Moving to PBL: Are We Ready To Start PBL In Our Nursing

Education In Egypt
Dr. Amina El-Nemer, Faculty of Nursing,
Mansoura Univerity, Egypt
Email: memylady@hotmail.com
Mob. 0103780828
Abstract:
Nowadays, within the Egyptian higher education there is an emerging political
agenda for developing curricula aiming for graduating highly motivated, intelligent
graduates who are not only learning how to do things effectively but also, to think
critically and to adopt new strategies for dealing with problems in the real world situation.
Problem Based Learning (PBL) has become increasingly prominent in nursing
educations all over the world. Using PBL is fitting with the Ministry of Higher Education
agenda for changing from teaching to learning and from passive learner to active
learner. Using PBL in teaching leads students to learn basic concepts rather than being
applying concepts they already learned also, it produces independent learners who can
continue to learn in their own, in their future career.

Design: This study was carried out using qualitative research methodology. It
aimed to apply and evaluate the introduction of PBL format in maternity course for
undergraduate nursing students from both students and staff point of views.

Setting: The study was conducted at faculty of Nursing , Mansoura University.

Results: The study revealed that nursing students had positive experiences of
using PBL. This experience provided students with multiple educational and transferable
skills and interactive learning experiences, which will advance their future education and
career development. However, the students experienced some challenges in the
transition to PBL teaching strategy.

Conclusion: PBL is a starting teaching strategy in the Egyptian nursing

education, so more training, preparation and cultural changes will be vital to introduce
such course. More studies are recommended to make sure that our nursing students
are achieving the educational objectives, which aim to prepare them for professions

1
 Introduction
Nowadays, within the Egyptian higher education there is an emerging
political agenda for developing curricula aiming for graduating highly motivated,
intelligent graduates who are not only learning how to do things effectively but
also, to think critically and to adopt new strategies for dealing with problems in
the real world situation. Nursing education is one of the pioneers in developing
and upgrading nursing curricula which aims to enable the future nurses to be up
to date with the international level, confident and welling to accept responsibilities
for their self development.

Also, my experience of lecturing undergraduate maternity nursing over

many years has made me aware that the traditional lecture (TL) is not suited to
all students. With lectures, the emphasis is on giving information rather than
learning. Lectures represent what teachers do and not necessarily what students
need as a result some students are lost in the teaching process. It is teacher-
dominated environment in which students are spoon-fed. Traditional method of
teaching has been criticised for not encouraging the development of enquiry
skills, which cause newly qualified nurses to lack competence(1).

Traditional education produces graduates who are dissatisfied and bored

with their education. They faced with huge amount of information to memorize,
much of which seems irrelevant to their future. They forget much of what they
learned and what is remembered can not be applied to the practice in the real
world situation. Also, there is growing evidence that much nursing practice is
ritualised; many researches are suggested that traditional methods i.e. ‘
Traditional lectures’ (TL) do not influence practice(2,3,4). Nowadays, Ministry of
Health and Ministry of Higher Educational are challenged to prepare and equip
students and practitioners with the skills and knowledge, which enable them to
deliver effective and standardized health care service.

2
 Faculty of Nursing Mansoura University has published its educational
objectives, which are congruent with the objectives of higher educational system.
These updated objectives have led to calls for reforming of 'traditional' education
as nursing students require educational preparations which enable them to
develop the clinical competence. This poses challenges for developing curricula,
which provide learning opportunities for these skills. It has been argued that PBL
is a way of learning that is promoted as being an educational strategy, which
provide the supporting framework for achieving those educational objectives(5,6,7).

PBL started to become a feature of educational programmes during the

1960's. Since then there has been a steady growth in the number of programmes
using PBL(6,8,9) and Mansoura Medical Collage BSc undergraduate medical
programme (2007). However, introducing of BPL in nursing curriculum in Egypt is
a new strategy.

