Contemporary nursing education faces the challenge of preparing new graduates with abilities to deal with ambiguity and adapt to change in environments of escalating complexity. Consequently, nurses must be proactive problem solvers and collaborative interdisciplinary team members. Such expectations require that educators move from traditional to more innovative teaching-learning paradigms for learning how to learn and how to lead in a changing world. Although students need a large body of knowledge to make sense of their work world, their active engagement is critical to learn ways that professionals think and solve problems.
Traditional classroom teaching approaches are inadequate to prepare new nurses for the demands of a rapidly changing practice environment (Porter-O’Grady, 2003). Collaborative teamwork is an essential skill for 21st century clinicians as they face increasing complexity in illness care and health promotion (Greiner & Knebel, 2003). Such capability is grounded in abilities that include acknowledgement of gray areas, critical thinking, consensus building, openness to new ideas, communication skills, and imagination. A different model of learning based on a constructivist learning environment (Jonassen, 1991) creates a partnership between students and faculty of discovery, unknowing, and problem unpredictability that not only contributes to nurses’ ability to adapt to changing environments but also gives students some control over their learning. Constructivist pedagogy fosters inquiry to solve unstructured problems, bridge current and future health care needs, and develop habits of exploring complex adaptive systems contextually as a necessary foundation for professional practice resilience in a complex health care environment.
The science of complexity coupled with strategies of problem-based learning (PBL) provides a plausible framework for developing meaningful learning partnerships in baccalaureate nursing education that incorporates collaborative learning, peer assessment, and principles of complexity science. Structured theoretically and empirically, students and faculty immerse themselves in real-time health care concerns for real people, develop flexible and adjustable functions depending on needs, and simultaneously learn to monitor their own ability to think critically within a group.
Baccalaureate nursing (BSN) degree students are typically expected to complete a community assessment as partial satisfaction of course requirements in community health nursing courses. Although varying in degrees, length, and day-to-day assignment practicalities, the expected outcome is the same: students are expected to come away from the course with a deeper sense of community strengths, challenges, demographics, and potential resources. Most should gain a better understanding of data gathering and accessing information as a foundation for developing an aggregate health perspective.
Our senior-level course traditionally began with an assignment that required groups of five or six students to develop a comprehensive community and population risk assessment followed by a scholarly written intervention plan for meeting one of the identified population needs. Students quickly discovered the demanding out-of-class hours and attention to unfamiliar census tract thinking, and they had little collaborative learning experience prior to the course. Within 6 weeks, students were expected to learn how to access and analyze large amounts of population data, explore unfamiliar locales within a large metropolitan area, develop efficient Internet searching, interpret observed community data, manage scheduling issues for group work outside of class, write one cohesive group paper, and learn graph and chart design for formal presentation. Unintended outcomes regularly included student-to-student conflict resulting in predictable, if not frequent, group anger, confrontation at some point during the project, and learning impediments. Some years progressed more smoothly than others, but the toll could be exhausting for students and faculty.
Although work groups are common expectations for staff nurses, learning to work effectively on a team requires adaptability and skill to be successful in creative problem solving. In an effort to improve learning outcomes and minimize factors that inhibit learning, principles of PBL and complexity science provided the framework for modifying the community project. Expected outcomes were broadened to include contextual critical thinking, application of concepts of systems adaptability, consensus-based teamwork, and peer evaluation. The major learning task was the co-construction of knowledge focused on complex, unstructured problems in real-time community clinical practice. This article describes how this teaching-learning project framed by principles of complexity science and collaborative PBL was designed, implemented, and evaluated in a BSN curriculum.
Beyond traditional cognitive, psychomotor, and affective learning, successful health practitioners are those who function effectively with adaptability, improvability, and interconnectedness, and are prepared to see emerging patterns and nonlinearity (Fraser & Greenhalgh, 2001; Plsek & Greenhalgh, 2001). Fraser and Greenhalgh (2001) contend that principles of complexity theory inform learning that is transformational, relational, and nonlinear. Active learning occurs to prepare for change and includes learner engagement with unfamiliar and uncertain contexts. Complexity theory incorporates elements of open systems theory, chaos theory, and change theory, and asserts that systems are influenced by many variables and changes to their relationships (Johnson & Webber, 2009).
