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Effect of case-based learning on the development of graduate nurses' problem-solving ability
Nurse Education Today 34 (2014) 47–51
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Effect of case-based learning on the development of graduate nurses' problem-solving ability Moon-Sook Yoo 1, Jin-Hee Park ⁎ College of Nursing, Ajou University, Yongtong-Gu Wonceon-Dong San 5, Suwon, Gyeonggi-Do, South Korea
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Article history: Accepted 20 February 2013 Keywords: Problem solving Decision making Nursing education Case study
s u m m a r y Case-based learning (CBL) is a teaching strategy which promotes clinical problem-solving ability. This research was performed to investigate the effects of CBL on problem-solving ability of graduate nurses. This research was a quasi-experimental design using pre-test, intervention, and post-test with a nonsynchronized, non-equivalent control group. The study population was composed of 190 new graduate nurses from university hospital A in Korea. Results of the research indicate that there was a statistically significant difference in objective problem-solving ability scores of CBL group demonstrating higher scores. Subjective problem-solving ability was also significantly higher in CBL group than in the lecture-based group. These results may suggest that CBL is a beneficial and effective instructional method of training graduate nurses to improve their clinical problem-solving ability. © 2013 Elsevier Ltd. All rights reserved.
Introduction Dramatic advances and transformations have been made in health care organizations in the past recent decades, resulting in the rapid growth of technology (Vittrup and Davey, 2010). Success of nurses in such fast changing modern hospital environment involves becoming skilled at higher-level critical thinking and problem-solving abilities to provide safe and effective care to patients with complex and variable needs (Kaddoura, 2010; Yoo et al., 2009). Graduate nurses are expected to problem-solve and plan interventions independently (Kaddoura, 2011; Vittrup and Davey, 2010). According to Benner (1984), graduate nurses are novice nurses entering the role of a registered nurse who have typically practiced less than 2 years in the clinical setting during their educational experience. Graduate nurses are required to think critically in order to identify complex situations and practice sound clinical judgments, while considering multiple aspects of care (Halfer and Graf, 2006; Vittrup and Davey, 2010). However, research has suggested that many graduate nurses often have difficulty thinking critically in clinical practice, especially in situations that require making quick and accurate decisions and actions (Kaddoura, 2010, 2011; Wilgis and McConnell, 2008). Additional research has focused on errors related to graduate nurses not being adequately prepared in performing critical thinking skills, prioritization, and in their general inability to convert theoretical training to real-world situations (Morrow, 2009; Saintsing et al., 2011). These ⁎ Corresponding author. Tel.: +82 31 219 7019; fax: +82 31 219 7020. E-mail addresses: [email protected] (M.-S. Yoo), [email protected] (J.-H. Park). 1 Tel.: +82 31 219 7012; fax: +82 31 219 7020. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.014
studies certainly indicate that such problems experienced by graduate nurses are common concerns within the international practice of nursing (Saintsing et al., 2011). Although graduate nurses can demonstrate minimal competencies, they need continuous educational support to further develop critical thinking and problem-solving abilities and to progress their professional roles as nurses. Therefore, hospital-based nurse educators should construct orientation programs that can facilitate the development of critical thinking skills and problem-solving abilities in graduate nurses (Wilgis and McConnell, 2008). This study was carried out to investigate whether case-based learning (CBL) would be useful in developing problem-solving abilities in graduate nurses. Literature Review Nurses are confronted with many clinical problems on a daily basis, and their ability to competently deal with such problems is critical for safe and effective nursing practice. The question of how best to develop more successful clinical problem-solving abilities among nurses has become an issue of major importance to nurse educators (Simpson and Courtney, 2002; Wilgis and McConnell, 2008). Problem-solving ability is tied to thinking ability, which is considered a prior condition of professional practice (Bentley, 2001). Problem-solving begins with the perception of a situation as a problem, and then includes a selection of appropriate choices from many, in order to achieve a desired goal and its subsequent implementation (Taylor, 2000; Terzioglu, 2006). Traditionally, nurse education curricula have adopted a contentfocused approach, with emphasis on teaching facts, concepts and their relationship to particular subject domains, which are limited in demonstrating application of these ideas to clinical situations
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(Kaddoura, 2011; Roberts, 2000). Furthermore, course delivery has mainly been teacher-centered (Cholowski and Chan, 2001; Yoo et al., 2009). To overcome these limitations, the field of nursing education has been increasingly focusing on teaching strategies to enhance critical thinking skills as well as on student-centered education, which concentrate on each student's needs, abilities, interests, and learning styles, placing the teacher as a facilitator of learning (Vittrup and Davey, 2010; Uys et al., 2004). CBL is an instructional method within the context of studentcentered learning to facilitate students' learning and to decide for themselves regarding their perspective field, through the use of case studies (Kaddoura, 2011). CBL is derived from constructivism, which is a theory of learning and an approach to education that lays emphasis on the ways people create meaning of the world through a series of individual constructs (Jonassen and Hernandez-Serrano, 2002). CBL that simulates realistic problems appears to be an ideal approach for preparing graduate nurses to deal with patients with a multiple of clinical problems (Kaddoura, 2011). Case studies, or cases, are descriptions of specific activities, events, or problems that are drawn from the real world of professional practice and include contingencies, complexities, and dilemmas to evoke integrative analysis and critical thinking in CBL education. CBL seek to engage students through the use of drama from a real situation. CBL can support authentic learning experiences by presenting episodes of real professional practice (Carroll and Borge, 2007). Therefore, CBL provide models of practice to graduate practitioners and is a teaching strategy which promotes clinical problem-solving abilities (Morrow et al., 2003). CBL has been shown to be effective as part of medical and nursing programs in the U.S., Europe, and Australia (Chan et al., 2008; Dietrich et al., 2010; Massonetto et al., 2004; Thurman et al., 2009; Tomey, 2003). Moreover, CBL is widely used in other fields of professional education — in business, law, and engineering (Carroll and Borge, 2007; Kaddoura, 2011). Although many claims are made for CBL as an effective learning and teaching method, there is a paucity of empirical data on the effect of CBL in preparing graduate nurses for professional practice, especially from Korea. In the current study, we tested the hypothesis that CBL for graduate nurses would improve their problem-solving abilities. Methods Study Design A