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Using enquiry in learning: From vision to reality in higher education
Nurse Education Today (2007) 27, 103–112
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Using enquiry in learning: From vision to reality in higher education q Maria Horne, Kath Woodhead, Liz Morgan, Lynda Smithies, Denise Megson, Geraldine Lyte * University of Manchester, School of Nursing, Midwifery and Social Work, Coupland III Building, Oxford Road, Manchester M13 9PL, United Kingdom Accepted 18 March 2006
KEYWORDS
Summary This paper reports on the contribution of six nurse educators to embed enquiry-led learning in a pre-registration nursing programme. Their focus was to evaluate student and facilitator perspectives of a hybrid model of problem-based learning, a form of enquiry-based learning and to focus on facilitators’ perceptions of its longer-term utility with large student groups. Problem-based learning is an established learning strategy in healthcare internationally; however, insufficient evidence of its effectiveness with large groups of pre-registration students exists. Fourth Generation Evaluation was used, applying the Nominal Group Technique and Focus Group interviews, for data collection. In total, four groups representing different branches of pre-registration students (n = 121) and 15 facilitators participated. Students identified seven strengths and six areas for development related to problem-based learning. Equally, analysis of facilitators’ discussions revealed several themes related to strengths and challenges. The consensus was that using enquiry aided the development of independent learning and encouraged deeper exploration of nursing and allied subject material. However, problems and frustrations were identified in relation to large numbers of groups, group dynamics, room and library resources and personal development. The implications of these findings for longer-term utility with large student groups are discussed. c 2006 Elsevier Ltd. All rights reserved.
Student nurses; Facilitation; Enquiry-based learning; Problem-based learning
Introduction q
A study funded by the LTSN Generic Centre, coordinated by the Teaching and Learning Support Unit, University of Manchester. * Corresponding author. Tel.: +44 161 275 5339; fax: +44 161 275 7566. E-mail address: [email protected] (G. Lyte).
Problem-based learning (PBL) has generated considerable international interest and recognition in recent years (Price, 2003; Blackford and Street, 1999; Amos and White, 1998; Alavi, 1995). As a
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.03.004
104 learning approach it offers potential to bridge theory and practice, through identification and evaluation of practice-based problems (Price, 2003). It differs from enquiry-based learning (EBL) in that the latter represents any form of learning that is motivated by enquiry, by asking for or seeking information in order to understand something (Concise Oxford English Dictionary, 2002, p. 474). In this paper PBL is discussed as one form of EBL. The paper presents findings from an LTSNfunded programme of professional development, involving 50 educators representing a range of disciplines, from four north-west universities. The programme was designed to build capacity for applying EBL; this paper focuses on the nursing component of the wider EBL project. Specifically, the nursing participants aimed to evaluate student and facilitator perspectives of the introduction of a PBL curriculum, as one form of EBL, with large student groups.
Background/literature Relevant literature was identified through a computer search of CINAHL, MEDLINE, British Nursing Index and ERIC. This yielded an abundance of PBL literature, particularly in medicine and allied professions (Dean et al., 2003; Kaufman and Holmes, 1996). The advantages of using PBL are also reported in continuing nursing education (Newman, 2003) and postgraduate multidisciplinary student groups (Carlisle and Ibbotson, 2005). On the contrary much less attention is given to PBL effectiveness in pre-registration nursing (Barrow et al., 2002). Three papers which involved large groups of nursing students were identified. The first, Alexander et al. (2002) from the United States describes the practicalities of implementing and evaluating PBL in a nursing curriculum. However, it is not primary research and the influence of PBL on student nurse performance is unclear in their work. In contrast, Pang et al.’s (2002) research-based Hong Kong study uses developmental action inquiry with eight teachers and 15 groups of 16 first year student nurses, to evaluate the impact that PBL on student learning. Only the student evaluation data is presented; key findings include issues around self-learning, tutor–student interaction and group learning. The third study has more significance for this paper because it is UK-based and examines the implementation of EBL as a ‘whole-curriculum’ strategy for pre-registration nursing education (Bebb and Pittam, 2004). The authors report on part of a wider evaluation of individual and group interviews
M. Horne et al. with 15 student nurse representatives from 20 preregistration EBL groups, to gain their experiences of learning. Factors they identified are similar to findings from other studies, and include adaptation to EBL, the EBL model in use, taking responsibility for learning and working within groups. Like the other papers analysed here, Bebb and Pittam (2004) have not included issues from facilitators, especially, where this relates to supporting large groups. So in spite of the broad evidence-base of PBL applications in healthcare curricula, there remains insufficient support for its longer term utility with large groups of pre-registration nursing students (n = 100 or more) and their facilitators.
The study Aims To ascertain students’ and facilitators’ perspectives of using individual and group enquiry to support learning, within a PBL framework; To gain a deeper understanding of facilitators’ perceptions of the longer-term utility of PBL with large student groups.
Research setting and participants The research was carried out in a higher education setting at the end of the students’ first PBL-based branch module, the first module of the second year of the programme overall. Each branch programme consists of six 15 week modules, with four weeks of theory, nine weeks on placement and two weeks for reflection and assessment. Introducing an enquiry-based curriculum represented major challenges, where the research was undertaken: the School concerned includes a population of approximately 1900 pre-registration nursing students, so moving away from the traditional large group lectures to small group self-directed learning raised concerns for lecturers and clinical staff alike. The majority of teaching and support staff (n = >150) and, clinical colleagues who had responsibility to support student nurse learning, had relatively little experience of such an approach. Evaluation of its introduction was considered vital, particularly in terms of adaptation to EBL generally and future developments for PBL specifically. A hybrid model of PBL was introduced to allow for a gradual introduction into the large preregistration programmes. In the foundation year
Using enquiry in learning: From vision to reality in higher education teacher-led, case-based learning is applied alongside students’ preparation for more self-directed and small group learning techniques. Emphasis in the first branch year switches to student-led small group work using an adaptation of the ‘seven jump process’ to structure activity (Schmidt, 1983) (Fig. 1). In the second branch year students are expected to take increasing responsibility for developing their own learning outcomes and for managing small group learning with the support of a facilitator. For the purposes of the evaluation a purposive sample of 121 students and 15 facilitators from four groups (within one cohort of 250 students) were selected, representing different branches of learning on the programme: community, child health, mental health and critical care. Approval to undertake this research was obtained from the University’s Senate Ethics Committee. The informed consent process was followed for all prospective participants: a verbal explanation was provided, outlining details of the study, including the option of nonparticipation or withdrawal at any time; anonymity and confidentiality was assured and facilitators did not lead the nominal group evaluation with their own group. In the event, nine students did not join the nominal group process.
