Dr. Frances KamYuet Wong is Professor, Ms. Cheung is Clinical Associate, Dr. Chung is Former Assistant Professor, Dr. Angela Chan is Assistant Professor, Ms. Kitty Chan and Dr. Maria Wong are Lecturers, School of Nursing, and Dr. To is Associate Professor, Department of Health Informatics and Technology, The Hong Kong Polytechnic University, Hong Kong, China, SAR.
The project team would like thank Ms. Helen Yau, Ms. Mei-Kuen Li, Mr. Wai-Keung Tse, and Ms. Helen Au Yeung for their tremendous help in making the project possible. The project is funded by the Teaching Development Grant, University Grants Committee of Hong Kong (Project Code: 2002/PolyU/3) and the Learning and Teaching Development Grant, The Hong Kong Polytechnic University (Project Code: 2005–08).
Names changed for anonymity purposes.
Address correspondence to Frances KamYuet Wong, PhD, RN, Professor, School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China, SAR; e-mail: email@example.com.
Clinical teaching happens in a continuum that spans from being directive to facilitative (Burrows, 1997; Lambert & Glacken, 2005). There are times when the directive method of clinical teaching is necessary, such as during emergencies. On the other hand, a facilitative method, such as problem-based learning (PBL), is needed to help students gradually become independent practitioners. Problem-based learning is recognized as a strategy that can help students develop important professional competencies, such as critical thinking, communication skills, interpersonal relations, and self-assessment (Chaves, Baker, Chaves, & Fisher, 2006).
Tanner (2006) offered the critique that clinical supervision still seems to focus on hands-on procedures and routines, rather than on the development of critical thinking and new learning. There is an increasing awareness of the need to incorporate more innovative pedagogy such as PBL in nursing curricula. Studies have been published on the learning effects of PBL (White, Amos, & Kouzekanani, 1999; Wong, Lee, & Mok, 2001). However, little discussion exists on the interaction between learner and facilitator, particularly in the real or simulated clinical context. This study fills this knowledge gap. We have recorded and analyzed a learning and teaching episode in a simulated clinical situation using a PBL approach involving a patient actor, a nursing student, and an expert clinical teacher. The results of the study enhance our understanding of the key manifestations and outcomes of a simulated learning situation adopting the PBL approach.
The two pedagogies of simulation learning and PBL have been widely used in professional curricula, and many studies have been published discussing the two approaches separately. Yet we have seen little effort to bridge them. We believe that the incorporation of PBL in a simulated learning environment helps students benefit from both pedagogical approaches.
According to Reilly and Oermann (1999), simulation is a category of experiential teaching methods. It provides a mimic situation that allows learning and evaluation to take place in a relatively risk-free environment. They elaborate that there are different kinds of simulation learning arrangements, such as computer simulation, interactive video, use of manikins, and use of real individuals to act as patients. Teachers can also use a case study method to present information related to a clinical situation for students to interact with and make clinical decisions.
Oermann and Gaberson (2006) suggested there can be well-structured and ill-structured problems in simulation learning. The well-structured problems provide information needed for problem solving and typically involve only one correct solution. The ill-structured problems resemble real-life clinical settings where students need to analyze situations, identify possible problems with the given data, solicit additional data when appropriate, and compare and evaluate multiple alternatives before they make an informed decision. The teacher in simulation learning controls the learning situation by establishing patient variables, specific learning objectives, and standard evaluation measures (Reilly & Oermann, 1999). The PBL approach is similar to simulation in the ill-structured problem but is more deliberate, given that it elicits students’ prior knowledge in learning to build on new knowledge, whereas the teacher acts mainly as a facilitator.
Problem-based learning is a form of contextual learning (O’Neill, Willis, & Jones, 2002; Price & Price, 2000; Wong et al., 2001). The context triggers cues to stimulate the development of issues related to the topic area (Carlisle & Ibbotson, 2005). In the process, the students analyze the contextual information, set hypotheses, use existing knowledge, or seek new information to come up with possible solutions (Biley & Smith, 1999; White et al., 1999). The effects of PBL are often optimized by providing opportunities for active discussion and debate, where the students can assimilate existing or new knowledge into the context and share and elaborate on their learning (Lusardi, Levangie, & Fein, 2002; Yuen Loke, Wong, & Wong, 1997).
