008b; Williams, 2004).
Tseng et al. (2011) reported that nursing students who received instruction that employed PBL strategies demonstrated signicantly
more self-directed learning than nursing students in the traditional program. Dornan et al. (2005) found in their qualitative study that PBL
instruction fostered self-direction and lifelong learning skills.
Self-directed learning outcomes of PBL have been shown to be affected
or related to the type of schooling students had prior to entering nursing school. In one study of 135 rst year nursing students enrolled in instruction with PBL, students were separated and studied by level of
education including high school diploma, college, and baccalaureate degree. Students with high school diplomas scored signicantly lower
than those with college or baccalaureate degrees (Williams, 2004).
In this study, many students reported that they experienced feelings
of uncertainty about PBL. In other words, as students transitioned
from traditional high school education or traditional university
program to PBL instruction, they felt uncertainty about their learning.
In summary, in the literature, research results regarding the effects
of PBL on critical thinking, problem-solving, and self-directed learning
are mixed. Also, when the effects of PBL were examined, most investigators studied its effects on critical thinking, problem-solving, and selfdirected learning. However, studies were not found that examined
the relationships among critical thinking, problem-solving, and selfdirected learning. This study explored the effects of PBL on critical
thinking, problem-solving and self-directed learning among Korean
nursing students and examined the association among the critical
thinking, problem-solving, and self-directed learning outcomes.
Methods
Design
A nonequivalent control group pretestposttest design was used
in this quasi-experimental study. The research compared the effects
of instruction using PBL strategies versus traditional education on
critical thinking, problem-solving and self-directed learning ability
of nursing students in Korea.
Sample
Participants in two groups comprised rst year nursing students
from two junior college nursing schools at the different cities in Korea
to prevent contamination. None of the students in either group had
been exposed to PBL previously. A power analysis determined that the
required sample size was 44 per group (Cohen, 1988): Signicance
level ( = .05), large effect size (Cohen's d = .70), and power (90%).
There were no dropouts. Students who had incomplete data were
excluded (2 in the PBL group and 4 in the traditional group). The
analyses were done with 46 nursing students in the PBL group and 44
participants in the traditional group.
Instruments
The Critical Thinking Ability Scale for College Students was developed by Park (1999) to assess dimensions of critical thinking of college
students. The scale has 20 items in ve sub-scales: Intellectual curiosity,
healthy skepticism, intellectual integrity, prudence, and objectivity.
Cronbach's alpha was found to be .74 (Park, 1999) and in our study a
Cronbach's alpha was .71. This scale is scored on a 5-point Likert-type
54
Data Analysis
SPSS was used to analyze the data. Chi-square (Fisher exact
probability) and t-test were employed to compare the baseline measurements of demographic characteristics and dependent variables
between the two groups. Analysis of covariance (ANCOVA) was
used to compare critical thinking, problem-solving and self-directed
learning scores between the PBL and traditional instruction groups,
controlling for baseline differences in the abilities, because the baseline differences in the abilities between groups were statistically
signicant.
Results
Table 1 presents comparisons of the demographics of the students
in the PBL group versus the traditional group. The mean age was
18.7 yr. (SD 2.01) in the PBL group and 18.6 yr. (SD 1.71) in the traditional group. Nearly all participants were female (91.3%). In terms of
prior education, more students had attended an academic high school
than had attended a vocational high school. To compare the outcomes
between the two groups, ANCOVA, using pre-test scores as the covariates was used (Table 2). Critical thinking scores increased 2.20 points
for students after PBL instruction and increased 0.82 points for
students in the traditional group, however this difference was not statistically signicant (F = 3.364, df = 1, p = .070). Problem-solving
scores in the PBL group increased to 4.13, however scores in the traditional group decreased to 1.30. There were no statistically signicant differences between two groups (F = .604, df = 1, p = .439).
Regarding self-directed learning ability, the post scores of who had
received PBL instruction increased to 2.65, and the traditional method
decreased to 1.66. However, the differences between groups were
non-signicant (F = 1.215, df = 1, p = .273).
The correlation coefcients (r) quantifying the relationships between
learning outcome scores were examined. The results revealed a positive
signicant correlation between critical thinking and problem-solving
(r = .713, p b .001), between critical thinking and self-directed learning
(r = .503, p b .001), and between problem-solving and self-directed
learning (r = .747, p b .001).
Discussion
Using the technique of PBL, students in previous studies have
demonstrated increased involvement in their learning and this led
to more improvements in critical thinking, higher levels of problem
solving, more motivation to nd new information, and increased
conict resolution skills (Seren and Ustun, 2008; Cooke and Molye,
2002). The present study tested the effects of PBL on critical thinking,
problem-solving, and self-directed learning skills with rst year
nursing students in Korea.
In this study, nding no signicant differences in groups in the
measure of critical thinking may have been due to a number of factors.
Table 1
Demographics of students in the PBL (N = 46) and control (N = 44) groups.
Characteristic
Gender
Female
Male
Age
Prior high school
Academic
Vocational
a
PBL
n (%) or M SD
Control
n (%) or M SD
38 (82.6)
8 (17.3)
18.67 1.71
44 (100)
0 (0)
18.57 1.31
2 (69.5)
14 (30.4)
22 (50.0)
22 (50.0)
2 (t)
.006a
.327
.744
.085a
55
Table 2
Outcomes of ANCOVA for critical thinking, problem-solving, and self-directed learning skills between the PBL group (N = 46) and control group (N = 44).
Variables
Critical thinking
Problem solving
Self-directed learning
Pretest
Posttest
PBL
Control
PBL
Control
M (SD)
M (SD)
Mean (SD)
Mean (SD)
51.21 (5.61)
112.15 (12.63)
107.78 (12.49)
56.72 (6.16)
126.95 (14.03)
114.72 (12.10)
53.41 (5.46)
116.28 (15.30)
110.43 (12.05)
57.54 (5.31)
125.65 (17.03)
113.06 (12.64)
Fa
3.364
.604
1.215
.070
.439
.273
First, it may be due to the limited duration of the PBL program. There is
little known regarding the length of time of PBL should be offered in
order to have an effect, and there are studies showing no signicant effects of PBL on critical thinking outside of Korea. However, most studies
of the effects of PBL on critical thinking in Korea have shown no significant effects (Choi, 2004; Yang, 2006). It is likely that the duration of the
study of the instruction using PBL was too short, or the measurement of
its effects on student abilities was measured in too short of a time frame.
In our study, the duration of the PBL instruction was one semester
(16 weeks). In contrast, research that has shown signicant increases
in critical thinking has studied PBL programs having PBL instruction
lasting for over one year with rst year nursing students (Yuan et al.,
2008b; Tiwari et al., 2006). Second, most rst year nursing students
are not accustomed to studying in group settings because most of
their previous education in Korean high school has been done via lecture. Thus, it may be difcult to adapt to PBL teaching and learning
styles.
Critical thinking is an ingrained trait and may be difcult to change
(Ravert, 2008), and may take signicantly more time to change critical
thinking through the use of PBL instruction than what we carried out in
our study. To address this, we suggest that longitudinal studies be
designed over periods of at least one year and especially when PBL is
applied with rst year nursing students. Further, PBL should be more
comprehensively and continuously employed in all nursing classes in
a curriculum in a coordinated fashion instead of in individual classes.
Enhanced problem-solving ability affects the quality of nursing care
and plays a vital role in the outcomes of the nursing care (Uys et al.,
2004). In the present study, though self-directed learning was not signicantly different, the post-test scores increased by 4.13 in the PBL
group. However, in the control group, the scores for self-directed learning decreased. A possible explanation for this result was the use of a
case segmentation scheme. Lohman and Finkelstein (2002) found that
students' ability to solve the problems was changed in accordance
with the case segmentation scheme of the PBL. Long segmentation
schemes comprise brief content (e.g., 4 parts), and short segmentation
schemes comprise content details divided into many parts (e.g., 10
parts). Students given a short segmentation scheme of 10 parts
improved their solving-problem ability more, relative to students
provided a long segmentation scheme of four parts (Lohman and
Finkelstein, 2002). A short case segmentation scheme helps students
efciently solve problems. In the present study, PBL cases contained
long segmentation schemes. It is recommended that future PBL cases
would be formatted in shorter segments.
Self-directed learning is one of the ingredients comprising the theoretical basis of PBL, consistent with modern theories on learning that
emphasize that learning should be self-directed (Dolmans et al.,
2005). In this study, a difference in self-directed learning between
the two groups was not found. This outcome could possibly be attributed to the fact that it was a hard time for rst year nursing students
to move from lecture (as in high school) to student-led tutorials in
PBL (in college). Because rst year students were accustomed to
lecture and depended on faculty direction, it may be difcult to
56
Acknowledgments
This study was supported by research funds from Chosun Nursing
College, 2010 and we would like to thank all student participants.
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Article 4
Howard S. Barrows
IJPBL is Published in Open Access Format through the Generous Support of the Teaching Academy
at Purdue University, the School of Education at Indiana University, and the Educational
Technology program at the University of South Carolina.
