Computer-supported Collaborative Problem-based Learning:
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Som Naidu and Mary Oliver
VOL. 11, No. 2, 1-22
It is hypothesized that problem-based learning has many advantages for learning and teaching, especially in practice-oriented professions. Although there is consensus on the generalized view of the process, there is not much in the form of specific guidelines on how problem-based learning (PBL) can be put to maximum use in group-based learning and teaching environments. Furthermore, little is known about what actually happens in the various phases of the process (such as problem analysis) and how these can be activated and systematically enhanced. The project reported in this paper set out to fill this particular void.
Nurses encounter problem situations on a regular basis as part of their work, which makes it imperative that graduating nurses are conversant with the problem-solving process as they make their transition from the classroom into the workforce. A sure and quick way to ensure this transition is to engage students in problem-based learning. In the course selected for this project, students were presented with three authentic problem situations representative of the content of the course. Students were required to approach the study of the problem with a defined architecture, which required focused reflections and the presentation of a critical reflection record at the end of a study period. All of these learning activities took place in a computer-mediated communications environment that enabled sharing of opinions and views on each of the problems among the student group. A study of the critical reflections of students on the problem situations revealed evidence of a systematic approach to problem analysis and problem solving.
On suppose que l'apprentissage par problèmes recèle de nombreux bénéfices tant pour l'apprentissage que pour l'enseignement, notamment dans le cas de professions axées sur la pratique. Bien qu'à priori il y ait consensus quant aux grandes lignes du processus, il n'existe néanmoins que très peu d'indications spécifiques relatives à la façon par laquelle l'apprentissage par problèmes peut maximiser l'efficience d'environnements centrés sur l'apprentissage collectif et l'enseignement. Par ailleurs, le niveau de connaissance de ce qui se passe dans chacune des diverses étapes du processus (tel l'analyse du problème) de même que comment celles-ci peuvent être activées et systématiquement améliorées, demeure encore aléatoire. Le projet présenté dans cet article avait pour but de combler cette lacune.
Les infirmiers et infirmières rencontrent régulièrement des situations de problèmes dans l'exercice de leurs fonctions, d'où l'importance de voir à ce que la formation dispensée aux nouveaux-nouvelles diplômé-es leur permette d'être adéquatement familiers-familières avec le processus de résolution de problèmes lorsqu'ils-elles font leur entrée sur le marché du travail.
Une façon rapide et certaine de s'assurer de cette transition est d'impliquer les étudiant-es dans un apprentissage fondé sur la résolution de problèmes. Dans le cours choisi pour ce projet, les étudiant-es étaient confronté-es à trois situations authentiques où les problèmes présentés étaient représentatifs du contenu du cours.
Les étudiant-es devaient aborder l'étude du problème selon une démarche qui nécessitait des raisonnements orientés ainsi que la soumission, au terme de la période d'étude, d'un dossier des raisonnements les plus déterminants. L'ensemble de ces activités d'apprentissage s'est déroulé dans un environnement de communication assistée par ordinateur, ce qui a permis aux étudiant-es de partager leurs opinions et perspectives sur chacun des trois problèmes posés. L'étude des raisonnements critiques soumis par les étudiant-es en rapport avec les situations de problèmes révèle la présence d'une approche systématique face à l'analyse et à la résolution de problèmes.
Despite several hours of supervised clinical practice in situ, many graduating nurses find their transition from the classroom into the workforce a stressful and traumatic experience. In the Australian context and perhaps elsewhere, too, hospitals and other employing institutions attempt to facilitate this transition process with graduate nursing and preceptor programs. Many of these programs are under strain as the institutions experience pressures on their staffing pool (DEETYA, 1994). To relieve the employing institutions of some of this responsibility, we believe that nurse educators and nursing education programs can and should be taking on a greater amount of the responsibility for the preparation of graduating nurses in their transition from the classroom into the workforce. They can undertake this responsibility by careful integration of authentic clinical decision-making processes into the existing curriculum content. This paper describes the architecture of one such attempt and its outcomes for the student cohort.
The project described in this paper was carried out within the context of a final year subject-Trends and Issues in Nursing II-in the Bachelor of Nursing program at University of Southern Queensland, Australia. This course, which examines legal, ethical, and practice issues in nursing, is taken by all final year undergraduate nursing students. These students who come to nursing education after finishing high school have limited knowledge and experience with approaching and solving clinical problems in practice-based situations. One of the causes for this deficiency in their education is the way their clinical education is currently structured. As trainees on supervised clinical practice, they are not offered the opportunity to take responsibility for clinical decision making. Decisions about the patients’ welfare is the responsibility of the clinical teacher whereas the student nurse is responsible for providing only individual components of patient care. In sum, then, nursing students have limited opportunity to develop clinical decision-making skills during their undergraduate study and as part of their clinical practice.