Problem-based learning is a dynamic pedagogy that can promote independent learning, critical thinking, and problem solving in real-life situations (White et al., 1999; Wong et al., 2001). A recent study used the pretest-posttest experimental design to compare the effects of the PBL method with those of the traditional lecture method. The results indicated that the PBL group had a higher level of knowledge and motivation than did the lecture group, although the two groups had similar attitudes toward learning (Hwang & Kim, 2006). Another study using a before-and-after quasi-experimental design indicated that PBL significantly enhances the deep approach to learning among undergraduate nursing students in the clinical context (Tiwari et al., 2006). In the same study, the qualitative data revealed that students undertaking PBL were motivated, self-directed, and active and interactive, and they enjoyed learning. Similar positive findings were obtained in another study (Wong et al., 2001), which aimed to educate nurses on how to care for dying patients. In that study, students who went through the program had an enhanced awareness of death and dying, could provide total patient care, and could incorporate the cultural dimension in care.
The PBL approach requires teachers and students to be active participants. Students must constantly reflect on the situation while they retrieve their existing knowledge or seek new information to solve the clinical problem (O’Neill et al., 2002; Wong et al., 2004). On the other hand, the teacher must assume the role of facilitator and guide students through the learning process, rather than assuming the role of expert (Lusardi et al., 2002; Price & Price, 2000; Wong et al., 2004). The clinical environment suits the contextual nature of PBL well (O’Neill et al., 2002; Price & Price, 2000). In the clinical situation, frequent formative and summative progress reports on the achievement of patient goals are part of the PBL process (Lusardi et al., 2002). However, studies are often limited to the use of PBL in the theoretical curriculum, and little has been published in the clinical area (O’Neill et al., 2002). Therefore, we conducted this study to investigate how we can apply PBL in the simulated clinical context.
This study is the second phase of a project principally aimed at introducing the strategy of PBL into clinical teaching. The first phase involved educating clinical teachers in the use of PBL and understanding the experiences of students and teachers after using PBL in clinical teaching. The results of this part have been reported elsewhere (Wong et al., 2004). On the basis of the results of the phase one study, we constructed a clinical case and selected a PBL-trained clinical teacher to integrate the PBL pedagogy in phase two of our study. Both the clinical teacher and the patient actor were briefed on the details of the constructed case. We selected a third-year student from our undergraduate nursing program to assume the student role in this exercise. We distributed simulated clinical notes to both the teacher and the student.
The clinical PBL episode was videotaped and transcribed. The transcript was analyzed using the strategy of conversation analysis, which aims at understanding how the world is organized. Silverman (2001) proposed three rules to guide the analysis of social interaction: to identify the sequences of related talk, to examine how speakers take on certain roles or identities through their talk, and to look for particular outcomes of the talk. In this context, the talk is the clinical PBL episode. The research team, including five experienced academics, first independently reviewed the transcripts and conducted an analysis using Silverman’s (2001) guidelines. The team then met and discussed their results. In the process, we constantly compared and contrasted the interpretations, returning to the original videotape and transcripts to check for validity, before reaching a consensus on the analysis.
The presentation of results will be in line with the framework of data treatment, which is the sequence of the clinical PBL, how the speakers take on certain identities through the clinical PBL, and the outcomes of the clinical PBL. The speakers here are Johnson, the student (S); Ms. Ho, the clinical teacher (T); and Mr. Wong, the patient (P).
Sequences of the Clinical PBL
Five sequential episodes from the 45-minute learning and teaching scenario were identified as follows: managing preoperative pain, preparing the patient for surgery, managing postoperative pain, providing postoperative care, and planning for discharge. These sequences reflect a typical care profile provided to a patient undergoing surgery.
