THE SUCCESSFUL USE OF Problem-Based Learning in an Online Nurse Practitioner Course
By Rounds, Linda R Rappaport, Bethany A
ABSTRACT The development of technology and online education has opened the door to creative use of new and existing teaching methodologies. The authors describe how they used problem-based learning in an online course as a method for teaching clinical decision making to nurse practitioner students. The close match between problem-based learning and the characteristics of adult learners and successful distance learners is outlined as support for use of this methodology. In addition, the authors describe the challenges, rewards, and lessons learned in this innovative approach to online education.
Key Words Online Education – Distance Education – Problem-Based Learning – Adult Learning – Nurse Practitioner Education
TEACHING METHODS IN NURSING ARE SLOW TO CHANGE. Even when nursing is taught online, teacher-centered methodologies persist and remain the primary techniques for imparting knowledge. Swenson and Sims (1) point out that although nurse practitioner education has made progress in moving away from the medical model, it still clings to traditional educational methods. * As the characteristics of nursing students change that is, students are older and have more life experience – the need to emphasize adult learning principles becomes more important. And with the explosion of knowledge demanding effective, lifelong learning skills, there is a growing need to search for new and creative approaches to education. * One approach, though not new, is problem-based learning (PBL). Used initially in medical education, PBL not only supports the principles of adult and student-centered learning, it also matches the characteristics of successful distance learning. Intended to develop effective critical thinking and clinical reasoning skills, PBL fosters independent, self-directed learning skills and builds an internal motivation to learn and question (2). BECAUSE THE GOALS OF PBL CLOSELY MATCH THE CHARACTERISTICS OF SUCCESSFUL DISTANCE LEARNERS AND ARE AIMED AT RELEVANT CLINICAL SKILLS, THE FACULTY AT THIS SOUTHWESTERN UNIVERSITY-BASED SCHOOL OF NURSING SELECTED THIS TEACHING METHOD FOR USE IN A NEWLY DEVELOPED ONLINE NURSE PRACTITIONER PROGRAM.
Problem-based Learning The medical school faculty at McMaster University first developed problem-based learning in the early 1970s (2). Since then, it has been adopted by numerous medical schools and other health professions schools throughout the world (3-7). More recently, PBL has been adopted in master’s and baccalaureate nursing programs (1,8-10).
PBL is described as independent, self-directed learning where faculty members function as facilitators rather than content experts (2). Students, working in small groups, explore assigned problems or cases based on their own identified learning needs and the needs of the group. In a problem-based exercise, the outcome, or correct answer, is less important than the problem-solving skills developed and the learning gained in understanding the problem. Faculty leaders ask questions, seek students’ rationales for their thinking, and guide the process. Rather than providing answers or telling students how to solve problems, faculty as facilitators provide guidance and urge students toward a deeper understanding of the work in progress (11). The goal of such education is not only knowledge, but the ability to apply it (8).
The expectations for sound decision making by new graduates are higher today than in the past (12). With traditional teaching in advanced practice programs, faculty lecture about or discuss diseases or conditions within frameworks such as body systems, acute and chronic problems, or developmental age groups. But patients rarely walk into the clinic saying, “I have new onset congestive heart failure.” Rather, the patient may present with a cough and shortness of breath within the context of a given personal history.
As in the clinic, PBL presents students with a chief complaint or problem and directs them to examine possible differential diagnoses, identify and explore learning needs, select the most likely diagnosis based on history and physical exam data, and develop a plan of care. This more closely resembles the real world of practice than traditional methodologies.
Creating PBL Online A federal grant to develop an online gerontological nurse practitioner program created the opportunity to not only explore and use problem-based learning, but adapt it to the Internet. Having taught in a medical school using PBL, the project director realized its potential for learning clinical problem solving. The challenge was to create an online technique that would fully utilize the methodology and advantages of PBL.
One of the first realizations when beginning to create the online, problem-based program was the close match between the goals for PBL and the characteristics of adult learners and successful distance learners (2,1314). (see Table.) Successful distance learners and adult learners are independent, goal directed, practical, good managers of time and resources, good problem solvers, and eager to grow and learn (13,14). The aims of PBL are to develop independent problem solvers who can apply knowledge to patient care and recognize when new learning or knowledge is needed (2). Thus, it seemed a natural match to use PBL in an online, distance learning format.
In developing the program, the nurse practitioner faculty reviewed the literature, met with experts in PBL, and completed the training for faculty facilitators teaching PBL in the medical school. Then it was time to create the online version of classroombased, problem-based learning.
