A variety of educational strategies in nursing have been the focus of much study (Dailey, 1992; Fuszard, 1989; Lowenstein & Sowell, 1992). Some studies argue that two distinct paradigms may exist within the nursing curricula - an educational paradigm and a practice paradigm (French, 1992). After conducting an analysis of British literature from 1961 to 1982, French notes that the educational paradigm over the past decade is teachercentered, with the student being the passive recipient, reminiscent of Herbert's pedagogy (Bigge & Shermis, 1992). The knowledge imparted is directed toward instrumental action, and the person continues to be viewed as mechanistic in the classroom. Outcomes of learning fail to exhibit a patient-oriented, critically thinking individual capable of adequate decision making in practice. The form of knowledge that emphasizes "know-how" (Benner, 1984) was notably lacking in French's analysis of nursing curricula over the past several decades. The National League for Nursing (1988) has demonstrated similar concerns toward the American system of nursing education and various reforms are being explored.
It has been the author's experience as clinical faculty for junior-level baccalaureate nursing students that basic science courses with knowledge acquired in the classroom, such as pharmacology, are not always retained and transferred to the practice setting. Faced with real patients and medications in the clinical setting, students are often unable to relate the cold facts of "knowing that" with the interpersonal, contextual "knowing how." Kimmel ( 1992) noted similar difficulties when teaching pathophysiology to second-year medical students, leading him to abandon the lecture format after deciding that this was not an adequate medium for the presentation of heavily conceptual material. Kimmel initiated the small discussion-group format to eliminate passive learning and incorporated contextual patient-oriented problems into a syllabus that, although content remained essentially the same, became highly motivating to students and encouraged questions and critical thinking.
These observations and the author's experience as clinical faculty have dictated the purpose of this paper - to explore a student-centered approach in nursing curricula, within the design of a problembased learning alternative, in an attempt to create conditions that will facilitate active learning and enhance the development of higher levels of cognitive thinking and motivation for lifelong learning. This is not to suggest the abandonment of lecture and other methodologies, but adoption of a curriculum in which "knowing how" and "knowing that* forms of knowledge are equally emphasized. For if the objective of nursing education is the development of a critically thinking reflective practitioner, the nursing community must review its present teaching strategies, outcomes, and existing educational philosophy in terms of teacher-student relationships, valued forms of knowing and learning, and society's expectation of the registered nurse. This paper examines an innovative teaching strategy, problem-based learning (PBL), and its relevance to Diekelmann's (1990b) challenge for a "curriculum revolution" in nursing. It is hoped that by reviewing the commonalities of these perspectives, nurse educators may reflect seriously on alternative educational strategies.
The problem-based learning curriculum (PBL) has become a recognized methodology in medical schools worldwide (DesMarchais, Bureau, Dumais, & Pigeons, 1992; DeVolder & DeGrave, 1989; Hill, 1992; Thomas, 1992; Yang & Zhang, 1991). Problem-based learning (PBL) is recognized as a valuable educational approach by the World Federation for Medical Education and the World Health Organization (Walton & Matthews, 1989).
PBL was initially explored as a result of the observation of learning outcomes described above, such as the inability to transfer learning from the classroom to the clinical setting. Students entering the clinical experience appeared to be "devoid of knowledge which they could be presumed to have possessed earlier ... in the neurology clerkship, students appeared to have forgotten neurophysiology although . . . they had passed examinations in the subject at an earlier stage" (Walton & Matthews, 1989, p. 543). The principle of PBL is to "put learners in a particular situation, and then to give them a task or challenges as a source for learning, and arrange it to be similar to work with which they will be confronted in their professional future" (Walton & Matthews, p. 543).
Barrows (1986) describes the objectives of a PBL curriculum as dependent upon the skill of the instructor (termed tutor in this strategy) and design of the method. He describes four broad objectives: 1) structuring of knowledge for use in clinical contexts; 2) development of clinical reasoning process; 3) development of effective self-directed learning skills; and 4) increased motivation for learning. He divides learning experiences into teacherand student-directed. Barrows allows for a variety of ways to implement problembased learning.
PBL is both a teaching and learning method with its own logic, based on cognitive theory. PBL attempts to address the problem of why students cannot recall or utilize basic science and if or why, classroom faculty are teaching content incongruent with practical settings. PBL aims to speed up the process and efficiency of clinical reasoning by placing learning in a functional context. Learning in context enables students to organize their longterm memory for ready retrieval (Kriel & A'Beckett Hewson, 1986). It encourages effectiveness of the application of different forms of knowledge and the understanding of various concepts in such a way as to clarify pertinent factors and their interaction and interconnectedness.