Identities Taken on by the Speakers Through the Clinical PBL
In the analysis of the interactions, we found that the student assumed the identities of an active learner and a neophyte nurse in caring for the patient under the guidance of the teacher. These identities had six manifestations in the clinical PBL situation: collection of information, data analysis, formulation of hypotheses, validation, discussion and reflection, and learning synthesis. The episode of managing preoperative pain is presented below to demonstrate the presence of these manifestations. The key interactions in this episode are evident, commencing when the patient was admitted to the ward:
T: Mr. Wong, where does it hurt?
P: On the right side [of the abdomen], where I’m touching.
T: I see…your bed is here; can you take a few steps [from the wheelchair to the bed]?
S: [The patient starts moving.] Good, take one step at a time slowly. Can you manage? [The patient gets into the bed.] Good, we’ll settle you in the bed.
[Patient is now settled in bed.]
S: Do you feel better now? Is it still painful?
P: I’m more comfortable now. Maybe if you can raise the head of the bed.
S: Sure…let me know how high.
P: That is fine, thank you.
S: Do you feel better now [in this position]?
P: Better now.
S: In a while, I’ll check your blood pressure and temperature for you, and see how you’re doing.
T: You take a rest here first.
S: The call bell is here. If you need a nurse, just press the bell.
P: Thank you.
[The clinical teacher and student left the bedside. Later, the student checked the patient’s vital signs, and the doctor examined the patient. The teacher and student read through the clinical notes and had to prepare the patient for an emergency laparoscopic appendectomy.]
In the postclinical conference, the clinical teacher and student reviewed this episode.
T: Johnson, how did you feel about your management of Mr. Wong? Let’s begin with the time when he was admitted.
S: When I helped Mr. Wong to get settled in his bed, he complained of pain. I was very scared. I was afraid that the moving hurt him. I felt better after I had positioned him comfortably in bed.
T: Would you do things the same or differently next time?
S: I tried to observe his facial expression. I stopped to ask how he was before proceeding to the next act. Next time, I’ll understand more what made his pain worse or better.
T: Okay, after you positioned him, you took his vital signs. Why?
S: I wanted to check if there were physiological abnormalities. His blood pressure and pulse were okay, but he had a temperature of 37.8°C. I think there are many reasons for low-grade fever, and wondered if there was any infection. I checked on the medical diagnosis, which was appendicitis, and then I could relate the two [pieces of information].
S: What makes you think that it was appendicitis and not another problem?
T: He complained of pain that was constant and non-colicky. At first, the patient said that the pain began as periumbilical pain when he was at home, then shifted to the lower right quadrant. Pain in the lower right quadrant is typical of appendicitis rather than other possibilities such as gastritis.
The analysis included interactions that had taken place both at the bedside and in the postclinical conference. The discussion in the postclinical conference helped to reveal the thought process of the student. In this episode, the student collected information on the location, intensity, and nature of the patient’s pain and checked his physiological manifestations. He observed the patient’s facial expression to detect whether movement aggravated the level of pain. He analyzed the data and formulated a hypothesis that certain positions might help the patient’s pain. After positioning the patient, the student checked on the comfort level again and validated his hypothesis. He also made a hypothesis about the association of low-grade fever with pain and validated his hypothesis against the medical diagnosis. In the subsequent postclinical conference, the student discussed and reflected on the episode, and synthesized his learning in understanding the symptom presentation of a patient with appendicitis.
Outcomes of the Clinical PBL
The outcomes of the clinical PBL identified in this study included patient-focused care, student-directed learning, inductive learning, and translation of theoretical knowledge into practical information. The episodes of preparing the patient for surgery and discharge planning help demonstrate these four outcomes. An extract from the episode of preparing the patient for surgery is presented here to demonstrate the first three outcomes:
T: What do we need to do to prepare the patient for surgery?
S: He needs to keep on fasting, but we’ll continue with the intravenous fluid replacement for him. Later, he needs to sign a consent form.
T: When was his last meal?
S: It was 10:00 p.m. last night.
T: How about skin preparation?
S: Let’s see. If there is a lot of hair at the operation site, we need to shave the patient.