Complexity theory is the basis of the science of complex adaptive systems that are dynamic, uncertain, self-adjusting, interactive, and often paradoxical (Lacayo, 2007). Problems are multilayered and may be unsolvable, with patterns of behavior that require health care practitioners to be interdependent, creative decision makers (Plsek & Greenhalgh, 2001).
McQuillan (2008) notes that complexity theory “draws attention to the evolving relationships among system elements at various levels of the systems” (p. 1772). Langton coined the phrase edge of chaos as a zone of complexity wherein a set of circumstances occur that create uncertainty with no clear linear next step; multiple approaches and adaptive behaviors are required to determine what to do (as cited in Plsek & Greehalgh, 2001). Disorder and direction may shift, but order gradually emerges as attention turns to those things that seem to be working best.
Complexity science provides a teaching-learning framework for asking different questions, simultaneously helping students learn to look for different answers for different contexts and different ways to do things. Hutchens (2007) suggests building a “good enough vision” wherein simple rules and a few basic boundaries provide direction, and “The rest is left to the flexibility, adaptability, and creativity of the system as the context continually changes” (Section 2, ¶ 4).
Pushing students away from comfort zones toward uncertainty, paradox, and tension stimulates innovative problem solving as well as capabilities to adapt to change, generate new knowledge, and continuously improve performance (Fraser & Greenhalgh, 2001). Central to educational approaches guided by complexity theory is the “uniqueness of each context…where ‘expertise’ [is] seen as the ability to access knowledge and make connections across seemingly disparate fields and life experiences” and “where learners actively build, rather than passively consume, knowledge” (Fraser & Greenhalgh, 2001, p. 800). Reflection is a key skill to find balance between tension and comfort, and coaching sets the direction for reflection of what did and did not work. Teaching students in this way requires scaffolding, a process of guiding students from what is known to what is to be known, and helps students develop higher levels of thinking than they would normally achieve without guidance from the teacher (Greening, 1998; Hydo, Marcyjanik, Zorn, & Hooper, 2007).
As a constructivist teaching strategy, PBL is relatively uncommon in nursing education despite evidence supporting its effectiveness for a variety of outcomes (Frost, 1996; Maag & Fonteyn, 2005; Richardson & Trudeau, 2003; Strobel & van Barneveld, 2009). Calls by the Institute of Medicine (Greiner & Knebel, 2003) and the World Health Organization (1993) to establish health education environments that promote outcomes of collaborative professional performance and synthesis of emerging information have failed to convince the majority of nurse educators to revise their traditional teaching strategies. PBL requires both critical thinking and complex thinking to solve problems (Fraser & Greenhalgh, 2001; Rideout, 2001; Walker & Leary, 2009).
Pedagogical research findings suggest that PBL improves reasoning and communication but does not surpass content knowledge as assessed by traditional examinations (Beers, 2005; Johnson, Maruyama, Johnson, Nelson, & Skon, 1981). Evidence suggests, however, that retention and recall of information are improved (Beers & Bowden, 2005; Distler, 2008; Sandstrom, 2006; Solomon, Binkley, & Stratford, 1996), as are collaborative skills (McKeachie, 1999; Rideout, 2001). Role perception, attitude, self-directed learning, and teamwork skills are improved (Chandra, Sharma, Sethi, & Dkhar, 1996; Curran, Mugford, Law, & MacDonald, 2005; Distler, 2008; Kocaman, Dicle, & Ugur, 2009; Lary, Lavigne, Muma, Jones, & Hoeft, 1997). Enhanced critical reflection has been reported (Williams, 2001), as well as student empowerment (Siu, Laschinger, & Vingilis, 2005). Successful use in simulated clinical learning also has been reported (Wong et al., 2008).
PBL typically begins with a problem or case study presented to students. Problem solving is grounded in group-initiated and self-directed learning and monitoring with facilitator guidance. Expected outcomes include collaborative constructed knowledge built on collective critical thinking and creative inquiry (Rideout, 2001). Learning issues are identified as the group asks, “What do we know?” and “What do we not know?” The process unfolds as group members begin to gather manageable bits of information outside of class and return later to begin initial analysis and develop hypotheses. Key to the PBL process is the shoulder-to-shoulder work of the group and the professor-facilitator, with each sharing in the function of the group. Typical facilitator roles include co-learner, process guide, problem clarifier, coach, questioner, learning director, and learning scaffold builder (De Grave, Dolmans, & van der Vleuten, 1999; Rideout, 2001). With problems presented at the beginning, a linear PBL process occurs wherein students address various components of the problem, adding information as they go until the problem is resolved.
