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Nurse Education Today 31 (2011) 129134

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Nurse Education Today


j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

A comparison of competencies between problem-based learning and


non-problem-based graduate nurses
Harrison Applin a,, Beverly Williams b,1, Rene Day b,2, Karen Buro c,3
a
b
c

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

Corresponding author. Tel.: + 1 780 998 0638.


E-mail addresses: happlin@telus.net (H. Applin), beverly.williams@ualberta.ca
(B. Williams), rene.day@ualberta.ca (R. Day), burok@macewan.ca (K. Buro).
1
Tel.: + 1 780 492 8054; fax: + 1 780 492 2551.
2
Tel.: + 1 780 492 6481; fax: + 1 780 492 2551.
3
Tel.: + 1 780 633 3911.
0260-6917/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2010.05.003

and self-directed learning. To gain support for the nursing curriculum,


the teaching methods must be aligned with teaching and learning
principles associated with adult education. Although various
approaches to learning are used in nursing education, traditional
lectures/discussion are still the mainstay of most nursing education
programs. Some nursing programs are using PBL in an effort to assist
students to develop higher level skills associated with professional
nursing practice. The purpose of this study is to determine if PBL or
NPBL has an impact on self reported competence as a registered nurse.
Literature
In the nursing literature, the concepts of competence and
competency are characterized by a variety of interpretations and
degrees of complexity (Bradshaw, 1998; Campbell and Mackay, 2001;
Watson et al., 2002). The majority of descriptions include knowledge,
skills, and attitudes as key aspects of competence and identify quality,
expectations, and skill as the context of being competent. Short
(1984) suggested that competence is a normative concept even though
it is often used descriptively. Competence is a quality or state of being
rather than a thing or an activity and therefore difcult to assess.
Despite this, competency has been described as a specic attribute used
to judge a person's adequacy or sufciency. DeBack and Mentkowski

130

H. Applin et al. / Nurse Education Today 31 (2011) 129134

(1986) also dened competence as a broad, generic ability or


characteristic of a person that transfers across settings and situations
and is not just a set of discrete skills. In this context, competence is
comprised of integrated skills and individual attributes such as
motivation. Competence is one of the main goals for professional
educational programs. Parry (1996) more recently dened competence
as a cluster of related knowledge, attitudes, and skills (competencies)
that is associated with performance on the job and that can be
measured against well-accepted standards. Alfaro-LeFevre (2002)
further developed the concept of competence by suggesting that
competence is reected in the knowledge, critical thinking, technical
and interpersonal skills (competencies) that a professional brings to
any professional practice situation. Competence can therefore be
achieved by mastering a number of competencies.
Strategies used to determine competence in nursing practice include
(a) questionnaire rating scales (Redfern et al., 2002); (b) ratings of
observation (Neary, 2000; Piercey, 2006); (c) criterion-referenced
rating scales and simulations, including objective structured clinical
examinations ([OSCE] McGaughey, 2004); (d) case studies (Piercey,
2006), (e) reection in and on practice (journaling; Clark et al., 2006;
Piercey, 2006); (f) self-assessment and evaluation (Piercey, 2006);
(g) portfolios (McGaughey, 2004); and (h) multimethod approaches
(Redfern et al., 2002) used to assess various essential competencies.
Teaching strategies used to assist learners in learning competencies essential to the profession vary widely. The adult education
literature suggests that learners are self-directed, problem centered,
and needing to learn useful information (Knowles, 1980; Vandeveer
and Norton, 2005). The literature also suggests that learners have
various learning styles and therefore require a variety of teaching
approaches (Cassidy, 2004; Desmedt and Valcke, 2004).
The use of lectures is one of the most widely used and accepted
teaching methods (Gulpinar and Yegen, 2005). The most noted
advantage of the lecture approach is that it facilitates the students'
ability to master and retain a wide variety of information with respect
to the basic sciences such as anatomy, physiology, and pharmacology
(Albanese and Mitchell 1993; Mennin et al., 1993; Sunbald et al., 2002;
Vernon and Blake, 1993). Lectures involve a process of systematic and
sequential building on previous learning. Faculty members are the
primary decision makers with respect to the educational experience
(Csokasy, 2005). This teaching method is teacher centered and involves
an isolated technique for instruction (Engel, 1991). Through lectures
content knowledge and teacher thinking is made visible to students
(Tan, 2004). As an adjunct to lectures, faculty may also choose to use
strategies such as discussions, forums, and panels (Galbraith, 1990).
Lectures have been described as less effective for learning in the
professions as learners frequently assume a passive information
receiving role. It has been argued that such a role does not facilitate
knowledge application and critical thinking which are essential for
practicing professionals such as nurses (Kumar, 2003). Bradshaw
(2004) argued that students who adhere to one form of learning such
as lectures and reading do not maximize their learning. Even though
lectures are still used extensively in professional practice education,
some educators and researchers are beginning to suggest that learner
engagement in learning is considered essential for professional
practice disciplines (Brown and Manogue, 2001). Approaches to
education that provide the learner with an opportunity to contextualize the information are more congruent with the needs of
professional practice (Gulpinar and Yegen, 2005; Ebert-May et al.,
1997). PBL has been identied as one approach to nursing education
that supports contextualization of knowledge essential to nursing
practice.
PBL as an approach to learning was introduced by Barrows and
Tamblyn (1980). It is based on the premise that learning in
professional practice disciplines results from the process of working
towards the understanding or resolution of a problem. The problem is
encountered rst in the learning process and serves as a focus or

stimulus for the application of problem solving or reasoning, as well as


for the search for the information or knowledge needed to understand
the mechanisms responsible for the issue and how it might be
approached. PBL has been identied as one approach to nursing
education that supports contextualization of knowledge essential to
nursing practice. Researchers noted that PBL students demonstrated a
variety of more efcient and successful set of studying skills, which is
was associated with independent and self-directed professionals
(Coles, 1985; Schmidt et al., 1987). PBL students were also more likely
than their traditional counterparts to adopt a deeper style of learning
(Coles, 1985; Newble and Clark, 1986). Advocates of PBL (Barrows,
1985; Gijselaers, 1996; Williams, 2001) pointed out that PBL has
positive educational outcomes in that students acquire an essential
body of retrievable and useable knowledge and skills. PBL strengthens
clinical reasoning and critical thinking (Albanese and Mitchell, 1993;
Day and Williams, 2000; Shuler and Fincham, 1998), promotes
problem solving (Patel et al., 1991), structures knowledge in a clinical
context (Norman and Schmidt, 1992; Thomas, 1997), motivates
learning and encourages teamwork and peer review, and increases
self-directed learning (Norman and Schmidt, 1992; Shuler and
Fincham, 1998). Biley and Smith (1998b) and Shin et al. (1993)
maintained that PBL enhances lifelong learning behaviors that
support future outcome competence.
PBL and NPBL learning have been widely compared in the medical
literature (Albanese and Mitchell, 1993; Barrows, 1985; Barrows and
Tamblyn, 1980; Boud and Feletti, 1997), and the use of PBL has been
supported by other health science professions including pharmacy
(Slack and McEwen, 1997), occupational health (Royeen and
Salvatori, 1997), physical therapy (Urbina et al., 1997), and dentistry
(Chaves et al., 1998; Townsend et al., 1997). The literature indicates
that both PBL and NPBL paradigms are relevant and transferable to
nursing education. However, Andrews and Jones (1996) suggest that a
change to PBL in nursing education would nurture high-quality
nursing skills by integrating theory, practice, and research within the
curricula. Although some research suggests that students in PBL
programs perform better than students in NPBL programs (Albanese
and Mitchell, 1993; Norman and Schmidt, 1992; Richards et al., 1996;
Sunbald et al., 2002; Vernon and Blake, 1993), others noted no
difference in performance (Alleyne et al., 2002; Antepohl and Herzig,
1999; Schmidt et al., 1987, Biley and Smith, 1998a; Schmidt, 1983,
Richards et al., 1996).
Method
This study was formulated as a comparative descriptive design
that employed a postal-survey approach. The sample consisted of all
June 2006 graduates from baccalaureate nursing programs leading to
entry to practice in one western Canadian province and was a nonprobability convenience sample. Cohen's (1997) power analysis was
used to estimate the required sample size. For a medium effect, a
sample size of 128 graduate nurses was required (n = 64 for each
group of PBL and NPBL graduates). Survey questionnaires were mailed
out by the provincial professional association to all 2006 graduates
who were 6 months post-graduation. Completed questionnaires
(n = 121) were returned in the self addressed envelopes provided.
The Graduate Competence Questionnaire that was used in the
study consisted of 50 forced choice items grouped under the following
four standards of practice identied by the professional association:
professional responsibility, knowledge based practice, ethical practice
and provision of service to the public. Developing the original
competencies was both a rigorous and an extensive procedure of
establishing criterion validity and face validity through consultation
and the expertise of nursing professionals who critiqued the
competencies (CARNA, 2007).
Graduates from all of the nursing programs were asked to indicate
their ability to meet the competencies using a 5-point Likert scale

H. Applin et al. / Nurse Education Today 31 (2011) 129134

response format (5 = strongly agree, 4 = agree, 3 = disagree, 2 =


strongly disagree, and 1 = need more experience). For the statistical
analysis, measures of competence for the four standards were obtained
by averaging the answers for the Likert scale items in the respective
groups. Two sample t-tests were used to compare the mean scores
measuring the competence in the four professional practice standards
for PBL and NPBL graduates. Since the scores are means of at least ve to
sixteen Likert scale items the assumptions for the t-tests are met. To test
for differences in the demographic variables we conducted Fisher's
exact test. In addition, graduates were asked the following open ended
questions: how did your nursing program prepare you to meet the
competencies listed above? and what suggestions would you give your
program to better prepare you to meet the above competencies?
Approval for the study was granted by the Health Research Ethics
Review Committee for the University. The reliability of the study
questionnaire determined by Cronbach's alpha (.771) for the four
professional standards calculated indicated that the graduates all
interpreted the statements in the same way.

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

Comparison of entry-to-practice competence


The statistical analysis is based on samples of size 64 for PBL
graduates and 57 for NPBL graduates. Each standard is assessed by a
score which represents the mean of the items in the questionnaire
concerning the standard. Cronbach's alpha for each standard was
above 0.7 indicating an acceptable degree of consistency within each
standard. For a description of the scores measuring the four standards
see Table 2.
The t-tests did not provide sufcient evidence for a difference in
the mean competence for the four professional standards: professional responsibility (p = 0.163), knowledge based practice
(p = 0.771), ethical practice (p = 0.495), and provision of service to
the public (p = 0.410), see Table 3.
Program contribution to meeting competencies
The graduates were asked how their nursing program prepared
them to meet professional practice competencies. The analysis for
the two open ended questions was based on the extraction of main
themes. The main themes that emerged from the PBL responses to
this question were: critical thinking, self-directed learning, evidence-based practice, and teamwork. The PBL graduates afrmed
that their nursing program supports a critical perspective for
entry-to-practice competency as a new graduate. One quarter of
the PBL graduates identied its signicance in supporting entry-topractice competencies with such comments as PBL pushed us to

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

H. Applin et al. / Nurse Education Today 31 (2011) 129134

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

*p b .05; ** p b .01; *** p b .001.

