The early benefits of a problem-based approach to teaching social inclusion using an online virtual town

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1 Nurse Education in Practice (2008) 8, Nurse Education in Practice The early benefits of a problem-based approach to teaching social inclusion using an online virtual town Mary Beadle a, *, Julie Santy b a Faculty of Health and Social Care, The University of Hull, Cottingham Road, HULL HU6 7RX, United Kingdom b Faculty of Health and Social Care, The University of Hull, United Kingdom Accepted 4 July 2007 KEYWORDS Problem-based learning; Social inclusion; E-learning; Virtual town Summary This article describes the delivery of a core pre-registration nursing and midwifery module centred on social inclusion. The module was previously delivered using a classroom-based problem-based learning approach. Difficulties with this approach led to changes to the module and its delivery. Logistic issues encouraged the module team to implement a blended learning approach using a virtual town to facilitate online learning and discussion activities. The paper describes and discusses the use of online learning technology to support student nurses and midwives. It highlights the benefits of this approach and outlines some of the experiences of the students including their evaluation of the virtual town. There is also an examination of some of the practical and theoretical issues related to both problem-based learning, online working and using a virtual town to support learning. This article outlines the approach taken and its implications. c 2007 Elsevier Ltd. All rights reserved. Introduction E-learning is the use of internet-based technologies to deliver a broad range of learning opportunities that enhance knowledge and performance. It is networked, and therefore allows storage, retrieval and sharing of information and learning material. It * Corresponding author. Tel.: address: [email protected] is delivered to the learner via a computer using standard internet technology and it focuses on the broadest views of learning that go beyond traditional paradigms (Rosenberg, 2001). It is about much more than the delivery of learning materials, but about a new approach to the facilitation of learning. As online courses and materials become increasingly available, interactive and innovative health and social care educators will be able to work through problem-solving simulations of /$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi: /j.nepr

2 The early benefits of a problem-based approach to teaching social inclusion 191 practice situations so that students are able to see the consequences of their actions, choices and the decisions they make. This will enable practitioners to learn about situations and actions in a safe environment by learning from their mistakes (Dawes and Handscomb, 2002). Background Over the past five years we have used problembased learning (PBL) to deliver education about social inclusion to first year student midwives and nurses. There are many examples of the use of problem-based learning and real life scenarios in health care education as well as in education generally, particularly where professional activity is involved and there is now a great deal of literature discussing the matter. The advantages of this approach are perceived to be in relation to student motivation and application, as it is important for students to see the relevance of any learning activity and to be able to apply it to their practice setting. Wray et al. (2004) describe group dynamic problems as a reality of PBL, which is well reported in other literature. This was one of the reasons for our decision to adopt the blended learning approach and adapt PBL to help to meet the needs and preferred learning styles of students. Tiwari et al. (2006) report positive elements of PBL when linked to real clients. This was also reported by Hwang and Kim (2006). These authors all linked an increase in knowledge and motivation to this type of learning. Tiwari et al. (2006) also discussed how the students found learning was more interesting and meaningful, giving them a sound knowledge base on which to assess and respond to patients needs. Sharp and Primrose (2003) describe the use of a virtual family to facilitate PBL activities with the development, over time, of a variety of problems within a single family. Ward and Hartley (2006) discuss the use of a virtual hospital as a computer-based tool to assist with PBL. They identify this as an alternative approach to the use of real clients in medical education, which can have ethical implications. They also discuss the complexities of using case files and questioned how effective clients records are in telling the patient s story. Nelson et al. (2005) discuss the use of a virtualreality package and PBL, highlighting the advantages of using triggers that focus on patients and their families, not limited to a specific topic area. Wallace et al. (2003, pp ) developed everyday scenarios using a shopping mall as their basis; describing its use as successful, with improvements in understanding, ability to reflect and student motivation. Evans and Swain (2003) used the principles of role-play in an online environment with social work students. They used real time situations in which the students worked under pressure and lecturers took on the roles of other health and social care workers. The main issues with this are that it is very time consuming for the lecturers. All these examples show how virtual scenarios can be utilised to support any learning activity, not just PBL and the importance of linking health care students learning to reality. Social inclusion The NMC (2004, p. 4) states that nurses, midwives and specialist community public health nurses must respect the patient or client as an individual. They must also identify and target care for groups with particular needs, maintaining communication with appropriate agencies (NMC, 2004, p. 42). Practitioners must respect the diversity of their patients and clients in terms of their cultural background. The Social Exclusion Unit (2006) defines social exclusion as what happens when people or places suffer from a series of problems such as unemployment, discrimination, poor skills, low incomes, poor housing, high crime, ill health and family breakdown. When such problems combine they can create a viscous cycle. Social Inclusion is often not as well defined as social exclusion but can be defined as the policies and actions required to reduce the impact of social exclusion on individuals, groups or communities. The NMC (2004) and QAA (2001) emphasise the importance of teaching and assessing students in both theory and practice in relation to the principles of inclusion. One of the fundamental principles of any health care education programme is that it must ensure that students practice in accordance with the Professional Code of Conduct (NMC, 2004). The QAA (2001) benchmarks outline these issues specifically and all programmes must be mapped against the relevant professional benchmarks, although there are similarities for all professions. Programmes leading to awards in health and social care must show evidence of exposure to the issues of social inclusion and exclusion both in theory and practice. In the past different terminology has been used such as equal opportunities, antidiscriminatory practice and anti-oppressive

