A doption of a problem-based learning approach in clinical learning

1. THE HONG KONG Adoption of a problem-based learning approach in clinical learning POLYTECHNIC UNIVERSITY School of Nursing Fax No.(852)2364 9663 / (852) 2142 1303 • Professor Frances Wong • Dr E. Angela Chan • Ms Kitty Chan • Ms Sharon Cheung • Dr Loretta Chung • Dr. Tony To • Dr Maria Wong

2. Clinical Problem-based learningWorkshop 17/1/2007

3. Introduction • What is problem-based learning (PBL) from 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

4. 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.

5. PBL Tutorials • Students’ PBL learning at the University aims toward how the student learns (life-long process) and encourages students to integrate concepts from nursing, psychology and sociology in their understanding of the situation/ issues or particular aspects. • Student’s 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, cooperative and reflective learning are valued.

6. 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

7. PBL Process • 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 can identify which tasks each will perform. • Self-study and preparation • Share the new knowledge effectively so that all the group learn the information and its applicability

8. PBL Process • 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

9. 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

10. 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.

11. Example • He also complaints of headache in the last week. • On assessment, you found that Mr. Leung’s vital sign was T0 : 36.8 0C, BP: 170/95mmHg, P: 92 bpm and R: 20 bpm. • His tentative diagnosis is high blood pressure.

12. Example • 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 other’s company.

13. 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?

14. Guiding questions • 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?

15. 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

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

17. 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 ever- enriching layers of new knowledge across disciplines

18. Student feedback (1) • Study and think independently • Build up confidence through learning and sharing • Learn common disorders and explore the case more in-depth • Enjoy sharing of experience

19. Student feedback (2) • Some students are initially uncomfortable with PBL simply because they are so used to SBL. • Some students questioned about the breadth of knowledge required and sometimes new information shared may not be relevant to the case • Lack of clinical knowledge to answer the questions • Difficult to integrate a wide range of information in order to solve a problem

20. Summary • PBL used a posed problem to drive the learning. • From the analysis of the problem, identify the issues at hand • Define what information is pertinent to solve the problem - justification • Learn the new knowledge and apply it to the problem. • Reflect on the process afterwards

21. Discussion • Past nursing experiences • Past clinical teaching experiences

22. Clinical environment strange emergency busy

23. Demystify the concept of PBL in clinical teaching • The characteristics of PBL • Core learning is the process of clinical reasoning within a clinical situation • Performance and outcome may supersede the development of the process given the demands in clinical settings • Tutorial PBL learning process is to carry out at clinical: post-conference (de-briefing)

24. Role of clinical teacher in clinical PBL • a modified role since s/he cannot take a total non-directive role. • assist students to identify appropriate issues for problem analysis (asking leading questions) • act to monitor progress • challenge the thinking process • raise issues to be considered • link other care episodes to the situation/problem considered • encourage students to be inquisitive about why, what if, on what basis etc. • help students to see the problems from different perspectives while allowing time for them to formulate their own conclusions in appropriate interventions

25. Role of the student in clinical PBL • Investigate their learning needs from the situation and issues • Recognize the need to continue searching for information and integrate the information into practice based on sound justifications • Work independently and interdependently with others in the process of data collection and analysis

26. Wong et al.’s study (2004): Adoption of a problem-based learning approach in clinical learning • Aim: to introduce the strategy of PBL in clinical teaching • Two phases • First phase involved educating the clinical teachers to use PBL and understanding the experiences of students and teachers after using PBL in clinical teaching

27. Wong et al.’s study (2004): Adoption of a problem-based learning approach in clinical learning First phase: • Focused group interview & collaborative phenomenological analysis • Examples of the questions: ‘How do you feel about the simulated PBL teaching experience? How different is it from your past experience in clinical teaching?’

28. Findings: themes • Dynamic process of learning • Shifting boundaries of teachers’ role • Shifting boundaries of students’ role • The contingent clinical learning environment

29. Dynamic process of learning:Asking questions (teacher asks questions & student answers) • When I encounter a case, I have my own judgement and know what particular concerns that need to be addressed. I turn the pieces of information that the student needs to know into questions. This is a way to make the student think. If the response is different from the one I have in mind, I’ll ask them to justify their proposal. If they can’t provide justification [or the justification is not reasonable], I’ll direct the student to think of alternatives. Finally, it’s the student who arrives at his/her own decision.’

30. Dynamic process of learning: Asking questions (staging the learning activities • We can start with some basic questions. [If the students do not have a clue what happens,] I can start with our daily life encounter. For example [I’ll ask the student] there is a recent reported case of Avian Flu, what do you need to consider?

31. Dynamic process of learning: Asking questions (staging the learning activities • I believe we can start PBL at the very early stage of the clinical placement. I do not start by telling them the entire procedure. I start by stimulating their curiosity, such as ‘now the specimen has arrived [at the laboratory], what should you do? This helps the student to appreciate the importance of preparatory work [prior to undertaking the actual analysis of the specimen]. As we move on, I can add more to the questions .. it is a systematic approach

32. Dynamic process of learning: Asking questions (staging the learning activities • A logical staging begins with clarifying concepts, defining the problem, then analyzing the problem, seeking new understanding, synthesizing new knowledge into the problem solution and finally solving the problem.

33. Dynamic process of learning: Discussing and reflecting on the experience • Periodic discussion is important to highlight the important learning experiences. [They can be informal in-between, but] the last meeting can be more formal. Allowing sufficient time for the students to read and reflect, the supervisor can help the students to link other care episodes to the problem being considered (Price & Price, 2000)

34. Shifting boundaries of teachers’ role • I know the procedure so well that I can be very conversant about the procedure. I can easily state what he should do, [in such way] I will turn the student to be a spectator. • After attending this workshop, I feel that my mentality has been changed. I’d think more on how to help students learn better, how to initiate questions [to prompt the student]. I feel that, mutually [between the teacher and student], we are more inquisitive.

