Facilitation as a teaching strategy : The experiences of nursing students

Curationis 28(4): 5-11 This study was undertaken to assess the needs/problems of students of nursing regarding facilitation as a teaching/learning method. Facilitation as a teaching and learning strategy was uncommon and innovative in nature and presented a challenge to the students as it was a new way of learning. Focus group interviews were conducted. The sample study consisted of eight (8) groups of learners from four universities engaged in this curriculum. To answer the research question a qualitative, exploratory, descriptive design was used and the students were selected purposively. Data analysis using transcribed focus interviews, was based on the combined approaches of Tesch (1990) in Cresswell (1994:153-155) and the basic steps of Giorgi (1970) as quoted by Ornery (1983:49-63). The themes identified were about the experiences of the facilitation process and problems with the facilitators. All the students experienced the facilitation of learning negatively in the beginning but became more positive later when they adapted to this method of learning.


Introduction
For decades the schools and universities in South Africa implemented a learning system which was lecture-based and co n ten t o rien ted .In the n in eties education was put under pressure to change from lecture-based and content oriented approaches to student-based learning.This transformation has also put nursing education in the spotlight to change (R epublic o f South A frica, 1995:5).For the education of nurses at

Curationis November 2005
university level it w ould m ean the following: Students would take a more active part in learning while lecturers changes their roles from that of autocratic dictators to that of facilitators of learning, leading students on their own paths of creative thinking.Students then would formulate and solve problems themselves and while being lead by a facilitator to develop their own paths of thinking.
The new orientation of learning came about in 1997 when the higher education policy directed tertiary institutions to broaden participation in the education to satisfy the developmental needs of the whole society (Republic of South Africa, 1997:1).In accordance with this directive some of the nursing departments in South A frica introduced com m unity-based education (CBE), and problem-based learn in g (P B L ), a stu d en t-cen tred approach which is different from the previous lecture based and content focused approach.The students were not used to self-directed learning.The challenge flowing from this change in ed u catio n strategy is to produce students who, at the end o f a o f a baccalaureate degree, are self-directed learn ers.T his challenge faces all ed u cato rs in h ig her education as educators should aim more broadly to develop the self-learning skills and personal growth of students (Uys & Cassimjee, 1997:132-138).

Problem statement
The m ajority o f students entering un iversity com e from a traditional learning background which is lecturebased and content oriented.According to Conrick (1994:237) these students have been indoctrinated over twelve years in the educational behaviourist theory which limited their development of self directed learning and problem solving.Until recently the same approach was used in nursing education.In contrast w ith this approach p roblem -based learn in g (PB L) dem ands active participation from the students.The stu d en ts who re g ister fo r the undergraduate nursing course come from school backgrounds where self-directed learning until recently has not been encouraged (Becker, 1999:4).Students therefore have to negotiate a range of adaptations as they make a transition from traditional learning behaviours to the self d irected , stu d ent-centred approach (D avies, 2000:15).It is during this transition that the students do not cope and experience problems with facilitation.B o u lto n -L ew is, W ilss and M utch (1996:84-106) found that students who continue with tertiary study bring with them considerable informal and formal know ledge of the learning process derived from earlier formal study.These stu d en ts still need to adapt to the facilitation process.
It was clear from these statements that the general education in any university m ust respond to the needs o f the students who enroll at these institutions (Giczkowski, 1995:13).Since students are u n fa m iliar w ith learning by using facilitation, their needs regarding the method are not known.It is therefore important to make an assessment of their needs in order to identify problems they may encounter.

Aim of the study
The aim of this study was to determine the experiences of students with regard to facilitation in the problem -based learning (PBL) and community-based ed u catio n (CBE) undergraduate programme of the Schools of Nursing of four (4) universities in South Africa implementing PBL in their curriculum.

Objectives
The objectives were to:

Research design
To answ er the research question a qualitative, explorative, descriptive and contextual approach was used.

Population and sampling
The p o p u latio n o f this study was purposively selected and included the learners in the schools and departments of nursing of four (4) South African u n iv ersities using fa cilitatio n as a teaching-learning method.Two main groups consisting of first and fourth years students were selected in each university.
The first years were in different group than fo u rth years.The re searc h er purposefully decided to include the first and the fourth year students for the purpose of obtaining the experience of those who have never being exposed to facilitation and those who had a great amount of exposure.The reason was that the experiences were expected to be different and it was easy to obtain data from a homogeneous group.
In total focus group interviews were conducted with eight (8) groups of students from four (4) universities.One group of the total of eight ( 8) was used 6 Curationis November 2005 as a pilot study.Each group of students consisted o f males and females from different cultural backgrounds.They also differed in their level of academic achievement ranging from low, average to high achievers.Each group consisted of learners in the same year of study.

