Problem-based case study to enhance

critical thinking in student nurses

NM Mogale, M.Cur student, Department of Nursing, Rand Afrikaans University
AC Botes, D.Cur, Professor, Department of Nursing, Rand Afrikaans University

Abstract Opsomming
The use of traditional teaching methods, for example the Die gebruik van tradisionele onderwysmetodes, soos
lecture method, does not stimulate critical thinking in stu­ by voorbeeld die lesingmetode, stimuleer nie kritiese denke
dent nurses. This problem can be solved by the utilisation by studentverpleegsters nie. Hierdie probleem kan die hoof
of problem-based case study in the classroom/clinical set­ gebied word deur gebruik te maak van probleemgebaseerde
ting. The purpose of this study is to describe guidelines gevallestudie in die klaskamer/kliniese omgewing. Die
for the implementation of problem-based case study in a doel van hierdie studie is om riglyne te omskryf vir die in
clinical setting among first year, comprehensive course werking stelling van probleemgebaseerde gevallestudie in
students at the Northern Province College of Nursing: die kliniese omgewing onder eerstejaar, omvattende kursus
Sovenga campus. studente aan die Northern Province College of Nursing:
The research design of this study was qualitative, explora­ Sovengakampus.
tive, descriptive and contextual and was conducted in the Die navorsingsontwerp van hierdie studie is kwalitatief,
following phases: verkennend, beskrywend en kontekstueel van aard. En is
Phase 1: The development and implementation of a pro­ in vier fases uitgevoer, naamlik:
gram for problem-based case study in the clinical setting; Fase 1: Die ontwikkeling en implementering van ‘n pro­
Phase II: The experiences of student nurses who were ex­ gram vir probleemgebaseerde gevallestudie in die kliniese
posed to problem-based case study in the clinical setting; omgewing;
Phase III: The perceptions of tutors regarding the imple­ Fase II: Die ervarings van studentverpleegsters wat
mentation of problem-based case study in the clinical set­ blootgestel is aan probleemgebaseerde gevallestudie in die
ting (focus group), and; kliniese omgewing;
ase IV: Guidelines for the implementation of problem-based Fase III: Die persepsies van studieleiers met betrekking
case study. tot die im plem entering van p ro b leem g eb aseerd e
The data from Phases I, II and III were used to formulate gevallestudie in die kliniese omgewing (fokusgroup), en
guidelines for the implementation of problem-based case F ase IV: R iglyne vir die in w erking stellin g van
study. probleemgebaseerde gevallestudie.
The sample group consisted of all 69 first year student D ie data v ir die form ulering van rig ly n e vir die
nurses at the Northern Province College of Nursing: operasionalisering van probleemgebaseerde gevallestudie
Sovenga campus and ten tutors teaching clinical courses is verkry uit Fases I, II en III.
at the same campus. Die Tesch (1990) benadering word gebruik met die
The Tesch (1990) approach is used for data analysis. analisering van data.
Nine guidelines for the implementation of a problem-based N ege rig ly n e vir die o p erasio n aliserin g van
case study approach were formulated and recommenda­ p ro b leem g eb aseerd e g ev allestu d ie is b e sk ry f en
tions for development of an instrument to measure critical aanbevelings, vir die ontwikkeling van ‘n instrument om
thinking in nursing were recommended. kritiese denke te meet, is aanbeveel.

ing, by directly engaging students in substantive learning ac­

tivities that require the kind of thinking we want them to de­
Introduction and problem velop. The possible solution to this problem, related to the
development and teaching of critical thinking, may be the im­
statem ent plementation of problem-based case study as a teaching strat­
The use of traditional teaching methods at Northern Province egy-
College of Nursing: Sovenga campus does not enhance critical Problem-based case study is defined as an instructional method
thinking in student nurses. The complexity of nursing practice characterised by the use of patient problems as a context for
demands that student nurses make competent judgements on the student to learn problem-solving skills and acquire knowl­
the basis of reasoning that represents critical thinking. Brown edge about basic and clinical science (Ablanese & Mitchell,
& Sorrel (1993:16) state that research in education indicates 1993:52-81). This radical change in teaching strategy is also
that critical thinking does not just happen for students. Beyer advocated by the Commission of Higher Education, which rec­
(1987:18) proposed that educators need to teach critical think­ ommends that the curricula should shift from a content teach­

