for pbl cases

VickyRN, MSN, DNP, RN · Sep 20, 2004

Welcome to the board, Frank!

Do you mean problem-based learning?

Perhaps this article will help:

http://www.highbeam.com/library/doc3.asp?DOCID=1G1:92448179&num=11&ctrlInfo=Round8%3AProd%3ASR%3AResult&ao=

Promoting, applying, and evaluating problem-based learning in the undergraduate nursing curriculum.

Source: Nursing Education Perspectives

Date: 9/1/2002

Author: Money, Barbara J.

ABSTRACT Since its development in the 1960s, problem-based learning (PBL) has become increasingly prominent in nursing education. In 1998, Samford University received a grant from the PEW Charitable Trusts to promote, apply, and evaluate PBL in its undergraduate curriculum over three years. Nursing faculty approached this project with tenacity and enthusiasm. PBL has become integrated into the nursing curriculum in clinical and nonclinical courses. Descriptions of its implementation in specific courses are provided, and its usefulness in nursing education is discussed. Evaluations and test scores indicate that PBL has had a positive effect on the students and exceeded the educational outcomes anticipated by the faculty.

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THE QUEST TO NURTURE THE WHOLE STUDENT HAS led faculty at Samford University to explore engaging forms of teaching and learning. A thorough investigation into a variety of teaching methods revealed that problem-based learning (PBL) promotes active learning in students and corresponds with the school's mission. Centered on a problem, query, or puzzle that the learner wishes to solve (1), problem-based learning can be used as a curricular approach or as a teaching strategy.

The educational philosophy supporting PBL is the belief that students should be actively involved in the process of learning. PBL originated at McMaster University, Hamilton, Ontario, Canada, in the late 1960s (2) and has since spread internationally (3). It was developed to improve medical education by moving from a subject and lecture-based curriculum to an interdisciplinary one guided by "real-life" problems. Students act as professionals and challenge problems, just as they would in a real clinical situation, with insufficient information and a need to determine possible solutions by a given deadline (4). Problems are set up to encourage students to probe deeply, think rigorously, and develop lifelong learning skills. In nursing education, PBL is now recognized as a promising way of providing nurses with the characteristics they need for contemporary practice (5).

In January 1998, Samford University received a $1 million grant from the PEW Charitable Trusts Foundation to promote, apply, and evaluate problem-based learning. Samford was the first university to undertake such a major commitment to the undergraduate implementation of PBL. This article describes the implementation of PBL in the School of Nursing curriculum.

Review of the Literature For nurse educators, the goal has always been to develop initiatives and innovations that will prepare graduates for practice. In today's rapidly changing health care environment, with its growing dependence on technology and genetic research, nurses must demonstrate competence in several key areas, including critical thinking, communication, and assessment and technical skills. There is also a new emphasis on evidence-based practice. Professional nurses are accountable for providing research-based evidence for nursing interventions, evidence supporting the cost-effectiveness of nursing practice, and the promotion of improved patient outcomes for a diverse and aging population (6-12).

Faculty must help future nurse professionals become self-directed learners and knowledgeable participants in evidence-based practice. Along with the development of excellent skills, nurses must understand the research process and know how to use data to influence others.

The predominant educational theory used to be the "bucket theory." Information stored in the student's head would be regurgitated upon request (13). However, the ability to retain knowledge does not necessarily produce a competent practitioner (2). Information presented exclusively in a lecture format is of limited use and unlikely to assist students in acquiring self-directed learning skills.

The recent nursing literature has called for a curriculum revolution, stressing innovative teaching strategies that allow the socialization of the student as a colleague and professional (14,15). Students are expected to understand and retain information based on relationships to preexisting structures and information (13,16). They become socialized by valuing learning, acquiring and accepting information from various sources, critically questioning others, and obtaining feedback on learning outcomes through faculty, self, and peer evaluations (17).

The ability to apply basic science concepts and content to the practice setting is difficult for students. Heliker noted that nursing students have particular difficulty with pharmacological concepts (17). Kimmel observed similar findings in a pathophysiology course for second-year medical students and determined that a lecture format is insufficient for presenting such content (18).

Studies have indicated that students in PBL courses are better able to explain disease concepts and processes (19,20). While numerous research studies promoting the efficacy of PBL in graduate and medical education have been conducted (3,19), there has been little research related to the efficacy of PBL in nursing curricula.

White and colleagues (21) conducted a qualitative and quantitative evaluation of 24 RN students who participated in a one-year course using PBL. Students responded to open-ended questions on a survey and participated in focus groups. In addition, changes in their learning styles before and after PBL classes were examined. These researchers described PBL as a teaching/learning strategy that empowers the student to be an active participant in the classroom setting and concluded that PBL can inject a renewed enthusiasm into the classroom environment.

Getting Started The faculty of the Ida V. Moffett School of Nursing have consistently sought to prepare professional, caring practitioners who possess effective clinical reasoning and communication skills. The goal has been to make course material relevant to the student by associating content to real-life situations.

When redesigning courses for the PBL format, the goal was to improve learning outcomes in several key areas--critical thinking, self-directed learning, communication, interdisciplinary collaboration, the ability to work and contribute within a team, and the development of lifelong learning skills. A three-member team reviewed how PBL has been implemented in nursing and other disciplines in the United States, Australia, and Canada. Files of relevant information from numerous articles, Internet sites, and e-mail communications with experienced faculty were compiled. A master list of all accumulated information was obtained.

To determine where PBL would best fit into the Samford curriculum and where it would be best to begin, the team attended a PBL workshop conducted by nursing experts. During the summer of 1998, a panel of nursing experts from several universities and varying backgrounds conducted a workshop for the entire faculty.

The team took several steps in conjunction with preparing the first course and subsequent courses. It developed a PBL Case Development Worksheet to guide in determining which content would be best implemented through PBL. It reviewed and revised problems that had been developed by other nursing faculty. And, it revised the course syllabus to include information on PBL.

The team also obtained permission to modify a tool developed by Amos and White to assess PBL skills (22). This tool measures the student in relation to the quality of submitted work--its organization, timelines, accuracy of content/process, and application to practice--and it evaluates participation in activities, critiques, discussions, and applications of learning. Each student participates in the evaluation of every other member of the group.

Getting started with PBL requires alterations in the class room environment and the establishment of a suitable library. A book company representative, informed about the PBL grant and the need for an up-to-date reference library, secured a large donation of books for the School of Nursing. Donations to the PBL library have continued over the last three years.

The PBL library is specific to nursing and housed on the same floor as the classrooms in the School of Nursing. It includes textbooks from all nursing specialties, such as pediatrics and medical-surgical, and books specific to such content areas as pharmacology and pathophysiology. Journals for the past two years are also available.