Recommended Citation
Hmelo-Silver, C. E. , & Barrows, H. S. (2006). Goals and Strategies of a Problem-based Learning Facilitator. Interdisciplinary Journal of
Problem-Based Learning, 1(1).
Available at: http://dx.doi.org/10.7771/1541-5015.1004
This document has been made available through Purdue e-Pubs, a service of the Purdue University Libraries. Please contact epubs@purdue.edu for
additional information.
Cindy E. Hmelo-Silver
Howard S. Barrows
Abstract
This paper describes an analysis of facilitation of a student-centered problem-based learning group. The focus of this analysis was to understand the goals and strategies of an expert
facilitator in support of collaborative learning. This was accomplished through interaction
analysis using video data and stimulated recall to examine two PBL group meetings. In this
paper, we examine how specific strategies were used to support the PBL goals of helping students construct causal explanations, reason effectively, and become self-directed
learners while maintaining a student-centered learning process. Being able to articulate
these strategies is an important step in helping others learn the art of PBL facilitation.
Keywords: facilitation, teaching strategies, pbl goals, interaction analysis
Introduction
Teaching is a complex cognitive activity, whether accomplished in a teacher-centered or
student-centered classroom (Leinhardt, 1993). How one teaches and the strategies that
are applied are intimately related to teachers beliefs about the nature of the teachinglearning process (Schoenfeld, 1998). Teachers must juggle many goals as they coordinate
pedagogical actions with various kinds of knowledge, such as subject matter knowledge,
pedagogical content knowledge, and knowledge of individual students. For experts,
teaching is a problem-solving context in which they must come to understand the meaning of students ideas rather than just correct them (Lampert, 2001). This is especially true
when teachers and students co-construct the instructional agenda in a student-centered
environment such as problem-based learning (PBL). PBL is an instructional method in
which students learn through solving problems and reflecting on their experiences (Barrows & Tamblyn, 1980). In PBL, the teachers role is to facilitate collaborative knowledge
The Interdisciplinary Journal of Problem-based Learning volume 1, no. 1 (Spring 2006)
2139
http://dx.doi.org/10.7771/1541-5015.1004
22
23
weighted average. Balls classroom was more student-centered; her goal was to develop
a particular type of intellectual community in which the pursuit of mathematical ideas
was highly valued. She juggled competing goals as the students and teachers co-constructed the agenda. She started her elementary mathematics class by asking students
for comments on the previous days lessons. They then discussed issues related to their
understanding.
The classroom of the novice teacher is typical of a traditional, teacher-centered
classroom, in which the teacher asks most of the questions (Graesser & Person, 1994). The
typical mode of discourse is the IRE pattern (Cazden, 1986) in which the teacher initiates a
known-answer question, generally aimed at getting a student to display his or her knowledge, the student responds, and the teacher evaluates that response, as was observed in
the novice teacher described by Schoenfeld (1998). Thus the goal focuses primarily on
having students learn facts. Even in one-on-one tutoring, the tutor asks 80% of the questions (Person & Graesser, 1999). The student is active but tutors often work with curriculum
scripts that drive the agenda.
In contrast, like the experts in Schoenfelds study, inquiry teachers have goals that
include higher levels of learning as well as remembering facts. A study of inquiry teachers
identified several different types of goals and strategies that were used (Collins & Stevens,
1982). Inquiry teachers goals encompassed having students learn theories and how they
are derived. This included having students learn what questions to ask, how to make predictions from theories, and how theories and rules can be tested. These analyses showed
that inquiry teachers use different kinds of strategies to achieve these goals. For example,
they may select appropriate cases and counterexamples to encourage students to generate
hypotheses, reveal misconceptions, and test ideas. Inquiry teachers tend to use questioning techniques to promote deep thinking; as a result students are more active than in IRE
discourse, but the teacher still leads the discussion, working towards global learning goals
but choosing strategies on the fly. Minstrell and Ball (Schoenfeld, 1998) went beyond the
description of inquiry teaching by helping students become aware of their own thinking,
consistent with a view of learning as sense-making. PBL facilitation has much in common
with student-centered inquiry teaching.
Student-centered learning has its foundation in social constructivist theories. This
perspective contends that learning occurs as knowledge is negotiated among learners,
often facilitated by a more knowledgeable group member and that students need to be
active, intentional learners (Bereiter & Scardamalia, 1989; Palincsar, 1998). Instructional
approaches derived from these perspectives use student-centered discourse as an instructional strategy. The role of the teacher becomes to guide the learning process rather
than provide information.
In student-centered discourse, students drive the discussion and the teacher serves
to scaffold the learning process (Collins, Brown, & Newman, 1989). In this model, the
24
agenda may be co-constructed by the students and teacher. Understanding how studentcentered learning can be facilitated is important in being able to implement constructivist
approaches such as PBL. One way to examine this is to analyze the goals and strategies of
a master facilitator as well as to examine how these affect and are affected by the group
discourse.1 One might argue that to some extent the role of the facilitator is to create affordances for productive discourse (Greeno, 1998). PBL is a premier example of a studentcentered learning environment as students co-construct knowledge through productive
discourse practices.
Problem-based Learning
Problem-based learning is an active learning method based on the use of ill-structured
problems as a stimulus for learning (Barrows, 2000). Ill-structured problems are complex
problems that cannot be solved by a simple algorithm. Such problems do not necessarily
have a single correct answer but require learners to consider alternatives and to provide a
reasoned argument to support the solution that they generate. In PBL, students have the
opportunity to develop skills in reasoning and self-directed learning. Empirical studies of
PBL have demonstrated that students who have learned from PBL curricula are better able
to apply their knowledge to novel problems as well as utilize more effective self-directed
learning strategies than students who have learned from traditional curricula (Hmelo,
1998; Hmelo & Lin, 2000; Schmidt et al., 1996).
The PBL method requires students to become responsible for their own learning.
The PBL teacher is a facilitator of student learning, and his/her interventions diminish
as students progressively take on responsibility for their own learning processes. This
method is characteristically carried out in small, facilitated groups and takes advantage
of the social aspect of learning through discussion, problem solving, and study with
peers (Hmelo-Silver, 2004). The facilitator guides students in the learning process, pushing them to think deeply, and models the kinds of questions that students need to be
asking themselves, thus forming a cognitive apprenticeship (Collins et al., 1989). As a
cognitive apprenticeship, PBL situates learning in complex problems (Hmelo-Silver, 2004).
Facilitators make key aspects of expertise visible through questions that scaffold student
learning through modeling, coaching, and eventually fading back some of their support.
In PBL the facilitator is an expert learner, able to model good strategies for learning and
thinking, rather than providing expertise in specific content. This role is critical, as the
facilitator must continually monitor the discussion, selecting and implementing appropriate strategies as needed. As students become more experienced with PBL, facilitators
can fade their scaffolding until finally the learners adopt much of their questioning role.
Student learning occurs as students collaboratively engage in constructive processing.
The dilemma for the facilitator is to provide affordances for this constructive processing
25
in the same way as Chi, Siler, Jeong, Yamauchi, and Hausman (2001) have argued that
good tutors do.
Much research on facilitation has focused on the role of the tutors subject matter expertise. Schmidt and Mousts (2000) review of studies of facilitation found three
important, interrelated factors that contributed to effective facilitation. Effective facilitators had a suitable knowledge base regarding the topic under study, a willingness to
become involved with students in an authentic way, and the skill to express oneself in a
language understood by students (p. 47). However, this research was based on student
and tutor ratings rather than on observations of facilitator performance. In a special issue
of Discourse Processes (Koschmann, 1999), several researchers analyzed the same brief
videotape clip of a PBL group meeting from different perspectives. Using conversation
analysis, Koschmann, Glenn, and Conlee (1999) identified several moves that the facilitator
made to scaffold the groups elucidation of their theory for the cause of a patients medical
problem. One move they identified was having the facilitator revoice what students said
in a way that helped them move forward in the discourse (OConnor & Michaels, 1992).
A cognitive analysis found that the facilitators moves helped scaffold an organized and
coherent approach to reasoning and diagnostic inquiry (Frederiksen, 1999). A sociocultural
analysis showed that the facilitator has an important role in creating a culture in which
the participants work to reach consensus, validate each others ideas, and establish norms
(Palincsar, 1999). The facilitator played a pivotal role that advanced the PBL discourse and
scaffolded learning.
These analyses make important contributions to understanding facilitation but
they are based on a very brief slice of a single PBL meeting and do not allow analysis of
the broader goals and strategies of the PBL facilitator. In this study, we examine two PBL
group meetings that typically occur with a problem. The first meeting occurred before
self-directed study for students to apply what they already knew and to figure out what
they still needed to learn, and the second followed their self-directed study, in which the
students applied their learning to their problem. We examine how the facilitator scaffolded
learning through the use of general strategies that were chosen based on the facilitators
beliefs and goals for facilitation.
Method
Data Sources
The participants in this study were five third-year medical students who were experienced in PBL and a master facilitator. The students had two years of experience in a PBL
medical curriculum. Howard Barrows (the second author) was the facilitator. Barrows is
a physician with a specialty in neurology and an experienced PBL facilitator and medi-
26
cal educator. Students worked over 5 hours in 2 sessions, approximately 2.5 hours each,
on the problem of a patient with pernicious anemia. The students knew each other
but had not previously worked together as a group. The sessions were videotaped and
transcribed.
