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Adoption of a problembased learning approach in clinical learning

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Title: Adoption of a problembased learning approach in clinical learning


1
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

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.
  • 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.

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. 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.

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
    others 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, 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.

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
    Ill 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. 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.

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 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.

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 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.

38
  • 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.

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

42
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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.
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