Using a computerised clinical database to enhance problem-based learning strategies for second year undergraduate nursing students.
Associate Professor Julianne Cheek PhD
David Gillham B.Sc., B.N., R.N., M.N.St.
Patricia Mills R.N., R.M., Dip.T.(N.Ed), B.E.,
Email please reply to Anna.Holasek@unisa.edu.au
This paper reports on an educational innovation namely the integration of a computerised nursing care planning database into the undergraduate nursing curriculum of an Australian university. The existing second year curriculum, premised on a modified problem-based learning (PBL) format, has been operationalised in a manner which enables the integration of computer based problem solving activities into the teaching and learning processes. These activities are designed to enhance student learning and develop the life-long learning capacity of students to problem solve with the aid of technology. Students use the database to solve clinical problems in a manner which replicates the clinical setting. This process is particularly important given the increasingly limited clinical placement opportunities available to students in times when strict funding constraints are applied to both the university and health care sectorsdiscusses problem-based learning in the context of the current University . This paper environment and undergraduate nursing education and relates these approaches to student centred learning with the use of computer databases.
In 1996 the University of South Australia implemented an educational innovation in an undergraduate nursing education program designed to strengthen conceptual links between the theory and practice components of the second year curriculum. This involved installing a clinical database used in a major teaching hospital into the University computer laboratory. The existing second year curriculum, premised on a modified problem-based learning (PBL) format has been operationalised in a manner which enables the integration of computer based problem solving activities into the teaching and learning processes.
Problem-Based Learning and Nursing Education:
Problem-based learning strategies have traditionally been developed and refined within the relatively well funded area of medical education where PBL is recognised as a valuable approach towards developing clinical problem solving amongst medical students (Glenn, 1995). This has led to:
a well defined and accepted framework for problem based curricula ... with a clear set of goals and a multi-stage learning process typified by the problem based tutorial. (Feletti 1993, p146)
However PBL is also being used in other health education areas. There are three major objectives common to using PBL in health professional education which includes the education of nurses - the focus of this paper:
The acquisition of an integrated body of knowledge related to the problem, the development or application of problem solving skills, and the learning of clinical reasoning skills. (WHO Report 1993, p3)
A broader definition of PBL, albeit congruent with that of WHO, is provided by Boud and Feletti who define PBL as:
An approach to structuring the curriculum which involves confronting students with problems from practice which provide a stimulus for learning. (cited in Candy et al. 1994, p140)
While definitions of PBL may vary slightly according to institution and discipline the reliance on student centred, self-directed learning and practical problem solving are common components of PBL.
PBL strategies are well suited to nursing education with particular benefits in relation to the development of decision making and problem solving skills:
PBL teaching methodologies demonstrate the complementary nature of theory and practice that promotes conceptual understanding, the development of reasoning skills, and self-directed learning strategies. (Barrows cited in Glen 1995, p94)
Glen goes on to highlight the advantages of PBL in developing theory-practice links which address the theory-practice gap, sometimes perceived as an inadequacy of university-based nursing courses. It is the ability of PBL to simulate the problem solving activities which are frequently encountered in the clinical workplace which makes this form of teaching effective for nurse education.
Clinical Database - Responding to a need
A frequent criticism of University based nurse education is the lack of clinical preparation of students (Nursing Education in Australian Universities, 1994). The opportunities for clinical placement for nursing students, like those of other practice based disciplines, are limited by funding constraints for student supervision and available clinical placements.
With both the health and education sectors facing further staff and budget reductions one of the greatest challenges facing Australian educators in applied areas such as nursing is how to provide students with enough suitable clinical learning experiences.
In response to this need, a hospital computerised database containing nursing care planning instructions was made available to students in the University computer pool.
Students used the database as a resource to assist them in devising nursing care plans appropriate for the clinical problems presented to them. The database provided components of nursing care plans which are used in clinical practice to provide a complete set of instructions to guide in the care of a patient thus providing greater links between theory and practice. The challenge to staff was to integrate this database of care plan components in a manner which enhanced PBL and maintained the philosophical stance of the curriculum.
The curriculum existing prior to the implementation of teaching using the computerised database used PBL to emphasise reflective nursing practice. Boyd and Fales (1983, p100) described reflective learning as:
The process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective.