T: What do we need to talk to Mr. Wong about?
[The clinical teacher instructed the student to enter into conversation with Mr. Wong.]
S: Mr. Wong, sorry for disturbing you from your rest. You’ll be going for surgery soon. Did the doctor explain to you what the surgery is for?
P: He seemed to be telling me that I have appendicitis.
S: Yes, do you know what the surgery involves?
P: Is it dangerous?
S: Did the doctor talk to you about this?
P: Not really.
S: Did he explain the surgical procedure?
[The student then gave the patient some information on laparoscopic appendectomy, the relative risk, and the preparation before surgery. The student also offered to arrange for the surgeon to see the patient. The patient then expressed his worries about his family.]
P: I worry about my family. My wife just gave birth to a baby.
S: I understand that your wife just gave birth to a baby. Is there anyone in the family taking care of Mrs. Wong?
P: Yes, my mother-in-law is helping out. I want to call my wife.
S: Sure, but you have to stay in bed now. I’ll arrange a mobile phone for you so that you can talk to her later.
[At the postconference.]
T: Why is it so important to keep the patient fasting?
S: The patient will undergo general anesthesia. If there is any food in his stomach, there is a risk of aspiration, which can be very dangerous to the patient.
T: What else do you need to check?
S: The doctor has ordered a CBP [complete blood picture], R/LFT [renal and liver function tests], amylase level, and other blood tests. I checked the results, and they are all in the normal range except for his WBC [white blood count] which is 12.7 and the normal range is 4.1 to 10.9. This is a sign of infection; together with the nature and location of his pain and the low-grade fever, this confirms that he has appendicitis.
T: Why did the patient need to have the clotting time checked?
S: The patient had his [partial thromboplastin time] and [activated partial thromboplastin time] checked to make sure that he was safe for surgery. If there is a problem with clotting and there is too much blood loss during surgery, he will be at risk for hypovolemic shock.
T: How about the renal and liver function tests?
S: The patient was receiving antibiotics. The liver will help metabolize the drug and both the liver and kidneys help to remove the toxins. Also, as the patient is undergoing anesthesia, the anesthesiologist will need to know how well the patient’s liver and kidneys are functioning in order to calculate the dose.
T: You mentioned the two antibiotics [cefuroxine sodium and metronidazole]. What are they and what are they used for?
S: That I’m not too sure of.
T: These two antibiotics are commonly used in our surgical unit. I’d like you to look them up and let me know what group these antibiotics belong to, their actions, and side effects.… Please tell me what you have found out tomorrow. You mentioned fasting just now. That of course is very important, what else?
S: Consent form. The form needs to include the name of the procedure, and the names and signatures of the patient, a witness, and the [name of the] surgeon.
T: What are the important things we need to take note of before having the consent signed?
S: Before signing, the surgeon will [usually] explain to the patient the surgical procedure, the risks, and the possible complications. The patient needs to express that he understands [what the surgery is about] before signing, and there is a need for a witness.
T: Mr. Wong is quite young and has the ability to understand what’s going on. How about if the patient is elderly?
S: Although an elderly person may be old in years, it depends on his mental state. I remember that there is a minor consent form that is used for patients under [age] 18.
[The clinical teacher explained the kinds of consent forms and asked the student to collect these different forms to show her the next day.]
In this episode of preparing the patient for surgery, the learning outcomes of clinical PBL were clearly displayed. First, patient-centered care was displayed. At first, the student was procedure oriented in preparing the patient for surgery, such as making sure he was fasting and maintaining the intravenous fluid. The clinical teacher then asked a pivotal question that changed the student’s focus from nurse to patient. She asked, “What do we need to talk to Mr. Wong about?” The student then started a conversation with the patient and found out that he was worried about his wife and newborn child. This reorientation of the student from being procedure focused to patient focused helped the student to deliver holistic care, which addressed not only the patient’s physical needs, but also his psychosocial needs. Second, the clinical teacher facilitated student-directed learning. In the discussion of antibiotics, the clinical teacher did not directly provide answers, but asked the student to do his own research first, then followed it up the next day. There is no urgency to the attainment of this piece of information, so the student had the opportunity to take time and search for the information. Third, inductive learning occurred—that is, generalizing learning from a specific situation to a general one. In the discussion of consent forms, the clinical teacher guided the student to capture the key elements for Mr. Wong in signing a consent form. Moving on from obtaining written consent in the situation of a healthy adult, the clinical teacher helped the student differentiate between the different kinds of consent form. The clinical teacher then asked the student to collect various forms to show her the next day, enhancing the learning level from understanding to application.
