VOL: 102, ISSUE: 21, PAGE NO: 34
Steve Wood, MSc, BSc, is head of department for mental health and learning disability, Anglia Ruskin University, Essex
Aim: To obtain the opinions of a group of mental health students on the effectiveness of problem-based learning (PBL) within a pre-registration nursing pathway.
Method: Focus groups were used to generate data and the sample consisted of 14 mental health branch students who, within the pre-registration nursing programme, formed a PBL group. The group met on an annual basis at key junctures during the three-year diploma programme. The focus groups were tape-recorded and the data interpreted and organised by utilising an adapted form of content analysis.
Results: Four themes were identified regarding the use of PBL: the students’ initial adjustment to PBL; the impact of PBL on their secondment status; the application of PBL in clinical practice; and the students’ reflective critique of PBL.
Conclusion: The discussion of the findings makes suggestions for the utilisation of PBL in future reviews of nursing curricula and outlines the implications for clinical practice. This includes the need to carefully plan the students’ initial placement experiences and provide extra support at this stage. In addition, mentor preparation on the use of PBL in practice needs to be extended to ensure flexibility in the PBL process. It should be balanced with formal student support and courses must be planned to incorporate the learning needs of all discipline groups.
When pre-registration nurse education pathways were revalidated in response to the standards and learning outcomes of the Department of Health (DH, 1999), ENB (2000) and UKCC (1999) many education centres took the opportunity to adopt problem-based learning (PBL) approaches as a major educational and teaching strategy.
A number of UK studies have evaluated the impact of these educational changes (Gerrish, 2002; Lord 2002; Tingle, 2002). However, to inform further curricula reviews, it is essential that the effectiveness of any new learning approach is also monitored by course providers (DH, 2003). Accordingly, a research study to determine the effectiveness of this approach, as perceived by a group of mental health nursing students, was undertaken.
This formed part of a larger research study that explored the impact of the theory-practice gap, the learning culture in clinical practice and the intentional and unintentional effects of the curriculum (Wood, 2005). The outcomes of both research studies were utilised within the review of the pre-registration nursing curricula at Anglia Ruskin University in April 2005.
PBL has been adopted as a learning and teaching strategy in many educational settings, both nationally and internationally. In particular, PBL has been utilised within professional education, for example, in nursing and social work (Boud and Feletti, 1997). PBL was initially pioneered with medical students at McMaster University in Canada (Barrows, 2000). It has now evolved to such an extent that there is comprehensive evidence to demonstrate the effectiveness of PBL with a range of disciplines (Price, 2003; Biley, 1999). However, in contrast, there is a paucity of research on the experiences of mental health students with this learning approach.
A hybrid model of PBL was adopted in the programme and used with the mental health students who participated in this research study. This model utilised the major principles and structures of PBL but was supplemented with more formal teaching methods such as lectures and skill development sessions (Melville et al, 1993). The students were organised into and remained in small, mental health specific learning groups for the entire three-year duration of the programme. These groups were facilitated by mental health lecturers, though the students were expected to agree group rules and nominate peers to undertake specific roles within the group, such as chairperson.
There is a need to contribute a mental health perspective to the substantive literature on the use of PBL within nurse education. Therefore, the aim of this study was to obtain the views of a group of mental health students on its use within a pre-registration nursing pathway.
Although the utilisation of PBL in pre-registration nursing programmes is a comparatively recent phenomenon, the number of studies evaluating its use within nursing curricula has significantly increased (Biley, 1999; Milligan, 1999). It is beyond the scope of this article to undertake an extensive critique of PBL. However, it has been described as a student-centred approach that promotes critical enquiry by initiating discussion on issues derived directly from clinical experience. It enables students to become autonomous problem solvers, to be reflective, self-aware and motivated regarding their own learning. PBL utilises group processes and facilitation to stimulate enquiry by using practice-based scenarios as ‘triggers’ for learning.
Students use a range of learning resources (for example, fact-finding visits, textbooks, the internet, and asking practitioners) to address the identified learning outcomes (Milligan, 1999; Biley and Smith, 1999). Despite the significant rise in PBL research interest, it was not possible to find any publications that exclusively studied mental health nursing students as a sample group. One reason for this could be because it is often assumed that the perceptions of mental health learners will be similar if not identical to that of the adult branch students (Wood, 2005).
Similarly, there has been an increase in the publication of research that explores the impact of contemporary change within nurse education. These also sample learners from all nursing disciplines. In this respect the literature is extensive and diverse, giving valuable insights into the learning experiences of the participants.