Delegation among peers for the most efficient problem resolution, and how to give and receive constructive criticism during the evaluation process are critical outcomes for nurses. Development of reflective insight, appreciation of changing emerging contexts, and peer evaluation of collaborative teamwork and critical thinking is just as critical in preparing new nurses to enter the world of practice. The strategy described in this article explains how a teaching-learning framework was structured with principles of complexity science and PBL to incorporate not only a relatively linear method of complex data analysis and intervention planning but also concurrently incorporating nonlinear dynamics in real-time system adaptability between order and chaos, with unpredictability, interconnectedness, emergence, and self-organizing behavior.
A descriptive pilot study was designed to ascertain whether using a teaching-learning framework guided by principles of complexity science and PBL would result in understanding contextually situated adaptive systems, higher level critical thinking, consensus-based teamwork, and improved student learning satisfaction.
Sample and Participant Selection
Complexity theory and PBL provided a fitting framework for substantially revising a project assignment during 3 academic years for three groups of students (n = 35) enrolled in a senior-level baccalaureate community nursing course. Students were introduced to the assignment using reflective discussion of their anticipated expectations of the community assessment and project planning assignment. Students were readily forthcoming with their preconceived ideas of how they would experience the assignment.
The novel complexity-PBL strategy was explained as a group collaborative effort to achieve the same assignment outcomes, but with a single larger group of 12 students rather than smaller groups of 5 or 6 students. The group would have control over the process and their own learning. Workload was to be as evenly distributed as possible, and a faculty facilitator was available to coach the students on a weekly basis.
Students were given the opportunity to request reassignment to another clinical group that was using the traditional approach. The teaching-learning study was approved by the university’s institutional review board. Students provided signed informed consent for purposes of having their evaluative comments reported anonymously as well as an understanding that they could request reassignment without retribution. In addition, students were informed that aggregated peer assessments based on a critical thinking evaluation tool would be conveyed to each student privately during final evaluations.
Indicating an eagerness to experiment with a new approach to the assignment, as well as some skepticism, students began an overview of the project, process, and expected project outcome. The assignment included the assessment of a designated community, identification of health risks based on population and other data, and development of a health promotion and illness prevention community intervention plan.
Consistent with the nonlinearity of complexity theory, instructions consisted of simple directions and a few boundaries, allowing group self-organization, freedom of interaction, and emergent direction to occur. Students were concurrently assigned community clinical experiences with various agencies and services. The group was expected to meet weekly throughout the project unless the group itself determined differently. Because students were truly novices to this type of assignment, both in content and design, students were given a learning process map for which they would have full control based on their fluid engagement and immersion with the community and emerging hypotheses, but the final product, the written intervention plan, was to be submitted before the end of the course.
As facilitator, the professor was a coach and mentor for the project. The facilitator’s role was to prompt group members with questions to guide deep learning, critical reflection, conceptual interrelatedness, and context-sensitive problem solving rather than to provide content or data; in addition, the facilitator monitored the group process. Students were required to keep journals during the process and understood their reflections were important to the process itself.
Two of the 12 weekly clinical hours were set aside each week for PBL. A nonlinear approach to PBL predominated the teaching-learning strategy. Students were empowered to control their process plan as long as the final paper deadline was met. Leadership emerged naturally, as did group consideration of uncertainties, unpredictable events, and unanswerable questions. Group members were free to meet at any other time as necessary, and the group could decide that it did not need to meet as long or at all if they determined that adequate progress was being made.
The process was initiated by the faculty facilitator with a group discussion of typical working group functions (i.e., support and camaraderie, using specialized abilities of individuals, organization of tasks, and setting consensus-based normative rules and procedures) and group issues (i.e., decision making; power and power sharing through group leadership and followership; and anticipating, monitoring, and managing tension and conflict). Consensus determined normative ground rules that students were to come prepared with data and their own analysis for the group, whereupon the group discussed the findings as a whole, revised data gathering plans as needed, and undertook where and how to access elusive but seemingly important data. Everyone had a task to do as determined by consensus and need for adaptability. Building trust was inherent in the rules, as was respect, fairness, honesty, and support.
