Nursing Education &Management

Tips and reviews on Nursing Education &Management

Home

Find

current
01/21/08

Problem Based Learning (PBL) in Nursing

“Problem based learning is the basic human learning process that allowed primitive man to survive in his environment”.
- Barrows & Tamblyn (1980)
Introduction
Problem Based Learning is a student centered learning model characterized by the use of real world problems as a context to learn critical thinking and problem solving skills while actively learning the knowledge content of the course. PBL is an increasingly popular educational strategy. It has now been applied to many areas like nursing, medicine, science, community health etc… It is an instructional design, quite different from “problem-solving” and the goal is not to solve the problem which has been presented. Rather, the problem is used to help students to identify their learning needs as they attempt to understand the problem, to put together, synthesize and apply information to the problem, and begins to work effectively to learn from group members and tutors.

Definition
PBL can be explained as “the learning that results from the process of working toward the understanding or resolution of a problem” Barrows, (1980).
PBL is “a conception of knowledge, understanding and education that is profoundly different from the more usual concept underlying subject-based learning.” (Margetson, 1991)
PBL can be best defined as the individualized learning that results from the processes involved in working toward the solution or resolution of a problem.

History of Problem Based Learning
The Faculty of Medicine at McMaster University in Canada was the first educational institute to adopt this model in 1969. Dr. Howard Barrows at McMaster is the first to apply problem-based learning to medical education. Barrow’s idea came from the concepts of adult learning (Knowles 1975). From the late 1970’s PBL methodology spread to several medical schools around the world and other professional courses adopted this method. Presently many medical schools all over the globe have adopted PBL method. Many have done so with several modifications to suit local needs and understanding. Hence, PBL method is quite heterogeneous and is continuously evolving. Adopting problem-based learning as a teaching and learning strategy is attracting wide interest within nursing education.

Characteristics
PBL was developed to bridge between classroom learning and professional practice in such professions as nursing and medicine. In the traditional approach, the teacher starts by giving new information, describing relevant problems, then showing how the information can be used to solve the problems. But with PBL, the teacher describes the problem - the scenario or situation that the students are asked to investigate - and then the students work out what they need to learn, and how to apply their new knowledge as solutions to the problem. The teacher’s role is as a facilitator of the student group, keeping them on track and helping them identify resources. It is based on small group, self-directed learning strategies with well-written objectives.

Traditional vs PBL methods
Traditional lecture ——— Small group learning
Subject based ——–Problem based
Disease focused ——– Patient focused
Competitive learning ——– Co-operative learning

Principles of PBL
1. The student is the focus of the educational programme, not the teacher, the curriculum or the curriculum contents.
2. The development of his/her learning capacities is emphasized.
3. The problems presented in the curriculum trigger the student’s abilities to analyse, to understand and to solve. The student will memorize knowledge obtained in this way much better than by content-based learning.
4. Cooperation with others and the importance of communication is emphasized.
5. Working on interdisciplinary problems or projects is part of any curriculum.
6. Much attention is paid to the development of practical skills.
7. The development of analytical and creative thinking skills
8. The development of self-directed learning ability
9. The integrated application of knowledge and skills within practice

Aims of PBL
The aims of PBL are to develop the students’ competency in a number of skills which will be important in their professional life:
 Problem-solving
 Self-directed learning
 Small group learning
 Critical thinking skills
 Integration of different parts of the curriculum
Savin-Baden (1996) listed 3 key reasons for PBL:
 First reason was developing ‘skills’ and more specifically clinical reasoning skills
 Second reason was that learning should take place in ‘context’ for students
 Final reason was the promotion of self-directed learning.

Objectives of PBL
 To develop an ability to identify relevant health problems.
 An appreciation for the individualized nature of the physical, biological and behavioural mechanism.
 To acquire the knowledge base necessary to define the health problems of the patients
 Reinforce the development of effective clinical reasoning process.
 Recognize, develop and maintain the personal characteristics and attitude.

Team members Group leader
 Scribe
 Group members
 Tutor

Student’s Role
The students are expected to somehow achieve the learning outcomes of the programs, but there is no mapped path for them to follow. So they have to assume a high degree of responsibility for their own education through effective self-learning, working with others and setting relevant goals for them selves and the group as a whole. Also, the students must take the initiative in using appropriate assessments of their progress, and be able to present demonstrations of their learning achievements. Group members’ roles include:
 Active participation
 Active listening
 Asking questioning
 Answering questioning
 Giving information
 Make decisions

Tutor’s/Facilitator’s Role
The role of the tutor in PBL is different than that of a course instructor in a traditional or lecture based course. They are rather facilitators. Tutors play a crucial role in helping the group to establish itself, setting norms for the group function, ensuring group trust, attending to the group dynamics and unique characteristics of the group. They need to be adept at listening, provoking activity when necessary, even playing devil’s advocate. They have to know when to intervene in the group discussion, and when to sit back and let the students resolve their own difficulties. An effective facilitator must be proficient in the PBL process, have insight into group dynamics, and understand the assessment of learning and curriculum issues.