To adapt traditional classroom space for teaching with PBL, six round tables and 24 to 30 chairs were requested for two small rooms in the School of Nursing. A nursing laboratory was redesigned to include two round tables with chairs, a PBL library, a worktable, a computer center with Internet access, and a color printer. Upon approval by the dean, the lab and classrooms were redesigned, and the PBL library was completed in 1999.

Course Descriptions No additional faculty were needed to teach the first or subsequent courses with PBL components. To date, several courses in the curriculum have implemented PBL, and the majority are in the process of incorporating PBL experiences and activities.

The first course to incorporate PBL was community health. The courses that followed include management, pathophysiology, statistics, research, adult health I, child-rearing family, and the RN mobility courses. Four required PBL courses are described in detail.

Community health nursing This is a six-hour, senior-level clinical course in the baccalaureate and post-RN mobility program. Community health nursing is offered in the final semester of the senior year, meeting for a three-hour classroom session and nine hours of clinical practice. PBL had been found to be effective in a similar community health course (23).

Planning entailed reviewing the overall objectives and content of the course, identifying content that would be appropriate for the PBL format, and developing modules for in-class PBL activities. Tutorial guides with key components and solutions for each problem were developed for the facilitators for each module.

All modules are based on real-life situations. Examples include carbon monoxide poisoning of a family, an outbreak of a food-borne illness, a bacterial infection, and a natural disaster. Students work on the modules during class time in groups of four to six. Each group works on a different problem and presents its findings to the other members of the class. Problems are designed so that they can be completed during one or two class sessions. (See Sidebar 1 for examples of PBL problems for community health and other courses.)

Community health and management: Senior PBL project A semester-long PBL community-management capstone project is conducted in a health care or community agency. Faculty in the community health program and the management course--a six-hour clinical taught the last semester of the senior year--work collaboratively, establishing criteria to meet each course's expected competencies. The PBL project grade is equivalent to 40 percent of the total grade in both courses. The individual student's test scores, written papers, and clinical journals constitute the remainder of the grade.

Groups of students spend 12 weeks immersed in a problem identified by managers or administrators in a community organization. In essence, the agency becomes a community for these students. Ample time is allotted in both classes for conducting computer and library searches and obtaining statistical data from the Centers for Disease Control and Prevention. The students are expected to determine possible solutions to the problem and make recommendations.

Facilitators from both courses meet weekly with the groups to assess progress and offer feedback. At the end of the term, each PBL group completes a formal poster presentation and an oral defense of the report. Each agency receives a copy of the written paper.

Pathophysiology This four-hour course, offered the first semester of the junior year, covers a wide range of content, from cellular injury and responses to organ system dysfunction. A series of lectures is organized into several units and accompanied by diverse audiovisual enhancements. Each unit contains or is followed by a PBL problem module, with the expectation that students will synthesize the associated content and concepts.

Modules are derived from real-life situations, historical documents, and projected clinical experiences. Each module focuses on the unit's key concepts. Examples include an infant with fever and dehydration, a child with fatigue secondary to sickle cell anemia, an adult with altering levels of consciousness, and several adults suffering from multiple disorders secondary to space travel.

The problems move from simple to complex. Completion of the problem can take several days or more than a month. Fifty percent of the student's evaluation is based on PBL and group performance. Evaluation is accomplished via the four PBL modules, self- and peer assessment, concept mapping, oral presentations, and multiple choice and essay exams. Use of PBL and concept mapping in pathophysiology provides an avenue for nursing students to practice their critical thinking, assessment, and communication skills.

Statistics for Health Care Professionals This three-hour course is organized into two units, the first an overview emphasizing descriptive statistics and introducing inferential statistics. The second unit considers situations requiring basic inferential strategies. Core content is presented in brief lectures accompanied by audiovisual enhancements. Computer practice is accomplished using analysis programs such as Microsoft Excel and SPSS software. PBL activities constitute 50 percent of the grade.

PBL activities are derived from real-life situations, clinical nursing problems, historical documents, and the accessibility of real data. The PBL weekly activities correspond to specific course topics throughout the semester. An in-depth, long-term project reinforces the student's ability to identify and read statistics as well as present descriptive statistics in a variety of graphical formats.

Evaluation and Outcomes The modified tool developed by Amos and White (22) serves as an ongoing evaluation tool for PBL activities in all courses. Quantitative individual evaluations are obtained from short answer, multiple choice, and essay examinations, end-of-course evaluations, and weekly PBL modules. Qualitative evaluations of individuals and groups are obtained through projects, papers, Web page development, concept maps, peer evaluations, self-evaluations, and semester-long problems.

Student evaluations are obtained quantitatively through end-of-course evaluations. For the evaluation reported on here, scores were above 4.5 on a 5-point scale in three courses. Students were also evaluated at the beginning and end of the last semester of the curriculum using a comprehensive exam developed by Health Education Systems, Inc. (HESI). This exam has 160 multiple choice critical thinking items similar to those on the national licensure exam (24). Overall, HESI results revealed increases in all areas and significant increases in the probability scores from the pretest to the posttest (p = .001) (25).

From many points of view, the introduction of PBL in the Samford School of Nursing can be described as highly successful. NCLEX results have been outstanding, with three recent 100 percent pass rates. Graduates are obtaining jobs that have often required experience, in areas such as emergency departments, intensive care, and community health. They are also being admitted to graduate schools directly from the undergraduate program. Employer and clinical agency satisfaction is high.

In the last four years, over 40 students have presented their PBL work at statewide nursing meetings, and 25 presented at the National Conference for Undergraduate Research. In the fall of 2000, Samford was host to a multidisciplinary international PBL conference attended by more than 600 persons. Through the PBL process, the School of Nursing is constantly examining teaching practices and exploring ways to reach desired educational outcomes in an unconventional, creative manner.

Key Words Baccalaureate Education--Community Health Nursing--Curriculum Development--Problem-based Learning--Teaching Methods

Sidebar 1.

Examples of Problem-Based Learning

COMMUNITY HEALTH In recent years, there has been an increase worldwide in reported cases of infection from contaminated water or food. Reported cases of E. coli 0-157 in both the United States and Japan are on the increase, due, in part, to inadequate food preparation or unclean, unsanitary water conditions. Young children are particularly susceptible to this infection and may suffer debilitating and expensive complications, such as acute renal failure.

This two-part problem was designed to assist nursing students to develop an understanding of the impact this infection has on the health and resources of individuals, families, and communities.

Part 1 Baby JW is an 18-month-old Hispanic toddler who is brought into the urban clinic by his parents. The parents report that they were vacationing in the city when JW developed a 24-hour episode of bloody diarrhea and stomach pains. The child is lethargic and crying.

Students break into groups and discuss possible problems and rationales, determining questions and possible treatments based upon current information. After 30 minutes, the groups return to the class to present their findings. After discussion, the students are given Part 2 and sent out in small groups again. Now students may use the telephone, library, their textbooks, other reading material, and the Internet. The students have o week to conduct research and are asked to bring relevant information to the next class.