Mac masters(10) (1996) define PBL as a concept of learning in which the

student is introduced to a problem or situation as a trigger point for the
identification of the learning needs. PBL helps develop independence, promotes
critical thinking, utilizing real life situation a long with promoting creativity and life
long learning. Undergraduate nursing students go on to future courses with
enhanced thinking critical skills and greater retention of knowledge(11). In PBL
students are progressively given more responsibilities for their education and
become independent of their teachers. This study describes, assess and
evaluate the implementation of PBL maternity course for third year nursing
students at Mansoura University, which for the first time using a PBL in BSc
nursing programme.
Study aim
The aim of this study was to explore the experience of introducing PBL as a new
teaching strategy for third year maternity nursing students, from the student’s and
staff point of views.

3
Methodology
As the study aimed to explore the experience of applying PBL teaching
strategy from student's point of views. The focus of this study was based upon
the main domains of education. Students, teachers and the contents. This study
challenges the positivist notion that reality is objective(12,13). The assumption
underpinning the study is that reality is subjective. The foundation of this study is
shaped by sharing real experiences from student’s point of views to generate
knowledge, as they are the main stakeholders in the educational system. The
nature of the study lends itself to the nature of qualitative methodology and to
methods that enable the collection of data reflecting thoughts, feelings and
experiences(14).

A qualitative approach appeared the most congruent with the aim of the
study because such methodology is suited to exploratory research that gives
important to context, setting and the participant’s reflections (15). It enables the
researcher to capture the holistic meaningful characteristics of real life event
without pre-supposing a universal and absolute truth in these areas(16). Such
methodology is deemed to have a high validity rating within its context as it
reflects real life(17).
Participants
The study sample consisted of:
1- All undergraduate, 3ed year, Maternity Nursing Students (one hundred and
fifty students).
2- Five assistant lecturers staff.
Ethical Consideration
Students were asked to participate in the study using new way of teaching
maternity course using PBL teaching strategies. After explaining the importance
of using PBL teaching style in their future career. All student agreed to participate
after assuring them, if they found difficulties to follow the course after 2 weeks
from the starting, we will go back to use the traditional way of teaching the
course.

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 Ethical approval to carryout the study was gained from Mansoura
University Ethical Committee before starting the study. All students and staff were
asked to sign a consent form to join the study.
Methods of Data Collection
1-Focus group interviews because it utilises group dynamics, which encourage
participants to present their point of views. Focus group interview is a form of
group interview that capitalizes on communication between research participants
in order to generate data. Although group interviews are often used simply as a
quick and convenient way to collect data from several people simultaneously,
focus groups explicitly use group interaction as part of the method(18).

2- Student Feedback Questionnaires were used aiming to triangulate the data

and to obtain more subjective evaluation after finishing the course. SFQ is a
standardized assessment tool that was developed to assess quality of teaching
on the basis of empirical and theoretical work in Mansoura University. The
questions in the tool assess the quality of the course in three main dimensions,
the course content, and teacher and teaching environment. Aiming to get real
feedback from the student regarding to the PBL teaching strategy we added
another part measuring the learning process, workload and student
independence. The University Educational Development Center approved the
changes made by the researcher to be applied only during the study time.

Using PBL in the Egyptian Nursing Education

The original motivation for changing the course format to the PBL was the
researcher concern to achieve the new educational objectives and to close the
theory practice gap on the application of knowledge to real nursing practice. It
was noticeable that in the exam the students get fewer marks for questions,
which require problem-solving skills, which are vital for nursing practice.
Therefore, in changing to the PBL Format the aims were to transmitting
knowledge towards developing the professional skills, develop student skills of
assessment, planning, implementation and evaluation in maternity nursing,

5
develop the independent study skills and develop student's oral and written
presentation skills. This type of learning puts the responsibility on the students
for their learning and addresses issues related actual practice which is supported
by current evidence will produce competent graduates.
PBL Design
The PBL content is designed using a hybrid model of PBL to allow for
easy starting and to fit into the standard time table of 48 contact hours over 12
weeks, one class for the duration of 4 hours every week. The PBL content was
for third year maternity students, they are mostly aged between 19 and 21 the
total number of students in the course were 150 students. The students divided
into 10 groups, 15 students each. Five case studies have been developed in
cooperation with a colleague from University of Central Lancashire. Every two
groups assigned to a case randomly.