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core activity and follows on from three generations of positivist evaluation models: measurement; the use of measurable objectives and judgement by evaluators (Koch, 2000). Koch (2000) explains this as a responsive focusing and hermeneutic dialectic, in that participants are invited to develop their own construction and self-interpretation of the situation being evaluated. Positivist approaches to evaluation seek specific, objective information that does not consider the context of what is being evaluated, or the many individual, group and environmental variables that can confound the responses of a structured, inflexible model (Curran et al., 2003). Nevertheless, while Guba and Lincoln’s model has wide appeal in health care, particularly in professional education, it has been criticised for its potential for bias in favour of those who are more articulate and more likely to project their views over others’ (Redfern, 2003). Consequently, methods of data collection that can gain a balanced construction of participants’ reality of a situation need to be used for fourth generation evaluations, such as the nominal group technique and focus group interviews.
Data collection Research design
Students
Fourth Generation Evaluation (Guba and Lincoln, 1989) was selected because it encourages dialogue, negotiation and empowerment for stakeholders. This is a qualitative evaluative approach using negotiation with participants/stakeholders as its
Nominal group technique (NGT) was used in this part of the study to gather qualitative data in line with Guba and Lincoln’s approach to evaluation. NGT is a structured group activity designed to elicit the views of group members about a particular
Share results
Evaluate results
Start here Study privately
The 'seven jump' tutorial process in PBL
clarify terms, concepts
Identify issues, problem
Set learning objectives Brainstorm possible explanations
Figure 1
The Maastricht seven jump process for PBL applied within the School’s Pre-Registration Programmes.
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M. Horne et al.
issue or topic (Delbecq et al., 1975). Through NGT, qualitative information from each member of the student groups, in turn, used negotiation to highlight priority issues. Judgements of the overall importance of identified issues that were agreed at group level remained with group members; individual issues that were not shared by the group overall were followed up by the individual and the evaluator, facilitating a shared dialogue and a reflexive approach to the evaluative process (Guba and Lincoln, 1989). In this study, students in the final week of their first branch module were asked to initiate the nominal group process, by identifying five strengths and five areas for development of the student experience and value of PBL. Prompts were provided by facilitators (the same for all groups) (Table 1). In order to overcome response bias in favour of dominant group members (Redfern, 2003), a ‘‘round robin’’ process was used to obtain all group members’ identified issues, prior to voting. The items recorded throughout the ‘‘round robin’’ were discussed to ensure that everyone understood what they were. Any areas of overlap were merged to avoid repetition and allow for more effective voting. Any statements which failed to receive
Table 1
Prompts for nominal group evaluation
Consider issues around Students own performance The groups performance The performance of other groups within the module Facilitator support General Issues relating to PBL as a form of teaching and learning
Table 2
any votes were discarded. Table 2 illustrates how the NGT was applied sequentially in this study.
Facilitators Focus group interviews were used in this part of the study because the method utilises group dynamics and social interaction to produce data and insights through social interaction and dialogue (Kitzinger, 1995). This can assist people to explore, develop and clarify their views more successfully than in individual interviews (Kitzinger, 1995). Kevern and Webb (2001) provide a good critique on the use of focus groups for critical social research in nurse education. Prompts were provided by the facilitator (Table 3) and data were collected over a one month period after completion of the 15 week modules.
Table 3
Focus group discussion guide
Consider and discus issues around The positive experiences of facilitating the PBL group The negative experiences of facilitating the PBL group How well they felt prepared for their role as facilitator Skills required of a facilitator How useful they found the workshops How do internal and external support structures/ systems assist their role? Relationships: student–facilitator, group dynamics and student preparation Resources – human, physical, time allocated, preparation of scenarios Areas of development
Applying the nominal group technique for the project
1. Split the four PBL groups evenly into quarters. Ensure that each nominal group consists of a mixture of students from all four PBL groups 2. Ask the students within the nominal groups to identify five strengths and five areas for development Suggested prompts Individual, group and other group performance Facilitator support General issues related to group learning 3. Ask each group to identify one of their strengths. Continue, in turn, until all suggestions have been exhausted 4. Repeat the exercise for areas of development 5. For each of the statements ask students to put up their hands if they agree with a particular statement. Count the number of hands and score the statement 6. The facilitator can then add up the total marks given to each statement. Statements that do not receive any points will be discarded 7. The facilitator can write up comments and scores for reporting 8. Nominal group data can then be compared with other concurrent module nominal group data
Using enquiry in learning: From vision to reality in higher education
Data analysis In total students identified 35 statements related to their experiences of PBL, seven strengths (Table 4) and six areas of development (Table 5). Each group’s facilitator totalled the marks given to each statement and discarded statements that did not receive any points. The facilitator wrote up comments and scores for reporting. Focus group interviews were content analysed using an iterative mode described by Grbich (1999) as an interpretive, ongoing, inductive process. The interviews were audio-taped and transcribed verbatim. Each researcher analysed
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transcripts from their own focus group interview to develop initial themes, followed by synthesis and clarification of all emergent themes by the research team to increase credibility of data collected (Miles and Huberman, 1994). To enhance dependability of interpretation, all the transcripts were then analysed for content and structure by the principle researcher and the level of agreement assessed (Mays and Pope, 1996; Miles and Huberman, 1994).