Data collection
Data was obtained by conducting focus group interviews with students.This is a special kind of interview situation that is largely q u alitativ e.The m o derator c o n d u c te d focus in terv iew s.The purpose of the interviews for this study was to obtain in-depth information from a few cases.This is characteristic of qualitative research (Moloto, 1999:38).Data was collected until saturation was reached (Parse, Coyne, & Smith, 1985:17).One primary open-ended question was asked and it w as, : " How do you experience facilitation as a teachinglearning method?".Field notes were taken by the researcher.These are broad, more analytical and more interpretive than a simple listing of occurrences (Polit & Hungler, 1993:215-216).The field notes were taken to validate information given by participants.

Data analysis
Data was analyzed using the qualitative analysis technique of Tesch (1990) as explained in Creswell (1994:153-154), as well as the basic steps for qualitative analysis by Giorgi (1970) as quoted by Omery (1983:49-63).According to Tesch (1990) data analysis requires that the re se a rc h e r be co m fo rtab le w ith developing categories.The transcribed audio-taped material from the focus group interview is reduced to categories and then themes which are interpreted acco rd in g to Tesch (1990) called " d e c o n te x u a lisa tio n " and "re c o n te x u a lisa tio n " is done.This analysis process consists of "taking apart" smaller pieces whereby the final goal will be the emergence of a larger consolidated picture (Tesch, 1990(Tesch, :97 in C resw ell, 1994:154):154).R eading the tran sc rip ts rep eated ly , id en tify in g sum m aries, elim in atin g red u n d an t inform ation, transform ing concrete information to usable scientific data then categorizing it according to repeated tendencies constituted the steps of data analysis according to Giorgi (1970).The researcher read through all interviews.As topics emerged, they were written in the margin.When this was completed, a list of all identified topics was made.Similar topics were clustered together, and this were arranged as major topics.Then the best fitting nam e that captured the substance was chosen for the clustered topic.The clustered were abbreviated as codes.The codes w ere w ritten next to the appropriate segment of the text.This process led to the discovery of new to p ics th at w ere not prev io u sly identified.In summary it can be stated that data was organized and refined; the most descriptive wording for the topics was found and then were turned into categories.

Reliability and validity of data analysis
In this research consistency, dependability, conformability, credibility and transferability (Leiniger 1991in Brink 1996:124) were used to ensure reliability and v alid ity .F our c rite ria for trustworthiness in terms of true-value, applicability, consistency and neutrality will be discussed.

Credibility (truth-value)
Truth-value determ ines w hether the researcher has established confidence in the credibility o f the findings of the research .In q u a lita tiv e research credibility refers to internal validity (Brink, 1996:124).In th is research crossexamination of data was carried out to confirm the credibility of the results.A literature review was conducted to control the data by comparing it with available literature and relevant research.
The re se a rc h e r co n ducted crossexamination by arranging for a moderator to be present during focus interviews whilst the researcher took field notes.The researcher and the moderator compared their data directly after focus group interviews to validate that information was heard correctly.

Transferability (applicability)
G e n eraliza tio n can n ot be m ade in q u alitativ e research because every research situ atio n is m ade up o f a p a rtic u la r re searc h er in p artic u la r interaction with particular informants (Lincoln & Guba, 1985:316).The study will therefore provide only the description necessary to enable someone interested in making a transfer to reach a conclusion that transferability may be contemplated as a possibility.

Dependability (consistency)
Consistency determ ines w hether the findings would be consistent if the inquiry were replicated with the same participants in a similar context.Variability can be expected in qualitative research due to the fact that the instrum ents assessed are the re searc h er and informants, both of whom vary greatly within the research project.Seeing that qualitative research em phasizes the uniqueness of the human situation, it is variation rather than identical replication that is sought (Field & Morse, 1985:11).Because variability can be expected in qualitative research, consistency is defined in terms of dependability.The research findings therefore depend on whether the learners have had more experience of the facilitation process because if they do then data will differ.To ensure consistency students in the sam e year o f study w ere grouped together for example first years were interviewed together but separate from fourth years.The same was done with the fourth years.

Confirmability (neutrality)
C onform ability guarantees that the findings, conclusions and recommen dations are supported by the data and that there is internal agreement between the investigator's interpretation and the actual evidence (B rink, 1996:125).Neutrality refers to the degree to which findings are a function solely of the inform ants and co n d itio n s o f the research.Freedom from bias in the research p rocedures and results is im portant, not the researcher's prior notions, motivations and perspectives.In qualitative research the value of findings increases when the distance between the researcher and informants is decreased (Lincoln & Guba 1985:323).These writers shift the em phasis of neutrality from the researcher to the data.The neutrality of the data becomes the important factor and not the neutrality of the researcher.L incoln and G uba (1985:32 3) fu rth e r suggest that conformability is the criterion of neutrality which is achieved when truth-value and applicability of data is established.The moderator was an expert with regard to group dynamics as she was a psychiatric nurse specialist with qualitative research experience.
The m oderator was an ex pert in conducting focus group interviews in an objective manner and that added to the maintenance of neutrality.