3 192 M. Beadle, J. Santy practice. New definitions for social inclusion recognise the need to enable practice to actively explore beliefs and values and the impact these might have on the quality of care. Problem-based learning Savin-Baden (2000) discusses the developments in PBL since the 1970 s. Boud and Feletti (1998, p. 2) define PBL as a way of constructing and teaching courses using problems as the stimulus and focus for student activity. There is an increasing trend in using PBL and a need to encourage students to actively learn about social inclusion issues. A previous validation of the pre-registration nursing and midwifery curriculum included this as the main delivery strategy for social inclusion education across the curriculum. This approach was used for approximately five years, leading up to a revalidation of the curriculum in Wray et al. (2004) identify student non-compliance with the process, group dynamic difficulties and questions around depth of learning as some of the difficulties with PBL. This has been confirmed by our experience. The logistics of a large cohort of students working in small groups with a lecturer as facilitator also proved a major issue in relation to resources. The students also talked about differences in the approach of facilitators. Tiwari et al. (2006) highlight difficulties in achieving a balance with facilitators participation and non-participation. Rowan et al. (2007) identify the challenges of effective facilitation. Carlise and Ibbotson (2005) describe the use of PBL and clinical scenarios with the use of key readings to support learning. This approach offers the opportunity to resolve one of the issues in PBL in relation to the time consuming need for students to access the literature independently. This is often one of the things that can lead to group relationship problems when there is inequity in students commitment to finding reading material and feeding back their findings to the rest of the group. This was something which our students mentioned in their evaluations and could lead to conflict within the groups during feedback sessions. This may also have been due to other group dynamic problems which would have surfaced regardless of the mode of delivery. It could also be said that to have these problems out in the open for discussion was a good way to resolve the conflict if somewhat uncomfortable for the students and facilitators even though this can take up valuable teaching and learning time. The virtual town Our pre-registration nursing and midwifery curriculum previously contained two modules focussed on social inclusion which took a PBL approach to delivery. Problems with this approach as discussed above were identified following evaluation and a decision was made to change the mode of delivery to blended learning, using a mixture of online activities and lecture style sessions. The key lectures previously used in the PBL approach were retained with some changes to the format. Previously we used scenarios based on real practice situations. These were delivered to the students in a written hard copy format at the beginning of each PBL session. This made the examples one-dimensional and not community based. There was no opportunity for the students to independently find out more about the client and family and the community in which they lived. This is a key concept in developing student s knowledge around social inclusion and exclusion as this is a skill the students will require in practice situations. We decided to create what we called a virtual community. In this sense a virtual community is taken to mean a virtual town created using the commercially available Blackboardä Virtual Learning Environment. We will use the term virtual town here to avoid confusion between this concept and that of a virtual community that is an Internet based community in the sense of online communication and activity. The standard Blackboardä VLE (Version 6) site template was used to create a variety of written and pictorial materials describing an imaginary town which we called Aisling a Celtic term meaning dream place. The town, although imaginary, is loosely based on some of the local communities in which our students practice and live. The population and social profile is similar to one of the local towns. This allows the students to identify with their local area. We have also been able to include issues such as rural living and immigrant and refugee communities, all of which are features of our student catchment area. The site was also used to include reference to current news and health care issues contemporaneously. The Aisling site contains a number of sections which provide individual and family profiles as well as details of local health and social care services, local business and employers as well as places of worship and a newspaper office. In addition a library has been added that contains information and literature to support students learning about social inclusion and exclusion issues such as reports, documents and articles. See Fig. 1. The site