Findings and discussion Student perspectives
Table 4
Student perspectives of PBL (1)
Strengths of PBL 1. Working as a team (N = 120: 99.2%)
Summary of statements
Acceptance Individual styles Values Peer support (co-operation) Personal relationships (co-operation) Interaction and dialogue 2. Improves Self awareness interpersonal/ communication skills Understanding of others’ points of view (N = 96: 79.3%) Learning from others 3. Develops teaching Use of all resources and presentation Technical skills skills (N = 95: 78.5%) Internet skills Development of presentation skills Planning and organisational skills 4. Encourages Confidence independent learning Self direction skills (N = 105: 86.8%) Self development Time management Clinical judgement 5. Develops problem Clinical decision-making solving skills Identifying patient needs especially those of Planning care assessment and prioritization (N = 84: 69.4%) People 6. Encourages more effective utilization Material Environment of resources (N = 91: 75.2%) 7. Encourages wider More use of electronic reading sources (N = 91: 75.2%) Searching for evidence Deeper exploration Research awareness Greater depth of knowledge
Analysis of students’ statements indicated that PBL aided the development of independent learning skills and encouraged deeper exploration of both nursing and allied subject material (Table 4). The majority of participants also had a positive attitude to PBL: 99.2% of statements that related to strengths indicated that it aided development of team working and peer support; accepting individual styles/values, and managing conflict and sharing experiences. The findings from this study also support the premise that PBL encourages self-awareness, confidence, self-direction and independent learning skills (86.8% of statements). These concepts, expressed in terms of interpersonal skills development, group interaction and self-reflection, are also identified as positive facets of PBL in medical evaluation literature (for example Ozuah et al., 2001). In addition, 79.3% cited improved interpersonal and communication skills on the basis of applying a non-judgemental approach to group interaction. Other strengths identified by students were that PBL aided development of teaching and presentation skills, such as planning and time management (78.5%); that it encouraged wider reading, depth of enquiry and increased research awareness (75.2%) and, better use of facilitator, clinical and technological resources. 69.4% of students related the development of problem-solving skills to their development of assessment skills in the workplace, demonstrating the ability to link theory and practice through PBL. It supports the findings from an earlier Canadian study (Morales-Mann and Kaitell, 2001), where students equated PBL-based problem-solving with clinical nursing process. However, problems and frustrations were also identified (Table 5). Students recognised that PBL depended on group collaboration for success, which raised concerns about teamwork and group dynamics,
108 Table 5
M. Horne et al. Student perspectives of PBL (2)
Areas of development
Summary of statements
1. Group dynamics/teamwork (N = 56: 46.3%)
Equal participation Demands on chairperson and scribe Commitment Attendance Impact of non-functional people Impact of overpowering people More facilitated sessions More preparation time for presentations More time in clinical practice to pursue PBL activities Time allocated to each ‘problem’/‘scenario’ Accreditation of PBL Formal assessment may add pressure Formal assessment would add recognition More involvement in difficult situations with novice students Consistency of information Keeping the same facilitator Teachers and students understanding Wanting all parts of the scenario at the outset Amount of information gathered Skills in using technology Research skills Communication skills
2. Resource and time allocation (N = 101: 83.5%)
3. Assessment (N = 64: 52.9%)
4. Role of the facilitator (N = 47: 38.8%)
5. Concept of the process (N = 60: 49.5%)
6. Personal development (N = 45: 37.2%)
particularly attendance, equality of input and division of labour (46.3%). The issue of group collaboration for PBL is well cited in the literature, indicating that difficulties can arise when tutorial groups are faced with students who either do not prepare for, or who do not attend meetings and tacitly let others do the work (Dolmans et al., 2001; Biley and Smith, 1999; O’Hanlon et al., 1995). Assessment/accreditation accounted for 52.9% of student statements and cited as an area of development (Table 5). However, feelings were mixed. Some students wished both the product and the process of PBL to be assessed, but some students liked the idea that it was not assessed due to the extra pressure this would place upon them. Other authors have dealt with such issues by introducing self or peer summative assessments for the process of PBL (Connolly and Donovan, 2002). Miflin et al. (1999) utilised formative assessment exercises based on the objectives of tutorial discussion, however, their students expressed doubts about the effectiveness of this in guiding their learning. Other areas identified for further development included resources and time allocation (83.5%); clarification of the role of facilitator (38.8%) and, personal development (37.2%). In particular, students wanted greater support in their application of ICT, research and communication skills for PBL activity.
Facilitators’ perspectives Preparation of facilitators Most teachers had initial difficulty with overcoming the teaching versus facilitator role.
Box 1 ‘The bit I found most difficult was when I knew the answer to what they were asking me. I wanted to tell them. Being a teacher, you are used to questions and answers and telling them what they wanted to know’ (adult branch facilitator). It has been emphasised that PBL facilitators should not ‘teach’ students but allow students to be self-directed (Maudsley, 2002). However, achieving a balance between non-participation and active facilitation can be difficult, especially when deciding at what time to intervene in the PBL process (Andrews and Jones, 1996). Interestingly, Maudsley’s (2002) descriptive study found that novice PBL facilitators characterised a good facilitator as knowing when and how to intervene. This highlights the importance of continued professional development for honing facilitation skills (Dolmans et al., 2001). Although most facilitators in this study found the preparation (of
Using enquiry in learning: From vision to reality in higher education workshops) they received helpful (Lyte, 2003), the general consensus was that experience in facilitation takes place through the experiential process itself. Box 2 ‘I don’t think that I needed more preparation. I think it’s just the experience of doing it (community facilitator).
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Facilitating the process of PBL Facilitators in the study were aware that the success of PBL could be influenced by the way in which they facilitated the tutorial group. It became an issue in two main areas: when to intervene, which has been discussed previously in Preparation of Facilitators and group dynamics.
Group dynamics Similar findings have been reported by Olmesdahl and Manning (1999), where facilitators’ initial perceptions that their preparation was adequate, were subsequently altered after exposure to the process. Most of the facilitators in this study expressed the need for further preparation to support them in their role and the problems they may encounter. Recognition of the need for further training and support is highlighted in the literature (Kaufman and Holmes, 1996).
Facilitators found that once students became confident in taking on unfamiliar roles, such as chair and scribe, they developed awareness and knowledge of the importance of working as a team. Box 4 It was really interesting to watch the group dynamics as the PBL progressed. . . once they were really comfortable in their roles they absorbed you as part of the group’ (child branch facilitator).
