Terese Ericsson & Carmen Sadikovic

School of Health Science

Blekinge Institute of Technology

Abstract – This paper investigates issues related to the teaching method Problem- Based Learning at the School of Health Science at Blekinge Institute of Technology. The School of Health Science (HAL) at Blekinge Institute of Technology (BTH) has been using PBL for approximately ten years. In many respects, it has been challenging for teachers to adapt to the new learning perspectives. For the most part, PBL has been perceived as more fun and stimulating by both students and teachers than traditional learning methods, particularly in theory. However, since it is not a strict and clear teaching method, it has in practice also been criticized, particularly as it has a tendency to create stress for the parties involved –  i.e. teachers and students – and because of the difficulty to achieve the learning objectives. Given the discrepancy between theory and practice, as well as the fact that PBL is still a fairly new pedagogical and didactical concept, there is a need for deeper understanding of the method and its potential. The aim of this study was to describe and compare students’ experiences of PBL at the nursing program at BTH. Furthermore the aim was to explore if whether, there is a glitch between PBL practice and PBL policy at HAL. A descriptive and analytical quantitative method were both used. A total of 44 persons aged 19-39 years, who participated in the nursing program at The School of Health Science at Blekinge Institute of Technology, were included in the study.

Keywords – Problem-based learning, nursing, education

1. Introduction

Active learning methods with problem-base learning (PBL) as an example of these have become increasingly popular in the academy world and it has been incorporated particularly into many clinical nursing programs and courses the last years (Clark, 2007). The method has been established as an independent didactic concept in higher education since 2005 (Pettersen, 2005). In Sweden PBL was introduced for the first time in 1986 at Linköping University, in the medical education and the number of PBL courses continue to increase (Edgren, 2011). PBL has been perceived as more fun and stimulating for both students and teachers (Albanese and Mitchell, 1993; Norman and Schmidt, 1992) engaging students into deep learning as  the students themselves must actively seek knowledge (Vernon and Blake, 1993).  However, since PBL is not a strict and clear teaching method, it has been criticized because it may create stress for the involved parties, teachers and students, because of the difficulty to achieve the learning objectives. It requires a lot of the teachers´ time since the groups are small compared to the traditional teaching (Berkson, 1993).  Adding to this is the circumstance that PBL relatively new in health care education while it has been used for many years in medicine, business and science education (Clark, Nguyen, Bray & Levine, 2008). Alesssio (2004) showed that students perceived traditional teacher-centered learning more favourably than student-centered PBL. On the other hand other studies showed that this type of learning is realistic, fun and interesting for the students in nursing programs/courses. And the students’ engagement is often high and their knowledge tends to increase (Haidet et al 2002; Cooke & Moyle, 2002; Levine et al, 2004). The School of Health Science at Blekinge Institute of Technology has been using PBL for approximately ten years and this has meant a challenge for the teachers as new learning perspectives are involved.  The teachers needed to develop the pedagogiy making it clinically and theoretically savvy, for it to correspond to the conditions required for students.  In 2009 a policy document was created as a tool for the teachers. The School of Health Science has also consulted a PBL pedagogue from another university, to guide the teachers and to implement this particular pedagogical method. With all respect the transition process has brought a degree of uncertainty and insecurity with regard to teaching the role with regard to the role or function of teaching. Therefore it is important to investigate the students´ evaluation and experiences of PBL at the School of Health Science.

2. Background

In Sweden, PBL has been used since the 80`s (Silén, 2004). Problem-based learning (PBL) is a student-centered pedagogy in which students learn about a subject in complex, multifaceted, and realistic context. The goals of PBL are to help the students develop flexible knowledge, effective problem-solving skills, self-directed learning, effective collaboration skills and essential motivation (Hmelo-Silver, 2004). Working in groups, students identify what they already know, what they need to know, and how and where to access new information that may lead to resolution of the problem. The role of the teacher (known as the tutor in PBL) is that of facilitator of learning providing appropriate scaffolding and support of the process, modeling of the process, and monitoring the learning (Schmidt, Rotgans, & Yew, 2011). Barret (2010) points out that the tutor/base-group supervisor has the responsibility to build the students confidence to handle problems encourage the students, while also stretching their understanding (ibid). The use of problem-based learning in health science education has grown in the past years (Michaelsen & Richards, 2005).  

