Introduction

What is problem-based learning (PBL) problemfrom the familiar subject based learning (SBL)? Illustrations with the different processes
SBL starts with told what we need to know then we learn it and then a problem was given for us to illustrate how to use it. PBL starts with a problem posed then we need to identify what we need to know, learn it and then apply it

SBL vs PBL
In the traditional education (SBL), teachers would lecture on different subjects, and students would be presented with problems within a specific subject area. Contrast this approach with PBL, it is not the particular subject matter that drives the process but rather the problem. Hence students do not start with a particular subject area. Different areas of their study in the form of knowledge and experience will emerge from the problem identification. Through this approach there is also the learning of the interrelationship of concepts.

PBL Tutorials
Students PBL learning at the University aims toward how the student learns (life-long process) and encourages (lifestudents to integrate concepts from nursing, psychology and sociology in their understanding of the situation/ issues or particular aspects. Students task is to discover what they need to know to address the problem posed. Other skills involved: problem solving skills, inquiry skills and thinking skills explicitly, not merely memorization. Self-directive, interdependent collaborative learning, Selfcooperative and reflective learning are valued.

PBL Process
Explore the problem, identify issues and create hypotheses Try to solve the problem with current knowledge or experience that may be pertinent to the case/situation Identify what one does not know that can impede the process of better comprehension of the problem and hence problem solving Prioritize the learning needs, set learning goals and objectives, and allocate resources so that the student knows what is expected of him/her and the timelines. For a group, members timelines. can identify which tasks each will perform. perform. SelfSelf-study and preparation Share the new knowledge effectively so that all the group learn the information and its applicability. applicability. Apply the knowledge to understand the issues at hand and come up with various possibilities to solve the problem Provide feedback to self and others through reflecting upon the new knowledge, the problem solution(s) and the effectiveness in the use of the process

The educational philosophy supporting PBL is the belief that students should be actively involved in the process of learning

Basic Tenets of Problem Based Learning

Instructional method using real world problems Students:
Acquire knowledge emphasis is on making meaning Increases relevance of new material Practice critical thinking and problem solving skills Identify and utilize learning resources

The predominant educational theory used to be the "bucket theory." Information stored in the student's head would be regurgitated upon request (13). However, the ability to retain knowledge does not necessarily produce a competent practitioner (2). Information presented exclusively in a lecture format is of limited use and unlikely to assist students in acquiring self-directed learning skills. self-

The recent nursing literature has called for a curriculum revolution, stressing innovative teaching strategies that allow the socialization of the student as a colleague and professional

The ability to apply basic science concepts and content to the practice setting is difficult for students. Heliker noted that nursing students have particular difficulty with pharmacological concepts (17). Kimmel observed similar findings in a pathophysiology course for second-year secondmedical students and determined that a lecture format is insufficient for presenting such content

When redesigning courses for the PBL format, the goal was to improve learning outcomes in several key areas--critical areas--critical thinking, self-directed learning, selfcommunication, interdisciplinary collaboration, the ability to work and contribute within a team, and the development of lifelong learning skills.

Getting started with PBL requires alterations in the class room environment and the establishment of a suitable library. The PBL library is specific to nursing and housed on the same floor as the classrooms . To adapt traditional classroom space for teaching with PBL, round tables and chairs for two small rooms in the School of Nursing All modules are based on real-life situations. Examples include carbon realmonoxide poisoning of a family, an outbreak of a food-borne illness, a foodbacterial infection, and a natural disaster. Students work on the modules during class time in groups of four to six. Each group works on a different problem and presents its findings to the other members of the class. Problems are designed so that they can be completed during one or two class sessions Facilitators from both courses meet weekly with the groups to assess progress and offer feedback. At the end of the term, each PBL group completes a formal poster presentation and an oral defense of the report. Each agency receives a copy of the written paper.

It was developed to improve medical education by moving from a subject and lecturelecture-based curriculum to an interdisciplinary one guided by "real-life" "realproblems. problems. Students act as professionals and challenge problems, just as they would in a real clinical situation, with insufficient information and a need to determine possible solutions by a given deadline

Why PBL?
Promotes critical thinking
Analysis Reasoning Decision making Independent judgment

Promotes group work brainstorming, cooperation, communication, problem solving Encourages ownership of the learning process
Prepares students to be life-long learners life-

All essential characteristics of a professional nurse

PBL i a l arn r- nt r d rdu ati nal m th d

. In PBL learners are progressively given more and more responsibility for their own education and become increasingly independent of the teacher for their education. PBL produces education. independent learners who can continue to learn on their own in life and in their chosen careers. careers. The responsibility of the teacher in PBL is to provide the educational materials and guidance that facilitate learning. learning.

Student Role
Present student group with problem Group roles emerge Group discussion
Identify previous knowledge Identify knowledge gaps Students rank learning issues Summarize new knowledge
Ongoing process for ALL

Th r l

f th PBL t a h r

The principle role of the teacher in PBL is that of a facilitator or educational coach (often referred to in jargon of PBL as a "tutor") guiding the learners in the PBL process. As learners become more proficient in the PBL learning process the tutor becomes less active. This is a new skill for many teachers and specific training is required.