Support networks and resources Formal support from peers was viewed as a valuable process, especially for new facilitators. Materials in the form of facilitator guides and real-life scenarios also appeared to be a key to success, highlighting the importance for their preparation in partnership with practitioners. However, some concerns were expressed about investment of PBL facilitation within practice areas, to link theory with practice.
Group functioning was recognised as a factor in developing student self-efficacy. This concurs with Qin et al. (1995), who found that co-operative groups, where people feel accepted are more likely to have higher rates of learning than competitive groups. Conflicts inherent in group work were highlighted by facilitators, particularly the fact that students found individual and group behaviour difficult to resolve at such an early stage of their branch studies.
Box 3 ‘Not all practice placement areas have invested in the facilitation of PBL. . . this has a direct impact on the level of support and encouragement offered (by clinical staff)’ (adult branch facilitator).
Box 5 ‘Within my group those that were the loudest were the ones that volunteered the information and I don’t feel that they always listened to the others who had a lot of information to actually give. . . those that had gone away and done the work’ (mental health branch facilitator).
Practice-based support for nursing students applying PBL has not been significantly explored in the literature. Where it is discussed, the use of virtual community support, such as computer mediated communication, appears a key way forward (Choi, 2003; Conway and Sharkey, 2002). These and like resource issues are key concerns for the successful implementation of PBL curricula (Alavi, 1995). As with practice-based learning, however, on-line learning materials are increasingly used to support the process, and this is particularly visible in medical programmes (Stromso et al., 2004).
Although conflict per se is not dysfunction, entrenched conflict may actually harm individuals and the learning environment (Hitchcock and Anderson, 1997). Certainly in this study, students felt that facilitators should have a more active role in difficult situations. It seems that facilitators need to provide a supportive environment for all students, addressing group issues as they arise (Hendry et al., 2003). Facilitator performance is known to directly influence group functioning which, sequentially, influences time spent on individual study and student achievement (Barrow
110 et al., 2002). Appropriate support, it seems, can promote meaningful learning and students’ development of analysis, critical thinking, problem solving and self-directed learning skills (Bebb and Pittam, 2004).
Preparation of students to study within a PBL framework
M. Horne et al. pressure ‘to perform’ (Connolly and Donovan, 2002) and has been criticised for disrupting their learning potential (Salvin-Baden, 1997). Facilitators, in this study, felt that ‘extra’ work generated by students, over and above the modular assessment, required further consideration, to acknowledge student effort and to necessitate all group members to contribute fully.
Preparation of students, or the lack of it, influenced the pace at which PBL could be implemented. Facilitators felt that many students experienced difficulty and insecurity in understanding the concept PBL. The extent to which students are exposed to PBL is a recognised factor in their level of involvement in the process (Schmidt et al., 1993). Students with modest or no experience of PBL tend to rely more heavily on their tutors as a source of guidance and information, influencing the student’s role within the group (Brandon and Basanti, 1997). It is assumed that small group structure helps to distribute the cognitive load among group members because the whole group tackles problems normally considered to be too difficult for each student alone (Pea, 1993). This shared knowledge construction enhances problem-solving and higher order thinking (Blumenfeld et al., 1996). Consequently, any sustained issues of student uncertainty in their role and that of their facilitator may leave students feeling insecure in their personal learning, with a resultant loss of interest in the subject matter (Brandon and Basanti, 1997). There is no assurance that group learning will equate to successful learning, but the stimulation of interactions between students is a prerequisite (Dolmans et al., 2001).
Presentation of case scenario
Assessment of PBL
This study has implications for PBL-related preparation, ongoing development and support of both facilitators and students. Managing change is acknowledged as being a major challenge in creating and delivering a PBL curriculum (Farmer, 2004). Hence ongoing evaluative research, such as this study, may inform both process and content for future programmes across the health disciplines. The accelerated use of ICT to support PBL and other enquiry-based learning is an obvious example. A key strength of this research is that it was carried out as part of a wider inter-disciplinary project to build capacity among academics for enquirybased learning. As such, it provided the opportunity for collaboration with teachers from other disciplines interested in EBL and PBL in particular. In addition, there was support from workshops
Facilitators felt that presentation of the learning achieved within PBL could be used as part of the assessment package, to acknowledge students’ contribution to both process and outcome. Box 6 ‘They felt they deserved some reward for the amount of time and the amount of effort that was put in’ (mental health branch facilitator). Kaufman (2000) has also argued for modern methods of assessment to be incorporated into PBL curricula. However, assessment within PBL has resulted in some students feeling under
Facilitators acknowledged the creativity of students’ presentation style. Overall though, they felt that presentations became competitive between groups and that a sharing of learning or seminar approach would be more appropriate. Box 7 ‘It would be really nice if we could have some sort of seminar approach, where people present some information for discussion and it stimulates some thinking. . . so it becomes more of a meeting of minds rather then a sort of stand up, write it down and switch off for the rest’ (community branch teacher). It can be seen that ongoing support, follow-up and evaluation of PBL development is needed to support facilitators in their role and identify areas in which collaborative work can assist in the process of narrowing theory and practice in nursing education.
Conclusion Summary and limitations
Using enquiry in learning: From vision to reality in higher education hosted by the project’s coordinators, incorporating assessment issues, evaluation and the student’s perspective, where a panel of students led discussions on their experiences of PBL and EBL generally. Thus, there was support from the wider project to inform the team’s endeavours and reflect on the benefits of working within a community of teachers from other disciplines. Notwithstanding, the research provides a snapshot only of students’ and facilitators’ reactions to a large scale introduction of a hybrid PBL curriculum. The sample formed one third of one cohort of students and facilitators, from a total population of six cohorts in one pre-registration nursing programme. Because of this, and the qualitative nature of the research, the findings have to be viewed within the context of the study itself. Nevertheless, they may have applicability for other similar programmes in nursing and other disciplines, particularly for informing evaluation processes with large student groups. The application of Guba and Lincoln’s (1989) evaluative approach was an effective strategy because it facilitated both negotiation and participation throughout the research. However, it has been beyond the scope of this article to discuss any methodological issues in depth.
Acknowledgement The authors acknowledge the students and facilitators who participated in the study. The authors acknowledge Peter Kahn and Karen O’Rourke, Teaching and Learning Support Unit, University of Manchester.