Part 2 JW is confirmed to have E. coli 0-157. He will have to be hospitalized at a local children's hospital. The family reports that they were at a local water park when JW became ill. JW's parents have no insurance and the father works as a waiter at a Mexican restaurant 30 miles outside the city. The mother speaks no English.

Each group meets at the beginning of class with the faculty facilitator to discuss their findings and resources. They discuss possible solutions, treatment options, and other problems that may arise based on their findings. Faculty offer feedback and explore options that may not have been considered. Each group then returns to the class and presents their findings to the class.

SEMESTER-LONG COMMUNITY-MANAGEMENT PROBLEMS

Example 1 Your group is to study the problem of change in the assigned emergency department (ED). In two weeks there will be a complete transition of all ED physicians as well as charting methods and nursing notes. You have been asked to evaluate this transition in relation to its effect on quality of patient care, staff, and physician satisfaction.

Example 2 Your group has been asked to study two medical-surgical units that are experiencing the highest nursing staff turnover rate in the hospital. You must determine factors influencing retention on these units.

Example 3 In your local hospital, the unit manager of an oncology/medical unit evaluated the incidence of catheter-related bloodstream infection present on her unit over the last six months. She found the rate on her unit to be higher than the national average. Determine if this rate is, in fact, higher than the national average. Determine why this may be happening on this unit.

STATISTICS (In-Class Five-Week Problem) In the 1860s, Florence Nightingale studied infant and maternal mortality rates in England. Over the decades, there has been a great deal of debate about the relationship between birth place and infant and maternal mortality rates.

The purpose of this problem assignment is to allow the students to explore a variety of health care statistical databases, compile statistics, make comparisons, and present findings in a graphic format, answering the question, "What are the issues, and have we made progress since Nightingale's time?"

Five students are given four weeks, with 30-45 minutes allotted in each class (which meets once weekly), to work on this problem. At the end of the fifth week, the students present their findings to the class in a PowerPoint presentation.

VickyRN, MSN, DNP, RN · Sep 20, 2004

Here's another article:

Preparing Problem Solvers for the 21st Century through Problem-Based Learning.

College Teaching; 3/22/2000; Edens, Kellah M.

Problem-based learning (PBL) is a constructivist teaching model that helps students learn to think and to solve problems--skills too frequently not acquired in traditional university course work. This approach is implemented widely in medical school education. It uses an authentic, complex problem as the impetus for learning and fosters the acquisition of both disciplinary knowledge and problem-solving skills. Professors introduce a confusing, open-ended problem, like those faced in the workplace and in everyday life, which leads students to an investigation from which subject matter content and instruction emerge.

That approach contrasts with the usual teaching practice of presenting concepts in a lecture format followed by well-structured problems. PBL, which engages students in developing a context-rich knowledge base and the skills for applying that knowledge, can be applied in a wide variety of classroom settings and fields. This article provides an overview of the PBL model, its application to college courses, specific examples of PBL currently used in several fields of study, and a brief description of a PBL cycle in an undergraduate educational psychology course.

Anchoring Learning to an Authentic Context

We professors face a continuing challenge to teach pre-professionals to learn to think and solve problems like professionals in their field and to link theory with practice. Calls for reform in higher education have grown as legislatures and national professional associations question the quality of classroom experiences (Braxton, Eimers, and Bayer 1996), which in some cases are based on teaching practices of the 1900s. Students are not well prepared for the job market and cannot perform decision-making and problem-solving tasks associated with their profession.

Thus, we need to examine and redefine the academic learning environment. A new approach emphasizes the students' active role in constructing knowledge and students' actively engaging in inquiry and problem solving, typically in a collaborative framework. Learning is anchored to real-world or authentic contexts--students learn how to apply inert knowledge to real problems.

Those authentic contexts are vital to the many fields that require specific professional training. That, of course, is a dramatic shift from the traditional view of cognitive development resulting from one's reception of knowledge transmitted by the instructor. Problem-based learning holds promise as a teaching tool that provides for the acquisition of problem-solving skills to meet the challenges of the twenty-first-century workplace.

The PBL Model

The PBL model was developed and introduced in response to demands to better prepare physicians for professional practice (see Barrows and Tamblyn 1980), and for the last thirty years it has been used increasingly in medical schools around the world. Similar to recent assertions of inadequate professional preparation in the sciences, business, and teacher education, criticisms of medical education included emphasis on memorization, fragmented course work, and a deficiency in providing graduates with hypothetico-deductive reasoning and problem-solving skills for lifelong learning (Barrows and Tamblyn 1980).

In a PBL environment, students take on the active role of problem solvers. A key element is the student's ownership of the problem and the natural way the problem unfolds as students lead an investigation from which subject matter content and instruction emerge. The instructor assumes the role of a facilitator, serving as a cognitive coach by monitoring, probing, and challenging students. Flexibility is a keystone of the PBL model. For example, PBL may be the entire focus of a course, or it may occur within the context of a unit of study. The length of time varies, depending on the scope of the particular problem.

Although teachers have developed several variations, of course, the core of the PBL model consists of the following characteristics (Barrows 1996): (a) Learning is student centered; (b) learning occurs in small groups; © teachers are facilitators or guides; (d) problems form the organizing focus and stimulus for learning; (e) problems are a vehicle for the development of problem-solving skills; and (f) new information is acquired though self-directed learning. Although the process is cyclical, it has at least three distinct phases.

Phase 1. Problem Development

The PBL cycle begins when learners meet an ill-structured problem, presented through a scenario or situation that directly involves students. Appropriate problems are difficult to define, ambiguous, are likely to change, and have many possible solutions (Stepien and Pyke 1997). Good problems share several important features (Allen 1996). First, the problem engages students in relevant settings, thus facilitating a connection between theory and application. Good problems also are open-ended and sometimes controversial, which challenges students to make justifications and demonstrate thinking skills. They should also be complex enough so that students must work together and rely on each other to solve them (Allen 1996).

Possibilities are derived from real problems, events (current and past), or a topic, theme, or central issue from the curriculum. Newspapers, magazines, movies, television, the Internet, and daily life all can trigger the idea for a good problem. The most effective learning cycles occur when the problem is developed with a particular group of students, the instructor, the available resources, and community in mind. Although problems that have been successfully implemented in several subjects are available online (see table 1 for examples) and in several recent publications (see Allen and Duch 1998; Wilkerson and Gijselaers 1996), to my knowledge, there are no reference books with a comprehensive listing of problems by subject area or field.

After the selection process, the instructor should fully conceptualize the problem by brainstorming about possible linkages to course content. Listing or mapping all possibilities is important, because although the process is student-directed, first the instructor needs to anticipate certain paths students may take in order to steer them in useful directions that support higher order thinking and problem-solving skills.

