Perceptions Of Nurse Educators About Problem-based Learning

The nursing education system has to aim at producing nurse professionals who are competent in the delivery of PHC to meet the changing needs of the South African society. This therefore, requires that nursing colleges in South Africa adopt curriculum approaches that de­ velop links between theory and clinical practice and consequently prepare stu­ dents to develop self directed learning skills, self reliance, the ability to utilise different intellectual, interpersonal and practical skills to make decisions and solve problems critically (SANC, 1985). A number of authors (Andrews & Jones, 1996; Creedy & Hand, 1994; Creedy, Horsfall & Hand, 1992; Heliker, 1994) suggested Problem -based learning (PBL) as the most appropriate educa­ tional approach which will equip stu­ dents with the skills necessary to func­ tion in a comprehensive and primary fo­ cused health delivery system.


Background
The nursing education system has to aim at producing nurse professionals who are competent in the delivery of PHC to meet the changing needs of the South African society.This therefore, requires that nursing colleges in South Africa adopt curriculum approaches that de velop links between theory and clinical practice and consequently prepare stu dents to develop self directed learning skills, self reliance, the ability to utilise different intellectual, interpersonal and practical skills to make decisions and solve problems critically (SANC, 1985).A number of authors (Andrews & Jones, 1996;Creedy & Hand, 1994;Creedy, Horsfall & Hand, 1992;Heliker, 1994) su g g e s te d P ro b le m -b a se d lea rn ing (PBL) as the most appropriate educa tional approach which will equip stu dents with the skills necessary to func tion in a comprehensive and primary fo cused health delivery system.Creedy and Hand (1994) maintained, however, that it was difficult to change educators' beliefs about their classroom practices because their pedagogical practices are based on their philosophi cal b e lie fs .F u rth e rm o re , D oring , Bramwell-Vial and Bingham (1995: 264) m aintained that the individual's em o tio na l response to change depends upon where the individual is at the proc ess of change because "response is ex acerbated by the individual's percep tions of change, their capacity to meet the change and the varying degrees they feel supported in the process."A change to PBL requires that nurse educators review their teaching practices and be liefs related to teaching and learning which will demand new skills and atti tudes from them.
A study conducted by Bernstein, Tip ping, Bercovitz and Skinner (1995) re vealed that most tutors perceived PBL as more effective than the traditional method and as superior in terms of re tention and reinforcement of information because according to the tutors, stu dents in PBL sessions discussed issues with understanding rather than regurgi tating m em orised facts.These views were supported by Vernon (1995) who reported that educators were generally positive about PBL as compared to the traditional m ethod because they per ceived PBL as being of value to them and to the students by improving their inter action with the students, motivating stu dents to learn, enhancing student-di rected learning, problem solving skills, and creating a free and relaxed atmos phere in which to facilitate learning.
The study by Doring , Bramwell-Vial and Bingham (1995) concluded that the ex tent of the educators' knowledge of PBL will influence the degree of their involve ment in PBL, their teaching practices, and their preparedness for and comfort with the process.This was also con firmed by Vernon's findings (1995) which revealed that educators who had expe rience or previous knowledge regarding PBL were more positive towards it and were even willing to continue participat ing as tutors in it, than those with no or little knowledge of PBL.
A number of university nursing depart ments in South Africa have transformed their curricula to adopt PBL.Through out the country, provincial health authori ties are offering workshops for their staff to explore PBL as an alternative educa tional strategy in South African nursing co lle ge s.A ttem p ting an educational change of this magnitude poses an im pressive challenge on nursing colleges in which the teacher-directed and con tent-based curriculum is still presently the most predominant approach used in nursing education.For nurse educators to adopt a change from the traditional teacher-centred approach to PBL, they must believe in student-centredness.An extensive literature search on the sub ject, however, yielded no South African studies dealing with the perceptions of 57 C urationis June 2000 nurse educators regarding PBL.
The investigators perceive PBL as a new approach in the South African nursing education institutions.Research of this nature can be of considerable value in identifying factors, specifically related to nurse educators, which can retard or prom ote the successful adoption and implementation of PBL.This study will make recom m endations fo r nursing colleges in South Africa to take note of when seeking to im plem ent PBL cur ricula through which the graduate will be equipped with the skills to cope with the changing primary health care needs of the society.