Data Analysis
The first author reviewed the videotapes and transcripts for the general strategies that
the facilitator used.2 Exemplars of the strategies were identified and discussed with the
facilitator. Using stimulated recall, the facilitator was interviewed regarding his goals and
strategies while viewing the videotape. A number of episodes on the tape were selected
as being representative of a particular kind of question being asked or strategy being
deployed. The interview was unstructured. Often, the facilitator would just begin commenting on the episode. If he did not begin commenting or if additional information was
desired, the facilitator was asked why he used a particular discourse move, what his goals
were, what he had hoped to accomplish, and/or whether what he had expected occurred.
This interview was audio taped and transcribed. The transcript was examined to identify
the themes that emerged from this discussion as well as for discussion of other strategies
reported in the literature.
In addition, interaction analysis (IA) was conducted to investigate the nature of facilitation strategies (Jordan & Henderson, 1995). This methodology assumes that knowledge is
situated in social interactionsthus the facilitation goals and strategies were situated in the
context of the facilitators actions. IA involves collaborative viewing of videotapes to avoid
the preconceived notions of a single researcher. IA examines the details of social interaction
as they occur in practice. The IA session was conducted with the first author and an experienced cognitive scientist, a professor at a large Midwestern university, to further elucidate
the data interpretation as they watched the videotape. Observations and hypotheses were
generated while watching the tape. The tape was stopped and/or replayed whenever one
of the participants noted something worthy of discussion. For example, on Tape 3 at 39:06
both analysts noted that the facilitator, on occasion, repeated what students were saying
at important junctures. This led to identification of revoicing (OConnor & Michaels, 1992),
a strategy observed in other student-centered classrooms. These ideas were discussed and
the first author summarized these ideas from extensive notes taken during the session. This
report was later shared with the second analyst. These ideas were member checked with
the facilitator to further ensure the reliability of interpretation.
27
what interventions can be undertaken, (2) employ an effective reasoning process, (3) be
aware of knowledge limitations, (4) meet knowledge needs through self-directed learning
and social knowledge construction, and 5) evaluate their learning and performance. The
facilitators performance goals were to (1) keep all students active in the learning process,
(2) keep the learning process on track, (3) make the students thoughts and their depth of
understanding apparent, and (4) encourage students to become self-reliant for direction
and information. The educational goals refer to what the students were expected to learn,
whereas the performance goals refer to behaviors that the facilitator wanted to encourage (in support of the educational goals). The remainder of the results are organized in
terms of strategies. Strategies can be used to achieve multiple goals that reflect a belief
in learning as a collaborative sense-making activity and a belief that students bear much
of the responsibility for their own learning.
The facilitators overall strategy to help students address these goals was to use
open-ended questions and the PBL process. The open-ended questions addressed most
of the educational goals while keeping all students involved and making their thinking visible. The PBL process refers to the small group process that features ill-structured problems,
hypothesis generation, revision, and evaluation, inquiry, decision-making, identification of
learning issues, self-directed study, and reflection. The structured whiteboard helps guide this
process. A list of some of the strategies that Barrows used as well as the goals they addressed
are summarized in table 1, and we discuss several of these in the sections that follow.
28
Table 1
Facilitation strategies
Strategy
Goals
E1, P3
E3, P3, P4
Revoicing
E1, P2
P1
Clarify ideas
Legitimate ideas of low-status students
Mark ideas as important and subtly influence direction of discussion
P2
Summarizing
E4, P1
P1
E1, E5, P3
P2
E5, P3
Generate/evaluate
hypotheses
E2, E4, P2
E1, E2, P3, P4
E5, P2, P4
Ensure all ideas get recorded and important ideas are not lost
E5, P4
P2
P2
Evaluate ideas
Maintain focus
Keep process moving
E4, P4
Encourage construction of
visual representation
E1, E5, P3
29
Note how the facilitator neither evaluated the students response nor offered additional
information at any time. This served to place the students knowledge in public view and
help them see the limits of their understanding (E3, P34). It also pushed students towards
thinking about how the disease arises and can cause a constellation of signs and symptoms
(E1). Barrows noted that he tries to push for definitions and explanations in
Those areas that I feel are really pertinent. . . . With every problem we have a
whole suggested list of learning issues . . . so every facilitator knows exactly
where the faculty feel they want the students to go. So your questions for
clarification and for definition are . . . what is going to have the biggest payoff
in terms of their learning in that particular area? So I let a lot of definitions and
a lot of statements go. The ones I really pick on are the ones I really think are
pertinent to what they are going to get out of this case.
This suggests that it is critical for the facilitator to always keep the learning goals in mind.
These learning goals go beyond the specific problem that the patient actually has and
include a broader conceptual space of associated conditions as well as the relevant basic
biomedical sciences.
30
Revoicing
Another strategy observed was that of revoicing (OConnor & Michaels, 1992), in which
the facilitator restated what the students said.
Megan: And another important um, hypothesis thats come [up] is a vitamin B12
deficiency, which weve crossed out. Hah, because we didnt think she had any
malnutrition. However, we found out that, um, in the elderly there is a much,
much higher prevalence of Vitamin B12 deficiency . . .
Donna: . . . I was just talking with my husband and . . . I was thinking
that vitamin B12 wasnt so much if you treated it. But, I was reading that
. . . neural deficits are irreversible. . . . So it is, you know. It does put in my mind
its . . . more of a serious . . .
Facilitator: Now you people are saying B12 all the time and yet when you say
we eliminated it, youre talking about pernicious anemia, right?
The facilitator addressed several goals here. First, he took the idea put forth by the
students and clarified it for the group as he restated it. This helped the students in explaining the disease process (E1). At the same time, this helped keep the learning process
on track as he provided the proper name for what the students were discussing (P2).
Second, he has legitimated Donnas idea by placing it up for the groups consideration.
Donna was a quiet but extremely thoughtful student and the facilitator recognized her
with this move and kept her active in the discussion (P2). Third, he kept an important idea
alive and subtly influenced the direction of the discussion (P2). The group had eliminated
pernicious anemia from among many hypotheses on the whiteboard in the first session.
Pernicious anemia was the cause of the patients problem and was in danger of being lost
from the discussion. By building on ideas that students had placed up for consideration,
he encouraged them to rely on their own thinking (P4).
Summarizing
When the process stalled or when the facilitator needed to be sure that a quiet student
was involved, he would ask a student to summarize. This served several goals. First, it
checked the understanding of less vocal students and involved them in the discourse (E1,
P1, P3). Second, it changed the flow of the discussion from being temporarily stalled to
being more focused so it helped keep the learning process on track (P2). Third, it provided
practice in case presentation, a skill that students will need as physicians (E2). Fourth, it
allowed students to check their shared understanding and show what they thought was
important (E4, E5, P1, P3).
Just before the next excerpt, the students were going through a number of signs
and symptoms. Up to this point, Jim had been very quiet. The facilitator asked, Jim, will
31
you summarize now what we know about this case? . . . And do it like youre presenting a
patient on rounds. Jim then gave a detailed summary of the case, an indication that he
was engaged in the discourse, if quietly so. This provided an opportunity for the facilitator
to check for shared understanding as he asked the group, Do you agree with his summary? The group responded:
Megan: . . . I do . . . But I might have included, um, the actual findings of the
Romberg.
Jim: Oh no. Again. Thats the most important test.
Megan: . . . The gait because I think that . . . broad based gait was very significant . . .
Jim: I dont know why I didnt say that.
Cheryl: I think the pain on . . . on the repeated pinprick is probably. . . . We dont
know what it means but its probably significant . . .
Facilitator: You said she lost her balance. You were saying thats not it. Its this
business here that you wanted him to say. You said on walking, she lost her
balance.
Jim: Yeah, at night she described that she lost her balance . . .
Cheryl: Well she says it more. That, she described it as instability, which I mean,
youre just making . . . she says instability as opposed to your interpretation of
what she means. . . . Because I didnt interpret it as a loss of balance.
In this discussion, the group focused on how they interpreted an important finding and
it was clear that different group members had different understandings. This provided
an opportunity for students to negotiate a shared meaning. In addition, because summarizing patients is a professional skill, the facilitator provided opportunities for Jim to
reflect on his performance and for other students to provide feedback (E5, P5). In the
discussion that followed, Jim noted specific places where he might have improved and
Jonathan provided additional constructive feedback as the students relied on themselves
for evaluation. The summary then provided a springboard for the students to move
through evaluating their hypotheses, as Barrows noted:
So I used this mechanism of summarizing the case then going to the hypotheses as an excuse, because now saying based on all this new information
youve got, how do you like these hypotheses now? Well as soon as they
suggested changes, well then I say why are you gonna make that change and
theyll bring out what theyve learned and the rest will start discussing what
they know about it and so indeed they are now reconstructing and structuring
that information they have learned back to the patient problem . . .