The following weeks consisted of group-determined student dyads or triads working as subcommittees of the whole to investigate initial population statistics, social system data, and morbidity and mortality reports; compare data to state or national information; and present findings to the group for discussion and analysis during group meetings. Additional data were collected through community member and leader interviews, local news, and participant observation. Together students determined data adequacy or need for further analysis prior to identifying health risks and program planning. A typist was appointed by the group to develop a draft of the project. Drafts were circulated among group members for discussion and revision prior to the due date.
Assessment and Measures
Simple frequency data provided results from a critical thinking rubric for peer evaluation and for student satisfaction with team functioning and the PBL learning strategy using a Likert-type scale; anecdotal student reflections of the process and faculty evaluation of the final paper provided additional descriptive results. Evaluation of the teaching-learning strategy was based on 10 statements and a 5-point Likert-type scale (1 = never and 5 = always). Five statements related to satisfaction with quality and quantity of work, group meeting attendance, equality of group member contributions, and respect within the group. Five statements related to PBL as a learning strategy for the assignment; as a fit for personal learning style; and as a vehicle that promotes critical thinking, fosters appreciation for group potential in problem solving, and adds to understanding of group dynamics. Higher level thinking skills were evaluated from the final paper submission of the community assessment and project planning assignment as well as by faculty monitoring during group meetings; team building and teamwork were also assessed through faculty observation during group interactions.
Peer evaluation of critical thinking was evaluated using Critical Thinking Indicators (CTI) described by Alfaro-LeFevre (2004). CTI was adapted with permission: to include a Likert scale rubric for peer evaluation and to reflect the “system” rather than “the patient” for a community aggregate focus. A 3-point Likert scale was used to rate peer critical thinking behaviors (0 = rarely or never, 5 = sometimes, and 10 = consistently or always).
Findings revealed a higher than expected level of satisfaction among the 35 students. In response to satisfaction with group functioning and with the PBL strategy, 82% of students were usually or always satisfied; none of the students responded never or rarely. Eighteen percent of students responded satisfaction sometimes centered on beliefs that other students may not have done their share of the work or that PBL did not fit an individual’s preferred learning style. Final papers for the community assessment and project planning assignment excelled substantially compared with those of previous years in breadth and analysis of complex data, depth of theory application, and acknowledgment of community unpredictability and adaptability, as well as in development of a context-sensitive identification of community and aggregate health risks.
Anecdotal comments are characteristically the most revealing of student opinions. Reflections from students, both written and verbal, provided perhaps some of the most compelling arguments for continuing the teaching strategy. According to students in the PBL group (some of whom were roommates of other students in the class who were not participating in the PBL strategy), they experienced significantly less stress and conflict than their peers, finished their project on time without loss of sleep the night before the due date, and valued the opportunity for ongoing mentoring in group process. Student comments of satisfaction included:
- “I learned so much this way, and I felt like it made for a more comprehensive, thorough project.”
- “It was a great learning experience and it helped…to have the whole group thinking together to accomplish this task.”
- “I think I learned more about myself and how I work with others than in any other group project.”
- “We all collaborated together and helped each other out when we needed it. We used our strengths.”
- “We used each other’s skills.”
With respect to higher level complex thinking, comments included:
- “[PBL] allowed more than one brain to work which allowed for deeper thinking.”
- “This [experience] has restored my faith in group work!”
- “PBL helped me become more of a group player. I typically like to work on my own, but after this project, I can appreciate the efforts of a group assignment.”
- “I now understand what it is like to be part of a true, centrally thinking, focused group.”
Negative comments were few. Most of the negative comments related to others being late with their work and slowing down the group.
Although most students seemly put careful thought into rating peers’ critical thinking using the CTI rubric, there was little discrimination among ratings. Students indicated they observed critical thinking behaviors in their peers either sometimes or consistently or always. Negative peer assessments were few but were consistent within the group as well as with the faculty assessment of behavior. Students generally viewed their peers as being consistently or always improvement-oriented, confident and resilient, empathetic, open and fair minded, sensitive to diversity, flexible, logical, reflective, and self-corrective. However, students were less likely to see their peers as being self-aware, proactive, creative, analytic, and alert to context (Alfaro-LeFevre, 2004), all characterizations necessary for being adaptable and responsive in a complex health care environment. Two students ranked all of their group members as having consistently or always demonstrated all critical thinking indicators according to the rubric; these students followed up with the comment that “everyone in the group worked extremely hard,” implying that working hard was quality enough.