Tutorial process conducted for problem-based learning
1. The problem-based strategy using the tutorial process is conducted in two sessions i.e. brainstorming and regrouping. Students meet in small groups of six to eight, with a “tutor” who is the facilitator. One student takes the role of the group leader who coordinates the session’s activities. Another student takes the role of the scribe, whose task is to keep track of the group’s process on the board.
2. Patient problems are presented in a variety of formats like carefully designed printed format, computer format, video clippings etc.
3. The tutorial group begins with the brainstorming session. The second session is the regrouping session.

Summary of the Process:
1. The problem is encountered first in the learning sequence, before any preparation or study has occurred.
2. The problem situation is presented to the student in the same way it would presenting reality.
3. The student works with the problem in a manner that permits his ability to reason and apply knowledge to be challenged and evaluated appropriate to his level of learning.
4. Needed areas of learning are identified in the process of work with the problem and used as guide to individualized study.
5. The skill and knowledge acquired by this study are applied back to the problem, to evaluate the effectiveness of learning and to reinforce learning.
6. The learning that has occurred in work with the problem and individualized study is summarized and integrated into the student’s existing knowledge and skills.

PBL – the Process
1. PROBLEM - situation, scenario
2. HYPOTHESIS - identifying issues, clarifying learning needs
3. RESOURCES - planning what to use
4. REPORTING BACK - learning from study and modifying information
5. ACTION PLAN - resolution via care/action plan

1. 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. Patient problems may be presented in two formats: real patients (instead simulations) or written case summaries.
Scenario - “Shaw”
Mary attends the S 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 Mary’s arms and legs.

2. 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
 Referral to Day Hospital

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

3. 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
 Journals: Nursing the elderly
 Media: video, websites
 Organisations: Age Concern

4. 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.

5. 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
 Old age home
 Counsellor
 Son -job, support
 Role of community nurses
 Supporting groups
 Key workers

Assessment and Evaluation in PBL
 Regular opportunities for feedback at the end of the each tutorial.
 Feedbacks should be:
• Specific
• Focussed at what is changeable
• Framed as positively as possible

Advantages of PBL
Many people find it much easier to learn from examples than from abstract theory. Building up their own links and experiences helps students recall information, so PBL helps them to learn and comprehend new material more easily.
 Development of an effective and efficient clinical reasoning process
 Increased retention of data
 Development of effective self-directed learning skills
 Increased student-faculty interaction.
 Increased Motivation for learning

Disadvantages
 Resource- expensive.
 Staff and students may be initially uncomfortable with PBL because they are used to subject-based learning, and they don’t really understand how to proceed in PBL.
 on the surface it looks like learning less.
 Measurement of learning outcomes is difficult.

Common difficulties in PBL
The quit group member
A group member who is very quit and not actively contributing to the group’s learning is considered as a problem. It is important to understand why the group member is quit-
Feeling intimidated by other group members?
Unprepared for the tutorial?
A strategy to hold back opinions till others have contributed?
Not given enough time by other members?
The dominating group member
Some individuals have a tendency to talk to the extent of disrupting group functioning. Tutors role here is to understand what lies behind the behavior. Some advice to avoid eye contact with the dominating member may be helpful. At the end of the tutorial, evaluate for the problem.
The group that keeps storming
Interpersonal conflicts are inevitable occurrence when people working together. It is a part of group formation process when people give up some autonomy to facilitate group work. If conflicts persists it is important to deal with. Evaluate at the end of the tutorial.

Professional Behaviors in PBL tutorials
 Respect
 Responsibility
 Self-awareness/self evaluation
 Communication skills

Approaching group problems in PBL
1. Listen carefully to everyone
2. Clarify issues with the group
3. Seek underlying causes
4. Facilitate group solutions
5. Follow up on decisions

Implementing PBL
PBL methodology supports adult learning behaviors such as trust, respect, freedom, team work, accepting differences, responsibility, commitment, active learning and physical comfort. Implementing a PBL course needs a coherent strategy. Staff development, the production of learning packs, the assessment strategy and some means of evaluating the success of the course must all be thought through in advance.