4 The early benefits of a problem-based approach to teaching social inclusion 193 Figure 1 Screenshot of the home page of the VLE site for the Aisling Virtual Town. is used across the Faculty of Health and Social Care for a variety of learning based activities and all students and staff across the Faculty have access to it. The site has a co-ordinator who changes and updates information but staff and students are able to make requests and recommendations for changes and additions to the materials and information. Presently the site is one-dimensional in that it contains mostly text and picture based activity which is simple and easy to produce and update. In the future it is intended to include the use of animated and video materials to bring the site and its contents more to life for the students. From recent student evaluations of the Aisling site students have spoken very positively of this site as well as making suggestions for its future development and the development of specific families and further supporting literature. The themes from the evaluations were in relation to the usefulness of having real situations to discuss and that this assisted in the application of theory. The students enjoyed the use of specific families and found that this helped in formulating ideas and developing discussions. The main advantage of using the existing VLE (Blackboardä) is that it provides academic staff with the ability to develop and adapt the site on an ongoing basis, negating the technical restrictions of a more complex system. New individuals and families are added on a regular basis along with local community facilities. New families and individuals are created based on the faculty staff s experiences of working with families and individuals in health and social care settings and discussions with students following practice placements. The families are sometimes created in response to an educational need. The Aisling site is now used across the faculty, often in support of student-led online activities and problem-based learning triggers. From a practical point of view, students would be expected to log on to the site at a certain time on a certain day. They would be given one or more family scenarios to consider from a family in the Aisling site. They would then be expected to use the Blackboardä group discussion forums to discuss the issues raised, often related to specific questions and issues. Each group discussion is moderated by a trained online lecturer. Students attendance for each session is recorded according to their contribution to the discussion forum over a period of time. We feel that such an approach to attendance enables us to work around many of the issues around motivation to log on and contribute to discussions identified by authors such as Salmon (2003). Online working McAllister and Moyle (2006) raise some issues regarding e-learning around the tendency for people to ignore social rules, to be blunter, more critical and less tolerant of expressed differences. We have found, in contrast, that this can be an advantage, with attitudes being admitted and therefore dealt with often by other students thus giving the opportunity for the exploration of students beliefs and attitudes. On some occasions students expressed inappropriate attitudes towards individuals

5 194 M. Beadle, J. Santy and families with social exclusion issues. The lecturers chose to wait to see how other students reacted and discovered that the attitudes were often challenged by other group members. Some lecturers found this difficult in the same way that it can be difficult to become a facilitator rather than a teacher. This confirms our feeling that such an approach helps to form appropriate attitudes in health and social care students, or at least offers them the opportunity to discuss the issues in an open manner. Some students displayed stereotypical views in ways that they may not have done in a classroom setting. We think that this may be due to less fear of embarrassment or of immediate challenges when working in online discussion groups rather than face to face situations. McAllister and Moyle (2006) also describe the advantages of online working in terms of students feeling more able to express views and opinions than they would in a face to face discussion especially for shy or tentative students. This was a theme identified from the student evaluations. Students commented that they found that they felt more comfortable participating online and other students who identified themselves as more vocal in face to face discussions highlighting that they found it helpful and interesting to hear the views of all the students online. Ali and Salter (2004) highlight the difficulties of giving focus to discussion topics if these are open-ended. Students often lose interest if the topic is not focussed and specific enough and have difficulty in applying learning to practice. They suggest giving opening and closing times for discussion. This was something that our students had thought would be useful. They also asked for feedback on their participation and learning. Glen (2005) describes how e-learning can be used for student active exploration and enhancing multiple ways of knowing. She emphasises the importance of students being active in the learning process rather than just being given information via technology. The giving of feedback on an individual student s activity could be one way of enhancing the student s learning and interest. There is also an issue related to the group nature of the collection of evidence, which is still evident in the new format. A great deal of tension was created within the student group when some students were not felt by the group to be pulling their weight in relation to collection of reading and other information in PBL groups. The use of the Aisling library as a starting point for finding evidence has been developed in order to assist in the process of collecting information and group working. This needs to be constantly developed. It could be argued that the students are not being assisted in developing their own skills in collecting and finding literature. Some students may only find evidence from this source, limiting their transferable skills and the quality of their assessments. Ali and Salter (2004) highlight the use of discussion forums as an assessment method, but we have chosen not to take this approach as it is still a developing area of learning activity. Feedback from the lecturers suggested that they found this approach to delivery energising as a new and different approach to teaching and learning. The logistics of delivering a module to a large number of students significantly improved with the use of the online sessions to balance large lecture theatre sessions. It enabled them to work in small groups with students but the logistics of small group work in a physical setting was negated. They however, acknowledged that the initial potential benefits of PBL such as learning about team working and how to access information were not so clearly developed. It is important that students and lecturers receive sufficient training and education in the use and facilitation of online discussion forums prior to and during the module (Nelson et al., 2005). Students have commented upon how useful the preparation sessions were. This approach to learning will never be effective unless time and effort is put into this training. Students and facilitators can find this type of learning a challenge and if they are also struggling to undertake on line activities as well then this can only lead to a negative learning experience. An additional benefit to such training is that it prepares students and lecturers for other online activities at a later date. The other difficulty with the previous module delivery was the linking of the summative assessment to the PBL activities. This has been identified as a challenge by other authors (Wray et al., 2004). Student evaluations showed that the students believed the assessment was poorly linked to their PBL activities. This was despite the assessment being directly linked to the triggers (the name used for our PBL scenarios/activities). The modules were assessed using a workbook, with activities related to each trigger. Each trigger was linked to a specific topic, for example learning disabilities, mental health, maternity care and families. The main issue within the assessment was that parts of the workbook were formative and should have been completed as part of the PBL process. It was a requirement that they were handed in as part of the assessment but only one section of the work was actually linked to a summative mark. This tended to make the students feel that they were

