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Beliefs and Learning Approaches of Undergraduate Nursing Students in a Problem-Based Learning (PBL) Environment
Ms Helen Forbes BAppSci (Adv.Nsg), La Trobe, Med st
The purpose of this paper is to compare the learning behaviours used by a high achieving and a low achieving undergraduate nursing student while they learned nursing skills and related theoretical concepts in a unit which uses the Problem-Based Learning (PBL) method. Interviews and journal entries provided data about the role of beliefs about learning and nursing which were shown to influence approaches to learning. Prior beliefs about nursing influenced perceptions of relevance of course content which, in the absence of clinical experience, affected motivation and interest. The PBL method enhanced understanding of the nurse's role. The high achieving student used a range of resources and interacted actively with peers and teachers to gain understanding. The low achieving student lacked skills and interest, used minimal resources, aiming only at reproduction of material.
The purpose of this paper is to describe how beliefs and approaches of a typically high achieving nursing student and a typically low achieving nursing student influence learning. In addition, the effect of a different teaching/learning method such as Problem-Based Learning (PBL), on beliefs and approaches to learning will be discussed. The data were collected through interview and journal analysis of undergraduate students in a unit within a Bachelor of Nursing Course. Students, cast in the role of the nurse, were presented with case studies on campus designed to trigger self-directed learning of particular nursing skills and relevant theoretical concepts. Students were required to explore the theoretical concepts on their own and share information with their peers in small group discussion. Self-directed learning of particular skills was supported by a range of relevant resources which included access to registered nurses in the laboratory. Finally, a clinical placement provided the opportunity for refinement of knowledge and skills.
Although there is no single definition of PBL, the various definitions have common elements. These elements include small groups of learners working with case studies in a self-directed manner to solve common practice-based problems (Barrows, 1985; Boud & Feletti, 1991; and Albanese & Mitchell, 1993). Use of problem-solving requires learners to examine information and construct knowledge for understanding (Margetson, 1991). While it is anticipated that problem-solving provides the means to knowledge development, the way in which learners approach their study determines quality of learning (Biggs, 1987).
Approaches to learning are determined by students' perceptions, motivation, intention, abilities and past learning experiences (Biggs, 1987). Quality of learning is determined by approaches selected by students in response to the learning context (Entwistle & Ramsden, 1983). Deep and surface learning describe fundamental differences in how students learn. These differences should be viewed primarily in terms of the learner's intentions; that is, either to understand or to reproduce material (Marton, 1976; and Ramsden, 1988). Deep learners, in their quest for understanding, need to see the significance and relevance of required facts and therefore interact critically with learning material as connections are made between new and old ideas (Ramsden, 1991). Surface learners, in an effort to acquire and regurgitate facts, use rote learning to remember material (Biggs, 1987).
The PBL method assumes that the learner will be self-directed and use deep approaches to learning. Candy (1991) cautions that not all students are capable of independent learning and, when required to change their approach to study, become anxious and resistant. Research into students' approaches to learning in a PBL environment is limited. A recent study by Duke, Forbes, Hunter and Prosser (1998) indicated that there was substantial variation in the conceptions and approaches of two groups of undergraduate nursing students who were learning nursing theory and skills in a PBL environment.
Therefore, examination of individual perceptions and learning behaviours in a PBL context will illustrate the effect on learning. Also of interest is whether students' learning approaches remain consistent when in different learning contexts. Student concerns and difficulties as well as favourable aspects of the learning method will also be highlighted.
In order to ascertian how beliefs about nursing and approaches to learning of undergraduate nursing students influenced learning a comparative case study design was used. Year 2 students were selected according grades achieved in year 1 of a Bachelor of Nursing course. These students were interviewed and each kept a journal of their learning activities. The journals were used by the researcher to guide the interviews.
Major issues which emerged in the study concerned students' beliefs about nursing and their beliefs about learning. In this paper it is not intended to report the study but to compare two students' beliefs about nursing, learning and their subsequent learning behaviours. It is anticipated that comparison of Allison and Jacqui will highlight the issues and facilitate discusion of the implications for nurse educators.