Staff development
The first requirement for the staff is to have a good understanding of the educational concepts underlying PBL, in particular the role of the facilitator, and how this differs from the role of a conventional teacher. Staff who has no familiarity of PBL can be supported by special workshops and other forms of formal professional development. In planning to introduce new PBL courses, you need to provide training resources for staff as a first layer.

Learning Packs
Learning packs are needed for a PBL course in two formats:
 A scenario description for the students, perhaps in several sections describing the patient’s progress over time.
 A much more detailed pack for the facilitators, highlighting the important learning concepts in the scenario, and providing background information and details of assessment procedures.

Evaluation Strategies in Curriculum
Tools used in evaluation of PBL curriculum include Oral examination and essay Test, Objective Evaluation, Multiple choice and True-False Tests, Observation of Patient Work-Up, Oral Presentation of Patient Problem, or Review of Write-Up, Simulations of Patient Problems, simulated Patient, Models and Mechanical Simulators. Some other strategies are:
 Case studies
 Objective Structured Clinical Assessment
 Self-assessment
 Peer assessment
 University evaluation
 Clinical evaluation

Nursing Research on the effectiveness of PBL
 Rideout et al (2001) conducted a detailed evaluation of PBL in which nursing students in a conventional program were compared to those in PBL curriculum. Students’ performance on RN exams didi not differ significantly, however the students in PBL group were more satisfied with their learning experience and relationship with instructors.
 The evaluation of problem-based learning (PBL) for three years(Mori M, Suzuki Y, Sakai T.) BL was evaluated in the course of nursing education for three years as problem solution, self-learning, integrated learning, and communication skills. The usefulness of PBL is supported by using the evaluation scale the appropriate problems, and tutoring capabilities.
 Problem-based learning in clinical nursing education: integrating theory and practice (Ehrenberg AC, Häggblom M.): this study was to describe nursing students’ and their preceptors’ experiences of problem-based learning and a new model for supervision in clinical education. The findings showed that a project based on PBL overall was perceived positively by students and preceptors
 Learning skills profiles of Master’s Students in Nursing Administration: assessing the impact of problem-based learning (Baker CM, McDaniel AM, Pesut DJ, Fisher ML): A comparison of graduate student performances before and after introducing PBL-based curricula found improvement in learning skills; personal learning skills and job skill demands.

Conclusion
PBL is a promising approach in nursing education. In PBL, small groups of students enact solving a real world problem. During this tutorial process, students build on their present knowledge and identify additional learning which is needed to solve the problem. A tutor observes and guides this process using preset guidelines, but does not participate or provide answers. Following the tutorial students search through various resources like books, journals, laboratories, online sources, clinic visits, discussion with faculty, senior students etc, looking for what they need to solve the problem. Students get a study guide from faculty. Following this active learning phase, students discuss their learning in the next tutorial and obtain further details of the problem, and identify further learning issues. This cycle continues until final resolution of the problem. Final session ends with students summarizing the problem and their learning. Active learning occurs throughout the process. The PBL method integrates knowledge across traditional discipline boundaries, teaching practical problem-solving skills. There are four main objectives of PBL: structuring of knowledge in clinical contexts rather than subject disciplines, clinical reasoning, self-directed learning, problem solving, and developing intrinsic motivation (Barrows, 1980).

References
Books
1. Barrows, H., Tamblyn, R. Problem-based learning: an approach to medical education. Medical Education. Volume 1. Springer Publishing Company New York:1980.
2. Dewey, J. Democracy and Education. New York. Mac Millan 1916.
3. Nufield .,Barrows,HS. The Mac Master Philosophy 1974.
4. Savin-Baden, M. Problem-based learning: a catalyst for enabling and disablling disjunction prompting transitions in learner stances? Ph D thesis University of London. Institute of Education, 1996.
5. Young, LE., Perterson, BL. Developing a student-centred Learning Environment. LWW Philadelphia. 2007.
6. Bound D., Feletti GI. The Challenge of Problem Based Learing. 2nd Edn. Kogan Page London, 1998.
7. Rideout, E. Transferring nursing education through problem-based learing. Sudbury, MA.Jones & Bartlet’2001.
8. Knowels, M. self Directed Learning. A guide for Learners and Teachers. Association Press, New York, 1975.
Journal Sources
1. Mori M, Suzuki Y, Sakai T. The evaluation of problem-based learning (PBL) for three years Stud Health Technol Inform. 2006;122:829
2. Ehrenberg AC, Häggblom M. Problem-based learning in clinical nursing education: integrating theory and practice. Nurse Educ Pract. 2007 Mar;7(2):67-74.
3. Baker CM, McDaniel AM, Pesut DJ, Fisher ML. Learning skills profiles of Master’s Students in Nursing Administration: assessing the impact of problem-based learning. Nurs Educ Perspect. 2007 Jul-Aug; 28(4):190-5.