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
Using enquiry in learning: From vision to reality in higher education q Maria Horne, Kath Woodhead, Liz Morgan, Lynda Smithies, Denise Megson, Geraldine Lyte * University of Manchester, School of Nursing, Midwifery and Social Work, Coupland III Building, Oxford Road, Manchester M13 9PL, United Kingdom Accepted 18 March 2006
KEYWORDS
Summary This paper reports on the contribution of six nurse educators to embed enquiry-led learning in a pre-registration nursing programme. Their focus was to evaluate student and facilitator perspectives of a hybrid model of problem-based learning, a form of enquiry-based learning and to focus on facilitators’ perceptions of its longer-term utility with large student groups. Problem-based learning is an established learning strategy in healthcare internationally; however, insufficient evidence of its effectiveness with large groups of pre-registration students exists. Fourth Generation Evaluation was used, applying the Nominal Group Technique and Focus Group interviews, for data collection. In total, four groups representing different branches of pre-registration students (n = 121) and 15 facilitators participated. Students identified seven strengths and six areas for development related to problem-based learning. Equally, analysis of facilitators’ discussions revealed several themes related to strengths and challenges. The consensus was that using enquiry aided the development of independent learning and encouraged deeper exploration of nursing and allied subject material. However, problems and frustrations were identified in relation to large numbers of groups, group dynamics, room and library resources and personal development. The implications of these findings for longer-term utility with large student groups are discussed. c 2006 Elsevier Ltd. All rights reserved.
Student nurses; Facilitation; Enquiry-based learning; Problem-based learning
Introduction q
A study funded by the LTSN Generic Centre, coordinated by the Teaching and Learning Support Unit, University of Manchester. * Corresponding author. Tel.: +44 161 275 5339; fax: +44 161 275 7566. E-mail address: [email protected] (G. Lyte).
Problem-based learning (PBL) has generated considerable international interest and recognition in recent years (Price, 2003; Blackford and Street, 1999; Amos and White, 1998; Alavi, 1995). As a
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.03.004
104 learning approach it offers potential to bridge theory and practice, through identification and evaluation of practice-based problems (Price, 2003). It differs from enquiry-based learning (EBL) in that the latter represents any form of learning that is motivated by enquiry, by asking for or seeking information in order to understand something (Concise Oxford English Dictionary, 2002, p. 474). In this paper PBL is discussed as one form of EBL. The paper presents findings from an LTSNfunded programme of professional development, involving 50 educators representing a range of disciplines, from four north-west universities. The programme was designed to build capacity for applying EBL; this paper focuses on the nursing component of the wider EBL project. Specifically, the nursing participants aimed to evaluate student and facilitator perspectives of the introduction of a PBL curriculum, as one form of EBL, with large student groups.
Background/literature Relevant literature was identified through a computer search of CINAHL, MEDLINE, British Nursing Index and ERIC. This yielded an abundance of PBL literature, particularly in medicine and allied professions (Dean et al., 2003; Kaufman and Holmes, 1996). The advantages of using PBL are also reported in continuing nursing education (Newman, 2003) and postgraduate multidisciplinary student groups (Carlisle and Ibbotson, 2005). On the contrary much less attention is given to PBL effectiveness in pre-registration nursing (Barrow et al., 2002). Three papers which involved large groups of nursing students were identified. The first, Alexander et al. (2002) from the United States describes the practicalities of implementing and evaluating PBL in a nursing curriculum. However, it is not primary research and the influence of PBL on student nurse performance is unclear in their work. In contrast, Pang et al.’s (2002) research-based Hong Kong study uses developmental action inquiry with eight teachers and 15 groups of 16 first year student nurses, to evaluate the impact that PBL on student learning. Only the student evaluation data is presented; key findings include issues around self-learning, tutor–student interaction and group learning. The third study has more significance for this paper because it is UK-based and examines the implementation of EBL as a ‘whole-curriculum’ strategy for pre-registration nursing education (Bebb and Pittam, 2004). The authors report on part of a wider evaluation of individual and group interviews
M. Horne et al. with 15 student nurse representatives from 20 preregistration EBL groups, to gain their experiences of learning. Factors they identified are similar to findings from other studies, and include adaptation to EBL, the EBL model in use, taking responsibility for learning and working within groups. Like the other papers analysed here, Bebb and Pittam (2004) have not included issues from facilitators, especially, where this relates to supporting large groups. So in spite of the broad evidence-base of PBL applications in healthcare curricula, there remains insufficient support for its longer term utility with large groups of pre-registration nursing students (n = 100 or more) and their facilitators.
The study Aims To ascertain students’ and facilitators’ perspectives of using individual and group enquiry to support learning, within a PBL framework; To gain a deeper understanding of facilitators’ perceptions of the longer-term utility of PBL with large student groups.
Research setting and participants The research was carried out in a higher education setting at the end of the students’ first PBL-based branch module, the first module of the second year of the programme overall. Each branch programme consists of six 15 week modules, with four weeks of theory, nine weeks on placement and two weeks for reflection and assessment. Introducing an enquiry-based curriculum represented major challenges, where the research was undertaken: the School concerned includes a population of approximately 1900 pre-registration nursing students, so moving away from the traditional large group lectures to small group self-directed learning raised concerns for lecturers and clinical staff alike. The majority of teaching and support staff (n = >150) and, clinical colleagues who had responsibility to support student nurse learning, had relatively little experience of such an approach. Evaluation of its introduction was considered vital, particularly in terms of adaptation to EBL generally and future developments for PBL specifically. A hybrid model of PBL was introduced to allow for a gradual introduction into the large preregistration programmes. In the foundation year
Using enquiry in learning: From vision to reality in higher education teacher-led, case-based learning is applied alongside students’ preparation for more self-directed and small group learning techniques. Emphasis in the first branch year switches to student-led small group work using an adaptation of the ‘seven jump process’ to structure activity (Schmidt, 1983) (Fig. 1). In the second branch year students are expected to take increasing responsibility for developing their own learning outcomes and for managing small group learning with the support of a facilitator. For the purposes of the evaluation a purposive sample of 121 students and 15 facilitators from four groups (within one cohort of 250 students) were selected, representing different branches of learning on the programme: community, child health, mental health and critical care. Approval to undertake this research was obtained from the University’s Senate Ethics Committee. The informed consent process was followed for all prospective participants: a verbal explanation was provided, outlining details of the study, including the option of nonparticipation or withdrawal at any time; anonymity and confidentiality was assured and facilitators did not lead the nominal group evaluation with their own group. In the event, nine students did not join the nominal group process.