Such an educational strategy has proven valuable not only in enhancing problemsolving capability, but in the acquisition of such nursing skills as the holistic approach and self-directed learning. Other advantages to the nursing student include learning team collaboration, learning to listen, and participation in interdisciplinary discussion. Nurses are often encouraged to seek out others both within and outside their field, to discuss patient situations, and make informed reasoned decisions. AU aspects of care would be thus decided, from assessment to discharge planning.
Incentives to learning when using a problem-based approach include the awareness of the relevance of the material or content. As real cases are presented and discussed and questions welcomed, cooperation overshadows competition and teacher-centered strategies. The student nurse becomes socialized as colleague and professional as she learns not only to value her own ways of knowing, but to obtain and accept information from various other sources, to question others critically, and to obtain feedback on her own learning outcome.
The disadvantage reported by those initiating the problem-based methodology in medical schools is that the requirements of a PBL curriculum are very demanding for both teacher and student. The method, being radically different from the didactic tradition, demands a different mind-set regarding learning objectives, process, and methods of evaluation. Noting that many of our health practice professional students have been conditioned primarily to didactic teaching and passive learning, the requirement to become active learners, critical thinkers, and problem solvers offers quite a challenge.
Although much of the literature on PBL is found in medical journals, it is important to note the relevance of the work of Diekelmann and Benner ( 1984) in relation to nursing education. Diekelmann (1990b) calls for a curriculum revolution, stressing critical review and explication of the practice of teaching in nursing. She calls for the creation of caring communities within which nurses practice, teach, and conduct research (Diekelmann, 1990a).
The philosophy to which Diekelmann adheres stresses dialogue among nurses, "engaged listening, seeking to understand, and being open to all possibilities" (Diekelmann, 1990a, p. 301). The concept of the reflective practitioner is emphasized here as it is within the problem-based strategy. Nurses must seek guidance and confirmation from one another. They must collaborate and cooperate. The nurse becomes empowered as critical thinker and valued participant of the health care team. Such a curriculum revolution promotes studentdirected objectives and clinician input as well as teacher-directed methodologies.
Diekelmann foresees the emergence of innovative strategies grounded in the experiences of these participants, a pedagogy rich in diversity and problem situations. Although Diekelmann does not promote one specific strategy, it is easy to incorporate the objectives and process of PBL into her framework of "Nursing Education: Caring, Dialogue, and Practice* (1990a).
When researching teacher-as-learner, Diekelmann acknowledges that "teacher becomes an explorer of meaning and significance with students" (1990a, p. 303). This way of teaching as "being with" the student describes the tutorial role in PBL in which both tutor and student come to view the whole picture in a more effective way, both learning in the process. Teachers must bring knowledge to the student in a meaningful way. Teachers-as-learners are "always open to new possibilities, constantly transforming and being transformed" (1990a, p. 303).
Diekelmann, describing her use of hermeneutic inquiry in the classroom, writes, "When studying a particular content area, I ask students to write their related experiences - paradigm cases. Students write their experiences as students or nurses, ones they will never forget because it taught them what it means to . . .* (1990a, p. 304). This approach again exemplifies problem-based learning in which learning in context, in story, is the primary format.
Benner (1984) also has illustrated how the stories of nurses reveal the practical knowledge embedded in practice. Diekelmann refers to these Ulustrations as 'emancipatory narratives because they recognize our expertise, help us know each other, transform our thinking, and help us in creating communities* (1991, p. 41). Narratives place all problems within a story context. The problems and dilemmas that emerge in such situations enable the opportunity for critical analysis, problemsolving, and reflection, and enhance a continued learning mode by motivating learning in relevant and practical arenas. The goals and objectives of PBL closely align with Diekelmann's views for innovative approaches and new programs in nursing as she rallies for a bridge between education, practice, and research - a bridge composed of dialogue and caring.
One of the only examples found in the nursing literature of an attempt to actualize PBL in nursing education comes from Australia. PBL is represented in 20% of Australia's nursing education programs while various aspects of PBL have been adapted to many existing courses (C reedy, Horsfell, & Hand, 1992). PBL had been adopted in nursing curriculum as a response to the ever increasing body of knowledge that must be incorporated within the curriculum, student perceptions that much of the subject material was irrelevant, lack of problem-solving capabilities, and lack of motivation for continued learning (Streeton, 1985).
As nursing students must be capable of applying concepts of nursing, the basic sciences, and the humanities to their professional practice, the practical or clinical emphasis of problem-based learning presents a most promising educational strategy and one that integrates theory and practice. The nursing faculty of LaTrobe University of Northern Victoria, AustraUa, are embarking upon a six-month faculty development program using PBL along with its constructivist philosophical underpinnings in an attempt to initiate the conceptual changes necessary to implement PBL (Creedy, Horsfell, & Hand, 1992).
