Adapting to and Implementing a Problem-and Community-based Approach to Nursing Education

The process of change, implemented by the School of Nursing at the University of the Orange Free State so that a paradigm shift in approaches to nursing education at undergraduate level could be achieved, is outlined. The necessity to change, the identification of external and internal variables that impact on change, the founding of a support system, the process of overcoming resistance to change, the evaluation of the process of change and options for the future, are discussed. The rationale for the implementation of a problem-based teaching strategy and the phasing in of a community-based approach to teaching as the heart of the process of change are discussed.

The University of the Orange Free State was traditionally an Afrikaans university that trained mainly white Afrikaans stu dents in the apartheid era.The political changes in the country became one of the greatest forces in the process of ch a n g e , e s p e c ia lly in p re c ip ita tin g change in the composition of the student population.
For the past five years South Africa has been a country where change has be come an everyday word and a lifestyle.In spite of this, the staff of the School of Nursing are in awe of the complexity of the change process, which was alluded to some four and a half centuries ago (1513) by Machiavelli (cited by Engel, 1989:96).
...there is nothing more difficult to plan, more doubtful in its success, nor riskier to achieve than change.
The changes brought about in the coun try and the new Health Care System as a whole, have demanded a paradigm shift in the approach to training on offer in the School of Nursing.The former pro gramme was community orientated and students spent a substantial amount of tim e in clinics and com m unity health centres, but the programme was prima rily hospital-based, and the health-care needs of communities were not consid ered as im p o rta n t v a ria b le s in p ro gramme planning.In addition, the teach ing approach was not consistent with the principles of adult learning.
The aim of this article is to describe how, with the passage of time, the staff of the School of Nursing, rather than merely c o n c e n tra tin g on change, regarded change as a process of successive chal lenges.
As progress was made the team also realized that barriers to new initiatives were not unique.The barriers identified by Kaufman, Mennin, Waterman, Duban, H ansbarger, S ilve rb la tt, O bershain, K antrow itz, Becker, Sam et & W iese (1989) were also relevant to the new pro gramme: fear of loss o f control; fear of the unknown; feeling comfortable with the status quo; the perception that academic promotion was based more on research than on teaching; the view that academic innovations are too costly; and concerns about resources.
Since initiating the process of change, the team soon realized that the four strat egies for overcoming barriers to change had to be implemented as the change process evolved: • Developing of broad ownership for the proposed innovation; • Wining converts by inviting participa tion; • Forming new alliances to broaden the support base; and • Sharing successes (Kaufman et at., 1989).
goal was therefore set to start the pro gramme two years after planning com menced.
For change to achieve broad support, it must be relevant to an audience wider than the small group who perform the planning, and should be linked to impor tant forces outside the institution.Taking external m otivation into account, it is beyond doubt that the political changes in the country were the most significant driving forces in the process of change.The national and international forces are discussed briefly.

Health -for -All Agenda for Action
The need for change was certainly aug mented by the powerful global move ment towards Health-for-AII by the Year 2000, and the necessity to orientate na tional health care delivery systems to wards primary care to serve that goal (WHO Alma Ata, 1978).The role of the health-professions education institutions in response to the health needs of popu lations gained prominence during the eighties.In an Agenda for Action the universities internationally were chal lenged to prepare health professionals for the prospective needs and demands of society (World Health Organization, 1991).

National Health Care Policy of the New Government, South Africa
In the National Health Care Policy the then new government places much em phasis on Primary Health Care, as a means of improving and maintaining the health of the South African population (Department of Health, 1996).The de livery of a comprehensive, high-quality primary health-care service has been a priority, especially for com m unities in underserviced areas.

National Commission of Higher Edu cation, South Africa
The National Commission of Higher Edu cation recommended that health-education institutions should revise their cur ricula in order to equip health-care stu dents and health-personnel educators with a comprehensive knowledge, com petency and attitudes to respond to the health-care needs of the population of South Africa (National Commission on Higher Education, 1996).In reality this meant contextualizing of learning and narrowing the gap between curricular content and the realities of health-care practice.