Electronic resources
1. http://www.cotf.edu/ete/teacher/teacherout.html
2. http://www.ucm.ac.mz/html/Learn/learn_2_learn.htm
3. http://depts.washington.edu/cidrweb/resources/pbltools.html
4. http://www.uclan.ac.uk/facs/health/nursing/sonic/index.htm

Nursing Education, Trends in Nursing

current
11/09/07

Leadership

Introduction
Leadership has played an important role in the human history since earliest times. The historians have glorified heroes in battle and valued the importance of their deeds for the future generations. In modern society, too, there is a great emphasis on leadership. There is a continual search for men with leadership qualities. The present day crisis in India is the crisis of leadership, which can give new dimensions to the people’s zeal in accordance with the concepts of democracy and socialism.

Leadership is often regarded as the important modifier of organization behaviour. It is regarded as primarily personal in character as being founded upon individual preeminence or accomplishment in a particular field of behaviour. The dictionary meaning of the verb ‘ to lead’ shows that the term is used in two different senses: (a) “to excel, to be in advance, to be prominent”, and (b) “to guide others, to be head of an organization, to hold “command”.

Characteristics of Leadership
From the above discussion we may define the following main elements in the concept of leadership.
(1) Firstly, leadership denotes a mutual behaviour pattern between the leader and his followers.
(2) Secondly, leadership is a two way affair. The followers influence the behaviour of the leader in as much as the leader influences their behaviour.
(3) Thirdly, the concept of leadership can be understood only in the context of followers. Without followers there can be no leader.
(4) Fourthly, leadership involves the element of willing and voluntary obedience by the followers. Leadership is based on cooperation and goodwill. Sheer threat and force cannot maintain one leader for long.
(5) Lastly, leadership is specific to a specific situation. A person cannot be a leader in all the fields.

Functions of Leadership
There is no unanimity of opinion as to what the functions of the leadership are. This is because detailing of functions depends on one’s general concept of leadership. Generally speaking, leadership functions are related to goal achievement and to the maintenance and strengthening of the group.
According to Bernard, a leader performs four main functions:
(a) the determination of objectives
(b) the manipulation of means
© the control of the instrumentality of action; and
(d) the stimulation of co-ordinated action

The most exhaustive effort to attempt at the functions of leadership has been made by the studies at Ohio State University. The Ohio State work was largely concerned with leadership in formal organizations, most particularly in the U.S Navy and lasted for seven years from 1946 to 1953. It established nine dimensions, three of which are mentioned below.
(1) Maintenance of membership. This involves the closeness of the leader to the group, the frequency of his interactions, and his acceptability to the group.
(2) Objective attainment. The leader has a basic responsibility for seeing that work patterns are stable and understandable. He must also see that the group achieves its goals.
(3) Group interaction facilitation. The leader works to facilitate effective interaction among organization members. Communication is a particularly important feature of this dimension.

Why a person assumes leadership?
Whether a person will assume leadership in a group or not depends upon the reward-cost outcomes expected by him and by his followers. The rewards of leadership are two fold: First are the satisfactions to be gained from successful accomplishment of the tasks; second are the rewards gained from leadership activity in itself. These include satisfaction of needs for achievement and dominance, as well as other social-emotional needs.

Persons who assume leadership incur number of costs. They have to spend their time and energy. Besides they bear strains, anxiety, rebuffs, loss of status and blame in case of failure. He also faces the cost of losing the friendship of the members who may be adversely affected in their position and prestige by his having assumed the leadership. He also risks his popularity. He also faces the cost of loneliness since he is often avoided because of his power and because he may have also incurred hostility.

Leadership styles
There are a number of different approaches, or ’styles’ to leadership and management that are based on different assumptions and theories. The style that individuals use will be based on a combination of their beliefs, values and preferences, as well as the organizational culture and norms which will encourage some styles and discourage others. The three most basic types of leaderships styles are
(1) Authoritarian
(2) Democratic and
(3) Laissez-faire.

Authoritarian
Under the authoritarian technique the leader determines the policy procedures and activities in the group. It induced greater dependency on the leader, marked inter- member irritability and aggressiveness, low frequencies of suggestions for group action and group policy, dissatisfaction with the group activities and high quantity but low quality of productivity, yet its not all bad.

Democratic
Under the democratic techniques the leader encourages participation by members in deciding group matters and behaves in a friendly, helpful manner to the members, giving technical assistance and suggesting alternative procedures. It produces low dependency on the leader, low incidence of inter-member irritability and aggressiveness, high frequencies of suggestions for group action and group policy, great satisfaction with group activities and an intermediate quality of production of high quality.

