Nurse Education in Practice (2006) 6, 185–191

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Using a virtual learning environment toaddress one problem with problem based learning

Keith Ward *, Jim Hartley

University of Huddersfield, Huddersfield HD1 3DH, United Kingdom

Accepted 14 December 2005

Summary A successful problem based learning approach to the education ofhealth care professionals is dependent upon facilitators having access to a bankof authentic scenario. The assertion made here is that methods employed to buildscenario, containing problems that act as triggers for learning, are difficult toauthor and compel the facilitator to define the problems at the outset negatingany need for the learner to engage in problem identification, a crucial skill for learn-ers to acquire. The article explores several methods of building scenario that havethe potential to offer a solution to the problem of problem pre-definition with theconclusion that they all have limitations and bring with them a new set of challengesfor the facilitator. The article goes on to introduce Penfield Virtual Hospital (Pen-field), a computer-based tool developed to address some of the challenges posedby scenario building particularly relating to problem pre-definition.

�c 2005 Elsevier Ltd. All rights reserved.

KEYWORDSVirtual learningenvironment;Problem based learning;PBL;Context based learning;Penfield virtualhospital;Virtual hospital

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Introduction

A problem-based approach to learning for the edu-cation of health care professionals is well estab-lished and has several advantages over otherapproaches; the problem solving skills that developby engagement with the educational process mirrorthe thinking skills required by clinicians and theteam approach to problem solving as process is

471-5953/$ - see front matter �c 2005 Elsevier Ltd. All rights reseoi:10.1016/j.nepr.2005.12.003

* Corresponding author. Tel.: +44 1484 473419; fax: +44 148473199.E-mail addresses: k.ward@hud.ac.uk, j.hartley@hud.ac.uk.

highly valued in the practice setting. Within thecontext of this article, problem based learning ischaracterised as a curricular approach, where con-tent is organised around scenario and vignetteswith problems acting as triggers for learning. Typi-cally, learners work in groups to find solutions tothe problems or to determine how best to managethe problems where no solution exists. This is incontrast to Problem solving learning characterisedby a subject approach and the giving of a problemor set of instructions with the expectation that thelearner will find the answers (see Savin-Baden,2000) for a wider discussion on the distinction be-tween the two approaches).

rved.

186 K. Ward, J. Hartley

At the very heart of a PBL approach to teachingand learning in the health sciences is the patient’sstory manifested as a set of problems embedded ina scenario and the learner’s engagement with thatstory manifested as a search for solutions. Facilita-tors recreate the patient’s story for the purposes oflearning in several ways. For example, wholly in-vent, modify from real stories, or based on theirown and/or the learners past experiences. Allthese approaches have value but all share one com-mon weakness recreating the story for learningcompels facilitators (to a greater or lesser extent)to identify the problem(s) to be addressed andtheir probable aetiology imposing a boundaryaround how learners will engage with the story.

For example, Edwards reporting on a PBL ap-proach in a medical school writes:-

‘Instead of following a set curriculum with lecturesand other classes, students are presented with aproblem and work in small groups with a facilita-tor.’ (Authors emphasis not in the original tran-script) (Wood, 2004, p. 26).

However, Edwards goes on to acknowledge thatproblem reformulation by the learner into termsthat they understand is an important next step.

Others have built their entire curriculum arounda set of pre-defined problems:

‘The implementation of PBL at the Republic Poly-technic Singapore is characterised by division of agiven curriculum (say, of a module) into 16 PBLproblems.’ ‘In effect students work in teams on agiven PBL problem for the span of a whole day.’(Sic) (Authors emphasis not in the original tran-script) (Venkatachary, 2004, p. 3).

Pre-definition of the problem as the startingpoint to learning is problematic on several fronts,as it:

� Negates any need for the learner to engage inthe process of problem identification.� Negates any need for the learner to assume anyownership of the problem.� Is more in keeping with a problem solvingapproach to learning than a problem basedapproach.� No longer mirrors practice (it would be unusualin a practice setting to be given a pre-definitionof the patient’s problems on initial contact).

Experts on problem solving techniques and pro-cess identify problem identification and problemformulation as a crucial first step in the problemsolving process, a step needing mastery if the lear-ner is to go on and become a skilled problem sol-

ver. In addition, enabling the learner to identifythe problem for themselves acknowledges a levelof perplexity (puzzlement) and ownership of theproblem in the learner, motivating them to seeka solution to their perplexity. Russell argues:

‘. . .unless there is a personal demand for a solu-tion, (I must address this perplexity) there is no selfdirection or genuine interest and no reflectionbecause there is no problem owned by the learnerthrough the acknowledgement of perplexity’ (Rus-sel, 1999, p. 180).