In the course-Trends and Issues in Nursing II-we sought to change this situation by providing final year nursing students with an opportunity to take on some responsibility for clinical decision making within their classroom education and outside their supervised clinical practice. We used a widely known learning strategy called problem-based learning within a computer-supported collaborative learning environment.
It is hypothesized that problem-based learning (PBL) has several advantages for stimulating cognitive processes. For instance, Schmidt (1993) emphasizes the cognitive effects of PBL in terms of knowledge activation and elaboration. However, despite the presumed benefits of PBL in facilitating cognitive and metacognitive processes, little is known about what actually happens in the process and how PBL can be utilized to achieve these learning outcomes. A generalized view of problem-based learning can be seen as comprising several phases spread over periods of group work and individual study (Barrows &Tamblyn, 1980; Schmidt, 1983).
The procedure starts with identifying a problem situation via a case or vignette (cf. Figure 1: Present a Problem). Next, students engage in problem analysis. During this phase students generate explanations for the occurrence of the problem in this case (cf. Figure 1: Expressing First Perceptions of the Problem on CSCLE). Based on this exercise, students identify what they know and do not know about the problem at hand and make decisions about individual research (cf. Figure 1: Exploring the Problem and First Perceptions on CSCLE). As the next step, this individual study is carried out, and its results are reported to the group. Afterwards, a re-evaluation of the problem takes place, and first perceptions are perhaps revised (cf. Figure 1: Revising First Perceptions of the Problem on CSCLE).
Problem analysis plays a major role in problem-based learning. Schmidt (1993) argues that it serves at least four goals. First, it helps students mobilize whatever knowledge is already available to them. This activation of prior knowledge (cf. Schank’s [1986] “explanation patterns” and “scripts”) is important because it focuses the learning effort and facilitates the understanding of new concepts that have to be mastered. Group discussion, if it is possible (as it was in this current project), will help students elaborate on their knowledge. Confronting the problem to be understood and learning from other students’ knowledge of what might explain the phenomena, especially in a collaborative environment, can enrich the cognitive structures of the participants. The knowledge already available at this point becomes tuned to the specific context provided by the problem. Finally, the discussion of the problem in a group situation is supposed to engage the students in the subject to such an extent that epistemic curiosity is aroused to find out in more detail which processes are responsible for the phenomena described.
In problem analysis, the existing knowledge is questioned and evaluated, which should promote restructuring of that knowledge. Brown and Palincsar (1989) argue that change is more likely when one is required to explain, elaborate, or defend one’s position to others as well as to oneself. Striving for an explanation often makes a learner integrate and elaborate knowledge in new ways. Although social conflict and interaction can be a good trigger for causing change, these authors emphasize that change in knowledge is more the result of processes of co-elaboration and co-construction because of shared cognitive conflict. A typical cognitive conflict in an educational setting results from a disagreement between existing knowledge and new, anomalous information. Chin and Brewer (1993) reviewed research on the role of conflict in promoting conceptual change and they hypothesized that these differences are because of four cognitive attributes: status of the anomalous data in the perception of the students; characteristics of the prior knowledge; student’s perception of the credibility and validity of the new information; and processing strategies.
These aspects play a key role in whether a cognitive conflict is experienced and whether change will occur. Regarding prior knowledge, Chin and Brewer (1993) suggest that the entrenchment of the prior theory, beliefs, epistemological commitments, and the background knowledge can result in a high resistance to change. Furthermore, an alternative theory that is accurate, has a broader scope, is consistent, simple, fruitful, and comprehensible, is more easily accepted than a theory that lacks one or more of these qualities. Credible, unambiguous data stemming from multiple sources are also more easily accepted. Those theories that reflect the above characteristics are more easily accepted than other data. Finally, the processing strategies applied in the evaluation of anomalous data have different outcomes as far as theory change is concerned. Deeper level cognitive processing promotes such a change. These strategies include such mental processes as carefully attending to contradictory information, attempting to understand the alternative theory, elaborating the relations between the evidence and competing theories, and considering the fullest range of evidence. The specific combination of these four factors affects how students deal with anomalous data. Students may ignore anomalous data, reject or exclude it, hold it in abeyance, or reinterpret it. They can, furthermore, change their theory marginally or radically.
Problem-based learning is an instructional strategy that attempts to induce cognitive conflict within students with the expectation that it will cause conceptual change. This conflict may result from a disagreement or mismatch between the existing knowledge of students and the facts that the problem situation brings to light. The purpose of the study described in this paper was to see if conceptual change actually did occur for the students and, if it did, then what was the nature and form of that change. Since conceptual change itself is a highly subjective and personal phenomenon, it could not be subjected to quantitative measures. Some qualitative tools had to be developed. In this instance, these comprised, firstly, critcal reflection records designed to induce specific expected learning outcomes and, secondly, a semi-structured questionnaire.