Problem-based learning may be actualized within an integrated curriculum of nursing education. A pharmacology/ nutrition course is amenable to such an approach. After each brief lecture, small discussion groups, facilitated by an appropriate tutor, would focus on a case study that would mimic as closely as possible an actual clinical situation. Collaboration, critical thinking, problem solving, and dialogue would be emphasized. The case must relate to the clinical practicum and courses presently attended, such as cardiovascular nursing, as medications and nutrition are related to a particular individual either real or hypothetical. A student might even play the role of the "case" under investigation.
The complexity of the case is determined by the level of theoretical and experiential knowledge of the students. Students, given the situation to be discussed beforehand, must arrive prepared to interact, to discuss possibilities, and to offer alternatives as they assess, intervene, and evaluate their nursing care.
Discussions clarify personal belief systems and values as well as promote peer understanding, broaden perspectives, and assist in the socialization to the professional role. Motivation toward learning is created when strategies are developed that recognize the needs and ways of knowing of the learner. As students become involved in their learning by taking active roles in relevant situations, learning takes on new meaning. Students are encouraged to take responsibility for their own learning and quickly learn that the following clinical day they may be confronted with a very similar situation.
Nursing education today faces a great challenge as it reviews the outcomes of traditional teaching strategies and seeks to explore new alternatives in preparing the nursing student for the complex and diverse profession of nursing. Problembased learning is one alternative to meeting the needs of a society with health requirements as diverse as its population. Nurses must be capable of exploring options, asking questions, articulating explanations, and developing appropriate nursing care plans based on reflective decisions. They must continue to value learning throughout their careers to maintain their expertise.
The role of the educator today is to probe student thinking toward conceptual understanding, to increase depth of subject knowledge, to provide student learning opportunities, and, by encouraging the articulation and contrasting of different points of view, to allow the emergence of common understandings. A problembased curriculum can provide the framework for the revolution in nursing education to occur.
- Barrows, H. (1986). A taxonomy of problembased learning methods. Medical Education, 20, 481-486.
- Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison- Wesley Publishing Company.
- Bigge, M., & Shermis, S. (1992). Learning theories for teachers. New York: Harper Collins Publishers Inc.
- Creedy, D., Horsfall, J., & Hand, B. (1992). Problem-based learning in nurse education: An Australian view. Journal of Advanced Nursing, 17, 727-733.
- Dailey, M. (1992). Developing case studies. Nurse Educator, 27(3), 8-11.
- DesMarchais, J., Bureau, M., Dumais, B., & Pigeons, G. (1992). From traditional to problem-based learning: A case report of complete curriculum reform. Medical Education, 26, 190-199.
- DeVolder, M., & DeGrave, W. (1989). Approaches to learning in a problem-based medical programme: A developmental study. Medical Education,23, 262-264.
- Diekelmann, N. (1990a). Nursing education: Caring, dialogue, and practice. Journal of Nursing Education, 29, 300-305.
- Diekelmann, N. ( 1990b). Preserving the practice of teaching in nursing. Journal of Nursing Education, 29, 195.
- Diekelmann, N. (1991). The emancipatory power of the narrative. Curriculum revolution: Community building and activism (pp. 41-62). (NLN Publication No. 15-2398). New Tfork: National League for Nursing.
- French, P. (1992). The quality of nurse education in the 1980s. Journal of Advanced Nursing, 17, 619-631.
- Fuszard, B. (1989). Innovative teaching strategies in nursing. Rockville, MD: Aspen.
- Hill, D. (1992). SCORPIO: A system of medical teaching. Medical Teacher, 14, 37-41.
- Kimmel, P. (1992, Spring). Abandoning the lecture: Curriculum reform in the introduction to clinical medicine. The Pharos, pp. 36-38.
- Kriel, J., & A'Beckett Hewson, M. (1986). Conceptual frameworks in clinical and preclinical textbooks. Medical Education, 20, 94101.
- Lowenstein, A., & Soweit, R. (1992). Clinical case studies: A strategy for teaching leadership and management. Nurse Educator, 27(5), 15-18.
- National League for Nursing. (1988). Curriculum revolution: Mandate for change (NLN Publication No. 15-2224). Proceedings of the fourth national conference on nursing education. New York: Author.
- Streeton, A. (1985). Problem-based learning and the academic practitioner gap. In D. Boud (Ed.), Problem-based learning in education for the professions. Sidney, Australia: Higher Education Research and Development Society of Australia.
- Thomas, R. (1992). Teaching medicine with cases: Student and teacher opinion. Medical Education, 26, 200-207.
- Walton, H., & Matthews, M. (1989). Essentials of problem-based learning. Medical Education, 23, 542-558.
- Yang, Y, & Zhang, L. (1991). Feasibility of problem-based learning in Jiujiang Medical College: Why not try it? Medical Education, 25, 34-37.