Community Partnership Programme
In 1991 the School of Nursing became involved in the development of a Univer sity Community Partnership Programme in the black community of Mangaung in Bloemfontein.This project was eventu ally funded by the Kellogg Foundation.A lth o u g h the p ro c e s s of b e c o m in g aware of and questioning the teaching process to which students of the School of Nursing were subjected, was initiated by many factors, awareness of the ne-

The srategies for T a b le 1 : T h e p ro ce ss o f c h a n g e implementing change
The strategies, described by Mennin and Kaufm an (1989), served as framework for the implementation of change in the School of Nursing, and they are associated with five phases of the process (see Table 1 The proc ess of change.):

Getting started
Part of the very first phase was not too plan too far ahead, but to get started so that the innovative program m e could become a reality expeditiously, and considering factors that could sustain change.
Numerous reservations, doubts and questions concerning the innovative track em erged in and outside the S chool.It was realized that w hile thoughtful planning and broad-based input could relieve anxiety, waiting too long could actually magnify doubts and paralyze decision making.The cessity for change became a reality dur ing the course of contact with commu nity members and the identification of their health-care needs.This particular project had a significant impact on the nursing programme.

Educational methods and strategies
The teaching approach followed in the School of Nursing was not adequately synchronized with principles of adult learning, with the result that many stu dents lacked problem-solving and critical-thinking skills.Passive academ ic behaviour was common and some stu dents demonstrated an inability to inte grate and apply know ledge from the basic sciences in the clinical context.The staff of the School were eager to produce assertive graduates who would be sci entific thinkers and lifelong learners, ca p a b le o f a d d re s s in g the c h a n g in g health-care needs of communities.

Change in the student profile
The student profile in the School of Nurs ing has changed rapidly since 1994.Stu d e n ts from d e p riv e d sc h o o l b a c k grounds were adm itted to the degree course and had specific learning and developm ental needs that dem anded attention.This support and development had to take place within the programme in the academic environment and clini cal practice.The programme that was developed to address the specific needs of these students indicated that the ad a pta tion and te ach ing app ro ach re quired that students had to: -be actively involved in the learning ma terial; -learn to work together in groups, pro moting their professional status, role and cooperation; -learn to solve problems; -learn that they could learn independ ently; -be protected from stressful experi ences in the teaching situation; -make personal contact with lecturers; -integrate learning material; -learn culture sensitivity; -read effectively; -write effectively; -learn language proficiency; and -develop inter-and intrapersonal skills.
The conclusion was that the specifica tions for change, identified through the exploration of the external and internal forces, could be addressed by im ple menting the principles of adult learning that pertain to problem-based learning, whereas the emphasis on awareness, responsiveness and accountability in addressing the health care needs of communities, could be achieved through community-based education.
The Head of the School supported the movement towards an innovative pro gramme, and initially identified one, and later two additional lecturers, to assist in taking the process forward as a team.
After extensive national and international exposure, the team members became advocates of problem-and communitybased learning.They also took a per sonal risk by supporting a then relatively unknown teaching methodology in the School.This team would be in charge of the process of change to a new teach ing strategy for the two years that fol lowed.
All innovative-tracks program m es re quire special financial allocations due to the cost incurred in the developm ent phase.Financial support helps to vali date the worth of the project, and en courages acceptance within the institu tion.It is also enormously costly in staff and time to create programme and re source materials de novo.
Educational resources and ideas were obtained from conferences, and visits to nursing schools and faculties of health sciences, nationally and internationally.
External funding was sought and ob tained, and these resources were used to support the planning and implemen tation of the project for five years.These funds were invaluable.Not only did they create opportunities for development; they also allowed us to equip a seminar rooms, purchase equipm ent, and ap point two additional lecturers to substi tute fo r team m em bers who were in volved full-time in the implementation of these new initiatives.