Five Maternity staff Introduced to the concept of PBL, Introduced to the

PBL as a teaching strategy using group discussion on cases and one workshop
on the facilitator roles. One staff assigned to 2 groups as a facilitator. The main
researcher was the coordinator between all the groups. Table 1 represents the
course timetable, which had been used during the study.

Each 2 groups of students have a compulsory tutorial lasting 60 min. while they
are tackling their problems to check that the students accepted the requirement
of the course and learning style. There was no compulsory tutoring during last 4
weeks however the students are free to seek tutorial advice during tutorial and
lectures session. This is to encourage students to take more responsibilities for
their learning. Table 2 represents the contents of the presentation session.

Each learning group consists of 15 students working together to explore

the learning underpinning the scenario. They have to nominate a chair; this
position will be nominated around the group weekly, by doing this they will be
given the opportunity of developing communication and leadership skills. The

6
facilitator was the scribe for the group to formulate the discussions into a
readable contents also, the facilitator helped student to come into some rules to
guide the group work.

Data collection and analysis

Data was gathered over a period of 14 weeks during the term time using
student’s focus groups and student’s feedback questionnaires at the end of the
term and student’s final scholastic achievements. 10 student focus groups were
undertaken. This can assist student to explore, develop and express their views
more successfully than in individual interviews(18).

Burnard’s fourteen stages of analysing interview transcripts were

utilised(19). Burnard’s method is based on a synthesis between a grounded theory
and a content analysis approach. This method was used to categorise and code
the transcribed interview data. The transcript were revised and analysed by
professors working at educational faculty to achieve the credibility of the data
Results and discussion
Since it is one of the pioneer study carried out in Egypt to explore and evaluate
the experience of applying PBL to nursing curriculum. It was important to identify
students’ point of views. Analysis highlighted several positive and negative experiences
associated with introducing of PBL as a teaching strategy. Which for the ease of
presentation have been divided into three main parts (a) students experiences, (b) teachers
experiences, and researchers experiences. In this paper we will discuss only student’s
experiences because it is long enough to publish as one paper.

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 Students’ experience of PBL
1- The findings from student’s focus group interviews represent that the PBL
helps them to achieve their learning objectives, such findings are supported by
many studies(20,21,22).
Communication skills and self confidence: Many students reported that
PBL teaching style improved their communication skills and self
confedence.
‘I think it helped me to communicate,
express and exchange ideas with colleagues’

Different learning style:

“interesting learning environment” “I did not get bored” “It was very interesting” “We are
responsible for the educational materials” “more close with the staff” “new way of
learning” “it is challenging learning way” “ I hated to set in lecture and just listen , most of
the time I was sleep but now there were no time to sleep . I was always in a team,
thinking about something, looking for information and reading, all the group was sharing
the responsibility of finishing our assignment”” I like it the competition between the
groups it was challenging”

These findings support many studies(21,22). That teaching using PBL is a

challenging learning method and interesting learning style as student reflected.

Other strengths identified by students were that PBL helps student to acquiring
new skills such as, working in a group, writing and presentation skills, computer
skills and using different sources of information in addition to their previous
information.
Working in a group:
“I learned working in a group and how to be a member of it”
Acquiring new skills:

8
 The data also, illustrates that gaining new skills and learning from each
others was the fundamental of learning. This data concur with(23) who pointed
that students were able to describe themselves as self learners and acquiring
many learning skills all through.

“I learned new skills of communication, writing and presentation skills ” “Thinking

differently (out of the box)” knowing about different sources of information and how to
look for the information you need” “gaining skills of using my previous knowledge and
experience and using other knowledge to build up a new knowledge I need”

However, dissatisfaction were also, identified, in the form of inadequate learning

environment which affected negatively on student’s learning experiences which
highlight the importance of adequate learning environment.