32
Therefore, the summary here served many purposes and moved the students from a point
where they were stalled to one where they were able to productively move forward in
their problem solving. The summary moved them to begin examining the fit between
their hypotheses and accumulated evidence (E1, E2, P3, P4).
Generating Hypotheses
Encouraging the students to generate hypotheses can help students focus their inquiry
and become aware of the limitations of their knowledge. This is important in promoting
effective reasoning and self-directed learning (E2, E4) as well as keeping the learning process moving along (P2). Without this, students may engage in unfocused data collection.
For example, Barrows asked Cheryl to present her hypothesis, and a learning issue was
created out of the hypothesis of diabetic neuropathy that she generated:
Facilitator: You wanna . . . tell me what diabetic neuropathy is?
Cheryl: . . . I cant really explain it well, but basically um, the high glucose levels,
um can cause nerve damage and its not uncommon for them, especially in
the extremities to have loss of sensation. So, feet especially is one area where
they lose sensation.
Jim: . . . I heard thats . . . through glucose getting into the neuron and then
getting converted to methanol.
Cheryl: I believe so but I dont know.
Jim: You dont know?
Megan: Nonenzymatic glycosylation.
Cheryl: Is it? I couldnt remember which
Jonathan: Its just . . . Nonenzymatic gly, glycosylation . . . its glycation.
Megan: . . . All diabetics . . . eventually experience problems of diabetes. For
example, the diabetic neuropathies, microvascular problems, um, that whole
host of other things . . . its definitely a possibility here . . .
Facilitator: And so youre all comfortable in the mechanism of diabetic neuropathy? That was okay? You got it down cold.
The facilitator ended the muddled discussion by asking the students if they were really
comfortable in their understanding and the students noted their need to learn more. This
prompted the students to monitor their understanding, realize that their understanding
was insufficient, and recognize the need to learn more about the mechanism of diabetic
neuropathy (E4, E5, P4). Thus, diabetic neuropathy ended up on the list of learning issues
to be addressed by self-directed learning.
33
34
Additional Strategies
Other ways that the facilitator encouraged students to map between symptoms and causal
mechanisms included asking students why they ordered particular tests, and late in the
second session, asking them to draw a flowchart that represented their understanding.
He noted that
. . . is a very valuable tool because it allows them to integrate everything theyve
learned into a very careful structure from the very basic mechanisms all the way
to the symptoms. But [it] also will then reveal where there are gaps or holes
in their thinking where they dont have an answer that makes sense or where
they may need to do more learning . . . bringing everything theyve learned
together around the problem and to really construct an understanding.
Drawing the flowchart elicited the biochemical mechanisms that accounted for the signs
and symptoms during an extended discussion. Drawing an additional anatomic diagram
brought their discussion from the biochemical level to a more macroscopic level of what
was happening in the spinal nerve tracts. This visual representation thus helped the
students create an integrated and coherent understanding. Constructing these representations addressed a number of educational goals for the students and performance
goals for the facilitator. In particular, it addressed the goal of explaining how the disease
process accounted for the patients signs and symptoms (E1) and made their depth of
understanding visible (P3). The drawing made salient where there were gaps in their
understanding that needed to be explained and often led to a great deal of monitoring
of their performance (E5).
The facilitator is always looking for moments in which he or she can use any of a
variety of strategies to (1) keep the process going with all students involved, moving in
productive directions, (2) help make students understanding and thinking transparent,
and (3) guide them towards the curriculums educational goals. These strategies are not
scripted in advance but are rooted in the students discussions while keeping the overall
goals in mind. The interview data makes it clear that goals are being juggled based on
what is happening in the tutorial session.
Discussion
Facilitation, like other forms of teaching, involves a dynamic interaction of the teachers
beliefs, goals, and knowledge. Barrows had a strong belief in the importance of students
taking responsibility for their learning and the importance of their constructing useable
knowledge, as his comments make clear. He shared with many inquiry-oriented teachers a
view of learning as a sense-making activity. As a neurologist, he had a deep understanding
35
of the subject matter involved in the problem and, as an experienced medical educator
and PBL facilitator, knowledge about how the problem might unfold. His general goal was
to have students construct causal explanations and he had a repertoire of strategies and
techniques to support him in that goal.
Like other inquiry teachers (Collins & Stevens, 1982), Barrows orchestrated group
discussions through questioning, but unlike the inquiry teachers, his goal was for students to internalize those metacognitive functions (P4). Elsewhere, we have shown that
these students asked more than half of the questions in the tutorial sessions, including
metacognitive and causal questions (Hmelo-Silver & Barrows, 2005). The facilitators questions built on student thinking and placed responsibility for sense-making with them,
much like Minstells reflective toss (Schoenfeld, 1998). Barrows selected his strategies
on the fly, as he used the students thinking as a basis for gently guiding them through
the problem. In one instance when a student noted a symptom as significant, Barrows
took that as an opportunity to help the group make their thinking visible and address
several goals:
. . . I want to find out . . . what is the depth of their understanding and I want
them to recognize what they understand. But sometimes Im doing, I think
in this instance to bring an issue up for the group to really work with and
understand how it fits everything together. So I think I did this more as an
attempt to . . . nail down an important point for them to recognize that they
had developed themselves . . . I didnt know [if they knew that] so thats why
I asked the question . . .
Clearly, these instances provided opportunities to build on and guide students thinking in
the moment. They could not be scripted in advance, as goals and strategies were juggled
in response to the group discussion.
The triggering conditions for the use of strategies were fluid, as Barrows consciously
avoided letting students know when they were on the right track; he left that responsibility
with them. For example, he may have pushed students to explain their thinking on most
of their initial hypotheses. While he may have avoided this for something peripheral, he
would always push on the hypotheses that were most likely to account for the patients
problems. He did this frequently enough that it did not clue the students in to the right
answer.
The PBL setting creates a cognitive apprenticeship that acculturates students into
the thinking practices of medicine. Through his actions, Barrows modeled appropriate
ways of thinking about patient illnesses in terms of their underlying causal mechanisms.
By making the students thinking visible, their ideas became objects for discussion, reflection, and revision. Barrows pushed students thinking to deep levels as he continually
asked them to explain themselves. The students appropriated part of the facilitators role
36
as they questioned each other (as in the hypertension example presented earlier). They
developed the useful habit of questioning their own thinking. The summarizing strategy
provided an opportunity for the group to monitor their progress (Brown & Palincsar,
1989).
Conclusions
As we noted at the beginning of this article, teaching is a complex task, and all the more
so in a student-centered learning environment such as PBL. Driven by his beliefs about the
importance of student reasoning and self-directed learning, and his confidence in his students capability as well as his content expertise, Barrows and the students co-constructed
an agenda as he built on the groups thinking and the group built on his facilitation. This
study demonstrated that an expert facilitator has a repertoire of strategies that can be
37
flexibly adapted to meet the goals of PBL. Barrows used modeling, scaffolding and fading
progressively as the students grew more responsible for their own learning and began
questioning each other. He modeled the questions students should be asking themselves
until they appropriated these questioning strategies themselves. Although there are limits
to what can be generalized from a single case, our analyses are consistent with other research on using student-centered discourse as an instructional strategy (e.g., Schoenfeld,
1998). We identified a number of specific strategies and some of the goals that they might
serve. Being able to articulate these strategies is an important step in helping new PBL
facilitators learn the art of facilitation.
Acknowledgments
This research was supported by a National Academy of Education/ Spencer Foundation
Postdoctoral Fellowship to the first author. We would also like to thank Allan Collins for his
valuable insights during an interaction analysis session. Parts of this research have been
presented at the 2002 annual meeting of AERA and at CSCL 2002.
Notes
1. We define a master facilitator as one with extensive experience and recognized expertise.
The master facilitator studied here was instrumental in the development of PBL and has
30 years experience facilitating and 25 years conducting facilitation workshops.
2. Elsewhere, we report on the fine-grained analysis of this video data (Hmelo-Silver & Barrows, 2005)
3. Transcripts have been edited for readability and length. All omissions in the transcript are
indicated by an ellipsis ( . . . ).
4. These codes indicate which goals are addressed, based on the key in table 1.
5. This refers to the measurement of blood pressure with the numerator being the systolic
measurement (the pressure in the arteries during the hearts contraction) and the denominator being the diastolic pressure (the pressure during relaxation of the heart).
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a r t i c l e i n f o
a b s t r a c t
Article history:
Accepted 15 October 2014
There are some strategies including problem based learning (PBL) that could enhance the learning
experience. This quasi-experimental design was conducted to compare the effects of PBL with traditional
clinical education that is commonly used for nursing students. The effects were observed by monitoring
differences in their special and general competencies, performance and attitudes towards learning experiences. In 2010, 70, undergraduate nursing students were assigned into two groups as either PBL
(n 34) or Control group (n 36) at Hamadan University of Medical Sciences in Iran. The research tools
used in this study were: the students' competency self-evaluation and the students' attitudes toward
their learning experiences questionnaires, and also a Coding system of performance checklist. The
groups were similar in most demographic characteristics.