be critical thinkers and always question what we were doing, PBL


established critical thinking by doing problem-based scenarios
and forced us to gure out solutions to our problems. PBL
graduates suggested that self-directed learning skills were an
important part of how the program prepared them to fulll
professional competencies with such comments as taught you
how to look up information you did not know. The PBL graduates
stressed that a PBL curriculum is an invaluable resource to support
research and evidence-based practice with such comments as
Clinically, my PBL education focused strictly on evidence-based
practice which gave me the skills to keep informed and practice
competently. The PBL graduates recognized that teamwork within
the nursing program and an interdisciplinary perspective were
essential in assisting them to meet the professional practice
competencies. Comments included Provided interdisciplinary
experiences to ensure professional team work in clinical settings
and Group work enhanced communication skills, team building
skills and the ability to collaborate with team members.
The NPBL graduates wrote fewer comments and the comments
were often very brief. The themes that emerged from the NPBL
graduate responses to this question were related to critical thinking
and teamwork. Less than 5% of graduates commented that In all
courses, assignments and class discussions promoted critical thinking skills and learning about what nursing entails in the health care
team.
Suggestions for program improvement
In a second open ended question graduates were asked for
suggestions about how their nursing program could better prepare
new graduates to meet the entry-to-practice competencies. The main
theme that emerged from both PBL and NPBL graduate responses was
a request for increased clinical hours. An additional recommendation
from the PBL graduates was to combine PBL and NPBL teaching
methods more often with such comments as Have more lecture and a
PBL component, and Use PBL with a combination of weekly lectures
that help to assimilate knowledge and develop critical thinking. The
NPBL graduates indicated that they would like more research
opportunities in the curriculum and stated In addition to nding
research, use research in day to day practice. NPBL graduates also
requested more real life scenarios and commented that case based
learning should be part of the curriculum.
Discussion
Typically graduates are surveyed 1 year following graduation. This
is the rst study that reports on graduate perceptions 6 months
following graduation before signicant acculturation into the practice
setting. This time period has also been identied as the time during
which new graduates begin to focus on the concept of competency in
nursing practice and examine their own competence (Casey et al.,
2004; Cowin and Hengstberger-Sims, 2006). Both PBL and the NPBL
graduates rated themselves in a similar way on the entry-to-practice

competencies, a nding that is similar to those of several other studies


(Bevis 2000; Kaufman and Mann, 1999; Newman, 1995; Solomon et
al., 1996). This is signicant as it suggests graduates identify
themselves as competent to practice regardless of curriculum
structure and/or teaching methods employed in basic baccalaureate
nursing education.
Equal numbers of PBL and NPBL graduates maintained that clinical
practice had a stronger inuence than classroom time in preparing
them to meet the competencies to practice as graduate nurses even
though clinical practice hours varied. The PBL program clinical hours
ranged from 1600 to 1700 and the NPBL program clinical hours
ranged from 1200 to 1400. Interestingly, graduates did not mention
laboratory experience as an inuencing factor in attaining competence. The pattern of clinical experience also varied among programs.
Generally PBL clinical experience occurred on consecutive days every
week over seven week blocks of time whereas NPBL clinical
experiences occurred on two alternate days every week over a
thirteen week term. One might hypothesize that consecutive clinical
practice would enhance condence and competence but this did not
seem to be the case.
PBL graduates suggested that more time on nursing units, more
hands-on nursing practice, more time spent on important nursing
skills, and more opportunity to practice these skills were ways to
further increase competency despite the fact that more than one-half
of the PBL program was comprised of clinical practice. NPBL graduates
also suggested that more clinical time would enhance entry-topractice competence. Both types of graduates recommended more
exposure to varied clinical placements and longer clinical placements.
Although PBL graduates proposed that a combination of PBL and NPBL
teaching methods would foster a better understanding of the
competence required of graduate nurses, NPBL graduates requested
smaller group discussions that focused on real life scenarios and more
research opportunities in the curriculum to enable graduates to apply
the research ndings to practice.
The PBL graduates in this study emphasized that the PBL learning
process enhanced their critical thinking skills through small-group
discussions, dialogue on and debate of nursing issues, and the use of
research skills such as nding and summarizing information to
address specic nursing issues. Day and Williams (2000) note that
critical thinking in a PBL curriculum is achieved through consistent
tutorial dialogue, discussion, analysis, and evaluation of thinking from
a nursing perspective. The PBL graduates further indicated that
clinical practice, skill competency, and evidence-based practice as
essential components of graduate nurse competency. Although the
NPBL cohort rated themselves as having met the entry-to-practice
competencies, less than 10% of the cohort commented on critical
thinking as an important aspect of practice.
PBL graduates noted that self-directed learning was encouraged
through group discussion, integrated dialogue, and use of a collaborative approach to problem solving. Williams (2001) note that selfdirected learning is another desirable outcome of PBL undergraduate
nursing programs. The NPBL graduates commented less on the
signicance of self-directed learning and communication in meeting
the entry-to-practice competencies. They reported that they are selfaware and emphasized that accountability, and professionalism are
important to the curriculum.
Having the ability to nd, assess, and decipher the evidence
necessary to critically analyze patient situations is very important in
ensuring competent practice (Callister et al., 2005). A commitment
to teamwork is essential in achieving competence (Amos and White,
1998; Doucet et al., 1998). While PBL graduates indicated that
evidence-based practice was a signicant focus in their program, few
NPBL graduates commented. Both PBL and NPBL graduates identied
teamwork as an essential program focus for competent practice.
These nding are congruent with those of Carey and Whitaker
(2002).

H. Applin et al. / Nurse Education Today 31 (2011) 129134

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

Theory of Reasoned Action in Exploring Factors Affecting


Lecturers*1Intention to Adopt PBL
Snigdha Barman0, Arunodaya Barman2*

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

think that others wanted them to perform the behavior (subjective


norm), this results in a higher intention (perceived belief control) and
they are more likely to do so.

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

Received on June 2, 2014 and accepted on September 17, 2015


1) Human Resource Associate, Monower Associates
Gulshan - 2, Dhaka - 1212, Bangladesh
2) Department of Medical Education, Faculty of Medicine and Health Sciences, Universiti Sultan Zainal Abidin
Janan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia
Correspondence to: Arunodaya Barman.
(e-mail: snigdhal35@live.com)

(6) 2016 Japan Health Sciences University


& Japan International Cultural Exchange Foundation

332

Barman S. et al.

Table 1. Factors individually influencing adoption o f PBL.


Factors

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

Figure 1. Theoretical framework of the study explained by Theory of Reasoned Action

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

After the origin at McMaster, rate o f adoption o f PBL at other medi


cal schools were slow through the 1970's and 1980's8). Adoption o f new
method o f teaching and learning not only reflect the need o f future
workforce but also the feasibility and intention of the programme coor
dinators and facilitators. It was found that the faculty who adopted the
PBL approach, they acknowledge that PBL is an effective apparatus to
incorporate theory into scientific practice.
An individual's intention is determined by three major factors: their
attitude toward the context, the subjective norm and their perceived
belief control7'0"1. However, there are studies those could not establish
the effect of all three factors on behavioral intention1213'. The attitude
component refers to the individual's intention toward engaging in that
specified context. The second component, which is subjective norm, is
the individual's perception of his/ her social influences or pressures by
their favorable people or institution authority to adopt or not to adopt
the given circumstance141. The perceived belief control refers to the indi
vidual's perception to their ability to perform the circumstance. By
nature, an individual will adopt a particular context that he/she thinks
highly admired by others and will exhort from circumstance that they do
not consider auspiciously and that are not favorable by others151.
Attitude considered as the first determinant o f the adoption. The
outcomes o f performing an attitude towards a behavior can be either
positive or negative161. Individual's knowledge and skills are expected to
influence their attitude. The knowledge is based on the lecturers' aware
ness on the term, definition, characteristics o f PBL. On the other hand,
the lecturers' skill is their ability to build students group learning in dif-

Factors Affecting Aadoption of PBL


ferent dimensions, ability to conduct loosely structured case, deal with
students' doubtful mind set. In this study it was found that knowledge
has got a significant positive influence when skills had no significant
influence on the attitude of respondents.
Subjective norms assess the influence that other people have on the
behavior of the individual.1,1Subjective norm like attitude, also expected
to be influenced by knowledge and skills. This study found that subjec
tive norm significantly influenced by the skills but not by the knowl
edge.
Drawing an analogy to the expectancy- value model of attitude, it is
assumed that perceived behavioral control is determined by the total set
of accessible beliefs about the presence of factors that may facilitate or
impede performance of the behavior. Finding of this study suggest that
the perceived belief control is significantly related to knowledge but not
to skills of the respondents.
The Theory of Reasoned Action suggests that supplementary vari
ables external to the theoretical framework may effect adoption only
indirectly by influencing its components181. Therefore, a particular vari
able may have an effect on adoptions if it meets one or more of the sub
sequent clause: (1) it influences the attitudinal component, (2) it influ
ences the normative component and (3) it influences the perceived
belief control component.
This study explored that Theory of Reasoned Action model facili
tates in predicting the adoption of PBL by examining the individual's
attitude, perceived belief control and subjective norms. The external
variables such as knowledge and skills of PBL were also being investi
gated to see their influence on the attitude, perceived belief control and
subjective norms.
C O N C L U S IO N

This study has demonstrated the applicability of the Theory of


Reasoned Action in explaining the adoption of PBL. Empirically it was
shown that the intension to adopt PBL in teaching and learning by the
teachers was influenced by their attitude, perceive belief control and
subjective norms. As an external variable though knowledge has got a
significant influence it was surprisingly noted that there was no signifi
cant influence of skills on the attitude and perceived belief control.
Subjective norm was significantly influenced by skills but not by
knowledge of the individuals.
In conclusion, this study has provided some valuable information to
the administration of schools to better understand the factors to be con
sidered in implementation of PBL curriculum in the schools.
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Bibliography #4

Transitioning to the Real World


Through Problem-Based Learning:
A Collaborative Approach to
Teacher Preparation
Dr. Lisa Barron
Assistant Professor
College of Education
Austin Peay State University
Clarksville, Tennessee
Dr. Lauren Wells
Assistant Professor
College of Education
Austin Peay State University
Clarksville, Tennessee
ABSTRACT
Problem-based learning (PBL) creates opportunities for authentic learning in teacher preparation programs. In addition to developing content knowledge and pedagogy, problem-based learning affords students the framework for
a holistic, collaborative approach to solving several interconnected problems. As students move through the process
of problem-solving, they take ownership of their learning and build self-confidence. This in-depth, guided learning
opportunity with peers provides benefits beyond the university classroom and transfers directly into the real world.
Students internalize problem-solving methods and are prepared to apply this knowledge not only in their classrooms,
but in their personal lives as well.
INTRODUCTION

Problem-based learning requires students to use content


knowledge to solve real-world problems. It is an instructional tool that actively engages prospective teachers and
forces them to approach problems from a teachers standpoint. Learning becomes active and on-going as students
seek additional resources to answer problems and to plan
strategies (Levin, 2001).
The work of PBLs can often be traced back to the work
of John Dewey. Dewey and his progressive movement asserted that students should be encouraged to investigate
and create. When teachers link learning to real-life activities, learners are motivated and involved. Therefore, real
learning becomes a natural result (Dewey, 1944).
Many medical schools are expanding on the work of Dewey by utilizing PBLs in their courses. PBLs were adopted
by medical and dental schools originally in the 1960s as
the preferable choice over the traditional medical school
model (Polyzois, Claffey, & Mattheos, 2010). Instead of
memorizing volumes of material, students were asked to
participate in groups where they reviewed cases, conductJournal of Learning in Higher Education

ed research, asked questions, and proposed treatment.


This type of real-world learning helps students develop
their diagnostic skills, while putting their content knowledge into practice. The goal is not solving the problem,
but rather using the problem to increase medical students
knowledge base and ability to find the answer, much like
they will be required to do as physicians (Wood, 2003).
PBLS IN HIGHER EDUCATION

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
the subject matter was outside of medical education. Although PBLs have become a part of the K-12 curriculum,
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

Lisa Barron and Lauren Wells

they really do. The metacognitive frame of mind, essential


to mature learning, is promoted through PBLs (Felder
and Brent, 2004). Students identify needed information,
retrieve it, analyze it, and synthesize it to determine if it is
applicable to the problem. This in itself provides practice
in developing skills that are portable to a variety of teaching and learning opportunities. Additionally, extended
opportunities to participate in roles and performances in
less structured environments prepare students for the real
world of teaching (Lave and Wenger, 1991).
Current learning theories emphasize the deep learning
that derives from situated learning in a social context.
PBLs naturally adopt this approach to learning and provide the necessary practice and engagement for teacher
candidates while they internalize this practice and hence
are able to model this learning strategy in their own classrooms (Lave and Wenger, 1991). In addition, PBLs offer
effective methods of assessment for teacher candidates.
Students are given the opportunity to apply their knowledge, utilize critical thinking skills, and demonstrate understanding (Flynn, 2008).
The Tennessee Board of Regents (TBR) is the sixth-largest state university and community college system in the
United States and prepares more than half of all teacher
candidates in the state in the TBR six universities and
thirteen community colleges. TBR has initiated a teacher
education redesign called Ready2Teach with the goal of
preparing future teachers who are ready to teach from the
moment they enter the classroom. An important component of the Ready2Teach initiative is to incorporate PBLs
in education and methods courses.
PARADIGM SHIFT

Transitioning to PBLs in the College of Education was


predicated by the need to engage teacher candidates in
authentic learning, collaboration, and analytical thinking
during the final phase of their program. The ultimate goal
was to develop teachers who value collaboration, solve
problems, and have internalized methods of research and
ways of thinking that will benefit them throughout their
careers and lives.
The majority of coursework encountered by students during their freshman, sophomore, and junior years at the
university follows the lecture, note-taking, and memorization model. This static model is not suitable for teacher
candidates preparing for extended field experience and
careers in teaching. PBLs provide an opportunity for engagement in deep learning through social support and
collaboration. As students increase their content knowledge and analytical thinking skills, they adopt these hab-

14

its for a life of learning. This is the key for success in the
classroom.
READING METHODS CLASS