Russell goes on to argue that learning in the ab-sence of any perplexity is a characteristic of pro-ject driven learning where problems are externalto the learner, often disputed by the learner asbeing genuine problems for their particularly pro-fession leading to potential conflict (an authoritytells me I must know this).

Albion’s wide review of the literature on con-structivist educational design and problem-basedliterature in particular, supports Russell’s argu-ment when he concludes:

Principle1: begin with an authentic problem

Problem-based learning should begin with anauthentic problem, which is genuinely problematicfor the learner and representative of problemsfound in professional practice (Albion, 2000, p. 2).

There are no (or difficult to locate) reports inthe literature relating to creating authentic sce-nario that enable the learner to define problemsfor themselves. However, the literature reportsthat a desirable attribute of problems used in PBLis that they should be ‘ill-structured’ or ‘ill de-fined’ (Koschmann et al., 1996, p. 65; Jonassen,1997, p. 32). It is not clear from the reports whateducational value derives from poorly definingthe problems or where this position originatedfrom. One explanation is that poorly defining theproblem is as close as the facilitator can get tonon-definition of the problem, representing a prag-matic solution to a real problem then one based onany particular educational theory or ideology.

The challenges facing the facilitator lies inengaging learners with the story without the bound-aries of predefinition of the problem(s) as an option,with an authentic problem and in a way that engen-ders in the learner a sense of ownership of theproblem.

One potential way to address the above chal-lenges is to marshal ‘live patients’ in front of learn-ers for the purposes of learning. The likely benefitto accrue from such an approach is that learnerscan identify real problems in a real patient’s story

Using a virtual learning environment to address one problem with problem based learning 187

while simultaneously engaging with the content oftheir particular domain. The use of live patientshas been utilised for medical education with gener-ally favourable results reported (Dammers et al.,2001; Aspergen et al., 1998; Chur-Hansen and Koo-powitz, 2004).

Dammers et al. reports that:

‘Real patients drawn from general practice werepowerful ‘triggers’ in a 7 week problem basedlearning module.’ She goes on to report ‘No seriouslogistical or ethical problems.’ (Authors emphasisnot in the original transcript) (Sic) (Dammerset al., 2001, p. 28.

The report of no ethical problems is despite pa-tients being ‘recruited’ by their own GP (withoutany reference to an ethics committee) whichshould question on the grounds of coercion alone(implicit or otherwise) the ethics of such an ap-proach and make transferability into other con-texts (acute hospitals) difficult.

In this particular study using live patients as thesource of the story did not address the issue ofpredefinition of the problems as patients with aparticular problem profile, were chosen by the tu-tor to fit in with ‘problems of the week’ and in-cluded chest pain, diabetes, surgical cases (see(Keppell et al., 1998) for a description of a prob-lem of the week approach in a medical faculty).However, as the module progressed students wereencouraged to define the problems for them-selves; there is no report on whether this encour-agement was successful. It is also not clear fromthe study if there were measurable gains in prob-lem solving ability or indeed, if this was an aim ofthe module.

Marshalling live patients for the purposes of PBLhas the potential to solve the problem of problempre-definition. However, reviewing the literatureon the use of live patients there is very little evi-dence of any responsibility for problem identifica-tion shifting away from the facilitator to thelearner. In addition, use of live patients brings withit a new set of challenges; how do learners makecomparisons between cases of similar conditionand position? How do we assess other professional’scontribution to the patient’s care outside of thefacilitator’s particular domain? Is this story andthe problems contained within it typical? The ten-dency is that facilitators recruit very complex atyp-ical patients for their students evidenced inDammers study (Dammers et al., 2001) and mirrorsthe tendency in invented stories towards complex-ity, contrivance and atypicality. It is not clear whattransferable skills learners gain from their interac-tion with highly complex atypical cases beyond

gaining case management skills relating to the par-ticular unique case. Transferable skills i.e. thoserelating to the methodology of problem solvingare not the focus leading to an educational encoun-ter more in keeping with a problem solving ap-proach than a problem based approach to learning.