The Purpose and Objectives of the Study
The purpose of this study was to deter mine and analyse the perceptions that nurse educators in South Africa hold re garding PBL and whether or not it would be feasible to implement this approach in the Nursing Colleges, as far as nurse educators are concerned.Hence, the o b je c tiv e s w ere to (a) exam ine the conceptualisations of PBL by nurse edu cators, (b) identify and analyse percep tions of nurse educators regarding PBL, and (c ) investigate the perceived barri ers and facilitating factors to implement ing PBL in nursing colleges.

M ethodology
This was a descriptive survey aimed at identifying the perceptions of nurse edu cators regarding PBL and its feasibility in nursing colleges.The target popula tion of this study was all nurse educa tors teaching at selected nursing col leges in the Free State and KwaZulu Natal provinces.It was decided to use one big and one small college in each of the two provinces.In the Free State province, the big college (main nursing campus) had 37 nurse educators with 90 students intake per year.The small college (sub-campus) had 22 nurse edu cators in its establishment with 75 stu dents intake per year.In KwaZulu Na tal, the big nursing college had 48 nurse educators with 120 students intake per year, and the small nursing college had 10 nurse educators and 20 students in take per year.
C o n v e n ie n ce sa m p lin g w as done whereby two nursing colleges, one big and one small were selected from each of the mentioned provinces due to their g e o g ra p h ic a l a c c e s s ib ility .The re searcher submitted before hand an ap pointment time table to the heads of col leges, to circulate amongst nurse edu cators for them to voluntarily indicate the times they availed themselves for inter views.Twenty nine (49%) of the total number of nurse educators (N'59) at both the small and big participating nursing col leges in the Free State Province and thirty (52%) of the nurse educators (N'58) at the participating nursing colleges in the KwaZulu Natal Province agreed to participate in the study.In all, therefore, 59 (50%) of the 117 nurse educators tar geted for participation in the study were interviewed.

Instrum entation and Data Collection
An interview schedule c o n s is tin g of closed and open-ended questions was d e sig n e d by the researchers.The closed ended questions were more on biographic data, teaching assignments and awareness about PBL.The openended questions sought information on perceptions and feelings about PBL as well as its feasibility in nursing colleges.
Consultation regarding the content va lidity of the instrument was confirmed by means of a discussion with research and educational experts (5).Experts sup ported the fa ct that the inform a tion sought on the perceptions of nurse edu cators regarding PBL through the inter view schedule was relevant and there fore demonstrated content validity.The instrument was not tested for reliability because an interview schedule aimed at obtaining qualitative data is not amena ble to traditional psychometric testing procedures.
A pilot study was conducted at a non participating nursing college.Four nurse educators were interviewed.The first in terview session took 11 minutes, the sec ond: 25 minutes; the third: 18 minutes and the fourth: 15 minutes.The total was 79 minutes which amounted to an aver age of 20 minutes.Responses obtained from the pilot study assured the investi gators that the interview schedule suc ceeded in eliciting information required to answer the questions raised in this study.
Structured individual interviews were used to collect data.Interviews were scheduled for 20 minutes each and ap pointments were arranged prior to visit ing the nursing colleges.A copy of the interview appointm ent-tim e table was sent to each of the heads of the selected nursing colleges, with a letter attached asking th ose nurse e du cato rs w ho agreed to participate in the study to in dicate by entering their names in the times that would suit them.
Each interview was recorded both on audio-tape and in writing.However, not all participants agreed to be interviewed on tape.Therefore, for these partici pants, only written records of the inter views were kept.The audio tapes were transcribed for analysis.

