The Impact of Problem Based Learning Module on Maternity Nursing Students ' Experiences and Achievements

Background: Problem Based Learning (PBL) has long been used within teaching in higher education to encourage student to have an active role in learning process. PBL is a favored approach in nurse education in some high-resource countries, where learning styles have become increasingly interactive and reflective, and group sizes tend to be small. To date, there have been few if any studies of attempts to apply PBL in countries where the learning style is largely didactic, and group sizes are usually large. Objective: The aim of this paper is to evaluate the impact of PBL module on third year undergraduate maternity nursing students undertaking a Problem Based Learning (PBL) program for their maternity care module. Methods: Focus group interviews, an interview questionnaire sheet, and scholastic achievement retrospective auditing. Results: The evaluation of PBL was generally positive. The students reported that the interactive learning process enhanced the acquisition of multiple educational and transferable skills. They believed that these were likely to advance their future education and career development. However, they also experienced some challenges in the transition to the PBL teaching strategy. Conclusion: The study suggests that PBL may be a useful strategy, even in settings where the underlying educational philosophies are culturally novel, and group sizes are large. However, further preparation of students is necessary to induce the cultural changes that could maximize the benefits arising from this style of learning in a developing world context.


INTRODUCTION
The nature of expertise and decisionmaking has been examined in medicine (1) , nursing (2) and midwifery (3) .Influential authors such as Eraut have proposed that medical decision-making is not linear, but based on the recognition and extension of complex patterns from one clinical case to another (1) .These archetypal and constantly evolving patterns have been termed 'illness scripts' (4).Expert nurses and midwives are Bull High Inst Public Health Vol.39No.1 [2009]   also reported to use complex decision making styles that cannot easily be reduced to a linear account (4).Problem Based Learning was developed to account for complex case-based decision making in medicine (6,7) .This has been successfully translated to medical education in a range of contexts, including the Gulf states (8) .
Problem Based Learning has also been generalized to nursing, professions allied to medicine, and, most recently, midwifery (9).However, most of the research in the area of nursing and midwifery to date has been undertaken in high-resource countries, where learning styles have become increasingly interactive and reflective, and group sizes tend to be small (10).To date, there have been few if any formal studies of attempts to apply PBL in countries where the learning style is largely didactic, and group sizes are usually large.This paper reports the views of maternity nursing students who were the first cohort to undertake a PBL based module in Mansoura university in Egypt.practice (11).In addition, didactic teaching does not allow the development of the profession, as it tends to reinforce established practices uncritically, rather than offering a space for debate, and, potentially, practice innovation (12,13).

BACKGROUND
The Egyptian health care and health educational systems therefore face a challenge in preparing and equipping students and practitioners with the skills and knowledge to enable them to deliver effective health care in a dynamic social context.Internationally, PBL started to feature in educational programs during the 1960's.Since then there has been a steady growth in the number of programs using this approach (14,15,16,17).PBL is a learning approach in which the student is introduced to a problem or situation as a trigger point for the identification of the learning needs.

STUDY AIM:
The aim of this study was to assess the impact of introducing PBL module as a new learning strategy on third year maternity nursing students' experiences and achievement.

2-DESIGN OF THE PBL MODULE
The course was designed using a hybrid model of PBL to maximize acceptability, and to fit into the standard time table of 48 contact hours over 14 weeks.This  Oral presentation of the case to the whole cohort.Critique, audience questions and clarifications 4 The groups had a compulsory tutorial lasting 60 minutes while they were tackling their cases to check that the students understood and could cope with the requirement of the course, and to assess their learning style.There was no compulsory tutoring during the last week: however the students were free to seek tutorial advice if they wanted it.This was to encourage students to take more responsibility for their learning.
Box 3 The contents of the presentation session for each two groups.
1-Group two gives a 25 minute presentation of their solution to the case 2-Group one questions them about their presentation 3-The audience questions the two groups 4-The tutor questions the two groups and the audience 1-Group one gives a 25 minute presentation of their solution to the case 2-Group two questions them about their presentation 3-The audience questions the two groups 4-The tutor questions the two groups and the audience Each learning group consisted of 15 students working together to explore the learning underpinning the scenario.They had to nominate a chair each week.This was to encourage the development of communication and leadership skills.The teacher-facilitator was the scribe for the group, so that their discussions could be formulated into a readable format.The facilitator also helped the students to design ground rules to guide the group work.