“inadequate access to the online library, we were using staff account because there
were no student account to access online library” “ lack of library resources” Lack of
spaces and classes, Most of the time,it was difficult to meet as a group to discuss our
problem, if it was not our lecture time” “ inadequate no of student computers and
internet lines to finish the assignment, ,most of the time, we were using the net
café to finish”

Lack of personal skills:

“ lack of computer skills”

Feeling overwhelmed, not sure and time pressure; Many students reported
feeling of overwhelmed and uncertain, however these feelings are common
related to the adaptation process of PBL while they still engaged in another
traditional cources due to receiving mixed messages from the different teaching
and learning styles(24).
“ it was very busy semester, some times it was hard to find time to meet”
“I was not sure about my knowledge, is it enough for my exam or not”

9
 Student expressed concern regarding the effectiveness of tutorial support,
lack of their preparation and to the time pressure that the course added to them.
It seems that the role of facilitator was not clear understood by most of the
students as they used to the traditional teacher who is the main source of the
information and knowledge. This reflecting(25) findings that some students would
have liked more guidance because they feel in confidence in their own abilities to
achieve the learning outcomes.
“most of the time, facilitator was not answer our questions ”
“Sometimes we were in need form the teacher to be involved in our discussions”
, sometimes it was hard to find them and sometimes they were busy with other
group”
“there were no written guide for the course, it was only the time table and the
problems”

Data from the Student Feedback Questionnaire (SFQ) assures the data
from the focus group interviews as it represents that the student’s experiences
were varied although they acquired new skills which will help them in their future
learning.

The majority of students was enjoying the course in comparing to the

traditional course and acquired new skills and independent learning. Also the
table highlights students concern regarding to tutorial support, course time in
comparing to traditional course and inadequate learning environment. However,
nearly half of the students won’t prefer to use PBL in the future courses. The
tutorial discussion was more productive than those of traditional teaching.
Written skills and oral presentation sessions was important learning skills.

10
Teachers experiences of PBL

Most of the staff reflected positive attitude to PBL course as they themselves

were learning all through the process and they were more engaged with the

students. but they went through many difficulties during the course.

“ it was good to go through such experience”

“ you will never know if you are a way” “ it challenged me every day” “ I
learned new skills” “ I was more engaged with my student as student were
enjoying the new way of learning”

Facilitation and the facilitator role: facilitation process appears not to be

fully understood among teachers even though the process of facilitation was

explained before starting the course. Teachers were not sure what to do, to

answer student questions or not to encourage them to challenge each others

or to guide the discussion to help them catch the learning objectives. These

findings supports(26) where the teachers found it difficult to achieve the

facilitator role and to shift from expert status to the facilitator which involves

loss of power and authority.

“ Some time, I was not sure what to do, to intervene or not, to guide and
divert the way the group think or not” “ they used to ask the teacher, they
were asking me many questions, some times I was answering and
sometimes I was giving the question back to them”

Some teachers felt discomfort to set back while student learning, it highlights
the difficulties of getting over the teacher role to the facilitator role. The
teacher in the study used to traditional teaching and this may explain their
feelings. Williams (26) recommended that the staff should be well trained to
transform from the traditional teaching to PBL.

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 “ it was not easy for me to set back and listen, I am the one who used to
teach not to listen”

Other teachers raised concern that it was not easy for the student who used
to spoon feeding education to be independent suddenly which make them
feel uncomforted and sometimes frustrated. Students in the study take time
to learn how to learn from each others and to share information as in other
study (26).

" I felt that the students were not happy , they were expecting more
intervene, answering their question as they used”

Students were not conscious of the interdependence and the limits of the
relationship between themselves and the tutor.

“ it was not easy for the student who used to spoon feeding to be
independent, they were follow me where ever I go asking”

Also there was a general consensus among the teachers that the new PBL

course needed to be well structured and have a clear guidelines for applying

and facilitation which will help n the continuous guidance and support.

“ staff preparation on facilitation and facilitator role was not enough, it is hard
to switch from being a teacher to a facilitator, it needs more time and
preparation”
“ we were in need for facilitator guide to use it when we need”

Working as a team
Most of the teachers in the study found that the students were not equally
involved in the group work and reporting of findings. The idea of sharing
information and put effort and share it with others who do not want to put any
effort caused many conflict inside the groups. Also, uneven group

12
participation has been identified as an issue else where (25,28). The teachers
experienced a great problems helping students to sort their inside group
problems. It takes time for students to learn about group dynamic and to
work as a team.