One difference in the problem-based curricula offered in medical schools, compared to that used in nurse practitioner programs, is that medical students frequently meet several times a week while master’s nursing students often have a given class one day per week. Online learning, on the other hand, can take place seven days a week at any hour of the day or night. Another difference is that many medical students are novices in health care, while nurse practitioner students are experienced nurses with preexisting knowledge of diseases and treatments. Thus, the approach to cases with the nurse practitioner students could be slightly different from that used with medical students.
Consultants recommended that students not complete all cases in an interactive mode. Rather, there should be a mix of interactive cases done by small groups and home study cases completed by individuals. This served two purposes. First, the individual cases did not require the time and intensity of online interactions. Second, using both types of cases made it possible to evaluate individual knowledge and skills as well as group work.
Since two of the essential skills underpinning the use of PBL are learning to develop a differential diagnosis and understanding evidenced-based practice, faculty created brief learning modules to help students review these skills and processes before beginning the problem-based cases. Initially, faculty oriented students to the process of PBL through oncampus discussions, online bulletin board discussions, and materials in the module. More recently, faculty members have used Wimba(R) (Horizons New York), a web-based, interactive, real-time audio tool for the orientation.
Implementing Problem-based Cases Once faculty completed the initial orientation with students, the first problem-based case began. cases were part of the clinical diagnosis and management courses for gerontological nurse practitioner students. These courses contained no lecture-type content and relied heavily on group and individual problem-based cases to meet the course objectives.
For each case, students received brief demographic data, vital signs, the chief complaint, and a photograph of the patient. (The photograph was a stock photo that was thought to represent how a patient in this case might look.) To create a foundation for group work, faculty identified several roles thought necessary to the success of the online cases. Some roles are common to all PBL, and some were designed for this particular use of the methodology. They included facilitator, group leader, scribe, recorder, and patient.
The facilitator was a faculty member who guided the group in the problem-solving process by asking questions, challenging students’ ideas, and encouraging them to identify their own learning needs (2). The group leader was a student volunteer who guided the group, often proposing schedules, timelines, or other organizational features. As the students gained experience in PBL over the course of several cases, often the group leader took on some of the functions of the facilitator. The scribe recorded the progress of the group in various areas – facts about the case, ideas or hypotheses regarding the cause of the presenting problem, and learning issues identified by the students. The recorder organized the work of the student group and put it together at the end of the case to present as a case report to faculty.
Faculty chose to use a live patient. One of the faculty members anonymously served as patient and answered questions posed by students during the history and physical exam, using the online bulletin board. The live patient interaction allowed faculty to assess students’ abilities to ask history-taking questions and determine physical exam priorities appropriate to the case. Particularly in a course where students are distant from campus, it was helpful to observe and evaluate these skills in a variety of ways. Once students and faculty identified their roles, students determined ground rules for conduct of the case. Ground rules were unique to each group, consisting, for example, of online courtesy and frequency of contributions. Examples might include, “check the bulletin board at least once per day,”"no more than one screen length for a single posting,” or “use subject headings that reflect the content of the posting.” Establishing ground rules was difficult at first, as students did not know what was important or needed, but became easier once students finished their first case.
Next, it was time for students to identify facts, hypotheses, and learning issues. Facts are those factual things that students know about the patient such as age, gender, past illnesses, current medications, or living circumstances. Hypotheses or ideas are those things that might be the cause of the chief complaint or presenting problem; often these are differential diagnoses. And learning issues are those things students do not understand or need to learn more about. For example, in a case where one of the differential diagnoses was pneumonia, a learning issue was the difference in presentation of viral and bacterial pneumonias. To help students document their thinking, a programmer created an online “scribe” for the group, where students could list content in each of these areas, much like using a flipchart or blackboard.
Completing the Process Students worked as a group throughout the case. Initially, they needed to work through the group dynamics. With only facilitation from the faculty, they determined the most likely diagnoses and developed a plan of care. Then they submitted a report summarizing their findings and plan. Once the students finished all the interactive cases in a given course, they completed peer and self-evaluations. Faculty also completed evaluations on each student. Peers and faculty members gave individual students feedback at the completion of the cases.
Online, problem-based learning was challenging for faculty to develop and for students to learn and use. However, by the end of the program, students paid faculty the ultimate compliment by no longer needing them to help them work through clinical problems. Students often moved forward while faculty watched from the sidelines, demonstrating that they had learned a useful method that helped them investigate and solve most new clinical problems they encountered.
Challenges and Rewards At the time this program was developed, there were no models for putting problem-based learning online. There were few entirely online programs, let alone programs using innovative methodologies. Thus, there were challenges in the program development process as well as new learning for students and faculty.
Without a model for implementation, it took courage to move a classroom-based approach to a new teaching-learning methodology and to the new online format. It required a belief in the methodology and trust in students’ abilities and their enthusiasm for learning.