Permission and Ethical C onsiderations
Permission for conducting the study was sought in a written form from health au thorities of the provinces concerned and the heads of the participating nursing colleges.However, the participants were verbally asked to participate as men tioned before.No forms of identification of participants were asked.They were assured that information gathered was to be kept confidential, and would only be used for the purpose of the research.

Lim itations
The researchers planned to interview all nurse educators in the selected nursing colleges.However, only 29 out of 59 nurse educators at the selected colleges in the Free state, and 30 out 58 in Kwa Zulu Natal agreed to participate.Never theless, the researchers regard this number as a very good response con sidering the fact that the research was conducted during a critical time when most nurse educators were not available because some were on study leave writ ing exams, others were busy marking students' examinations, others were con ducting exams.

Data Analysis
Data obtained from the closed-ended questions were analysed by means of descriptive statistics.Qualitative data was analysed according to the catego ries derived from each question in the interview schedule.Themes, however, were derived from the interviewees' own responses.The unit of analysis for the open-ended questions' statements was the whole statement.That is, meaning was derived using the "w hole" state ments rather than sentences or words.

Findings Salient Sample Characteristics
Of the 59 nurse educators, 45 were tu tors, 11 were subject heads and 3 were vice principals.Most (n 1 27) of the par ticipants had 2 -6 years active teaching experience, followed by those who had seven or more years of teaching.Nine participants, however, had less than two years of teaching experience.

Nurse Educators' Awareness Of PBL
Ninety-five percent (n 1 56) of the re s p o n d e n ts re p o rte d th a t th e y were aware of PBL whereas 5% (n ' 3) said they were not aware of it.Seventy per cent (70%) of the respondents became aware of PBL from sources such as in formal discussions with colleagues, and feed back reports from those who at tended PBL workshops or conferences.Forty-one percent (41%) of them read about PBL in literature, while 21% said that they attended PBL workshops or conferences and at least five of them said they attended a course that was prob lem-based.

Conceptions Of PBL
Five themes emerged from statements used by all nurse educators in explain ing the meaning of PBL, namely: (a) ap proaches to teaching and learning, (b) the nature of the teaching-learning proc ess, (c) an educational approach, (d) the process of PBL, and (e) the chang ing role of the teacher in PBL.The fol lowing excerpts from the respondents' own statements illustrate these observa tions.
"PBL means that the student has to work through his/her own learning.Therefore, it involves: discovery learning, guided learning-where the teacher is a facilitator and programmed learning.""I think it is a method that focuses on problems but it is more of a self-directed learning approach because the students are the ones who identify problems and solve them .""PBL is process driven rather than con tent driven.It involves presenting stu dents with a problem and allowing them to solve that problem themselves, using theoretical resources such as a library, practical resources such as patients in the wards.I will then act as a resource person, guiding them along the proc ess." "It means you send students out into the clinical setting with objectives.Whilst in teracting with clients they identify prob lems.They can consult resources to get information related to the problems they have identified.The resources in this case would be books or people around the students.After researching on the problem, they come back to the tutor for clarity." There seemed to be a confusion, how ever, betw een PBL and com m un itybased education (CBE).This was evi denced by the fact that some nurse edu cators viewed PBL as specifically related to community needs.
" PBL means that students are going to be placed in the community where they'll identify and solve problems.Their prac tical training will be based on the prob lems they identified in the community.""To me it m eans the learning that is based on the needs of the consumer of health, which involves going out in the community, planning for the community needs and then executing that plan."S eventy-one percent (71%) of those nurse educators who defined PBL in terms of the role of the teacher viewed the teacher as a facilitator.In the con trary, the other 29% viewed the teacher as a provider of information.