Others have captured the patient’s stories incomplete case files to address some of these chal-lenges (In Context, 2005). The inContext projecthas collected one hundred and ninety five completesets of patient’s records from across four key nurs-ing domains Adult (medicine and surgery) Paediat-rics, Mental Health and Learning Disability.Developed as case based learning materials fornurses through coding against the QAA BenchmarkStatements for Nursing 2001 (Ward et al., 2004);the entire case file stock in PDF file format areavailable for download from a dedicated web site(In Context, 2005). Facilitators can reference thiscomprehensive stock of case based learning mate-rials to enable learners to define their own prob-lems from the care records as an option, makecomparisons between similar cases, identify contri-butions from different professional groups andfrom typical cases, (captured through collectionof the case notes from real wards over a three-month time window).

However, use of case based learning materialsderived from patient’s case notes brings with itits own set of challenges:

� How well do the patient’s records tell the story?� How do we recreate the patient’s story in theclassroom for learning?� The complexity of the record set is such that itmight exclude some (junior) learners from mak-ing sufficient sense of it to place them in a posi-tion to identify the problems (or have sufficientknowledge to appreciate what ought to perplexthem).� Printing/copying full sets of patient’s case notesas case based learning materials is resourceintensive.� The facilitator has very little control over thesequence of exposure to the record set inprinted format.� Reference to multiple records for comparativepurposes compound the problems.

The patient’s story is not an absolute but aninterpretive account. The story contained in thepatient’s case notes is an example of one accountof the story that has value in triggering PBL.

Recreating the patient’s story in the classroomfor learning is dependent upon the facilitator’s abil-ity to appreciate the patient’s story as contained in

188 K. Ward, J. Hartley

the case notes and their ability to overlay the de-sired learning outcomes onto that story. There aretools that can help both processes; generic com-puter authoring packages that facilitate the over-laying process and more bespoke packages that inaddition offer models for developing the learningscenario (story). (Stewart and Bartrum, 2002; Ries-beck, 1998) (for a wider discussion on intelligentauthoring systems, see Murray, 2003). In addition,harnessing technology to access learning materialsaddresses the challenges posed by printing, distri-bution and sequencing and there aremany examplesof on line Virtual hospital that act as repositoriesfor resources capable of supporting a PBL approach(Edinburgh University Virtual Hospital on line, 2005;University of Iowa, 2005). However, authoring pack-ages have their limitations; the authored environ-ment takes more time then conventional methodsto populate with learning materials at the outset,personnel need training in the use of the package,resistance from sceptics who doubt the credibil-ity of this approach to learning (Abbanat et al.,1994).

Others, Penfield Virtual Hospital addresses manyof these limitations.

Penfield virtual hospital

The Penfield Virtual Hospital (Penfield, 2003) rep-resents on a computer’s screen a period in the lifeof an acute general hospital, manifesting wardsand units that are relevant to the domains of adult,paediatric, mental health and learning disabilities.The illustration, for example (Fig. 1), presents thevirtual hospital’s user interface for its adult surgi-cal ward.

Wards in Penfield are fully populated with therecords of patient care based upon a significantsubset of the case materials collected by theInContext project (In context, 2005) i.e., real pa-tient’s records. An image representation of a pa-tient in the appropriate ward or unit representseach case file used by the virtual hospital. The im-age in Fig. 1: identified by the magnifying glassrepresents the patient allocated to the learnerfor this particular scenario. Facilitators have attheir disposal the full set of patients records heldin the hospital database from which they can buildscenario for learning. In addition, facilitators havecontrol over the sequence and timing of how pa-tient’s records reveal to the learner. As learnersinteract with their allocated patient Penfield sys-tem manages all the other patient activity admit-ting patients, discharging patients, transferringpatients, to theatre, patients dying etc. creating

a sense of dynamism through change in the virtualenvironment.

The Penfield Virtual Hospital provides the facil-itator with a re-usable environment and a datasource (patient’s records) that does not need cre-ating, re-creating or copying by the facilitator forany single instance of use in the learning environ-ment. The learner is readily able to accessthrough a simple interface on the computer’sscreen a large number of records of patient care,any one or more of which act as examples to sup-port learning.

Unlike typical authoring environments, the Pen-field Virtual Hospital is not a simple static image ona computer’s screen it is able to present to its usersits state at any point in its life that is determinedby the facilitator, for examples

� Which patients are occupying each ward or unitin the virtual hospital at that point in its life(useful for comparative purposes or for prioritis-ing care.), which patients are not yet admittedinto the hospital and who is discharged fromthe hospital.� What records of care are created for any patientin the virtual hospital at that point in its life andare made available to the learner, what recordsof care are not yet created for any patient andmust be hidden from the learner (useful forincrementally revealing records).