Next, the problem situation should be developed and student roles established. To reflect the "messiness" and complexity of real problems, the scenario/situation should also include problems that grow and change, with no simple, formulaic solution. For example, the problem is likely to have a time or financial constraint that will affect its solution.

The professor should anticipate the flow of activity during all PBL stages: beginning, inquiry, investigation, and problem solution and debriefing, so that he or she can effectively coach the students (Stepien and Pyke 1997). Authentic assessments to obtain evidence about students' understanding of the issues in the problem and their reasoning skills also need to be developed. In contrast to traditional tests, the assessments should mirror tasks performed by real problem solvers placed in the same situation as the students. Moreover, assessments should involve higher order thinking and reasoning skills, include individual and group products, and encourage self-assessment (Stepien and Pyke 1997).

Phase 2. Initiation of PBL Events, Inquiry, and Investigation

Problem-based learning begins when students write the problem definition statement, build hypotheses that launch an investigation, and list what they already know and what they need to know in order to solve it. Listing What we know, What we need to know, and What we need to do is an important component of the process, in which the content that needs to be learned to solve the problem and the possible sources of that new knowledge are identified through group discussion. During this phase, as students gather and share information, the What we need to know board is updated. Need to know information is shifted to What we know as new information is acquired. Students identify other needed information as the problem evolves, and it is added to the What we need to know list. Assessment of information-seeking strategies and problem-solving logic is embedded within this phase.

Phase 3. Problem Solution

Students generate possible solutions, examine their "fit," and propose the most appropriate one. A final performance assessment and debriefing also occur during this phase to help students build their understanding of concepts and skills encountered during the problem cycle.

How Does PBL Look in the Classroom?

Although PBL is being used more frequently, generally speaking, it is relatively new in undergraduate courses. PBL has been integrated, however, into college introductory science courses (Allen, Duch, and Groh 1996), chemical engineering (Woods 1996), art history (Miller 1996), educational psychology (Pyke and Pourchot 1997), leadership education (Bridges and Hallinger 1996), criminal justice (Hans 1999), nutrition and dietetics (Lieux 1996), and a masters program in business education (Stimson and Milter 1996).

PBL also has been implemented in other contexts, such as K-12 public schools, in programs designed for gifted students as well as regular students (see Stepien and Gallagher 1993; Dods 1997). Specific examples of PBL in these settings are far ranging, but our focus here is on undergraduates. In all instances, students encounter a problem that is a typically "messy" situation mirroring those confronted in professional practice. The problems are presented in different formats, including videotapes, live simulations, and written cases. Table 1 provides a brief overview of problems that have been successfully investigated by undergraduates in several fields of study.

Table 1.-Sample Problems in Undergraduate Courses

Subject/field Problem Title Related concept(s)

Leadership "Safety and Student violence and

Education Order" gangs

(Bridges and Parent and community

Hallinger relations

1996)

Medicine "Unkind Rates of Cesarean

Cuts" (Rangachari sections

1996) Laprasopic surgery

Negative publicity

Criminal "Crime and Case Negotiation

Justice Punishment"

(Hans 1999)(a)

Subject/field Student role

Physics Electrical

wiring planner

Physics John Henry

Biology NSF Panel

member (grant

reviewer)

Biology An interested

stakeholder (e.g.,

parents of

embryo, clinic

physician)

Chemistry Heat storage

system consultant

Art History Consultant for a

major motion

picture

Business Advisor to CEO

of company

Medicine Chief of surgery

Criminal One of four

Justice roles: prosecutor,

victim, defense

attorney, or

defendant

Subject/field Scenario/situation

Physics You are good friends with Sharon and Stanley who

are building their dream house and need your help

in determination how many circuits the house

needs to be safe. You need to construct a wiring

plan for their mode of living.

Physics Lt. John Henry investigates a serious automobile

accident at the intersection of Main St. and

State St. The investigation is critical because

there may be a fatality involved. Students are

given a sketch of the accident scene and more

information as the problem unfolds.

Biology You must review a proposal based on J.H. Martin's

ideas about counteracting global warming by dumping

iron into the ocean waters off Antartica. You

are concerned that the application hasn't

addressed the possible ecological impact of

seeding a 60 sq. kilometer plot south of the

Galapagos Islands. You must justify your

decision to fund or not to fund.

Biology A segment on NBC's Dateline and articles from

the New York Times report incidences of a mix

at two fertility clinics. As the problem unfolds,

student address issues about the error in embryo

implantation procedures at one of the clinics.

Chemistry You are invited to spend the weekend at a

cousin's new energy-efficient cabin in the

Poconos, which is constructed with solar cells

and collectors for generating electricity and

heating their home. They are still deciding the

best way to trap and store energy for use at

night and on cloudy days, and need advice on

several ideas, including a magazine article

on using "phase-change materials" to store energy.

Leadership You must address complex issues of student

Education violence and gangs in the form of several

unanticipated disruptions, instigated by

individuals who have been trained to assume

specific roles. These interruptions include

a student sent to the office for misbehavior,

the student's parent, a newspaper reporter

with questions about the incident, and a

subsequent negative article.

Medicine Dr. Waldo Pepper, chief of surgery, must respond

to an article in a tabloid weekly titled

"Region Surgeons Scalpel-Happy, Study Finds,"

which suggests that the hospital's surgeons are

incompetent and greedy.

PBL in Educational Psychology: A Case Study

The following PBL episode, Is Educational TV Educational? was designed for students in a small introductory honors class in educational psychology for aspiring teachers (n = 16). PBL phases include the design phase, specific learning events, critical events, and embedded assessments. The cycle described below lasted approximately eight weeks. A brief summary of each phase highlights the cyclical and generative nature of PBL.

Problem Development

The idea for the problem sprang from a newspaper article that I read during the beginning of the semester. It concerned the approaching deadline for the three major national television networks to comply with an FCC mandate to carry three hours per week of educational programming for viewers under 16. The problem for the students, who were retained as educational consultants, was to determine if, and if so, in what specific ways, so-called educational shows are truly educational for children and adolescents.

During the design phase, I analyzed the problem to determine what content from educational psychology would be pertinent and to identify specific issues, topics, and concepts that might be seen by students as "need to know" content. Related issues, topics, concepts, and skills embedded in the context of the problem included:

how children learn, learning processes, instructional design, cognitive

developmental stages, language development, social-emotional development,

individual differences, information processing, perception, attention,

motivation, reinforcement, "educational" criteria, age appropriateness,

moral development, multiculturalism, diversity, media literacy, media

ethics, cultural influences, effects of advertising, evaluation approaches,

research methods, data collection and analysis methodology, reporting

findings, conclusions, implications and recommendations, collaborative

work, and decision making.