The architecture of the instructional environment applied as part of this study is presented in Figure 1. The three critical ingredients of this design architecture are problem-based learning, computer-mediated communications, and collaborative learning. We will now describe the role of each attribute in th e environment.
Trends and Issues in Nursing II covers legal, ethical, and practice issues in nursing. In the CSC-PBL environment, each topic is studied within the context of an authentic problem that reflects real-life situations in typical work environments and by doing so makes learning realistic and meaningful for the learners. For each topic, students are presented with a problem in the following manner: The lecturer introduces the problem to students, outlines its attributes in detail, describes the learning process that students will follow, and defines the learning tasks that are to be accomplished.
Such a problem-centred approach to teaching and learning presupposes that knowledge evolves through social interaction, that cognitive conflict is the stimulus for learning, and that understanding is gained through our interactions with the environment (Cognition and Technology Group at Vanderbilt, 1991).
The bulk of the learning process takes place in an electronic environment with the help of computer-mediated communications technology. In this instance, students were organized into four groups and assigned to a mailing list with a unique mailing address running on a listserve software that enables group communication. A message (a piece of text) sent to this unique address on the mailing list from a remote terminal would be read by all registered participants of that group. The four groups were titled: Trends and Issues 1, 2, 3, 4.
For each topic addressed in this course, the learning experience in this electronic environment unfolded in four stages over a period of four weeks. In the first week, students were required to articulate their first perceptions of the problem as presented to them in the lecture and develop some hypotheses that were their conjectures regarding the problem, including its causes, effects, and possible solutions; then they were to outline how they were going to go about searching for evidence to support their hypotheses; and then they were to collect that evidence. They “posted” these comments on the electronic mailing list they were registered in so that everyone could read the others’ approach to the understanding and resolution of the same problem. In the second week, after reading the initial reactions and comments of others on their own thoughts, students were to re-examine their first perceptions of the problem, expand and refocus their conjectures regarding the problem, and, if necessary, revise their hypotheses and data gathering strategies and post these on the mailing lists. In the third week, as a result of the electronic discussions, students would be able to identify new or related issues, revise their conjectures regarding the problem, and perhaps make modifications to their problem resolution strategies. In the fourth week, students prepared and presented their own “critical reflection record” on the mailing list. This would be their final comment on the problem situation and how they sought to resolve it.
Each of the issues covered in the course (i.e., the legal, ethical, and practice issues in nursing) was treated in a similar manner. The assignment of students to electronic mailing lists and their use for the purposes of sharing students’ comments among a group was driven by the known benefits of collaborative learning. In collaborative learning, the emphasis is on partnership among students and between the students and the instructors. There is interdependence within the student group and an emphasis on personal and professional growth in all those involved in the learning process and also a shared responsibility for each other’s learning (Bruffee, 1995).
Current thinking on learning and instructional design focuses on supporting groups of learners collaboratively engaged in critical reflection and problem-solving activities. This more social and learner-centred focus represents a shift away from behaviourist approaches to instructional design. Viewing learning “in context” means two somewhat related and yet different things. On the one hand, it means that the social, interpersonal, and cultural surroundings within which learning occurs affect both the learning processes and outcomes. Secondly, “in context” has also come to mean that skills, strategies, and learning processes, rather than being relatively neutral tools available for varied general application, are closely connected to their immediate contexts of practice. They are thus highly situated (Lave & Wagner, 1991).
The three problem situations that comprised the focus of the learning activities in this environment were: circumstances surrounding a coronial inquest; managing ethically difficult care situations; multicultural nursing.
Mrs. A’s unexpected death in a Sydney Hospital on 2 February 1993 illustrates how a Coroner can not only reach a conclusion but also make recommendations about changes to protocols on the administration of medication. Mrs. A, a 79-year-old woman with chronic rheumatoid arthritis, was admitted to Liverpool Hospital on 13 January 1993 with a fractured pubic ramus. Although Mrs. A was in no way terminally ill, her general health could be said to be deteriorating. At the time of her admission, she had been prescribed Methotrexate (which is usually used oncologically) for her rheumatoid arthritis. Prior to hospitalisation, Mrs. A was taking Methotrexate 2.5 mg tablets weekly and in a single dose.
After Mrs. A’s admission on 13 January, Dr. B (who had just commenced her orthopaedic internship) filled out the medication chart. Instructions for the nurses concerning Mrs. A were legible and clear: “Take three tabs on Fri.” At this time there was no Health Department procedure or directive requiring hospitals to score out the days of the week on which medication was not to be administered. In this case there were six such days. Two days after admission, on Friday 15 January, Mrs. A was given a dose of Methotrexate in accordance with Dr. B’s instructions. That week ran from her date of admission-Wednesday 13 to Tuesday 19 January 1993.
