Research article

Nursing Ethics 17(3) 373382 The Author(s) 2010 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733009355380 nej.sagepub.com

A comparison of problem-based learning and conventional teaching in nursing ethics education

Chiou-Fen Lin
Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan

Meei-Shiow Lu
Taipei Medical University, Taipei, Taiwan

Chun-Chih Chung
Taipei Medical University Hospital, Taipei, Taiwan

Che-Ming Yang
Taipei Medical University, Taipei, Taiwan

Abstract The aim of this study was to compare the learning effectiveness of peer tutored problem-based learning and conventional teaching of nursing ethics in Taiwan. The study adopted an experimental design. The peer tutored problem-based learning method was applied to an experimental group and the conventional teaching method to a control group. The study sample consisted of 142 senior nursing students who were randomly assigned to the two groups. All the students were tested for their nursing ethical discrimination ability both before and after the educational intervention. A learning satisfaction survey was also administered to both groups at the end of each course. After the intervention, both groups showed a significant increase in ethical discrimination ability. There was a statistically significant difference between the ethical discrimination scores of the two groups (P < 0.05), with the experimental group on average scoring higher than the control group. There were significant differences in satisfaction with self-motivated learning and critical thinking between the groups. Peer tutored problem-based learning and lecture-type conventional teaching were both effective for nursing ethics education, but problem-based learning was shown to be more effective. Peer tutored problem-based learning has the potential to enhance the efficacy of teaching nursing ethics in situations in which there are personnel and resource constraints. Keywords ethical discrimination ability, learning satisfaction, nursing ethics, teaching, peer tutor, problem-based learning

Corresponding author: Che-Ming Yang, 250 Wu-Hsing St, Taipei 11031, Taiwan. Email: cyang@tmu.edu.tw

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Introduction
It is widely accepted that health care professionals should strive continuously to strengthen their ethical discrimination ability to enable them to make appropriate decisions when faced with ethical dilemmas. Nurses are confronted with unique ethical problems arising from their involvement in patient care, and ethics has therefore taken on an increasingly prominent role in nurse education.1 We were interested to find out whether learning efficacy can be enhanced by the use of an innovative teaching method in nursing ethics education.

Background
Decision making by individual professionals and organizations can be influenced, either consciously or subconsciously, by the value systems embedded in the history of the profession concerned. The assumption is that values are determinants of social behavior; and thus it is important to understand how values influence job satisfaction, motivation and commitment, and consciously or unconsciously affect the way in which people act in their personal and professional lives.2 Moral values have been defined as the distinction between good and bad or right and wrong behavior. As such, moral values have great influence on the way nurses think and act, and play a major role in patient care.2 Professional ethics education such as nursing ethics is important because members of the profession need to know how they should behave. Hosmer3 points out that ethics education is not about clear cut choices, but more about multiple choices in complicated situations. It does not aim to change peoples religion or customs, but instead to assist them with their decision making. The objectives include: cultivating ethical aspiration, increasing sensitivity to ethical issues, and enabling the ability to recognize ethical dilemmas, conduct ethical analysis and make decisions. Similarly, the objectives of nursing ethics education should focus on the establishment of professionalism and ethical thinking. The core course content needs to encompass such subject areas as theories of ethics, ethical principles and their application, ethical codes and guidelines, critical thinking, ethical decisionmaking skills, and the rights and responsibilities of patients and nurses.4 As indicated in the literature, ethics education provides nurses with the tools to reflect critically on their care practices5 and the inclusion of an ethics course in the nursing curriculum does increase student nurses moral reasoning abilities.6 There are primarily two approaches to ethics education for nurses: the first consists of introducing nurses to the principles of right action and the second is a virtue ethics approach, which places greater emphasis on attitude in caring.5 The first approach involves learning in a classroom setting, whereas the second means learning from role models and mentors. There are also two models of classroom ethics education: offering a separate course, or integrating ethics throughout the nursing curriculum.6 Although there is a consensus regarding the importance of positive role modeling for students,6 classroom teaching is a convenient starting point, especially in undergraduate nursing education, and a separate course can ensure that all the planned information is delivered in a systematic and coherent way. The question then becomes: what is the most effective course design in terms of curriculum and teaching methods? Teaching methods generally include formal lectures, seminars, classroom discussion, role playing and case analysis.6 Researchers and educators have stressed that knowledge about ethics and attitude learning should be based on real situations and start from identifying problems.7 Some therefore argue that working with real cases in small group discussions encourages students to apply their previous knowledge and new concepts learned in the course, and thus helps them to bridge the gap between theory and practice.8 Problem-based learning is a highly structured and learner-centered teaching method. The principal features include the following: problems are the starting point for learning; real problems are used; thinking must be in terms of problems, not disciplines; orientated knowledge is acquired; learning is student initiated; and there is an emphasis on group discussion.9 In this process, tutors merely facilitate learning. There are