I made plans for twists to the problem to occur through subsequent memoranda that would put constraints on the solution and provide subtle hints to alternative paths. I also designed assessments of subject content and of problem-solving processes to occur during and at the conclusion of the PBL activity.

PBL Events, Inquiry, and Investigation

I introduced the problem with a brief memorandum requesting that the students serve as consultant teams to determine the extent to which the major networks were in compliance with the federal regulations for educational programs. Attached to the memo was a copy of a newspaper article indicating that the regulation would take effect beginning the following Saturday. The article also contained the exact wording of the federal regulation. The memorandum stated that the class should divide into three consultant teams, yet no provisions were made for how the teams should be selected or what each team should investigate. The memo was intentionally vague and ambiguous.

Next, students began to define the problem and make decisions about forming teams, goals, and active steps to reach those goals. Many questions were generated during that phase, and my role as cognitive coach was key to the resolution of many questions and to movement toward problem solution. In this role, I modeled and coached by posing challenging questions, monitoring and adjusting levels of challenge, managing group dynamics, and keeping the process moving by encouraging active decision making and searching for meaning on the part of the students (Finkle and Torp 1994). In this student-directed learning environment, decisions about the appropriate steps toward a solution were in their hands.

The students made important decisions during this phase: Three teams were formed to study the educational showings on each of the major networks--ABC, CBS, and NBC. Each team functioned independently of the other two and determined the roles of its members, the questions asked about the programs, and methodology used. Within each team, members assumed specific tasks, including multiple observations of programs and collection of data, and were accountable to their team for completion of tasks.

Students used a variety of resources--ranging from ABC's Web home page and other Internet sources, to journal articles, textbooks, and knowledgeable individuals--to investigate educational programming, evaluation methods, developmental characteristics, and other relevant concepts. Each team eventually designed an instrument based on formulated "Educational TV Criteria" to obtain systematic data on an individual show's educational merit.

After the students had been immersed in the problem for five weeks, they received a memo from a professor who taught the same course inviting them to share their findings from the investigation with his class. After they accepted the invitation, another memo followed that specified the date and the amount of time allotted for their presentation. The amount of time for them to convey their findings was limited to one hour, a realistic constraint that forced them to think about their priorities.

Problem Solution

Each team compiled a complete report. In a panel discussion, each team reported to the other teams so that questions could be fielded across teams. During this session, questions reflected higher level thinking, focusing on explanations and justification for decisions and conclusions. Examples of questions included, "How did you choose the indicators for language development?" and "What was your reasoning for having three team members view the same show?"

The reports of the teams differed substantially. One team, for example, surveyed a group of adolescents to determine their important issues, and they examined adolescent TV shows for their portrayal of social-emotional developmental issues. In addition to many observations and ratings by team members about delineated criteria, another team observed children as they actually viewed one of the programs and conducted interviews with them.

All of the teams participated in the final performance assessment; that is, they made a formal presentation to the other class, and two of the teams also presented their findings to yet another class. One of the teams decided to send their report to the manager of the local ABC affiliate station.

Evaluating PBL: Identifying Promises and Pitfalls

Two meta-evaluations (Albanese and Mitchell 1993; Vernon and Blake 1993) investigating the effectiveness of PBL in the medical school environment have supported PBL as a viable approach, finding that students may show better clinical problem-solving skills and that they are stimulated and motivated by PBL as a method. A significant difference between traditional curriculum students and PBL students on conventional tests of knowledge, however, has not been found, despite observations by faculty and self-reports by PBL students of cognitive and behavioral differences.

Moreover, evaluations of problem-based learning in several disciplines suggest that although PBL shows promise, difficulties also may be encountered. PBL is a radical change from traditional course work and tends to increase faculty and student workloads, so that monitoring of time is necessary.

Students, however, generally report satisfaction with the method (Kingsland 1996). They sometimes perceived that they were "learning less" because they seem to be covering less material than students in a lecture class. But they also perceived that they developed more problem-solving skills and were more active and interested students (Lieux 1996). Other findings indicate that compared to other students, PBL students have more positive perceptions of the learning environment, more confidence with problem-solving skills, more positive attitudes toward lifetime learning, and better processing skills (Woods 1996).

An evaluation of the PBL episode Is Educational TV Educational? was conducted at the end of Phase 3 and provided evidence about its benefits and difficulties consistent with previous findings. A written summative evaluation and focus group discussion at the end of the semester and the final written and performance assessment showed distinct benefits of PBL congruent with findings from evaluations in other fields.

At the conclusion of the cycle (Phase 3), students clearly were actively engaged in "constructing their own meaning" and in directing their own learning as shown by their choice to present to another class and to contact a local TV station. On their end evaluation, the majority of the students gave a high rating to the PBL activity as an effective instructional tool.

With the scale, 1 = strongly disagree to 5 = strongly agree, students strongly agreed with the following statements: "In the problem-based learning cycle, I learned to apply problem-solving strategies to the kinds of problems that I expect to encounter in real life" (M = 4.6); "The activity provided a means for useful peer interactions that facilitated problem solution" (M = 4.9); "I would like to use PBL approach as an instructional strategy when I teach" (M = 4.2).

Students' open-ended responses about the most useful aspects of PBL included "feeling responsible for my own learning, getting to know other classmates, improvement of problem-solving capabilities"; "Just when we thought that we understood what we were doing, we were faced with more problems--this was very realistic and representative of real life"; "The opportunity to work in a team where everyone pulled their own weight and to create your own definition of what to do;" and "The flexibility in structure, we were forced to work through it ourselves." The overall grade awarded by students for the PBL unit was a B+.

The final written and performance assessment indicated that application of specific concepts relevant to cognitive, language, and social and emotional developmental characteristics was more prevalent in the PBL environment than in a more traditional assignment assessed during a previous semester. Students also agreed, or somewhat agreed, that "PBL should be used for other courses at the college level" (M = 3.8).

The final written and performance assessments of content and problem-solving and decision-making skills indicated that students effectively learned relevant concepts and used problem-solving skills adeptly. Peer evaluations of problem-solving skills also provided a way for me to assess individual team members' use of these higher level skills when assessing the team as a whole. From my perspective, designing and participating in the PBL episode in the role of cognitive coach was stimulating, particularly when it was apparent that students truly were constructing their own individual meaning rather than acquiring meaning as defined by the instructor.

We did encounter several pitfalls, however, and those were reflected in the students' evaluations. Some features inherent in the PBL process (e.g., an ill-structured problem that is intentionally ambiguous and changing) created difficulties. When the problem was initially introduced, several students asked me to "show us exactly what you want us to do" or asked for "more structure and guidance." One open-ended response to the evaluation indicated that "the assignment was not clear."