The following episode on discharging the patient demonstrates the fourth learning outcome, which is translating theoretical knowledge into practical information:
P: The doctor said I can go home. How should I take care of my wound? It hurts a little now. What if it really hurts later?
S: The doctor has prescribed some pain medication for you. It should help control your pain. If the pain worsens, you should come back to the hospital to see if there are other problems. As far as wound care is concerned, you should keep the wound dry; don’t let it get wet.
S: Do you need to do any vigorous activity?
P: Not really.
S: You need to avoid vigorous activity so as not to strain the wound.
T: I seem to remember that you’re a teacher, right?
[The student and the clinical teacher went on with the discharge advice.]
At the postclinical conference, the teacher and student reflected on and discussed what had happened:
T: Mr. Wong is worried about his wound. By asking him what his normal daily activities are, you can provide him with more specific information.
S: I see, that is to help him to return to normal life gradually, yet at the same time avoid complications.
In this episode, the clinical teacher helped the student translate theoretical knowledge into information that was practical and useful for the patient. At first, the student provided the patient with textbook advice on wound care and activity limitation after surgery. The clinical teacher then asked if the patient was a teacher, and reoriented the student to provide advice related to the patient’s normal daily activities. As the student reflected on the postclinical conference, the goal was to help the patient to return to normal life and avoid complications.
This study described a successful experience in adopting the PBL approach in a simulated clinical environment. It also generated data for the research team to propose a model for future practice. On the basis of the findings, a model for adopting PBL in a simulated clinical context is proposed (Figure). In the middle is a scenario, which is the clinical learning context and which provides triggers for the PBL process. In the process, the student and teacher interact and display six key manifestations: collection of information, data analysis, formulation of hypotheses, validation, discussion and reflection, and learning synthesis. There are four learning outcomes: patient-focused care, student-directed learning, inductive learning, and translation of theoretical knowledge into practical information.
Figure. A Model for Adopting Problem-Based Learning in a Simulated Clinical Context.
Our study provides a complete picture of adopting PBL in a simulated clinical context. Findings reveal the dynamic interactions among the student, teacher, and patient; the processes involved; and the outcomes achieved. Similarities exist between PBL applied in a clinical context and PBL applied in classroom in terms of the expectations that the student will collect information, analyze data, formulate and validate hypotheses, discuss and reflect on the experience, and synthesize learning (Lusardi et al., 2002). However, PBL that takes place in the clinical setting is different from classroom PBL. Problem-based learning in the clinical context captures the advantages of the contingency nature of the clinical setting and the presence of a real (or in this case, simulated) patient that triggers the student to address learning issues of “as they are” rather than “as if they were.” The significance of realism in clinical learning is supported by a study that compared PBL (using a paper-and-pencil case) with simulation-based learning (using a computer-controlled manikin), which found that students in the simulation-based group performed better in critical assessment and management skills. The primary difference in the simulation-based group compared with the PBL group was that the realistic patient environment seemed to have enhanced learning (Steadman et al., 2006).
