As a result of new learning theories and new nursing interests the focus of nursing and nursing education is changing. Education in general is also changing with a focus on teaching strategies that promote thinking and doing rather than memorizing specific facts (Dalis, 1994). Constructivist-learning theorists emphasize that students must be able to manage concepts in ways that demand increasing problem-solving and critical-thinking skills (Brooks & Brooks, 1993; Duffy & Jonessen, 1992). Learners, especially nurses, must have a true understanding of content for application to occur in practice situations.
Nurse educators globally are attempting to prepare nurses for the greater demands of increasing levels of care found in both hospital and community-based nursing practice today (Edwards, Hebert, Moyer, Peterson, Sims-Jones, & Verhosek, 1998; Cravener, 1997). This increase in levels of care requires learners to be open to new perspectives and ways of knowing. Nurses working in communities around the world require special skills in problem solving, clinical reasoning, critical thinking, and collaboration.
In this paper, an educational strategy to enhance generation of these skills in students at a post basic college of nursing in Pakistan is described. Nursing education in Pakistan, a country with 66% of the total population in the rural area and changing trends in health care needs (ul Haq, 1997), is no exception to the current educational trends. In addition to the traditional hospital-based care, nurses in Pakistan are increasingly becoming responsible for providing primary health care in the rural areas.
Postgraduate nursing education in Pakistan occurs primarily in one of the four colleges of nursing throughout the country, with the exception of two universities that offer BScN degrees. In these colleges, nurses can select from a variety of speciality areas such as: community health, ICU/CCU, pediatrics, mental health, or ward management. The number of nurses in each speciality program ranges from 10-20 students per speciality. The college that I was associated with for two years has seven specialities. The first semester of these one year speciality courses includes "core courses." Core courses are attended by all students in the college specialities. One of these core courses, Advanced Nursing Practice, was my first teaching assignment at this college of nursing. For two years I was responsible, in collaboration with four other faculty members, for teaching core concepts in the Advanced Nursing Practice course. I was in Pakistan working on a large multicomponent Canadian International Development Agency funded program that included strengthening the postgraduate nursing programs in administration and teaching.
Although I have taught nursing in Pakistan in a variety of institutions and at a variety of levels, this was my first experience with such a large group of learners. Walking into a classroom with nearly 100 postgraduate nursing students is a challenge for any educator. It is even more formidable when the students I was facing spoke English as a second language. In addition, the situation was further complicated by my past experience of teaching nurses primarily in small groups!
To provide educational experiences for students in this college it was necessary to conduct an assessment of the learning environment. Through this assessment several problems were identified. These problems are not unique to Pakistan but do challenge educators to use more empowering educational strategies in this environment that is more traditional and less flexible than the climate of "revolution" in western education (Alien, 1990; Di ekelmann, 1988; Rentschler & Spegman, 1996).
The first problem identified was the prevalence of use and adherence to the "banking" model (Friere, 1985) of education, a model that assumes all that is worth knowing will be "deposited" into the student by the teacher. Adherence to this model results in faculty and students lacking experience with liberating and empowering teaching strategies that foster development of critical-thinking and self-directed learning skills. To prepare these learners for advanced nursing practice, it was important to select teachinglearning strategies that would develop competent problem solvers, critical thinkers, and collaborators.
A second major problem that needed to be solved was the language barrier. Students have vastly different abilities in English with some students being extremely disadvantaged when content is taught in Englieh only. While using some strategies recommended for students with English as a second language (i.e., all material in writing) (Phillipe & Hartley, 1990; Shearer, 1989) I was concerned that some strategies would heighten their expectations consistent with the "banking" model, further fostering their inability to evaluate their own gaps in knowledge and access information required to solve clinical problems.
A third major problem, related to oppression, is that nurses generally do not value or trust what others or themselves "know" or think. Moreover, students do not acknowledge their personal experiences as a form of knowledge. This kind of thinking is commonly found in oppressed groups, including nurses in developed countries (Downey, 1993; Lee & Saeed, 2001, in press). Students have seldom had an experience where they were expected to work collaboratively: relying on and valuing others' knowledge and experience. This ability te establish relationships with co-learners that is comfortable and interactive with freely shared ideas, which may not always be unanimous, has not been expected nor present in the students' past educational experiences.
Finding a way to create a learning process that would address these problems was a major challenge. The educational strategy described in this paper attempted te address these issues.
Knowing your students' strengths and weaknesses is an important element in teaching. I soon realized that students and I differed in areas other than language and culture. Studente had very different expectations of a teacher and learner-expectations created by the context in which they worked and lived. I was concerned that the learners would not only reject the new philosophical underpinnings of liberating teaching-learning strategies but would experience grief at the loss of the passive learner role (Bevis & Watson, 1989). In the past, I had taught many small-group problem-based learning classes with students in North America and in Pakistan but those students had better English language skills and greater experience with more empowering educational strategies within different philosophical environments. Students were unfamiliar with the concept of personal responsibility for one's learning and poorly skilled with strategies to be able to accept this responsibility. The students in the college of nursing had little background in using teachers as facilitators and resources rather than authorities. The challenge was to create an environment that would focus responsibility for learning on the students and change the focus of the learning experience from teacher (banking model) to student (empowerment model). I knew, however, that these students were eager to learn and in my past experiences had found that, at least initially, they are tolerant of foreigners introducing innovations into Pakistani systems. I sensed that I could use then- enthusiasm and tolerance to my advantage.