Throughout the PBL cycle, students sometimes were frustrated with the generative nature of the PBL process; information and resources were often needed on short notice. For example, when the teams were preparing for the presentation to another class, a last-minute decision to include film clips of several of the shows necessitated a scramble to obtain appropriate taped segments and to learn how to use the equipment provided in the large lecture hall. It was impossible to plan for many events within the cycle. Although that was frustrating, it was certainly typical of modern life.

At the end of the semester, students acknowledged the discomfort created by the ambiguity--"We had no idea if we were on the right track"--but generally were satisfied with the end of the episode and problem resolution. The majority of students strongly agreed or agreed with the statement "I prefer a structured assignment--that is, I like to know exactly what to do, when to do it, and how the final product should look" (M = 4.6).

In the focus group discussion, several students commented that structured assignments were much easier and quicker to complete than the PBL task, and because of other course work obligations and time constraints, they preferred structured tasks. The open-endedness and ambiguity of PBL threatened this class of honors students' sense of security concerning "knowing how to play the academic game." Nevertheless, the majority indicated that their motivation level and sense of accomplishment were high for the PBL task.

Problems also were present from my perspective, for, like the students, I confronted ambiguity. For example, I was not always certain that the students were really understanding and benefiting from the PBL process. It sometimes was difficult to refrain from divulging information or dispensing advice. The syllabus could not be planned in advance and followed in a straightforward manner. In contrast to "keeping on schedule," class sessions evolved at an unpredictable pace. My experience was consistent with reports from faculty in other fields about PBL's taking more time and about uncertainty about the pace of activities, both of which may diminish teachers' enthusiasm.

PBL as a Constructivist Curricular Tool

We should examine new curricular tools as college courses shift from being teacher-centered to student-centered, with the teacher's role changing "from sage-on-the-stage to the guide-by-the-side" (Stimson and Milter 1996, 40). PBL appears to be a viable tool for reconstructing college course work because it models contemporary views of complex learning as contextualized in an authentic setting. PBL provides opportunities for students to make a direct link between theory and practice, between "knowing that" and "knowing how." Students learn how to apply inert knowledge to problems that they are likely to encounter in their professional career.

PBL offers flexibility in its implementation, although important common features exist, such as student-centered learning with the teacher as facilitator and an ill-structured problem serving as the initial stimulus and framework for learning. The three phases of the PBL model serve as a guide or a map that we teachers can creatively adapt in many fields and classroom settings. We can design activities to fit the needs or resource and space constraints of a particular course.

For the full potential of PBL to be realized, however, dialogue among faculty involved is essential so that initial difficulties do not suppress enthusiasm. Moreover, research is needed on PBL processes and on specific learning outcomes in diverse undergraduate settings, so that its merit as an instructional tool and its benefits in stimulating life-long learning can be evaluated.

VickyRN, MSN, DNP, RN · Sep 20, 2004

Here's another one:

Teaching on the front lines: Using the Internet and problem-based learning to enhance classroom teaching

Source: Holistic Nursing Practice

Date: 1/1/2002

Author: McGrath, Debra

Holistic Nursing Practice

01-01-2002

Teaching on the front lines: Using the Internet and problem-based learning to enhance classroom teaching

Byline: McGrath, Debra

Volume: 16

Number: 2

ISSN: 08879311

Publication Date: 01-01-2002

Page: 5

Type: Periodical

Language: English

Working on the front lines in health care at the bedsides, in the primary and specialty care offices and in the community with patients; and in health care education, teaching graduate and undergraduate students, is more challenging today than ever before. Shifts in reimbursement from fee for service to a managed care model, increasingly informed consumers, and increasingly complex health problems create a tension that often leaves the advanced practice nurse (APN) managing conflicting human and business interests. Nurse educators must prepare providers to function in that world.

Using Problem-Based Learning (PBL) to provide APN students with experiences that will supply them with rehearsal will better prepare them to function in today's primary care environment. Providing PBL using the Internet is the next logical step and may insure that this type of experience is more widely available to students. Key words: active learning framework, case-based learning, distance learning, problem-based learning

INTRODUCTION

Nurses and nurse educators find themselves on the front lines every day in a variety of settings and in a variety of roles. Working on the front lines is more challenging than ever before, because dramatic changes in the health care landscape have shifted primary care from a fee-for-service payment model toward a managed-care model. Managing costs has become more important than ever, yet people are living longer with increasingly complex health problems. Moreover, consumers come to the health care provider more informed and more aware of what they want from the health care system. The resulting tension often leaves the nurse in the primary care setting with the task of managing conflicting human and business interests that are often fundamentally irreconcilable.

These changes require changes in the way that nurses are taught. New approaches to nursing education are needed to prepare our graduates for their work on the front lines.

BACKGROUND

The first change is the need to teach efficiency as well as efficacy in the primary care setting. In the current climate of managed care, "standardization" of care is a common mandate. No longer is the insurer content to let the provider decide what is optimal treatment for a patient. Care giving must meet the criteria of a "gold standard" of care, as described by the managed care organization. Optimizing care is a laudable goal, but for practitioners who must see four patients per hour and minimize the use of diagnostic tests and specialist care, this goal seems more and more unattainable. Although clinical guidelines for many diseases, such as diabetes and asthma, are published by the Agency for Healthcare Research and Quality (http://www.ahrq.gov), they are often not followed. In this context, efficiency becomes not just good business but good patient care. Hence, the ability to work efficiently and efficaciously ought to be incorporated into APN curricula.

Another change that is demanded by the managed care organization climate is the need to learn evidence-based practice. It is no longer acceptable to make treatment decisions based on personal experience with a disease process. Providers must look to the evidence to judge the effectiveness of a medical therapy. It is well documented that providers are overutilizing therapies (such as antibiotics) that often do not improve outcome and underutilizing other therapies that have been proven to enhance outcome (such as the use of steroid inhalers for patients with asthma). Training programs, therefore, need to place more emphasis on the scientific foundations of modern patient care.

A welcome change for nurses in the new world of health care is that patients are playing a larger role in the plan of care than ever before. Managed care organizations have identified that patients have rights as consumers of care. The effective utilization of resources and collaboration with patients and their families must not be lost as nurses move into the advanced practice role.

Increasingly, patients are presenting in primary care practices with preformed ideas about their conditions and disease processes and about what treatment they would like prescribed. New sources of information are available to health consumers through pharmaceutical advertising on television, in the print media, and on the Internet, where health information Web sites are springing up everywhere and scrolling banners on Web sites offer unsolicited information. Patients are often unaware of the biases that determine what information is delivered from these sources, and it becomes the job of the health care provider to help patients interpret the information and apply it to their circumstances.

Creating partnerships with patients and removing barriers to care are hallmarks of advanced practice nursing. Success in the modern health care environment requires the provider to work quicker and to ensure that each patient is receiving comprehensive, holistic, patient-centered care that is based on the latest available research.