( 27;
Curationfe'Aúgust 2001
ing centred curricula to a learning and outcomes based cur­ clinical domains namely Pietersburg, Mankweng and Doctor
ricula. These outcomes cannot be reached by traditional teach­ Machupe Mphahlele. Forty-six (46) participated in the program.
ing methods. The South African Nursing Council (1992:3) ex­
plicitly indicates in its philosophy that the development of
critical thinking in nursing students is essential. This develop­ Phase II: Experience of student nurses
ment of thought is necessary as we must function as inde­ who were exposed to problem-based
pendent nursing practitioner and apply the scientific methods.
The use of traditional teaching methods, such as the lecture case study
method does not stimulate critical thinking in student nurses. The objective of this phase was to explore and describe the
This is further compounded by the fact that nurse educators experiences of student nurses at Northern Province College of
have inherited a population of students from disadvantaged Nursing: Sovenga campus, after exposure to problem-based
secondary schools, who do not have the level of cognitive case study in the clinical setting. This was done in order to
thinking that is necessary for effective problem-solving and identify principles that will be used for the implementation of
critical thinking (Klaasens, 1988:15). the problem-based case study.
The nursing college has in great need of a change in teaching
strategies to enhance critical thinking. No program or teaching
strategy to enhance critical thinking existed in the nursing col­ Population and Sampling
lege. Because of the absence of an appropriate, cultural sensi­ From the total population of 69 students (N=69), registered in
tive instrument to measure critical thinking the researcher de­ January 1999 for the program leading to registration as a nurse
cided on an exploratory, descriptive strategy to develop, im­ (General, Psychiatric and Community) and midwifery at North­
plement and assess the problem-based case study as teaching ern Province College of Nursing, 46 students (n=46) from
strategy in clinical practice. Sovenga campus were included using a non-probability
purposive sampling (Bum and Grove, 1993: 246).

Purpose and objectives of Data collection

the research The method used to collect the data from the students was
naive sketches (Ilson, C rystal, Well, Long and Corney
The purpose of this study was to describe guidelines for the
1987:1026). The students were asked to describe their experi­
operationalisation of problem-based case study in the clinical
ences after exposure to the problem-based case study ap­
setting for first year comprehensive course students at the
proach.
Northern Province College of Nursing: Sovenga campus. The
specific research objectives were:
• To develop and implement a program of problem- Data analysis
based case study to enhance critical thinking in Data was analysed by open coding, based on the Tesch-ap-
first year comprehensive course students at the proach (1990) (in Creswell, 1994:154-155). Sketches were inde­
Northern Province College of Nursing: Sovenga pendently analysed by the researcher and an independent
campus. coder.
• To explore and describe the experiences of the
first year comprehensive course students, who Phase III: Focus group interview with
were involved in problem-based case study as a
learning strategy at the Northern Province Col­ tutors teaching clinical courses.
lege of Nursing: Sovenga Campus. Focus group interviews were conducted with tutors teaching
• To explore and describe the perception of tutors clinical courses at Sovenga campus in order to elicit their views
regarding implementation of the problem-based regarding implementation of problem-based case study in the
case study in the clinical setting at Northern Prov­ clinical setting.
ince College of Nursing: Sovenga campus.
Population and Sampling
Purposive sampling was used (Bums & Grove, 1993:246 and
Research design and methods Polit & Hungler, (1997:229) based on the assumption that the
The research design of this study was qualitative, explorative, researcher’s knowledge about the population can be used to
descriptive and contextual (Polit and Hungler, 1995:640-651). consciously select the participants. In this instance the re­
The research was conducted in four phases. searcher wanted a sample of tutors teaching clinical courses,
namely general nursing, midwifery, psychiatric and community
nursing. The recommended size of the focus group ranges
Phase 1 : Development and from six to twelve participants (Krueger, 1994:78). In this study
implementation of a program for ten tutors participated in the focus group.

problem-based case study.