During the 2011 spring semester, students in a reading


methods class in the College of Education in a university
in middle Tennessee had the opportunity to fully engage
in a multi-layered problem. Utilizing PBLs in pre-service
reading methods classes is an effective strategy to prepare
future teachers because it gives them many opportunities
to work collaboratively to solve common problems they
will face in their own reading classrooms.
Students were divided into teams of four and worked
in these teams throughout the semester. Prior to receiving the PBL that would require much research, analysis,
critical and creative thinking, students were given two
brief warm-up problems to practice (Appendix A). After
reading the problem, teams worked together to list what
they knew based on the information they have been given, what they needed to find out, and identified any additional learning issues. One student was designated as
the scribe to write down key points of the discussion and
make notes to distribute to the rest of the groups. Another
student was selected to be the leader to guide discussion
and make sure everyone stayed on track. This activity was
completed in class.
In addition to the warm-up PBLs, students learned about
and practiced several reading strategies appropriate for
students in kindergarten through sixth grade during the
first six weeks of class. Brief case studies of individuals
were also given out and analyzed by the PBL teams to
determine appropriate reading strategies to use with each
case. Three research articles were selected by the instructor to lay the groundwork for students to begin thinking
about several aspects of the PBL. Students responded to
the articles using the Six Habits of Comprehension (Zwiers, 2006). This process was previously modeled by the instructor and practiced by the students (Appendix B). As
students worked toward solving the PBL, more research
was initiated through the collaborative teams. A group
discussion portal was set up for each team to post articles,
comments, and notes from previous meetings, and allowed students to have virtual meetings and discussions
outside of class meetings.
The actual PBL was given to teams during the sixth week
of class (Appendix C). Five more articles were assigned
and as students worked toward solving the PBL, more research was initiated and sought through the collaborative
teams. A group discussion portal was set up for each team
to post articles, comments, and notes from previous meetings.
Fall 2013 (Volume 9 Issue 2)

Transitioning to the Real World Through Problem-Based Learning:A Collaborative Approach to Teacher Preparation

At the end of the semester each team presented its final


project to the class. Although all teams had the same
problem, each project was unique. Teams successfully
identified the problems and determined a variety of ways
to address them based on their research. District teaching guides developed by the teams provided strategies for
improved reading instruction based on research and state
standards.
As teams presented their projects it became clear that students had learned to link research-based reading strategies
to state standards and classroom instruction. Projects indicated an understanding of the purpose of assessments.
The rubric given to students early in the development of
the project assisted them as they planned and explored
the research (Appendix D). While carefully reading and
assigning a score to each project with this same rubric,
the significant learning fostered by the PBL became even
more evident. The writing was fluid and thoughtful. Academic language was used appropriately and woven seamlessly throughout all aspects of the project.
In addition to the reading content knowledge students
gained through this process, they were also compelled
to think about and address other facets of teaching they
will likely encounter in their own schools and classrooms.
Students learned how to collaborate and work as a team.
They had to think about involving parents, soliciting their
input, and keeping them informed not only about their
childs progress, but also about curriculum decisions.
They learned how to address successes as well as failures in
an inclusive, tactful manner.
As the demands and expectations of beginning teachers
increase, teacher preparation programs must continually
look for relevant ways to prepare teacher candidates. Utilizing PBLs in a reading methods course is one strategy
that can encourage active learning, creative thinking, and
practical application.
REFERENCES

Dewey, J. (1944). Democracy and education. New York:


The Free Press.
Felder, R., & Brent, R. (2004). The intellectual development of science and engineering students, Part 2:
Teaching to promote growth. Journal of Engineering
Education, 93(4), 279-291.
Flynn, L. (2008). In praise of performance-based assessments: A teachers outlook on testing is changed after
students are assessed through hands-on tasks. Science
and Children, 45(8), 32-5.

Journal of Learning in Higher Education

Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge: Cambridge
University Press.
Levine, N. (2001). Energizing teacher education and professional development with problem-based learning.
Virginia: Association for Supervision and Curriculum
Development.
Polyzois, I., Claffey, N. and Mattheos, N. (2010). Problem-based learning in academic health education.
A systematic literature review. European Journal of
Dental Education, 14: 5564. doi: 10.1111/j.16000579.2009.00593.x
Walker, A. & Leary, H. (2009). A problem based learning
meta analysis: Differences across problem types, implementation types, disciplines, and assessment levels. Interdisciplinary Journal of Problem-based Learning, 3(1),
6-28.
Wood, D. (2003). Problem based learning. British Medical Journal, 326(7384), 328-330. Retrieved from
http://www.ncbi.nlm.nih.gov.ezproxy.lib.apsu.edu/
pmc/articles/PMC1125189/
Zwiers, J. (2006). Building reading comprehension habits
in grades 6-12. Newark, DE: International Reading
Association.
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

Lisa Barron and Lauren Wells

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:

Stopping By Woods On a Snowy Evening


Whose woods these are I think I know.
His house is in the village though;
He will not see me stopping here
To watch his woods fill up with snow.
My little horse must think it queer
To stop without a farmhouse near
Between the woods and frozen lake
The darkest evening of the year.
He gives his harness bells a shake
To ask if there is some mistake.
The only other sounds the sweep
Of easy wind and downy flake.
The woods are lovely, dark and deep.
But I have promises to keep,
And miles to go before I sleep,
And miles to go before I sleep.
1. In one to two sentences state the main idea of the poem, then write a summary of the poem.
2. Do you have any schema (prior experience or knowledge) that helps you understand the meaning of the
poem? Describe your experiences.
3. What inferences and predictions did you make as you read the poem?
4. What questions do you have? What answers do you have?
5. What strategies did you use to understand word meaning?
6. What steps did you take to monitor your comprehension?

16

Fall 2013 (Volume 9 Issue 2)

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.

Journal of Learning in Higher Education

17

Lisa Barron and Lauren Wells

Appendix D
District Teaching Guide PBL

Identifies the problem and six sub


problems.
Thoroughly addresses how each
deficiency will be addressed. Research is provided to support each
decision.
Includes several state standards
that are aligned with the strategies
included in the teaching guide.
Includes several methods to integrate reading into other subject
areas. These methods are supported
with research.
Thoroughly describes how student
learning will be assessed to determine if the plan is working.
Includes a detailed plan to initially
inform parents of the curriculum
change. More than one method to
inform parents is included.
Clearly addresses how parents will
be informed of their childs progress in the new curriculum.

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.

Includes a few methods to integrate


Does not include methods to inreading into other subject areas.
tegrate reading into other subject 10
There is little research to support
areas.
decisions.
Provides a general description of Fails to address how students will
10
how students will be assessed.
be assessed.

Includes a general plan to initially


inform parents of curriculum
change. Only one method to inform parents is included.
Lacks specifics about how parents
will be informed of childs progress.
Is not clearly written and contains
Is well-written and free from spellsome spelling and grammatical ering and grammatical errors.
rors.

Does not include a plan to inform


10
parents of curriculum change.
Fails to include information about
how parents will be informed of 5
childs progress.
Is poorly written and contains several spelling and grammatical er- 10
rors.

GROUP PBL PRESENTATION:

Is creative and all team members


participate. Team uses a visual aid
and provides a handout to audience.

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.

Fall 2013 (Volume 9 Issue 2)

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

Intcrnmiotial Mcdiciil Journal Vol. 17. No. 2. pp. 1 0 3 - 1 0 6 . June 2010

Im

HEALTH & ENVIRONMENT

Developing Skills in Problem Based Learning


Facilitation: An Insight
Nabishah Mohamad", Robert Chen^', Ilina Isahak
Harlina H Siraj', Srijit Das^

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-

comes outlined are achieved'".


Premier Institutions in Malaysia like Universiti
Kebangsaan Malaysia (UKM) had the PBL curriculum
itiiplemenied since last 20 years and had also undergone
enarmous changes. Variations in the way the PBLs wcte
tondueted by individual facilitators are expected.
Therefore, training of PBL tutors was crucial in en.suring
successful implementation of the curriculum^'.

MATERIALS & METHODS


A need analysis was conducted as part of the preparation lo implement the new curriculum. This revealed that
67% of the staff had indicated that they required further

Reeeived on June 23, 2009 and accepted on August 31. 2009


I ) Deparlment of Medieal iiducation. LIniversiti Kebangsaan Malaysia Medical Centre
2) School of Medicine & Health Sciences. Monash University
3) Department ol Microbiology. Universiti Kebangsaan Malaysia Medical Centre
4) Department oT Anatomy. Universiti Kebangsaan Malaysia Medieal Centre
Correspondence to: Nabishah Mohamad
(e tiiail: nabishahmoPyahoo.com)

2010 Japan International Cultitral Exchange Foundation

104

Nabishah M. et al.

Table 1. Inrormation on the workshop


Number of work.shops conducted
Duration of each workshop
Number of participants per workshop
Total tiuniber of participants registered
Number of participants wbo completed tbe training
Number of participants attended hui did not complete the training
Number of participants who did not turn up
Total number of trainers involved

training on how to facilitate a PBL tutorial. A total of 20


work.shops were conducted between 2005 and 2008. These
workshops ran for 2 days. Feedback from participants was
obtained iit the end of each workshop. Workshop activities
included demonstration of the PBL tutorial, facilitator
training sessions and lectures.

20
2 days
6-12
191

173
9
9
20

to workshop participants and were analyzed. A 15-itcm


questionnaire covered each of the workshop activities as
well as the facilities provided during the training sessions.
Satisfaction was rated as "0* to ' 5 ' whete '0" was "disastrous" and "5' was considered as "excellent". The questiiinnaire was validated as one of the earlier study on patient's
health in this region had stressed upon the importance of
such validation*^.

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

Developing Skills in Prtiblem Based Learning Facililation

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.

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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.

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
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

CONTEXT Tutors in problem-based learning


(PBL) tutorials have a complex role to play in
facilitating students learning. This includes
providing support for students acquisition of
content knowledge and skills in critical thinking, coaching of group processes and modelling of reflective practice. Few studies which
investigate the key role of tutors in the PBL
tutorial process are qualitative in design.

RESULTS Three main themes arose from the


inductive analysis of qualitative data: (i) role
confusion by tutors; (ii) tutor management of
sensitive issues, and (iii) facilitation style.
The theme of tutors facilitation style was
dominant and three sub-categories were
apparent. These were: (i) managing the
learning in PBL tutorials; (ii) facilitating group
processes, and (iii) guiding group discussion.

METHODS This study explores the nature and


technique of facilitation provided by PBL tutors
from the students viewpoint. Data were
obtained from written responses to an openended question asking students about the
effectiveness of their PBL tutor(s) and from
in-depth interviews carried out with two
randomly selected students.

CONCLUSIONS Findings highlight the need


for tutors to regularly review the PBL tutorial
processes and group dynamics within the
tutorial setting. These findings have implications for tutor training and programmes of
ongoing professional development for PBL
facilitators.

Medical Education 2009: 43: 377383


doi:10.1111/j.1365-2923.2009.03293.x
1
Discipline of Medical Education, School of Medicine, University of
Queensland, Brisbane, Queensland, Australia
2
School of Biomedical Science, University of Queensland, Brisbane,
Queensland, Australia

Correspondence: Dr Tracey Papinczak, Discipline of Medical


Education, School of Medicine, University of Queensland, Herston
Road, Herston, 4006 Queensland, Australia.
Tel: 00 61 7 3365 5548; Fax: 00 61 7 3365 5522;
E-mail: t.papinczak@uq.edu.au

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T Papinczak et al

INTRODUCTION

The University of Queenslands graduate-entry


degree in medicine the Bachelor of Medicine and
Bachelor of Surgery (MBBS) incorporates a problem-based learning (PBL) approach. With its strong
emphasis on active and self-regulated learning
undertaken within collaborative small groups, PBL
incorporates many factors required for powerful
learning environments.1 A key element of successful
learning in PBL tutorials is the provision of instructional support scaffolding to assist students.2
Scaffolding occurs when an individuals learning is
mediated by another person, predominantly by providing structure to the learning, along with supportive communication.3 This definition best describes
the concept of scaffolded instruction as utilised
within the MBBS programme. Although the concept
of scaffolding can take many forms,4 in its widest
sense it refers to support for all aspects of the
learning experiences in PBL tutorials.
Based on the existence of a zone of proximal
development as proposed by Vygotsky,5 scaffolding
of learning involves the structuring of questions, tasks
and processes by the PBL tutor (or more knowledgeable peers) as part of social interaction and
dialogue within the tutorial group. Scaffolded
instruction comprises a number of key tasks, including: asking strategic questions; ensuring learning is
taking place at the metacognitive level; keeping the
learning process moving forward at the appropriate
pace; recognising problems and assisting students;
challenging students understanding; facilitating student exchanges; modelling and coaching, and modulating the task to meet student requirements.6,7
Initially, scaffolding is established to provide a
supportive structure in which students can learn
about learning (metacognition) and about the process of PBL. This guided practice is then gradually
withdrawn as students establish competence,
confidence and autonomy.
Thus, it is the PBL tutors role to facilitate and
activate the group of learners in much the same way
as a symphony conductor does an orchestra.2 Barrows6 describes this as modulating the challenge of
learning. By guiding and supporting students learning, the tutor becomes both the steward of the group
process and the metacognitive coach.8 Margetson
suggests that scaffolding of critical thinking requires
the tutor to question, probe, suggest and challenge
students understanding and to support reflection on
learning.9 The maintenance of group processes,