BELIEFS ABOUT NURSING
The students' pre-entry beliefs about the nurse's role are related to their perceptions of relevance of first year course content. For example, Allison perceived that nursing was about fulfilling tasks and Jacqui's perception was that nurses helped the sick to feel better. Neither student perceived first year units based on behavioural and biological sciences as relevant to nurses' work. The requirement that students study this content contributed to feelings of frustration for Allison and confusion for Jacqui, with subsequent affects on both students' motivation and interest. The beliefs of the students in this study are consistent with the beliefs of the participants in Andersson's (1992) study who viewed similar content as irrelevant to the nurse's role in patient care. Where content is perceived to be irrelevant, a surface approach to learning is more likely to be taken (Fransson, cited in Ramsden, 1991).
A basic expectation of any nurse education program is that new graduates attain particular abilities and a realistic understanding of the nurse's role. In order to do this, transformation of students' beliefs may be necessary. According to Posner (cited in White, 1992) beliefs are not readily altered, however. He states that unless the person finds a new conception that causes dissatisfaction with their existing beliefs, the original beliefs will remain intact. Andersson (1992) found that the perceptions of the majority of student nurses tended to be task-orientated and stable for the length of their three year course.
It would seem, however, that the use of the PBL method provides experiences whereby beliefs about nursing can change. When the PBL method is employed, a number of separate elements are presented to learners in a particular sequence (Barrows, 1985). For example, students are provided with a case study designed to motivate problem solving. A common strategy is the Situation Improvement Package (SIP) which directs students towards specific concepts and skills that are deemed to be professionally relevant. SIPs are based on real patients drawn from the clinical setting. The student is required to identify patient problems that need to be managed by either solving or improving the situation. Students are expected to work independently of the teacher, examine their knowledge and identify any gaps which will prevent solution of the problems in the SIPs. Consequently, the student then must be able to develop the required knowledge by researching the literature, and share that information with their group. Therefore, skills to reflect on knowledge, identify and explore appropriate resources, communicate information to other students, monitor and change approaches to learning as necessary are prerequisites for success with this method.
When working with SIPs, Allison and Jacqui expanded their beliefs about nursing. Allison discovered that nurses do more than complete tasks. Instead, the patient is the focus of care and the nurse needs problem-solving abilities. Consequently, she realized that nurses use knowledge from a range of disciplines and was then able to appreciate the relevance of biological and behavioural science content presented in previous units. While Jacqui also recognised the need for nurses to have problem-solving abilities, she was unable to see the relevance of this content since her competing belief was that the clinical learning environment was superior to the theoretical and laboratory settings.
Some components of beliefs about nursing also changed following the subsequent clinical experience. When the reality of the clinical experience and the students' beliefs were in agreement, then beliefs were confirmed and strengthened. For example, Allison confirmed her belief about the necessity of knowledge that she developed through her recent PBL experience. Jacqui, on the other hand, experienced conflict between her belief that nurses help the sick and her experience of the behaviour of some nurses towards patients. She witnessed what she perceived to be cruelty and heartlessness by nursing staff. Instead of her beliefs being confirmed, a new belief was accommodated. That is, Jacqui perceived that some nurses develop heartless attitudes and are capable of cruelty. Her beliefs were subsequently modified as she accepted this behaviour as a consequence of being in the job too long. Even though beliefs can be in conflict with experience, new and positive beliefs can also develop. For example, both students' beliefs had common elements and, through their observations, they both realized that nurses not only perform tasks but also talk to their patients and meet their physical, psychological and social needs, thus expanding their beliefs about nurses' work. Additionally, Allison recognised that in order to treat the person as an individual the tasks themselves are not as important as the way in which they are performed. Kiger (1993) also noted that when reality and beliefs are in agreement, beliefs are confirmed and strengthened. Further, she saw that new and more positive perceptions can be accommodated when beliefs conflict with experience.
Clinical experience combined with changed beliefs about nursing assisted Jacqui to recognise for the first time the relevance of most of the earlier course content. However, because the nursing staff behaved contrary to her expectations, Jacqui was reluctant to use any of the staff as a learning resource. Olsson and Gullberg's (1988) study found that if incongruence exists between perceptions of the nurses' role and the reality of clinical experience, the development of knowledge, skills and attitudes could be retarded.