PROBLEM-BASED LEARNING

Today's health care providers must be responsive, critical thinkers; be comfortable with evidence-based practice; have a heightened awareness of resource allocation; and use and possess superior interpersonal skills.1 Achieving these challenging objectives requires educational activities that allow practice and rehearsal so that the learner gains confidence and competence. The challenge for nurse educators is to develop course work that provides for effective learning and the opportunities for practice and rehearsal in the classroom. Coles and Holms describe this process well:

Effective learning is concerned with learners attempting to establish more and more complex networks of knowledge, rather than storing information that is discrete and separate entities. High-quality learning, the basis of problem solving and professional thinking, results from "pulling things together," that is by constantly structuring and restructuring what we know into more and more elaborate knowledge.2 Problem-based curricula offer one way to provide effective learning, practice, and rehearsal time. Many schools of nursing are exploring the implementation of a problembased curriculum out of a desire to increase the relevance of the classroom; to teach lifelong learning and critical thinking skills; and to create an active, stimulating learning experience. In a PBL curriculum, knowledge acquisition and the process through which that knowledge is applied are equally important. In fact, one can argue that the process is more important than the content, because it has a more lasting impact on the learner. Applying the same process of evidence-based and patient-centered care in each patient encounter will ensure comprehensive assessment, accurate diagnosis, and an appropriate treatment plan that is sensitive to resources and the individual wishes of the patient.

By definition, PBL is a method of group learning that uses true-to-life problems as a stimulus for students to develop problemsolving skills and to acquire domain knowledge.' PBL uses a set of domainspecific simulated patient cases to serve as a starting point to explore a problem. A case is chosen for its complexity and opportunities to explore various aspects of real-life patient encounters. PBL has several characteristics that distinguish it from the knowledge-- banking style of education:

* The emphasis is on a student-centered approach and the development of lifelong learning.

* Faculty act as facilitators and not as dispensers of facts and information.

* Students work through a problem or case as they choose; faculty do not prescribe steps.

* Domain-specific knowledge is acquired through solving the problem.

* Process is as important as (or more important than) content.

Advantages of PBL

PBL has many advantages. Morales-Mann and Kaitell3 report that, in a synthesis of all evaluative research published by Vernon and Blake in 1993,4 implementation of PBL in the classroom led to increases in student mood, faculty attitudes, class attendance, academic process, and a sense of humanism. Albanese and Mitchell,' as reported by Morales-Mann and Kaitell,3 state that, in a medical school where PBL was implemented, students felt more nurtured and faculty and students felt more satisfied with their teaching-learning experiences. In general, students graduating from a PBL curriculum perform at least as well in standardized testing and in clinical circumstances as do their counterparts who graduate from a conventional medical or nursing curriculum.1 Self-directed learning, engagement in the learning process, and levels of satisfaction are higher for students completing a PBL curriculum.

In the past, APNs have typically been taught using the banking style of education and the apprentice model in the clinical setting. In such learning environments, students tend to be passive to the learning process and may become easily frustrated, disengage, and ultimately lose their appetites for learning. In addition, they are at risk of acquiring the same inadequate lifelong learning and practice habits of the "master" with whom they apprentice. This model of educating health care professionals can perpetuate bad habits and stifle the hunger for knowledge that is naturally found in the novice.

Although the change to PBL is often initially resisted by faculty and students, it is a superior method for teaching the skills needed for the APN. Students must acquire knowledge in a specific domain or specialty and apply that knowledge in a clinical situation with real patients. In today's world, becoming an APN must include domain knowledge acquisition and development of skills in critical thinking, diagnostic reasoning, and clinical decision making, complemented by skills in speaking, writing, and lifelong learning. PBL is the optimal method to encourage the development of these skills.

Disadvantages of PBL

PBL does have some disadvantages. The first impediment to implementing PBL is student resistance. Most students enrolled in APN programs today have been educated using the banking style of education for their entire educational experience. PBL requires students to approach learning with entirely different attitudes. In the PBL model, the instructor is no longer the purveyor of information. Students must seek information from themselves, others in their group, and outside resources-not just the instructor. In PBL, the acquisition of new knowledge comes through working through real-life situations; deciding what questions need to be asked, the relative importance of those questions, and how to formulate those questions so that one gets at the desired information; answering those questions; then deciding what new questions need to be asked and answered. Ultimately, the student must come to a solution to the problem and learn through success or failure. Overcoming years of banking education in learners is a challenge and one that instructors who use this method will continue to confront.

The next hurdle to overcome is faculty resistance. Faculty members are most comfortable being the "sage on the stage," as opposed to the "guide on the side," and students reinforce this preferred role. Faculty must learn to allow students to engage in trial and error, sometimes exploring what may seem like fruitless pursuits. PBL instructors understand that students may learn as much or more from their mistakes as from their successes. Faculty must be open to a more incremental approach to learning, where one exercise in knowledge acquisition leads to and builds on the next. Although PBL is structured and learning objectives are identified, instructors who embrace PBL become comfortable with the unexpected and are open to learning that occurs in a different way and at a higher level than it does in the banking style of instruction. In PBL, facts are not simply delivered but rather analyzed and processed by the learner into information and ultimately applied to real-life situations; hence, the end product is larger than the sum of the parts.

The final hurdle to overcome for full implementation of PBL is limited resources. The problem-based teaching/learning model requires much lower faculty/student ratios than does banking education, where one instructor provides lectures to perhaps up to 100 students. One article identified an ideal faculty/student ratio of closer to 1 faculty member per 9 or 10 students. Where one faculty member was sufficient in the banking style, 10 are required in the PBL model. Given the current economic constraints and scarcity of resources in higher education, it is no wonder that administrators are not quick to adopt this model.

The hurdles of student resistance and faculty discomfort are difficult hurdles to overcome. It is best to find a few faculty members who are interested in teaching with a unique method and to start slowly. Enthusiastic faculty will be very effective in encouraging students. One article identified the need for a workshop or retreat prior to beginning PBL that targets both faculty and students. Faculty will be more enthusiastic if they feel confident, and students will respond better to an enthusiastic and confident faculty member. Often, it takes only one course to convert faculty and students to a new way of thinking about learning. As with all challenging experiments, the first steps away from the status quo are the most difficult and the most disconcerting to those involved.

Web-enhancing a course

One approach dealing with the economic and time constraints of PBL is to utilize the Internet as a resource. The strategy behind this approach is to transfer the knowledge acquisition part of a course to a Web-based format so that the students' face-to-face time with the instructor is freed for openended, exploratory, problem-solving discussions about patient cases.

Faculty can post lecture information to a Web site for students to view from anywhere, at any time. PowerPoint lecture presentations can be delivered by the Internet with voiceover narrative so that students get the most out of the experience. Faculty can also create HTML handouts from the PowerPoint program that can be uploaded to the Web site so that students can print the handout before viewing the lecture presentation.