The following week, Wednesday 20 to Tuesday 26 January, the first two days, Wednesday 20 and Thursday 21 January, were scored out as they were the previous week. But the remainder of that week, excluding the dosage day Friday 22 January, was not scored out. Sister C gave the prescribed dose to Mrs. A on Friday 22 January but then Nurse D gave her further doses on each of the next two days, Saturday 23 and Sunday 24 January. Nurse E gave a further dose on the subsequent two days, Monday 25 and Tuesday 26 January.
The following week, on Friday 29 January, a further dose was given by Sister F. The nurse had no difficulties in reading Dr. B’s instructions. Neither Nurse D, Nurse E, nor Sister F had the previous week’s scored out sheet at their disposal. Apart from mouth ulcers and chapped lips for which she was given Bonjela, Mrs. A’s health on 29 January remained relatively stable. Then between February 1 to 2 her condition suddenly deteriorated. She died late on 2 February. A Coronial inquest was held in Sydney in September 1994 before Coroner Abernethy.
A postmortem found that death was the result of gastrointestinal haemorrhage following, or due to, thrombocytopaenia due to, or following, coronary artherosclerosis [and] soft tissue haemorrhage. (Langslow, 1995, cited in Australian Nursing Journal, Vol.2, No 9, 1995)
A young female patient wanted her doctor to be precise about her cancer diagnosis. He was not on duty and therefore another surgeon on the ward gave her this information. The nurse caring for this patient knew that he was the wrong person to inform the patient about her severe cancer diagnosis and poor prognosis. The nurse let the patient know of her opinion and tried to persuade her to wait for her doctor, but the patient still wanted to be informed and so she was informed by the other surgeon. The patient reacted with anger and despair. The nurse states “even if you know the right thing to do, you do not always succeed.” The nurse found it hard to come to terms with the patient’s decision even though the nurse knew what was the good and the right thing to do in this situation.
Societal institutions are limited in their accountability to the needs of diverse populations and are not adequately responding to health promotion and illness prevention for multicultural populations. As a consequence, the diverse health needs of many individuals are not addressed because such problems are inappropriately identified as culturally based instead of being recognized as predominantly situational in origin.
Yet little emphasis is given to cultural concerns in the provision of services and in the development and imqplementation of policy. Society is being challenged to work with an increasingly changing population that is highly differentiated in terms of language, individual motivation, cultural identity, gender, religion and age, and the intra-and interpersonal resources available to individuals. Most significantly, the interactive effects of these factors must be understood as they impact on the health consumer. Nurses are in an ideal position to initiate care that is culturally sensitive and to monitor how these impact upon individual’s health status. (Adapted from Mardiros, 1992. In G. Gray & E. Pratt (Eds.), Issues in Australian Nursing, 3).
The project reported in this paper spanned 12 months, the first five of which were spent on the design and development of the course using a Problem-based Learning Model. Setting up the computer-mediated communication environment took up another four to six weeks, including registering students on the appropriate mailing lists and ensuring that the lists worked. The course is taught over 16 weeks from July to November each academic year, and there are usually about 80 to a 100 students. Our approach to the evaluation of the course in this instance was utilization focused, and so we were interested in the use and utility of the instructional design architecture to instructors and students. We were also interested in the effectiveness of the design architecture for achieving the learning and instructional outcomes that were identified.
Two types of data are presented and discussed in this paper. The first is an analysis of each student’s “Critical Reflection Record.” There were three of these records for every student (covering the three topics of the course). The second type of data was derived from a questionnaire that sought the student’s impressions on the use of computer-mediated communications and “reflecting in and on action” as a learning strategy as part of the instructional design architecture. These data are presented and discussed in that order.
For each one of the topics covered in Trends and Issues in Nursing II, students were required to produce a critical reflection record. It was a critical commentary that a student would make after three weeks of reflecting on a problem situation. Like all other reflective comments, the critical reflection record was to be presented on the mailing list so that all members of a mailing list could read the critical reflections of the others. Each critical reflection was to be more than a summary of the discussions that had taken place in the preceding weeks. It was to reflect critical analysis of the problem, including discussion of the following:
This critical reflection record was submitted as an assessable item, which was graded by the instructor using the above requirements as marking criteria. Students were given both generalized and individualized feedback on their critical reflection records.
The critical reflection records were intended to enable learners to develop skills that were considered desirable for facilitating their transition from the academic setting into the workforce. These reflection records were carefully analyzed to ascertain if indeed there was evidence in them of the expected learning outcomes for the students (see Figure 2). Each critical reflection record was examined for evidence of the extent to which it reflected the desired learning outcomes. Results of this analysis for all four groups of students are presented below with only a selection of excerpts from the critical reflection records for all three of the problem situations. These excerpts were selected for their potency and do not evenly represent the three problem situations.
In relation to this index, we looked for insightful and meaningful analysis of the nature, size, and complexity of the problems posed on each of the topics, including issues surrounding it. We found plenty of evidence of this characteristic in students’ critical reflection records. Here is a selection of excerpts from some of their reflection records.