The PBL students' general and special competencies improved in the post-test signicantly more than
those of the control students (P < .001). The PBL students' attitude was signicantly better than the
control group (P < .01) as well. There was also an incredible enhancement only in the PBL students'
performance (P < .01). Therefore the Problem-based learning fostered nursing students' competency,
attitude, and performance.
2014 Elsevier Ltd. All rights reserved.
Keywords:
Problem-based learning
Competency
Performance
Attitude
Nursing students
Iran
Introduction
Educated nurses must be capable of responding to the patients'
changing needs in the health care environments. They must also be
able to apply their knowledge in a variety of clinical settings
(Giddens and Brady, 2007; Higuchi and Donald, 2002; Oldenburg
and Hung, 2010; Tanner, 2006). When the nursing students enter
clinical settings, they will meet conditions that need the critical
innovative responses to complicated problems. Although the main
goal of nursing education is to decrease the gap between the
theoretical concepts taught in the classroom and the actual practice
of nursing (Etheridge, 2006; Tiwari et al., 2006), it has been
frequently observed that nursing students with appropriate theoretical bases have insufcient skills in the clinical environments
(Morgan, 2006). Therefore, it is necessary for the nursing students
to have an educational program which includes strategies to solve
Literature review
There are numerous studies about the effectiveness of PBL in
medical and nursing education in the classes (Gurpinar et al.,
2005; Tiwari et al., 2006; Sand-Jecklin, 2007; Dehkordi and Heydarnejad, 2008; Badeau, 2010; Lin et al., 2010; Sangestani and
Khatiban, 2013), but we found very few evidences of using it in the
nursing clinical education. In this regard, Ehrenberg and
ggblom (2007) studied the second year nursing students and
Ha
their preceptors' experiences of the PBL in a clinical education
project. 45 students and 30 preceptors answered a questionnaire
and participated in an interview. The researchers found that the
students and their preceptors had perceived the educational
project positively. In addition to this, students felt more freedom
and responsible for their education. Wang et al. (2004) also integrated a set of Problem Solving strategy with Nursing Process
(PSNP) in the core courses in a post-RN baccalaureate nursing
program at a university in Taiwan. They assessed effectiveness of
PSNP by observing the students' ability in solving the clinical
problems. The overall students' scores showed that their abilities
were increased.
Methods
699
Participants
All the 70 third-year undergraduate nursing students that were
registered for one-credit clinical course of the Hematologic and
Oncologic Nursing Care were invited to participate in the study.
These students belonged to two separate classes and were assigned
randomly to either PBL (34 students) or NPBL group (36 students).
Each of these groups also included four internship subgroups with
8e9 students. The mentioned credit takes three days per week for
10 days (60 h) in a semester to complete. The two groups were
trained in the same ward of the hospital in the morning for two
three-days of a week. The two groups also stayed in different dormitories or own houses, so the possibility of their interactions was
very low.
Intervention
NPBL group
All the students in the NPBL group were trained in the nursing
care as routine, meaning that they were mostly practicing based on
the task assignments. They performed the procedural care without
any nursing care plan. They also had a lecture about the patients'
disease in the ward and wrote an NP for their patients at the end of
training using the textbooks.
PBL group
The PBL clinical course plan used was designed according to
Alfaro-Lefevre (2002), who stated that the 5 steps of problem
solving method are similar to those of the nursing process
(including nursing assessment, nursing diagnosis, planning,
implementation and evaluation). This course plan had three episodes as follows: 1- The rst day was for orienting and familiarizing
the students with the ward, objectives, expectations, training tasks,
and assessment methods. 2- For the other days, all the students had
to study a patient's problem for the following day based on the
compiled curriculum. Every morning, the students discussed about
a patient's problem written on the white board and then attempted
to write an NP to solve it for about 20e30 min together. A tutor
coordinates these sessions and the students' efforts in the ward.
After that, each student was asked to write a nursing care plan to
solve his/her patient problems every day. In the most cases, the
selection of the patients was delegated to the students in order to
maximize their participation in organizing education. 3- On the last
day, the students were evaluated with their cooperation. In order to
control the quality of intervention, the developed PBL clinical
course plan was approved by the Nursing Medical Surgical
Department of Hamadan University of Medical Sciences.
Data collection
The research instruments were three questionnaires and a
checklist. We developed and modied these instruments according
to the related literature. Our study tools and aims were sent to 11
academic members of three major Iranian Universities of Medical
Sciences with the purpose of ascertaining the content and face
validity. Adjustments were made according to their comments. The
internal consistency of the instruments was estimated by the
Cronbach's a. The instruments were as follows:
Research design
This quasi-experimental study was performed with a
nonequivalent control group pretest-post-test design; and a
nonequivalent control group only post-test design for the students'
attitudes and performance (Polit and Beck, 2004). It performed at
Hamadan University of Medical Sciences, Iran in 2010.
700
applying Nursing Process with 15 items. This form was developed according to Alfaro-Lefevre (2002) to determine the general knowledge and skills in doing each phase of the NP. The
reliability had the Cronbach's a of .93 and .87 for general
knowledge and skills respectively. 1-b) the Special expected
knowledge and skills in applying Nursing Process according to
the Hematology and Oncology Nursing Care objectives in our
Nursing and Midwifery School. The latter part consisted of 19
items about expected knowledge and skills of the NP for the
hematologic and oncologic patients. The Cronbach's a of .95 and
.93 were sequentially accounted for special knowledge and
skills. In the both mentioned parts, the students were asked to
read each item and evaluate their knowledge and skills in two
columns one by one on a 5-Likert scale from excellent 4 to
very weak 0. The range of possible mean scores was from
0 to 4 (none < .8; weak > .8e1.6; medium > 1.6e2.4;
good > 2.4e3.2; excellent > 3.2e4). The Cronbach's a of .95 and
.93 accounted for special knowledge and skills respectively. This
questionnaire was used as the pre- and post-test.
3) A self-rating scale named Students' attitudes toward their
learning experiences containing 21 items on 5-Likert scale from
strongly agree 4 to strongly disagree 0. The attitudes scores
were estimated very negative < .8; negative > .8e1.6;
neutral > 1.6e2.4; positive > 2.4e3.2; very positive > 3.2e4. The
Cronbach's a was .80. The open-ended question in this questionnaire was what were your best and worst experiences in
this course?. The students' responses to the mentioned questions were analyzed with a conventional qualitative content
analysis. This scale developed according to Alper (2008) who
studied attitudes toward learning. The Cronbach's a for the
reliability was .80. This questionnaire was completed by the PBL
and NPBL students after the clinical course.
4) Also a Coding system checklist with 14 items was applied to
assess the students' performances in NP. We considered the
written NP with 5 steps as the student's performances. The
range of the possible mean scores was from 0 to 3 (not
considered the aspects < .6; considered a few aspects > .6e1.2;
considered some aspects > 1.2e1.8; considered most
aspects > 1.8e2.4; and considered all aspects > 2.4e3). Each
student in the PBL and NPBL groups were asked to write an NP
for his/her allocated patient on the last day of the clinical
training. A master lecturer (out of the research) blind to the
student groups rated these reports according to the Coding
system checklist. The inter-rater reliability was .96 for the
simultaneously completed 10 checklists.
Data analysis
Descriptive statistics was utilized for frequencies, percent and
means. Demographic characteristics were compared between PBL
and NPBL groups via the Chi-squared and two-sample t-test in the
case of normal distribution of data.
The Students' competencies self-evaluation scores had normal
distribution so they were analyzed by paired t-test in each group,
and t-test between two groups. To analyze the effects of the pretest
scores on the post-test mean scores in both groups, the two-way
ANOVA was used because of normality of data. To compare students' attitude scores in the PBL and NPBL groups a ManneWhitney
U test was used because the data did not have normal distribution.
The ManneWhitney U test also was applied to compare the two
groups' performances mean scores in ve steps of NP due to the
non-normal distributions of data. Finally, we utilized Pearson test
to determine the relationships among the attitudes, competencies,
and performances mean scores in two PBL and NPBL groups.
All statistical analysis was done by SPSS-16 Software for Windows (SPSS Inc., Chicago, Illinois, USA) and Signicance level was
set at .05.
Ethics
The Ethics Committee and Research Council of Hamadan University of Medical Sciences approved the study. Each participant
signed voluntarily informed consent form before the enrollment in
the study. We found no attrition in our study subjects.
Results
Participants' characteristics
The students' demographic characteristics are shown in Table 1.
The mean (SD) age of NPBL and PBL groups were 22.14 (1.18) and
22.21 (1.12) years old, respectively. The students' diploma GPA
scores were 17.36 (1.72) in the PBL and 17.33 (1.40) in the NPBL
group out of the highest possible GPA of 20. No signicant differences (P > .05) were found regarding the above mentioned characters between the two groups. The previous courses GPA mean
score (16.21 .98 in the NPBL students and 15.71 .92 in the PBL
ones) of the NPBL group was better than that of the PBL group
(t 2.20, df 68, P < .05).