These studies have highlighted that many student stressors result from a tension between dependence and a search for independence (Gerrish, 2002; Hamill, 1995). Stressors include the focus of the theory component, assessments, management preparation, course organisation, supernumerary status, financial pressures, time-management problems, preconceptions of nursing, initial placements, personal development and personal difficulties (Gerrish, 2002; Howard, 2001; Spouse, 2000; Macleod Clark et al, 1997a; 1997b; Jones and Johnston, 1997).
Other reasons that have been cited for stress include experiences on clinical placement, external pressures, academic difficulties, personal relationship problems, incorrect career choice, family factors and health and financial difficulties (Deary et al, 2003; Last and Fullbrook, 2003; Randle, 2003; Glossop, 2002; Howard, 2002; Glossop, 2001). Many mature students also experience financial, childcare, relationship and family problems (Lauder and Cuthbertson, 1998).
The small number of studies that utilise just mental health students as a sample have highlighted the importance of giving students experience of user involvement in classroom work to enhance awareness of client needs (Wood et al, 1999). Similarly, direct user involvement in mental health branch education by way of client review presentations identified that students were less likely to rely on the use of professional terminology and jargon, and more able to empathise with clients’ distressing experience. Therefore, they were more likely to take an individualised approach to assessment and intervention (Frisby, 2001).
An educational initiative in which group supervision was implemented is described within one cohort of pre-registration mental health nursing students. Here the students reported a number of benefits including: greater understanding of the benefits of clinical supervision; skill development; the opportunity to reflect on practice; and the reduction of stress (Ashmore and Carver, 2000).
Another study demonstrated the importance of the skill of self-disclosure with mental health students disclosing more than adult students. The perceptions of and outcomes for a group of mental health nursing students have also been explored. This investigation centred on five main themes: career choice; personal change and development; evaluation of the curriculum; ideas about mental health nursing; and career plans (Ferguson and Hope, 1999).
Ferguson and Hope (1999) found that prior clinical experience appeared to be a very important factor in deciding to become a mental health nurse. Concerns about the relevance of the foundation programme to mental health students were also expressed. Recommendations from their research included: the need to investigate the specific experiences of mental health students; the requirement to teach the students in small, discipline-specific groups; the need for adequate support and supervision to prevent them becoming disillusioned; and a suggestion that small, supervised, client caseloads should be utilised to increase the confidence and skills of students.
The aim of this study was explained in a preliminary meeting, following which a group of 14 mental health branch students agreed to participate. Approval was given by the university’s research committee. Consent of willingness to participate in the study was obtained from the students and recorded at the beginning of each focus group. This group reflected appropriate gender, age, ethnic, social and practice experience differences. Accordingly, sampling procedures were based on the concepts of judgement sampling, whereby individuals who have distinct qualifications as informants comprise the sample and purposive sampling, which gathers people with similar experiences but who offer different perspectives (Marshall and Gretchen, 1999; Burgess, 1991).
The researcher utilised a focus group strategy to follow the same group throughout their three-year programme. This type of qualitative research is concerned with understanding how it feels to be ‘a certain person in a certain situation’ by capturing the essence of the experience being studied (Hammersley and Atkinson, 1994). Focus groups are an established means of data generation and use group interactions to allow the exploration of views and experience by capitalising on communication between members (Morgan, 1997). This extended engagement of participants improves the validity of the data and accurately elicits differing perspectives (Kruegar and Casey, 2000).
The focus group met on a yearly basis at key junctures within the programme. These meetings took place six weeks after starting the course, six weeks following completion of the foundation programme and during the third year when the cohort were in the branch programme. Each focus group was conducted in a suitably quiet room on the university campus and lasted approximately 90 minutes. The meetings were tape-recorded and a semi-structured approach was adopted. Therefore, the questions utilised as the basis for exploration were founded on the students’ perceptions of their experiences of the PBL process and related themes that emerged within each focus group. Content analysis was used to interpret and categorise the data.
Content analysis of the data highlighted a number of issues regarding the use of PBL, described below.
Adjustment to PBL
PBL, while founded on an established framework and process, usually requires students to be self-directing early in their programme. To support this approach, academic staff are expected to adopt the role of facilitator to promote learner enquiry. Details of this strategy were discussed at interview and sent with pre-course literature. The learners acknowledged that PBL was being utilised in response to the documented limitations of the former Project 2000 nurse education curriculum and could enhance their learning in the longer term. However, most still considered this approach to be in conflict with their anticipated views of the course learning and teaching strategies. Accordingly, the students found adjustment to PBL quite problematic, mainly because of reservations about the effectiveness of this approach:
‘We are aware that we don’t know where to start and we don’t know where to start looking. I don’t know. Maybe next year, when we’ve been in placements, we’ll know where the books are. We’ll know a bit more about it. We can go and find out. At the moment, we just don’t know where to start.’