378

considered to represent a balance between supportive


and more directive approaches, is also important to
sustain focus and support group interaction.6,8,9
The relationship between the tutor and
student should be collegial and collaborative.
Authoritarian attitudes are particularly inappropriate as PBL is a co-operative, reflective and
critical educational approach.8,10 Tutor intervention
should be based only on the need to ensure
students approach a problem appropriately, to
challenge students assumptions and to facilitate
reflection on both what has been learnt and the
dynamics of the group.10,11 The complex and multiskilled nature of their scaffolding role makes it
likely that some tutors will be unsure of how to
determine an appropriate balance between too
much and too little structure with each unique
PBL group.
The conceptions of teaching held by tutors can
influence their perceptions of their role within the
tutorial setting. Gow and Kember12 explain that two
prevailing conceptions of teaching are evident:
learning facilitation (where teachers scaffold the
learning), and knowledge transmission (where
teachers adopt a didactic, more authoritative
approach). Research has shown that tutors who rate
themselves as content experts struggle to maintain a
scaffolding role and tend to lapse into didactic
approaches more frequently than tutors with less
content expertise.13 Making the transition from a
more traditional teaching role to that of a PBL tutor
is inherently difficult as new skills must be acquired
and multiple roles redefined.14 These skills, as
described by Barrows,6 include: supporting
metacognitive development, strategic and reflective
questioning; modulating the challenge of the
learning to meet student requirements, and
monitoring students educational progress and group
dynamics. The traditional didactic function of
teacher must be replaced by a multi-faceted role of
mentor, coach, model and guide.8,9
The purpose of this study was to explore students
perceptions of the effectiveness of their tutors in
managing the PBL process and the learning
within the tutorial. It was anticipated, based on
past experience, that tutors efforts to find the
right balance in their scaffolding roles would
attract student comment. A small number of
qualitative studies focused on students perceptions
of their PBL tutors have been published. These
include a study that gathered Taiwanese students

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Facilitation in problem-based learning


perceptions of good tutor traits,15 and studies
that collected information on what expert and nonexpert tutors do in PBL tutorials,16 how the smallgroup process is evaluated,17 the strengths and
weaknesses of PBL and traditional medical education,18 and student stressors in adapting to PBL.19
Few qualitative studies give medical students freedom
to comment anonymously on any aspects of PBL tutor
effectiveness about which they feel strongly.

facilitation styles. These data were used to triangulate


findings from the study of written feedback.

RESULTS

Three main themes arose from inductive analysis


of data: role confusion by tutors, management of
sensitive issues, and tutor style.
Role confusion

METHODS

Participants were students in the first 2 years of the


MBBS programme during 2007 (n = 695). Students,
in small groups of eight to 11, undertook 5 hours of
PBL tutorial time each week for 36 weeks of the year.
Working in collaboration with group members, students analysed a problem of practice, formulated
hypotheses, and conducted self-directed learning to
try to understand and explain all aspects of the
patients problem. The majority of Year 2 PBL tutors
were clinicians, but Year 1 PBL tutors comprised
approximately equal numbers of clinicians and
non-clinicians.
Data were obtained from written responses to an
open-ended question asking students about the
effectiveness of their PBL tutor(s). This data collection method was chosen in order to gather a large
number of responses that reflected students principal perceptions of tutors facilitating their PBL
groups. Although all students were invited to give
anonymous written feedback, comments were
received from 295 students, representing a response
rate of 42.4%.

There was a perception that some tutors were caught


in role confusion in that they were unable to find a
consistent style of facilitation with which they were
comfortable. Clearly, some students found inconsistent tutor scaffolding, where tutors lapsed into a
didactic and regulatory role at times, impacted on the
PBL environment. One Year 1 student made her
frustration overt:
If [the tutor] chooses to act with discipline, she
needs to follow that role the whole time and not
stand back sometimes!
Occasionally, students were themselves unclear or
confused about the role they wished tutors to take
with their PBL groups:
The tutor takes a controlling and teaching position,
which is sometimes good; but I think things would be
better if she took a more relaxed approach and
allowed us to talk through the problem [further]
without telling us the answer.
Management of sensitive issues

Anonymous written responses were compiled into a


common document. The constant comparison
method promoted by Glaser and Strauss20 guided
data analysis. As themes appeared, comparison
occurred across the categories and with previous
research findings. This inductive approach enabled
relationships to be uncovered and conceptualisations refined. In order to improve reliability,
independent coding was undertaken by two
researchers. With such a large sample size, data
saturation was reached.

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:

In order to provide richer and more thorough


descriptions, in-depth interviews were conducted with
two randomly selected students, one in Year 1 and the
other in Year 2. Both students were simply asked to
describe their experiences with PBL tutors in their
tutorial groups. Comments clearly focused on tutor

I think all students see their PBL tutor as a role


model to some degree how they react to
situations, intervene in certain situations is important. How a tutor reacts will dictate how a student
behaves and what they believe is appropriate and
inappropriate.

Some sensitive issues arose during our group discussion and the consensus was that our tutor handled
these expertly and confidentially and with aplomb...

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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.

group to get off track for significant lengths of time,


overly relies to students, allows the group to modify
the PBL process as they see fit and provides
minimal guidance.
A much larger proportion of qualitative data was
critical of tutors with overly directive styles. Students
seemed much more critical of tutors who were
controlling of the PBL process than those who were
more laid back. Some comments include:
I feel at times [the tutor] would take too much
control over the flow of PBL instead of allowing
the students to work through the process themselves.
He was encouraging about certain things but often
dominated...
I would recommend that [the tutor] allow us to
exhaust our hypotheses before he intervenes and
suggests his hypotheses to ensure we have explored
all possible spheres. [These actions] reduced the
effectiveness of our PBL process dramatically by
preventing students from hypothesising [widely]...

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

[The tutor] should be more flexible. [He had a]


tendency to beat a dead horse. We dont know or we
know, either explain, find out or move on. He held
up too much.
An in-depth interview revealed one students perceptions of what he labelled the proceduralist tutor,
one who is inflexible and unwilling to reflect on the
quality of the learning taking place:
Proceduralists follow the PBL process to the letter,
do not recognise differences in group dynamics and
individual learning styles, and are more concerned
with the sequential completion of tasks than the
quality of the thought processes behind the
information covered by the group. They are more
willing to accept formalised presentations than
organic discussions of key concepts.
Those tutors who seemed to find the right balance in
scaffolding the learning were valued by students:
[This tutor] is a really supportive tutor who provided
effective guidance while allowing the group
self-directed learning...
[Her] teaching style fitted very well with PBL forms
of learning. Asked more questions than gave
information. Supportive. Encouraging...

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Facilitation in problem-based learning


I thought [the tutor] was fabulous very supportive
and respectful and flexible within the group. She let
us run the group as we wanted, but would put us
back on track get us to consider something we had
missed.
Scaffolding of group processes
The second theme centred on the facilitation of
group processes. One aspect of the scaffolding role of
tutors was seen to involve the provision of a framework of respect and responsibility within which group
members can function. It seemed that some tutors
either expected the group to sort out their own
management issues or lacked the awareness and skill
necessary to scaffold this process. One Year 2 student
in the final block of the year commented that the
tutor needed to focus on:
Discipline [the tutor needed to] enforce all group
members to respect each other and be quiet when
others are talking and all members to participate.
Another Year 2 student noted that:
A few people dominate group explanations and
seem very derisive dismissive of other peoples
knowledge this should have been stopped very
early.

discussion. Tutors who found the right balance in


their scaffolding role were valued for their skill:
[She] was an excellent tutor. She used her clinical
knowledge to guide us in the right direction with our
discussion, while still allowing us to use our own
knowledge and apply it to the situation. She challenged us to think beyond the obvious...
In my opinion, the ideal tutor is one who is able to
ask questions of the group that stimulate discussion
and highlight areas of current knowledge and gaps in
the knowledge of the group. However, they need to
be able to bring the discussion back on track when it
is straying off course. The best tutors have been
very judicious with their use of explanation or
teaching; instead, they have demonstrated a mastery
of questioning to guide discussion, often reflecting
questions asked by a student back to the group,
evaluating the answer and supplementing or
moderating it, rather than simply answering
questions.
Students were quite critical of tutors who intervened
too often, even if the information was clinical:
maybe if he concentrated on what we need to
know now, not relaying on [to] us his own extensive
knowledge...

The need for greater tutor control over group


processes was highlighted and was perceived as
including the moderation of disagreements, promotion of courtesy and respect for others opinions, and
support of good work habits. Students noted that
their tutors should be:

He offered clinical experience but often it was quite


irrelevant and took us off track.

stepping in when people talk over each other,


when people have disagreements that impact on the
groups functioning and learning...

wasted a lot of time [talking about] irrelevant


information, personal experience, family life and
medical problems

[making sure that] the group be made to focus, as


much as we like to think idealistically.

shouldnt have intervened so much, or tried to


take over as much. She was quite enthusiastic and
encouraging, but she went off on way too many
personal tangents.

Scaffolding group discussion


The final category within the theme of tutor
style reflected the balance that tutors must find
between providing relevant information to keep
group discussion focused and relevant and
allowing the session to evolve in line with the
self-directed nature of PBL. Some tutors appeared to
interject too frequently (either with relevant medical
information or with personal reflections), whereas
others held back information, to the detriment of the

Tutors who interrupted with personal medical stories


were not seen as helpful. These medical students
commented that their tutors:

Those tutors who failed to scaffold the process of


discussion and debate by refraining from providing
any information were judged just as harshly. One
student commented that the tutor needed to:
allow a freer flow of ideas and discussion, intervening when it was clear that the group had reached
an impasse, or did not have information necessary to
continue.

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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.

Scaffolding of learning, group processes and group


discussion were all richly described, both in a
positive sense for skilled tutors and in a critical
manner for those perceived as being less skilled.
These findings strongly emphasise the key role that
tutor scaffolding plays in the learning experiences
of students in PBL tutorials, which research shows
can flow on to enhanced enjoyment, motivation
and achievement.15,23

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

It is important to consider the influence of context


when appraising students perceptions of tutor scaffolding. Dolmans et al.24 describe a tutors performance as a situation-specific rather than a personal
trait, sensitive to the demands of the student group. It
is probable that more effective tutors moderate their
style of facilitation to best meet the teaching situation, whereas less effective tutors either fail to
recognise the need for moderation or maintain a
preferred style in a context-independent manner.
Research shows that PBL tutors who perceive their
teaching styles to be facilitative and collaborative are
often perceived by students as being more assertive
and less facilitative.25 Therefore, tutors whose styles
were evaluated as controlling may, in reality,
consider themselves quite facilitative tutors.

In this study, students shared their personal


observations of three aspects of the tutors role in
facilitation. Firstly, some tutors were perceived as
being caught in role confusion, with no clear or
consistent approach to scaffolding the PBL experience. Furthermore, some students were equally as
confounded in their expectations of scaffolding.
Didactic approaches are more familiar to most of
these postgraduate students and PBL represents a
less familiar and possibly more stressful way of
learning.21 Conway and Little22 describe a comfort
zone in which both students and tutors operate,
but which is challenged as facilitators learn to let go,
attend to group dynamics, and find a balance
between supporting students learning and letting
students learn to embrace self-directed learning.
Secondly, the manner in which tutors were able to
deal with sensitive issues attracted comment. The
scaffolding provided by PBL facilitators must extend
to the modelling of appropriate ways for future
medical professionals to handle potentially embarrassing or awkward scenarios. This finding is unique
and represents a challenge to tutor training
programmes to develop ways of instructing tutors
in modelling practices for just such situations.
Finally, the majority of reflections on tutor scaffolding focused clearly on the theme of facilitation
style. It was clear that many tutors found it difficult
to attain or maintain a balance between directive
and less directive approaches to facilitation.

382

Findings may not generalise to other contexts,


including students and tutors in undergraduate
medical programmes. The bias associated with the
fact that we received comments from less than 50% of
students in the sample represents a limitation to this
research. Reactivity, which can present a threat to
validity, was minimised through data collection techniques which preserved anonymity. Validity of findings was supported by data triangulation through the
use of in-depth interviews with two randomly selected
students.
The results of this study have implications for tutor
training and programmes of ongoing professional
development. It is clear that Barrows vision6 requires
PBL tutors to regularly review the learning and group
processes within PBL tutorials and to engage in selfevaluation of performance. Tutors need to be made
aware of their need to take up this important
responsibility and supported in doing so. Barrows6
highlights the need for all parties to be frank, open
and constructive in their reflections. Such an
approach would pave the way for students and tutors
to engage in productive dialogue about scaffolding
expectations within PBL tutorials.