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core activity and follows on from three generations of positivist evaluation models: measurement; the use of measurable objectives and judgement by evaluators (Koch, 2000). Koch (2000) explains this as a responsive focusing and hermeneutic dialectic, in that participants are invited to develop their own construction and self-interpretation of the situation being evaluated. Positivist approaches to evaluation seek specific, objective information that does not consider the context of what is being evaluated, or the many individual, group and environmental variables that can confound the responses of a structured, inflexible model (Curran et al., 2003). Nevertheless, while Guba and Lincoln’s model has wide appeal in health care, particularly in professional education, it has been criticised for its potential for bias in favour of those who are more articulate and more likely to project their views over others’ (Redfern, 2003). Consequently, methods of data collection that can gain a balanced construction of participants’ reality of a situation need to be used for fourth generation evaluations, such as the nominal group technique and focus group interviews.
Data collection Research design
Students
Fourth Generation Evaluation (Guba and Lincoln, 1989) was selected because it encourages dialogue, negotiation and empowerment for stakeholders. This is a qualitative evaluative approach using negotiation with participants/stakeholders as its
Nominal group technique (NGT) was used in this part of the study to gather qualitative data in line with Guba and Lincoln’s approach to evaluation. NGT is a structured group activity designed to elicit the views of group members about a particular
Share results
Evaluate results
Start here Study privately
The 'seven jump' tutorial process in PBL
clarify terms, concepts
Identify issues, problem
Set learning objectives Brainstorm possible explanations
Figure 1
The Maastricht seven jump process for PBL applied within the School’s Pre-Registration Programmes.
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M. Horne et al.
issue or topic (Delbecq et al., 1975). Through NGT, qualitative information from each member of the student groups, in turn, used negotiation to highlight priority issues. Judgements of the overall importance of identified issues that were agreed at group level remained with group members; individual issues that were not shared by the group overall were followed up by the individual and the evaluator, facilitating a shared dialogue and a reflexive approach to the evaluative process (Guba and Lincoln, 1989). In this study, students in the final week of their first branch module were asked to initiate the nominal group process, by identifying five strengths and five areas for development of the student experience and value of PBL. Prompts were provided by facilitators (the same for all groups) (Table 1). In order to overcome response bias in favour of dominant group members (Redfern, 2003), a ‘‘round robin’’ process was used to obtain all group members’ identified issues, prior to voting. The items recorded throughout the ‘‘round robin’’ were discussed to ensure that everyone understood what they were. Any areas of overlap were merged to avoid repetition and allow for more effective voting. Any statements which failed to receive
Table 1
Prompts for nominal group evaluation
Consider issues around Students own performance The groups performance The performance of other groups within the module Facilitator support General Issues relating to PBL as a form of teaching and learning
Table 2
any votes were discarded. Table 2 illustrates how the NGT was applied sequentially in this study.
Facilitators Focus group interviews were used in this part of the study because the method utilises group dynamics and social interaction to produce data and insights through social interaction and dialogue (Kitzinger, 1995). This can assist people to explore, develop and clarify their views more successfully than in individual interviews (Kitzinger, 1995). Kevern and Webb (2001) provide a good critique on the use of focus groups for critical social research in nurse education. Prompts were provided by the facilitator (Table 3) and data were collected over a one month period after completion of the 15 week modules.
Table 3
Focus group discussion guide
Consider and discus issues around The positive experiences of facilitating the PBL group The negative experiences of facilitating the PBL group How well they felt prepared for their role as facilitator Skills required of a facilitator How useful they found the workshops How do internal and external support structures/ systems assist their role? Relationships: student–facilitator, group dynamics and student preparation Resources – human, physical, time allocated, preparation of scenarios Areas of development
Applying the nominal group technique for the project
1. Split the four PBL groups evenly into quarters. Ensure that each nominal group consists of a mixture of students from all four PBL groups 2. Ask the students within the nominal groups to identify five strengths and five areas for development Suggested prompts Individual, group and other group performance Facilitator support General issues related to group learning 3. Ask each group to identify one of their strengths. Continue, in turn, until all suggestions have been exhausted 4. Repeat the exercise for areas of development 5. For each of the statements ask students to put up their hands if they agree with a particular statement. Count the number of hands and score the statement 6. The facilitator can then add up the total marks given to each statement. Statements that do not receive any points will be discarded 7. The facilitator can write up comments and scores for reporting 8. Nominal group data can then be compared with other concurrent module nominal group data
Using enquiry in learning: From vision to reality in higher education
Data analysis In total students identified 35 statements related to their experiences of PBL, seven strengths (Table 4) and six areas of development (Table 5). Each group’s facilitator totalled the marks given to each statement and discarded statements that did not receive any points. The facilitator wrote up comments and scores for reporting. Focus group interviews were content analysed using an iterative mode described by Grbich (1999) as an interpretive, ongoing, inductive process. The interviews were audio-taped and transcribed verbatim. Each researcher analysed
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transcripts from their own focus group interview to develop initial themes, followed by synthesis and clarification of all emergent themes by the research team to increase credibility of data collected (Miles and Huberman, 1994). To enhance dependability of interpretation, all the transcripts were then analysed for content and structure by the principle researcher and the level of agreement assessed (Mays and Pope, 1996; Miles and Huberman, 1994).