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generally five steps in the problem-based learning process: analysis of problems, establishment of learning objectives, collection of information, summarizing, and reflection. Two types of tutors are employed in problem-based learning: expert and non-expert. Some insist that problem-based learning tutors have to be experts in the relevant field, whereas others support the use of non-expert tutors such as peer tutors. Some propose that tutors must be equipped with both the ability to facilitate group discussion and professional knowledge of the related subject matter. However, financial and human resource constraints can limit the use of expert tutors.10 One study has shown that there is no significant difference between expert and non-expert tutors in terms of stimulating, leading, and controlling the processes of group discussion.11 At times, non-expert tutors can concentrate more easily on facilitating the group discussion process rather than controlling the academic content of learning,11,12 and learners often prefer tutors to be non-directive.10,12 Especially in times of faculty manpower constraints, the use of peer tutors appears to be a reasonable alternative. The Economists Intelligence Unit ranked Taiwan second only to Sweden in its world health ranking in 2000.13 According to Taiwans 2005 National Health Statistics,14 more than 97% of the population of approximately 22 million was insured through mandatory national health insurance. Cancer remained the most common cause of death. Although Taiwan spent only about 6% of its gross domestic product on health and the per capita health expenditure in 2005 amounted to USD942, there were ample health service providers and health care professionals. There were 31.8 acute care beds per 10,000 people and 46.2 registered nurses per 10,000 people in 2005, giving a total of 105,183 registered nurses.14 Modern nursing education in Taiwan started before the Second World War. Two tracks of nursing education have evolved since then: junior college level and college level. Junior colleges enroll ninth-grade graduates and provide a five-year nursing education course. Nursing colleges accept students graduating from senior high schools and from junior nursing colleges, who must study for four or two years, respectively, to gain a bachelors degrees in nursing. All these nurses can be licensed as registered nurses as long as they pass the national licensing examination. With the rapid advance of nursing as a distinctive academic discipline, we have also seen a rapid growth of graduate nursing programs in Taiwan. There are now 39 junior nursing colleges and college programs, 19 masters programs and seven doctoral programs. In order to monitor and improve the quality of nursing education, the Taiwan Nursing Accreditation Council was established in 2006 to accredit nursing schools.

Aim
This study aimed to compare the educational results of peer tutor problem-based learning and conventional teaching in nursing ethics education.

Methods Participants
The study sample consisted of seniors in the Department of Nursing at Taipei Medical University. These students were randomly assigned to two groups. They were informed about this research and given the opportunity to take other classes instead if they wished. Although nursing ethics was a required course, the students were free to choose from other nursing ethics classes. Owing to withdrawals after registration, there were 72 students in the experimental group and 70 controls. There was no significant difference between these two groups in terms of personal characteristics and discrimination of nursing ethics before the intervention.

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Research participants

Intervention

Learning effect

Randomization

Problembased learning

Experimental Student characteristics Control

Nursing ethical discrimination ability

Learning satisfaction

Conventional teaching

Figure 1. The conceptual framework of the research design

Ethical approval
This study was funded by the National Science Council, Executive Yuan, Taiwan, ROC, approved by the curricula committee of Taipei Medical University, and conducted in Taipei, Taiwan in 2005. Confidentiality of all records was strictly preserved according to the bylaws of Taipei Medical University regarding academic record keeping. According to the Medical Care Act of Taiwan, only clinical trials are required to be referred to hospital ethics committees. The scientific value and ethical considerations of all the other kinds of research are reviewed by the Taiwanese funding agencies as a whole.