The program was developed from existing knowledge frame­ Data Collection
works, using patients with elimination needs as an example. Data was collected by means of focus group interviews (Polit
The program was implemented at Sovenga campus using three and Hungler, 1997:457). Phases 1 and 2 were explained to the
28
Curationis August 2001
tutors. The following open-ended question was asked: “What case study achieved the use of multiple methods to
are your views about the implementation of problem-based address the research problem.
case study at our college?” The interview was tape-recorded. • Peer group debriefing. The researcher and a co-coder
A verbatim transcription of the discussion was made in the analysed the content of the naïve sketches transcrip­
interest of trustworthiness. tion of the focus group.
• The focus group interview was tape-recorded and
Data analysis transcribed and field notes were taken during the in­
Data analysis was done according to Tesch (1990) (in Cresswell, terview.
1994:154-155). • A dense description of the research methods is given.

Phase IV: Guidelines for the Ethical considerations

The researcher complied with the ethical guidelines for research
implementation of problem-based case as described by DENOSA (1998).
study
The data from phase I, II, III were used to formulate phase IV,
which are the guidelines for the implementation of problem- Conceptual framework and
based case study.
literature review
A conceptual framework for this study is reflected in figure 1.
Trustworthiness This conceptual framework is used as a theoretical base for a
The researcher used Lincoln and Guba’s model (1985), which programme of problem-based case study. This conceptual
identifies criteria and strategies for establishing trustworthi­ framework is divided into three components, namely
ness. The following measures were employed: v Context: Situational Analysis,
• Method triangulation. Focus groups, literature re­ v Descriptions and definitions of key concepts,
view, naïve sketches and exposure to problem-based v Curriculum process.

Figure 1 Conceptual fram ew ork of the study

CONTEXT: SITUATIONAL ANALYSIS

South African Qualification Authority (SAQA)

National Qualification Framework (NQF)
Act of Higher Education
South African Nursing Council (SANC)
College System
Outcome Based Education (OBE)
Practice and Theory Correlation Principles
CURRICULUM Practice of a nurse
PROCESSS
• SPECIFIC
C ontext:
OUTCOMES Situational
• LEARNING
STRATEGIES AND analysis
METHODS: In this study the context of
> Learning styles problem -based case study
> Learning styles CRITICAL THINKING was based on the views of
> Learning theories LEVELS SAQA (SAQA, 1997); NQF,
> Adult learning PROBLEM-BASED Act o f H igher E ducation,
principles LEARNING SANC (1992), College system,
> Teaching methods CASE STUDY Outcomes-based Education,
• EVALUATION COMMUNITY BASED Practice and Theory Correla­
• PROBLEM: ANXIOUS EDUCATION tion Principles and Practice of
(STRESS)_________ Nursing.
The Commission on Higher
Education made recommenda-