Students' competency self-evaluation
Although the results of the paired t-test showed an improvement in the NPBL group's general skills scores (t 2.67, df 35,
P < .05), there were no difference in their general knowledge selfevaluation scores before and after the clinical education. According
to this test, the PBL group students reported huge increases both in
the general skills (t 7.38, df 35, P < .001) and general
knowledge scores (t 6.66, df 35, P < .001) after the clinical
course. The two-way ANOVA demonstrated that despite the PBL
students having been evaluated their general knowledge and skills
lower than the NPBL students at rst, they reported a signicant
improvement in their general competencies (F(2,58) 15.74,
P < .001) after the clinical course (Fig. 1).
The paired t-test showed a signicant improvement in the NPBL
students' specic knowledge (t 3.16, df 35, P < .01) and skills
scores (t 1.53, df 35, P < .05) and in the PBL students' specic
knowledge (t 9.05, df 33, P < .001) and skills scores (t 8.84,
df 33, P < .001) at the end of the clinical education. The two-way
ANOVA also demonstrated that the PBL students had explicated
their specic knowledge and skills scores lower than the NPBL
students at the beginning, however they evaluated themselves
Table 1
Demographic characteristics of the PBL and NPBL students (n 70).
PBL (n 34)
n (%)
NPBL (n 36)
n (%)
Sex
Male
Female
9 (26.47)
25 (73.52)
8 (22.22)
28 (77.78)
Marital status
Married
Single
8 (23.53)
26 (76.47)
6 (16.67)
30 (83.33)
Inhabitant
Own house
Dwell
5 (14.71)
29 (85.29)
21 (58.33)
15 (41.67)
Variables
Chi-squared test
701
Table 2
Mean scores of the PBL and NPBL students' outcomes.
Group
NPBL
PBL
No.
36
34
Attitudes
(means 0e4)
Performance
(means 0e3)
Competency
changes
Mean
SD
Mean
SD
Mean
SD
2.77
3.01
.40
.29
1.35
2.87
.18
.17
.33
.92
.51
.56
Fig. 1. Comparisons of the mean scores of the PBL and NPBL group students' selfevaluation of general competencies pre and post clinical course.
more competent than the NPBL (F(1.3,43) 9.93, P < .001) following
the clinical course (Fig. 2).
Students' attitudes toward their learning experiences
Both the PBL and the NPBL students had the positive attitudes
toward their learning experiences (Table 2). The comparison of the
mean-scores of the PBL students' attitudes towards their learning
experiences was signicantly more positive (t 2.86, df 68,
P < .01) than that of the NPBL group.
The qualitative content analysis of the PBL students' answer to
the open-ended question led to three themes. The best students'
experiences were: the discovery of their own abilities and weaknesses in the patient care, the development of their NP handling
in the clinical area and the progress in the communication skills
with other professionals and patients. There were no unpleasant
experiences in this course according to the all PBL students' responses. On the other hand, what extracted of the NPBL students'
answers was their unpleasant experience about their disability in
caring for the end stage patients and lack of the excellent
experiences.
Based on the Pearson correlation test, there was no signicant
correlation between the PBL students' attitudes with their competencies mean differences (r .03, P .89). Conversely, the
correlation of the NPBL students' attitudes with their competencies
mean differences was signicant (r .51, P .002). To be precise,
despite the knowledge and skill (competency) mean differences,
the PBL students had positive attitudes.
The students' performances on using NP to solve the real patients' problem mean scores in two-group students were shown in
Table 3. T-test has revealed an important enhancement in the PBL
students' performances (Z 4.61, df 68, P < .001).
In both PBL and NPBL groups, there were no signicant correlations between the students' attitudes with their performances in
using NP (PBL: r .08, P .67; NPBL: r .12, P .51) and between
their performances with the mean differences of the competency
(PBL: r .04, P .83; NPBL: r .12, P .49).
The ndings also showed no signicant differences between the
students' demographic characteristics with their mean scores of
competencies, attitudes, and performances.
Discussion
Students' competency self-evaluations
Our ndings showed that despite the PBL students being evaluated lower in their general knowledge and skills lower than those
of the NPBL group at rst, the PBL students reported higher scores
than those of NPBL students at the end of clinical education. These
ndings suggest that the PBL process enhanced students' general
knowledge and skills in all ve steps of the NP (assessment, diagnosis, planning, implementation and evaluation). The same results
were obtained about the students' special knowledge and skills.
The students' capability of nding, assessing and interpreting the
patients' data is very important to conrm their competency
(Callister et al., 2005). In fact, our intervention completely engaged
the PBL students in the learning process. These students were asked
to do purposeful activities and use critical thinking when working
in clinical setting.
There are many researchers who believe that the PBL curriculum
has comparable or even better effects in medical educated professional competencies than traditional ones (Prince et al., 2005;
Table 3
Comparison of the PBL and NPBL students' performance in applying nursing process
for their patients' problems (means were 0e4).
NP phases
Groups
Mean
SD
Mean rank
ManneWhitney
Assessment
PBL
NPBL
Total
PBL
NPBL
Total
PBL
NPBL
Total
PBL
NPBL
Total
PBL
NPBL
Total
2.92
1.46
.12
.28
53.50
18.50
2.88
1.40
.30
.39
2.91
1.34
.24
.32
2.99
1.33
.09
.32
2.65
1.19
.60
.40
34
36
70
34
36
70
34
36
70
34
36
70
34
36
70
Z 7.36
df 1
P .000
Z 7.40
df 1
P .000
Z 7.50
df 1
P .000
Z 7.71
df 1
P .000
Z 6.843
df 1
P .000
Diagnosis
Planning
Intervention
Evaluation
Fig. 2. Comparisons of the means scores of the PBL and control group students' selfevaluation of the special competencies pre and post clinical course.
53.15
18.83
53.46
18.54
53.50
18.50
51.41
20.47
702
Sciences with the number of P/16/35/151560 and the nursing students in doing this project. The authors would like to thank Farzan
Research & Technology Institute for technical assistance.
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2014 Elsevier
Received: 8 November 2008 / Accepted: 2 November 2009 / Published online: 15 November 2009
Springer Science+Business Media B.V. 2009
Abstract This study aimed to evaluate the integration of a simulation based learning
activity on nursing students clinical crisis management performance in a problem-based
learning (PBL) curriculum. It was hypothesized that the clinical performance of first year
nursing students who participated in a simulated learning activity during the PBL session
would be superior to those who completed the conventional problem-based session. The
students were allocated into either simulation with problem-based discussion (SPBD) or
problem-based discussion (PBD) for scenarios on respiratory and cardiac distress. Following completion of each scenario, students from both groups were invited to sit an
optional individual test involving a systematic assessment and immediate management of a
simulated patient facing a crisis event. A total of thirty students participated in the first post
test related to a respiratory scenario and thirty-three participated in the second post test
related to a cardiac scenario. Their clinical performances were scored using a checklist.
Mean test scores for students completing the SPBD were significantly higher than those
who completing the PBD for both the first post test (SPBD 20.08, PBD 18.19) and second
post test (SPBD 27.56, PBD 23.07). Incorporation of simulation learning activities into
problem-based discussion appeared to be an effective educational strategy for teaching
nursing students to assess and manage crisis events.
Keywords Simulation Problem-based learning Nursing education
Crisis events Clinical competency
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S. Y. Liaw et al.
Introduction
Nurses are often faced with high patient acuities. Patients receiving care in acute general
wards are often older, undergoing major surgical procedures or are acutely ill which creates
an increase in the acuity and dependency of patients being cared by nurses in general ward
areas. The majority of premonitory signs and symptoms of cardiac arrest in patients on
medical wards are usually preceded by observable deterioration in the patients condition
but such warning signs and symptoms are frequently missed, mismanaged and/or misinterpreted by nursing and medical staff (Franklin and Mathew 1994). The early recognition
and treatment of these signs may prevent the need for cardio-pulmonary resuscitation and
ICU admission.
Critical care outreach services and guidelines for detecting critical illness have been
developed in many acute hospitals to support ward staff in managing patients at risk.
However, it is ultimately ward nurses, who are often the first person to encounter a patient
in crisis, and initially manage such critical care situations (Gibson 1997). Ward nurses
must be able to assess patient deterioration, evaluate the assessment data, and notify the
doctor promptly (McArthur-Rouse 2001). Such knowledge and skills should be addressed
in preregistration nursing curricula, rather than post-registration critical care courses.
The Alice Lee Center for Nursing Studies (ALCNS), National University of Singapore,
uses a PBL approach to teaching and learning in the undergraduate nursing program. The
integration of simulation technology into PBL is seen to provide opportunities for nursing
students to integrate theory from PBL sessions into real life practice situations. The
main focus is to develop students clinical competency for providing safe, competent,
timely and appropriate patient care during the management of crisis events.
Although the clinical laboratory and clinical practicum in the preregistration nursing
curriculum provide effective learning experiences for nursing students, opportunities for
exposure to clinical crises cannot be guaranteed during clinical practice. Technological
advancements in nursing education now include the human patient simulator, which can
capture a variety of patient conditions and create opportunities for learners to manage
emergency situations in a planned and prescribed way. Patient simulation in nursing
education has been reported as an effective learning tool (Beyea and Kobokovich 2004;
Feingold et al. 2004; Nehring et al. 2001). One of the major strengths of simulation-based
learning is that it provides opportunities for problem solving in a clinical situation and
integration of knowledge and skills without the fear of harming a real patient.