quasi-experimental design using pre-test, intervention, and post-test with a non-synchronized, non-equivalent control group was employed. Study Subjects A convenience non-probability sampling method was used to select a sample and to attain a total sample of N = 190 new graduate nurses from university hospital A. Institutional Review Board approval was obtained from the university hospital prior to data collection. The target population for this study consisted entirely of new graduate nurses hired to work as registered nurses at large university hospitals in Korea. Selection of subjects was based on the following inclusion criteria. They were expected to be new graduates without any previous experience as RNs. The selected participants started their employment at university hospital A. This study was explained in detail before obtaining informed consent. Participation was voluntary. If graduate nurses agreed to participate in the study, they were asked to sign the informed consent form. After signing the consent, a coded demographic questionnaire was administered. Finally, 96 graduate nurses, who were hired from university hospital A in 2009, were assigned to the traditional lecture-based group. Ninety-four graduate nurses, who were
hired from university hospital A in 2010, were assigned to the CBL group. Power analysis for the two-group test of mean differences to reach 90% power and an effect size of 0.50 with an alpha value of 0.05 required a minimum sample size of 86 participants in each group (Cohen, 1988). The effectiveness of CBL or PBL education programs from a previous study was used as a reference for power calculation (Thistlethwaite et al., 2012). Instrument Subjective Problem-Solving Ability The problem-solving inventory (PSI) was used for the purpose of evaluating how graduate nurses perceive themselves as problem solvers. The PSI was developed in 1982 by Heppner and Petersen, and it has since proven to be valid and reliable. It was translated to Korean in Jun (1994). The scale is simple to use and participants are able to complete it by themselves. Respondents were required to rate each item on a 6-point Likert scale (1 = strongly agree, to 6 = strongly disagree). The PSI has a total score (i.e., the sum of three factors) and three factors derived from factor analyses. The three factors are as follows (a) problem-solving confidence (PC), (b) approach-avoidance style (AAS), and (c) personal control (PC) (Heppner and Petersen, 1982). The PSC refers to an individual's belief and trust in one's own problem-solving ability. The AAS is defined as a general tendency to approach or avoid a wide range of problemsolving activities. The PC refers to an individual's belief that one is in control of his or her own behaviors and emotions while solving problems (Heppner et al., 2004). A total score is derived from these factor scores and serves as a global index of problem-solving ability. Reliability estimates have revealed that these constructs are internally consistent (alpha coefficients ranged from .72 to .90). Lower scores indicate effective problem-solving attitudes and behaviors, whereas higher scores denote an individual's assessment of oneself as a relatively ineffective problem solver. The a coefficients for the sample used in this study were .82 for the PSI total, and .82, .89, and .74 for the PSC, AAS, and PC, respectively. Objective Problem-Solving Ability We developed a simulated test to measure objective problemsolving abilities. This simulated test consists of three cases which depict common clinical problems that nurses may encounter in the hospital. An expert group consisting of instrument development and professional educators created an appropriate scenario and its relevant questions. The questions were developed based the Performance Based Development System (PBDS), which composes of six subcategories: problem recognition (e.g. What are the major issues in this case?), reports essential clinical data (e.g. What are the important data and what might they mean?), initiates independent nursing intervention, differentiation of urgency (e.g. What interventions should be initiated now? Or how should this patient be managed?), anticipates relevant medical orders (e.g. Now what should be done and what can the patient expect?), and provides relevant rational to support decisions (e.g. What do you think is the best way to deal with the problem and why?). The PBDS assessment is designed to identify critical thinking learning needs and to assist with the development of an individualized orientation action plan to prepare better nurses for safe clinical practice (Performance Management Services Inc., 2006). The simulated test was then revised in order to obtain consensus for the measurement of criteria, wording, and general presentation. Following revision of the content, the simulated test was further evaluated in a pilot study involving 12 nurses. All participants were interviewed to determine if they found the questionnaire clear and understandable. They were also asked to provide suggestions for the improvement of wording of any items they found confusing. All
M.-S. Yoo, J.-H. Park / Nurse Education Today 34 (2014) 47–51
participants noted that they found instrument items clear, concise, easy to read, easy to complete, and easy to understand. Respondents were asked to review each case and to then state, in writing, what they think the problem is, actions they would take in response, and their rationale. Two experts scored each participant's test using a guide developed by the expert group. Corrections were cross-checked by other experts. Inter-rater reliability was tested with the intra-class correlation coefficient (ICC). The ICC was 0.95, which was considered acceptable. Procedures Development of CBL CBL was developed between June and October of 2009. The development process was divided into selection of cases, video production and manual development. For the selection of cases, the 7 most frequently occurring clinical nursing problems that may potentially lead to nursing errors were provided by the department of nursing at university hospital A. The panel of seven experts, including professors and clinical nursing instructors from the college of nursing, selected 3 problems that were determined to be in need of most urgent education. The selected problems were nursing errors caused by miscommunication between nurses, nursing errors caused from not following the principles of medication administration and nursing errors caused from not observing the principles during transfusion. The panel developed 3 cases for CBL which included the causes, processes and results of the accident, in accordance with Five Ws and one H problem solving method. The Five Ws and one H are questions whose answers are considered basic in information-gathering (MediaSmarts, 2012). An education consultant helped with the objective development, case construction and flow. Clinical nurse specialists reviewed the cases for realism, accuracy and clinical relevance. A scenario was created based on such developed cases, and it was made into a film with re-enactments by nursing students. Video filming and editing were done by professional video specialists. Creating cases and video production were conducted between June and September of 2009. The CBL manual was developed by the researchers and a CBL education consultant during October, 2009. The manual was composed of a summary of patients, learning objectives, case presentation, with increasing coverage of clinically relevant information, questions for group discussion, teaching guides and references to all related disciplines. Finally, five facilitators, each with over 3 years of clinical experience, were selected from a pool of clinical instructors from a college of nursing to be responsible for promoting CBL to graduate nurses. Orientation programs were conducted for facilitators, stressing their roles to help group members understand their objectives and to assist them with searching for solutions and building sustainable agreement. Facilitator education was conducted between September and October, 2010. Implementation Data collection for this study was conducted between October, 2009 and February, 2010 for the lecture-based group (N = 96) and between October, 2010 and February, 2011 for the CBL group (N = 94). Before starting the program, subjective problem-solving abilities and objective problem-solving abilities of graduate nurses participating in this study were measured in order to confirm the homogeneity between the CBL group and the lecture-based group. Application of CBL For CBL, graduate nurses were divided into groups, each consisting of 5 or 6 participants. In the CBL group, 5 to 6 graduate nurses and 1 facilitator formed a single team, and they were given a video of 10 to