Procedure
This study adopted an experimental design (Figure 1). The peer tutor problem-based learning method was applied to the experimental group and the conventional teaching method to the control group. Three tools used in this study were teaching plans, the nursing ethical discrimination ability scale and the learning satisfaction survey. Three teaching plans to be used for problem-based learning were conceived by an expert panel of seven. Each plan included learning objectives, a clinical case exhibiting ethical dilemmas, and guidelines for peer tutors. The same expert panel developed the nursing ethical discrimination ability scale after consulting the relevant literature.8,15 The final scale included nine situations and 41 questions measured on a Likert scale. The learning satisfaction survey was developed by the 10 members of another expert panel after consulting the literature.16 The whole research process was divided into three stages and seven steps (Table 1) as set out below. Stage I: 1) Designing the curricula for peer tutor problem-based learning and conventional teaching: The core components of the curriculum include basic theories of ethics and virtue, the four ethical

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Table 1. The research process Stage I Step 1) Designed the curricula for peer tutor problem-based learning and conventional teaching 2) Constructed the nursing ethical discrimination ability scale 3) Constructed the learning satisfaction survey 4) Administered the pre-test nursing ethical discrimination ability scale 5) Conducted educational intervention 6) Administered the post-test nursing ethical discrimination ability scale 7) Administered the learning satisfaction survey

II III

Table 2. Sample situation and questions from the ethical discrimination ability scale: Johnny is 10 years old. He suffers from acute lymphocytic leukemia and has received treatment for two months without improvement. His attending physician decides to prescribe a new drug that is still under investigation. Both parents have agreed to this trial and yet requested the physician not to inform Johnny, to avoid increasing his anxiety. Level of agreement Statement 1) Johnny is a minor with no autonomy; therefore, his parents can make medical decisions for him. 2) Johnny is already 10 years old. If telling him will not increase his anxiety, the physician should still explain to him and obtain his oral consent. 3) In order not to increase Johnnys anxiety, it is acceptable not to inform him that this treatment is a clinical trial. 1 2 3 4 5 Comment

principles of biomedicine, the nursepatient relationship, rights and responsibilities of patients and nurses, codes of ethics and ethical guidelines, the ethical issues surrounding artificial procreation and organ transplantation, etc. Three teaching plans were conceived for use with problem-based learning. Each plan included learning objectives, a clinical case with ethical dilemmas, and guidelines for the peer tutors. The guidelines included details of the problembased learning steps, how to play the role of a facilitator in the process, and the potential ethical issues for each clinical case. 2) Designing the nursing ethical discrimination ability scale: The content validity of this scale was verified by experts. The final scale included nine situations and 41 questions. The level of agreement with the ethical statement enunciated in each question was measured using a Likert scale. The content validity index was set at above 0.86. Test-retest was conducted with 92 students and the reliability score reached 0.95. A sample situation and associated questions from the ethical discrimination ability scale is presented in Table 2. 3) Designing the learning satisfaction survey: This instrument was validated by experts for content validity. The final version consisted of three open-ended and six closed questions measured on a 5-point scale. Learning satisfaction is measured by the respondents subjective feelings not by objective observations. Internal consistency reached 0.8 and the split-halves reliability was 0.76. The results of the closed questions of the learning satisfaction survey are given in Table 3.

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Table 3. Results of the learning satisfaction survey Control group Experimental group (n 72): (n 70): mean (SD) t-value mean (SD) 3.51 (0.73) 3.99 (0.68) 3.84 (0.62) 3.89 (0.64) 3.92 (0.60) 3.99 (0.49) 3.70 (0.69) 3.67 (0.70) 3.76 (0.67) 3.76 (0.65) 3.59 (0.48) 3.86 (0.67)

Closed question Level of satisfaction with the teaching method Level of satisfaction with self-motivated learning Level of satisfaction with moral self-cultivation Level of satisfaction with understanding of nursing ethics issues Level of satisfaction with critical thinking Level of satisfaction with intellectual stimulation