Perceptions Of Nurse Educators Regarding PBL
Fifty five (95%) of the 59 nurse educa tors viewed PBL positively .Themes emerging from the statements made by those nurse educators who viewed PBL positively included: (a) the expected outcomes of PBL, such as retention of information, self-directed and active stu dent leaning as well as student motiva tion (b) the changed role of the student, and (c) challenges facing the teacher.Some had the following to say: " If the student identified the problem and discovered information for herself, then she will never forget that information."I think PBL is the best approach because it allows the student to find out things for herself, to grow and to develop, and what is important, it develops the stu dents' creative thinking, critical thinking and problem-solving skills." I think it is important because it helps the students to feel self-actualised espe cially if they have researched and dis covered information on their own."PBL is a good approach but it requires th a t the fa c ilita to r sh ou ld be broad minded and well developed to be able to manage the students' viewpoints.Some of the positive views expressed by the nurse educators could be seen as advantages of teaching with PBL.For instance some stated that: " I wish we could adopt PBL because it would eliminate the problem of having to teach students everything which is in the syllabus, even irrelevant stuff, result ing in wastage of students' and tutors' tim e and unnecessary exhaustion of manpower (sic)." " It enables students to see things (on site) practically, rather than theoretically.It is a realistic approach which has a long-term impact on the students' learn ing even after graduating." A few nurse educators (n ' 4) saw mainly disadvantages in PBL.These were often related to time factors, and perceived inability of students to cope with PBL.
" I think that it is a good strategies except that it might be difficult for students who can't follow or understand easily."" It is time consuming because it takes long for both the teacher and the stu dent to review literature and research on problems identified."Furthermore, a few were guarded in their optimism for implementing PBL in the nursing colleges.This was related to the timing of PBL implementation in a nurs ing education programme.They were not opposed to PBL provided it was im plemented in the second year of the pre registration programme.In their view, first year students are still immature and therefore, need support of a teacher in learning.For instance one nurse educa tor stated: " I like it but my concern is that first year students do not have enough know l edge and professional skills to work out problems in the community on their own.So I personally feel that it should be started from the second year level when students at least have an idea of what nursing entails."

Factors That Would Facilitate Or Hinder The Implementation Of PBL
Many facilitative factors of PBL imple mentation were mentioned by respond ents and the most frequently mentioned were (a) in-service training of nurse edu cators and clinical staff regarding PBL, (b) positive change of attitudes towards PBL by the nurse educators, students and the college authorities, and (c) in clusion of PBL in nurse teacher educa tional programmes.The above observa tions are evident in the following state ments: "The most crucial factor that I can think of is the in-service training and educa tion of nurse educators and the clinical sisters about PBL.By the way, don't for get that this is a new approach and we don't know much about it.My dear, if we do not know how to use it, then forget about its implementation.It is only if we understand what it entails, that maybe we can consider it.So I think that more workshops should be conducted to up date us ."" It is important that nurse educators are updated about this approach.In actual fact, I think PBL should be implemented in the training of nurse educators so that they can get the skills and knowledge of its processes and be able to implement it better.I wish that the institutions which are presently offering PBL programmes could take more nurse educators, even if it is on a part-time basis." "The most frequently mentioned hinder ing factors for the implementation of PBL in nursing colleges were (a) lack of in formation on PBL, (b) inadequate prepa ration of students for PBL, and ( c ) nega tive attitudes towards PBL due to resist ance to change.""We will have problems with PBL be cause the type of students we get from high school never had a chance to dis cover information for themselves.They always expect the tutor to teach them everything, as a result they will not be able to cope with this method.""Our negative attitude.It will take time for us to outgrow our traditional teach ing because we are used to it.The nurse educators are reluctant to let go of the teaching and learning to the student because they feel they are experts and should therefore take sole control of the teaching and learning process."" I question the present attitude of staff and students tow ards PBL.Are they ready to accept and implement it?I don't think so...I foresee a lot of resistance, especially from students because they were never introduced to this type of learning even at high school.They be long to the old school of thought of just coming to class and assimilating infor mation.So we have to sell the idea of PBL before it is implemented." Concern about lack and/or inadequacy of both human ( n ' 19) and material re sources (n 1 28) was seen a major hin dering factor by a number of nurse edu cators.These factors, coupled with large class sizes (n 119) and a content-packed and examinations oriented curriculum (n ' 21) were seen by the participants in this study as some of major hindering fac tors to the implementation of PBL in nurs ing colleges.

