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Running head: PROBLEM-BASED LEARNING ENHANCING CRITICAL THINKING 1

Problem-Based Learning Enhancing Critical Thinking Skills in Nursing Students

Antoinette McNeil, BSN, RN, CCRN

Washington Adventist University

Theoretical Foundations of Teaching and Learning in Nursing - Hybrid

NUED 525

D. Paxson Barker, PhD, MS, RN

June 27, 2013

PROBLEM-BASED LEARNING ENHANCING CRITICAL THINKING 2

TABLE OF CONTENTS

ABSTRACT 3

INTRODUCTION 4

BACKGROUND 4

ANALYSIS OF THEORY 9

PROS AND CONS 11

IMPLICATONS FOR NURSING 12

REFERENCES 13


Abstract

Nursing education is about promoting critical thinking, which is a process of reflection which

involves more than analyzing facts (Bradshaw & Lowenstein, 2011) .There has been many

discussions regarding how best to teach critical thinking to nursing students. Lecturing has been

the main teaching method in nursing schools. Since learners today are of the technological era

educators are looking for innovated teaching methods that will stimulate thinking and keep

students engaged. Problem-based learning (PBL) is a methodology that engages the learners in a

vigorous quest to seek data to accurately solve a simulated real-life problem (Neimer, Pfendt, &

Gers, 2010). Critical thinking is a skill that nursing students must develop when practicing at the

bedside upon completion of their nursing program. Much research has been done on PBL. The

question asked is Problem-based learning effective in teaching critical thinking skills to nursing

students?


Problem-Based Learning Enhancing Critical Thinking Skills in Nursing Students

Critical thinking skills are a must for nursing students. Curriculums are developed to

help nursing students develop critical thinking skills which are vital to their practice. Many

classes that are taught in nursing school are lecture based, which many students find non-

stimulating. Problem-based learning (PBL) is an innovative method to help medical and nursing

students develop critical thinking skills. PBL allows basic science knowledge to be relevant to

students’ learning needs by relating it to a clinical problem (Callis et al., 2010). Problem-based

learning is an educational process where learning is centered on problems and not discrete

subject-related courses (Bradshaw & Lowenstein, 2011). Students who have participated in PBL

have found it to be stimulating and enjoyable.

In PBL, students are responsible for critical analysis of real-life clinical problems

(Neimer et al., 2010). If the PBL environment is well designed then, effective problems will peak

the students interest and motivate them to probe for a deeper understanding of the concepts being

taught (Neimer et al., 2010). For scenarios to be effective they will require students to make

decisions or judgments based on facts, information, logic, and /or rationalization (Neimer et al.,

2010).

Background

Problem-based learning was started in the late 1960s at McMaster University in Ontario,

Canada (Badeau, 2010). Howard Barrows developed this self-directed model to improve

education in the school of medicine (Badeau, 2010). Problem-based learning was developed to

progress medical education by moving from a subject and lecture based curriculum to an

interdisciplinary one guided by ‘real-life’ problems (Badeau, 2010).


There are five components to PBL and they are: problem-based, student-centered,

reiterative, small group and facilitation (Badeau, 2010). Problem-based learning is characterized

by small group self directed learning which is facilitated by faculty tutors using well thought-out

real-life problems (Badeau, 2010). In 2009 the Institute of Medicine wanted a move from

instructor-driven learning methods to student-focused learner driven method (Chunta &

Katrancha, 2010). In 2010 the American Nurses Credentialing Center supported an accreditation

philosophy which states that learning activities are a component of professional development and

should be based on national standards of educational design (Chunta & Katrancha, 2010).

Critical thinking has been widely accepted as being associated with the provision of

quality care. It has been defined by the American Philosophical Association Project as

purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation and

deduction and is founded on the conceptual criteria on which judgment is based (Ozturk, Muslu,

& Dicle, 2008). Keeping this in mind, developing critical thinking skills in nursing is essential in

establishing a scientific foundation for the profession, creating a discipline in which truth is

sought and implemented, where the use of theoretical perspectives are increasingly being tested

and utilized are important to nursing (Ozturk et al., 2008).

Nursing education programs are being pressured today to produce newly licensed nurses

who are fully prepared for entry into the clinical practice. The clinical setting is where students

learn to apply classroom theory to real-life clinical scenarios and to develop problem-solving and

decision-making strategies (critical thinking skills) which will eventually carry over into their

professional practice (Carrega & Byrne, 2010). Problem-based learning is an innovative method

that is used in the classroom to help nursing students develop critical thinking skills.