Examples:
“Since Mrs. A’s death occurred suddenly, an investigation into the case was warranted. Issues that surround the problem involve law, competencies and ethical practice. Although Dr. B’s order was apparently clear and legible nurses D and E misinterpreted the order and consequently administered the medication. Also in question is the monitoring of her condition.”
“This case study demonstrates an extremely typical scenario of an ethically difficult care situation. A patient demands her diagnosis, which unfortunately is not available. The patient responds badly. How do we, as nursing professionals, manage problems like this one in order to produce the most effective care. No ethical problem is a duplicate of another, every one of them varies. Lastly, communication between the doctors and the nurse could have been improved 100%. Was the doctor aware of how the nurse felt? Do doctors listen to nurses?”
“In this case two nurses behaved incompetently in administering medication since unordered doses of the drug were given to the client. The nurses failed to employ independent, autonomous thinking. It is important to raise the idea of the nurse as the client’s advocate. In this case the nurses lacked evaluation and decision-making skills. The accountability of the nurses must be examined. The need and importance of a sound educational base in which nurses operate is paramount.”
“It may be assumed that the initial problem begins when, upon hospitali-zation, the new orthopedic intern orders METHOTREXATE - 3 tabs. A number of issues surround this case and a degree of negligence and carelessness could be said to exist in all of the following: Lack of clarity specified in the doctor’s medication prescription; the lack of hospital policy regarding this; the unprofessional conduct of nurses in not seek-ing clarification with the doctor; and rights of drug administration. This case emphasizes the importance of the nurse knowing about the drug she/he is administering.”
“Mrs. A has a non-English speaking background. When caring for culturally different people nurses should be culturally sensitive and provide holistic practice. Collaboration between health care professionals, the client and the client’s family is essential. Major barriers when caring for such patients are language and communication difficulties. Nurses and health professionals require other resources to help counteract the difficulties . . . greater awareness needs to be shown.”
“This situation posed a problem for both the nurse and the patient. While the patient wanted her diagnosis the nurse faced the problem of not being able to let her have it as she knew that the patient would not be obtaining the information in the most appropriate and supportive environment. The nurse has respected the client’s basic rights of self determination, freedom and dignity by refusing to let her have the report. The anguish experienced by the patient could not be avoided in this case. This could be avoided with better collaboration between nursing staff and the treating doctors.”
“This problem involves professional, ethical and legal responsibilities of the hospital, doctor and nurses. Profqessionally and legally the hospital had a duty of care. These include training all hospital staff on the correct procedures that must be followed. Doctors and nurses are professionally and legally bound to provide the highest standard of care. Nurses in particular have to be aware of the occurrence of drug errors and therefore be familiar with legal requirements when administering drugs. Most of my fellow students seem to agree that the problem could have been avoided if the “rights” of medication had been observed.”
The incorrect administration of a drug to Mrs. A resulted in the loss of a human life and grief to Mrs. A’s family and friends. This case demonstrates a lack of knowledge on the part of nurses and an absence of teamwork within the hospital ward. The nurses in this case fell below the standard of care which they owed Mrs. A. The disregard with which these nurses have treated drug administration has directly caused the loss of human life. This incident could have been avoided if the rights of drug administration had been followed. This case clearly demonstrated the absence of communication among the hospital staff. The case also raises the issue of disempowered patients.”
Notice that these excerpts show the recognition of the nature, size, and complexity of the problem. We believe that the opportunity presented to students by the critical reflection record caused them to think of nursing practice from the point of view of nursing care issues, nurse-doctor relationships, patient’s rights and nurse’s responsibilities, drug administration protocols, and care of patients from non-English-speaking backgrounds by nurses with English-speaking backgrounds.
In relation to this index, we were searching for awareness in students of what their student peers were thinking about the problem situation and its implications for nursing practice. We observed that students were generally aware of what other students in the group thought about the problem and its implications for nursing practice. Some examples of excerpts from their critical reflections follow.
Examples:
“Achieving an understanding of multicultural nursing issues assists in providing holistic nursing care. I therefore agree with Kylie who expresses support for provision of cultural concerns in the development and implementation of nursing care.”
“I agree with Kylie in saying that a nurse advocate would have supported the client’s decision.”
“Nurses must question doctor’s orders and ask the patient questions about their own medications. I therefore agree with statements made in Kenley’s first reflection regarding the doctor-nurse relationship.
“After reviewing the reflections of my peers, it is wonderful to recognize the understanding among us of the importance of multicultural nursing issues and ways in which we as the nurses of the future can cope with this.”
“Fourthly, the nurses I feel owed Mrs. A duty of care. Many students in our group recognized that the doctor in his writing of the order didn’t follow the acceptable way for writing up medications to be administered.”