The impact on secondment status
Some students developed alternative ways of dealing with what they perceived to be a lack of direct teaching input by asking qualified nurses and experienced learners for support. Such an activity could be considered to be part of the enquiry process. Therefore, it is difficult to determine if their concern about the perceived lack of knowledge was a result of their relative inexperience at such an early stage of the course, if it was an expected part of PBL (to promote enquiry) or if it demonstrated a limitation of PBL.
Nevertheless, the students did express some concern with regard to whether PBL would provide an effective foundation for the three years of learning on which they had just embarked. They stated that if PBL did not prove effective then this could result in them being discontinued from the programme. This would subsequently impact on their employment with the mental health trusts (a number of the group were seconded to the course) and therefore they would lose their job as a result. Reservations about PBL were also expressed regarding the effectiveness of the overall strategy and the stages within the process:
‘I thought coming to university and studying the nursing course, I was going to be learning and doing new things. But it doesn’t seem that way, not at the moment anyway.’
‘I think if we’re struggling at access level, where are we going to be at level three? I mean that’s heavy going at that level.’
The application in clinical practice
The students’ reservations with regard to the effectiveness of PBL were also initially transferred to their placements. This was particularly noticeable in the expectation to identify learning needs and to actively pursue these needs. It is interesting to note, however, that if this was the case then the mentors had been well prepared for their role. The students also expressed concern about achieving study time while in practice and difficulties with the course expectation to integrate their academic work within the placement experience. While they found some mentors to be ‘unsure about learning contracts and the expectations of PBL’ they encountered no hostility or problems with their status of ‘new type of nursing student’, with many practitioners describing the new programme as ‘back to the old days’ (referring to pre-Project 2000 courses):
‘My mentor asked me: ‘What are you supposed to do?’ And if I don’t say what I am supposed to do, then I just sit. I ended up sitting. And how am I supposed to know what I am supposed to do? I expected to be directed by my mentor.’
The students’ reflective critique
There was no major change of view among the students at the second focus group and they still expressed concern about the expectations of the PBL approach, the responsibilities associated with being self-directed and their level of knowledge for the stage of the course. Similarly, the framework utilised for the PBL approach was considered to be quite restrictive with more flexibility required in its application. In this respect the students emphasised the importance of the PBL facilitator’s role in enabling the transition to independence and self-motivated enquiry.
Reflecting on the common foundation programme (CFP), the learners considered this to be rather biased towards the adult nursing branch, evidenced within the wording of the learning outcomes, the focus of lectures and the scenarios used as triggers for learning. While the general statements made about PBL did continue to reflect difficulties, personal motives to embrace the aims of this learning philosophy were also evident:
‘In some lectures none of us understand it. And a few weeks later, when we ask, they’ll say: ‘We’ve taught you about that. You should know.’ ‘
‘Others (students) say it is up to us. What we put in we get out.’
By the third focus group, the students took a more reflective perspective of PBL and their own personal development. These views were influenced by adjustments that had been made to the branch programme to achieve greater consistency in the time the students spent in practice and to adopt a more integrative (with mental health practice) assignment process. The changes were made in response to student evaluation and resulted in a marginally different course structure and assessment schedule to that used within the CFP. This required further adaptation on the part of the students but served to reinforce their views regarding the perceived limitations of PBL.
A few of the group members had also developed study patterns that evolved around family commitments. Some of the reservations expressed still related to PBL but also demonstrated personal anxiety about the implications of the course stage they had now reached and the consequences of failing assignments. Difficulty was continuing to be experienced in attaining the skill level required to fully utilise IT. Those students who did embrace this found associated benefits, including enhanced access to tutorial staff:
‘I still like to be taught. The easiest way to learn is for someone to tell me about it. More lectures would be good.’
Overall it seemed that the students were starting to adjust and possibly accept PBL and there were hints that this strategy was beginning to positively influence their approach to learning and study. They were now able to critique PBL as a concept and suggest ways in which this might be enhanced. The influence of the CFP in establishing a framework and modus operandi for the three years was again mentioned, with the need for enhanced interdisciplinary and PBL group working being cited.
The success of the group was correlated with not losing too many members on their journey to becoming registered mental health nurses (students either leaving or being discontinued from the course). Their suggestion to use PBL as just one of a range of learning strategies, or at a later stage, had started to be adopted within pathways at other education centres:
‘PBL is really difficult to deal with initially. It shouldn’t be used in first year. (It should be used in the) second or third because you need a knowledge base (structured lectures) first. Once you know, it is a bit easier.’
‘I have benefited. I picked up a lot from group discussion. The practice and theory is making more sense and the course is coming together.’