The use of the PBL approach in the clinical environment is seldom reported in the literature. The less frequent application of PBL to clinical learning and teaching may be attributed to the fact that the clinical learning environment is less predictable and that service needs often take priority over learning needs. In a clinical situation, in which life and death issues are often involved, the clinical teacher sometimes cannot afford to be entirely nondirective (Price & Price, 2000; Wong et al., 2004). The use of a simulated clinical environment will help to overcome these concerns, yet at the same time maintain the advantage of realism in learning. An occupational therapy program has experienced success in building standardized simulations of clinical cases in the PBL curriculum. They found that students can learn about taking risks in a relatively safe environment (Lindstrom-Hazel & West-Fraiser, 2004). The use of standardized patients can be developed for the simulated clinical environment. Standardized patients are commonly used in health professional education. They can provide realistic presentations of patients with specified conditions to allow students to experience the real sense of treating a patient. Simulation learning has three more advantages: First, it can provide learning experiences that may be lacking or rare in real clinical settings (Atlas et al., 2005). Second, the simulated learning can be videotaped for subsequent self-evaluation and peer analysis (Becker, Rose, Berg, Park, & Shatzer, 2006). Third, simulated clinical learning can condense learning events that may take several days or even weeks in a natural course of development. In our study, the learning scenario took only 45 minutes, but it covered four events that involved the patient’s admission, preoperative, postoperative, and discharge stages.
This study documented a successful experience of adopting PBL in a simulated clinical learning and teaching situation. Gaberson and Oermann (1999) outlined a comprehensive definition for clinical teaching, which states that it is:
a series of deliberate actions on the part of the teacher to guide students in their learning. It involves a sharing and mutual experience on the part of both teacher and student and is carried out in an environment of support and trust. Teaching is not telling, it is not dispensing information, and it is not merely demonstrating skills. Instead, teaching is involving the student as an active participant in this learning. The teacher is a resource person with information to share for the purpose of facilitating learning and acquisition of new knowledge and skills. (p. 57)
The definition is well written, but the extent that this definition can be realized in reality remains a concern. Tanner (2006) asserted that the issues of students being engaged in repetitive tasks and having few opportunities to develop new learning and clinical judgment continue. As specified by Gaberson and Oermann (1999), clinical teaching is a series of deliberate acts. Our study explicitly delineates the manifestations and outcomes of learning in a simulated situation that uses the facilitative PBL method. We show that by adopting a PBL approach in simulated clinical learning, educators effectively reverse the conventional model of teaching. In the conventional model, students ask questions and teachers provide the answers. Such traditional models are designed for students to learn from the teacher, who is an authority. In the PBL setting, the teacher asks questions, resulting in the students answering with their own solutions and making their own judgments (Wong et al., 2004).
This study also shows that the effects of clinical learning can occur in a simulated environment. A simulated environment has at least three advantages. First, it offers an aspect of realism to learning in a relatively safe and stable environment. In the real clinical environment, where service needs take precedence over learning needs, the adoption of PBL is sometimes difficult. Second, it can provide learning experiences that may not always be available in real clinical settings. Third, a simulated environment with the design of standardized patients can provide a complete scenario of a specific condition, so that students can experience the full range of learning issues.
From this study, we developed a PBL framework for use in clinical simulations. However, more research is needed to test the efficacy of the model. We hypothesize that our PBL model produces six manifestations and four outcomes in the clinical setting. We hope that more elaborated simulated scenarios, involving computerized simulated models, will be developed to elicit more patient responses. Such scenarios would help test the hypotheses we proposed in this study. There is also a need for more research in real clinical environments, using comparable patient cases, to help validate the PBL process and effects we derived from a simulated environment. Our framework has a staff development value because clinical teachers can use it as a guide to implement the PBL pedagogy when they supervise students in real clinical settings.
- Atlas, RM, Clover, RD, Carrico, R, Wesley, G, Thompson, M & McKinney, WP2005. Recognizing biothreat diseases: Realistic training using standardized patients and patient simulators. Journal of Public Health Management and Practice, (Suppl.), S143–S146.
- Becker, KL, Rose, LE, Berg, JB, Park, H & Shatzer, JH2006. The teaching effectiveness of standardized patients. Journal of Nursing Education, 45(4), 103–111.