P-value

1.560 0.252 3.786 0.003 0.729 0.954 1.127 0.746 4.437 <0.001 1.313 0.506

Stage II: 4) Pre-test completion of the nursing ethical discrimination ability scale: All students were tested and scored on this scale before classes began. 5) Conduction of the educational intervention: Owing to space limitation, each group could be assigned only one classroom. The whole course was taught or supervised by the same teacher over eight weeks, for 1 hour 40 minutes every week. The teaching in the control group was lecture based and complemented by question and answer sessions and discussions. These students had 20 minutes to discuss course content with the teacher before the end of each class. The experimental group received an introduction to the course in the first week. Then the students were divided into 10 groups of seven to eight people each and small group sessions were held. Each problem-based learning case was discussed and studied for two weeks. The final week was used to clarify questions and share thoughts with the whole group. Teaching of the experimental group was primarily by peer tutors, complemented by the teacher. One student was selected as the peer tutor for each case in every group. The peer tutors received relevant guidelines before each class, and were instructed not to disclose these to their group members unless they failed to make progress during discussion. The teacher circulated among the small groups during the discussion sessions and the tutors could seek advice from them at any time. After each class, the teacher discussed the group sessions with the peer tutors, answering questions and clarifying ethical issues. The small group problem-based learning discussions comprised five elements: (1) analysis of problems: the students read the teaching case within their own group, asked questions and sorted out problems; (2) establishment of learning objectives: the students tried to answer their own questions and identify learning objectives for the unsolved problems; (3) information collection: the students sought information about the learning objectives after class; (4) summary: the students were asked to evaluate the information collected by each member during the second discussion session; and (5) reflection: the group decided how the information could be applied to solve the ethical problems. Stage III: 6) Post-intervention administration of the nursing ethical discrimination ability test: This test was administered to both groups immediately after the whole course ended. 7) Post-intervention administration of the learning satisfaction survey: This survey was also administered to both groups immediately after the whole course ended.

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Table 4. Comparison of pre- and post-intervention results on ethical discrimination ability scale Group Both (n 142) Experimental (n 72) Control (n 70) Pre-test: mean (SD) 3.45 (0.34) 3.45 (0.32) 3.45 (0.37) Post-test: mean (SD) 3.62 (0.32) 3.65 (0.32) 3.58 (0.32) t-value 4.729 4.569 2.372 P-value <0.001 <0.001 0.020

Data collection
In summary, as noted above, data were collected from the two groups by means of the nursing ethical discrimination ability scale both before and after the intervention, and through the learning satisfaction survey after the intervention.

Results
There was a statistically significant difference between the nursing ethical discrimination ability scores of the two groups (P < 0.05) after the educational intervention, with the experimental group on average scoring higher than the control group. Moreover, the results of tests pre- versus post-intervention showed statistically significant differences from each other for both groups, which indicates that both teaching methods had a positive impact in terms of learning (Table 4). A repeat measure analysis of variance was computed by applying the pre-intervention test results as a covariate, teaching methods as an independent variable, and the post-intervention test as a dependent variable so as to eliminate the influence of the students original background on the post-intervention test results. After the pre-test factor was controlled, there was a significant difference between the two groups for the results of the post-intervention test of nursing ethical discrimination ability (F 22.222, P < 0.001). The average for the experimental group was significantly higher than that for the control group, which means that, in terms of their nursing ethical discrimination ability, the students who received problem-based learning performed better than those who underwent conventional teaching (P < 0.001). For the learning satisfaction survey (Table 3), the control group was more satisfied with the teaching method than the experimental group; nonetheless, it was not statistically significant overall. The experimental group scored higher on questions of self-motivated learning, moral self cultivation, understanding of nursing ethics issues, critical thinking and intellectual stimulation. The experimental group was significantly more satisfied with self-motivated learning (P 0.003) and critical thinking (P < 0.001).

Discussion
According to a recent meta-analysis of 13 studies evaluating physician competency,17 when compared with a control group who had studied using traditional curricula, newly graduated physicians showed a significantly stronger appreciation of the legal and ethical aspects of health care and were more able to cope with uncertainty if they had been exposed to problem-based learning at medical school. There was also evidence to support a beneficial effect on communication skills and ongoing self-directed learning. These findings corroborate our hypothesis that problem-based learning is suitable for ethics education. Our results show that nursing ethics education can strengthen students ethical judgment regardless of whether they are taught by problem-based learning or conventional methods. This improvement was more evident in the problem-based learning group than the control group. A similarly designed study conducted on medical students produced comparable findings,15,18 although this was a cohort study in which peer tutors were not used.