35. Shifting boundaries of teachers’ role • The clinical supervisor cannot afford to be entirely nondirective for it often involves life and death issues. • PBL challenges the clinical supervisor to help students to arrive at their own conclusions. • The supervisor has to be patient to let the students formulate their own conclusions and be sensitive to know when and where to intervene (Price & Price, 2000).

36. Shifting boundaries of students’ role • What we have learned in the classroom is very boring .. with problem-based learning, the teacher guides me step by step, to make me comprehend the case at hand better. Since I’m involved in dealing with the situation, I feel my I have stronger participation [in the learning process]. Without problem-based learning, I sometimes feel like an observer, and the learning is less efficient. • Some students come to the clinical setting, at a loss of what to learn. I think the students need to come with purpose … there is a set of clinical learning objectives to go with each unit. For example in the medical unit, there must be specific cases like patients with cardiovascular condition, respiratory condition. And, in the laboratory, there are microbiology cases. .. we need to have an expectation on the students.

37. The contingent clinical learning environment • There are multiple learning opportunities in clinical …. In the clinical we may be confined by the concept of ‘role modelling’ and the learning is restricted with what’s being modelled .. the spirit of PBL is that you can stimulate the student to think more, e.g. did the student explore the background of the patient [that is related to his onset of asthma]? • When we encounter some urgent cases, if we don’t seize the opportunity to deal with it, it’ll be gone quickly. In such case, we cannot [take time to] explain this and that [to the students] for the patient is already dead [if we don’t take action]. We need to revisit the situation [with the students afterwards].

38. The idea behind PBL is more than learning, but we want the student to construct one’s own knowledge in a real-life situation. We don’t want the students to wait till they graduate to experience the real life environment. … it’s a process where the teacher and student mutually discuss and negotiate in solving the clinical problem .. It is therefore important for the teacher to gradually reveal his/her knowledge .. if the teachers said it all at the beginning [of the learning process], the students do not have the courage to express their own opinion. The usual thinking [of the students] is that the teachers’ approach is a more correct one. .. We hope not to learn for the problem, but learn from the problem-solving process, so that when the students face a similar situation [in the future], there is transferability [of learning] .. Nursing is a human service, we hope students can translate knowledge to the realization of the value of caring.

39. A framework for adopting problem-based learning in a simulated clinical setting (Wong et al. 2006): • Based on the results of phase one (Wong et al. 2004), we have constructed a clinical case and selected a clinical teacher who has demonstrated the competence in employing PBL to participate in the second phase of study. • The clinical PBL episode was video-recorded, transcribed and analysed using the strategy of conversation analysis (Silverman 2001).

40. Findings (Wong et al. 2006) • Sequences of clinical PBL: • a typical care profile provided to a patient undergoing surgery • Identities taken on by the speakers (teacher and student) through the clinical PBL: • The student assumed the identities of an active learner and a neophyte nurse in caring for the patient under the guidance of the teacher. • These identities had six manifestations in the clinical PBL situation. • They were collection of information, data analysis, formulation of hypothesis, validation, discussion and reflection, and learning synthesis. • Outcomes of the clinical PBL: • patient-focused care, student-directed learning, inductive learning, and translation of book knowledge into practical information

41. Conclusion • Clinical PBL captures the advantages of the contingency nature of the clinical and the presence of a real patient that triggers the student to address learning issues of ‘as they are’ (Wong et al. 2006). • Clinical PBL enables the students to better comprehend the clinical problem, to be actively involved in search of solutions and ultimately through this process to construct their own knowledge and to integrate theory and practice. • It is a dynamic process wherethe teachers actively strategize students’ learning and seize learning moments for students within an unpredictable clinical environment(Wong et al. 2004).

43. References • Alexander, J. G.; Mcdaniel, G. S.; Baldwin, M. S.; and Money, B. J. (2002). Promoting, Applying, and Evaluating Problem-Based Learning in the UndergraduateNursing Curriculum. Nursing Education Perspectives, 23(5), 248-253. • Amos, E. and White, M. J. (1998). Problem-Based Learning. Nurse Educator, Volume 23(2).11-14. • Chenoweth, L. (1998). Facilitating the process of critical thinking for nursing. Nurse Education Today, 18(4), 281-292. • Happell, B. (1998). Problem-based learning: Providing hope for psychiatric nursing? Nurse Education Today, 18(5), 362-367. • PBL Working team (2002). A problem-based learning handbook for Higher Diploma/BSc (Hons) in Nursing: A practice guide. The Hong Kong Polytechnic University, School of Nursing (https://www/polyu.edu.hk/nhs/Polyu/pbl)

44. References • Price, A. and Price, B. (2000). Problem-based learning in clinical practice facilitating critical thinking. Journal for Nurses in Staff Development (JNSD) 16(6), 257-266. • Silverman, D., (2001). Interpreting qualitative data (2nd ed). SAGE Publication Ltd, London. • Woods, D. (2000). Problem-based learning: How to gain the most from PBL. Ontario: D.R. Woods/McMaster University. • Wong, FKY, Chan, EA, Cheung, SCM, Chung, LYF, To, TSS, Wong, MLWY & Wu, CST. (2004). Problem-based learning: an innovative model for clinical education. Evidence-based nursing education and related issues. The Hong Kong Society for Nursing Education. Ming Pao Pub. Ltd. Pp40-56. • Wong, FKY, Cheung, SCM, Chung, LYF, Chan, K, Chan, EA, To, TSS & Wong, MLWY. (2006). “A framework for adopting problem-based learning in a simulated clinical setting.” submitted.