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15 minutes per case to watch. After watching the videos, graduate nurses assessed the cases and shared their opinions through discussions by proposing alternatives for the cases. CBL was divided into 4 steps for a total of 50 minutes including discussion, and during this time, the team facilitator adjusted the time and direction of the discussion in order to ensure smoothness and to avoid deviation from the given topic. In such manner, the program lasted a total of 150 minutes and was conducted over 3 sessions, one per week, 50 minutes per session. The following is organization of CBL. Step 1: Showing the cases through video presentation. In this step, graduate nurses were given the cases to be analyzed and solved. Graduate nurses of the CBL group watched the case videos and analyzed the problems during this process. Step 2: Analyzing the cases by individuals. This step establishes detailed plans for solving problems, and during this step, graduate nurses analyzed the situations that led to errors in order to experience a systematic problemsolving process. Factors, such as rising problems, relevant causes or evidence, what nurses must immediately do in cases of such problems, and predicted damage as a consequence were assessed using the videos. Step 3: Group-discussion to solve the problems. Based on the individually collected solution plans, data were collected. Through discussions, graduate nurses were encouraged to compare and analyze the source of the problems discussed, and to draw various results based on the proposed/ discussed solutions. The role of the facilitator was limited to keeping students focused on learning objectives and ensuring group dynamics. During this step, graduate nurses engaged in discussions with nursing medical, social and ethical perspectives. They then compared and analyzed their opinions on the problem-solving process of individual cases. Step 4: Finding proper solutions. This step proposes solutions to the problems, based on the results and data gathered from the aforementioned discussions.
Traditional Lecture-Based Education for the Control Group Traditional lecture-based education for the control group was conducted through the traditional lecture style, and the lectures were given by the division leader of the Quality Management Department from university hospital A. The lectures lasted a total of 150 minutes and were conducted over 3 sessions, one per week, 50 minutes per session. The lectures were based on nursing errors that frequently occur in clinical practice, and on proper problem-solving processes with a focus on the same cases as those of CBL which were determined to be in need of urgent education. Post-Test The post-test was conducted 10 weeks after the education program to measure objective problem-solving abilities and subjective problem-solving abilities. The post-test was conducted 10 weeks to confirm the long-term cognitive storage of the effect of the developed education (Yoo et al., 2009). Results Tests of Homogeneity of Two Groups The general characteristics of the subjects are presented in Table 1. There were no statistically significant differences between the two groups of graduate nurses in their general characteristics. The pretest scores were compared for the two groups (Table 2). No
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Table 1 General characteristics of the subjects. Variables
Age Working department
Educational level
Categories
Medical ward Surgical ward Intensive care unit Emergency department 3-year college 4-year college
Table 3 Objective and subjective problem-solving ability at post-test (10 weeks later). t or χ2
CBL group (n = 94)
Lecture-based group (n = 96)
N (%) or mean ± SD
N (%) or mean ± SD
23.43 ± 2.20 26 (27.7) 27 (28.7) 28 (29.8) 13 (13.8)
23.50 ± 2.27 23 (24.0) 24 (25.0) 33 (34.4) 16 (16.7)
0.230 1.059
55 (58.5) 39 (41.5)
64 (66.7) 32 (33.3)
1.350
p
.818 .787
Post-Test Score: Differences Between Lecture-Based and CBL Groups Results of the present study indicate that significant differences among the groups were observed in their problem-solving abilities. The CBL group scores were determined to be significantly higher compared with the lecture-based group scores on objective problemsolving ability (Table 3) in the post-test (p = .003). The total score of subjective problem-solving ability was also significantly lower in the CBL group than that of the lecture-based group (p b .001). This showed that graduate nurses in the CBL group were more confident in their problem-solving abilities than those in the lecture-based group. Discussion This study attempted to examine the effects of CBL on problemsolving abilities of graduate nurses. The results showed that the participants in the CBL program had higher scores in both subjective and objective problem-solving abilities compared to lecture-based education participants. This finding supports previous studies that claimed that CBL is a superior instructional method compared with didactic teaching in promoting a learner's problem-analysis, decision-making, and problem-solving abilities (Chan et al., 2008; Dietrich et al., 2010; Kaddoura, 2011; Kwak and Jang, 2009; Lumlertgul et al., 2009; Massonetto et al., 2004; Sprang, 2010; Thurman et al., 2009). A number of studies reported that universally graduate nurses in their first career role as registered nurses are facing a problematic transition into the workplace and difficult complex work environments all of which are disparate with their previous theoretically driven university world (Fero et al., 2009; Saintsing et al., 2011; Vittrup and Davey, 2010). Theorists suggest that one method of helping graduate nurses smooth transition into practice is to enhance problem-solving abilities (Uys et al., 2004; Vittrup and Davey, 2010). Problem-solving not only concerns identifying patients' problems and developing a nursing care plan, but it is a mandatory skill for a nurse to function as a safe, competent, intuitive and innovative clinician in an environment where new Table 2 Objective and subjective problem-solving ability at pre-test (homogeneity test).
Objective problem solving ability Subjective problem solving ability Problem-solving confidence Approach-avoidance style Personal control
Lecture-based group (n = 96)
mean ± SD
mean ± SD
t
Lecture-based t group (n = 96)
mean ± SD
mean ± SD
63.87 ± 5.60 61.05 ± 7.10 93.79 ± 8.76 101.92 ± 7.37 33.18 ± 3.80 47.13 ± 5.50 14.22 ± 2.89
35.19 ± 2.93 52.40 ± 4.72 14.85 ± 2.66
p
−3.04 .003 6.95 b.001 4.04 b.001 6.73 b.001 2.14 .034
.245
significant differences were detected in pre-test problem-solving abilities between the CBL and lecture-based groups.