Formative evaluation by the faculty facilitator occurred during regular group discussions and presentation of data; attendance and preparation for each group meeting; conflict negotiation and management; and dialogues reflecting deep thinking, creativity, and communication skills. As the group developed coherence, what began as discomfort and a high degree of uncertainty among the students evolved into cohesive intra-group support and goal-directed, self-organized order.
Faculty coaching included group probing based on complexity principles such as areas of uncertainty, unclear problem borders, and community patterns of behavior and adaptations. The facilitator sought to draw students into contextually specific discussions regarding interconnectedness of community variables, questions that seemed unanswerable, and apparent adaptations in the community. Students were directed toward understanding systems and subsystems, and inherent norms and patterns of behavior that contributed to aggregate health problems. Other coaching related to group process and peer review, such as “Stop, and let’s talk about what is going on here.” Sometimes private guidance was also required, such as “You have done a nice job with being open to the rest of the group’s ideas,” or “You are viewed by group members as a leader with outstanding writing skills, but you are also viewed by some of the more quiet students as being intimidating and dominant in problem solving.”
Teaching-learning strategies that allow students to be constructive learners provides a firm foundation for challenges in the practice setting. A PBL experience based on real-world environments and context is one strategy that fosters constructivist learning as well as collaborative problem solving. The addition of complexity principles as a theoretical underpinning to PBL strengthens PBL and contributes to the science of nursing education through extending knowledge of an existing teaching strategy by intentionally guiding student exploration of conceptual interrelationships, unpredictability, challenge, and change in the practice setting.
Complexity principles concurrently provide faculty with a framework for evaluating the student group’s self-organization, exploration of problems with unclear boundaries, tension and paradox, nonlinearity, unpredictability, emerging novel ideas, and inherent patterns. Group dynamics are reflected back to students as an evolving interactive system embedded in larger systems. As students develop collaborative thinking and problem solving, guided coaching creates potential for higher learning achievement, innovative thinking, stimulation at the edge of chaos and uncertainty, and enhanced skills of self-reflection and self-awareness.
Students were proud of their accomplishments. Unless a member simply did not follow through on obligations and agreements to the group, students were more likely to give their peers the benefit of the doubt than to rate them poorly. Although students generally supported one another in their efforts, they became acutely aware of their own shortcomings based on how others perceived them as each student was privately counseled using aggregated data from peer reviews.
Students (and faculty) learned to take risks in the group for the benefit of the project, allowing the process and product to emerge; complexity learning challenged students to integrate prior and theoretical learning with day-to-day application for the benefit of a dynamic community. Learning satisfaction was consistently high, exceeding students’ own expectations. Copies of the final project planning were requested by several agencies in the community that were anxious to see what the students had learned about the population.
Although the piloted complexity-guided PBL teaching-learning strategy is a promising approach to prepare new nurses for a challenging health care environment, this teaching-learning project has several inherent limitations as a research study, and several recommendations are offered. Limitations include the student convenience sample and the use of teacher-designed student assessment instruments and faculty observation to assess higher order thinking. Because no attempt was made to randomize or control for student characteristics, there is no assurance that student characteristics did not account for differences in student achievement. Faculty involvement was intense during implementation and may provide a plausible accounting of some degree of student improvement. Finally, CTI was piloted in a teacher-designed evaluation rubric without formal instrument testing for reliability and validity.
Students would likely benefit from modifications to the assessment of critical thinking by reconsidering instrumentation for peer measurement to establish reliability and validity for future use, and improve accuracy in overall impressions. Regular peer assessment throughout the curriculum might also contribute to ratings veracity as students become more comfortable with the process. Faculty must be secure in their ability to allow processes and outcomes to emerge, to guide students with clear understanding of principles of complexity without overdirecting them, to provide adequate time and support for careful student reflection, and to allow students to negotiate expected outcomes and conflicts. Students need time to develop group cohesiveness, making this teaching strategy time intensive for faculty facilitators. Faculty unfamiliar with PBL and complexity theory need additional time prior to the teaching strategy to learn the process themselves to be most effective with the emergent design.
This study suggests that complexity theory strengthens PBL as a legitimate teaching-learning model to prepare new nurses for undertaking unpredictable challenges and multilevel system changes in the practice setting. Students and a faculty facilitator met together regularly in addition to classroom and clinical work as they gathered, analyzed, problem solved, and co-created an understanding of their community. In 6 weeks, students had completed a written community assessment and intervention plan of the same census tract that other students before them had produced but with higher levels of thinking and clearer realization of complex interactions and interrelated problems.