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Curationis August 2001
tions that health institutions revise their curricula in order to Learning theories and principles
equip health care students and health care personnel educa­ Learning theories view learning from different philosophical
tors with knowledge, competency, attitudes, and comprehen­ perspectives. In this study emphasis was based on theories
sively to respond to the health care needs of the population of from which the constructivistic theory developed namely:
South Africa. The South African Qualification Authority • Meaningful verbal learning theory of Ausubel
(SAQA, 1997) critical outcomes, namely problem solving skills,
(1963:35).
team ship, self-responsibility skills, research skills, communi­
• Bruner’s discovery learning theory, which emphasised
cations skills, technological and environmental, and literacy
student’s active involvement (Mellish et al, 1998:31).
and developing micro-vision can be applied in problem based
case study. SANC (1992:3) explicitly indicates in its philoso­ • Vygotskys theory of interactional learning which em
phy that the development of critical analytical thinking in the phasised the roles of cultural and social process, as
nursing student is essential. The context situational analysis well as language, in mediating cognitive development
clearly depicts that nursing practice needs an independent prac­ (Mellish etal, 1998:32).
titioner who is a critical thinker and good problem solver. A
possible solution is the implementation of problem-based case Nursing students are regarded as adult learners because of
study as a teaching strategy. Therefore, we need to describe clinical milieu demands. The following assumptions regarding
concepts related to problem-based case study. adult learning are relevant (Knowles , 1971) (in Mellish et al,
1998:67-68):
• adult learners need to know why they must learn some
Definition of key concepts thing
• a learner moves from dependence to independence
Critical thinking during maturation
In this study critical thinking means rational analysis and evalu­ • experience plays a role in learning
ation of ideas, influences, assumptions, principles, arguments, • adults readiness to learn relates to the things that
conclusions, issues, statements, beliefs, and actions (Bandman adults need to know and do in real life
& Bandman 1995:7; Paul, 1990; Paul & Heaslipp, 1995:40). • adult learners have a life-control orientation to learn
ing and adult learners’ motivation is largely internal.
Problem -based case study
Reilly and Oermann (1992:239) state that the case study pro­ Relevant teaching methods
vides a holistic view of client’s problems and promote problem
The matching of adult learning principles and cognitive learn­
solving learning. Problem-based learning is defined as an in­
ing styles with teaching methods is widely held to result in
structional method characterised by the use of patient prob­
greater learning achievement, greater learner satisfaction and
lems as a context for students to learn problem-solving skills
use of learning experience, improved understanding and better
and acquire knowledge about the basic and clinical sciences
learning comprehension. The following are relevant teaching
(Albanese & Mitchell, 1993:53). Barrows (1997) (in Adejumo
methods that should encourage an adult learner to be actively
1997:1) in an attempt to explicate the meaning of problem-based
involved in learning and use her previous experiences in solving
learning, presented the following key words to describe prob­
the problem, namely case study, problem-based case study, group
lem-based education namely, student centred, integrative prob­
discussion, mentoring, preceptor ship and accompaniment.
lem-based, inquiry based, self-directed, collaborative, re-inter­
active, self-monitored, and practice based.
Evaluation
Com munity based education Evaluation in this study relates to outcomes-based education.
Community based education is a means of achieving educa­ Assessment criteria were formulated for the evaluation or as­
tional relevance to community needs. Key principles of com­ sessment of learning outcomes.
munity-based education are namely, community centred learn­
ing multi disciplinary learning, intersectoral collaboration, and
community based learning activities (Adejumo, 1997:4). FIN D IN G S
Principles for a problem-based case
Curriculum Process
study program (phase 1)
The curriculum process was used as a framework for the pro­
From the conceptual framework the following principles were
gram of the problem-based case study. The curriculum process
includes the following aspects: identified and used for the development and implementation of
the program for problem-based case study:
• Principles of community-based education and adult
Specific outcomes
learning as described under conceptual framework.
In this study specific outcomes were related to basic health
• The learner should demonstrate knowledge, skills and
needs of patients. The learners should demonstrate knowl­
edge, skills and attitudes for the assessment, diagnoses, plan­ attitudes related to the assessment, diagnoses, plan­
ning, implementation and evaluation of the elimination health ning, implementation and evaluation of the health
needs and problems of the individual patient. needs and problems (principles of outcome-based
education and the nursing process).

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Curationis August 2001
 • The case must be presented as a problem. Table 1 Categories of student
• Assessment criteria (knowledge, skills, values and experiences
attitudes) to be used in evaluation/assessment of stu­
dent learning. Specific learning outcomes and as
sessment criteria should be formulated for each as­ Positive experiences
pect of the learning content. Holistic approach

• Pre-knowledge, related to basic sciences should be

• Holistic understanding of patients needs and problems
assessed.
• Improve interaction with patient.
• The learning that has occurred in working with the • Understand and are able to give health education to
problem and self-directed study is integrated into the patient
students’ framework of existing knowledge, skills and • Gained a lot. It helps to understand the patient
attitudes. problem/ need
• Meaningful learning
• Assess student by self-evaluation, peer evaluation • Comprehensive learning
and tests. • Focus on problems and understanding nursing-
care for a patient with a specific need/ problem
• Feedback by tutor.
better.