Laissez-faire.
In the laissez faire technique the leader allows complete freedom for decisions and activity, keeping his own initiative and suggestions to a minimum. The group show little dependency in the leader, great irritability and aggressiveness, high frequencies of suggestions for group action and group policy , considerable dissatisfaction with group activities and immediate productivity.
Other leadership styles are
• Charismatic Leadership
• Participative Leadership
• Situational Leadership
• Transactional Leadership
• Transformational Leadership
• The Quiet Leader
• Servant Leadership
Charismatic Leadership
The Charismatic Leader gathers followers through dint of personality and charm, rather than any form of external power or authority.
Charismatic Leaders who are building a group, often focus strongly on making the group very clear and distinct, separating it from other groups. They will then build the image of the group, in particular in the minds of their followers, as being far superior to all others.
The Charismatic Leader will typically attach themselves firmly to the identify of the group, such that to join the group is to become one with the leader. In doing so, they create an unchallengeable position for themselves.

Participative Leadership
A Participative Leader, rather than taking autocratic decisions, seeks to involve other people in the process, possibly including subordinates, peers, superiors and other stakeholders. Often, however, as it is within the managers’ whim to give or deny control to his or her subordinates, most participative activity is within the immediate team. The question of how much influence others are given thus may vary on the manager’s preferences and beliefs.

Situational Leadership
Leaders define the roles and tasks of the ‘follower’, and supervise them closely. Decisions are made by the leader and announced, so communication is largely one-way. Leaders define roles and tasks, but seeks ideas and suggestions from the follower. Decisions remain the leader’s prerogative, but communication is much more two-way. Leaders pass day-to-day decisions, such as task allocation and processes, to the follower. The leader facilitates and takes part in decisions and problem-solving, but control is with the follower. The follower decides when and how the leader will be involved.

Transactional Leadership
Transactional leadership is based on contingency, in that reward or punishment is contingent upon performance. When the Transactional Leader allocates work to a subordinate, they are considered to be fully responsible for it, whether or not they have the resources or capability to carry it out. When things go wrong, then the subordinate is considered to be personally at fault, and is punished for their failure, just as they are rewarded for succeeding.

Transformational Leadership
Transformational Leader can be a wonderful and uplifting experience. They put passion and energy into everything. They care about you and want you to succeed. Transformational Leadership starts with the development of a vision, a view of the future that will excite and convert potential followers. This vision may be developed by the leader, by the senior team or may emerge from a broad series of discussions.

The Quiet Leader
The approach of quiet leaders is the antithesis of the classic charismatic and often transformational, leaders base their success not on ego and force of character but on their thoughts and actions. Although they are strongly task-focused, they are neither bullies nor unnecessarily unkind and may persuade people through rational argument and a form of benevolent Transactional Leadership.

Servant Leadership
Servant-Leadership is a practical philosophy which supports people who choose to serve first, and then lead as a way of expanding service to individuals and institutions. Servant-leaders may or may not hold formal leadership positions. Servant-leadership encourages collaboration, trust, foresight, listening, and the ethical use of power and empowerment.

Role of Nurses in leadership
Most nurses have grown accustomed to leading and managing their activities as student then in professional practice by assuming leadership for the management of their individual work loads and providing nursing care for their patient/clients. Some have consciously applied the management process to their practice; others have acquired managerial skills through trail and error. Effective nurses are those who blend the qualities of both leader and manager, who have followers willing to be influenced by them, and who understand and apply the principles of management to practice.

A nurse performs multiple role during a day. In nurse case management, for example, the nurse is a manager, planner, organizer, director and controller, co-ordinator, collaborator, expert clinician and communicator with patients and families and all others who influence care. Each member of a role set is influenced by his or her own performance and the actions of others.

The nurse manager’s role: as nursing service departments become decentralized the role of the head nurses is changing from a clinical to a management focus. Adjusting the role changes from centralized to decentralized management requires certain level of expertise. This may be accomplished through mentoring, in service education and formal education.

Following are some of the roles that community health nurses practice:
The home health nurses role: provides core of home health services to patients following a physician-approved plan of treatment.
The nurse practitioners: are registered nurses who provide primary patient care and who have special training beyond that required for nursing licensure in medical history taking, physical assessment skills and patient management. All functions are completed within standardized guidelines and orders developed by and sanctioned by an appropriate governing body.

A nurse midwife: birthing process from inception through delivery.
Occupational health nurse: provides consultations services, assess environmental hazards, complete pre-employment histories and physical examinations, provide health educations and are on staff as full or part time nurses available to employees.