Perhaps student improvements and satisfaction during this project were the result of coincidental student characteristics or could be accounted for by increased faculty involvement. Nevertheless, pushing students out of their comfort zone into seemingly more chaotic and emergent learning resulted in unique achievements related to teamwork and professionalism; demonstration of significant in-depth theoretical understanding of the community and subsystems; knowledge construction and creativity to guide planned intervention; and self-awareness, resilience, and a high degree of satisfaction as a team.
The practice environment needs academia to prepare nurses for the future; only by guiding students to explore the edges of certainty can this be achieved. This article describes how PBL guided by principles of complexity science was used in a baccalaureate community health clinical course to assess and plan interventions for an at-risk community population, to build professional trust and collaboration through peer review and teamwork, and to explore students’ response to change in learning strategy for a course project. Prompted by student apathy, mediocre achievements in group assignments, and group conflict among senior nursing students, a traditional community assessment project and intervention plan was recreated to improve students’ quality of learning. A theoretical framework of complexity science principles and PBL provided a balance between constraint and freedom. The introduction of adaptive and responsive systems and the ability to contextualize and observe inter-dynamics can only be introduced with this type of learning approach. A model of learning that honors complexity, adaptability, and professional collaboration establishes learning partnerships that result in higher level learning and fosters much needed skills of creativity, innovative problem solving, and group coherence for the work setting. We should do no less.
- Alfaro-LeFevre, R. (2004). Critical thinking and clinical judgment: A practical approach (3rd ed.). St. Louis, MO: Elsevier.
- Beers, G.W. (2005). The effect of teaching method on objective test scores: Problem-based learning versus lecture. Journal of Nursing Education, 44, 305–309.
- Beers, G.W. & Bowden, S. (2005). The effect of teaching method on long-term knowledge retention. Journal of Nursing Education, 44, 511–514.
- Chandra, D., Sharma, S., Sethi, G. & Dkhar, S. (1996). Pharmacotherapeutic education through problem based learning and its impact on cognitive and motivational attitude of Indian students. European Journal of Clinical Pharmacology, 51, 1–5. doi:10.1007/s002280050152 [CrossRef]
- Curran, V.R., Mugford, J.G., Law, R.M. & MacDonald, S. (2005). Influence of an interprofessional HIV/AIDS education program on role perception, attitudes and teamwork skills of undergraduate health sciences students. Education for Health, 18, 32–44. doi:10.1080/13576280500042606 [CrossRef]
- De Grave, W.S., Dolmans, D.H. & van der Vleuten, C.P. (1999). Profiles of effective tutors in problem-based learning: Scaffolding student learning. Medical Education, 33, 901–907. doi:10.1046/j.1365-2923.1999.00492.x [CrossRef]
- Distler, J. (2008). Problem-based learning: An innovative approach to teaching health assessment in advanced practice nursing curriculum. International Journal of Nursing Education Scholarship, 5(1), Article 23. doi:10.2202/1548-923X.1577 [CrossRef]
- Fraser, S.W. & Greenhalgh, T. (2001). Coping with complexity: Educating for capability. BMJ, 323, 799–803. doi:10.1136/bmj.323.7316.799 [CrossRef]
- Frost, M. (1996). An analysis of the scope and value of problem-based learning in the education of health care professionals. Journal of Advanced Nursing, 24, 1047–1053. doi:10.1111/j.1365-2648.1996.tb02942.x [CrossRef]
- Greening, T. (1998). Scaffolding for success in problem-based learning. Medical Education Online, 3, 1–15. Retrieved from http://med-ed-online.net/index.php/meo/article/view/4297/4488
- Greiner, A.C. & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
- Hutchens, D. (2007). Emerging principles of complexity. Retrieved from http://www.davidhutchens.com/Biz%20Writing/articles/emergingprincipl.html
- Hydo, S.K., Marcyjanik, D.L., Zorn, C.R. & Hooper, N.M. (2007). Art as a scaffolding teaching strategy in baccalaureate nursing education. International Journal of Nursing Education Scholarship, 4(1), Article 20. doi:10.2202/1548-923X.1330 [CrossRef]
- Johnson, B.M. & Webber, P.B. (2009). An introduction to theory and reasoning in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
- Johnson, D.W., Maruyama, G., Johnson, R., Nelson, D. & Skon, L. (1981). Effects of cooperative, competitive, and individualistic goal structures on achievement: A meta-analysis. Psychological Bulletin, 89, 47–62. doi:10.1037/0033-2909.89.1.47 [CrossRef]
- Jonassen, D.H. (1991). Objectivism versus constructivism: Do we need a new philosophical paradigm?Educational Technology Research and Development, 39(3), 5–14. doi:10.1007/BF02296434 [CrossRef]
- Kocaman, G., Dicle, A. & Ugur, A. (2009). A longitudinal analysis of the self-directed learning readiness level of nursing students enrolled in a problem-based curriculum. Journal of Nursing Education, 48, 286–290.