TOOLS OF THE STUDY
1-Focus-group interview method has expanded rapidly during the past decade (19) .Kreuger (20) asserts that the purpose of this method is to use group interaction to produce data.This method is effective when the aim is to investigate the way ideas develop within a certain context (21) .
PBL uses principles of group dynamics as part of the learning process and therefore the focus group is a congruent research method.

2-A structured feedback questionnaire
Were used to account for the views of These notes of the qualitative data were read back to the groups at the end of the session to check agreement.

Box 4
One main question was used to guide the focus groups Tell me about the new module, process, experiences, feeling, learning skills, facilitation, resources and barriers.

DATA ANALYSIS
1-Data from the focus groups interviews were analyzed using Burnard's fourteen stages of analyzing interview transcripts.
Burnard's (22) method is based on a synthesis between a grounded theory and a content analysis approach.This method was used to categories and code the transcribed data.The analysis was pragmatic rather than deeply theoretical:

Interviews (Qualitative data)
The responses will be discussed as a whole rather than the individual groups.
The quotes presented below are sentences or fragments of discussion that emerged from the interactions in the groups.The code after the quote is the group number in which this kind of discussion took place.
Three main themes emerged from the analysis: 1-aquiring new skills 2experiences of different learning styles; and 3-pressures of time and uncertainty.

Acquiring new skills
The students were very clear in their description about the skills they developed throughout the module.This can be summarized in Box 5. ''Our IT skills and presentations skills really improved'' G2, 4, 5, 6, 7.

Experiences of different learning styles
Most of the students reported that they enjoyed the new approaches to learning  These findings are supported by other studies in this area Savin-Baden 2000 (22) Ward and Lee 2002 (23) Rowan et al 2007a, 2007b (24,25) .The tutorial discussion was seen to be more productive, exciting, and challenging than traditional teaching.
These findings indicated that the PBL approach helped the students to achieve their learning objectives, as has been the case in many other studies in this area.In addition, there were indications that, although the module only lasted 12 weeks, there was a subtle and positive shift in relationships between students and lecturers.
It is not clear if this persisted after the module was complete.Feelings of time pressure and of uncertainty are common to those who are undertaking PBL in one aspect of their studies while they still engaged in other more traditional courses Rowan et al 2007 a, 2007b (24,25) .Under these circumstances students receive mixed messages from the different teaching and learning styles O'Hanlon et al 1995 (26) Solomon and Finch 1998 (27) .
However, further developments in using this approach in a setting where individualized question based learning is not the norm will require additional effort to prepare both students and teachers, and to supply the resources necessary to support the kind of eclectic learning required.
Overall, the academic achievements for the students were satisfied at the end of the PBL module when compared with the subsequent, traditionally taught modules.
During informal discussion, the tutors reported anecdotally that some students' grasp of the subject was much better than that of those on traditional courses.It is possible that, if it is a true measure of capacity, the lower achievement was due to the unfamiliarity of the students and academic staff with the new approach, or that the standard assessment strategy was not sensitive to the skills the PBL approach was designed to develop.It is of interest that student achievements were satisfied.
Also, students reported developing many learning and transferable skills.This is consistent with Blumberg and Michael 1992 (28) and Ward and Lee 2002 (23)  to nursing education with full support and commitment from the educational system.Some forms of hybrid PBL models might have to be considered at the beginning to reduce the gap between the traditional authoritative Egyptian educational system and the self-directed ethos of PBL.This study is a guide for lecturers who would like to move from a didactic style to a more student-led approach to learning and teaching and helps students develop successful strategies for learning how to learn and communicate complex information in Nursing.