“Fellow students’ reflections which centred on the client and her rights increased my awareness of other problems that aren’t as obvious.”
“Many students have commented on this. The question is did the nurse do this? Did she consider her emotional needs first.”
“Many other members of our group agreed with the above and especially about the need for nurse/doctor collaboration and patient advocacy.”
“On reading the reflections of others, I am reminded of an issue that I had not considered previously. This is the issue regarding the practice of scoring or not scoring out the days on the medication chart.”
“From reading the reflections of my peers over the last few weeks it is obvious that the majority of the group feels that lack of communication between the nursing and medical staff and the inability of the nursing staff to follow the five rights of drug administration led to this problem.”
Clearly there is awareness in these student reflections of what others are thinking about the same problem. It was possible because we used computer-mediated communications to post and share the critical reflections in a collaborative and supported environment. Without this communications channel and the entailing structure, it would have been quite difficult to achieve the same level of shared knowledge and understanding of the case/problem within the student cohort. This shared understanding also caused individuals to be reminded of their own beliefs, stories, and “explanation patterns” about nursing issues that the case/problem has brought into light. If being reminded of one’s prior experience and prior “explanation patterns” has caused one to change one’s understanding of the issues in some meaningful way, then learning has occurred (see Schank, 1986).
A feature of our instructional design architecture in this context required students to investigate every realistic possibility for solving the given problem and only to then settle for the best solution option. This index allowed us to look for evidence of this trait in students’ critical reflections, and we found that generally students did a great deal of research, discussed each of the problems with colleagues, and read each other’s reflections before making decisions. Mostly this was evident by the many sources of information they made reference to and/or cited to make or sustain their claims. Constant checking and verifying data sources and hunches with student peers was another indication of an attempt to look for the best solution option.
In our design architecture, following the search for data sources, students were to validate their preferred solution option. Validating meant whether students sought for and shared views with others on possible solution options to ensure that they were on the right track. Upon close examination of the critical reflections, we noticed that students in this course attempted to share their views for this purpose. Here are some excerpts from a selection of the reflection records.
“My colleagues agreed that there was a need of an ethical decision making model. Jane and Lois were in agreement regarding the communication barrier that it posed. Caroline stressed the importance for a good rapport to be established if a patient’s needs were to be taken into account.”
“After reviewing other students work, I agree with the view of Simone and Lois re: the intern not being authorised to order Methotrexate without the guidance of the Registrar”.
“Upon reviewing fellow nursing students’ reflections, it was interesting to note that almost all had shared similar views regarding the administration and consequences of the prescribed medication. Only Jane’s reaction showed empathy. I found her reflection added new dimension to the Coronial Enquires.”
“After reading the reflections of my peers, it appears to me that many of the other students felt the same way as I did. Simone agreed that the nurse involved provided the patient with options. Along with Sonnie and Megan, I felt that by doing this the nurse has acted within the ethical guidelines.”
“On reading several of last week’s mail I feel many of us have identified similar concerns regarding the death of Mrs. A. Malcolm discussed the despair felt by reading this avoidable case and like Miranda and Leanne, I felt that nurses had an obligation.”
“After reading your reflections I am now questioning my own reflection and as to how I came up with my conclusion. So I have started to question....”
“After reading a few of the reflections put forward by other students I still feel the same but am able to justify my point of view a little better. A few students say that the nurse may not be able to handle. . . .”
“Similar views were shared among the group such as autonomy, non-maleficence and causing no harm. It was also agreed by the group that the availability of resources should have been considered. These include whether there were enough staff to support the patient.”
“After reading what Jane had to say this week, I must admit I agree with her. There can be no right or wrong decisions when it comes to ethical decision making. We can only reflect on the results and try and use them to make us wiser.”
“My peers see the situation as a learning experience for the nurse so if the situation occurs again the nurse will know what to do. My peers also see that the nurse was ethically correct in what she did, but then other people say that she breached her duty of care. I see the situation as a learning experience for the nurse as she was ethically wrong in trying to “persuade” the patient to wait for her physician.”
“From reading other people’s perceptions regarding Mrs. A, I have found my perceptions to be similar to theirs. Generally, students found that the breach of the rights of patients was an important issue as was the nurses’ lack of knowledge of the drug and its effects.”
The students clearly demonstrated a willingness to share their “explanation patterns” on the subject with others in their group. To a large extent, this sharing was facilitated by the innovative use of computer-mediated communications in this learning environment. Such sharing and negotiation of understanding of the case/problem situation is seen as a desirable and intended learning outcome and one that is the focus of the computer-supported collaborative problem-based learning (CSC-PBL) design architecture described in this paper.
In our attempt at problem-based learning, we hoped that students would be able to make the connection between theory and practice from the problem situations that were presented to them. Much to our delight, we found the students readily exhibiting coalescence of theory and practice; it was evident in their frequent references to the published literature for support of their observations and their critical commentary on the cases. Here are excerpts from a selection of the critical reflection records
Examples:
“It is important to examine the legal implications for such a case. Stauton and Whyburn (1993) state that the purpose of a coroner’s inquiry is to detect unlawful homicide.”