2.1 The Nursing Program at Blekinge Institute of Technology

The Nursing Program at Blekinge Institute of Technology (BTH) offers the scientific knowledge on which general healthcare is based. The program also provides knowledge of the anatomy, physiological functions, development and behavior of healthy and unwell people. The program demonstrates the link between a person’s state of health and the physical, mental, social and cultural environment, and also provides knowledge about the values and ethics in the profession and the general principles for care and welfare. The students will have the opportunity to practice, integrating and implementing new research results and learning to reflect on their own personal approach in relation to research and development (BTH, 2012). Person-centered care is characterized by the patient being seen, understood and treated based on individual needs, values and expectations. The nurse and his/her team should be able to deal with the patient and relatives using evidence-based knowledge, empathy and an ethical approach (McCormack, 2004).

There are 75 nursing students every term and the education leads up to a first-cycle qualification of a Nurse degree. The education also leads up to Bachelor of Science in Nursing. The teachers at HAL department strive to develop teaching methods that correspond to the requirements for students to have clinical and theoretical knowledge. Written policies and the educational models are the basis for HAL; this educational basic view permeates all teaching, with the policy flowing into goals that are clearly rooted in our educational ethos. The policy document highlights that there are no set educational truths or answers, and that education is largely about influence. It is therefore essential that the educators/teachers have thought out the educational/pedagogical policy. This educational policy also gives a sense of security in the teaching profession and clarity in the relation to the students, at the same time the students know what they can demand of the teachers at the School of Health Science (pedagogic policy document, HAL, 2011).

2.2 Problem-based learning the at School of Health Science (HAL)

The Nursing program at the School of Health Science has used PBL as a teaching model, method and ideology for ten years, the method, providing opportunities to develop problem-solving ability in groups (PBL policy at HAL, 2010). PBL improves the work as a nurse to quickly enter and act professionally. The students are assigned to a base group each term and a teacher/lecture acts as a tutor. The students are expected actively participate in group meetings, participate in discussion and thus be responsible for their own learning. Besides group meetings the students have lectures, seminars, workshops, training methodology etc. (BTH, 2012). In connection with each term the nursing students have the opportunity to answer an anonymous questionnaire about their views and experiences on PBL at HAL. The questionnaire revealed that the students had different opinions regarding support from their base-group tutors; some of them felt that they receive sufficient support and others expressed that they did not receive sufficient support. It was also found that some of the students felt that the tutors had knowledge of the subjects, while others did not.  In regard to the question of how close the PBL conform to an ideal form/method of teaching, the answers from the students varied greatly, from “no opinion at all” to “to the full”.  The nursing students have also the opportunity to meet the teachers twice per term in meetings called “basrådsmöten”, in this meeting that the  nursing students wanted the teachers  were more consistent and work towards the same goals in their teaching. This is the reason why the School of Health Science today has a PBL pedagogue from another university, with the role to guide and support the teachers, to try to achieve a common understanding of PBL and develop PBL as a teaching method and ideology at the School of Health Science.

With all respect, it seems that the teachers have different opinions on how the teaching should be planned and implemented the students at HAL sometimes feel that they do not get the same information and the guidance in the problem-based groups. It has also emerged from the students that the teachers even have different views of what PBL is and how the method/ideology should be used. It is important for both the teachers and the students at The School of Health Science to feel safe and secure in the implementation of PBL in the nursing program.

2.3 Students´ experiences of PBL

Problem-based learning has been verified to be effective and successful in health science education and the students showed a high level of engagement and motivation, (Seidel & Richards, 2001; Dunaway, 2005). Cooke and Moyle (2002) showed that the students felt that their learning had actually improved and that PBL is fun, stimulating, interesting and motivating. It appeared in the study that the students hoped that PBL could be introduced much earlier (ibid). In contrast, Alessio (2004) showed that the students perceived traditional teacher-centered learning more favorably than PBL, and recommended research about different ways in which PBL can be introduced and gradually implemented into health sciences programs. The latest research, Nilsson, Fredholm and Silen (2010) indicate that PBL students focused on a more intellectual dimension of nursing and clearly related nursing to a professional role and the PBL students increased their own learning development. Further research is needed to understand how PBL affects the students understanding of nursing (ibid). The aim of this paper was to describe and compare students’ experiences of PBL at the nursing program at BTH. Furthermore the aim was to explore if there is a glitch between PBL practice and PBL policy at HAL.