Faculty Role
Guide, probe, question, direct Support student inquiry Provide direction to resources Can stop group discussions to focus on key learning outcome content Monitor group functioning

Th l arning gr up
Learning is ideally in small groups of 5 to 7 learners. As the group members work together to problem solve and learn they acquire collaborative or team learning skills. In some settings, as in secondary education, learner groups may initially be much larger (15-35). (15-

Students are presented with clinical situations, usually in the form of a paper package. In small package. groups (between 10-20 students) with a 10facilitator, they embark on the process by identifying the issues surrounding the situation and then identifying their learning needs. needs. Following self-directed study the students reselfregroup to feed back and evaluate their learning in order to move to the next stage - usually an action or care plan. plan.

How to Create Problems

1. Identify major concept or main idea 2. Include some details that propel the students toward learning objectives
Specific guiding questions

3. Provide adequate access to resources

Defining the problem

What are the issues? What are known? What is the situation? Rather than focus on many questions about the situation - focus on the given information and the situation the evidence must substantiate the hypotheses with additional information given - accept or refute the hypotheses

Example
Mr. Leung, 60 years old, a Chinese man who is new to the clinic. He is a driver. In the last month, Mr. Leung was having his blood pressure checked at the pharmacy, and was found to be high. You are the nurse interviewing Mr. Leung at the clinic. He denies on any medication for high blood pressure. He is obese. He also complaints of headache in the last week. On assessment, you found that Mr. Leungs vital sign was T0 : 36.8 0C, BP: 170/95mmHg, P: 92 bpm and R: 20 bpm. His tentative diagnosis is high blood pressure

He was prescribed a list of examinations and laboratory test, as well as medications for relieving his headache. Mrs. Leung accompanies her husband to the clinic. She is worried about him, as they have no children and rely on each others company.

Some Guiding questions

What is the meaning of high blood pressure? What body system is involved? What will be the possible physiological changes? What is the meaning of obesity? What kind of information do you seek for in order to understand his present situation? What are the appropriate health assessment skills for this client? What are the common patterns of reaction to stress? Why is the wife so worried?

Some areas of discussion

Health history taking Physical examination Physiological changes Body and nutritional assessment Reactions to stress and coping Treatment and nursing care for client with high blood pressure and headache

Reframing the situation

Reframe the situation as new information emerge Working on possible solutions Critically examine the various possibilities with justifications provided

A trat gy t impl m nt PBL f ar a :

d n th

main

Learning Pa k : These continue to evolve as changes in practice need to be reflected in the packs. A pack may be a single scenario or it may be a group of characters involved in 3 - 4 different scenes FIGURE 1: MATTHEW With thi pa kage tudent mplete an a ti n/ are plan f r enari 1 bef re m ving nt enari 2. Thi pr gressi n pr vides a wider pi ture rather than f using solely on progression provides focusing one event. Scenario 1: Matthew and his girlfriend are involved in a car accident. They are taken to the local Accident and Emergency Unit. You are the receiving nurse. Here the student, besides having to nurse Matthew, would need to care for his girlfriend, possibly his parents, and also may have to deal with the police. Scenario 2: Matthew requires surgery for a fractured femur and a ruptured liver. Following theatre he is transferred to the Intensive Care Unit. You are assigned to care for Matthew. Students would be expected to gain more detailed knowledge of surgery and to deal with technology not normally found in an ordinary ward. Scenario 3: After 6 days Matthew has stabilised and is showing signs of improvement. He is transferred to the Rehabilitation Unit where he is greeted by you as his Primary Nurse. Here the student learns about the multidisciplinary team. Throughout each scenario, students would be expected to consider the psychological and social impact on Matthew, as well as the physical trauma of the accident.

The objectives of PBL is to produce learners who will

Engage the problems they face in life and career with initiative and enthusiasm. ProblemProblem-solve effectively using an integrated, flexible and usable knowledge base. Employ effective self-directed learning skills to selfcontinue learning as a lifetime habit. Continuously monitor and assess the adequacy of their knowledge, problem-solving and selfproblemselfdirected learning skills. Collaborate effectively as a member of a group.

THE MINIMAL ESSENTIALS FOR PROBLEMPROBLEMBASED LEARNING IN MEDICAL EDUCATION

ProblemProblem-solving or clinical reasoning skills Clinical skills SelfSelf-directed learning skills Team skills.

MEDICAL EDUCATION ESSENTIALS

1. 2.

3.

4. 5.

Students must have the responsibility for their own learning. learning. The problem simulations used in problemproblembased learning must be ill-structured and illallow for free inquiry Learning should be integrated from the wide range of disciplines that are related to understanding and treating patient problems are basic to the science of medicine. medicine. Collaboration is essential What students learn during their selfselfdirected learning must be applied back to the problem with reanalysis and resolution. resolution.