“Staunton and Whyburn (1994, p. 221) state that a coronial inquest must be held if a person dies a sudden death and due to an unknown cause. The cause of Mrs. A’s death was sudden and unforseeable as Mrs. A was admitted with a fractured pubic ramus.”
“In considering what is an appropriate standard of care, the law expects nurses to carry out their professional responsibilities and an understanding of this principle and its application is crucial (Staybtib & Watbyrb 1985, p. 50). In the case of Mrs. A, Nurses D and E had a duty of care to ensure that the medication. . . .
“Effective nursing requires one to deal with different aspects of and changes in a patient’s personality (Husted & Husted 1991, p. 94). Husted and Husted (1991) also discuss that a patient has the right to self determination. In the case study the nurse had a conflicting interest concerning the disclosure. . . .”
“On a professional basis, if I were to administer Methotrexate on doctor’s orders, my first priority would be to look the drug up if I did not know what the drug was. Kelly and Nothrop (1987) contend that every nurse is expected to know the indications for the drug, its dose. . . .”
These excerpts show students trying to make the connection between theory and practice. One indicator is their citations from published literature about various attributes of the problem at hand. The instructional design architecture in this course set out to facilitate the achievement of this outcome by explicitly requiring students to relate theory and practice in their critical reflection records.
A major feature of the instructional design architecture being discussed here is collaborative learning, which was mostly facilitated by computer-mediated communications technology. Therefore, we sought for evidence in students’ critical reflections of collaborative learning practices, and we noticed that students generally offered supportive comments to one another and sought clarification from others on the computer conferencing system. Here are excerpts from a selection of the reflections.
Examples:
“Sharon, I think your comments are well thought out. There are some good points about particular days being mentioned by the doctor. Bernadette.”
“I am not sure whether we have to include a reference list with our reflections. Just in case, here they are. Kathy could you please let me know. Thanks, Michael.”
“After discussing this with other students, there have been several other issues raised. One major one would be that. . . . .”
“I agree with many different issues discussed so far. However, I do not fully understand Megan’s comment. Maybe you could explain this to me Megan!!!”
“I have been thinking about the discussion we have just had. Grace and I must admit if a pregnant lady told me that she had a dream and saw....”
“In conclusion, we all seem to be in agreement that cultural concerns demand a priority on the agenda of social health care policy. . . .
“Through this critical reflection, our group has considered each others’ varied perceptions of Mrs. A’s case. . . .”
“Collectively, as student nurses we all appear to have the same initial perceptions of this case study. It is the general consensus of the group that this dilemma was handled ethically but that the nurse could have been more compassionate and. . . .”
These few excerpts show that students were engaging in collaborative learning processes with their supportive comments, request for more information and clarification, and agreement with what others were saying.
This result may have been caused by the communication channel provided with computer-mediated communications technology and/or by the requirements of the instructional design architecture. It seems likely that both features of the learning environment had a hand in causing collaborative learning to occur, something that we considered to be a desirable learning outcome for students in this course.
As mentioned above, computer-mediated communications technology (CMC) served the explicit purpose of facilitating collaborative learning in this course. Therefore, in addition to looking for evidence of collaborative learning practices in students’ critical reflection records, we evaluated the extent to which CMC technology was able to achieve this outcome with the help of a questionnaire that was administered on-line towards the end of the course. This questionnaire included twenty-eight statements about collaborative learning. Students were required to respond to each question on a three-point scale ranging from “Not at All,” “To Some Extent,” to “Very Much So.” Sixty-six students returned their completed questionnaires. The results of its analyses are presented and discussed in the following.
The first three items in the questionnaire dealt with students’ facility with and use of the communications technology itself. Most of the students said that they had no problems with typing messages directly on the computer, although they encountered more than a few problems with sending and replying to messages on the CMC system. We think the bulk of these problems was related to the hardware accompaniments rather than the skill level of the users. The next three questions dealt with students’ ability to keep track of the discussions that were going on and their willingness to participate on the CMC system. Most of the students claimed they had no difficulty in keeping track of the discussions. In addition, they were not reluctant to express their thoughts and feelings publicly nor to comment on other’s posting on the CMC system.
We asked students how valuable it was for them to be able to read other students’ reflections on the CMC system and also to receive comments from others on their own thoughts. As is evident in the following figures, the majority of the students valued being able to read other students’ reflections and to receive comments from others on their own thoughts. Computer-mediated communications was used in this instructional environment explicitly to facilitate meaningful interaction and collaborative learning practices among students as well as between students and the lecturers. Students felt that the CMC system facilitated such interaction. We also asked students the extent to which they felt collaborative learning occurred in this learning environment. The bulk of them believed that collaborative learning had occurred.