Problem-based and simulation-based learning are linked closely to the principles of
constructivism and collaborative learning making the integration of these strategies possible. Both educational approaches involve working on a case scenario with the problem as
the stimulus for learners to construct their own knowledge. Collaborative learning takes
place in both instructional strategies as interactions in small group occur among learners
and facilitators. The major differences are the learning environment and feedback mechanisms. Unlike problem-based learning, simulation-based learning requires students to role
play the case scenario using a patient simulator and medical equipment. The students
receive feedback on their performance from the patient monitor, physical assessment and
verbal feedback during debriefing. In many PBL formats, students assess and manage the
patient described in a written scenario and receive verbal feedback from peers and the
facilitator within a group discussion.
A recent review of the literature recommended that simulation-based learning should be
integrated into the educational curriculum for optimal results (Issenberg and Scalese 2007).
This implies that simulation-based learning should be integrated rather than as an
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405
extraordinary or optional activity. Such integration can be achieved without causing any
major changes to the course content or timetable (Gordon et al. 2004). In the current study,
ALCNS faculty implemented this strategy by transferring some of the time spent discussing case scenarios to role playing in the simulation laboratory.
Although many studies have evaluated the effectiveness of simulation-based learning,
there are relatively few experimental studies testing the effect of simulation on clinical
performance (Radhakrishnan et al. 2007; Weller 2004). To date, there are no published
studies in medical or nursing education that evaluated the implementation of simulation
learning with problem-based discussion. Simulation-based learning is known to be associated with significant financial outlay to acquire resources. Therefore, the value and
usefulness of simulation technology in problem-based learning has to be explored. The aim
of the present study was to evaluate the clinical performance of nursing students who
participated simulation training with problem-based discussion in managing crisis events in
comparison with those that participated only the problem-based discussion. Two study
hypotheses were formulated as follows:
Hypothesis 1:
Hypothesis 2:
Method
Design and sample
A quasi-experimental study was conducted. Potential participants were Year 1 nursing
students in a Bachelor of Science (Nursing) program, undertaking a nursing module related
to care of patient with respiratory and cardiovascular disorders. As the study was conducted within the module, the Year 1 students were assigned by the researcher to either
simulation with problem-based discussion (SPBD) group or problem-based discussion
(PBD) group based on their pre-assigned tutorial groupings. All students from both SPBD
and PBD groups were invited to participate in the test scenarios. The researcher had a
meeting with potential participants to explain the nature of the study and request their
participation. The participants were asked to sign a written consent prior to data collection
and anonymity in the reporting of results was assured.
Instrument
The clinical performances of nursing students were measured using checklists developed
by the researcher. Two sets of checklists were developed for the two test scenarios. The
checklists consisted of two subcategories: assessment (history and physical examination)
and immediate actions. These checklists outlined the essential actions that a Year 1 nursing
student might reasonably be expected to perform. The content validity of the checklists
was established by a panel of nursing and medical experts and refined after testing with
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406
Table 1
S. Y. Liaw et al.
Checklists
Assessment
Ask questions related to chief complaint
Take vital signs
Perform SpO2 monitoring
Auscultate for breath sound
Immediate intervention
Reassure patient
Help to sit patient upright
Deliver oxygen
Check medication record to administer
ventolin nebulizer
Call Dr using SBAR communication tool
Reassure patient
Help to sit patient upright
Deliver oxygen
Perform ECG
Check medication record to administer SL GTN
Check blood pressure and pain level
Administer 3 doses of SL GTN at 5 min interval
Call Dr using SBAR communication tool
2 Year 2 nursing students. A weighting system (score of 1 to 3 points) was used to score
checklist items: 1 point for no attempt, 2 points for an unsuccessful attempt and 3 points for
a successful attempt. The checklist is shown in Table 1.
Procedure
The intervention phases of the study consisted of core topics of instruction implemented
within a module/subject focusing on contemporary nursing practices. All students were
given an orientation on the manikin features, opportunities to listen to heart/lung sounds,
take a pulse and check blood pressure. Following the orientation, the students underwent
two intervention sessions (5 weeks apart), one using SPBD and one using only PBD (See
Fig. 1). The students from the two groups (SPBD and PBD groups) were crossed over in
the two intervention phases, producing two experimental cohorts: (1) One group received
respiratory SPBD followed by a cardiac PBD. (2) Another group received a cardiac SPBD
followed by a respiratory PBD. By the end of all the intervention phases, all students had
received two different teaching methods for each clinical scenario. Thus, no student would
be disadvantaged as all received the same content including the two different styles of
learning.
Two case scenarios focusing on acute care management for respiratory and cardiovascular issues were developed. The educational content of these case scenarios were
based on curricular objectives. Students in both the SPBD and PBD groups worked through
the same scenario with a facilitator. All nurse educators, facilitating either the experimental
or control groups, were briefed before these educational sessions and received similar tutor
guidelines and learning objectives. For all intervention sessions, the same instructors taught
all simulation sessions while another group of instructors led all the problem-based
discussion.
Both SPBD and PBD groups worked on the case scenario during an hour brainstorming
session whereby students attempted to identify clinical problems and develop hypotheses
and learning issues through group discussion. Students then had time for self-directed
learning to research their assigned learning issue. Group members reconvened during
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Orientation to
Simulator
Brainstorm issues of
Case Scenario:
Respiratory distress
R/T Pneumonia
SPBD Group
Simulation-based learning
(n=13)
PBL Group
Problem-based Discussion
(n=17)
Test Scenario on
Respiratory Distress (n=30)
4 weeks
Brainstorming of
Case Scenario: Chest
Pain R/T Angina
SPBD Group
Simulation-based learning
n=18
PBL Group
Problem-based Discussion
n=15
Test Scenario on
Chest Pain (n=33)
Fig. 1 Study design conceptual flowchart. SPBD = Simulation problem-based discussion; PBL = problem-based discussion
the following week to re-examine the scenarios. The PBD group spent about 1 h 40 min
discussing their learning issues and information to resolve the crisis event. The SPBD
students were divided into 2 smaller groups (4 students in a group). Each group participate
a 20 min hands-on practical simulation experience in managing a crisis event on a SimMan
patient simulator. While one group of students completed the simulation exercise, the
remaining students observed the scene through live video recording. Each small group
simulation role play took about 20 min. This was then followed by an hour of debriefing
session in which students discussed the case scenario based on their experiences, how the
situation may have been managed more effectively, and integrated findings from the
students self-directed learning. Thus, both PBD and SPBD groups spent an equal amount
of time (1 h 40 min) in each learning methodology.
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Table 2 Scenarios
Intervention I
Post test I
Intervention II
Post test II
Test scenarios for all students using a manikin with simulation capabilities took place
one week after each education intervention session. The post-test scenarios were altered
from the intervention scenarios to ensure that students were assessed on their application of
clinical reasoning and not on their recollection of learned steps. For instance, from the
given test scenario, students were required to assess the patient history, perform a physical
assessment and carry out appropriate nursing interventions to manage the event (See
Table 2).
Students were allocated an individual time for the post-test and two nurse educators,
blinded to the education intervention the students received, assessed student performance.
For consistency, one was responsible for running the scenario and the other assessed
student performance using the checklist. Students performance was videotaped for the
purpose of reviewing for any scoring error. Students received a brief orientation, were
given the scenario, and asked to manage the presented case individually. A short debrief
took place immediately to discuss the case scenario and consolidate learning. To prevent
discussion among students, they were asked to sign a confidentiality agreement. The study
received Institutional Human Research Ethics Board approval and was conducted from
February to May 2008.
Data analysis
Data were analyzed using statistical package SPSS. The data from the posttest checklists
were analyzed using independent t-tests to compare the mean scores between experimental
and control groups, and missing data were replaced by group mean.
Results
The first experimental cohort who participated in the respiratory test scenario comprised of
thirty nursing students (13 from SPBD & 17 from PBD) and were between the ages of 20
and 22 (Mean = 20; SD = 1). There were 33 nursing students (18 from SPBD & 15 from
PBD) in the second experimental cohort who participated in the cardiac test scenario.
Participants were between the ages of 20 to 22 (Mean = 20.2; SD = .52).
Hypothesis 1:
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Mean
SD
Mean
SD
8.83
0.80
8.19
1.24
1.64
0.113
11.25
1.64
9.82
2.04
2.06
0.049*
Overall score
20.08
1.93
18.19
2.55
2.23
0.034*
0.00*
8.44
1.34
6.93
1.16
3.43
17.44
1.92
14.60
2.06
4.1
0.00*
Overall score
27.56
2.15
23.07
2.69
5.34
0.00*
* p \ .05
This hypothesis is supported by the findings of this study. As shown in Table 3, means
and standard deviations for the performance post-test scores are presented. For the first test
scenario on respiratory distress, the SPBD group had an overall mean score of 20.08
(SD = 1.93) and the PBD group 18.19 (SD = 2.55). Although the results indicated that
the SBPD group had significantly higher average overall scores than the PBL group
(t = 2.23; p = 0.034), the difference in the overall mean scores between the two groups is
very small. There were no significant differences between groups in relation to physical
assessment (t = 1.64; p = 0.113) but marginally significant to immediate action scores
(t = 2.06, p = 0.049).