CBL group (n = 94)
Objective problem-solving ability Subjective problem-solving ability Problem-solving confidence Approach-avoidance style Personal control
CBL group (n = 94)
p
information and clinical situations are constantly changing (Terzioglu, 2006; Uys et al., 2004). This study revealed that CBL is a powerful educational strategy which improves graduate nurses' problem-solving abilities. CBL would be beneficial to graduate nurses when considering a graduate nurse transition program that meets the learning requirement in today's health care setting and consequently help to achieve the ability of graduate nurses to problem solve and make adequate decisions. Despite that it is widely agreed that problem solving skills are essential in the practice of nursing and CBL is an effective method to enhance clinical problem-solving abilities of graduate nurses (Thurman et al., 2009), there are few studies on their effectiveness in Korea (Kwak and Jang, 2009). Therefore, future work is needed to examine the effectiveness of CBL in enhancing problem-solving abilities and clinical decisionmaking in nursing education. Also, prospective follow-up studies are needed to confirm such effects, as the present study merely identified the effects of case-based education over a period of 10 weeks. The most important factor in CBL is the development of authentic cases to stimulate the complexities of situations that occur within typical hospital wards, and to effectively place graduate nurses in the role of decision-makers and problem-solvers (Gilboy and Kane, 2004; Sprang, 2010; Tomey, 2003). Problem-solving in CBL is based on a rich repertoire of cases and stories that are extracted from the experience of expert practitioners (Oliver et al., 2000). This study developed actual and authentic cases of clinical situations that required rapid and acute decisions of nurses; the cases were real and detailed. In the future, more cases should be developed with various topics and lessons. However, such case development requires much time and effort (Kwak and Jang, 2009; Tomey, 2003), and hence, an efficient method of case development should also be studied. One limitation of this study is the small sample size. The subjects represented 190 graduate nurses from university hospital A. This may not fully allow for generalizing the findings to the general population of graduate nurses. Moreover, this study was a quasi-experimental intervention research lacking randomization. Also, the results were affected by the personal effort of graduate nurses to gain knowledge and the time lag between implementation of the lecture-group and the CBL group. Larger random controlled trials are needed to control for threats to internal and external validity so that the results can be generalized. Another limitation is that the study evaluated the outcomes of CBL using only quantitative methods. Both qualitative and quantitative methods are suggested to explore the effects in depth and to validate and generate empirical data on CBL. Despite these limitations, this research is significant due to the scarcity of studies related to CBL in the field of nursing education. Further studies are needed to confirm the effects of CBL on nursing education. Conclusion
52.72 ± 8.31
54.16 ± 14.77
0.83
.409
120.67 ± 12.42
120.38 ± 11.07
−0.17
.865
39.47 ± 4.97 60.37 ± 5.93 18.76 ± 3.14
39.85 ± 4.75 59.54 ± 5.79 19.07 ± 2.43
0.54 −0.98 0.78
.587 .330 .437
It is imperative that graduate nurses be able to think critically to face the challenges of today's fast-paced and technologically advanced nursing practice. A positive outcome of this study was the finding that CBL was more effective in the development of problemsolving abilities for graduate nurses than traditional lecture-based
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education. The results of this study have valuable implications for teaching, learning and nursing educational research, and offer an effective learning structure in the professional development and education of graduate nurses in the workplace. CBL should be encouraged in graduate nursing transition programs to develop graduate nurses' problem-solving abilities, which may impact the quality of nursing care and in turn improve patient safety. It would be of great value to direct further research toward the effects and outcomes of CBL programs for graduate nurses. Acknowledgements This work was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2009-0064675). References Benner, P., 1984. From Novice to Expert, Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Menlo Park, CA. Bentley, G.W., 2001. Problem-based learning, In: Lowenstein, A.J., Bradshaw, M.J. (Eds.), Fuszard's Innovative Teaching Strategies in Nursing, 3rd ed. Aspen Publishers, Gaithersburg, MD, pp. 83–106. Carroll, J.M., Borge, M., 2007. Articulating case-based learning outcomes and assessment. International Journal of Teaching and Case Studies 1 (1), 33–49. Chan, W.P., Hsu, C.Y., Hong, C.Y., 2008. Innovative “Case-Based Integrated Teaching” in an undergraduate medical curriculum: development and teachers' and students' responses. Annals of the Academy of Medicine, Singapore 37 (11), 952–956. Cholowski, K.M., Chan, L.K.S., 2001. Prior knowledge in student and experienced nurses’ clinical problem solving. Australian Journal of Educational & Developmental Psychology 1, 10–21. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences. Erlbaum, Hillsdale, New Jersey. Dietrich, J.E., De Silva, N.K., Young, A.E., 2010. Reliability study for pediatric and adolescent gynecology case-based learning in resident education. Journal of Pediatric and Adolescent Gynecology 23 (2), 102–106. Fero, L.J., Witsberger, C.M., Wesmiller, S.W., Zullo, T.G., Hoffman, L.A., 2009. Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing 65 (1), 139–148. Gilboy, N., Kane, D., 2004. Unfolding case based scenarios: a method of teaching and testing. Journal of Emergency Nursing 30 (1), 83–85. Halfer, D., Graf, E., 2006. Graduate nurse perceptions of the work experience. Nursing Economics 24 (3), 150–155. Heppner, P.P., Petersen, C.H., 1982. The development and implications of a personal problem solving inventory. Journal of Counseling Psychology 29 (1), 66–75. Heppner, P.P., Witty, T.E., Dixon, W.A., 2004. Problem-solving appraisal and human adjustment: a review of 20 years of research utilizing the problem solving inventory. The Counseling Psychologist 32, 344–428. Jonassen, D.H., Hernandez-Serrano, J., 2002. Case-based reasoning and instructional design: using stories to support problem solving. Educational Technology Research and Development 50 (2), 65–77. Jun, S.G., 1994. The Effect of Physical Skill Rehabilitation Program for Patients with Schizophrenia. Doctoral Dissertation, Soongsil University, Seoul, Korea.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Effect of case-based learning on the development of graduate nurses' problem-solving ability Moon-Sook Yoo 1, Jin-Hee Park ⁎ College of Nursing, Ajou University, Yongtong-Gu Wonceon-Dong San 5, Suwon, Gyeonggi-Do, South Korea
a r t i c l e
i n f o
Article history: Accepted 20 February 2013 Keywords: Problem solving Decision making Nursing education Case study
s u m m a r y Case-based learning (CBL) is a teaching strategy which promotes clinical problem-solving ability. This research was performed to investigate the effects of CBL on problem-solving ability of graduate nurses. This research was a quasi-experimental design using pre-test, intervention, and post-test with a nonsynchronized, non-equivalent control group. The study population was composed of 190 new graduate nurses from university hospital A in Korea. Results of the research indicate that there was a statistically significant difference in objective problem-solving ability scores of CBL group demonstrating higher scores. Subjective problem-solving ability was also significantly higher in CBL group than in the lecture-based group. These results may suggest that CBL is a beneficial and effective instructional method of training graduate nurses to improve their clinical problem-solving ability. © 2013 Elsevier Ltd. All rights reserved.