- Biley, FC & Smith, KL1999. Making sense of problem-based learning: The perceptions and experiences of undergraduate nursing students. Journal of Advanced Nursing, 30, 1205–1212. doi:10.1046/j.1365-2648.1999.01188.x [CrossRef]
- Burrows, DE1997. Facilitation: A concept analysis. Journal of Advanced Nursing, 25, 396–404. doi:10.1046/j.1365-2648.1997.1997025396.x [CrossRef]
- Carlisle, C & Ibbotson, T2005. Introducing problem-based learning into research methods teaching: Student and facilitator evaluation. Nurse Education Today, 25, 527–541. doi:10.1016/j.nedt.2005.05.005 [CrossRef]
- Chaves, JF, Baker, CM, Chaves, JA & Fisher, ML2006. Self, peer, and tutor assessments of MSN competencies using the PBL-evaluator. Journal of Nursing Education, 45, 25–31.
- Gaberson, KB & Oermann, MH1999. Clinical teaching strategies in nursing. New York: Springer.
- Hwang, SY & Kim, MJ2006. A comparison of problem-based learning and lecture-based learning in an adult health nursing course. Nurse Education Today, 26, 315–321. doi:10.1016/j.nedt.2005.11.002 [CrossRef]
- Lambert, V & Glacken, M2005. Clinical education facilitators: A literature review. Journal of Clinical Nursing, 14, 664–673. doi:10.1111/j.1365-2702.2005.01136.x [CrossRef]
- Lindstrom-Hazel, D & West-Fraiser, J2004. Preparing students to hit the ground running with problem-based learning standardized simulations. American Journal of Occupational Therapy, 58, 236–239.
- Lusardi, MM, Levangie, PK & Fein, B2002. A problem-based learning approach to facilitate evidence-based practice in entry-level health professional education. Journal of Prosthetics & Orthotics, 14, 40–50. doi:10.1097/00008526-200206000-00005 [CrossRef]
- Oermann, MH & Gaberson, KB2006. Evaluation and testing in nursing education (2nd ed) New York: Springer.
- O’Neill, PA, Willis, SC & Jones, A2002. A model of how students link problem-based learning with clinical experience through “elaboration”. Academic Medicine, 77, 552–561.
- Price, A & Price, B2000. Problem-based learning in clinical practice facilitating critical thinking. Journal for Nurses in Staff Development, 16, 257–266. doi:10.1097/00124645-200011000-00004 [CrossRef]
- Reilly, DE & Oermann, MH1999. Clinical teaching in nursing education (2nd ed) Sudbury, MA: Jones & Bartlett.
- Silverman, D2001. Interpreting qualitative data (2nd ed) London, UK: Sage.
- Steadman, RH, Coates, WC, Huang, YM, Matevosian, R, Larmon, BR & McCullough, L et al. 2006. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Critical Care Medicine, 34, 151–157. doi:10.1097/01.CCM.0000190619.42013.94 [CrossRef]
- Tanner, CA2006. The next transformation: Clinical education. Journal of Nursing Education, 454, 99–100.
- Tiwari, A, Chan, S, Wong, E, Wong, D, Chui, C & Wong, A et al. 2006. The effect of problem-based learning on students’ approaches to learning in the context of clinical nursing education. Nurse Education Today, 26, 430–438. doi:10.1016/j.nedt.2005.12.001 [CrossRef]
- White, MJ, Amos, E & Kouzekanani, K1999. Problem-based learning. An outcomes study. Nurse Educator, 242, 33–36. doi:10.1097/00006223-199903000-00011 [CrossRef]
- Wong, FKY, Chan, EA, Cheung, S, Chung, LYF, To, T & Wong, M et al. 2004. Problem-based learning: An innovative model for clinical education. In Chan, SWC, Lopez, AM & Wong, FKY (Eds.), Evidence-based nursing education and related issues (pp. 40–56). Hong Kong: Ming Pao.
- Wong, FKY, Lee, WM & Mok, E2001. Educating nurses to care for the dying in Hong Kong: A problem-based learning approach. Cancer Nursing, 24, 112–121. doi:10.1097/00002820-200104000-00006 [CrossRef]
- Yuen Loke, AJT, Wong, FK-Y & Wong, MW-L1997. Arranging journal writing and dialogue in developing reflective thinking in nursing education. Educational Research Journal, 12, 51–59.