The ability of the facilitator to create one ormore scenes in the virtual hospital then forms thebasis of the means through which scenarios buildto promote learning. The facilitator is able to de-velop the scenarios through the judicious sequenc-ing of scenes that focus the learner’s attention topatient states or events of interest, controllingthe learner’s exposure to records describing thosestates or events. Such an approach enables thefacilitator to reduce the complexity of the care re-cords for learners by exposure in small manageablechunks.

The Penfield Virtual Hospital therefore comprisesa structured presentation of a large number of pa-tients’ records of care, on top of which the facilita-tor is able to overlay the scenario – the scenes in thelife of the virtual hospital and the instructions forone ormore interactions in each scene that the lear-ner will make with the virtual hospital.

The interaction might be one that simply asksthe learner to read and to understand a patientcare instance or event described in one or more re-cords of care. The instruction might require agreater degree of interaction on the learner’s part,for examples;

Figure 1 The Penfield interface showing the surgical ward.

Using a virtual learning environment to address one problem with problem based learning 189

� Access to a single patient or group of patient’srecords of care as the basis for identifying theproblem(s) the patient(s) might be experiencingat this particular point in time.� A response to a question posed in a descriptive,multiple-choice or ranking style that tests thelearner’s comprehension (Penfield has a fullyintegrated learning management system thatallows questions to be raised in context of thelearner’s interactions).� Manipulation of Penfield’s fully functional dutyroster to address resource management andward management issues.

The virtual hospital will page onto the com-puter’s screen each instruction in the scenarioand scene, in the order determined by the facilita-tor and at the point where the learner requires it(for example, the learner has completed the inter-action requested by the scenario’s precedinginstruction). Penfield tracks where the learner isin the scenario, recalls the exact place and placesthe learner at this point when they next log onallowing learners to progress at their own pace.

The Penfield environment as explained above asmany advantages over conventional authoring envi-ronments but retains some key challenges; stafftraining in use of the tool and acceptance beingtwo examples.

Conclusion

This paper is timely; there is resurgence of interestin a PBL approach to nursing education. One expla-nation for this resurgence is the relative failure ofcurrent nursing curricula to produce practitionerswho are ‘fit for purpose’ (Making a DifferenceDepartment of Health1, 1999) and agencies likethe Department of Health and the Quality Assur-ance Agency advocating a nursing curriculum basedon meeting patients’ needs and service delivery:

� ‘The patient’s experience is central to learningand healthcare’ first principle of nine (Depart-ment of Health2, 2003 Principles for the qualityassurance of healthcare Education May 2003 p.25).

190 K. Ward, J. Hartley

� Quality Assurance Agency and Subject Bench-marking exercise emphasising the need to locatetheory development in the context of clinicalpractice (Benchmark Statement, 2001).

Recreating the context of patient care andservice delivery in the classroom for learningis not easy, severely hampered by a lack of acomprehensive bank of authentic scenario andtools that enable the overlaying of learning ontoscenario. Using live patients and case based learn-ing materials as the basis for scenario developmenthave had some success, but all have limitationsparticularly relating to compelling the facilitatorto pre-define the problem(s) at the outset negatingany need for the learner to engage in problem iden-tification or assume any ownership. Exposure oflearners to a databank of comprehensive recordsof care held in Penfield can signpost the startingpoint for learning without the boundary of pre-def-inition of the problem as an option.

Preliminary data from user evaluations demon-strates that users enjoy engaging with the patientsin Penfield but need to appreciate utility beyondengagement with the patient context relatingeither to preparation for their assessment and/orclinical role. Utility and the relationship betweenthe curriculum and Penfield has driven recentdevelopments particularly in relation to integrationacross the curriculum, the alternative being Pen-field as a ‘bolt on’ a strategy doomed to fail. Akey part of the curriculum integration process re-quires that staff fully understand what Penfield‘is’ and how it contributes to learning in their stu-dents and this has been addressed through in-houseworkshops. An exciting an innovative model basedon a knowledge and thinking skills (particularlyproblem solving and critical thinking skills) contin-uums has emerged from these workshops, a modelcapable of truly recreating the context of care inthe classroom for learning.

A PBL approach to the education of health careprofessionals as much to offer and tools such asPenfield developed to facilitate such an approachare crucial for its success.

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