Introduction Dramatic advances and transformations have been made in health care organizations in the past recent decades, resulting in the rapid growth of technology (Vittrup and Davey, 2010). Success of nurses in such fast changing modern hospital environment involves becoming skilled at higher-level critical thinking and problem-solving abilities to provide safe and effective care to patients with complex and variable needs (Kaddoura, 2010; Yoo et al., 2009). Graduate nurses are expected to problem-solve and plan interventions independently (Kaddoura, 2011; Vittrup and Davey, 2010). According to Benner (1984), graduate nurses are novice nurses entering the role of a registered nurse who have typically practiced less than 2 years in the clinical setting during their educational experience. Graduate nurses are required to think critically in order to identify complex situations and practice sound clinical judgments, while considering multiple aspects of care (Halfer and Graf, 2006; Vittrup and Davey, 2010). However, research has suggested that many graduate nurses often have difficulty thinking critically in clinical practice, especially in situations that require making quick and accurate decisions and actions (Kaddoura, 2010, 2011; Wilgis and McConnell, 2008). Additional research has focused on errors related to graduate nurses not being adequately prepared in performing critical thinking skills, prioritization, and in their general inability to convert theoretical training to real-world situations (Morrow, 2009; Saintsing et al., 2011). These ⁎ Corresponding author. Tel.: +82 31 219 7019; fax: +82 31 219 7020. E-mail addresses: [email protected] (M.-S. Yoo), [email protected] (J.-H. Park). 1 Tel.: +82 31 219 7012; fax: +82 31 219 7020. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.014
studies certainly indicate that such problems experienced by graduate nurses are common concerns within the international practice of nursing (Saintsing et al., 2011). Although graduate nurses can demonstrate minimal competencies, they need continuous educational support to further develop critical thinking and problem-solving abilities and to progress their professional roles as nurses. Therefore, hospital-based nurse educators should construct orientation programs that can facilitate the development of critical thinking skills and problem-solving abilities in graduate nurses (Wilgis and McConnell, 2008). This study was carried out to investigate whether case-based learning (CBL) would be useful in developing problem-solving abilities in graduate nurses. Literature Review Nurses are confronted with many clinical problems on a daily basis, and their ability to competently deal with such problems is critical for safe and effective nursing practice. The question of how best to develop more successful clinical problem-solving abilities among nurses has become an issue of major importance to nurse educators (Simpson and Courtney, 2002; Wilgis and McConnell, 2008). Problem-solving ability is tied to thinking ability, which is considered a prior condition of professional practice (Bentley, 2001). Problem-solving begins with the perception of a situation as a problem, and then includes a selection of appropriate choices from many, in order to achieve a desired goal and its subsequent implementation (Taylor, 2000; Terzioglu, 2006). Traditionally, nurse education curricula have adopted a contentfocused approach, with emphasis on teaching facts, concepts and their relationship to particular subject domains, which are limited in demonstrating application of these ideas to clinical situations
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(Kaddoura, 2011; Roberts, 2000). Furthermore, course delivery has mainly been teacher-centered (Cholowski and Chan, 2001; Yoo et al., 2009). To overcome these limitations, the field of nursing education has been increasingly focusing on teaching strategies to enhance critical thinking skills as well as on student-centered education, which concentrate on each student's needs, abilities, interests, and learning styles, placing the teacher as a facilitator of learning (Vittrup and Davey, 2010; Uys et al., 2004). CBL is an instructional method within the context of studentcentered learning to facilitate students' learning and to decide for themselves regarding their perspective field, through the use of case studies (Kaddoura, 2011). CBL is derived from constructivism, which is a theory of learning and an approach to education that lays emphasis on the ways people create meaning of the world through a series of individual constructs (Jonassen and Hernandez-Serrano, 2002). CBL that simulates realistic problems appears to be an ideal approach for preparing graduate nurses to deal with patients with a multiple of clinical problems (Kaddoura, 2011). Case studies, or cases, are descriptions of specific activities, events, or problems that are drawn from the real world of professional practice and include contingencies, complexities, and dilemmas to evoke integrative analysis and critical thinking in CBL education. CBL seek to engage students through the use of drama from a real situation. CBL can support authentic learning experiences by presenting episodes of real professional practice (Carroll and Borge, 2007). Therefore, CBL provide models of practice to graduate practitioners and is a teaching strategy which promotes clinical problem-solving abilities (Morrow et al., 2003). CBL has been shown to be effective as part of medical and nursing programs in the U.S., Europe, and Australia (Chan et al., 2008; Dietrich et al., 2010; Massonetto et al., 2004; Thurman et al., 2009; Tomey, 2003). Moreover, CBL is widely used in other fields of professional education — in business, law, and engineering (Carroll and Borge, 2007; Kaddoura, 2011). Although many claims are made for CBL as an effective learning and teaching method, there is a paucity of empirical data on the effect of CBL in preparing graduate nurses for professional practice, especially from Korea. In the current study, we tested the hypothesis that CBL for graduate nurses would improve their problem-solving abilities. Methods Study Design A quasi-experimental design using pre-test, intervention, and post-test with a non-synchronized, non-equivalent control group was employed. Study Subjects A convenience non-probability sampling method was used to select a sample and to attain a total sample of N = 190 new graduate nurses from university hospital A. Institutional Review Board approval was obtained from the university hospital prior to data collection. The target population for this study consisted entirely of new graduate nurses hired to work as registered nurses at large university hospitals in Korea. Selection of subjects was based on the following inclusion criteria. They were expected to be new graduates without any previous experience as RNs. The selected participants started their employment at university hospital A. This study was explained in detail before obtaining informed consent. Participation was voluntary. If graduate nurses agreed to participate in the study, they were asked to sign the informed consent form. After signing the consent, a coded demographic questionnaire was administered. Finally, 96 graduate nurses, who were hired from university hospital A in 2009, were assigned to the traditional lecture-based group. Ninety-four graduate nurses, who were