“At the beginning, it was difficult for the students to work in a group as a
team, I spent most of the time, solving their internal clashes” , but with the
time, they started to go through group dynamic process”
“ during the presentation of the first problem, it was clear that It was one
man show, from the critique and the questions asked to all the groups, I made
it clear for them that every one has to be involved and share responsibilities”

Learning Facilities
Reference was also made to a need for improving the learning facilities
through the PBL course in order to achieve the course objectives. Our
educational infrastructure has been designed with large lecture halls which
unsuitable for small group work. The requirement for accessing to enough
appropriately sized and prepared rooms may make it difficult to implement
this course with large numbers of students. These findings are similar to and
reinforce previous evidence that has suggested that applying PBL needs
proper learning facilities and support system (26). Also, there were a need fro
student and facilitator guidance to help and guide all through.

“ lack of small classes for tutorial sessions were a big problem” “ using the
lecture theater to tutor all the groups at the same time was very annoying and
affected the learning process negatively”
“ students access to internet library, PCs and internet lines were not enough
and not available for the students when they need them”
“ there were a need for student guide to guide them all through and decrease
the burden on facilitators”

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 Student Numbers
Number of each tutorial affected their effectiveness however they used to teach
large number of students they felt over whelmed with 30 students and that the
PBL course needs more time hours that the traditional course. These findings
concur with the evidence that shows that teaching a PBL course needs 20%
more time rather than the traditional method (29).

“30 students is huge number to tutorial and support ,I used to teach 100 students
or more but as a facilitator I felt over whelmed, in traditional teaching I am giving
the lecture and that set, as a facilitator I had to be their most of the time to follow
the group progress and to be sure that they are using different learning
resources”

Others reported that facilitation role added more burden on teachers as they had
to help students learning other skills such as ( Computer skills, writing and
presentation skills, communication skills).

“ I even had to teach them some basic computer skills, like emailing, searching
and using different searching engine”

Training and preparation

Many teachers reported the need for more training on PBL and facilitation,
this result supporting the majority of PBL literature which highlights the need
for teacher’s preparation and expertise (30.31). However, as this approach is
new to the Egyptian education, expertise is lacking.

“ as a staff we were in need for more preparation, in PBL, facilitation and

facilitator roles, assess student work load”
“ students were in need for pre course preparation, what PBL is, philosophy,
importance, group dynamics, some IT skills.

14
Researcher experiences
As a coordinator, I observed that the students were enjoying the change
and were developing individual skills as the course progress such as (working in
a team, interpersonal communication skills, writing and presentation skills, wider
reading, and independency). The tutorial discussions were more productive than
those of traditional teaching. Written skills and oral presentations sessions were
important learning skills.

Final scholastic achievements for PBL students were not seen clearly
improvement but it shows scholastic achievements for the same group on the
second traditional course at the same year. During tutorial discussion, it was
clear that students' grasp of the subject were much better than that of the others
traditional courses. Those students used to the traditional approach of education
and this might explain why they experienced some difficulties in their final exam,

Also, less fewer marks were explained by students in the feedback

questionnaire as many students indicated that they were concerned that they did
not train enough for the exam type using the applied questions, however, they
showed improvement in their second traditional teaching course final marks in
comparing to the trend of this course from last year. This may explain that PBL
course helped students to develop educational learning skills which have been
transferred to the next traditional course and helped them improving their
scholastic achievements comparing with the trend of the previous semester as it
shown in Figures 1 and 2.

However, students’ positive experiences of PBL course were not

appeared more positively in students’ final marks, student were able to see
themselves as learners and developing many learning and transferable skills.
This consistent with Blumbera and Michael(32) who reported that PBL students are
developing many learning skills and using library resources more than students
in traditional courses.

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With the adoption of PBL there was an explicit expectation to utilize appropriate
teaching approaches. This may necessitate teachers changing their existing
skills and believes around traditional teaching. During the PBL course the
teachers experienced some anxiety about changing from teaching strategies
which they were comfortable using, to the PBL course that they were applied for
the first time.

At the beginning, some teachers appeared to develop classroom activities

where students had minimal or no input, indicating that both learning and
teaching processes were teacher-centred and teacher controlled. In commenting
(33,34)
on teacher change, Saylor have proposed that changes in teaching
strategies are more easily and rapidly made than changes in teaching
behaviours. During the course, teachers were seen to develop as changes to
teaching strategy and teaching behaviour. As it has been noticed that teachers
began to achieve success and comfort with the new PBL course.