Building support and overcoming resistance
It is of crucial importance for planners to build support from different departments in the institution, as well as the relevant com m unities and governm ent institu tions.Equally, isolation from these part ners should be avoided at all cost so that their ability to contribute productively to the innovative initiatives are not jeopard ized.
The p lanners of the innovative p ro gramme held workshops to familiarise partners with new teaching initiatives; moreover, staff were invited to attend several training sessions on the imple mentation of the programme.The train ing sessions were considered to be criti cal in building support for the new ap proach and prom oting confidence in staff.Staff were also fully involved in the development of a new programme and in the production of teaching materials.
It was also envisaged that staff could obtain o w nership of the program m e through these interventions.

Curationis September 2000
Although support is most important, the basic values underlying the innovation should be protected and defended at all times so that specific educational meth ods are not compromised in any way.
The critics' assessments were acknowl edged so that even they would have ownership -this was achieved by tak ing their criticism seriously and making modifications to plans of action on the basis of their feedback.
Staff are more likely to support innova tive programmes that are consistent with their values, and if they feel they retain ultimate control over its continuation.The innovative programme was there fore described as an experiment that had to be evaluated.

Evaluation
It is most important for planners o f inno vative programmes to establish feasibil ity, effectiveness and the effects on stu dents and the institution.Evaluation re quires the collection o f baseline data, periodic assessment, as well as quanti tative and qualitative measurements.To this end, one Ph.D. study has been com pleted and two masters degree studies are nearing completion.(The results are and will be published elsewhere.) In addition, one of the most important contributions to the field of education involves the evaluation of the process of change and sharing a rigorous analysis of the change process itself, such as the strategies that yielded either success or failure, and the context in which these were applied as the forces that sup ported and opposed change.Since es tablishing the programme, our network ing and communicating change, the pro gramme and the School have gained in prom inence at the University.Several lecturers have also been invited to share implementation experiences at national and international level.

Networking
Developing institutional linkages is im portant.Refreshing insig hts em erge when health-science institutions share how e d u ca to rs from d iffe re n t b a ck grounds and cultures identify and solve educational problems.
Networking was done at national and international level.Planners of the inno vative programme attended international conferences, visited Schools and under took field trips where similar initiatives were implemented.Exposure to these experiences was later expanded to the rest of the staff involved, and this seemed to be crucial in creating a sense of un derstanding and coherence during im-

AL AND FIC OMES
: Conceptual framework plementation.The School also obtained membership of the International Network of Community-oriented Educational In stitutions.This membership has been fruitful in obtaining and exchanging in form ation with institutions with similar innovative programmes.The School is in the process of developing a "sister school" relationship with another insti tution.

Options for the future of the programme
After a trial period, the innovative pro gramme will demonstrate its worth and encourage conversions within the insti tution.
The School of Nursing has transformed the nursing courses, but the other basic courses are still offered in the traditional mode.From discussions with other aca demic stakeholders it is clear that when enough is known about the curricular changes to be made, action should be taken on the basis of this knowledge.An attempt should be made to transform the entire programme to be consistent with the content and methods employed in the innovative programme.The present option of combining the two tracks into a hybrid may be sustained.

Conceptual framework
The new conceptual framework involves com m unity partnerships and em pha sises the health-care needs of commu nities and the learning needs of students.
The new approaches clearly indicates the emphasis on the above-mentioned needs (see Figure 1).