Ethical issues
Participants were fully informed about the research.S tudents w ere invited to participate freely and to mention their needs as well as problems without fear of victim izatio n or intim id atio n .
Confidentiality was maintained as raw data was only accessible to the researcher and the independent coder.Recorded data was destroyed when the research was completed.Participants were also inform ed that they had the right to withdraw from the research if they did not want to continue.The researcher m ust respect the autonom y of p artic ip a n ts to decide about th eir involvem ent in any research study (Gelling, 1999:42).To ensure that this ethical issue was adhered to the protocol was subjected to the critique o f the E thical C om m ittee o f the F aculty concerned.Permission was sought and granted by all authorities where research was conducted.

Definition of concepts Facilitation
Facilitation is a learning process where students are led by a facilitator through their own paths of thinking to show how they come to a certain conclusion (White &Ewan, 1991:107).

Problem-based learning
A definition of PBL is elusive because several variations have been developed  1994:7).Some researchers, such as Boud and Felleti (1991:21) define PBL as an integrative programme of study that engages students in problem-formulation and solving.For the purpose of this study PBL is an instructional method in which the students are self-directed in their learning using patients' problems to learn problem solving skills.

Self-directed learning
This is a student-centred approach where students are facilitated into an active role in learning (Moloto, 1999:24).Brookfield (1985), as quoted by Uys and Cassimjee (1997:132-138), states that self-directed learning does not mean that students' work completely on their own but that they interact with resource people.

Results and discussions
Three main themes regarding facilitation process were identified ; experience of the stu dents in general, fe e lin g s/ emotions related to facilitation process and problem s related to facilitators.
Responses from students as indicated in figure 1 explains the reasons for them ex p erien cin g fa cilitatio n process negatively when they were initially introduced to this strategy of learning.

Students' experience of Figure 2 Emotions of students facilitation method in general
All the students stated that they found facilitation initially difficult due to various reasons as indicated in Figure 1.
The students m entioned that it was difficult for them to adapt to the process of facilitation because to them it involved change from the lecture method which they were accustomed to as indicated in figure 1.The following excerpts and accompanying literature illustrates the students' experiences "The first time it was difficult for me because it is a change from what we are used to".
"It is not done like the way it is done at school.At school we are just basically lectured".
"You are so used to having someone standing in front of you and lecturing at school and all of a sudden all that changes.It becomes a challenge".
The school setting is different from the university.Students at school are used to relying on their teachers as the source of information.For the most part they do not ch a lle n g e the teacher and the information imparted to them is taken as "gospel" meaning something which is safely believed (Conrick, 1994:238).Rees (1991:43)

Emotional experienced by students
The difficulty of facilitation process and the expectations of facilitators elicited certain em o tio n s am ongst the students.The students in this research expressed m ostly negative em otions when they were first facilitated but positive emotions were also expressed as indicated in Figure 2.
Figure 2 denotes emotions as mentioned by the students during data collection.These emotions were both negative and positive for some students.The following excerpts illustrates the how students' expressed those emotions "Looking at the person who introduced PBL you somehow hated them".
"The difficulty is you become scared and depressed" .
"Initially it was more of a shock than anything" Students opinions may have been that that they could not learn by being facilitated as they did not understand the facilitation process and this was the possible cause o f negative em otions amongst them.Researchers have found th at startin g a d egree m ay cause frustrations especially when student expectations about the university turn out to be entirely different from what they envisaged when the subject's content differs from what they expected (Peelo, 1994:37).Most students were shocked by the idea of being facilitated and not lectured.The shock may be related to the expectations about the course and the responsibility associated with it (Taylor, 1997:28).
One student experienced facilitation positively and said: "For me it was amazing, I had to be my own lecturer, it was just a wow!!I felt good that I have done so m eth in g " .T his student dem onstrated p o sitiv e feelings in contrast to other students.Kirkpatrick (1985) in Holtzhausen (1999:54) states that change, with special reference to h ig h er ed u catio n al change, causes different em otions w ithin different individuals as some will associate it with anxiety and fear whilst others view it with hope and as a solution.