Problem-based learning is seen as a highly structured and learning-centered teaching

method. Problem-based learning features include the following: problems are the starting point

for learning; real-life problems are used; thinking must be done in terms of problems and not

disciplines; oriented knowledge is acquired; learning is student initiated; and there is an

emphasis on group discussions (Lin, Lu, Chung, & Yang, 2010). In PBL tutors are used to help

facilitate learning of the students.

In PBL self-directed learning (SDL) is a major component of this learning method. Self-

directed learning has been defined as a process in which individuals take the initiative with or

without the assistance of others, to diagnose their learning needs, create learning goals, identify

human and material resources for learning, choose and implement appropriate learning strategies

and finally to evaluate learning outcomes (Kocaman, Dicle, & Ugur, 2009). Increasing students’

self-directed learning skills will help them to effectively obtain and use knowledge and help

them prepare for their professional careers (Kocaman et al., 2009).

Critical thinking is a core competency that has been identified by nursing education that

is essential for individuals to become self-directed learners (Badeau, 2010). It has been noted

that inductive and deductive thinking are part of the critical thinking process (Badeau, 2010).

Teaching and learning strategies that are used to achieve critical thinking are SDL activities,

interactive discussions, role playing, PBL, mastery learning, case studies, clinical rounds,

journaling and reflective practice groups (Badeau, 2010).

It has been determined that a important part of SDL and critical thinking is reflection

(Badeau, 2010). The purpose of reflection is to attach understanding and meaning to a nurse’s

practice of care and it also challenges nurses to think critically regarding their nursing practice,

to identify gap in their practice, and to seek change based on current evidence (Badeau, 2010).


Problem-based learning allows the nurse the skills to be reflective and a self-directed

practitioner.

There are studies exploring the outcomes of PBL curriculums and self-directed learning

(SDL) in nursing students. One study looked at self-directed learning readiness (SDLR) of

students enrolled in a problem-based curriculum. This particular study was conducted at nursing

school in Turkey in which a PBL curriculum had been used in this school for at least 8 years

(Kocaman et al., 2009). The PBL curriculum had the following characteristics: PBL was done in

groups of 6-8 students and was facilitated by a faculty tutor; the program was divided into a

series of 2 week modules with five tutorial session devoted to explore patient scenarios;

integrated into each module was communication, ethical issues, critical thinking, assessment, and

technical skills; person, health, environment, nursing were major concepts in this curriculum;

initially the focus was on health promotion and the role of nursing enhancing health of

individuals and as student progressed then the focus was on caring for the ill patient; and finally

student evaluation which looked at nursing knowledge and skills, problem solving ability, SDL,

and group participation (Kocaman et al., 2009).

Ozturk et al., 2008) explored the effect of problem-based and traditional education on

senior nursing students’ critical thinking dispositions. This study was also done in Turkey

looking at the traditional method of teaching which was lecturing and being noninteractive. This

method relied memorization and limited incentive to stimulate student’s thinking process

(Ozturk et al., 2008). In the PBL method, students worked with problems that resulted from real-

live situations. These students worked in small groups identifying learning goals and engaging in

self-study only to return to discuss and apply the new learning (Ozturk et al., 2008). The

California critical thinking disposition inventory which was developed by Facione and Facione


was used which looked at open-mindedness, analyticity, systematicity, critical thinking and self-

confidence, inquisitiveness, and maturity (Ozturk et al., 2008).

Yuan, Williams, & Fan, 2008) studied student’s perceptions of the change in critical

thinking; the California Critical Thinking Dispositions Inventory (CCTDI), The California

Critical Thinking Skills Test (CCTST) and The Watson-Glaser Critical Thinking Appraisal

(WGCTA) were used in this study (Yuan, Williams, & Fan, 2008). This study examined the

student’s responses regarding truth-seeking, open-mindedness, analyticity, systematicity,

confidence, inquisitiveness and maturity (Yuan et al., 2008).

The CCTST is standardized multiple choice test that has 34 questions targeting critical

thinking skills which include analysis, evaluation, inference, deductive reasoning, and inductive

reasoning (Yuan et al., 2008). The other test used was WGCTA which is an assessment tool used

to measure the foundation critical thinking skills which include inference, recognition of

assumptions, deduction, interpretations and evaluation of arguments (Yuan et al., 2008).