Some students were not careful regarding the sources of information they
use. Some students found it easy to just go to Google and came up with any
information. They were advised to report on proper references. They were
learning quite a lot without realizing, it is about skills and confident of using
knowledge. Introducing PBL is a cultural shift, we got to determine what we need
from our students, we are looking for future professions who are using their
knowledge and skills to improve their practice.

Conclusion:
The study is showing evidence that PBL is effective learning strategy even
with large group of students, students in the study reported that PBL helped them
integrating different sources of knowledge, enhancing their educational and
transferable skills and affected their future education. PBL teaching strategy can
achieve the objectives of the new educational agenda and will take nursing
education forward for better nursing profession. Additionally, it illustrates issues

16
that can limit the success of teaching PBL course and stressing the importance of
proper preparation and training for both staff and students which will enhance the
effectiveness and achievement of nursing educational objectives using PBL
teaching style.

Recommendations:
1- PBL is a new teaching style which challenge both students, teachers and
organizational structure but need proper training for both students and staff and
good course preparation.

2- The findings of the study may be important to other nurse educators who may
consider introducing PBL teaching strategy as an advanced learning for large
group of students.

2- Study raised several interesting issues meriting further exploration.

Acknowledgement:
I would like to deeply thank our maternity and gynaecology Nursing students and
academic nursing staff who participated in the study.

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 Table (1) Course time table G 1 & 2
Week Sessions
1 Introducing the PBL teaching format, important, aims, contents,
evaluations, Organise groups, Hand problem 1
2 Compulsory tutorial, mini lecture 1
3 Mini lecture 2, submission of problem 1
4 Oral presentation of problem 1, group 2 critique, audience questions
and clarifications
Course timetable G 3,4 & 5,6
Week Sessions
5 Discuss the progress of the course, Hand problem 2 and 3
6 Compulsory tutorial, mini lecture 3
7 Mini lecture 4, submission of problem 2 & 3
8 Oral presentation of problem 2 & 3, group critique, audience questions
and clarifications
Course timetable G 7,8 & 9,10
Week Sessions
9 Discuss the progress of the course, Hand problem 4 and 5
10 Tutorial, mini lecture 5
11 Mini lecture 6, submission of problem 5 & 6
12 Oral presentation of problem 4 & 5, group critique, audience questions
and clarifications
Table (2) Two hours presentation session
G 1 give a 30 min. presentation of their G 2 give a 30 min. presentation of their
solution to the problem solution to the problem
G 2 question them about their G 1 question them about their
presentation presentation
Audience question to the two groups Audience question to the two groups
Tutor question the two groups and the Tutor question the two groups and the
audience audience

Student Feedback Questionnaire (SFQ) after the exam.References

Categories Grade Mean score,
N=150
Enjoying the course Very much 54321 Not at all 4.5
Course content and preparation Very much 54321 Not at all 3.5
Tutorial support Very much 54321 Not at all 3

18
Working in a team Very much 54321 Not at all 4
Learning in comparing to Very much 54321 Not at all 4.2
traditional course
Time in comparing to traditional Very much 54321 Not at all 2.2
course
Acquiring new skills Very much 54321 Not at all 4.2
Learning environment and Very much 54321 Not at all 2
facilities
Independent learning Very much 54321 Not at all 4
Using PBL in other courses Very much 54321 Not at all 3

Figure (1) Final Scholastic Achievements for PBL Students

Final Scholastic Achievements for PBL Students

70

60
No. of Students

50

40 Maternity group, term 1

30 Same group, term 2

20

10

0
e

od

d
s
nc

ile
oo

as
o
le

Fa
G

P
el

V
xc
E

Scholastic Achievements

Figure (2) The Trend of Final Scholastic Achievements for Previous

Semester

19
 Sholastic Achievments Trend for
Previous Semester

70
60

No of students
50
40
30
20
10
0

Good

Pass

Failed
V Good
Excellence
achievements
Scholastic

Scholastic Achievments

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