With the implementation of the problem-based case study pro­

gram/approach students were divided into groups of four or Skill development
five in different clinical units. The following protocol was used • Thinking skills are developed
with the implementation of the program. • Skill on history taking, assessment, formulation of
nursing diagnosis and planning, intervention were
• A group of students in each clinical unit were as developed
signed to identify a patient with elimination need/ • Development of problem solving skills without the
problems. help of a doctor.

• After identifying a patient, they were then expected

Student involvement
to identify and study relevant theoretical frameworks
from basic sciences. During the presentation of the • Interesting
patient, students were asked to justify the assess­ • Student centred
ment data, diagnoses, planning and implementation • Active participation
based on the theoretical framework of the basic sci­ • Self, peer and tutor assessment
ences, like physiology.
• Build self - confidence
• Encourage group work
• During presentation, students were expected to use
the nursing process as a guideline to solve the iden­ • Address adult learning principles
tified problem.

• After presentation followed self-evaluation, peer Correlation of theory and practice

evaluation and feedback from the tutor. • Good correlation between theory & practice
• Understanding the logic of relevant of theory
Phase II: Experiences of student nurses • Remember better
The objective of phase two was to explore and describe expe­
riences of student nurses who were exposed to problem-based
case study. The experiences were divided in positive and nega­
tive.
Negative experience
Table 1: Provides a schematic representation of six main cat­
egories and sub categories of student experiences, which were • Poor performance
generated from the coding of naive stretches. • Anatomy and physiology not well presented by other
groups
• Anxiety
Phase III: Perceptions of tutors • Lack of group leaders
The objective of phase III is to explore and describe the per­
• Inadequate time for skill feedback
ceptions of tutors regarding the implementation of the prob-
lem-based case study in clinical setting. A focus group was • Interference with feedback for basic skills
conducted with ten tutors. Table 2 shows an overview of cat­
egories of focus group results.

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Curationis August 2001
Table 2. Categories of focus group Operationalisation
To operationalise this guideline the following action should be
results implemented using the example of elimination needs. The
method, strategies and resources used must be compatible with
Curriculum Review adult education principles in a tertiary educational setting.
• A need to review curriculum, it must be problem - • Activate pre-knowledge of all basic science for better
based curriculum. understanding of the problem. Students need to know
• Redesign clinical workbook in such a way that it en the anatomy and physiology, social science and natu­
ral science related to each problem. Self-evaluation
courages student participation
pre-test can be employed to activate the pre-knowl­
• it must contain problems on human needs
edge.
• student nurses must assess patients with basic needs
• Provision of adequate time to practice basic skills be­
and solve these problems. fore formative evaluation, for example, he/she will be
expected to practice the following skills namely giv­
Training Schedule ing of a bedpan, administration of suppository and
• Redesign present schedules especially time tables. giving an enema. This is followed by a competency
The theory to be presented in the morning and corre­ test of skills by the tutor during formative and
lation of the theory and practice in the afternoon. summative evaluation.
• Use of critical thinking, problem solving and group
M ulti - disciplinary learning skills should be encouraged through the assignment
• Involvement of registered nursed, in the clinical units of problem-based case study.
to act as preceptors in the units for the student. • Inculcate value of respect, empathy, responsibility,
• Multi - disciplinary team members must be involved, autonomy and dignity of the client or patient. For
for example doctors, social workers and psychologist example, providing privacy can ensure the dignity of
and physiotherapist. a client/ patient. Emphasis should be placed on
• All disciplines must work together multicultural aspects of the community. Respect for t
he human rights of client/ patient.
• Mini research problem in various disciplines.
• Use nursing process that includes assessment, diag
noses, planning, implementing and evaluation of ba­
Library facilities
sic human needs.
• Library time for students to be increased
• Utilising adult learning principles, which are active
• Improvement of library facilities learning, deep-holistic life long learning and construc-
provision of enough seating facilities tivistic learning.
• accessibility at all times especially in the evening. • Use of outcomes-based approach as stipulated by
the South African Qualification Authority requirements.
Implem entation of problem- base case • Use of a competency based approach with compe­
study tence in theoretical and practical aspects.
• Implementation of the problem-based case study at • Use of a problem-based learning approach, which is a
all levels. method preferred by adult students.
• Expose the student first in the situation before expo • Provision of clinical accompaniment by the tutor to
sure to theory so that they can utilise their own previ enhance theoretical and practical correlation.
ous knowledge. • Provision of mentoring of students by the nurse edu­
• Student and teacher empowerment. cator to empower and enable students.
• Provision of preceptor ship of students in a clinical
setting.
Conclusions: Guidelines and • Use of inductive strategy, where the students have to
discover information by themselves.
operationalisation of • Use of deductive strategy, when a general principle is
used in specific cases
problem-based case study • Use of co-operative strategy, where group work is
essential for learning, for example, group discussion.
Data derived from Phase I. II, III were used to formulate guide­ • Use of facilitation, where the tutor makes it easier for
lines for operationalisation of problem-based case study (phase students to participate in otherwise difficult events.
IV).

