A new approach for nursing education in Egypt

Problem based learning: A new approach for nursing education in Egypt

Habib, Farida

The effectiveness of a community oriented problem-based learning (COPBL) approach was compared to traditional lecture based teaching in a baccalaureate level university nursing program in lower Egypt. A quasi-experimental non-concurrent group design was conducted on a sample of third year nursing students (n=106) taking a required maternal-child nursing course. Divided into two groups of about equal size, one group was taught using a COPBL approach and the other using traditional lecture based methods. Three outcome

measures were analyzed at the completion of each course: evaluation of faculty performance by students, the students’ mean knowledge acquisition score, and a course evaluation. Findings revealed a significantly higher rating of effectiveness of COPBL faculty performance by nursing students, a significantly higher mean knowledge acquisition score, and qualitative analysis of course evaluations indicated higher satisfaction with the curriculum, as compared to traditional lecture methodologies.

KEY WORDS: Egypt; Baccalaureate; Education; Community-Oriented; Nursing; Problem-based Learning.

The effectiveness of community oriented problem-based learning (COPBL) versus traditional teaching approaches (lecture based teaching) continues to be debated worldwide (Albanese & Mitchell, 1993). According to a health sciences literature review, the problem-based learning (PBL) approach has been used primarily in medical education (Bruhn, 1997; Bensing, 1998), although there is evidence a growing number of nursing faculties are using PBL in nursing education (Amos & White, 1998; Biley & Smith, 1998; Andrews & Jones, 1996).

In 1996, the High Institute of Nursing at Menoufiya University and the University of Maryland School of Nursing approached the Binational Arab Republic of Egypt – U.S.A. Fulbright Commission in Cairo for funding to implement the PBL approach in an undergraduate nursing curriculum in Egypt. The two schools, sharing the philosophy of population-based nursing and primary health care, decided to utilize a community-oriented curriculum was well. The immediate goal of this multicultural project was to observe whether the advantages of the PBL approach generally reported in the literature with a community orientation could be replicated in an Egyptian High Institute of Nursing, i.e. a university nursing education setting. A quasi-experimental study was conducted in the baccalaureate nursing program at Menofiya University located in Shibin El Kom, one of the nine towns in a primarily rural governorate in lower Egypt.

First, Menoufiya University maternal-child nursing faculty members were trained in COPBL via a series of workshops on problem-based philosophy and methodologies conducted by US nursing experts familiar with this approach. Next, faculty from both schools designed a COPBL syllabus for maternal-child health for third year undergraduate nursing students. Then, three evaluation tools were collaboratively created to measure and compare three variables: 1. faculty teaching performance, 2. student’s knowledge acquisition, and 3. students’ course evaluation. Faculty from both schools continued to collaborate throughout project implementation. Finally, Menoufiya University nursing faculty divided 106 thirdyear BSN students into two groups. The first group of 52 students was taught their maternal-child nursing course with the High Institute’s regular syllabus, and the second group of 54 students through the COPBL syllabus. Following the conclusion of each semester, Menoufiya faculty administered the three evaluation tools, as well as reviewed and analyzed requested subjective comments from each group. The results were clear. According to the results of the study, the COPBL approach generated greater student enthusiasm and significantly improved academic outcomes than did lecture based teaching methodology. Background

Traditionally, most students spend the majority of their

school careers in passive learning environments in which faculty are disseminators of information, and students are required to memorize information or use specified algorithms to “solve problems”. Active learning environments, in contrast, encourage students to engage in the process of building and testing their own mental models from acquired information. In such a learner-centered environment, faculty becomes a facilitator of learning, and students become active participants, engaging in a dialogue with their colleagues and with the instructors. To facilitate a successful transition to an active learning environment, both faculty and students must make adjustments to what have been their respective “traditional” roles in the classroom. For the instructor who is committed to promoting active learning, the challenge lies in helping students understand the necessity of becoming active colleagues in learning. This process can be facilitated if the curriculum includes exercises to direct students’ attention to a number of issues that impact their learning (Glick & Armstrong, 1996). PBL is one such active learning strategy. Widespread interest in problem-based learning (PBL), particularly within professional health care education, has generated discussion devoted to aspects of curriculum design and implementation, the problem-based learning process itself, and its benefits to students (Bruhn, 1997). Problem-based learning has many facets and Barrows (1986) suggests that there are at least six different approaches. These range from Type I (lecture based case studies) through Type 6 (where a whole course is integrated and presented as series of problems, otherwise known as Reiterative PBL) (Urbina, Hess, Andrews, Hammond, & Hansbarger, 1997). The result of a meta-analysis of academic reports based on the experiences of various PBL programs from 1970 to 1992 generally support the superiority of the PBL approach over the more traditional lecture-based curricula (Vernon & Blake, 1993; Albanese & Mitchell, 1993).