The subject identified for integration was Acute Care Nursing which aimed to develop the knowledge, attitude, technical and caring skills required to enable students as reflective practitioners to meet the health care needs of clients experiencing alteration to health as a result of disease or dysfunction. Students therefore used a process of PBL and reflection to not only attain technical knowledge and skills but to develop themselves as caring informed practitioners. The process of internal examination and changes in conceptual perspective which enhance this development are often stimulated by reflection on events associated with clinical hospital placements which are an integral component of the subject.
Jones (1995, p783) supports this view by referring to Schon's (1987) work which "identified reflection as a process of knowledge attainment emerging in practice, and is best suited to solving complex practice based problems." The importance of reflection in clinical learning in nurse education is further supported by James and Clarke (1994, p86) who suggest that "reflection is central in many theories of experiential learning (Kolb 1984) which is arguably the dominant form of learning in nursing." Minghella and Benson (1995) identify reflection as a means of establishing theory-practice links, providing student centred education and focusing on client centred nursing care.
The combination of PBL and reflective practice provides a model of praxis where reflection and action are tightly interwoven (Crowe, 1994).However, both are dependent on very skilful facilitation particularly when staffing and funding constraints are present. While reflection may be readily incorporated into clinical placement, students may need encouragement to develop reflective processes. Encouraging reflection in the classroom using the database as a source of information was made easier by the actual nature of the database content. The database had been developed by nurses very strongly aware of the value of the needs of the individual and the use of reflection in relation to both physical and non-physical needs of patients. The quality of the information contained in the database greatly enhanced the opportunities for facilitators to use patient scenarios to emphasise holistic nursing care and reflective practice using problem-based learning.
Integration of the Computer Database
The increased reliance on computers in hospitals has led to increased demands on Registered Nurses including the need to utilise computer technology, rapidly and efficiently. The importance of educational preparation in computing is strongly supported by Hardy et al. (1996, p221) who state "it is essential that all health care professionals have a solid grounding in health informatics or information technology."
To ensure students had some background knowledge of computing the computing instruction component began with a general introduction to hardware and software providing detailed instruction in the use of the program which enabled students to navigate the database. This provided basic computing experience while exposing students to the program they were likely to use on a daily basis in the clinical setting. The use of care planning databases was then introduced with a discussion of issues such as the potential for the lack of individualised patient care, production of unwieldy quantities of paperwork and patient confidentiality.
Students were then given direct practical instruction and provided with workbooks to give them an opportunity to establish a basic knowledge of the program. When this initial instruction was completed students began to explore the database and program themselves.
Once students had developed satisfactory competence in using the computer program, the challenge for staff and students was to integrate the use of the program into the curriculum, maintaining the PBL approach and emphasising reflective practice.
Students were provided with moderately complex practice based scenarios of clinical problems, a variety of learning resources and questions which promote self-reflection. The scenarios included a wide variation of practical activities, descriptions of simulated patient progress and hospital or community health facility documentation. The computerised database was included among the learning resources provided to students who. had access to practical and technical equipment and worked through the various scenarios and activities with teaching staff acting as facilitators to provide guidance where necessary.
At all stages reflection and problem solving were emphasised. This approach is supported by Richardson (1995) who highlights the importance of minimising the theory-practice gap suggesting students should reflect on their own values, assumptions and experiences which can be identified in response to scenarios.
Maximising the Educational Value of the Database
Each week students were asked to prepare nursing care plans using the computerised
database. Students were highly motivated because they immediately recognised the value of this process as it reflected part of their employment role upon graduation. The challenge for educators, however, was to maximise the use of the database so students used the care planning information for problem solving, linking theory to practice and developing metacognitive abilities in the use of technology. It was very important that the care planning activity of each week did not simply become a paper producing task which had to be completed prior to tutorial sessions.
The application of a PBL approach to the computing component of the subject Acute Care Nursing was achieved by asking students to work in groups to prepare nursing care plans based on the weekly clinical learning scenarios in preparation for tutorials. As suggested by Clarke et al. (1996) such collaboration, while reflecting the practice setting, also helped to develop teamwork, encourage reflective practice and promote respect and commitment for continuous improvement.
Students explored the database to locate defined problems which most closely matched the scenarios. In this way students identified clinical problems directly from the hospital databases just as they would in the practice setting. Students moved through the database to obtain the appropriate level of information they required according to their individual background knowledge. Having obtained the care plans from the database, students then modified and individualised the plans, added pathophysiological or other rationale and presented them at tutorials for discussion. Subsequent modification to plans was then encouraged in response to changing scenarios reflecting patient alteration over time. Students were encouraged to critically examine the scenarios, using logic to negotiate the care plan database and engaging in collaborative reflective activities to produce and individualise the care plans.