hired from university hospital A in 2010, were assigned to the CBL group. Power analysis for the two-group test of mean differences to reach 90% power and an effect size of 0.50 with an alpha value of 0.05 required a minimum sample size of 86 participants in each group (Cohen, 1988). The effectiveness of CBL or PBL education programs from a previous study was used as a reference for power calculation (Thistlethwaite et al., 2012). Instrument Subjective Problem-Solving Ability The problem-solving inventory (PSI) was used for the purpose of evaluating how graduate nurses perceive themselves as problem solvers. The PSI was developed in 1982 by Heppner and Petersen, and it has since proven to be valid and reliable. It was translated to Korean in Jun (1994). The scale is simple to use and participants are able to complete it by themselves. Respondents were required to rate each item on a 6-point Likert scale (1 = strongly agree, to 6 = strongly disagree). The PSI has a total score (i.e., the sum of three factors) and three factors derived from factor analyses. The three factors are as follows (a) problem-solving confidence (PC), (b) approach-avoidance style (AAS), and (c) personal control (PC) (Heppner and Petersen, 1982). The PSC refers to an individual's belief and trust in one's own problem-solving ability. The AAS is defined as a general tendency to approach or avoid a wide range of problemsolving activities. The PC refers to an individual's belief that one is in control of his or her own behaviors and emotions while solving problems (Heppner et al., 2004). A total score is derived from these factor scores and serves as a global index of problem-solving ability. Reliability estimates have revealed that these constructs are internally consistent (alpha coefficients ranged from .72 to .90). Lower scores indicate effective problem-solving attitudes and behaviors, whereas higher scores denote an individual's assessment of oneself as a relatively ineffective problem solver. The a coefficients for the sample used in this study were .82 for the PSI total, and .82, .89, and .74 for the PSC, AAS, and PC, respectively. Objective Problem-Solving Ability We developed a simulated test to measure objective problemsolving abilities. This simulated test consists of three cases which depict common clinical problems that nurses may encounter in the hospital. An expert group consisting of instrument development and professional educators created an appropriate scenario and its relevant questions. The questions were developed based the Performance Based Development System (PBDS), which composes of six subcategories: problem recognition (e.g. What are the major issues in this case?), reports essential clinical data (e.g. What are the important data and what might they mean?), initiates independent nursing intervention, differentiation of urgency (e.g. What interventions should be initiated now? Or how should this patient be managed?), anticipates relevant medical orders (e.g. Now what should be done and what can the patient expect?), and provides relevant rational to support decisions (e.g. What do you think is the best way to deal with the problem and why?). The PBDS assessment is designed to identify critical thinking learning needs and to assist with the development of an individualized orientation action plan to prepare better nurses for safe clinical practice (Performance Management Services Inc., 2006). The simulated test was then revised in order to obtain consensus for the measurement of criteria, wording, and general presentation. Following revision of the content, the simulated test was further evaluated in a pilot study involving 12 nurses. All participants were interviewed to determine if they found the questionnaire clear and understandable. They were also asked to provide suggestions for the improvement of wording of any items they found confusing. All
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participants noted that they found instrument items clear, concise, easy to read, easy to complete, and easy to understand. Respondents were asked to review each case and to then state, in writing, what they think the problem is, actions they would take in response, and their rationale. Two experts scored each participant's test using a guide developed by the expert group. Corrections were cross-checked by other experts. Inter-rater reliability was tested with the intra-class correlation coefficient (ICC). The ICC was 0.95, which was considered acceptable. Procedures Development of CBL CBL was developed between June and October of 2009. The development process was divided into selection of cases, video production and manual development. For the selection of cases, the 7 most frequently occurring clinical nursing problems that may potentially lead to nursing errors were provided by the department of nursing at university hospital A. The panel of seven experts, including professors and clinical nursing instructors from the college of nursing, selected 3 problems that were determined to be in need of most urgent education. The selected problems were nursing errors caused by miscommunication between nurses, nursing errors caused from not following the principles of medication administration and nursing errors caused from not observing the principles during transfusion. The panel developed 3 cases for CBL which included the causes, processes and results of the accident, in accordance with Five Ws and one H problem solving method. The Five Ws and one H are questions whose answers are considered basic in information-gathering (MediaSmarts, 2012). An education consultant helped with the objective development, case construction and flow. Clinical nurse specialists reviewed the cases for realism, accuracy and clinical relevance. A scenario was created based on such developed cases, and it was made into a film with re-enactments by nursing students. Video filming and editing were done by professional video specialists. Creating cases and video production were conducted between June and September of 2009. The CBL manual was developed by the researchers and a CBL education consultant during October, 2009. The manual was composed of a summary of patients, learning objectives, case presentation, with increasing coverage of clinically relevant information, questions for group discussion, teaching guides and references to all related disciplines. Finally, five facilitators, each with over 3 years of clinical experience, were selected from a pool of clinical instructors from a college of nursing to be responsible for promoting CBL to graduate nurses. Orientation programs were conducted for facilitators, stressing their roles to help group members understand their objectives and to assist them with searching for solutions and building sustainable agreement. Facilitator education was conducted between September and October, 2010. Implementation Data collection for this study was conducted between October, 2009 and February, 2010 for the lecture-based group (N = 96) and between October, 2010 and February, 2011 for the CBL group (N = 94). Before starting the program, subjective problem-solving abilities and objective problem-solving abilities of graduate nurses participating in this study were measured in order to confirm the homogeneity between the CBL group and the lecture-based group. Application of CBL For CBL, graduate nurses were divided into groups, each consisting of 5 or 6 participants. In the CBL group, 5 to 6 graduate nurses and 1 facilitator formed a single team, and they were given a video of 10 to