However, little, if any, attention appears to have been paid to the potential application of PBL in Egyptian nursing education. Therefore, after discussion among the two schools and the Binational Fulbright Commission, the following objectives for this project were agreed upon: 1. comparative evaluation of faculty teaching performance of both teaching methods as perceived by nursing students; 2. comparison of students’ knowledge acquisition relative to the two different teaching approaches; and 3. comparison of the effectiveness of the teaching methods as perceived by nursing students through course evaluations. This multicultural project piloted the implementation of the COPBL approach in one of the required nursing courses in an undergraduate nursing curriculum in Egypt. Program Implementation Methodology

This was an intervention study (quasi-experimental non

concurrent group design) conducted at the High Institute of Nursing, Menoufiya University, Egypt. A sample of 106 third year Bachelor of Science in Nursing (BSN) students scheduled for a required maternal-child health nursing course, were arbitrarily divided into two groups. The first group (n=52) was taught with traditional methods of teaching during fall semester, 1997. The second group (n=54) was taught with the COPBL approach during spring semester, 1998. The two groups were comparable regarding age (mean 20.21 and 20.26 years respectively), social status, and prior education. While the first group took maternal-child nursing the second group was concurrently taking a pediatric nursing course, and groups switched courses upon respective completion. No student in either group had any nurses’ education; training or health related job experience prior to the study. All students were female and most were from rural villages within Menoufiya Governate.

The strategy of project implementation consisted of three phases: preparation, implementation, and evaluation. 1. Preparation phase:

A. Development of COPHL Teaching Tools: the problems and teaching materials to be utilized in the COPBL approach were developed over a period of nine months.

These materials included: a faculty version and student version of ten maternal-child health clinical scenarios or problem-based case studies as well as the suggested order for utilizing the cases. The faculty version consisted of the course learning objectives, the course content, the ten developed case studies, and a checklist of faculty tasks for the course as a whole and for each class session. The student version consisted of course learning objectives and the ten problem-based maternal child health case studies.

B. Faculty Development: two nursing faculty members from Menofiya University spent two months at the University of Maryland School of Nursing in Baltimore receiving instruction about problem-based learning. Working with U.S. nursing faculty, Menoufiya University’s BSN maternal-child nursing course was revised into a COPBL format. While studying at the University of Maryland, these visiting nursing faculty members observed small group PBL sessions in the Epidemiology Department at the School of Medicine. The Dean from the High Institute of Nursing participated in two workshops on COPBL at the University of Maryland School of Nursing. Two teams of University of Maryland nursing faculty members also made one visit each to Menoufiya University to conduct COPBL workshops and collaborate with the maternalchild clinical instructors chosen to teach the new approach. Workshop content included active teaching concepts, adult learning precepts, the use of clinical cases and scenarios, community orientation strategies, review of the health professions’ literature about PBL, and design of COPBL classes and curriculum. All total, there were four formal workshops conducted between Menoufiya University, and the University of Maryland School of Nursing. C Development of Evaluation Tools and Selection of Outcome Measures: Three tools were developed to measure and evaluate any differences between traditional teaching and the COPBL approach. The first tool measured faculty teaching performance as evaluated by students (Schmidt, Arend, Moust, Kokx, Boon, 1993). It consisted of a 7-rank rating scale for 18 items with responses ranging from “less than adequate” (1) to “outstanding” (7). The second tool was a written examination, which included pre-natal, natal, post-natal, family planning, gynecological, and reproductive health content designed to test maternal-child nursing knowledge acquisition. The third tool was a course evaluation with qualitative components. Its purpose was to measure students’ perceptions of course effectiveness, to determine which part of the course and teaching techniques they found most helpful, and what content they wanted be added or removed from the course syllabus. Two open-ended questions were designed to elicit less structured and more subjective comments from the two student groups. 2. Implementation phase:

The students were monitored over two semesters, fall 1997 and spring 1998. The traditional teaching approach used in 1997 consisted of 15 weeks of didactic lectures and large class conferences. This was supplemented with clinical training in various settings, such as hospitals and maternal-child health centers. The methods of evaluation were a multiple-choice final examination and two written essays, administered at the end of the fall semester. Immediately following in January 1998, the COPBL approach was used in teaching the same maternal-child nursing content via 15 didactic lectures, and small group conferences of 10 to 15 students working on the 10 community oriented problem-based case studies. Each case study required meeting in two or three sessions for one to two hours a week. Students’ total class time, whether in lectures, conferences or small problem based learning groups, totaled

60 hours for the 15 week semester. Further, COPBL students received the same or equivalent clinical assignments in the same clinical settings used by the traditionally taught students. At the beginning of the traditionally taught semester, each student was given the class and clinical schedule, overall course introduction, and traditional maternal child-nursing syllabus. Lectures and class conferences for discussion were provided to these 52 students in one large group, and handouts of lesson objectives were provided at the time of each class.

At the beginning of the COPBL semester, the 54 students were given the class and clinical schedule, overall course introduction, and the new COPBL maternal-child-nursing syllabus, including the ten problem-based case studies. This second group was then divided into smaller groups ranging from 12 to 15 students for conferences. During each small group conference session students discussed the previously assigned case study. At the end of each session, another case study was assigned to prepare for the next group conference. 3. Evaluation phase: at the end of each semester, faculty administered three evaluation tools to each class. Both classes were administered the same first and third tool.

The second evaluation tool had two versions. The first group’s final examination consisted of both 60 multiple choice questions plus two essay questions to measure knowledge acquisition of cognitive subject matter. The second group was only given 60 multiple-choice questions measuring acquisition of the same subject matter, Results

All three outcome measures showed that the COPBL in

tervention made a difference. First, the evaluation of faculty performance by the students in the COPBL class was statistically significantly more favorable than that by students in the traditionally taught maternal-child nursing class (p=0.04). Secondly, by using the independent t-test, it was found that the students’ mean knowledge acquisition score in the COPBL class (16.44 out of a possible score of 20) was statistically significantly higher than the mean score of 14.1 for the conventional class (p–0.0001), Finally, a clear majority of COBPL students were satisfied with the effectiveness of the COPBL methodology. Students taught by the COPBL approach also stated that they had improved their communication skills, selfconfidence and patient education techniques. COPBL students reported that they could more readily apply their new maternal-child health knowledge to various clinical situations. The students also related that they would retain the knowledge longer than other nursing subjects taught by traditional teaching approaches. Finally, observation revealed the COPBL students used the nursing library more than the traditionally taught students, which is consistent with the findings of other studies (Bruhn, 1997). Faculty Teaching Performance

Table 1. presents faculty teaching performance as rated by the students taught by COPBL approach versus the traditional approach. The COPBL faculty performance rating was statistically significantly higher than the traditional method faculty performance rating based on mean scores (COPBL79.59, traditional-64.09; p=0.047). Analyzing individual items on the faculty performance rating scale, mean scores for 16 individual items of the 18 items used were also generally higher among the COPBL class. Clearly, overall the students who were taught by the COPBL approach rated faculty teaching performance higher. The two items rated most highly by the students in the COPBL class were, “The faculty facilitated development of student problem solving skills”, and “The faculty encouraged effort and rewarded student contribution.” The two items COBPL students rated lower than the traditional class were, “The faculty assisted in development of individual communication skills within the group,” and “The faculty provided clear insight into the objectives and expectations of the course.” These responses by COPBL students indicated they accepted the faculty as group facilitators to guide their learning, thus maintaining an active learning climate. COPBL students did not expect faculty to provide them with knowledge since they recognized that learning was their own responsibility (Biley & Smith, 1998). Knowledge Acquisition

The tables below compare the COPBL approach with the traditional approach regarding students’ knowledge acquisition scores. There was a highly statistically significant difference between the mean test score of the students taught by the COPBL approach and that of students taught by the traditional approach (p=0.0001). The mean total score of students taught via COPBL was 16.44 out of a possible 20, which is equivalent to a B grade (Good). The totals mean score of students taught via the traditional approach was 14.1 that is equivalent to a C grade (Satisfactory).