Problems that students experienced with facilitators
The students spelt out some general problems with facilitators which they experienced as h in d ran ces that contributed to making facilitation difficult as indicated in Figure 3.
During data collection it seems that students were dissatisfied about their fa c ilita to rs because o f lack o f understanding of the facilitation process as indicated in figure 3.
The students views were that facilitators were not working and that they gave their work to them.One student said: "Another thing you see that the facilitators they are just resting, they are taking all the work to the students.You don't see if the facilitator has prepared anything they dig information from you" .This is a classical case of misunderstanding of self-directed learning (Brookfield (1985) in Uys & Cassimjee, 1997:132-138).As such the fa cilitato r can be seen as inherently lazy because of the changed roles.Brookfield (1995:13) states that learners often complain that facilitators are abdicating their educational role by placing on the learners the responsibility for making judgments about the content and direction which they as students are not equipped to do.Townsend (1994:107) emphasizes that students need to take control of their learning and becom e self-sufficient learners who are pro-active, challenge and question set deadlines.Furthermore they must find resources for themselves and facilitators m ust let go of their authority to enhance student growth and autonomy.Other students experienced that facilitators did not guide them because of the perception of their being self-directed learners.The following excerpt and accompanying discussions from the literature illustrate this experience of the students: "I think it has to be explained thoroughly to som e o f the lectu rers, because although the stu d en t w orks independently the lectu rer has to participate by directing students.It seems other lecturers do not know that.When they come to facilitate all that they said was that, 'I understand that you are PBL stu d e n ts' and they gave us no direction".This is also a problem related to the misconception of self-directed learning (SDL).In SDL the process of learning and teaching is learner-centred (Lunyk-Child, Crooks, Ellis, Ofosu., 0 "Mara.& Rideout, ,2001:117).Rooth (1995:25) has observed that some facilitators incorrectly believe that because there is a great deal of freedom in facilitation, one should give minimal direction.Eaton (1999:85) states that in a learning environment a certain type of experience has to be gained but learners do not know specifically what is available to extend their learning, and require a great deal of guidance.It is therefore imperative that facilitators guide the students on how to extend their learning by giving them structure.
Students were frustrated with facilitators who would not accept that they lack knowledge in some areas.One student asserted: "When you say something that she doesn' t know she will not accept it, she thinks it is wrong because she doesn't know".This behaviour shows lack of knowledge of the self and selfunderstanding.Mulholland (1994:42) found that in open discussions as in facilitation, gaps in knowledge become apparent and learners may ask questions to which the teacher does not know the answ er.T his is th reaten in g to authoritarian teachers who are required to fa cilitate learning .M ulholland (1994:42) explains that it is not necessary to know everything or even pretend to have know ledge.R ooth (1995:21) m en tio n s that it is im portant that facilitators become aware of their limits and be wiling to acknowledge that they do not know everything.They should have a strong sense of who they are, believ e in them selves, know th eir potentials, abilities and lim itations.Brockbank and McGill (1998:161) state that facilitators must recognize that they can make mistakes and admit that they do not know everything.

Conclusions
It is very evident from the discussion that the students experienced facilitation as a difficult teaching method because of the way in which facilitation differs from the lecture method.Katz (1995:54) states that in facilitation there is a change in the locus of control because the students are involved in their learning.Brown and Smith (1996:49) agree that with the traditional lecture method the content of the material is entirely within the control of the lecturers.It is indeed this lack of control that threatens the students as well as the facilitators and which makes them reluctant to want to accept that they lack knowledge in some areas.Students sh ould be enco uraged to seek inform ation regarding strategies that institutions will use to educate them when they apply to study.Orientation sessions that simulate facilitation process should be organized at the beginning o f the study term so that students can have an idea of how their learning will take place.Neville (1999:400) states that students should be given a clear structural plan w hich is a course outline.S teinert (1996:203) believes that setting clear goals and objectives can be of assistance in student learning.It is imperative that students should be given some structure to guide them especially in their first year of study.Students who are already in the programme and has already experienced learning through facilitation process for example those in their second or third year of study, should be appointed as mentors to the novice to support them.Data collected also seem to indicate that facilitators were uncertain of their roles as some did not provide guidance to students.Facilitators should also be trained to equip them with facilitation skills.

Recommendations
R ecom m endations for the study are sp ec ific ally focused on stu d en t orientation, empowerment and support as well as the role of facilitators.

Orientation of learners
Information about the learning method and facilitation process should be sent to the students when they apply to study so that they can make informed choices prior to acceptance.They should have knowledge of the method of learning they are going to use in their tertiary education.Knowledge of what one is dealing with helps alleviate anxieties and p eople can prepare them selves emotionally to deal with change.
The students should be given sufficient orientation to outline their work pattern th ro u g h o u t the year.In ad d itio n a structured plan should be provided especially with students who are in their first year of study since those who are completing are more experienced and have adapted to the process of facilitate Support for students

Figure
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