To overcome the problems previously described I had to reduce the language barrier. My advantage was that I had numerous translators and cultural experts on the faculty as well as in the classroom. My concern was, however, that those students who didn't understand the interactions that occurred in the classroom would be excluded from learning. I felt my first task was to reduce the amount of instructional time and focus on the most important points only. Consequently, large group sessions were constructed so that students could be introduced to the expectations of the course, the problem-solving process and problem scenarios.
The size of the group was also a barrier to achievement of the learning outcomes. Large groups were reduced into more manageable groups. Because students in this large group were part of smaller groups (ranging in size from 6-20 learners) clustered around a clinical speciality, I used these groups to compose smaller groups. When students arrived for class, I instructed them to sit in groups according to their speciality. It was my thought that one way to foster synergy (cooperation, respect, and valuing thencolleagues professionally) both for the present and for the future, would be for them to work in their speciality groups (Gaskins & VanderMeer, 1998).
The second part of this learning activity was to provide students with a paperproblem situation that would require them to use a variety of resources to eliminate or reduce the problem. Tb accomplish this purpose the problem situations included several key concepts from the Advanced Nursing Practice syllabus framed in real Ufe situations in Pakistan as recommended by Edwards, Hebert, Moyer, et. al. (1998). As mentioned earlier, this course has always been organized around physiological systems. Each group received a problem scenario addressing the physiological concepts as they related to their speciality. Additional concepts required for more advanced nursing practice were also introduced into the problem situations. For example, pediatrie speciality students who were working collaboratively on a juvenile diabetic problem situation had to determine how the health problem would influence this adolescent client's life style and achievement of social and psychological tasks.
Although this holistic approach has been used extensively in the West, students in Pakistan found this task quite difficult for several reasons. In the past they had always been asked to look at the health problems in whatever context they were described. Since most textbooks and journals are from developed countries and in English and the problems they recount are from significantly different cultures, it was easy for students not to relate to the problems and to give "pat" answers. In addition, because rote learning is the rule rather than the exception, students had only rudimentary skills in navigating through the literature. Since students were expected to locate the problem in the context of Pakistan with its social, political, and cultural implications, they were challenged and discouraged at being unable to find the answers quickly.
In spite of following the recommended procedure for teaching skills, students were frustrated and angry. I was prepared for these emotions because of the expectations I knew students had (that I would "tell" them everything I knew about the problem and answers would be readily available) that were not met. To reduce the frustration and anger I worked with groups during their research to guide them in: (a) identifying gape in knowledge; (b) determining possible hypotheses (c) denning and locating potential resource materials; (d) reinforcing use of the problem-solving process; and (c) recognizing, using, and valuing the experiential knowledge that each of them brings to a learning situation. Students were reluctant to admit that their own Ufe experiences might be relevant and helpful in determining appropriate strategies for reduction or elimination of the problem(s) they identified.
Several strategies were used to reduce the language barrier. First, a national faculty member in the college translated problem-solving information, instructions, questions, and answers. Second, when students had completed their problemsolving, each group presented to the larger group their problem list and nursing interventions. Their presentations were in Urdu, the national language, although most groups did have overheads in English. Students learned from each other in their first language.
Course evaluations were performed to determine the level of students' learning and satisfaction with this educational approach. Although during the course students verbally expressed a number of concerns such as language, the nature of the expectations and the amount of work required to complete their tasks, in the final course evaluations students consistently expressed satisfaction with this way of learning. Students reported that they had developed better learning and problem-solving skills and expressed a desire to continue to develop these skills. With each experience of working together in their speciality groups students appeared to develop more collégial relationships, acknowledging that each person has knowledge that is unique as a result of his/her unique backgrounds and experiences.
Examinations were conducted to determine the students' level of knowledge about particular physiologic (systems related), social and psychological problems, and nursing interventions. Consensus testing as described by Gaskins & VanderMeer (1998) was used. Students were randomly assigned to groups rather than placing them in their speciality groups. The purpose of this action was to (a) provide them with an opportunity to practice skills with a greater variety of colleagues, and (b) stimulate learning through the discussions that would ensue around the scenario in which they were expected to demonstrate their learning. Students were given a choice of one of two scenarios agreed upon by each group through consensus. Students were then expected to perform the nursing process identifying all actual and potential clients' problems and goals, intervention, expected outcomes, and evaluation measures for two problems. Students were also expected to give rationale for problems identified and interventions suggested. Students not only did well on the exercise but stated that they had "learned a lot from this examination and felt they had learned to listen to other group members' ideas and suggestions."
From my own perspective, I know that introducing small-group problem solving in a nonproblem-based curriculum is less effective than in a problem-based curriculum; however, as Edwards, Hebert, and Moyer, et. al. (1998) suggest, with appropriate preparation and support students can learn from this approach even in a traditional educational environment. I also recognize that going into the learning situation with expectations of learning critical thinking, problem solving and collaboration skills without making them explicit from the outset is not consistent with a philosophy of student centered, empowering education. In the future, these objectives will be introduced along with the other information shared in the large group. In spite of these limitations, this educational approach was effective, as demonstrated by students' examination results and course evaluations. The approach also describes an effective strategy for reduction of group size so that more student centered activities can be initiated. In addition, forming groups of mixed intellectual strengths helps to develop partnerships in learning to create knowledge, power sharing, and acknowledgment of the value of experience in knowledge building (Downey, 1993; Huff, 1997).
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