Findings and discussion Student perspectives
Table 4
Student perspectives of PBL (1)
Strengths of PBL 1. Working as a team (N = 120: 99.2%)
Summary of statements
Acceptance Individual styles Values Peer support (co-operation) Personal relationships (co-operation) Interaction and dialogue 2. Improves Self awareness interpersonal/ communication skills Understanding of others’ points of view (N = 96: 79.3%) Learning from others 3. Develops teaching Use of all resources and presentation Technical skills skills (N = 95: 78.5%) Internet skills Development of presentation skills Planning and organisational skills 4. Encourages Confidence independent learning Self direction skills (N = 105: 86.8%) Self development Time management Clinical judgement 5. Develops problem Clinical decision-making solving skills Identifying patient needs especially those of Planning care assessment and prioritization (N = 84: 69.4%) People 6. Encourages more effective utilization Material Environment of resources (N = 91: 75.2%) 7. Encourages wider More use of electronic reading sources (N = 91: 75.2%) Searching for evidence Deeper exploration Research awareness Greater depth of knowledge
Analysis of students’ statements indicated that PBL aided the development of independent learning skills and encouraged deeper exploration of both nursing and allied subject material (Table 4). The majority of participants also had a positive attitude to PBL: 99.2% of statements that related to strengths indicated that it aided development of team working and peer support; accepting individual styles/values, and managing conflict and sharing experiences. The findings from this study also support the premise that PBL encourages self-awareness, confidence, self-direction and independent learning skills (86.8% of statements). These concepts, expressed in terms of interpersonal skills development, group interaction and self-reflection, are also identified as positive facets of PBL in medical evaluation literature (for example Ozuah et al., 2001). In addition, 79.3% cited improved interpersonal and communication skills on the basis of applying a non-judgemental approach to group interaction. Other strengths identified by students were that PBL aided development of teaching and presentation skills, such as planning and time management (78.5%); that it encouraged wider reading, depth of enquiry and increased research awareness (75.2%) and, better use of facilitator, clinical and technological resources. 69.4% of students related the development of problem-solving skills to their development of assessment skills in the workplace, demonstrating the ability to link theory and practice through PBL. It supports the findings from an earlier Canadian study (Morales-Mann and Kaitell, 2001), where students equated PBL-based problem-solving with clinical nursing process. However, problems and frustrations were also identified (Table 5). Students recognised that PBL depended on group collaboration for success, which raised concerns about teamwork and group dynamics,
108 Table 5
M. Horne et al. Student perspectives of PBL (2)
Areas of development
Summary of statements
1. Group dynamics/teamwork (N = 56: 46.3%)
Equal participation Demands on chairperson and scribe Commitment Attendance Impact of non-functional people Impact of overpowering people More facilitated sessions More preparation time for presentations More time in clinical practice to pursue PBL activities Time allocated to each ‘problem’/‘scenario’ Accreditation of PBL Formal assessment may add pressure Formal assessment would add recognition More involvement in difficult situations with novice students Consistency of information Keeping the same facilitator Teachers and students understanding Wanting all parts of the scenario at the outset Amount of information gathered Skills in using technology Research skills Communication skills
2. Resource and time allocation (N = 101: 83.5%)
3. Assessment (N = 64: 52.9%)
4. Role of the facilitator (N = 47: 38.8%)
5. Concept of the process (N = 60: 49.5%)
6. Personal development (N = 45: 37.2%)
particularly attendance, equality of input and division of labour (46.3%). The issue of group collaboration for PBL is well cited in the literature, indicating that difficulties can arise when tutorial groups are faced with students who either do not prepare for, or who do not attend meetings and tacitly let others do the work (Dolmans et al., 2001; Biley and Smith, 1999; O’Hanlon et al., 1995). Assessment/accreditation accounted for 52.9% of student statements and cited as an area of development (Table 5). However, feelings were mixed. Some students wished both the product and the process of PBL to be assessed, but some students liked the idea that it was not assessed due to the extra pressure this would place upon them. Other authors have dealt with such issues by introducing self or peer summative assessments for the process of PBL (Connolly and Donovan, 2002). Miflin et al. (1999) utilised formative assessment exercises based on the objectives of tutorial discussion, however, their students expressed doubts about the effectiveness of this in guiding their learning. Other areas identified for further development included resources and time allocation (83.5%); clarification of the role of facilitator (38.8%) and, personal development (37.2%). In particular, students wanted greater support in their application of ICT, research and communication skills for PBL activity.
Facilitators’ perspectives Preparation of facilitators Most teachers had initial difficulty with overcoming the teaching versus facilitator role.
Box 1 ‘The bit I found most difficult was when I knew the answer to what they were asking me. I wanted to tell them. Being a teacher, you are used to questions and answers and telling them what they wanted to know’ (adult branch facilitator). It has been emphasised that PBL facilitators should not ‘teach’ students but allow students to be self-directed (Maudsley, 2002). However, achieving a balance between non-participation and active facilitation can be difficult, especially when deciding at what time to intervene in the PBL process (Andrews and Jones, 1996). Interestingly, Maudsley’s (2002) descriptive study found that novice PBL facilitators characterised a good facilitator as knowing when and how to intervene. This highlights the importance of continued professional development for honing facilitation skills (Dolmans et al., 2001). Although most facilitators in this study found the preparation (of
Using enquiry in learning: From vision to reality in higher education workshops) they received helpful (Lyte, 2003), the general consensus was that experience in facilitation takes place through the experiential process itself. Box 2 ‘I don’t think that I needed more preparation. I think it’s just the experience of doing it (community facilitator).
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Facilitating the process of PBL Facilitators in the study were aware that the success of PBL could be influenced by the way in which they facilitated the tutorial group. It became an issue in two main areas: when to intervene, which has been discussed previously in Preparation of Facilitators and group dynamics.
Group dynamics Similar findings have been reported by Olmesdahl and Manning (1999), where facilitators’ initial perceptions that their preparation was adequate, were subsequently altered after exposure to the process. Most of the facilitators in this study expressed the need for further preparation to support them in their role and the problems they may encounter. Recognition of the need for further training and support is highlighted in the literature (Kaufman and Holmes, 1996).
Facilitators found that once students became confident in taking on unfamiliar roles, such as chair and scribe, they developed awareness and knowledge of the importance of working as a team. Box 4 It was really interesting to watch the group dynamics as the PBL progressed. . . once they were really comfortable in their roles they absorbed you as part of the group’ (child branch facilitator).