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Medical ethics core curricula can encompass a range of issues, including theories of ethics, ethical codes and guidelines, informed consent, confidentiality, etc.19 Owing to time constraints, it is difficult for lecturebased teaching to cover all of these. Many ethicists have therefore maintained that professional ethics education should adopt the use of clinical case analyses through small group discussion in order to strengthen ethical discrimination and problem solving ability, and cultivate a lifelong learning capability.8,20,21 Because problem-based learning is based on analyzing clinical cases, the present study supports the assertion that students who participate in small group discussions for clinical case analyses perform better. A statistically significant improvement was found for ethical discrimination ability in members of the problem-based learning group after intervention in only four of the nine post-test situations. This finding could be attributed to the use of peer tutors. Owing to the limited resources and time, the peer tutors used in this study received only very limited preliminary training. Researchers have noted that expert tutors are better at eliciting higher cognitive functions.11 However, administering proper training to tutors has been shown to prevail over this shortcoming.12 There was also a statistically significant improvement in ethical discrimination ability in the control group, indicating that conventional teaching is also effective. In addition, their level of satisfaction with the teaching method was greater than the intervention group. This phenomenon could be caused by two possible factors. First of all, most students in Taiwan are used to lecture-type passive learning. The demands of problem-based learning, such as previewing, class participation and expressing themselves publicly, could have caused stress for the intervention group students. The other reason could be the relatively low number of cases studies used for this research. Owing to time constraints, only three were used. Previous studies that used 1012 cases resulted in higher learning satisfaction rates, suggesting that more content could increase satisfaction; on the other hand, it may mean that students respond better when more time is spent on problembased learning.22 Students taking part in the problem-based learning expressed higher satisfaction with self-motivated learning and critical thinking compared with the control group. This finding is consistent with the characteristics of problem-based learning described in the literature.7,2224 Other studies have shown that the problembased learning format improves self-directed learning, critical thinking, communication and the ability to work in a team.25 Lecture-type teaching mostly focuses on conveying facts. The reason that problembased learning was shown to be superior to conventional teaching is probably because this method is better for achieving the ultimate goals of ethics education, that is, self-learning and critical thinking. As noted earlier, there are two models of classroom nursing ethics education: either a dedicated course or the integration of ethics teaching throughout the curriculum. Some studies have suggested that many schools fail to offer a separate nursing ethics course because no-one is available to teach it.6 This, regardless of whether it is universally agreed, reflects the fact that there are simply not enough qualified ethics teachers in many countries, which is where peer tutor problem-based learning can be useful because it augments the educational reach of the faculty. Qualified ethics teachers can supervise more in-depth discussions by applying problem-based learning than by running a whole course on a more general level. This approach allows better use of the limited numbers of ethics faculty staff for reaching more students.

Limitations of the study

This study was conducted in only one university, which limits the generalizability of the research results. We relied solely on the faculty members who were teaching the nursing ethics course when this research was conducted. However, the differences in learning satisfaction may have been due to the teachers themselves. Likewise, although the peer tutors had been given training in advance, this was not standardized, there was no adequate evaluation of whether they were qualified to be peer tutors, and there was no assessment of how they performed their tasks. Moreover, learning results can be affected not only by teaching methods but also

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by teaching materials. Although our teaching materials were validated by an expert panel, they are still not widely accepted in standard textbooks or teaching plans. Whether our research results were biased in either direction by the teaching materials requires further validation.

Conclusions
The findings of this study indicate peer tutored problem-based learning and lecture-type conventional teaching are both effective for nursing ethics education in terms of improving ethical discrimination ability, but problem-based learning is more effective. Students undergoing problem-based learning reported higher satisfaction with self-motivated learning and critical thinking ability in comparison with the control group. When there are faculty constraints, peer tutored problem-based learning can help to improve learning efficacy in nursing ethics education. Acknowledgement Funding for this study was provided by the National Science Council, Executive Yuan, Taiwan, ROC. The authors would like to acknowledge a research grant (NSC 922516-S-038004) from the National Science Council. Conflict of interest statement The authors declare that there is no conflict of interest. References
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