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Facilitation in problem-based learning


The ability to monitor and adjust the pace, the
cadence and the rhythm of the learning process2
represents not only a complex skill but one that must
be practised and refined. Like the symphony conductor, the effective PBL tutor activates and motivates
his or her students to support their cognitive growth.
Further qualitative research is needed to gain further
insights into students and tutors experiences and
expectations of scaffolding.

Contributors: all authors contributed both to the research


processes and to the drafting and final editing of this
document.
Acknowledgements: none.
Funding: none.
Conflicts of interest: none.
Ethical approval: This study was approved by the University
of Queensland.

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383

Bibliography #5

ORIGINAL RESEARCH

Facilitating the Integration of Problem-Based


Learning in Radiologie Science Education:
The Role of the Educator
Nina Kowalczyk, Ph.D., R. T.(R)(CT)(QM), FASRT

ABSTRACT

This qualitative research study examines the role of


the educator in a problem-based learning program.
Course observations and interviews were conducted
with nine skilled educators at McMaster University,
Hamilton, Ontario. In determining how to implement problem-based learning, critical decisions must
be made about curriculum design and faculty development. Problem-based learning is a self-directed,
learner-centered teaching method, and the educator
serves as a facilitator. For faculty to make the transition to problem-based learning and fuUy embrace
the concept, educators must believe they have the
skills and resources to facilitate the process. Strategies for successful implementation of problem-based
learning into radiological sciences are discussed.

A s THE LEVELS OF ACADEMIC REQUIREMENTS COn-

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

Nina Kowalczyk, Ph.D., R.T.(R)(CT)(QM), FASRT,


is Assistant Professor/RA Clinical Coordinator,
Radiologie Sciences and Therapy, in the School
of Health and Rehabilitation Sciences at The
Ohio State University in Columbus. She may be
contacted at Nina.kowalczyk@osumc.edu.

Facilitating the Integration of Problem-Based Learning 3

4 Radiologie Science & Education ^\7{^)u\y20^2


development and student assessment in order to create effective problem-based learning activities in the
radiologie sciences. These findings imply clearly that
educators are vwlling to use problem-solving teaching
strategies if the necessary resources are readily available for implementation of this learning method.

Small-group activities allow students to


connect with the experiences of their
classmates, thus encouraging a deeper
learning by making sense of different
viewpoints and leading to supportive and

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

collaborative learning relationships.

to provide explanation and elicit appropriate action.


Self-directed learning (Knowles, 1970) requires each
student to be fiiUy engaged in becoming competent
by designing and reflecting upon the learning experiences in a personal manner.
Learning in small groups of 5 to 10 students and
a facilitator is the method of choice in implementing PBL (Kowalczyk, 2011). Small-group activities
allow students to connect with the experiences of
their classmates, thus encouraging a deeper learning
by making sense of different viewpoints and leading
to supportive and coUaborative learning relationships.
Experiential learning places responsibility upon the
educator to serve as a facilitator providing "an environment of trust, authenticity, integrity, and mutual
respect" (Fenwick, 2003, p. 109). In PBL, the facilitator acts as a resource while the students reflect and
work through the PBL process.
In the purest sense, PBL requires an entire curriculum organized around problems relevant to learning outcomes versus a curriculum organized by topics
or disciplines, and it is applicable to both classroom
and clinical settings (Rideout, 2001). However, this is
not a viable option in the radiologie sciences for a variety of reasons; thus, a hybrid approach, in which the
curriculum includes a combination of courses, offered
utilizing a traditional teaching approach and utilizing
a PBL teaching method, may be the suggested model
for education in our professions. This requires a revision of the curriculum, allowing course content applicable to PBL to be identified and integrated from
a variety of topics typically taught in discrete courses
within the educational program, and it also requires a
major shift in the teaching methods employed.

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

Facilitating the Integration of Problem-Based Learning 5

of the PBL process and the role of the facilitator is


the first step in making a transition to a hybrid curriculum design. For PBL to be effective, the role of
the educator must change from a traditional didactic
lecturer to a facilitator of student-directed learning.
Therefore, the purpose of this research is to describe
the role of the facilitator and the faculty training necessary to prepare educators for this role.

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

a philosophy of problem-based learning in 1977, and


all programs within the College of Health Sciences
continue, to this day, to be committed to this philosophy of self-directed learning. Although each program
within the College of Health Sciences embraces this
philosophy, each professional program has adopted a
distinctly unique approach to PBL in their specific
discipline. This study specifically focuses on the PBL
process within the School of Nursing.
In determining how to implement the philosophical process of PBL, decisions must be made about
group size, group composition, group development,
and group interaction. Emphasis must be placed on
the benefits to be gained in learning outcomes. This
requires a very structured approach to the group design, including creating groups of students with a
variety of clinical experiences. The difference in livedexperiences of the group members enriches the group
activity and encourages a deeper level of experiential
learning. It is also critical for the facilitators to clearly
understand constructivism from Vygotsky's (1978)
perspective relative to the importance of peer interactions within a socio-cultural environment. This is
critical, as it is this socio-cultural relationship that
leads to deep learning. Therefore, as students progress through the PBL process, the group assignments
change each year so that students and educators do
not become dependent upon a symbiotic relationship.
This was explained by a faculty member of the McMaster School of Nursing as follows:
Faculty need to understand the pedagogy "will not
do the reenactment. If they do not understand the
difference between surface and deep learning, they don't
understand learningfrom Vygotsky or others; then
they only skim the surface. What we try to do is to get
faculty involved in case scenario development so they
understand the depth. This is the challenge ofPBL-based
learning and competency based learning. Some people
think there is no structure, but there has always been
structure because there have always been aimsfor that
team. There have always been learning outcomes.

As mentioned above, the educator plays a very


critical role in implementing a successful PBL program. Individuals serving as facilitators in the PBL
process work closely with the PBL course planners.
The course planners are responsible for coordinating
all of the small group classes to ensure the same content is covered in each course. Each facilitator is given
a tutor-guide, created by the course planner, to help
them direct the process. The tutor-guide includes
key concepts, required readings, case scenarios, chart

6 Rad/o/og/c Science & Education 17(1) July 2012

information, internal and external resources, related


theory, and ideas for collaborative activities. One of
the course planners explains how the facilitator is a
part of the group, but she also shares resources at set
times to keep the group on task and headed in the
correct direction.
The students and facilitator read the scenario as a
group, and they do mind mapping or brainstorming to
determine what they know and what they don't know.
Once they have been through that, then thefacilitator
can share the chart data with them to help validate
where they are going or to help shift their direction.

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

building knowledge in multiple areas during the


PBL process. The nursing students are introduced to
theory in the first term of the first year of the program. Theory-to-practice is facilitated in the second
and third year PBL courses through research. By the
time the students are at the senior level, the expectation is that they actually use theoretical models when
they are facilitating the PBL sessions. One informant
provides this example:
We have placed each of those skills at specific points.
We have integrated a session on theory, so ourfocus in
discussions can begin to have a more theoretical basis.
There may be theoretical concepts and frameworks that
relate to what we are talking about depending upon
where that learning is going. In level 2 we introduce
leadership, 'Where does that fit and what is my role
in it?' We include other concepts such as diversity and
advocacy. We have a curricularplan and we use that
as a roadmap as to what concepts we are working to
develop, and some greater than othersfor each year. ...
The emphasis of when theory is greater is scaffolded, so
in level 4, theory is greater because students are more
prepared to dialogue at the level. If you get at a very
high theoretical level, it can be very abstract and they
are not readyfor that at the beginning stages of the
educationalprogram. They are still trying to gain their
skills and understand what it means to be a nurse, what
their role is and what other roles are; over time they can
develop that higher level of thinking.

The Role of the Facilitator


Implementing problem-based learning requires a
major shift in the role of the educator. Since this educational approach is self-directed, learner-centered
instead of teacher-centered, the role of the educator
is to serve as a facilitator in the learning process. In
this role, the facilitator is very much an equal participant of the group, as well as an observer. Facilitators
must be comfortable with giving up some control of
the learning. This is a difficult shift for many educators, especially if they were not educated in this manner. However, educators must be held accountable
for adapting their educational approaches based on
scientific evidence of the best practices to both their
academic institutions and to their students. One experienced faculty member shared this insight:
Letting go of control and letting go of power, some
faculty are not comfortable... There is a real shift in the
educational environment, at least in North America
and certainly in Europe, about accountability, and that
is about accountability that you are doing best practices,
not only in your research, your commission work, but

Facilitating the Integration of Problem-Based Learning 7

also you are doing it in your education. That whole thing


about scholarship in teaching has become much more
relevant. I can't teach how I've taughtfor the last 15
years without reflecting and contemplating new ideas. I
think that is really important.

Educators play a key role in modeling behavior


to help students develop critical thinking skills and
become life-long learners. This implies that students
must be given the responsibility and accountability for self-directed learning. Role modeling is even
more important when using PBL groups larger than
5 to 7 individuals to ensure quality group dynamics.
If graduates are expected to demonstrate these behaviors, they need also to be given the opportunity to
practice these behaviors as students in a safe environment. As the students become comfortable with the
setting, expectations, and group dynamics, they begin
also to model behavior to one another and evaluate
the group dynamics. It was quite evident through my
observations in 4* year PBL courses that facilitators
did model this behavior earlier in the educational
process. The 4* year students observed in this study
served as excellent facilitators in the PBL process.
Tutors have to role-play life-long learning; they have
to play out the questions and say, "I don't know the
answer to that question" or "Is that my opinion you just
heard," or "Did I base that on evidence?" "Do you think
we couldfindevidence, or is thatjust an opinion, and
where does it comefrom?"
If we really expect them to show leadership behaviors
when they leave the program, then we need to give them
the opportunity to lead and not be successful, without the
tutor rescuing them in a safe environment.
Modeling, role modeling, and labeling are very
important. Students need to know exactly what the
tutor is doing, so we must label clearly. Sometimes
weforget to do that... we know in our mind we are
asking some critical questions, or engaging them, or
trying to synthesize content, but we need to label these.
The expectation is, by level 4, the students will take on
that role. And so, where in our process have they picked
up the pieces ofthe role, and where do they learn to
actually act out the role? In level 2, what we have done
is we have created a co-facilitator type role, so we have
started to develop a process where students take on half
responsibility in facilitating the group, and hoping to
get them more comfortable before level 4. We are still
working on that level of participation.
Absolutely, they come up with their own learning...
they are not given that in level 4 or level 3. But in
level 1 and level 2 they are morefocused so the tutor can
model for them and the students can learn to be more

independent, to come to those realizations... "What is


important? What is the priority? What do we need to
look at in this case?" That gives the student some kind of
satisfaction, right?"

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?

Early in the learning process, a skilled facilitator


knows to wait and allow students to find their own
way, however this may be difficult for educators new
to PBL. Keeping the focus on learner-centered education may appear difficult when students are struggling. It is also important for the facilitator to know
each student well and be able to monitor student

8 Radiologie

Science

& Education

17{I)\u\y20n

development and achievement on a weekly basis.


During the first year of the program some students
have a very difficult time with PBL and self-directed
learning. The McMaster University nursing program
acknowledges this and assigns the most skilled facilitators to the first-year PBL courses. Facilitators are
responsible for helping students at an individual level,
as well as at the group level, and they are accountable
to counsel students and set concrete performance expectations, if necessary. Additionally, the facilitator
must feel comfortable and confident in monitoring
and helping to direct the group interactions.
Faculty Training and Support
One of the major successes of McMaster University
College of Health Sciences is the superb faculty support system. Faculty development is offered through
workshops within the College of Health Sciences and
within the School of Nursing. In order for faculty to
make the transition to PBL and to fully embrace the
concept, educators must believe they have the skills to
facilitate the process. Therefore, understanding that
nursing faculty come from very different backgrounds
and addressing individual needs is crucial. The faculty
workshops are intended to help new faculty become
better educated regarding the PBL process and more
comfortable with the process of being a facilitator
in the small-group PBL environment. One faculty
member who participates in faculty development
shared this insight:
This is one of the most diffcult challenges that faculty
experience when they movefrom feeling like.you have
to be everything to everybody at thefront of the room,
"where I have all of the content, I determine the process.
Ido the evaluation, Ido everything. It is a challenge
when you move them to this other model where it is very
much a group decision. You know, you use the guide-bythe-side philosophy instead of the sage-on-the-stage; it
moves the responsibility awayfrom you. You do not have
to know everything. You are a group member and you
are part of that group who decides which direction you
will go. You are the person who coaches and encourages,
and highlights things that may have been missed or may
need to be addressed in more depth. "

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

day, the educators participate in facilitating a mock


PBL group, with a skilled educator monitoring the
process. Educational sessions are also included regarding the use of resources, since the resources play
a large role in the PBL process Although change can
be frightening, faculty have to adopt an open-mind to
appreciate that the way they are accustomed to teaching is not the only way to teach.
Establishing a mentor/mentee program is another
effective component of the training to introduce a
new faculty member to the PBL process. McMaster
School of Nursing offers formal and informal mentorship programs. In the formal process, new facilitators are assigned as co-tutors to actual PBL courses
so they can learn from experienced tutors within the
classroom. Tutor-guides are available for all facilitators at each academic level. These are developed by
the course planner and updated on a regular basis.
The course planner is an experienced educator who
approaches the PBL course from a global perspective.
Tliis individual is responsible for all of the PBL tutors
in one academic level of the nursing program, working closely with the course tutors. The course planners
are ultimately accountable for the student grade assignment, as well as ensuring that the course content,
goals, objectives, and learning activities are met. This
hierarchical arrangement requires collaboration and
helps to equalize the course responsibilities.