6 The early benefits of a problem-based approach to teaching social inclusion 195 required to hand in a piece of work not all of which would go towards the overall mark. The students also claimed to struggle in finding a link between their programme or branch and the assessment. The two modules had both theory and practice assessment requirements. The need to improve the assessment process was identified as a priority for the new modules, to ensure that it was clear to the students how their online activities would link to the assessment. Linking online activities to the assessment was deemed important to student motivation to participate in the online discussions. Each activity is related to a specific family or group of people within Aisling, the online discussion is then facilitated around the specific needs of families for example; mental health issues, substance misuse, a child with a learning disability. The assessment had now been split between two modules, one being assessed by practice and one assessed by an essay. For the module assessed by theory the students can choose the topic of their essay from a suggested list. This is in order to ensure that the student can choose an area of interest and one that they feel will link effectively to their programme/branch. In adding more structure and focus to the work it was hoped that students would find the work less challenging and add more depth to their study. The link to a specific community was also thought to assist students in valuing the assessment as a way of learning and linking the theory to practice. The inclusion of reading material linked to each online activity as a starting point for students was hoped to improve the use of literature within the assessment. The over reliance on internet sources not always of a reputable nature was a significant problem in the previous modules. The module assessed by practice has specific practice learning outcomes linked to social inclusion/exclusion, with a specific activity to be undertaken during a maternity services visit. The fail rate for the module has reduced, but as the module has only run twice all the way through in this format it is not possible to draw conclusions from this. The most recent data identifies that the old format fail rate for the module ranged between 10% and 29%. With the new format the range is 0 15%. What has to be taken into account is that we are not comparing like with like as the module assessment is different, particularly in relation to the assessment of practice which is now in one module. Within the old format modules were assessed by both theory and practice. The modules assessed only by practice in our experience tend to have higher pass rates, explaining the fail rate of 0%. Conclusion Student evaluations of the module when delivered previously with a PBL approach were problematic. Students found the PBL work stressful and often could not see its meaningfulness. They also found group dynamics difficult and complained that the work they undertook during the module did not always seem to relate to the assessed work they were expected to produce. The module has run fully only twice at the time this article was written. We have, however, already noticed significant improvements in the students views of the module. We experienced no problems with group dynamics. Interestingly a number of contentious issues related to social inclusion did arise in some of the discussion groups. These issues were often related to student attitudes towards various issues within society. This encourages us to feel optimistic that this approach to delivery of the module might be a worthy way of seeking to dispel myths and inappropriate attitudes around patients and clients with social exclusion issues. Whilst acknowledging that PBL is a useful approach to making links between theory and practice, we have found it difficult to reconcile some of its logistical difficulties and its lack of popularity with students. We have found the move to the use of a virtual town with which to generate practice based scenarios a useful way to engage students in discussion. Furthermore, we have found the move to online group discussion a useful way to engage students in activities that enhance their learning and attitudes towards socially excluded groups. We recognise that this approach has yet to be researched but feel optimistic that it is a useful method of varying the delivery approaches in teaching health and social care students about practice and the theory that underpins it. Acknowledgement The authors wish to thank Sally Siddall for the significant contributions she made to the original ideas for and the development of the Aisling Virtual Town. References Ali, S., Salter, G., The use of templates to manage on-line discussionforums.electronicjournalofe-learning2(2) < (accessed ).

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