Hypothesis 2:
This hypothesis is supported by the results of the study. As displayed in Table 3, for the
second test scenario (chest pain), overall post-test scores showed that the SPBD group had
a significantly higher overall mean score of 27.56 (SD = 2.15) than the PBD group (mean
of 23, SD = 2.69) (t = 5.34, p = 0.01). The SPBD group had statistically significant
higher scores than the PBD group on subcategories for both physical assessment (t = 3.43,
p = 0.01) and immediate actions (t = 4.1, p = 0.01) in the posttest on chest pain.
Discussion
Our study demonstrated that performance scores of students in managing crisis events were
higher in the SPBD group than those in PBD group. Integrating simulation learning into
problem-based learning facilitated acquisition of clinical competence compared with
conventional problem-based learning. The results also indicated that students who completed simulation activities have higher performance scores for assessment and provide
immediate actions before the arrival of the doctor. The skills of assessment are important
for nurses to identify early warning signs of critical illness so that they are able to intervene
promptly. The immediate actions to manage patients airway, breathing and circulation
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may help to prevent further deterioration of patients condition to the point where cardiopulmonary resuscitation may become necessary (McArthur-Rouse 2001).
There was a small (1.89) but statistically significant difference in the overall mean
scores on the respiratory test scenario between the SPBD and PBD groups. This small
difference was due to the fact that the subcategory assessment scores being not statistically
significant different between the two groups. This may be explained by the simplicity of
the tasks required for assessing patient with respiratory distress. Another explanation could
be that the students have had experiences with this form of physical assessment before the
study.
T-test values obtained in the first test scenario (t = 2.23, p = 0.034) were lower than
those obtained for the second test scenario (t = 5.34, p = 0.01). A possible explanation
could be that the list of tasks for managing patient with chest pain required more complex
nursing actions to be executed compared to clinical actions in the care of patients with
respiratory distress. Another possible reason could also be that the intervention and posttest for the respiratory case scenario was undertaken before the cardiovascular case scenario (a month apart). Thus, factors such as improved teaching skills of the simulation
facilitators gained from the respiratory case scenario and improved knowledge and skills
acquired by students from the ongoing lecture and laboratory skills classes could have
resulted in better performances by students in the cardiovascular case scenario.
Several studies have used a randomized controlled trial design to compare simulationbased learning with problem-based discussion but their findings were controversial
(Steadman et al. 2006; Wenk et al. 2008). Wenk et al. (2008) demonstrated that both
problem-based discussion and simulation-based teaching have comparable outcomes in
theoretical knowledge and clinical skill. Steadman et al. (2006) found simulation base
learning to be superior to problem-based learning in the context of critical assessment and
management skills acquisition. However, neither study focused on the theoretical basis for
PBL. Dolmans et al. (2005) in their review of PBL concluded that future research should
focus on developing and improving PBL to bridge theory and practice. Our study demonstrated that the incorporation of the clinical performance of simulation with a theoretical
emphasis of problem-based discussion further improved PBL processes and resulted in
improved clinical competence.
There are several reasons why the integration of simulation into problem-based discussion could result in superior performance. One reason is that simulation provided
learners with the opportunity to practice their clinical skills in a realistic and non-threatening environment. This allowed them to review and practice their skills and develop a
systematic approach to the management of a crisis event (Weller 2004). In the present
study, the opportunity for the experimental group students to participate in simulation, after
their clinical skills laboratory, allowed them to engage in repetitive practice. Repetitive
practice is crucial for clinical skill acquisition as it makes skill demonstration effortless and
automatic (Issenberg et al. 2005). A study done by Alinier et al. (2006) demonstrated the
effectiveness of intermediate-fidelity simulation in development of nursing students
clinical skills performances. In addition to clinical skills performance, the present study
also required students to manage crisis events which require cognitive abilities including
clinical reasoning skills.
In addition to the development of practical skills, simulation may facilitate contextual,
constructive and active learning. The transfer of learning from paper case to realistic
clinical situation through simulation may enhance the contextual nature of learning in PBL.
The clinical experiences gained from simulation allowed students to link these experiences
to the discussion of the problem. This enabled the students to build more personal
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interpretations of the problems and thus, contributed to the enhancement of the problembased discussion (Mamede et al. 2006). Simulation, which involves a variety of learning
strategies such as role playing, viewing videos and discussion, further enhance learning in
PBL environment by making learning more engaging for students. Jeffries (2002) stated
that the use of a variety of learning strategies in simulation can accommodate the diverse
learning styles of nursing students which is an important pedagogical principle of good
teaching. According to Hodgson (1997), learning is deepened when learners are able to
perceive the meaning and intrinsic relevance of the subject matter to their own purposes.
Immersion into the nursing role in simulation provides students with valuable insights on
the relevance of their clinical skills and knowledge to their field of work.
While the integration of simulation into PBL not only enhanced the process of PBL
discussion, the PBL process itself could foster simulation learning processes. In conventional simulation-based learning, a case scenario is normally presented to students
immediately before they commence their simulation role play, and their post simulation
discussion is based on the experiential learning gained from the simulated role play.
However, the integration of simulation into PBL in the current study provided students
with opportunities to explore the case scenario in-depth. The theoretical knowledge gained
from the PBL brainstorming of the case scenario and self-directed learning could have
facilitated the transition of theoretical knowledge into students clinical performances
during the simulation role play and encouraged the application and synthesis of knowledge
during post-simulation discussion.
Feedback mechanisms could also explain the effectiveness of simulation with problembased discussion compared to problem-based discussion. There are various sources of
feedback incorporated into simulation training. These include direct feedback from the
simulator based on learners actions, verbal feedback from facilitator and critical review of
the recorded role play. Students who engaged in problem-based discussion, on the other
hand, received only verbal feedback from their peers and facilitator. Issenberg and Scalese
(2007) identified feedback as one of the most important features of simulation to enhance
effective learning. Feedback slows the decay of acquired skills and allows learners to self
assess and monitor their progress towards skills acquisition (Issenberg and Scalese 2007).
Although a similar set of learning objectives were given for both SPBD and PBD, the
learning activities during problem-based discussion may not have adequately covered
management of the crisis events. This could be largely due to the self-directed learning
process embedded in problem-based learning which encouraged learners to determine the
learning issues to be discussed and the role of tutor as facilitator. Dolmans et al. (1993)
identified that in problem-based learning environments, students learning activities covered an average of 64% of intended course content. The role of the tutor in problem-based
discussion is not to transmit knowledge but probe students knowledge deeply to stimulate
activation and elaboration of their prior knowledge and problem-solving skills (Dolmans
et al., 2005). The use of simulation in the current study allowed facilitators to foster
learning, monitor and direct students role playing and evaluate students clinical performance during debriefing.
Limitations
The study used a homogenous convenience sample of year 1 nursing students that limits
generalization of results. As the study was conducted within an existing module of study,
the random allocation of students into the SPBL and PBL groups could not occur. A pretest
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to evaluate the students performances was also not conducted due to time and logistic
issues. The institutional ethics review board did not approve the inclusion of a third group
of students to act as control. This study was limited to students clinical performance. It did
not evaluate other outcomes such as knowledge and self efficacy. Thus, future randomized
controlled trails could assess additional outcome measures to provide more objective
evidence on the use of simulation in problem-based learning. As simulation technologies
have been widely used as an assessment tool for clinical competency, a simulation-based
evaluation exercise using patient simulator was chosen to be used in the post test study.
The improved performance on the simulator, however may not necessary translate into
improved performance in clinical settings. Unlike the controlled simulation environment,
the clinical performances in the clinical setting can be influenced by many factors such as a
chaotic situation that is outside the nurses control.
Conclusion
Nurses need to be prepared and competent in identifying patients at risk of cardio-respiratory crises and implement immediate management interventions. Education plays an
important role in developing this clinical competency. Our study found that the use of
simulation with problem-based discussion provided a more effective way for students to
learn how to identify and manage a crisis event compared with the use of problem-based
discussion alone. Simulation creates opportunities for students to experience a clinical
situation and such clinical experiences can enhance the development of PBL by stimulating
students towards contextual, constructive and active learning. The results of our study give
support for the inclusion of simulation-based learning into PBL. This may require transferring some of the time spent discussing case scenarios during problem-based discussion
to role playing in the simulation laboratory. As well as using a randomized controlled trial
design, future research should consider additional outcome measures including long-term
retention of knowledge and clinical performance as objective measures to support the
integration of simulation into problem-based learning.
Acknowledgments This study was funded by a teaching enhancement grant from National University of
Singapore Center for Development of Teaching and Learning to Alice Lee Centre for Nursing Studies. We
thank Prof Debra Creedy, PhD, RN, for her review of the manuscript and Moon Fai Chan for his statistical
consultation.
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