Discussion and Conclusions


Information gained from the analysis of narrative
data obtained in this study clearly implies that radiologic educators have much to learn from their nursing counterparts. However, it is critical to understand
that PBL course design is very dependent upon the
area of focus. PBL in nursing is very different than
PBL in the radiologie sciences. Nursing practice is
embedded in the social sciences, but the field of radiologie sciences is heavily aligned with the physical
and biologic sciences. The technologic requirements
of our profession profoundly rely on scientific concepts based in physics, chemistry, anatomy, and physiology. Therefore, our model of PBL is unique, and we
as a profession must determine how it is best implemented.
As mentioned earlier, a scaffold hybrid PBL approach is most appropriate to our profession. Integrating basic elements of PBL into the introductory
radiologie courses is necessary to form the base upon
which the PBL process is built. A conscious effort

Facilitating the Integration of Problem-Based Learning 9

We must find the courage to move from


teacher-centered teaching methods to
methods that develop and encourage
independent, self-directed learning.
must be placed on skill development by incorporating theoretical models of humanistic behaviors such
as team dynamics, leadership, confUct resolution, and
communication into all introductory coursework. As
educators, we must clearly introduce various theoretical models of practice into the curriculum and facilitate group learning. We also must integrate multiple
course subjects into PBL activities in the higher-level
courses requiring students to scaffold or build new
knowledge on previous concepts. This will help students reflect on previous content and experience a
deeper level of learning. Thus students wiU develop
an understanding that professional clinical practice in
the radiologie sciences is based upon integrating all
of the concepts learned throughout the professional
curriculum.
The McMaster nursing program incorporates
PBL based on a 4-year model, thus baccalaureate
level radiologie science programs may be able to use
this model to more easily integrate theory into the
curriculum. But, it may be difficult to envision how
we can utilize the nursing model in 2-year, associatelevel programs. The results of this research indicate
that perhaps just introducing students to the theoretical frameworks and facilitating discussion of how
these frameworks impact upon clinical practice may
result in continued self-development upon graduation. If we emphasize that PBL is inherent in aU
aspects of professional practice, graduates wiU be able
to transfer this knowledge to a variety of clinical situations. Teaching students to engage in group activities whenever an issue or problem arises should set
the base upon which critical-thinking skills are built
and developed through experience.
However, the commitment to PBL requires a
change in our role as educators. We must find the
courage to move from teacher-centered teaching
methods to methods that develop and encourage
independent, self-directed learning. This requires
a willingness to implement best learning methods
based on strong scientific evidence. We must embrace
this change and serve as positive role models as facilitators of learning. Lastiy, this research serves as a first

step in defining the educator's role in implementing


PBL, but additional research is required. We must be
committed to sharing our experiences and expertise
within our communities of practice to develop confidence in our abilities to create an environment in
which our graduates demonstrate the ability to be
successful life-long learners.

References
Constas, M. (1992). Qualitative analysis as a public event:
The documentation of category development procedures.
American Educational Research Journal, 29, 253-266.
Fenwick, T.J. (2003). Learning through experience: Troubling
orthodoxies and intersecting questions. Malahar, Florida:
Krieger Publishing Company.
Glaser, B., & Strauss, A. (1967). The discovery of grounded
theory: Strategiesfor qualitative research. New York: Aldine
de Gruyter.
Knowles, M. S. (1970). The modern practice ofadult education:
Andragogy vs. pedagogy. New York: Cambridge Books.
Kowalczyk, N., Hackworth, R., & Case-Smith, J. (2012). Perceptions of the use of critical thinking teaching methods,
Radiologie Technology, 83{3), 1-11.
Kowalczyk, N. (2011). Review of teaching methods and critical thinking skills, Radiologie Technology, 83{2), 120-132.
McLoda,T. A. (2003). Problem-based learning in allied
health and medicine. The Internet Journal of Allied Health
Sciences & Practice.
Miles M, Huberman A. (1994). Qualitative data analysis.
Thousand Oaks, CA: Sage.
Pew Health Professions Commission. (2000). Recreating
health professionalpracticefor a new century. Executive summary. San Francisco, CA: University of California.
Rideout, E. (2001). Transforming nursing education through
problem-based learning. Sudbury, MA: Jones and Bartlett
Publishers.
Scientific Software Development, (2004). Adas.ti, in. 5.0
[computer program] ed. Scientific Software Development,
Berlin.
The Joint Review Committee on Education in Radiologie
Technology. (2001). Standardsfor an accredited educational
program in radiologie sciences. Chicago, IL.
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.

Nurse Education Today 34 (2014) 5256

Contents lists available at ScienceDirect

Nurse Education Today


journal homepage: www.elsevier.com/nedt

Effects of problem-based learning vs. traditional lecture on Korean


nursing students' critical thinking, problem-solving,
and self-directed learning
Eunyoung Choi a, 1, Ruth Lindquist b, 2, Yeoungsuk Song c,
a
b
c

Chosun Nursing College, Gwangju, South Korea


University of Minnesota School of Nursing, Minneapolis, Minnesota, USA
Kyungpook National University College of Nursing, Research Institute of Nursing Science, Daegu, South Korea

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

logically assess and formulate interventions to impact patient care


(Ozturk et al., 2008; Yuan et al., 2008b). Critical thinking has been
shown to be enhanced by PBL; it enables students to solve problems
in clinical situations and to provide rationale for their actions
(Cooke and Molye, 2002).
Problem-solving abilities have been shown to be better in students
who have received instruction with PBL relative to those who received
instruction by lecture (Uys et al., 2004). PBL resulted in the increase of
students' critical thinking and self-directed learning, which are needed
to solve clinical problems.
Most studies of PBL have focused on its positive effects on critical
thinking (Jones, 2008; Yuan et al., 2008a). Published studies focused on
PBL's effects on problem-solving ability and self-directed learning are
sparse, and the ndings of some of the studies were not signicant or
negative. Choi's (2004) study of PBL versus traditional lecture with 76
second-year nursing students showed that the critical thinking scores
of the students in the traditional lecture group were higher than those
of the PBL group. Several other studies reported no signicant differences

E. Choi et al. / Nurse Education Today 34 (2014) 5256

between PBL versus traditional lecture on self-directed learning or


problem-solving in rst year college students (Lohman and Finkelstein,
2002; Williams, 2004).
Critical thinking and problem-solving abilities are skills viewed as
essential for health professionals as the foundation for clinical reasoning (Hendricson et al., 2006), and the ability to engage in self-directed
learning is important for success of the health professional student
while in school, and in their health career after graduation. Critical
thinking and problem solving are occasionally viewed as intertwined
abilities, and merged into a single construct such as reective judgment or deliberative assessment (Hendricson et al., 2006). Optimal
strategies to promote the optimal development of these abilities
in students remain elusive, and the inter-relationship among these
abilities that are targeted by nursing curricula remains of interest.
In Korea, PBL has been slowly adopted in nursing schools since the
early 2000s, however there have been few studies examining the
effects of PBL on nursing student learning outcomes. Members of
nursing faculties desire to have Korean nursing students receive the
best evidence-based instruction possible to prepare them optimally
for careers as professional nurses. If PBL can be shown to result its
improved learning outcomes in Korean nursing students relative to
traditional strategies, then its adoption is ought to be continued or
accelerated. If, however, PBL is not demonstrated to have outcomes
superior to traditional instructional strategies, then traditional instruction should continue and perhaps other alternative instructional
strategies should be sought and tested. Therefore, the purposes of
this study are to explore and compare the effects of PBL versus
traditional education on critical thinking, problem-solving skills and
self-directed learning ability of Korean nursing students, and to examine the relationship among these learning outcomes.
Background
PBL is a process-focused instructional strategy as opposed to
content-based; as a strategy, it employs small groups that are centered
on solving well-integrated clinical problems instead of large groups as
in traditional instruction, with content delivered mainly through lecture
and limited self-directed learning (Uys et al., 2004). Most investigations
of the use of PBL in nursing have studied its effects on critical thinking,
problem-solving, and self-directed learning (Yuan et al., 2008b;
Lekalakla-Mokgele, 2010; Worrell and Profetto-McGrath, 2007).
Critical thinking is one of the essential core competencies of nursing education to enhance clinical site-based learning and theoretical
knowledge (Ozturk et al., 2008; American Association Colleges of
Nursing, 2007). PBL, as a method of instruction, has been generally
accepted as a standard method of instruction to improve critical
thinking. Tseng et al. (2011) found among 120 nursing students
that the PBL group had higher scores in critical thinking than the
non-PBL group. Cooke and Molye (2002) established that instruction
with PBL motivated students to nd new information, leading to
a more critical thinking. Conversely, Choi (2004) showed that PBL
helped the students' problem-solving but not critical thinking
among second year nursing students. Yuan et al. (2008b) reported
in a published literature review that the PBL instructional approach
was questionable for nursing education due to the lack of large high
quality randomized controlled trials that have determined its effects
on critical thinking.
Problem-solving is recognized as a critical outcome of importance
wherever PBL is mentioned (Solomon, 2005), but studies of the effects
of PBL on problem-solving in the nursing literature are sparse. In one
study by Uys et al. (2004), investigators reported that the PBL group
attained higher levels than the non-PBL group of problem-solving skills
in 128 graduate students enrolled in nursing school. The majority of the
responses of students in the PBL group that were given to the problems
posed reected highly constructive strategies (at the advanced beginner level or above), whereas responses of the students in the non-PBL

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

E. Choi et al. / Nurse Education Today 34 (2014) 5256

scale of 1 to 5 (1 = absolutely do not agree to 5 = absolutely agree).


Total scores have a possible range from 5 to 100, with higher score
indicating stronger critical thinking ability.
The Problem-solving Scale for College Students and the Selfdirected Learning Scale for College Students were developed by Lee
(2003) at the Korean Education Development Institute. Each scale
has responses assessed on a 5-point Likert-type scale (1 = absolutely
do not agree to 5 = absolutely agree). The tool for problem-solving
included 45 items and 5 subscales: Issue specication, cause analysis,
counterproposal development, plan and practice, and evaluation.
The total scores may range from 5 to 225; higher scores indicate
better problem solving. Cronbach's alpha of the developed scale
was .94 (Lee, 2003) and Cronbach's alpha for our sample was .90.
Self-directed learning had 40 items and 3 subscales: learning plan,
practice, and evaluation. The scores may range from 5 to 200
and higher scores reected stronger self-directed learning ability.
Cronbach's alpha of the developed scale was .93 (Lee, 2003) and
Cronbach's alpha for our study sample was .83.
Data Collection and Procedures
Prior to data collection, the protocol was reviewed and ethical permission for the study was received from the university human ethics
committee in Korea. Written informed consent was obtained from
the participating students. The PBL and traditional education program
approaches were conducted over one semester comprising 16 weeks.
Students in both groups completed a demographic form, and critical
thinking, problem-solving, and self-directed learning questionnaires
at the same time, prior to PBL and traditional lecture instruction.
For the PBL group, there were 46 students assigned to 10 PBL
groups; each PBL group consisted of 45 students. The PBL group
worked over 32 h with 4 learning packages developed by the Korean
Nursing College. Each PBL session was 2 h per week for 16 weeks and
was facilitated by a faculty member who taught PBL with nursing
students for 4 years. One scenario held 4 sessions. During the rst
session, students in each group read the clinical scenario (Korean
clinical situation) to identify the major concepts and meaning. A
scenario is provided as an example:
Mr. Park, 80 years old, has worn a long leg cast for 6 days due to a
left femur fracture, lies down in the bed. Mr. Park's daughter
worries he does not move to frequently. She asks the nurse to
explain range of movement (ROM) and the method used to move
him into the wheelchair again.
Based on their current level of knowledge, students and faculty
reviewed the scenario together to conrm the signicant concepts
and problems. During the second session, students in each group
discussed important factors in the nursing scenario and searched for
advanced information using textbooks and the internet and then
presented their work and the faculty encouraged the students to
think critically and gave feedback. At the third session, each group
presented a solution to the problem from the scenario. The faculty
had the students debate their approaches and solutions to the problem to help the students increase their understanding of the issues
within the scenario. Finally, during the fourth session, students
in each group role-played the nurse in similar situations to that of
the scenario. The faculty member then wrapped up the class and
answered any nal questions the students may have had.
The 44 students assigned to the lecture group received didactic
lectures for 2 h per week for 16 weeks on the same content as that
of PBL group: asepsis, safety, activity and exercise, nursing process,
hygiene, vital signs, and environmental health.
Questionnaires were again administered to assess critical thinking, problem-solving, and self-directed learning skills of students in
both groups when the semester was nished.