Test scores of the two classes were also compared in specific content areas. For example, the mean score of COPBL students on pre-natal test items was 3.43 while it was 3.11 for students taught by the traditional approach (p=005). Similar statistically significant differences held in post-natal, gynecologic, and family planning content areas. However, there was no statistically significant difference between the two group’s scores for the natal area (labor and delivery). The higher mean scores in all areas of maternal-child nursing knowledge following the COPBL approach provides some evidence that knowledge acquisition was better in nursing students taught by COPBL than those taught by the traditional approach. In all content areas except one, labor and delivery, differences rose to the level of statistical significance with p set at 0.05 level or below. However, the group taught by COPBL was one semester ahead of the other group and had taken a basic pediatric nursing course which included some neonatal content and a pediatric clinical experience. This exposure may have had an effect on the outcomes. Therefore, the narrative comments of the COPBL students as reported in the course evaluation section, and the observed increase use of the library by COPBL students, may be more important than their objective test scores. Course Evaluation

The majority of the students in the COPBL class (86.3%) maintained that they learned the most from case study discussions while 90% of the students in the traditional class stated that they learned the most from lectures. A majority (65.6%) of the students in the COPBL class reported that they were satisfied with the syllabus and did not want to add anything to it. A smaller percentage of the COPBL students (23%) stated that they wanted to add more case studies about gynecology. In the traditional class, the majority of the students stated that they wanted to add more content about gynecology and abnormal labor. One similarity between the two groups was that a majority (over 65%) of both classes stated that they wanted to delete the male reproductive system and sexually transmitted diseases from the syllabus. This was most probably due to cultural reasons. Qualitative Course Evaluation Comments: Students taught by the COPBL approach stated that they improved their communication skills, self-confidence and client education skills. COPBL students also reported that they would retain this maternal-child health content longer, and could utilize it more readily in the clinical setting, as compared to other class subjects they had learned through traditional methods. DISCUSSION

According to the study, the COPBL approach generated

increased student enthusiasm and significantly higher test achievement scores as compared to the traditional teaching approach. Faculty teaching performance as evaluated by COPBL students was evidenced to be more favorable compared to ratings by students taught with the traditional lecture and large group discussion approach.

Limitations: This study used a quasi-experimental design and the interventions were not implemented concurrently. Prior knowledge due to class sequencing and information exchange between subjects may have contributed to the observed effects. Recommendations:

1. Expand the use of the COPBL approach in other High

Institute BSN nursing courses including Psychiatric, Adult Health, and Medical-surgical nursing.

2. Develop a too] for the faculty to assess and evaluate the COPBL syllabus as well as a tool to measure faculty satisfaction with teaching via the COPBL approach. 3. Retest all of the students in this study after one year to measure and compare the retention rates of maternal-child health and nursing knowledge.

4. Utilize other tools to measure different aspects of the COPBL approach and make additional and different comparisons, especially attempting to replicate the findings with third year BSN students at Menoufiya University, but reversing the presentation sequence of each teaching methodology. Conclusion

This multicultural project achieved the goal of conduct

ing a pilot study to implement COPBL in Egypt for one semester in one introductory undergraduate nursing course. In comparing this approach with traditional lecture based teaching, faculty and students from both schools were exposed to differences in culture, university systems, and faculty and student lifestyles. Through dissemination of these findings both within the U.S. and Egypt, as well as at the International Council of Nurses Centennial, a ripple effect of cross-cultural sharing is expected. The investigators thank the Fulbright Commission for its role in expanding horizons and facilitating contributions to the international scientific foundation of nursing education, practice and research.


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Farida Habib, DNS, Professor and Delal Khalil Eshra, DNS, Dean and Professor, are both with High Institute of Nursing, Menoufiya University, Menoufiya, Egypt. Jane Weaver, JD, MS, Consulting Attorney, Rockville, Maryland. Wendy Newcomer, PhD, RN, Assistant Professor School of

Nursing, University of Maryland, Baltimore, Maryland. Charles O’Donnell, RN, MS, Doctoral student, and Martha Neff-Smith, PhD, RN, CS, MPH, FAAN, Visiting Professor are both with the Decker School ofNursing, Binghamton University, Binghamton, New York.

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