Analysis of student learning indicated that those aspects of PBL identified by Candy et al. (1994, p140) as the use of "critical, creative, logical and lateral thinking skills" had been satisfied through the use of computer assisted activities. Students responded enthusiastically producing completed scenario based care plans prior to each weekly session. While exact reasons for the positive response from students will only be obtained when the project has been fully evaluated, the four I's of good teaching described by Feletti (1993, p154) as Interesting, Interactive, Integrated and Independent seem to have been satisfied.
The computerised database was therefore more than a textbook replacement. Students learned to use a program which extended their clinical practice, familiarised them with a current nursing care plan database and developed their computer based problem solving skills which further enhanced their life-long learning capabilities.
Constraints on Nursing Education and Possibilities of Problem Based Learning - A Cautionary Note
Although PBL assists students to establish conceptual links between theory and practice, if financial, staffing and other resources for PBL itself are limited then the advantages of this approach to learning will be restricted. This is compounded if PBL also involves the use of expensive technology such as banks of computers. Consequently, the integration of a computer database into the learning process needs careful planning so logistic problems such as limited computer resources and student contact time are considered.
The nature of the PBL simulation places great demands on the facilitator who must be both knowledgable in relation to the clinical content and skilled in PBL delivery (Barrows, 1986). In the present climate of reduced funding and limited student contact for university nurse education courses these skills are even more critical. If contact time is limited there will be reduced opportunity for reflection and student driven exploration of problems during class time. Unless the facilitator is familiar with and skilled in PBL delivery, there will be a tendency to provide students with solutions to clinical problems in order to deliver the required knowledge within the time allocated. For successful PBL delivery students need time to explore for themselves and at their own pace.
Student perspectives and their attitudes towards clinical learning also need to be considered. Candy et al. interviewed students in PBL courses who admitted that they lacked the confidence that comes from supervision and guidance and had not developed a sound knowledge base:
You didn't really know a lot of the time what was important, because until we built our knowledge base, we felt, a lot of the time, that we were stumbling in the dark and we were solving problems, but we felt we needed more information. (Candy et al. 1994, p143)
Although some students may be more comfortable with PBL once their knowledge base is sound, using a rigid PBL model to teach technical skills may also be problematic. There are times when students require direct clinical demonstration emphasising fine technical details: for example, technical skills related to central venous lines, when demonstration may be incorporated into a more flexible delivery of PBL.
A further consideration is the need to provide a variety of teaching methods to accommodate the individual learning styles and abilities of students. The methods should also match the characteristics of clinical problems encountered in nursing. These problems may not always be readily resolved using the rational sequential problem solving process, characteristic of PBL (Baker, 1996). While PBL may be used effectively for nurse education, there are some circumstances where skilfully modified delivery of PBL may be necessary to capture the complexity and non linear aspects of problem solving in the clinical setting.
The use of clinical databases in nursing education has distinct advantages. The major advantage of care planning databases is that they provide an up to date example of the nursing care carried out in the clinical setting. Nursing students are quick to recognise the importance of any efforts to minimise the theory-practice gap and value the opportunity to direct their own learning using real life scenarios and a current computerised database.
While the enthusiastic attitude of students has enhanced the development of this project, it has also become apparent that the use of the database is congruent with the principles of PBL and reflective practice which drive the teaching and learning process. Not only are students provided with the chance to use a large and well developed clinically based information resource to assist their problem solving activities but they are also developing information retrieval skills which will serve them well in the workplace.
The computer's real pedagogical power lies in its capacity to develop the `metacognitive' skills...those very skills- problem solving, a critical approach, the ability to retrieve, organise analyse and synthesise data, the ability to `learn to learn' -that are increasingly necessary and increasingly prized in society. (Duguet cited in Candy et al. 1994, p 169)
While the use of computer technology may facilitate the development of these desirable skills, evaluation of this project suggested that the effective use of educational technology is dependent not only on the quality of the technological innovation but on how this is embedded in the teaching and learning process.
The authors wish to acknowledge the Committee for Advancement of University Teaching (CAUT) who funded the project.
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