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)

Fisher exact test for least signicant difference test.

2 (t)

.006a
.327

.744
.085a

E. Choi et al. / Nurse Education Today 34 (2014) 5256

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

Note. PBL = problem based learning.


a
F score is from analysis of covariance with pretest scores as covariates.

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

engage in self-directed learning during their rst year (Kassab et al.,


2005; Lekalakla-Mokgele, 2010; Miin et al., 1999). Conversely,
senior students may feel discomfort if instructors control the learning
(Lekalakla-Mokgele, 2010). That is reected in the ndings of previous
investigators that students respond differently based on the level of
the students' level or year in school. With advancing grade or level of
education, students may expect to gradually become better at selfdirected learning, and may take more responsibility for their education
in a self-directed manner (Kassab et al., 2005).
The correlation analysis showed signicant positive relationships
among critical thinking, problem-solving and self-directed learning.
In order to promote critical thinking, we have to adopt proper educational methods to simultaneously improve problem-solving and selfdirected learning. Additionally, as self-directed learning is so frequently employed in nursing education, critical thinking to solve
problems also will and should be developed.
Limitations
This study has limitations. Results cannot be generalized to other
settings because it was employed with small samples of rst year
nursing students at two junior colleges in Korea. Further research
will be needed to more fully examine PBL as an approach to nursing
education and larger representative samples will be needed. Another
limitation is the non-randomized design and lack of comparability
in the two groups of students. Participants came from two junior
colleges to prevent the contamination between the experimental
and the control groups. However, there were differences between
groups in baseline dependent variables, and thus ANCOVA was used.
Conclusions
Although learning outcomes showed a trend to improve more in
the PBL group as compared to the traditional group, there were not
statistically signicant differences between the PBL and traditional
groups, suggesting no true differences. It is likely that the study was
underpowered or that insufcient strength or time of instruction
using PBL strategies were provided, or not enough time passed to assess
effects of PBL instruction on student learning outcomes. The correlations among critical thinking, problem-solving, and self-directed learning were signicant and positive. The higher the self-directed learning
score, the better the problem-solving and critical thinking ability. We
believe that well-structured PBL holds promise for nursing education
to promote critical thinking, problem solving, and self-directed learning
ability.
Further research should, ideally, include larger more representative
samples, and employ randomization or other strategies to assure better
baseline comparability between groups.
Findings of this study indicate that more research ought to be
conducted on the effects of PBL on problem-solving and self-directed
learning abilities. Additionally, studies of the long-term effects of PBL
are needed in nursing education.

56

E. Choi et al. / Nurse Education Today 34 (2014) 5256

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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Interdisciplinary Journal of Problem-Based Learning


Volume 1 | Issue 1

Article 4

Published online: 5-22-2006

Goals and Strategies of a Problem-based Learning


Facilitator
Cindy E. Hmelo-Silver
chmelosi@indiana.edu

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.

Goals and Strategies of a


Problem-based Learning Facilitator

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

Cindy E. Hmelo-Silver and Howard S. Barrows

construction. In this paper, we first consider differences between student-centered and


teacher-centered classrooms. We then present a study of a master PBL facilitator in order
to identify the goals and strategies that characterize the teachers role in guiding student
learning. To place this in context, we will examine the cognitive activities involved in teaching and how teachers use different student-centered discourse strategies.
The goals and beliefs that teachers hold help frame the strategies that they implement. Schoenfeld (1998), through detailed analyses of expert and novice teachers,
examined how teachers knowledge, goals, and beliefs lead them to implement action
plans. In his study, the novice teacher used a teacher-centered approach, asking knownanswer questions, listening to students responses, and then evaluating the responses.
For example, when teaching a lesson on exponents, this teacher asked for the answer
to a problem, the student responded correctly that he subtracted, and the teacher
answered OK, an evaluation of the response. The teacher asked the student what he
subtracted and then elaborated on the students correct response. All this proceeded
according to the teachers plan. This teacher believed that the students responses provided springboards for teacher explanations. When students responses diverged, his
limited pedagogical content knowledge prevented him from adapting his plan. Later, on
a more difficult problem, students responses were not what the teacher expected, and
the teacher had to generate an alternative example. The students did not understand
the connection between the new example and the original problem, and they did not
produce an answer that the teacher could use to build an explanation as in the earlier
example. The teacher did not have an understanding of how incorrect student responses
could be a window into their understanding and how these understandings could be
used to focus discussions.
In contrast, Schoenfeld (1998) found very different results in the analyses of expert
teachers (Jim Minstrell and Deborah Ball). Minstrell viewed learning as a sense-making
activity and used questioning in productive ways. The lesson studied focused on issues
of measurement in everyday contexts. Rather than being driven by a topic from the text,
as with the novice teacher, the lesson was driven by problem-centered discussions. The
teacher used questioning to guide student thinking. In particular, he used a technique
called the reflective toss. In the reflective toss, the teacher takes the meaning of a student
statement and throws responsibility for elaboration back to the student. He used these
statements to help students clarify meaning, consider a variety of views, and monitor
their own thinking. For example, as students were discussing how one might decide
what number might be a best value from a list of measurements, a student noted that
one number in a list was repeated several times. Minstrell asked the student for clarification and if there were any other repeated numbers. Another student proposed what
was essentially a formula for a weighted average. This was unexpected. As Minstrell
asked the students for further explanation, they developed a formula for calculating the

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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

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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

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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-

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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.

Results: Analysis of Facilitation Goals and Strategies


The facilitators overall educational goals for the students were for them to be able to (1)
explain disease processes responsible for a patients symptoms and signs and describe

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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.

Pushing for Explanations


One specific strategy that the facilitator frequently used was to push students for an explanation, as he did in the example below,3 when Megan threw out the idea of multiple
sclerosis as the cause of the patients problem:
Megan: . . . given . . . numbness in your feet, I had multiple sclerosis as a possibility. She is an older woman and multiple sclerosis, I believe, usually presents in
the younger generation 30s and 40s, but it . . . can happen in an older person.
So . . .
Facilitator: And tell us what multiple sclerosis is.
Megan: Um, multiple sclerosis is . . . a progressive and chronic debilitating disease um, where you get various points of sclerosis within the brain itself and it
can affect . . . peoples motor function. And its called multiple sclerosis because
there are multiple areas of these sclerotic plaques that occur in the brain.
Facilitator: What causes those plaques?

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Table 1
Facilitation strategies
Strategy

Goals

How goals accomplished?

Use of open-ended and


metacognitive questioning

E14, P1, P3, P4 General strategy to encourage explanations


and recognition of knowledge limitations

Pushing for explanation

E1, P3
E3, P3, P4

Construct causal models


Students realize limits of their knowledge

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

Ensure joint representation of problem


Involve less vocal students
Help students synthesize data
Move group along process
Reveals facts that students consider to be
important

Generate/evaluate
hypotheses

E2, E4, P2
E1, E2, P3, P4

Help students focus their inquiry


Examine fit between hypotheses and accumulating evidence

Map between symptoms


and hypotheses

E1, E2, P3, P4

Elaborate causal mechanism

Check consensus that


whiteboard reflects discussion

E5, P2, P4

Ensure all ideas get recorded and important ideas are not lost

Cleaning up the board

E5, P4
P2
P2

Evaluate ideas
Maintain focus
Keep process moving

Creating learning issues

E4, P4

Knowledge gaps as opportunities to learn

Encourage construction of
visual representation

E1, E5, P3

Construct integrated knowledge structure


that ties mechanisms to observable effects

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Key for Goals:


Educational goals for students:
E1. Explain disease processes responsible for a patients symptom and signs and what
interventions can be undertaken.
E2. To employ an effective reasoning process.
E3. To be aware of their knowledge limitations.
E4. To meet their knowledge needs through self-directed learning and social knowledge
construction.
E5. Evaluate their learning and performance.
Performance goals for facilitator:
P1. To keep all the students active in the learning process.
P2. To keep the learning process on track.
P3. To make the students thoughts and their depth of understanding apparent.
P4. To encourage students to become self-reliant for direction and information.
Note: These codes for the goals are used throughout the results section

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.

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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

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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 . . .

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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.

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Using the PBL Routine: Cleaning Up the Boards


One way that the facilitator guided students to evaluate hypotheses was by taking advantage of the PBL routine, in particular, the structured whiteboard, where the groups
hypotheses, accumulated information about the problem, and list of information to be
pursued during self-directed study were recorded. In this next example, during the second
session, Barrows asked students to clean up the board: . . . lets clean up on a few other
things . . . is that blood pressure very significant or not? Why? This led Jonathan to talk
about high blood pressure (i.e., hypertension) and guidelines for managing it.
Jonathan: . . . [reads aloud from handout] . . . treatment in elder patients should
be the same as in younger patients to less than 140/905 if at all possible. . . .
They talk about how because you get . . . less . . . compliance of the vessels
with older patients, um, the difference between the systolic versus diastolic is
probably more important than either one alone . . . And . . . she has elevated
systolic without so much elevated diastolic. So I, its actually worse for her cardiovascular risk. . . . But since we only have one value . . . we need to have her
come back . . . to evaluate her or refer her for care within one month, according
to the table on the top. Cause she fits in the systolic of 160 . . .
Jim: I mean thats . . . significant . . . . how much weight does this article hold?
Like what kind of research was done? . . .
Jonathan: Well, my understanding is this has countless numbers of people
involved . . . this is like the authoritative source for hypertension . . .
Cheryl: So these are the guidelines that are implemented.
Jim: This is it, what we should follow . . .
Although this was not the major issue in the case, hypertension was something that the
students were concerned about. They evaluated their hypothesis by first examining some
abstract information from the guidelines that Jonathan distributed. After reading those,
he began to map the patients symptoms to the guidelines, supporting his hypothesis
about hypertension (E1, E5). This required sophisticated reasoning (E2). But then Jim
raised the question of how trustworthy his information was and Jonathan responded
by noting that it was a very large study, so Jim now agreed that this was valid (E5, P4).
Thus in this segment, the simple act of cleaning up the board led students to evaluate
their hypotheses by mapping patient data to their hypothesis, and to consider the value
of evidence that one of their group members was using. We also note here that it was a
student who questioned the reliability of the information, providing an example of how
the students begin to take on some facilitation functions. It also helped move the learning
process along as students deliberated over hypotheses, ruling some out and considering
the importance of others during their group discussions (E4, P2, P3, P4).

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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

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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

volume 1, no. 1 (Spring 2006)

36

Cindy E. Hmelo-Silver and Howard S. Barrows

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).

Implications for Other Domains


Although the example here is set in the context of medical PBL, the lessons are applicable
to PBL in other domains. Most of the goals, except for explaining the disease process (E1),
are domain-general. Even this first goal can be adapted to a more general form such as
creating causal explanations. In Hmelo-Silver (2000), these goals and strategies were
made explicit in prompt cards that student-facilitators used in an educational psychology course. In that course, one goal was to solve classroom problems using educational
psychology principles to explain their solutions. Some of these goals and strategies have
since been incorporated into technology support for PBL in educational psychology and
used to provide advice for beginning facilitators (Hmelo-Silver, Derry, Woods, DelMarcelle,
& Chernobilsky, 2005). We believe that, regardless of discipline, teaching about appropriate goals for PBL and providing suggestions for effective strategies might be fruitfully
incorporated into facilitation workshops.
Although these strategies may need to be adapted for different disciplines, they
provide a useful starting point. Our research suggests that it is important for facilitators
to make explicit their educational and performance goals and to identify strategies that
can be used to achieve those goals. For example, Hmelo-Silver (unpublished data) frequently accomplishes her explanatory goal by asking students, What is the psychological
rationale for your idea? But she has also observed that there are other, more explicit
strategies that have served to derail a groups conversation. It is critical for facilitators
to be reflective in terms of evaluating how effective strategies are in achieving desired
goals.