3. Method

3.1 Sample & setting

The sample for this study included nursing programs students (n = 44). The inclusion criteria for the sample were students studying at term two, four and six at the School of Health Science in south of Sweden, Karlskrona. The participants were randomly selected from the students list from the students’ administrator who works at the School of Health Science. After that the students were invited to participate in the study trough group tutors. The recruitment took place over eight weeks during the spring of 2012. The School of Health Science, located in Karlskrona, south-east Sweden, has around 75 students every term.

3.2 Data collection and data analysis

The data collection was conducted in mars 2012.  The students were informed about the study by their group tutor and were asked to fill out a questionnaire covering first variables such as age, gender, term and a question about how many hours a week they devoted to their studies counting education/classes and tutorials. The second phase in the questionnaire consisted of seven questions about their experiences of PBL. Descriptive statistics describe the findings in a concise and understandable way, using tables, graphs and numerical measures. Statistical tests are used to compare and analyze data using different test methods (Ejlertsson, 2003). Descriptive statistics were used to report response rates to the various issues regarding the students experiences of PBL included in the questionnaire. According to Ejlertsson (2009) Spearman´s rs correlation coefficient describes if the variables depend on each other, based on ranks for variable values instead of the exact values and it does not require linearity. The correlation coefficient always lies between – 1 and 1. The null hypothesis is that the correlation is zero, i.e. no connection/correlation (ibid). In this study Spearman´s r correlation was used to examine the relationship between the students´ age and the students´ attitude towards PBL, and it was  also used to examine the relationship between question 1 (“I think that PBL is a good pedagogic model in the nursing program”) and question 5 (“I think I get enough help from the group tutors to study independently”),  6 (“I think I get enough support of the group tutors at the practical moments in the nursing program”)  and 7  (“I knew what PBL was when I applied to the nursing program”). The Spearman´s correlation was also used to examine the relationship between the number of hours per week devoted to studies, education/tutorial and question 5 and question 6. All data were processed and analyzed using SPSS for Windows statistical software version 20 (SPSS Inc. 2012).

3.3 Ethics

This project was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki. Although under the Swedish Ethical Review Act (SFS 2003:460) this project does not require ethical clearance, we nevertheless sought and received ethical guidance and advisory opinions from the Ethical Advisory Board in south-east Sweden. All participants received information about the project and were informed of their right to withdraw at any time. To ensure compliance with the Data Protection Act (Swedish Personal Data Protection Act 1998:204), data was stored securely and anonymised and only the project team had access to the data.

4. Results

4.1 Students´experiences of PBL

The results in this study are based on a comparison between students´ experiences and what the PBL policy document says. A total of 44 students from term 2, 4 and 6 participated in the study. The majority of the sample were women (64%), the mean age was 24 years and age distribution was similar in all terms. The number of hours that the students spent on education and tutorials per week did not differ significantly between the terms (2, 4 and 6), the mean was 23.73 hours and the range between 7-48 hours. The results show that the students experienced PBL as a good pedagogical method in the nursing program despite a major part of the students (n = 29) 65.9% did not know what PBL was before they started the nursing program at BTH. Further the result shows that many of the students experienced that the introduction to PBL was not sufficient and 43.2% (n=19) reported that they would like to have several PBL introductions during the education. Experience of satisfying help from tutors turned out to be something that most of the students agreed about and in the sample 31.8% (n = 14) of the respondents were reported to be totally satisfied with the help. When it comes to the support in the practical moments the students were just quite satisfied with the help from the teachers.