Guideline 1 Guideline 2
Problem-based case study should emphasise the importance Review of curriculum to accommodate problem-based case
and enhance skills, knowledge, and values of nursing care. study, outcomes-based education and training and commu-

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nity-based education. courages the student to engage in free enquiry as it
occurs in the real world.
Operationalisation • Participating as responsible citizens in the life of lo­
To operationalise this guideline, the South African Qualifica­ cal, national and global communities. For example, dur­
tion Authority expects the whole curriculum to have the fol­ ing discussions of an elimination problem, students
lowing critical outcomes. develop a team spirit. Such qualities can even be trans­
• Learners will identify and solve problems and make ferred to organisations and communities from where
the student comes.
decisions using critical and creative thinking. For ex­
ample, students are expected to identify causes of
faecal elimination problems such as constipation, and • Being culturally and aesthetically sensitive across a
solve this accurately using critical and creative think­ range of social contexts. For example, students should
ing skill. respect cultural beliefs of the patient, and those of
• Learners will work effectively with others in a team, peers, especially during group discussions.
group, organisation or community. For example, in this • Exploring education and career opportunities.
study students are allocated in groups of four or five • Developing entrepreneurial opportunities.
in various clinical units. They are expected to discuss
patient problems in a group. This helps them to share • Redesigning of the curriculum to a problem-based ap
ideas and learn to establish good interpersonal rela­
proach, for example, revisiting philosophy, vision and
tionships with other team members.
mission, teaching methods, and evaluation methods.
• Learners will organise and manage themselves and
• Redesigning of the clinical workbook in such a way
their activities responsibly and effectively. For exam­
that it enhances student participation. The workbook
ple, although we expect them to work in a group, we
must have problems on human needs and students
also expect them to work as individuals. Students are
must assess patients with basic needs and solve the
expected to share the work among them in prepara­ problem.
tion for presentation to peer members, presenting
• Modification of the training schedule, so that the af­
anatomy and physiology or conducting an interview.
ternoons should be reserved for the correlation of
• Learners will collect, analyse, organise and critically
theory and practice.
evaluate information. For example, students are ex­
• The focus will be more community-based rather than
pected to conduct an assessment of a patient with an
institutional.
elimination problem. He/she must critically organise
and analyse the information in order to come up with • Forming learning outcomes in knowledge, skills, atti­
an accurate nursing diagnosis and an intervention of tudes and values in General Nursing Science.
a patient’s needs/problems.
• Learners will communicate effectively using visual, Guideline 3
symbolic and or language skills in various modes. For Utilisation of multidisciplinary learning by using other mem­
example, students learn to communicate effectively bers of the health team.
with a patient with a faecal elimination problem, com­
municate effectively with other members of the team Operationalisation
during group discussion, have the opportunity to
To operationalise this guideline, the following should be im­
present the case study and even write theoretical parts
plemented:
related to faecal elimination.
• Other multidisciplinary members must be involved,
• Learners will use science and technology effectively
such as doctors and physiotherapists, in the teach­
and critically showing responsibility. Problem-based
ing of students.
case study helps students to apply, for example, physi­
• Members from various disciplines, for example the
cal science in solving faecal elimination by encourag­
Community Nursing Science, Midwifery Science, Gen­
ing the patient to maintain thigh flexion, which in
eral Nursing Science and Psychiatric Nursing Science
creases the pressure in the abdomen.
work as a team. Reformulation of problems is institu­
• Learners will demonstrate an understanding of the
tional or community-based.
world as a set of related systems by recognising that
• Workout competencies should be at the end of the
the problem-solving context does not exist in isola­
education program rather focusing on a specific dis­
tion. Students are made to think divergently that, for
cipline.
example, constipation can have various causes, such
as psychological problems, namely, lack of privacy,
lack of activity in orthopaedic or critically ill patients Guideline 4
and abuse of laxatives. Library facilities need to be improved, to meet the needs of the
• Reflecting on and exploring a variety of strategies to students.
learn more effectively. For example, outcomes based
education expects the learner to be a self-directed
learner seeking information related to faecal elimina­ Operationalisation
tion from a textbook on his/her own and discussion To operationalise this guideline the following actions should
of faecal problems with other team members. It en­ be implemented:

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Curationis August 2001
• Library time for students to be increased • The workbook should consist of psychomotor skills
• Adequate library facilities, such as books, journals, and problem-solving skills related to basic human needs.
videos, and computers, sufficient seating facilities e.g.
desks and chairs
Guideline 8
• Accessibility at all times especially in the evening
The effective integration/correlation of theory and practice to
until21h00. enhance knowledge, skills, attitudes and values.

Guideline 5 Operationalisation
Accurate student allocation and training schedules should be To operationalise this guideline the following should be imple­
done in such a way that it enhances their knowledge, skills, mented:
attitudes and values in nursing care. Student learning needs
• A competency-based approach will be used to en
should be considered.
sure competence in theory and practice. These com­
petencies include knowledge skills, problem solving,
Operationalisation critical thinking, ethical decision making, listening, in­
To operationalise this guideline, the following actions should terviewing, assessing community needs and self di­
be implemented: rected study.
• Effective clinical allocation during the learning pro­ • Clinical accompaniment by the tutor to enhance theo­
gram should be in a general hospital unit as well as in retical and practical correlation.
the community so that the student gains more expo­ • Mentoring of students by the nurse educator to em­
sure to nurse patients with various basic human needs. power and enable students.
• Effective integration of theory and practice • Preceptor supervision of students in the clinical areas
• Provision of adequate time for students to practice is required.
the skill required for preparation of formative and • Facilitation where the tutor makes it easier for students
summative evaluation to participate in otherwise difficult events.
• Allocation of students into groups, when preparing • Planning of a program.
problem-based case study.
Guideline 9
Guideline 6 Problem-based case study should focus on the development of
Assessment (evaluation) in problem-based case study is com­ critical thinking skills.
pulsory to evaluate whether the outcomes in knowledge, skills,
attitude and values have been achieved.
Operationalisation
To operationalise this guideline, the following should be imple­
Operationalisation mented:
To operationalise this guideline, the following actions should • Activation of prior knowledge plays an important role
be implemented: in learning. Teaching requires not only the imparting of
• Assessment will be done on specific outcomes and new information but also the conveying of meta-knowl
according to assessment criteria. edge in such a way that it will restructure old ways of
• Assessment will be in the form of diagnostic assess­ knowing.
ment, formative assessment and summative assess­ • Self-directed learning. This can be enhanced by the use
ment. of modules, learning contracts and the use of self di­
• The above assessment will be achieved by conduct rected computer laboratories.
ing pre-testing, standardised testing, assignments, • The use of clinical journals to enhance critical thinking.
clinical performances, student feedback, case study • Engage students in reasoning. During reasoning, peo­
research and essay projects. ple should treat one another as equals.
• The attitude of the teachers and the intellectual atmos­
Guideline? phere of the class have to instil confidence in students
that rational disagreement will not be penalised in any
Redesigning of the clinical workbook in such a way that it
way but highly rewarded.
encourages active student participation.
• Utilisation of teaching strategies that will stimulate
higher order thinking such as Critical thinking, analy­
Operationalisation sis, synthesis, application, writing and problem solv­
To operationalise this guideline, the following should be im­ ing.
plemented: • Begin activities with structured group experiences and
• The workbook must be used throughout their clinical proceed to the analysis, evaluation and application of
placement to enhance learning what was learned.
• The workbook should have due dates for completion • Critical thinking must be taught as an integral part of
to ensure that it is presented for formal evaluation other nursing program subjects.