Discussion
The findings of this study revealed that the meaning of PBL is perceived differ ently by different persons.Some nurse educators defined PBL by describing its processes.Others defined it in terms of its distinctive features, such as student centred learning, self-directed learning, the process of learning.Others defined it in terms of its expected outcomes with reference to the knowledge and skills it develops in students such as creative thinking, critica l thinking and self-di rected learning (SDL) skills.Similarly, Albanese and Mitchell (1993), based on an extensive review of research on PBL, conceded that it is difficult to arrive at a precise definition of the term.
The basic meaning of PBL by nurse edu cators, however, encompassed a teach ing/learning process that involves prob lems which have to be solved by stu dents through searching for information on their own, as self directed learners.Therefore, the meaning that the major ity of nurse educators attached to PBL did not differ much from the meaning given by Barrows and Tamblyn (1980: 18) who defined PBL as "the learning that results from the process of working towards understanding or resolving a problem." The knowledge that the nurse educators have about PBL seems to have influ enced their views about it.For example, the m ajority of nurse educators who knew what PBL was viewed it positively, and those who said they did not know what it was, held noncommittal or nega tive views about it.Besides knowledge about PBL, other factors that could sig nificantly have influenced the respond ents views were more in terms of its ben efits to the students, and their state of preparedness to utilise it as a teaching learning strategy.Similar findings were mentioned by Doring et. al (1995) and supported by Vernon (1995).
The participants were mostly positive about the effectiveness of PBL in areas of active student learning, academic and professional developm ent of the stu dents in terms of intellectual and prob lem solving skills.These findings are congruent with Norman andSchm idt (1992), Schm idt's (1983) views that PBL enhances the graduates' life-long learn ing skills.Similarly, emphasis on student centred learning and self directed learn ing was viewed by Barrows (1986) as the cornerstones of PBL.
The m a jo rity of nurse edu cato rs fa voured PBL because they believed that it will motivate students to learn from selfdiscovery.In addition, the views of the respondents that PBL m otivates stu dents are supported by findings of the studies conducted by Vernon andBlake (1993), andW illiam s et al (1995).In South Africa, there is a need to produce autonomously and independently think ing nurses so that they are capable of rendering com prehensive health care (Gwele & Uys, 1995).A reality of this objective can only be achieved if the educators foster an environment that is conducive for students to become moti vated to direct their own learning.This however, has serious implications on the traditional role of the teacher because he or she has to let go of totalitarian con trol of the teaching/learning process.Nurse educators need to realise that the call for increased self-direction on the part of the students does imply either covertly or overtly, that nurse educators are abdicated from their responsibility to help students learn.Some of the re spondents in the present study, however, saw the requirement for self-direction on the part of the students as a major bar rier to implementation of PBL in South Africa.
PBL is generally regarded as an innova tive approach and its adoption entails a whole range of processes of change which dem ands personal and profes sional reflection by educators (Creedy & Hand, 1994).That being the case, it is interesting to note that the majority of nurse educators did not raise much con cern about their perceived changed role in PBL but were more concerned about that of the students.Yet, according to Hord cited in Gwele and Uys (1995), it would have been natural for these edu cators to reflect on how they perceived PBL would affect their class room prac tices, in view of the fact that it is an inno vative approach.However, the lack of concern for what a change from a con tent-driven to a problem-based curricu lum would mean for them as nurse edu cators, might be attributable to the fact that none of the participating colleges were contemplating this change at the time of data collection.Hence there was no perceived immediate threat to their roles as nurse educators.
The few nurse educators who did raise concerns about their changed role in PBL, viewed PBL more as an approach that dem anded their intellectual skills and competence.They mentioned that as facilitators, PBL requires them to be broad-m inded and knowledgeable re garding the subject matter related to the problem, so that they are able to guide students appropriately.Similarly, Creedy et al (1992) supported the idea that the teachers facilitating PBL groups should have specialist in-depth knowledge of the subject so that they are able to track and explain the reasoning process un dertaken.Within the context of this study however, the need to be knowledgeable ,about the subject matter was seen as extra burden on nurse educators.
A number of factors were identified by nurse educators as either facilitating or hindering the implementation of PBL in nursing colleges.Although generally nurse educators favoured PBL, the fact that they lacked information about it was of great concern.It was therefore not surprising that they perceived this as a major hindering factor of PBL implemen tation in nursing colleges.It is realised that this is a critical and legitimate con cern, and nurse educators strongly felt that there is an essential need for them to be updated on PBL through w ork shops, in s e rvice tra in in g or sh o rt courses.The majority of literature per taining to PBL, highlights the need for providing knowledge and skills to edu cators regarding PBL (Andrews & Jones, 1996;Creedy et al, 1992;Doring et al, 1995).For example, Doring and co l leagues asserted th a t fo r PBL p ro gram m es to be s u c c e s s fu lly im p le mented, educators m ust understand and be com fortable with the process, their roles and its outcom e.Similarly, fin ding s of the stu d y c o n d u cte d by Gwele (1996), confirm ed that accept ance and ownership of a major curricu lum change by educators is important for facilitating adoption and implemen tation.
Nurse educators in the study felt that knowledge about PBL is also required by college authorities and clinical staff, as people who are involved in the edu cation of students in terms of the influ ence they have in the endorsement and a d o p tio n o f th e e d u c a tio n a l p ro grammes.A similar view, but a different theme, was held by Gwele and Uys (1995), who maintained that all the peo ple who are involved in the education of students, need to be involved at all lev els of curriculum planning and decision making.This seems to be a very impor tant factor in innovative processes.