Self-assessment quizzes that relate to the lecture presentation can be added to the Web site. These quizzes can be taken either before or after the student views the lecture material or may be taken both before and after. This approach often demonstrates to students their strengths and weaknesses and directs study habits.

As an added resource, faculty can search the Internet for valuable Web sites. A powerful search engine can be found at http:// http://www.google.com that often yields valuable and rich resources. The same criteria for inclusion that are applied to traditional information sources (textbooks and journals) should be applied to Web sites. Web sites should meet the following criteria: 5

* Stated criteria for inclusion of information (Is the information applicable to the course objective?)

* Authority of author or creator (Is this source scholarly, substantive news or of general interest, popular, sensational?)

* Comparability with related sources

* Stability of information (Is the source reliable and is information regularly updated?)

* Appropriateness of format (Is it easy to read?)

* Software/hardware/multimedia requirements (Are the technological requirements attainable?)

Students should also be taught how to search the Internet for resources and how to evaluate a Web site, and should be encouraged to provide URLs (Uniform Resource Locators, which are Web site addresses) that could be useful to the class.

In this model, face-to-face classroom time is used to present real clinical problems in the form of case studies and to work through them as though they were real patient encounters. As students advance through clinical didactic courses, the cases should increase in complexity, requiring the learner to think beyond the actual diagnosis and to consider the complexities of social issues, barriers to care, adherence to care, and ethical considerations. These kinds of discussion are time-consuming, but in Web-enhanced courses, class time has been preserved by use of the Web for the less complex types of instruction.

A case should be considered for incorporation in the course if it meets at least one of the following criteria:

* Supplements the students' real patient encounters by filling clinical experience gaps (eg, common presentations of uncommon problems or uncommon presentations of common problems)

* Illustrates a method or approach to a problem

* Provides for evaluation of knowledge acquisition

* Meets the goals of the course

* Meets the needs of instructor and/or students

Cases that meet these criteria will be relevant to the course and to what students may encounter in real life. It is best if cases come from real clinical experience or represent a composite of several real-life experiences. The active learning framework

A cutting-edge solution to delivering casebased education on the World Wide Web is now being tested in a prototype version. Known as the Active Learning Framework (ALF), this system uses agent technology to present didactic content in the form of a case and to evaluate student's knowledge acquisition, clinical decision making, and diagnostic reasoning skills simultaneously. The ALF is a highly interactive, Web-based method for delivering case studies to students. It was developed by the National Medical Knowledge Bank project that was funded from 1995 to 2000 by the National Institutes of Standards and Technology as a part of the Advanced Technology Program. ALF grew out of a joint venture between Millennium Health Solutions, NCR-HITC division and MCP-Hahnemann University College of Nursing and Health Professions.6

The ALF has several unique qualities. It uses intelligent agent technology to provide students with self-directed learning experiences guided by an online "tutor." The agents "communicate" with each other during a learning experience and use a series of content databases to bring activities to the screen, depending on how the student is moving through the case. Students are frequently asked to present evidence from the information they are gathering about the patient, and agents offer feedback on their data gathering and decision making. In this process, students are allowed to navigate the case at will and to learn from the experience of suboptimal data collection or premature decision making while benefiting from formative feedback as they work. They receive summative evaluation data at case completion.

The ALF evaluates the student on the process of diagnostic reasoning and clinical decision making, in addition to evaluating the student's knowledge of the subject matter. Evaluation is accomplished using an algorithm that awards students with points when they correctly identify key concepts and removes points when they miss key concepts. For example, in a case about fatigue where the patient has hypothyroidism, the student is expected to ask key questions in the "History of the Present Illness" section. If those questions are included, the student gains mastery points. If those questions are excluded, mastery points are lost or not added. Similarly, if the student selects all questions to be asked and views all patient responses in a single step, mastery points on process are lost or not added. If questions are selected, responses viewed, and the subsequent question is then chosen, mastery points on process are added to the overall mastery score. Students can also gain mastery points through responses to learning activities that ask the students to identify evidence as they move through the cases. Mastery points are added if students correctly identify evidence that supports or refutes any of the differential diagnoses they have chosen for that particular case.

Students using ALF are not pointed in any particular direction when they begin a case. This open-ended format, which does not cue the student to the correct approach, permits an unbiased evaluation of a student's diagnostic reasoning and clinical decisionmaking skills. It also provides opportunity for feedback to correct weakness in those skills. Both the online tutor and the student report that is available upon completion of a case provide feedback. In the current prototype of ALF, students are evaluated in the following areas:

* Acquiring an investigative focus

* Developing a hypothesis

* Evaluating the problem

* Identifying the problem

* Constructing a plan of action

* Using an efficient strategy

Flexibility is another asset of the ALF. Course directors can change the case, the learning activities, and the evaluation process to satisfy the objectives for a course. In addition, ALF is scalable to large numbers of users. It can be accessed from a home computer, using a regular dialup modem. It does require a Pentium III or comparable computer, Internet Explorer version 5.0, and RealPlayer version 6.0 or higher. Both of these software applications are available in free, downloadable versions. High-speed Internet access does enhance ALF by making page downloads faster and smoother, but it is not essential, particularly if the student works during low Internet usage times.

ALF is currently being pilot tested by nurse practitioner and medical students in its prototype version. It is populated with six cases surrounding the same chief complaint of fatigue. ALF is also the core application for two grant submissions-one that modifies the framework for patient education for children with asthma and one that adds an information access module to the framework for the education of medical professionals, nurse practitioners, physicians, and physician assistants.

SUMMARY

The 21st century holds many challenges for health care providers and health professional educators. Providers will continue to be faced with more complex patients, shrinking financial resources, and more exciting options for treatment. Old problems will be solved, and new ones will arise. Despite the many changes that will fragment patient care, one of the greatest challenges will be to preserve the holistic view and see the patient as a person with responsibilities, vulnerabilities, and qualities that go beyond his or her illness.

The greatest asset for a student and, ultimately, the patients that he or she will care for is to develop problem-solving skills in the safety and security of the classroom that can then be applied to the real clinical environment. In the end, the real winners are the patients, their families, and the public. Providers who can think on their feet and engage in evidence-based practice will ultimately improve patient care and decrease costs.

Faculty will be called upon to set the standard for quality patient care during the educational process. PBL requires more up-front investment of resources from the academic institutions but in the end produces a professional who has learned and applied problemsolving skills. Using the Internet and intelligent agent technology will allow more students the opportunity to study in a PBL curriculum.

longwzf · Sep 20, 2004

vicky thank u for ur kindness and i believe what u gave here will help me understand pbl much better.im reading this artical and finding more.

xiexie

wang zhi fang from china

VickyRN, MSN, DNP, RN · Sep 20, 2004

You're very welcome! :)