Some faculty expressed concern that online students could not possibly learn as much or as well as students sitting in a classroom with a teacher. Furthermore, some faculty feared students might receive an inferior education because PBL taught a method of problem solving, rather than specific information about diseases or health problems. But students were challenged by the method. Most had come through an educational system where they were given information and were expected to memorize facts. This new method required them to explore and analyze information and to identify what they needed to learn in an environment where they could not see fellow students or the teacher. Group dynamics and group process were challenging. Students needed to clarify roles, equalize participation, and take responsibility for their own contributions.
One of the greatest challenges for faculty in implementing PBL online was relinquishing control of the learning. The students were not the only learners in this experience. Faculty needed to have a different mind set and a different, enlightened approach to their roles as educators. Problem-based learning can be challenging for the seasoned educator, and putting PBL online only increased the demands. With no immediate verbal or nonverbal communication, allowing students greater responsibility for their own education required trust in the student’s desire and ability to pursue learning. And guiding students via a computer screen and written words required trusting oneself as a teacher, as well as trusting in the methodology. However, the rewards were tremendous.
When students and faculty completed cases using online PBL, they realized that they had engaged in an educational approach that mirrored skills needed in the real world. Building on previous knowledge and experience, the online format fostered autonomy and independence, hallmarks of adult learners. In the final role practicum course that followed the PBL courses, the students presented interesting or challenging cases from their own practices and led the discussions. It quickly became clear that, as a group, the students were able to use critical thinking skills – analyzing cases, researching aspects they did not understand, and synthesizing knowledge from various disciplines to make a recommendation for patient care without direction from the faculty member.
In the online format, because of the visibility of discussion and participation on the bulletin board, the students’ understanding and comprehension of the process became apparent quickly. Their decision- making processes were visible, unlike in the classroom, where students’ thinking can sometimes be hidden. Similarly, the online method clearly documented who contributed to the final presentation or the problem’s solution.
In the end, students were successful. They graduated and they found positions as nurse practitioners. The graduates of the program have also been successful on national certification exams with the percent passing consistently exceeding the national average.
Lessons Learned Using problem-based learning online has been time intensive for faculty. While the process of using a live patient has been considered well worth the outcome in evaluating students’ history-taking abilities and priorities for the physical exam, several methods have been proposed for reducing the time commitment required for this part of the case.
One suggestion has been the use of sequential written information rather than live patient responses. For example, students could have initial access to the history of present illness, followed in several days by other parts of the history. Other options include creating a menu for students to select from to gain the desired information. It might be a pull-down menu from which students could select such aspects of the case as history of present illness, medications, or a selected portion of the physical exam. Another suggestion has been to use Wimba, which would allow students to take the history in real time, reducing the amount of time required to do it on a bulletin board.
Online problem-based learning can also be time intensive for students. Consequently, student groups have identified ways to share the work. Some students have divided various parts of the case study among themselves, although everyone was expected to participate in the discussion. Others have divided portions of the history and physical exam among different students. Some groups have even designated days off from the discussion, giving themselves time for other life commitments or just time to reflect on the work in progress. Students have found that creating a timeline for the case is helpful in keeping the group on track toward their final goal and providing structure to the online format.
Unexpected Outcomes Faculty have noted that a number of unexpected outcomes have emerged from using PBL in an online format. Working through cases in groups has created close ties among students. Upon graduation, they have a ready network of colleagues to consult with electronically for a variety of needs. In addition, faculty have found that the online format fosters a unique closeness between faculty and students. They believe they know students better as professionals and individuals and are more aware of their behaviors than in previous classroom experiences.
The student-centered approach, the use of adult learning principles, and the frequent interaction in the online environment have contributed to the development of mutual respect and support, as well as increased familiarity with students’ knowledge and skills. Problem-based learning, when used in an online course, has helped students accomplish goals identified by Barrows for a variety of professionals – they have become “independent, problem-solving, self-motivated learners” (11, p. iii).
With no immediate VERBAL OR NONVERBAL COMMUNICATION, allowing students GREATER RESPONSIBILITY for their own education required TRUST in the student’s desire and ability to PURSUE LEARNING. And guiding students via a computer screen and written words REQUIRED TRUSTING oneself as a teacher, as well as trusting in the methodology. HOWEVER, THE REWARDS WERE TREMENDOUS
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About the Authors Linda R. Rounds, PhD, RN, FAANP, FNP, is a professor, and Bethany A. Rappaport, MSN, RN, GNP, is an assistant professor, School of Nursing, University of Texas Medical Branch, Galveston. For more information, contact Dr. Rounds at lrounds@utmb.edu.
Copyright National League for Nursing, Inc. Jan/Feb 2008
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