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15 minutes per case to watch. After watching the videos, graduate nurses assessed the cases and shared their opinions through discussions by proposing alternatives for the cases. CBL was divided into 4 steps for a total of 50 minutes including discussion, and during this time, the team facilitator adjusted the time and direction of the discussion in order to ensure smoothness and to avoid deviation from the given topic. In such manner, the program lasted a total of 150 minutes and was conducted over 3 sessions, one per week, 50 minutes per session. The following is organization of CBL. Step 1: Showing the cases through video presentation. In this step, graduate nurses were given the cases to be analyzed and solved. Graduate nurses of the CBL group watched the case videos and analyzed the problems during this process. Step 2: Analyzing the cases by individuals. This step establishes detailed plans for solving problems, and during this step, graduate nurses analyzed the situations that led to errors in order to experience a systematic problemsolving process. Factors, such as rising problems, relevant causes or evidence, what nurses must immediately do in cases of such problems, and predicted damage as a consequence were assessed using the videos. Step 3: Group-discussion to solve the problems. Based on the individually collected solution plans, data were collected. Through discussions, graduate nurses were encouraged to compare and analyze the source of the problems discussed, and to draw various results based on the proposed/ discussed solutions. The role of the facilitator was limited to keeping students focused on learning objectives and ensuring group dynamics. During this step, graduate nurses engaged in discussions with nursing medical, social and ethical perspectives. They then compared and analyzed their opinions on the problem-solving process of individual cases. Step 4: Finding proper solutions. This step proposes solutions to the problems, based on the results and data gathered from the aforementioned discussions.
Traditional Lecture-Based Education for the Control Group Traditional lecture-based education for the control group was conducted through the traditional lecture style, and the lectures were given by the division leader of the Quality Management Department from university hospital A. The lectures lasted a total of 150 minutes and were conducted over 3 sessions, one per week, 50 minutes per session. The lectures were based on nursing errors that frequently occur in clinical practice, and on proper problem-solving processes with a focus on the same cases as those of CBL which were determined to be in need of urgent education. Post-Test The post-test was conducted 10 weeks after the education program to measure objective problem-solving abilities and subjective problem-solving abilities. The post-test was conducted 10 weeks to confirm the long-term cognitive storage of the effect of the developed education (Yoo et al., 2009). Results Tests of Homogeneity of Two Groups The general characteristics of the subjects are presented in Table 1. There were no statistically significant differences between the two groups of graduate nurses in their general characteristics. The pretest scores were compared for the two groups (Table 2). No
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Table 1 General characteristics of the subjects. Variables
Age Working department
Educational level
Categories
Medical ward Surgical ward Intensive care unit Emergency department 3-year college 4-year college
Table 3 Objective and subjective problem-solving ability at post-test (10 weeks later). t or χ2
CBL group (n = 94)
Lecture-based group (n = 96)
N (%) or mean ± SD
N (%) or mean ± SD
23.43 ± 2.20 26 (27.7) 27 (28.7) 28 (29.8) 13 (13.8)
23.50 ± 2.27 23 (24.0) 24 (25.0) 33 (34.4) 16 (16.7)
0.230 1.059
55 (58.5) 39 (41.5)
64 (66.7) 32 (33.3)
1.350
p
.818 .787
Post-Test Score: Differences Between Lecture-Based and CBL Groups Results of the present study indicate that significant differences among the groups were observed in their problem-solving abilities. The CBL group scores were determined to be significantly higher compared with the lecture-based group scores on objective problemsolving ability (Table 3) in the post-test (p = .003). The total score of subjective problem-solving ability was also significantly lower in the CBL group than that of the lecture-based group (p b .001). This showed that graduate nurses in the CBL group were more confident in their problem-solving abilities than those in the lecture-based group. Discussion This study attempted to examine the effects of CBL on problemsolving abilities of graduate nurses. The results showed that the participants in the CBL program had higher scores in both subjective and objective problem-solving abilities compared to lecture-based education participants. This finding supports previous studies that claimed that CBL is a superior instructional method compared with didactic teaching in promoting a learner's problem-analysis, decision-making, and problem-solving abilities (Chan et al., 2008; Dietrich et al., 2010; Kaddoura, 2011; Kwak and Jang, 2009; Lumlertgul et al., 2009; Massonetto et al., 2004; Sprang, 2010; Thurman et al., 2009). A number of studies reported that universally graduate nurses in their first career role as registered nurses are facing a problematic transition into the workplace and difficult complex work environments all of which are disparate with their previous theoretically driven university world (Fero et al., 2009; Saintsing et al., 2011; Vittrup and Davey, 2010). Theorists suggest that one method of helping graduate nurses smooth transition into practice is to enhance problem-solving abilities (Uys et al., 2004; Vittrup and Davey, 2010). Problem-solving not only concerns identifying patients' problems and developing a nursing care plan, but it is a mandatory skill for a nurse to function as a safe, competent, intuitive and innovative clinician in an environment where new Table 2 Objective and subjective problem-solving ability at pre-test (homogeneity test).
Objective problem solving ability Subjective problem solving ability Problem-solving confidence Approach-avoidance style Personal control
Lecture-based group (n = 96)
mean ± SD
mean ± SD
t
Lecture-based t group (n = 96)
mean ± SD
mean ± SD
63.87 ± 5.60 61.05 ± 7.10 93.79 ± 8.76 101.92 ± 7.37 33.18 ± 3.80 47.13 ± 5.50 14.22 ± 2.89
35.19 ± 2.93 52.40 ± 4.72 14.85 ± 2.66
p
−3.04 .003 6.95 b.001 4.04 b.001 6.73 b.001 2.14 .034
.245
significant differences were detected in pre-test problem-solving abilities between the CBL and lecture-based groups.