The students also described their increasing confidence and development in practice. This was often expressed in terms of role differences to Project 2000 students and in practical skills developed, particularly drug administration and care planning. Spending longer in clinical placements, which allowed the students to become more involved in care processes, enhanced this level of confidence. Some difficulties were still expressed by students, regarding the use of PBL principles in practice. Interestingly, the students often developed their own mutual support mechanisms to overcome these difficulties:
‘I still haven’t learnt as much as I would have liked but then we recall something and you realise we must have done.’
‘Sometimes they forget you’re a student and they expect too much. It takes time.’
PBL has been described in the literature as a student-centred approach to learning and teaching. Such strategies have been utilised within nursing curricula for many years (Burns and Glen, 2000). The documented benefits of these learning strategies include enabling students to become responsible, self-aware, motivated and more analytical in the learning process (Price, 2003). This requires considerable adjustment on the part of the student, but once this change has been made it results in the aforementioned benefits.
The participants in this study experienced difficulty both initially and during the first year in adjusting to the self-directing requirement of the PBL approach. Personal anxiety was also expressed about the consequences of failing assignments. Similarly, these problems were transferred to their placement experiences and were particularly noticeable in the expectation to actively contribute to the development of learning contracts. Such difficulties are often associated with student-centred approaches. Some students claimed they had to develop alternative ways of dealing with what they perceived to be a lack of direct teaching input by asking qualified nurses and experienced learners for support. However, it could be suggested that such a response is in fact a part of the enquiry process.
Owing to the very nature of PBL it is difficult to put a time frame on how long the transition process will take (Biley, 1999). Clearly, there will be individual differences and the development of analytical skills will evolve. Motivation to adjust to adult learning approaches does also arise from the heightening of personal anxiety. This can be used positively but can cause the doubting of personal confidence and negative self-examination. Such a phenomenon seems to have occurred among the mental health students, with the learners blaming the limitations of PBL as potentially impacting on their secondment and employment status.
It is positive to note that the learners did not encounter any hostility or problems with their status of ‘new type of nursing student’. This was in contrast to the early experiences of students when Project 2000 was first introduced, with many students encountering hostility owing to the revised course expectations and new academic culture (White, 1995). Indeed, many practitioners described the new programme as ‘back to the old days’ and referred to the popular 1982 (and earlier) syllabus that created the widespread use of the social and psychological models of care, the uniqueness of psychiatric nursing and the importance of the therapeutic relationship (Cutcliffe, 2003).
In some ways the adjustment difficulties of this particular group are surprising, given contemporary mental health practice emphasis on the need for personal growth and active problem solving (Nolan, 2000). However, the students’ assertions of sustained difficulty in making the transition to PBL seems to suggest a limitation of this approach. An alternative strategy would be to utilise PBL as just one of a range of student-centred approaches to learning rather than adopting this as the only course-learning strategy. Alternatively, the students’ suggestion of using PBL later in the course after they have adapted to the programme is worthy of further consideration in the future.
By the third focus group the students were making the transition to fully embrace PBL and there was evidence that this strategy was beginning to positively influence their approach to learning and study. The learners were now able to critique PBL as a concept and, based on their experiences, suggest ways in which this might be enhanced. The students also took a more reflective viewpoint of PBL and were able to identify their own increasing confidence and development in practice. These were often expressed in terms of role differences to Project 2000 students and in the practical, therapeutic and care planning skills that were developed.
It could be suggested that the small sample size used in this study limits the findings to this particular group of students. However, the difficulties that have been identified and the students’ subsequent adjustment to PBL seem to have general relevance for mental health nursing students.
As broad themes based on previous research were explored within the focus groups, a different perspective on the use of PBL has been elicited. This includes the students’ initial adjustment to PBL, the impact of PBL on their secondment status, the application of PBL in clinical practice and the students’ reflective critique of PBL. Some of these themes require further exploration and evaluation. Therefore, it would be useful to meet with the students again approximately one year after their qualification. Such a focus group would ask the participants to critically reflect on the adjustment problems again and to review the application of PBL within their practice roles.
The pre-registration nursing programmes founded on the requirements, standards and learning outcomes of the UKCC, ENB and DH have now been reviewed and revalidated. This review incorporated the views of students, in particular what became evident was the need to carefully plan the students’ initial placement experiences and provide extra support at this stage. In addition, mentor preparation on the use of PBL in practice needs to be extended to ensure flexibility is available in the PBL process. It should be balanced with formal student support and courses must be planned to incorporate the learning needs of all discipline groups. This final point is fundamental when developing frameworks for new interprofessional programmes.
- This article has been double-blind peer-reviewed.
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