Adoption of a problembased learning approach in clinical learning

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Adoption of a problem-based learning approach in
clinical learning
THE HONG KONG
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

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Clinical Problem-based learningWorkshop
17/1/2007
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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

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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.

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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.
• 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, cooperative and reflective learning are
  valued.

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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

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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

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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

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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

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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.

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Example

• 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.

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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
  others company.

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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?

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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?

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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

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Reframing the situation

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

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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

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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

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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

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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

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Discussion

• Past nursing experiences
• Past clinical teaching experiences

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Clinical environment
strange emergency busy

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• 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)

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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

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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

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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

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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?

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Findings themes

• Dynamic process of learning
• Shifting boundaries of teachers role
• Shifting boundaries of students role
• The contingent clinical learning environment

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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, Ill ask them to justify their proposal.
  If they cant provide justification or the
  justification is not reasonable, Ill direct the
  student to think of alternatives. Finally, its
  the student who arrives at his/her own decision.

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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
  Ill ask the student there is a recent reported
  case of Avian Flu, what do you need to consider?

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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

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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.

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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)

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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. Id 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.

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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).

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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 Im
  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.

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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 whats 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 dont
  seize the opportunity to deal with it, itll 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 dont take
  action. We need to revisit the situation with
  the students afterwards.

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• The idea behind PBL is more than learning, but we
  want the student to construct ones own knowledge
  in a real-life situation. We dont want the
  students to wait till they graduate to experience
  the real life environment. its 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.

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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).

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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

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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 where the teachers
  actively strategize students learning and seize
  learning moments for students within an
  unpredictable clinical environment (Wong et al.
  2004).

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References

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References

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