Lin et al., 2010 compared the educational results of peer tutor problem-based learning

and conventional teaching in nursing ethics education. In this study seniors in the Department of

Nursing at Taipei Medical University were used. The peer tutor PBL method was applied and

tools used in this study were teaching plans, the nursing ethical discrimination ability scale and

the learning satisfaction survey (Lin et al., 2010). Three teaching plans were used for PBL that

were formulated by a expert panel of seven and each plan included learning objectives, a clinical

case exhibiting ethical dilemmas and guidelines for peer tutors (Lin et al., 2010).

This research was divided into three stages and seven steps. Stage I: was the designing

the curricula for peer tutor PBL and traditional teaching; designing the nursing ethical

discrimination ability scale; and designing the learning satisfaction survey. Stage II: the pre-test


completion of the nursing ethical discrimination ability scale was done which the student took

before class began and the conduction of the educational intervention. This course was taught

over an eight week period which for one group involved lectures followed by question and

answer sessions and discussions. The other group was PBL and the groups were small with 7-8

people and each PBL case was discussed and studied for two weeks. The PBL discussions were

comprised of the five elements of PBL. Stage III: was the administration of the nursing ethical

discrimination ability test and the learning satisfaction survey. Both of these test were

administered at the end of the course (Lin et al., 2010).

Analysis of Theory

In the first study described there were significant differences in the mean SDLR scores of

nursing student based on their year in the nursing program and would increase at each time point

(Kocaman et al., 2009). It was noted that the SDLR mean scores were lower the first year and

fourth year scores were higher than other years (Kocaman et al., 2009). Students described how

important facilitators were to guiding and support the students’ during the transformation period

in becoming effective and satisfied self-directed learners (Kocaman et al., 2009)

When the student’s entered their final year the program changed to where they spent the

majority of their time in clinical practice and one day/week facilitating discussions on clinical

situations of their choosing. With the emphasis on self-responsibility and independence in the

clinical practice contributed to increase score of SDLR in student their final year (Kocaman et

al., 2009).

In the second study that was looked at found that the critical thinking disposition scores

were higher in the students enrolled in the PBL model than those were in the traditional model

school (Ozturk et al., 2008). When looking at open-mindedness and truth-seeking the PBL


students again scored higher than the traditional students but when it came to analyticity,

systematicity, inquisitiveness, and self-confidence there wasn’t a difference between the two

schools (Ozturk et al., 2008).

In the third study looked at revealed that the CCTST and CCTDI that were administered

revealed that students critical thinking increased. The students’ critical thinking skills and

dispositions increased after using PBL for one year (Yuan et al., 2008). When both PBL and

traditional students were enrolled in a two semester course, their pretest revealed there were no

differences in their critical thinking but after taking the two semester’s course the PBL students

critical thinking was greatly increased over the traditional students (Yuan et al., 2008). However,

the WGCTA students at the beginning scores improved but later at the end of the course students

who had scores dropped at the end of the program (Yuan et al., 2008). Another test was

administered to student and that revealed that PBL improved students’ meta-cognition and

problem solving process but not their critical thinking skills (Yuan et al., 2008).

The fourth study revealed that there was a significant difference in nursing ethical

discrimination ability scores between the PBL and traditional educational groups (Lin et al.,

2010). The results of the pre versus the post-intervention test showed a significantly difference

from each other between the PBL and the traditional group, which revealed that both groups had

been impacted in learning by the respective teaching methods (Lin et al., 2010). The PBL groups

scored higher on questions regarding self-motivated learning, moral self cultivation, and

understanding of nursing ethics issues, critical thinking and intellectual stimulation (Lin et al.,

2010).

Students who participated in the PBL experiment expressed a higher satisfaction with

self-motivated learning and critical thinking as compared to the traditional learning group (Lin et


al., 2010). The traditional method of teaching which is lecturing focuses on conveying facts

where as PBL helps to promote self-learning and critical thinking (Lin et al., 2010).

Pros and Cons

As a facilitator of learning, one must look at the pros and cons of any innovated teaching

methods for learning to determine if it is the best method to teach a concept. When it comes to

PBL there are advantages to it such as PBL scenarios encourage communication of nurses by

promoting learning and asking questions (Chunta & Katrancha, 2010). Problem-based learning

scenarios supports the principle of adult learning and promotes independent, self-directed

learning skills that foster critical thinking (Chunta & Katrancha, 2010).

The statement that PBL provides a more enjoyable and stimulating learning environment

for students as well as faculty is one of the strongest arguments in favor of PBL (Badeau, 2010).