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

The Interdisciplinary Journal of Problem-based Learning

Goals and Strategies of a Problem-based Learning Facilitator

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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Cindy E. Hmelo-Silver is an associate professor of educational psychology in the Graduate School of


Education, Rutgers University. Email: chmelo@rci.rutgers.edu.
Howard S. Barrows is a professor emeritus of the University School of Medicine, Southern Illinois
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Correspondence concerning this article should be addressed to Cindy E. Hmelo-Silver,


10 Seminary Place, Room 320, New Brunswick, NJ 08901.

volume 1, no. 1 (Spring 2006)

Nurse Education in Practice 14 (2014) 698e703

Contents lists available at ScienceDirect

Nurse Education in Practice


journal homepage: www.elsevier.com/nepr

The effects of using problem-based learning in the clinical nursing


education on the students' outcomes in Iran: A quasi-experimental
study
Mahnaz Khatiban, Gita Sangestani*
Mother & Child Care Research Center, Hamadan University of Medical Sciences, Hamadan, Iran

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

* Corresponding author. Hamadan, Iran. Tel.: 98 813 8380150; fax: 98 81


38380447.
E-mail
addresses:
gsangestani@yahoo.com,
sangestani@umsha.ac.ir
(G. Sangestani).
http://dx.doi.org/10.1016/j.nepr.2014.10.002
1471-5953/ 2014 Elsevier Ltd. All rights reserved.

the problems (Wang et al., 2004). It can be obtained by making


changes in the traditional educational strategies (Tiwari et al.,
2006) particularly in the clinical nursing education.
Clinical education is one of the most important components in
the nursing education. Clinical environments are the places where
the nurses grow, develop and learn the nursing practice (Herrman,
2002). There are some strategies that could enhance the learning
experiences, one of them commonly used is problem-based
learning (PBL) (Rideout et al., 2002).
The use of PBL began at McMaster University in Canada, in the
late 1960s (Alexander et al., 2002). Nursing educators at the universities have supported the notion of the self-directed PBL for a
long time (Badeau, 2010). It is active and student-centered
instructional strategies which can help the students utilize their
knowledge and skills in new situations (Williams and Beattie,
2008). PBL strategy improves students' learning and helps them
to solve the real-life problems by searching the scientic data
(Niemer et al., 2010).
In Iran, the nursing clinical education is traditionally a trainerfocused strategy. It means that a trainer directly trains, supervises
and evaluates an 8e10 student group in each clinical course. The
education is commonly limited due to differences in nursing

M. Khatiban, G. Sangestani / Nurse Education in Practice 14 (2014) 698e703

practical duties according to the routines of the wards. Hence, we


tried to apply the PBL strategy in the nursing clinical education for
the rst time. As the experts suggested that, regardless of using any
educational strategy, students' outcomes evaluation should be
considered (Pazargadi et al., 2009), we evaluated the students'
outcomes to know the PBL effectiveness.
We know the outcomes of an educational program are challenging. On the other hand, the students' knowledge, skills, attitudes and behaviors could be measured as the outcomes of a new
training method (Kraiger et al., 1993). Two learning outcomes
categories are considered: specic and generic. The rst one is the
knowledge and skills which are directly related to the discipline,
while the second one is linked to any disciplines such as the
problem solving (Adam, 2004). As there is a similarity between the
steps of the Nursing Process (NP) with those of the problemsolving method (Alfaro-Lefevre, 2002; Lee and Brysiewicz, 2009),
we considered the students' knowledge, skills and performances
in NP as the students' outcomes. NP provides a practical approach
to evaluate students' competences (Kimberly, 2007). This study
was conducted to evaluate the effects of the PBL compared with
the traditional method (non PBL NPBL) on the students' outcomes as follows:
1 Comparison of the students' general and special knowledge and
skills self-evaluation between the NPBL and PBL group before
and after clinical course.
2 Comparison of the PBL and NPBL students' attitudes toward
their learning experiences after clinical course.
3 Comparison of the PBL and NPBL students' performances in
using NP to solve the patients' problems after the clinical
course.

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.

1) The demographic characteristics questionnaire included items


such as students' age, gender, marital status, current living
place, GPA in the last semester and the GPA in the high school. It
was designed based on Safari et al. (2006) study.
2) The Students' competency self-evaluation questionnaire with
two parts: 1-a) the General expected knowledge and skills in

700

M. Khatiban, G. Sangestani / Nurse Education in Practice 14 (2014) 698e703

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

c2 .02; P > .05

c2 1.39; P > .05

c2 .01; P > .05

M. Khatiban, G. Sangestani / Nurse Education in Practice 14 (2014) 698e703

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

The students' performances in using the NP

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

M. Khatiban, G. Sangestani / Nurse Education in Practice 14 (2014) 698e703

Schmidt et al., 2006; Neville, 2009). For example in Germany, 101


graduates from a PBL-based curriculum in a medical school evaluated their competencies more than those of 4720 graduates from
conventional curricula (Schlett et al., 2010). In the Netherlands,
Cohen-Schotanus et al. (2008) compared the effects of the PBLbased and conventional curricula in 294 participants. They found
no differences in their clinical and general competencies and career
development via a multivariate analysis. In nursing, the students'
perception of their knowledge signicantly increased due to the
PBL curricula (Rideout et al., 2002). In China, the PBL students had
positive changes in their competency levels in the pre- and posttest (Wai-chi Chan et al., 2009). In Iran, the PBL midwifery students had more improvement in their nal exam scores and
stronger attitudes to their learning than those of the control group
(Sangestani and Khatiban, 2013). In a qualitative evaluation study,
graduate students and their supervisors were asked to identify the
problem-solving situations in which they had been involved. The
majority of situations at the novice level were belonging to the
NPBL group. The level of problem-solving ability in the PBL group
was higher than that in the NPBL group (Uys et al., 2004). However,
in the study performed by Applin et al. (2011) the PBL and NPBL
graduate nurses reported the same entry-to-practice competencies.
Students' attitudes toward their learning experiences
In the present study, the PBL and NPBL students' attitudes toward learning experiences were positive regardless of the clinical
education methods. Charleston and Happell (2004) have introduced the positive experience as one of the most important determinants of nursing students' attitudes towards nursing.
Kimberly (2007) also noted positive attitudes can lead to better
patient care outcomes.
Both groups had similar attitudes towards their professional
relationships with staff and the trainers and also to the use of basic
sciences in the solving clinical problems. The PBL students had
signicantly more positive attitudes towards learning experience
than the NPBL students in the other items. They believed that the
PBL strategy can increase their skills in the diagnosis of the patient
problems, tendency to learn, ability to apply theory in the practice,
feelings condent to their learning skills, ability to identify their
weaknesses, feelings comfortable in the professional relationships
and learning how to apply NP for the patients. All of these were
expected because the PBL students experienced a continuous
interaction in the small groups who are all striving towards a
common goal rather than learning as a solitary activity. These
ndings were similar to the ndings by Rideout et al. (2002), Alper
(2008) in Turkey, Wai-chi Chan et al. (2009) in China, Iputo and
Kwizera (2005) in South Africa, Khan et al. (2007) in Pakistan,
Rahman et al. (2004) in Bangladesh, Dehkordi and Heydarnejad
(2008) and Sangestani and Khatiban (2013) in Iran.
In this study, the PBL students preferred to apply this method in
all clinical curriculums of the nursing. They found it as an efcient
method in the clinical learning. Most of the Swedish staff and
students also found the PBL strategy more satisfying, with the
students also expressed their time in the clinical education more
efcient (Staun et al., 2010).
Students' performance in using of the NP to solve patients' problems
In the present study, PBL students performed signicantly better
in using NP to solve their patients' problem than the NPBL ones. We
suppose that it was due to the involvement of the students' theoretical knowledge to the realistic problems. These situations stimulated the discussion, collaborative analysis and problem solving.
This nding is supported by some studies about PBL students'

outcomes. In China, the PBL students applied the new knowledge


they acquired in the clinical practice (Wai-chi Chan et al., 2009). In
Turkey, the PBL students were signicantly more successful in the
exams particularly in the knowledge of the health management
and chronic disease (Gurpinar et al., 2005). Uys et al. (2004), in a
qualitative research, found out that the students experiencing the
PBL program had higher abilities than the other students in solving
the problems. Wang et al. (2004) showed that the RN-BSN students'
learning increased with the integrated strategy of NP and problem
solving in the clinical education of nursing. Baker et al. (2007), in
conducting research about the master degree nursing management
students found that the learning skills, individual and professional
skills increased after experiencing this strategy of education. Tiwari
et al. (2006) demonstrated improved problem solving skills
through using PBL. Lee and Brysiewicz (2009) found that adding a
nine-step problem solving process in acute care clinical courses
was moderately effective. As well, inserting information on the
nursing diagnosis, could improve students' performances. Iputo
and Kwizera (2005) explained that the introduction of PBL at the
South Africa Facilities can also improve the students' performances.
In Bangladesh, the PBL course improved the students' practices in
the clinic signicantly, especially in problem solving and selfdirected learning. These students stated that PBL is better than
traditional ward teaching and recommended the PBL to be included
in the Undergraduate Medical Curriculum (Rahman et al., 2004).
Mori et al. (2006) showed that the PBL strategy was useful in the
nursing students' self-learning, learning integrity and communication skills learning after three years.
Strengths and limitations
It was the rst time in Iran that a PBL clinical course was applied
via a quasi-experimental design which led to an improvement in
the students' outcomes (knowledge, skills, attitude and performance). However, this was done for a small group of students. To
generalize the results this strategy should be included throughout
the whole nursing educational programs. Then the outcomes
assessment should be followed in the subsequent years.
Despite of the trainer's efforts for involving the PBL students in
searching for related literature and the internet, the full contribution was not possible due to the time limitation.
Conclusion
In this study the PBL strategy was applied in nursing clinical
education which is regarded as the most controversial part of the
nursing education. The use of PBL in the Hematology and Oncology
ward led to the desired students' outcomes such as a better sense of
general and special competencies, a more positive attitudes towards their learning experiences and an improvement in their
performances.
Regarding the above mentioned points, the researchers suggest
the application of PBL strategy for other undergraduate and postgraduate medical students in different clinical settings. Then again,
we must keep in mind that before implementing this program, we
need to train the clinical trainers and/or mentors.
Conict of interest
Authors declare no conicts of interests.
Acknowledgment
We wish to give considerable acknowledgment to the funding
from the Research Chancellor of Hamadan University of Medical

M. Khatiban, G. Sangestani / Nurse Education in Practice 14 (2014) 698e703

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

Adv in Health Sci Educ (2010) 15:403413


DOI 10.1007/s10459-009-9208-9
ORIGINAL PAPER

Developing clinical competency in crisis event


management: an integrated simulation problem-based
learning activity
S. Y. Liaw F. G. Chen P. Klainin J. Brammer A. OBrien
D. D. Samarasekera

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

S. Y. Liaw (&)  P. Klainin  J. Brammer  A. OBrien


Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University
of Singapore, Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574, Singapore
e-mail: nurliaw@nus.edu.sg
F. G. Chen
Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore,
5 Lower Kent Ridge Road, Main Building, Level 2, Singapore 119074, Singapore
D. D. Samarasekera
Medical Education Unit, Yong Loo Lin School of Medicine, National University of Singapore,
Block MD 11, Level 1, 10 Keng Ridge Cresent, Singapore 119260, Singapore

123

404

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

123

Developing clinical competency in crisis event management

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:

Nursing students who received simulation training with problem-based


discussion would have superior clinical performance in managing a
patient with respiratory distress than those who underwent only problembased discussion
Nursing students who received simulation training with problem-based
discussion would have superior clinical performance in managing a
patient with acute chest pain than those who underwent only problembased discussion

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

123

406

Table 1

S. Y. Liaw et al.

Checklists

Checklist for respiratory scenario post test I

Checklist for cardiac scenario post test II

Assessment
Ask questions related to chief complaint
Take vital signs
Perform SpO2 monitoring
Auscultate for breath sound

Ask questions related to chief complaint(pattern, quality,


radiation, severity, time)
Take vital signs
Perform SpO2 monitoring
Auscultate for breath sound
Auscultate for heart 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

A 65-year-old post-operative patient, who has


undergone lobectomy, developed respiratory
distress resulting from COPD exacerbation

A 70-year-old patient with medical history of asthma


developed shortness of breath from an acute
asthma attack.

Intervention II

Post test II

A 85-year-old patient, with a medical history of


chronic cardiac failure and atrial fibrillation,
complained of severe chest pain and was found
diaphoretic. His ECG revealed acute myocardial
infarction.

A 65-year-old patient, with history of ischemia heart


disease, was admitted for uncontrolled
hypertension. He complained of chest pain to the
ward nurse. His condition was classified as stable
angina.

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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Nursing students who received simulation training with problem-based


discussion would have superior clinical performance in managing a
patient with respiratory distress than those who underwent only problembased discussion

Developing clinical competency in crisis event management

409

Table 3 Comparison on post-test scores for SPBD and PBD group


SPBD Group (n = 13)

PBD Group (n = 17)

Mean

SD

Mean

SD

Scenario 1: Respiratory distress (n = 30)


Assessment score

8.83

0.80

8.19

1.24

1.64

0.113

Immediate action score

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*

Scenario 2: Chest pain (n = 33)


Assessment score

8.44

1.34

6.93

1.16

3.43

Immediate action score

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:

Nursing students who received simulation training with problem-based


discussion would have superior clinical performance in managing a
patient with acute chest pain than those who underwent only problembased discussion

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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