CBL group (n = 94)
Objective problem-solving ability Subjective problem-solving ability Problem-solving confidence Approach-avoidance style Personal control
CBL group (n = 94)
p
information and clinical situations are constantly changing (Terzioglu, 2006; Uys et al., 2004). This study revealed that CBL is a powerful educational strategy which improves graduate nurses' problem-solving abilities. CBL would be beneficial to graduate nurses when considering a graduate nurse transition program that meets the learning requirement in today's health care setting and consequently help to achieve the ability of graduate nurses to problem solve and make adequate decisions. Despite that it is widely agreed that problem solving skills are essential in the practice of nursing and CBL is an effective method to enhance clinical problem-solving abilities of graduate nurses (Thurman et al., 2009), there are few studies on their effectiveness in Korea (Kwak and Jang, 2009). Therefore, future work is needed to examine the effectiveness of CBL in enhancing problem-solving abilities and clinical decisionmaking in nursing education. Also, prospective follow-up studies are needed to confirm such effects, as the present study merely identified the effects of case-based education over a period of 10 weeks. The most important factor in CBL is the development of authentic cases to stimulate the complexities of situations that occur within typical hospital wards, and to effectively place graduate nurses in the role of decision-makers and problem-solvers (Gilboy and Kane, 2004; Sprang, 2010; Tomey, 2003). Problem-solving in CBL is based on a rich repertoire of cases and stories that are extracted from the experience of expert practitioners (Oliver et al., 2000). This study developed actual and authentic cases of clinical situations that required rapid and acute decisions of nurses; the cases were real and detailed. In the future, more cases should be developed with various topics and lessons. However, such case development requires much time and effort (Kwak and Jang, 2009; Tomey, 2003), and hence, an efficient method of case development should also be studied. One limitation of this study is the small sample size. The subjects represented 190 graduate nurses from university hospital A. This may not fully allow for generalizing the findings to the general population of graduate nurses. Moreover, this study was a quasi-experimental intervention research lacking randomization. Also, the results were affected by the personal effort of graduate nurses to gain knowledge and the time lag between implementation of the lecture-group and the CBL group. Larger random controlled trials are needed to control for threats to internal and external validity so that the results can be generalized. Another limitation is that the study evaluated the outcomes of CBL using only quantitative methods. Both qualitative and quantitative methods are suggested to explore the effects in depth and to validate and generate empirical data on CBL. Despite these limitations, this research is significant due to the scarcity of studies related to CBL in the field of nursing education. Further studies are needed to confirm the effects of CBL on nursing education. Conclusion
52.72 ± 8.31
54.16 ± 14.77
0.83
.409
120.67 ± 12.42
120.38 ± 11.07
−0.17
.865
39.47 ± 4.97 60.37 ± 5.93 18.76 ± 3.14
39.85 ± 4.75 59.54 ± 5.79 19.07 ± 2.43
0.54 −0.98 0.78
.587 .330 .437
It is imperative that graduate nurses be able to think critically to face the challenges of today's fast-paced and technologically advanced nursing practice. A positive outcome of this study was the finding that CBL was more effective in the development of problemsolving abilities for graduate nurses than traditional lecture-based
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education. The results of this study have valuable implications for teaching, learning and nursing educational research, and offer an effective learning structure in the professional development and education of graduate nurses in the workplace. CBL should be encouraged in graduate nursing transition programs to develop graduate nurses' problem-solving abilities, which may impact the quality of nursing care and in turn improve patient safety. It would be of great value to direct further research toward the effects and outcomes of CBL programs for graduate nurses. Acknowledgements This work was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2009-0064675). References Benner, P., 1984. From Novice to Expert, Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Menlo Park, CA. Bentley, G.W., 2001. Problem-based learning, In: Lowenstein, A.J., Bradshaw, M.J. (Eds.), Fuszard's Innovative Teaching Strategies in Nursing, 3rd ed. Aspen Publishers, Gaithersburg, MD, pp. 83–106. Carroll, J.M., Borge, M., 2007. Articulating case-based learning outcomes and assessment. International Journal of Teaching and Case Studies 1 (1), 33–49. Chan, W.P., Hsu, C.Y., Hong, C.Y., 2008. Innovative “Case-Based Integrated Teaching” in an undergraduate medical curriculum: development and teachers' and students' responses. Annals of the Academy of Medicine, Singapore 37 (11), 952–956. Cholowski, K.M., Chan, L.K.S., 2001. Prior knowledge in student and experienced nurses’ clinical problem solving. Australian Journal of Educational & Developmental Psychology 1, 10–21. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences. Erlbaum, Hillsdale, New Jersey. Dietrich, J.E., De Silva, N.K., Young, A.E., 2010. Reliability study for pediatric and adolescent gynecology case-based learning in resident education. Journal of Pediatric and Adolescent Gynecology 23 (2), 102–106. Fero, L.J., Witsberger, C.M., Wesmiller, S.W., Zullo, T.G., Hoffman, L.A., 2009. Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing 65 (1), 139–148. Gilboy, N., Kane, D., 2004. Unfolding case based scenarios: a method of teaching and testing. Journal of Emergency Nursing 30 (1), 83–85. Halfer, D., Graf, E., 2006. Graduate nurse perceptions of the work experience. Nursing Economics 24 (3), 150–155. Heppner, P.P., Petersen, C.H., 1982. The development and implications of a personal problem solving inventory. Journal of Counseling Psychology 29 (1), 66–75. Heppner, P.P., Witty, T.E., Dixon, W.A., 2004. Problem-solving appraisal and human adjustment: a review of 20 years of research utilizing the problem solving inventory. The Counseling Psychologist 32, 344–428. Jonassen, D.H., Hernandez-Serrano, J., 2002. Case-based reasoning and instructional design: using stories to support problem solving. Educational Technology Research and Development 50 (2), 65–77. Jun, S.G., 1994. The Effect of Physical Skill Rehabilitation Program for Patients with Schizophrenia. Doctoral Dissertation, Soongsil University, Seoul, Korea.
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