Problem-based learning (PBL)
Problem-based learning as a teaching methodology has been extensively theo rized and its application in a number of practice-based professions has been reported in som e detail (Townsend, 1990, Boud & Feletti, 1991).It is one of an in c re a s in g ly large ran ge o f a p proaches to teaching and learning which challenges traditional educational as su m ptions a bo ut know ledge, kn ow l edge ownership (expertise), and appro priate pow er re la tio n s h ip s betw een teacher and learner.
D ifferent in te rp re ta tio n s of problembased learning exist.The School of Nurs ing associates w ith the d efin itio n of McMaster University, where the analysis of health-care problems is seen as the main method of acquiring and applying knowledge, the developm ent of inde pendent lifelong learning skills by stu den ts and the use of sm all tu to ria l groups, with five or six students and a tutor in each group as the central edu cational event (Neufeld, W oodward & Mac Leod, 1989).
Thus, in problem -based learning the learners focus their attention on a prob lem which may be clinical or communitybased.While attempting to define, ana lyse and solve the problem through the process of sharing experiences and work, students learn fundamental prin ciples and facts, which can be trans ferred to different problems they may encounter in the future.Concurrently, they also learn the process of problem solving.Learning is thus both meaning ful and relevant.
Students are encouraged to define their own learning issues, arising from the problem at the first tutorial where the problem is presented.Work is allocated in the group and the students undertake learning tasks on their own and report back at the second tutorial.The group then attempts to answer questions from the problem they have been given.The effect of this process is that not only does the student acquire knowledge and de velop self-directed learning skills, but im portant social and com m unication skills are required.A high level of moti vation and interest is maintained among the students (Prideaux, Farmer & Rolfe 1994).
According to Schmidt (1993), central to the process is that, while thinking and talking about the particular problem, stu dents build a context-sensitive structure of the processes, principles or mecha nisms underlying the visible phenom ena, which may help them understand the complex problems presented.
This constant supportive challenge of the level of m etacognitive awareness, combined with the application of knowl edge, skills and attitudes, encourages "deep" rather than "surface" approaches to learning by students.Students end up acting as reflective practitioners (Van Niekerk & Van Aswegen, 1993).
The underlying principles incorporated in this teaching m ethodology are: • to shift learners towards independ ence for example moving away from the narrow world of the teacher and text; • the development of analytic and crea tive thinking skills; • the development of self-directed learn ing abilities; • the encouragement of co-operative learning; • the integrated application of skills and knowledge in the context of practice; and • the encouragement or motivation to engage in learning.

Community-based education (CBE)
A c o m m u n ity -b a s e d e du catio n p ro gramme is one that functions in partner ship with communities and service pro viders.Exposure to this approach gives students the opportunity to understand the capacities and initiatives of the com munities they serve.On the other hand, communities are also given the oppor tunity, through interaction, to understand the stre n g th s and lim ita tio n s of the health-care system, and in the process they may learn to take care of their own health.
The com m unity-based education ap proach used by the School of Nursing can be classified as an interdependent, consultative, training-focused, and serv ice-orientated programme.The levels of community, university, health-care serv ice and student involvement are high.
Community involvement is considered to be high due to the community partner ship programme.The communities were selected and prepared for communitybased education by two lecturers, in collaboration with community leaders, in the community partnership programme.Community members accom pany stu dents in their communities to familiarise them with the environment and cultural activities and to assist them in interpret ing patient data as some students are not familiar with the languages spoken in some communities.This service to the students is arranged by established committees.
Student involvement includes providing a health-care service; the involvement of the university is in the technical, finan cial and academic fields, and such in volvement is enhanced through owner ship and commitment to the community partnership program m e. Facilities for rendering a health care service is pro vided by the Provincial Administration.
The unique opportunities for learning offered to students by this approach not only develops their ability to address the real health care needs of communities, but also develops their interpersonal skills, such as leadership characteristics, the ability to work in teams and compe-tence to interact with communities.
It also provides opportunities to staff for improving student and programme as sessment, such as the assessment of communication, management and lead ership skills (see figure 2).

Conclusions and summary
This problem-based learning and com munity-based education approach has been considered as a developmental and support model for teaching/learning and seems to meet the needs of the stu dents and com m unities.In teaching/ learning, it involves facilitators, lecturers, student support services, communities and health-care services (see Figure 2).Because problem-based learning takes place in small-group context, students may be supported in their efforts to at tend to their socio-economic, non-cognitive, psychological, health and lifestyle needs.Attention can also be paid in the small groups to learning cultural sensi tivity, which is of great importance for political reasons in South Africa.Com munity-based learning contributed in no small measure to this dimension.The limitations of the teaching process that were highlighted by the external and in ternal factors discussed above are also addressed in this model.
the school and other similar institutions that are well-established (nationally and internationally).* Develop a sister school relationship; and * Affiliate with a larger, recognized and well-organized organisation or net work.PHASE 5 Options for the future of the programme * Maintain the innovative programme; * Merge the two tracks into a hybrid; and * Convert the entire programme to the innovative track.