We asked students several questions about how they thought the nature and quality of their perceptions about the course content may have been affected by the reflections in the CMC environment. Most of the students felt that their interactions on the CMC system helped them to validate their perceptions of the problems and caused these to become richer. Many felt that their ability to form plausible and multiple hypotheses and their overall problem-solving ability had also increased as a result of these interactions, which had also caused them to become more aware of their strengths and limitations as learners. In addition, the majority of the students believed that their interactions via CMC had caused qualitative changes to occur in their thought processes. For instance, many thought that the quality of their reflections had improved. And as they experienced confirmation as well as changes of beliefs and understandings as a result of these interactions, they began to value the relationship between theory and practice increasingly.
We were also interested in the extent to which the use of computer-mediated communications in this instructional design architecture influenced students’ motivation to learn and their attitudes towards learning. It seemed that, for some students at least, CMC and the interactions on it caused an intrinsic motivation to learn. This observation is considered a positive and significant influence even if it were true for a handful of participants. Many agreed that the reflection-based learning activities on the CMC system, while being an enjoyable experience, had also encouraged learning independence. Almost everyone said they would like to see more courses in the nursing studies program making use of computer-mediated communications as it had clearly led them to become not just more involved with this course but more self-confident as learners.
The project reported in this paper set out to conceive and implement an instructional design architecture that had the potential to cause desirable changes in graduating nurses’ approaches to problem solving and, in so doing, facilitating their transition from the classroom into the workforce. In order to achieve this goal, the proposed instructional design architecture needed to incorporate a version of problem-based learning, problem analysis, and group problem solving. A design architecture was developed and dubbed “computer-supported problem-based learning” (see Figure 1). In this architecture, problem-based learning incorporating a model of problem analysis (i.e., articulating, hypothesizing, planning, and data gathering) was adopted within a collaborative learning environment.
The learning goal for students was to engage in collaborative problem solving and produce critical reflections on the problem situations that were presented. Although the context for this study was an on-campus course, the instructional design architecture can be readily employed in distance education and open learning situations. The one thing that would be different in such settings would be the manner in which participants used the computer conferencing software. As on-campus students, participants in this project were able to use the computer terminals available in the university’s computer laboratories. In an off-campus setting they would need to dial-in to a server to use the facility.
Evidence from students’ reflections on the problems posed suggest that on all six identified criteria (see Figure 2), there was visible change in students’ thinking and approaches to problem solving. Students found the computer-mediated communication channel used for the purposes of collaborative reflections useful to their learning experience. The instructional design architecture described and evaluated in this study is thus an example of how the realities of the workplace can be suitably integrated into the classroom to facilitate the transfer of learning from one context to the other. On the whole, the project is also an example of how knowledge of learning and instructional sciences can be brought to bear upon nursing education generally and, as in this case, specific problems related to nursing practice.
Barrows, H. S., & Tamblyn, R. (1980). Problem-based learning: An approach to medical education. New York: Springer.
Brown, A. L., & Palincsar, A. S. (1989). Guided, cooperative learning and individual knowledge acquisition. In L. B. Resnick (Ed.), Knowing, learning and instruction (pp. 393-451). Hillsdale, NJ: Lawrence Erlbaum.
Bruffee, K. A. (1995). Sharing our toys: Cooperative learning versus collaborative learning. Change, 27(1), 12-18.
Chin, C. A., & Brewer, W. F. (1993). The role of anomalous data in knowledge acquisition: A theoretical framework and implications for science instruction. Review of Educational Research, 63, 1-49.
Cognition and Technology Group at Vanderbilt. (1991, September). Some thoughts about constructivism and instructional design. Educational Technology, 31(9), 16-18.
DEETYA. (1994). National review of nurse education report. Canberra, Australia: Department of Education, Employment, Training and Youth Affairs.
Lave, J., & Wagner, E. (1991). Situated learning: Legitimate peripheral participation. New York: Cambridge University Press.
Schank, R. C. (1986). Explanation patterns: Understanding mechanically and creatively. Hillsdale, NJ: Lawrence Erlbaum.
Schmidt, H. G. (1993). Foundations of problem-based learning. Some explanatory notes. Medical Education, 27, 11-16.
Dr. Som Naidu is Associate Professor (Educational Technology) in the Multimedia Education Unit at The University of Melbourne in Parkville, Victoria, 3052, Australia. E-mail: s.naidu@meu.unimelb.edu.au> Phone: +61 3 9344 7446 Fax: +61 3 9344 7576.
Mary Oliver is a lecturer in the Faculty of Sciences, Department of Nursing at the University of Southern Queensland, Toowoomba, Australia. E-mail: oliver@usq.edu.au> Voice: +6176 312 694 Fax: +6176 312 721.
ISSN: 0830-0445