RECOMMENDATION:
It is not anticipated that all results will be transferable to other contexts.However, it is argued that some key principles that have underpinned the experience at the education was one of the pioneers in developing and upgrading nursing curricula to enable future nurses to be up to date with international developments, and to be motivated and confident enough to accept responsibility for self development after qualification.The authors of this paper have many years experience of lecturing on undergraduate maternity nursing program and community Medicine program.This experience has led to the conclusion that the traditional didactic lecture is not suited to all students.The emphasis is on giving information rather than learning.Lectures represent what teachers do and believe, and not necessarily what students need.As a result, some students are lost in the teaching process.This traditional method has been criticized in other contexts for not encouraging the development of enquiry skills, with the consequence that newly qualified nurses lack competence in the complex and uncertain world of real clinical comprised one class for the duration of 4 hours every week.Five maternity academic staff volunteered to run the sessions.The first author introduced the concepts and skills necessary to these staff in a series of three training workshops prior to the commencement of the course.This process specifically aimed to develop skills in facilitation, and was based on one of the five case studies that were to be used with the students.The 150 students entering the maternity phase of the program at the time the PBL methods were introduced were aged between 19 and 21.After the first two weeks, when they undertook standard clinical skills training in the skills laboratory, they were divided into 10 groups of 15 students each.The cases were assigned randomly to the groups in the first instance, The course was delivered in three cycles, each of four weeks, so that each two groups were exposed directly to one case as a responsible groups and indirect to four cases as an audiences over the remaining 12 weeks of the program.The academic staff were each assigned to two groups as a facilitator.The two groups both had the same case study.The lead researcher was the coordinator between all the groups.
students, and to permit assessment of evaluations across the cohort.The instrument chosen was a standardized tool that was developed to assess quality of teaching on the basis of empirical and theoretical work in Mansoura University.This therefore also can permitted comparison between modules.Student feed back questionnaires were anonymous.They were one page long, Bull High Inst Public Health Vol.39No.1 [2009] with 10 questions.They comprised a series of statements requiring a Likert-type response on a 1-3 scale, where 3=agree , 2 = neutral and 1=disagree.3-Retrospective auditing of student scholastic achievements in recognition of the fact that some students might feel academically disadvantaged by having to undertake a radically new approach to their education, the achievements of the students were compared to their colleagues in the next semester who had undertaken the routine maternity module.However, this was only a crude indication of the possible impact of PBL on academic achievement.It provides an indication of what aspects will need to be addressed in future comparative studies in this discipline and setting.DATA COLLECTION Two types of data were collected, qualitative and quantitative immediately after the module.The focus groups interviews were undertaken by the first author who has the function of guiding the groups rather than asking questions.One main question was used to guide the focus groups interviews as in Box 4. Notes were taken during the focus group by facilitators.
the purpose of the work was to locate what worked well, and what could be improved for future cohorts.The transcripts were checked by three academic staff from the community department of the faculty of medicine.The data were analyzed initially by the first author.After this, the transcripts and analysis were given to the same academic staff to review the themes and codes with the transcripts, to maximize the credibility of the analysis.There were no major disagreements about the themes that emerged.2-Student feed back questionnaires were anonymous.They were distributed at the end of the last session of the course.The quantitive data were analyzed the Statistical Package for Social Science (SPSS) version 15.Statistical methods used involved frequency and percentage.3-Scholastic achievement was recorded by grade, and is reported as comparative graph.
The following selected quotes highlight some of their descriptions of the skills: 'I think it helped me to communicate, express and exchange ideas with colleagues'G3,4,6,7,8,9,10."Our writing and presentation skills were improved, sometimes we were correcting each others work before presentation and most of the time we were doing mock presentations to improve our presentation skills" G2,5,7 10 "It is like learning to think differently, to convey and defend our ideas."G9' Knowing about different sources of information and how to look for the information you need' G1, 3. ''Gaining skills of using the previous knowledge and using other knowledge to build up a new knowledge I need'' G 4,2,5.''It forced and motivated us to read different sources and acquire the ability to understand difficult topics ''5, 6,7,8,9,10.
on PBL course and traditional maternity course.Figure1compares the scholastic achievements of the students on the PBL maternity module, and their colleagues attending the same module were taught traditionally during the second semester.There were marked improvement in the first group were the percentage of students with very good and excellence achievements (68%,25) compared to (53%,16%) respectively between the two groups however the intention was to see the achievement of the PBL students comparing to their colleague for illustrative purposes only, and as a basis for hypothesis generation.DISCUSSION This study was a pragmatic examination of an educational change that was occurring in the local curriculum.As such, it is most useful in terms of local amendments to PBL-type provision.It is limited by the Bull High Inst Public Health Vol.39No.1 [2009] inclusion of only one cohort, and by the fact that the evaluation was focused on service development, rather than being a formal indepth research study.However, as the first account we are aware of the use of PBL in the context of large class sizes where traditional 'chalk and talk' teaching methods are the norm, we believe that the findings may be of interest to those working in other similar contexts.In general, the students taking part in the innovation enjoyed the change and reported the development of specific skills as the course progressed.These included working in a team, improved interpersonal communication skills, the development of writing and presentation skills, stimulation of wider reading, and increased independence.

Faculty•Figure 1 :
Figure 1: Final Scholastic Achievements of study participants, maternity (PBL) compared to subsequent maternity (traditionally taught) module

Course time table for one cycle Sessions Weeks
Introducing the PBL teaching format, aims, content.Introduce evaluation methods.Organize groups, hand out case 1 1 Compulsory tutorial, mini lecture 1 2 Mini lecture 2, submission of material related to work on the case study 3