34
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 Boston. Allyna Bacon. Handbook of college teaching, theory
Discussion of the findings and applications. London: Greenwood Press: 3-22.

and conclusions and BURNS, N & GROVE, SK 1993: The practice of nursing re­
search: conduct, critique and utilization, 2ndEdition. London: W.B.
recommendations Saunders Company.
The students’ experiences with the problem-based case study
approach/program were mostly positive. The program facili­ BROWN, N H & SORREL, J M: The use of clinical journal to
tated a more holistic approach and better understanding of the enhance central thinking. Nurse Educators. 18, (5) September /
patients and their health problems/needs. The program also October 1993:16-18.
contributed to the development of independent problem solv­
CRESSWELL, J W 1994: Research design: Qualitative and
ing and thinking skills for the assessment, diagnosis, plan­
quantitative approval. London: Sage Publications.
ning, implementation and evaluation of nursing care. The stu­
dents became active participants in the learning process and DEMOCRATIC NURSING ORGANISATION OF SOUTH AF­
learned to work together as a team. The problem-based case RICA 1998: Ethical Standards for nurse researchers. Pretoria :
study approach also facilitated better theory-practice correla­ DENOSA.
tion. The students related the negative experiences to the
anxiety experienced by the students and the inadequate feed­ KLAASENS, E L 1988: Improving teaching for thinking.
back and discussion of the basic sciences. Nurse Educator. 13 (7): November/December 1988:15-19.

The tutors were very enthusiastic about the problem-based

KRUEGER, R A 1994: Focus Groups, Second edition. London:
case study approach. They recommended a change in the cur­
Sage.
ricula, clinical workbooks and the education time schedule to
accommodate the new approach. They also emphasised a multi­ ILSON, CRYSTAL, D, WELL J C, LONG,T L & CARNEY, F
disciplinary involvement in the new approach and the improve­ 1987: Readers digest Universal dictionary. London: Readers Di­
ment of supportive facilities like the library. gest Association Limited.

From the students and tutors experiences and perceptions, the KLOPPER, H C 1998: Nursing education: a reflection.
problem-based case study approach seemed to be a viable Johannesburg: Siyferelf Publishers.
clinical teaching strategy for the nursing college. For the
operationalisation, of the problem-based case study approach LINCOLN, NS & GUBA, E G 1985: Naturalistic inquiry. Lon­
don: Sage Publishers.
in clinical nursing education, the aspects of the students’ ex­
periences and tutors’ perceptions were integrated in the nine MELLISH, J M, BRINK, H & PATON, F 1988: Teaching and
guidelines. learning the practice of nursing, 4thEdition. Heinemann: Johan­
nesburg.
The following recommendations for further research were made,
MORTON, M & “SALJO”, R 1976: On qualitative differences
namely: To test/measure whether the problem-based case study in Learning process and outcome. British Journal of Educational
approach will enhance the development of critical thinking. In Psychology. 461976:4-11.
order to measure the development of critical thinking in stu­
dent nurses, a cultural sensitive instrument should be devel­ PASH, G 1976: Styles and strategies of learning. British Journal
oped in Nursing Education in South Africa. of Psychology. 76:128-148.

PAUL, R W 1990: Critical thinking. Rohnert Park: Sonoma State

University.
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