BELIEFS ABOUT LEARNING
While the aim of any professional course is that students develop ways of thinking and practising which are appropriate to the specific profession, universities also have expectations of the students in regard to learning. It is anticipated that students studying at tertiary level will have an independent approach to learning, which includes the use of well-organised study methods, an ability to deeply engage with learning materials in order to understand and the ability to work independently of the teacher. Nursing students are expected to have the same approaches to their study so that they learn knowledge and skills required for registration as nurses. Nursing students bring with them, not only particular beliefs about nursing which influence their motivation and approach to learning, but educational experiences, and beliefs about learning which are just as influential (Entwistle & Ramsden, 1983).
Perceptions, Aims and Approaches to Learning in a PBL Environment
Pre-entry beliefs about learning differed between the two students. Allison defined learning as being stressful, while Jacqui thought that learning was imposed.
Learning Theoretical Concepts
The perceptions about PBL and the students' approaches to learning in the PBL environment differed. Allison perceived that the PBL unit would help her to think and act like a nurse and develop her independent learning skills. She set congruent learning goals. Jacqui perceived that the unit required her to use knowledge to solve problems in order to improve the patient's situation and that PBL would get her to think logically. Her learning goals, however, reflected her focus on learning skills which was consistent with her belief that practical learning is the only relevant learning.
Selection of learning strategies also varied between the two students. Allison identified that she required particular knowledge to solve the SIPs. While she did not know to what depth she should go when researching the literature, she decided to allow her interest in the topics and understanding of concepts to determine how deeply she should explore the material. She used the library and accessed a range of texts to find relevant material. She was pleased with her efforts and felt satisfied that she understood the concepts that were identified in the SIPs. Jacqui, on the other hand, did not perceive that she needed a range of knowledge to solve the SIPs and only researched topics as directed by her group facilitator. For Jacqui, the lack of congruence between her goals and the purpose of the subject has lead to poor decision-making about learning strategies.
A further complication for Jacqui was that she did not know how to use the library or how to find information in textbooks. It would appear that when a student like Jacqui does not have the necessary motivation or skills to reflect on knowledge and search the literature, then identified learning issues will not be identified let alone explored. On the other hand, when a student like Allison is highly motivated, sets goals that are congruent with those of the unit and possesses the ability to reflect on her own knowledge, independent examination of the identified learning issues is more likely.
The ways in which the students used the group discussions varied also. Allison's purpose was to clarify her understanding and to evaluate the relevance of the material she found in the literature. She described contributing energetically to group discussions. Jacqui took a passive role as receiver of information since she realised that she did not have enough knowledge to contribute actively. The approaches of these two participants seem to be consistent with Baird and White's (1982) position that high-quality learning outcomes are associated with adequate decision-making.
Learning Skills in the Laboratory
Both students identified that the purpose of the unit was for them to learn the fundamental skills of nursing. Allison's learning goal was to learn the skills as well as she could in the laboratory and then find out how nurses in the clinical environment carry them out with patients. Jacqui aimed to perform the skills correctly so that neither she nor her patients would be harmed. Both students perceived that the clinical setting would give them the opportunity to practise their skills which would help to develop their confidence. In relation to goals in the clinical environment, Jacqui aimed to perfect the skills and gain confidence, identifying that the clinical placement would give her the opportunity to practise on patients. Her motivation for learning reflected the responsibility nurses have to care for patients safely.
Both students appeared to have learnt from their previous experience of learning health assessment skills in the first year of the course. Allison now believed that it was better to learn the skills by herself without relying on demonstrations from the lecturer. She familiarised herself with each of the skills by using all of the recommended resources. She established a small practice group with fellow students and met regularly for practice sessions in the laboratory. She then sought feedback from available registered nurses and her peers. She described frequent interactions between herself, her peers and the nurses while she was learning the skills. Before going on her clinical placement, Allison felt that she was as prepared as she could be; however, she was anxious that her clinical teacher might have different expectations of her. Jacqui, on the other hand used some of the recommended resources in the laboratory, but did not perceive that the skills were difficult enough to require a teacher's involvement. Any problems she had were in relation to trying to exactly reproduce the skills. She did not seek feedback from any of the nurses.