Conclusion
The findings of this study have offered a description of some nurse educators' conceptions, perceptions and feelings about PBL.What is most important is that this study identified some factors which can facilitate or hinder the adoption and implementation of PBL in nursing col leges.
For PBL to be adopted at nursing col leges, an extensive amount of planning will first be required.Although nurse edu cators are aware and positive about PBL, there will be a need for them to be pre pared by conducting a series of educa tional programmes such as workshops, seminars, forums, short courses, so that they know what PBL exactly entails in terms of the different forms of PBL avail able, the process of learning involved, the facilitation role of the teacher, the self directed role of the student, the objec tives of PBL, the depth and breadth of kn o w le d g e in PBL, the lea rn ing re sources required, and the evaluation approaches used, and many other PBL related issues.It is evident in the study, that nurse edu cators perceived PBL as a strategy that will mostly affect the student.Yet, in fact, it will require a lot of changes on their part before the students are affected because of the dominance of traditional teaching/learning practices in the nurs ing colleges.Besides, the findings of the study show that nurse educators were concerned about the ability of the stu dents to learn on their own.In view of the demands of the contentbased curricula used in most of the nurs ing colleges, the implementation of PBL will be impossible unless a restructuring of that curricula is effected to accommo date PBL.
Nurse educators felt that the students' attitudes towards self-directed learning could be some of the hindering factors to implementing PBL at nursing colleges.
A study aimed at examining the students views regarding PBL especially as it re lates to self-directed learning, would be beneficial to nursing education in the country.Forums consisting of students and staff from schools where PBL is implemented need to be established.Such forums would provide an arena for potential PBL adopters to ask questions of concern from them.That is, dissemination is of utmost importance for nurse educators in South Africa at this stage.