Support networks and resources Formal support from peers was viewed as a valuable process, especially for new facilitators. Materials in the form of facilitator guides and real-life scenarios also appeared to be a key to success, highlighting the importance for their preparation in partnership with practitioners. However, some concerns were expressed about investment of PBL facilitation within practice areas, to link theory with practice.
Group functioning was recognised as a factor in developing student self-efficacy. This concurs with Qin et al. (1995), who found that co-operative groups, where people feel accepted are more likely to have higher rates of learning than competitive groups. Conflicts inherent in group work were highlighted by facilitators, particularly the fact that students found individual and group behaviour difficult to resolve at such an early stage of their branch studies.
Box 3 ‘Not all practice placement areas have invested in the facilitation of PBL. . . this has a direct impact on the level of support and encouragement offered (by clinical staff)’ (adult branch facilitator).
Box 5 ‘Within my group those that were the loudest were the ones that volunteered the information and I don’t feel that they always listened to the others who had a lot of information to actually give. . . those that had gone away and done the work’ (mental health branch facilitator).
Practice-based support for nursing students applying PBL has not been significantly explored in the literature. Where it is discussed, the use of virtual community support, such as computer mediated communication, appears a key way forward (Choi, 2003; Conway and Sharkey, 2002). These and like resource issues are key concerns for the successful implementation of PBL curricula (Alavi, 1995). As with practice-based learning, however, on-line learning materials are increasingly used to support the process, and this is particularly visible in medical programmes (Stromso et al., 2004).
Although conflict per se is not dysfunction, entrenched conflict may actually harm individuals and the learning environment (Hitchcock and Anderson, 1997). Certainly in this study, students felt that facilitators should have a more active role in difficult situations. It seems that facilitators need to provide a supportive environment for all students, addressing group issues as they arise (Hendry et al., 2003). Facilitator performance is known to directly influence group functioning which, sequentially, influences time spent on individual study and student achievement (Barrow
110 et al., 2002). Appropriate support, it seems, can promote meaningful learning and students’ development of analysis, critical thinking, problem solving and self-directed learning skills (Bebb and Pittam, 2004).
Preparation of students to study within a PBL framework
M. Horne et al. pressure ‘to perform’ (Connolly and Donovan, 2002) and has been criticised for disrupting their learning potential (Salvin-Baden, 1997). Facilitators, in this study, felt that ‘extra’ work generated by students, over and above the modular assessment, required further consideration, to acknowledge student effort and to necessitate all group members to contribute fully.
Preparation of students, or the lack of it, influenced the pace at which PBL could be implemented. Facilitators felt that many students experienced difficulty and insecurity in understanding the concept PBL. The extent to which students are exposed to PBL is a recognised factor in their level of involvement in the process (Schmidt et al., 1993). Students with modest or no experience of PBL tend to rely more heavily on their tutors as a source of guidance and information, influencing the student’s role within the group (Brandon and Basanti, 1997). It is assumed that small group structure helps to distribute the cognitive load among group members because the whole group tackles problems normally considered to be too difficult for each student alone (Pea, 1993). This shared knowledge construction enhances problem-solving and higher order thinking (Blumenfeld et al., 1996). Consequently, any sustained issues of student uncertainty in their role and that of their facilitator may leave students feeling insecure in their personal learning, with a resultant loss of interest in the subject matter (Brandon and Basanti, 1997). There is no assurance that group learning will equate to successful learning, but the stimulation of interactions between students is a prerequisite (Dolmans et al., 2001).
Presentation of case scenario
Assessment of PBL
This study has implications for PBL-related preparation, ongoing development and support of both facilitators and students. Managing change is acknowledged as being a major challenge in creating and delivering a PBL curriculum (Farmer, 2004). Hence ongoing evaluative research, such as this study, may inform both process and content for future programmes across the health disciplines. The accelerated use of ICT to support PBL and other enquiry-based learning is an obvious example. A key strength of this research is that it was carried out as part of a wider inter-disciplinary project to build capacity among academics for enquirybased learning. As such, it provided the opportunity for collaboration with teachers from other disciplines interested in EBL and PBL in particular. In addition, there was support from workshops
Facilitators felt that presentation of the learning achieved within PBL could be used as part of the assessment package, to acknowledge students’ contribution to both process and outcome. Box 6 ‘They felt they deserved some reward for the amount of time and the amount of effort that was put in’ (mental health branch facilitator). Kaufman (2000) has also argued for modern methods of assessment to be incorporated into PBL curricula. However, assessment within PBL has resulted in some students feeling under
Facilitators acknowledged the creativity of students’ presentation style. Overall though, they felt that presentations became competitive between groups and that a sharing of learning or seminar approach would be more appropriate. Box 7 ‘It would be really nice if we could have some sort of seminar approach, where people present some information for discussion and it stimulates some thinking. . . so it becomes more of a meeting of minds rather then a sort of stand up, write it down and switch off for the rest’ (community branch teacher). It can be seen that ongoing support, follow-up and evaluation of PBL development is needed to support facilitators in their role and identify areas in which collaborative work can assist in the process of narrowing theory and practice in nursing education.
Conclusion Summary and limitations
Using enquiry in learning: From vision to reality in higher education hosted by the project’s coordinators, incorporating assessment issues, evaluation and the student’s perspective, where a panel of students led discussions on their experiences of PBL and EBL generally. Thus, there was support from the wider project to inform the team’s endeavours and reflect on the benefits of working within a community of teachers from other disciplines. Notwithstanding, the research provides a snapshot only of students’ and facilitators’ reactions to a large scale introduction of a hybrid PBL curriculum. The sample formed one third of one cohort of students and facilitators, from a total population of six cohorts in one pre-registration nursing programme. Because of this, and the qualitative nature of the research, the findings have to be viewed within the context of the study itself. Nevertheless, they may have applicability for other similar programmes in nursing and other disciplines, particularly for informing evaluation processes with large student groups. The application of Guba and Lincoln’s (1989) evaluative approach was an effective strategy because it facilitated both negotiation and participation throughout the research. However, it has been beyond the scope of this article to discuss any methodological issues in depth.
Acknowledgement The authors acknowledge the students and facilitators who participated in the study. The authors acknowledge Peter Kahn and Karen O’Rourke, Teaching and Learning Support Unit, University of Manchester.
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