- Lacayo, V. (2007, February). What complexity science teaches us about social change. MAZI, 10. Retrieved from http://www.communication-forsocialchange.org/mazi-articles.php?id=333
- Lary, M.J., Lavigne, S.E., Muma, R.D., Jones, S.E. & Hoeft, H.J. (1997). Breaking down barriers: Multidisciplinary education model. Journal of Allied Health, 26, 63–69.
- Maag, M. & Fonteyn, M. (2005). Using a collaborative learning method to enhance mastery of pathophysiology content. Journal of Nursing Education, 44, 435–436.
- McKeachie, W.J. (1999). Peer learning, collaborative learning, cooperative learning. In McKeachie, W.J., Teaching tips: Strategy, research and theory for college and university teachers (10th ed., pp. 158–166). Boston, MA: Houghton-Mifflin.
- McQuillan, P.J. (2008). Small-school reform through the lens of complexity theory: It’s “good to think with.”Teachers College Record, 110, 1772–1801.
- Plsek, P.E. & Greenhalgh, T. (2001). The challenge of complexity in health care. BMJ, 323, 625–628. doi:10.1136/bmj.323.7313.625 [CrossRef]
- Porter-O’Grady, T. (2003). A different age for leadership, part 1: New context, new content. Journal of Nursing Administration, 33, 105–110. doi:10.1097/00005110-200302000-00007 [CrossRef]
- Richardson, K. & Trudeau, K.J. (2003). A case for problem-based collaborative learning in the nursing classroom. Nurse Educator, 28, 83–88. doi:10.1097/00006223-200303000-00011 [CrossRef]
- Rideout, E. (2001). Transforming nursing education through problem-based learning. Boston, MA: Jones and Bartlett.
- Sandstrom, S. (2006). Use of case studies to teach diabetes and other chronic illnesses to nursing students. Journal of Nursing Education, 45, 229–232.
- Siu, H.M., Laschinger, H.K. & Vingilis, E. (2005). The effect of problem-based learning on nursing students’ perceptions of empowerment. Journal of Nursing Education, 44, 459–469.
- Solomon, P.E., Binkley, J. & Stratford, P.W. (1996). A descriptive study of learning processes and outcomes in two problem-based curriculum designs. Journal of Physical Therapy Education, 10, 72–76.
- Strobel, J. & van Barneveld, A. (2009). When is PBL more effective? A meta-synthesis of meta-analyses comparing PBL to conventional classrooms. Interdisciplinary Journal of Problem-based Learning, 3(1), Article 4. Retrieved from http://docs.lib.purdue.edu/ijpbl/vol3/iss1/4/
- Walker, A. & Leary, H. (2009). A problem based learning meta analysis: Differences across problem types, implementation types, disciplines, and assessment levels. Interdisciplinary Journal of Problem-based Learning, 3(1), Article 3. Retrieved from http://docs.lib.purdue.edu/ijpbl/vol3/iss1/3/
- Williams, B. (2001). Developing critical reflection for professional practice through problem-based learning. Journal of Advanced Nursing, 34, 27–34. doi:10.1046/j.1365-2648.2001.3411737.x [CrossRef]
- Wong, F.K., Cheung, S., Chung, L., Chan, K., Chan, A. & To, T. et al. (2008). Framework for adopting a problem-based learning approach in a simulated clinical setting. Journal of Nursing Education, 47, 508–514. doi:10.3928/01484834-20081101-11 [CrossRef]
- World Health Organization. (1993). Increasing the relevance of education for health professionals: Report of a WHO study group on problem-solving education for the health professions. World Health Organization Technical Report Series, 838, 1–29.