4.2 PBL practice and policy at HAL

The pedagogical policy document for School of Health Science (2011) says that all students have equal value, and equality between men and women must be respected and promoted. This means that the learning do not prevent anybody, regardless of gender, ethnicity, religion or other belief, sexual orientation or disability, from participating in the nursing program. The pedagogical policy document (2011) at HAL does not report any specific hours of scheduled time of learning in the nursing program. It says that learning should be based on students’ needs, but the basic principle in the theoretical sections of the program should at least be three days a week scheduled with various forms of educational activities, such as base group discussions, lectures and practical training. The PBL policy document (2010) highlights that by using PBL in a training program and integrating the different topics with each other, the encouragement and training of the holistic knowledge vision will increase. In practice this can  sometimes be difficult for the students. The PBL policy document (2010) says that PBL is introduced at the beginning of the first term and this introduction has been further developed since 2011, as the earlier introductions not perceived as sufficient by either students or teachers. The result shows that in practice the students would like to have the introduction several times. The PBL policy document (2010) says that the skills training prepares students in practical training for clinical training and for future professional function. Platform trainings must be as authentic as possible. Trainings skill can take place with or without the supervisor. Instructional videos, computer software, docks and other facilities are used to reach educational goals. At HAL dummies are used in skills training, the use of dummies reduces the risk of infection, injuries and complications. It seems that there is no glitch between the PBL policy document and practice when it comes to this. Several times the PBL policy document (2010) points out several times the base-group tutors’ role in PBL teaching.  According to the policy document, each student must know exactly what is expected of him/her for the method to be as efficient as possible. The group tutors must be familiar with PBL and with their role which is to support and guide the students in the group.  And also to motivate the students´ own learning and build on from the students need. The group tutors are also important for the students´opportunities to further development. A prerequisite for a good learning climate is that there is an interaction between the group tutors and the group. In this study it appears that half of the students (n = 19) experienced that they received  enough help and support from the base-group supervisors, but 14 of them experienced that they were not getting the help they needed.

4.3 Students´ experiences of PBL and PBL practice and policy at HAL

Statistical significant correlation exists between question 1 and question 5 (p= 0.04) but there is no statistical significant correlation between question 1 and question 6 and 7 (Table 10). This means that there is no relationship between students’ opinion if PBL as to whether PBL is a good pedagogic model and the students’ knowledge about PBL that the students had when they started the nursing program and the support from the tutors. However,  there is some connection between the experience of finding PBL to be a good pedagogic model in the nursing program and feeling that they get enough help from the group tutors to study independently (Table 1).

Table 1. Corellation between PLB and students´ experiences

5. Conclusions

To the best of our knowledge, this study gives a small description of students’ experiences and the glitch between practice and policy of PBL in the nursing program at HAL. The PBL policy says that with PBL as a learning method the students learn to take responsibility for their own knowledge and it increases their opportunities for learning and ability to seek knowledge as professionals. This is supported by Nardi and Kremer (2003) who found in nursing classes that most of the students reported comfort when attempting to solve ambiguous problems in healthcare. According to Neville (2009) PBL also has a positive impact on social and cognitive domains. By working in small groups, students get better communication and interpersonal skills. The students devote on average 23 hours per week to studies and education. This is surprisingly low considering that the nursing program at HAL is a full time education (40 hours per week). Since 2011 the introduction to PBL, in term one, has been changed and a PBL coach has also been tied to HAL to help the teachers to develop PBL in the nursing program. Despite this many of the students did not find the introduction to PBL satisfying. In addition the results show that many of the students want to have repeated introductions to PBL during the education.  Cooke and Moyle (2002) show that many of the students felt that their learning had been greatly enhanced by using PBL, so much that they hoped that PBL could be introduced much earlier and several times in the education (ibid). The results point out that many of the students agree in moderate to the questions on whether they get enough help from group tutors both in practical and theoretical needs. The PBL document lifts this and states the interaction between students and tutors as very important. Also Nilsson Fredholm and Silén (2010) report group interaction as essential for discovering how the group members,  students and tutors, contribute in different ways to the learning process and for learning how different perspectives can improve and increase the individual students knowledge (ibid). The result indicates a possible glitch between the policy document and practice. It seems to be important to find a balance between what the students can understand on their own and what can be accomplished with a good tutorial. If the tutorial is adapted to the students´ needs, the students´ academic performance can be “proximal”.

This study represents a glimpse of the students’ experience of PBL in the nursing program at the School of Health Science appears. Our study results support PBL as a useful instructional pedagogic for teaching in the nursing program. It also gives team building and communication skills to solve complex clinical and theoretical problems as a professional. However in our opinion the PBL policy document needs to be more detailed to be able to optimize the support to teachers at HAL. Further research is also needed to explore the effects of problem-based learning in the nursing program for preparing the nursing students to work in a complex multi-team environment.

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