Students and faculty had the feeling of being more rewarded and nurtured in PBL than the

traditional learning method of lectures (Badeau, 2010). Research reveals that PBL is more

effective than the traditional approach due to it facilitates a greater student motivation, breadth of

interest, learning satisfaction, confidence with clinical functioning, knowledge achievement and

the use of various learning resources and self-directed work (Badeau, 2010). Problem-based

learning methodology engages problem-focused self-directed learning providing opportunities

for learners to enhance their critical thinking, critical analysis, reflection and problem solving

skills (Badeau, 2010)

The disadvantages to PBL is that educators have a difficult time letting go of the

traditional role of an educator and to encourage learners to play a more active role in their

learning (Chunta & Katrancha, 2010). Developing scenarios is time consuming especially if they


are to be good real-life scenarios. An educator must be clinically competent in developing

scenarios and to be able to facilitate the PBL process (Badeau, 2010).

Another disadvantage is the fear that knowledge gaps and reinforcement of wrong

information may exist (Badeau, 2010). It is thought that students may not attain a comprehensive

knowledge base of the problem or issue being studied (Badeau, 2010).

Implication for Nursing

Problem-based learning does promote students to self-directed, increase open-

mindedness and truth-seeking scores. It has been demonstrated that students in PBL curriculums

report higher satisfaction with self-motivated learning and critical thinking ability as compared to

students in the traditional curriculums (Lin et al., 2010). Problem-based learning works best

when students are engaged while working through a case (Wiznia, Korom, Marzuk, Safdieh, &

Grafstein, 2012). It is imperative that students prepare to discuss the learning objectives of the

case presented, yes it may require work outside of the classroom for the student but it improves

and leads to a better understanding and retention of concepts being taught (Wiznia et al., 2012).

While research on PBL in nursing education is still in its infancy there is still a need for

more research to clarify the effects of PBL on critical thinking development within the nursing

educational context (Yuan et al., 2008). More research is needed but the research that is present

in the literature reveals that PBL is an innovated method that educators need to take time to learn

to that they can be the facilitators of learning that they are.


References

Badeau, K. A. (2010, November/December). Problem-Based Learning An Educational Method

for Nurses in Clinical Practice. Journal For Nurses in Staff Development, 26(6), 244-249.

Bradshaw, M. J., & Lowenstein, A. J. (Eds.). (2011). Innovative Teaching Strategies in Nursing

and Related Health Professions (5th ed.) Sudbury, MA: Jones and Bartlett

Callis, A. N., McCann, A. L., Schneiderman, E. D., Babler, W. J., Lacy, E. S., & Hale, D. S.

(2010, October). Application of Basic Science to Clinical Problems: Traditional vs.

Hybrid Problem-Based Learning. Journal of Dental Eduation, 74(10), 1113-1124.

Carrega, J., & Byrne, M. (2010, September/October). Problem-Based Scenarios to Learn Clinical

Teaching Skills. Nurse Educator, 35(5), 208-212.

Chunta, K. S., & Katrancha, E. D. (2010). Using Problem-Based Learning in Staff Development:

Strategies for Teaching Registered Nurses and New Graduate Nurses. The Journal of

Continuing Education in Nursing, 41(12), 557-564.

Kocaman, G., Dicle, A., & Ugur, A. (2009, May). A Longitudinal Analysis of the Self-Directed

Learning Readiness Level of Nursiing Students Enrolled in a Problem-Based Curriculum.

Journal of Nursing Education, 48(5), 286-290.

Lin, C., Lu, M., Chung, C., & Yang, C. (2010). A comparison of problem-based learning and

conventional teaching in nursing ethics education. Nursing Ethics, 17(3), 373-382.

Neimer, L., Pfendt, K., & Gers, M. (2010, March/April). Problem-Based Learning in Nursing

Education A Process for Scenario Development. Nurse Educator, 35(2), 69-73.

Ozturk, C., Muslu, G. K., & Dicle, A. (2008, July). A comparison of problem-based and

traditional education on nursing students’ critical thinking dispostions. Nurse Education

Today, 28(5), 627-632.


Wiznia, D., Korom, R., Marzuk, P., Safdieh, J., & Grafstein, B. (2012). PBL 2.0: enhancing

problem-based learning through increased student participation. Retrieved from

http://www.nebi.nlm.nih.gov/pmc

Yuan, H., Williams, B. A., & Fan, L. (2008, August). A systematic review of selected evidence

on developing nursing students’ critical thinking through problem-based learning. Nurse

Education Today, 28(6), 657-663.

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