6.

7.

8. 9.

10. 11.

A closing analysis of what has been learned from work with the problem and a discussion of what concepts and principles have been learned is essential. Self and peer assessment should be carried out at the completion of each problem and at the end of every curricular unit. Continual opportunities must be provided for clinical skills to be learned. he sequence of activities carried out in problem-based problemlearning, and problems employed in problem-based learning, problemmust accurately reflect medical practice. Student examinations must measure student progress towards the goals of problem-based learning. problemProblem-based learning must be the pedagogical base in the Problemcurriculum and not part of a didactic curriculum.

A more accurate title might be "student-centered, problem-based, "studentprobleminquiryinquiry-based, integrated, collaborative, reiterative, learning."

Advantages of PBL
PBL usually synthesizes a broad range of subjects and topics Old and new knowledge embedded in the context of the problem helps us to integrate the knowledge and see their relationships The problem is employed to build up evereverenriching layers of new knowledge across disciplines

Disadvantages of PBL
Transition is difficult for students and faculty
Non-traditional delivery of information Non-

Increased time to teach content

Increased prep time

Finding problems writing problems Faculty lack of skills as facilitators

The traditional and well-known "Case wellapproach", popular with business schools, may or may not be problem-based problemlearning. Often the case is used to integrate previously-learned knowledge previouslyand hence would not be, according to this definition, problem-based learning. problem-

Daily Log
Date What do we need to know? Where can we Person get the Responsible information? for obtaining information Status

Participation feedback for PBL

0-5
General Participation Works independently on assigned tasks Active participation Completed work as agreed upon by the group

6-7

8-9

10

Risks

StudentStudent-centered approach More enjoyable and satisfying Encourages greater understanding Develops lifelong learning skills

Not prepared for PBL Requires more time Learning is messier Anxiety Group dynamics Less content knowledge may be learned

Faculty feedback
Some students have a hard time transitioning to a new style of learning e.g., I learn better when information is fed to me from the professor. More work and less structured Have to be on your toes Balance between giving enough direction, but not too much. Students seem more receptive to this pedagogy when additionally preparing for graduate school.

Risks

Class attendance increases Students spend more time studying Intrinsic rewards Promotes interdisciplinarity

Difficulty creating problems More preparation time Student questions about the process Group dynamics require faculty intervention What to assess and how

A Worked Example of a PBL Scenario

Please note: this is an example, and there will be local variations PBL the Process PROBLEM - situation, scenario HYPOTHESIS - identifying issues, clarifying learning needs RESOURCES - planning what to use REPORTING BACK - learning from study and modifying information ACTION PLAN - resolution via care/action plan

Problem A PBL tutorial begins with a problematic situation that is relevant to the area of study, e.g. video, written scenario - a brief way of referring to a complex phenomenon. Scenario - "Mary Shaw" Mary attends the Sandhills Day Centre 3 days a week. She is 75 years old and is a widow. Her 32 year old son lives with her. A nurse reports bruising on Marys arms and legs.

Hypothesising/Brainstorming The first task for the students is identifying clearly what seems to be the problem. Once they are agreed, they can start to list possible explanations of the situation reported. This leads into clarifying what learning is needed to come up with a solution. Then they can divide the research work between the group. Problem Identification Fall Elder abuse Blood/clotting disorder Attending a Day Centre

Possible explanations Sensory deficits Altered home environment Part son plays as carer Blood disorders Cerebro-vascular disorders Alcoholism

Learning needs A & P of the C.V. system Pathophysiology T.I.A.s and Stroke Nursing care Sensory deprivation Falls in the elderly Alcoholism in the elderly

Elder abuse Sons as carers Community networks Role and function of day hospitals Issues related to bereavement Self-images Family networks

Resources Developing skills at locating information is one of the most important parts of PBL. Apart from using traditional academic resources such as textbooks and journal articles, students need to learn how to find and evaluate information from websites, broadcasts, newspapers and magazines. They might carry out laboratory work, or identify academic staff or other contacts who can help them. Resource Guide People: Researcher in elder abuse Library: Search terms e.g. elder abuse, day hospitals Books: 610.00 610.700 Journals: Nursing the elderly Media: video, websites Organisations: Age Concern

Reporting back When the group next meets, each student has to report on their progress with their assigned task. The group compares the new information with the problem as initially understood. Reflecting on what they have learned, the students can decide if they are happy to move on to the final stage, or if they need to do further research. Action Plan The final stage of the PBL process is the formal conclusion reached by the group, hopefully a solution to the initial problem. This might take the form of an Action Plan, or a Nursing Care Plan, which could be part of the formal assessment of the PBL course. Note that the level of depth of learning on the subject of the PBL scenario will depend on the time available. There is no simple "right" amount of time for a group to work through a scenario Care Issues
Day hospital care care on discharge Hospital at home Bereavement counsellor Son - job club, support Role of community nurses Stroke club Key workers