Developing Skills in the Clinical Setting
It was apparent that when all resources are used for learning skills and the learner interacts with the resources and discusses possibilities and problems with fellow learners and facilitators, the learner is satisfied with the outcome. Allison approached the clinical learning experience in the same way as she approached skill learning in the laboratory. She identified and used the available resources, of which her teacher was one. Allison also described frequent interactions between herself, her peers, the nursing staff and her clinical teacher. On the other hand, Jacqui found that the only learning resource of value was her fellow students who gave her some feedback. She was confused when some nurses performed the skills differently from what she thought was the correct manner. Jacqui did not seek feedback from her clinical teacher until she was assessed on the last day. She believed that her final assessment was unfair perceiving that she was more capable than her teacher thought her to be.
New Beliefs About Learning After PBL Experience
As a consequence of experiencing the PBL method, these two learners developed more complex meanings about learning. Allison now viewed learning as an exciting experience. Learning the skills made her feel like a nurse. By the end of the clinical experience she saw herself as an independent learner and believed that nursing and learning are patient centred. It would appear that Allison has developed a higher order qualitative conception of learning where she has constructed a personal philosophy about learning and nursing. While Jacqui's belief about learning now included problem-solving, the idea that trial and error is reasonable in the clinical setting had also been incorporated.
This paper compared the beliefs, perceptions and approaches to learning of two undergraduate nursing students as they learnt nursing knowledge and skills within a framework of self-direction using PBL. It would appear that when reality and beliefs are in agreement, then beliefs are confirmed and strengthened. Furthermore, when beliefs are in conflict with experience, new and more positive perceptions can be accommodated. In contrast to Andersson's (1992) finding that beliefs about nursing do not change over time, it would seem that the two students developed more complex beliefs about the nursing role after experience of the PBL method.
Comparison of these students also confirms findings of educational research in areas other than PBL. For example, congruence between perceptions and goals are more likely to lead to adequate decision-making about learning approaches.
The study by Duke et al. (1998) indicates that there are a range of conceptions and approaches to learning. Drawing on the categories of description described in that study, it would appear that Allison uses a deep approach to learning theory and skills. She clearly details using all available resources with the intention of understanding. On the other hand, Jacqui is working at a surface level, using limited resources with the intention to reproduce theory and skills.
Learning in a PBL environment relies on the perceptions of the activities and context and the establishment of pertinent goals by the learner. However, strong beliefs about nursing appear to influence whether the learner establishes goals which are congruent with the subject aims. Decisions about the particular learning behaviours are taken as a result of these perceptions and goals. Motivation and organisational abilities, as well as basic research skills, influence whether learning goals are met. It would seem that learners who accept responsibility for their own learning by being actively involved in exploring the literature, sharing information and contributing to group discussion, are more likely to feel satisfaction with their approach and knowledge development whereas those who adopt a surface approach may see the learning process as alienating.
It is apparent that beliefs, whether they are about nursing or about learning, are powerful influences on students and the learning approaches they select. Different learning environments appear to contribute to learners developing more complex perceptions, which in turn influence approaches to learning. Underlying beliefs about how and where nursing should be learnt appears to be particularly influential especially in regard to decision- making about how actively involved the learner will be in the process of theory and skill development.
While it would seem clear that clinical experience provides opportunities for testing and changing beliefs about nursing,it is also apparent that use of the PBL method in units where theory and practical skills are learnt also provides similar opportunities for some students.
The issues raised by this study could well be in common with other educators using this or other teaching methods where it is expected that learners will exercise a fair degree of self-directive behaviour. While future research should focus on approaches to theoretical learning and skill development using a larger sample investigation of which resources facilitate skill development and at what stage they should be introduced is also important. Such investigations could lead to the development of a model of skill development. Also of importance is the need to investigate how to identify and support the student with poorly developed learning strategies.
It is apparent that students need support when using the PBL method for the first time. Regardless of intention, some anxiety appears to be part of the process for students. Changing the course structure so that it is totally integrated using the PBL method as the only teaching/learning method is one possibility. Students would then gain more opportunity to develop self-directed learning skills through repetition and would develop earlier self- reliance.
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Last modified on: Tuesday, 24-May-2011 09:15:04 EST