The fundamental aim of pre- and post-registration midwifery education is to develop safe, competent practitioners ‘so that, on registration, they can assume full responsibility and accountability for their practice as midwives' (Nursing and Midwifery Council (NMC), 2009: 3). The key challenge for educators and mentors, therefore, is to ensure that each student is equipped with the necessary skills to be able to practise autonomously and provide the highest possible standard of care at the point of registration.
Enquiry-based learning (EBL) is an approach to learning that has been implemented in a number of universities as a means of encouraging students to more effectively apply theory-based knowledge to practice, both during their studies and post-registration. It generally involves students working together in small groups (or learning sets), formulating their own learning outcomes and exploring scenarios that arise from an initial ‘trigger’, presented by tutors. A trigger can take many forms—for example, a photograph or fictional extract from case notes or video—and it should always be firmly located within ‘real life’ (Price, 2001), in this case, midwifery practice. The tutor in this situation acts as a facilitator, guiding students through the enquiry, occasionally making suggestions and supporting feedback both within the small learning sets and the group as a whole. The facilitator also has a pivotal role in ensuring that the learning outcomes are appropriately set, managed and achieved. EBL, therefore, demands a high level of cohesiveness among learners and the teaching team.
Evidence suggests that the EBL process encourages critical thinking and enhances application of theory to scenarios regularly encountered in practice. It is also thought to improve retention of information (Levett-Jones, 2005). Nurses report that their evidence-based practice and, therefore, care of patients has been enhanced as a result of engaging with an EBL curriculum (Kirwan and Adams, 2009). However, the student-led philosophy inherent with EBL can pose a difficult transition for learners who are perhaps more used to a didactic teaching approach, so the role of the facilitator is fundamental to overall success (Ashby et al, 2006). The lack of student input into the development of triggers has also been identified as a source of tension (Barron et al, 2008).
EBL was pioneered at Case Western Reserve and McMaster universities in the 1950s and 1960s (Boud and Feletti, 1997), and has been applied to medical education at the University of Maastricht for a number of years, although it is seen less often in midwifery and nursing education. The University of Worcester reapproved its BSc Hons midwifery programme in 2012 to one entirely based on the EBL approach to classroom education—a bold move, as it required current students to undergo a significant philosophical and practical learning shift. It would not have been possible to resource the existing and new curricula to run together at the same time; therefore, following consultation with the students, a decision was made to move to a single EBL curriculum.
This paper presents a summary of the findings from a study that evaluated students' opinions and experiences of the first year of the new curriculum.
Literature review
The literature described here highlights views on EBL from the perspectives of the lecturers involved, from a range of disciplines such as medicine, nursing and, more recently, midwifery. Principally, the studies identify that one of the key aims of altering a curriculum from traditional to EBL is to enhance the theory–practice dynamic, thus ensuring that students are adequately prepared for clinical placements. One report by Rowan et al (2009) describes the views of two small groups of graduate midwives who had followed a problem-based learning (PBL) or traditional curriculum. They were asked to what extent they believed the curriculum designs had prepared them for practice. When compared to the views of the midwives who had experienced a traditional curriculum, the results suggest that PBL does encourage midwives to question and challenge practice. However, there is a lack of research that has measured specific outcomes, such as examination results, or sought the perspectives of other key stakeholders involved in midwifery education.
Qualitative investigations have identified similar themes including: the role of the tutor and consistency in the methods by which facilitators implemented their role; the impact of the peer group in feedback sessions; levels of student motivation to complete assignments; and preparation for practice (Brown et al, 2008; Rowan et al, 2008; 2009; Tully, 2010; Hamilton et al, 2012). One specific issue that is common to the literature is students' concern regarding the acquisition of basic physiological knowledge (Fisher and Moore, 2005; Rowan et al, 2008). It is interesting that, within the literature reviewed, the authors did not appear to view this as a problematic issue in an EBL curriculum. This may be because the authors have presumed that any knowledge gaps are issues to do with preparation of individual modules, or individual tutor styles, rather than directly as a result of applying EBL. However, some studies report contradictory findings. For example, the students in Tully's (2010) study perceived that EBL had enhanced their theoretical knowledge in a way that the traditional approach could not.
The consistency of the facilitator role in EBL is an important theme in the literature, although it would have been valuable to have also gained a sense of the guidance and supervision students received in terms of the EBL process. In most of the research described here, EBL is new to the teaching team, just as it is to the students. Consistency as an issue should resolve as programme teams evaluate their provision and teachers become more confident with the philosophy of EBL and its process.
Individual differences among tutors in terms of teaching and communication style are noticed and frequently reported by students. Fisher and Moore (2005) suggest that the inclusion of students in programme evaluations may enable tutors to ensure that modules are providing all of the possible benefits of EBL, and also encourage students to become more engaged in the programme delivery. Barron et al (2008) offer another perspective, suggesting that students should be involved in creating triggers, thereby helping to ensure that the overall enquiry/problem accounts for individual differences in learning styles, an issue identified by Levett-Jones (2005). This inclusive approach should also help to familiarise students with the philosophy of EBL and illustrate more effectively what is expected of them during enquiry feedback, an issue identified in a report by Hamilton et al (2012).
Aim
The evaluation described here had two broad aims. Firstly, as the University of Worcester has incorporated EBL throughout the midwifery curriculum, students were asked to discuss whether this is more effective with some modules than others, and whether the facilitator role is clear and consistent across modules and levels. Secondly, the concern attached to the leap from traditional learning to EBL was investigated. For this, the perspectives of the final-year students who have undertaken 2 years of the traditional curriculum and only their final year as the EBL curriculum were essential. These students may feel at a disadvantage as the adaptation period, described by Barron et al (2008), occurred during the crucial final year. It is important to consider, however, that in future years this will not be the case as all new students will follow the EBL curriculum from the start of the programme. This will, therefore, provide an opportunity for students to become familiar with its demands, with the expectations of year 3 being some way off.
Ethics
Although students in higher education are regularly asked to provide feedback about all aspects of their degree programmes, and the research team anticipated a high level of student interest, the researchers took steps to ensure that students clearly understood the purpose of the evaluation before agreeing to participate. It was not presumed that students who provided feedback as part of their course programme would consent to do the same for this project. To ameliorate the risk of students feeling obliged to participate in an evaluation led by their tutors (Rigby et al, 2012), the cohorts were approached by the Institute of Health and Society's research assistant, who was unknown to them, during semester 2 of the first year of the new curriculum. They were provided with written information about the evaluation, as well as a facilitated opportunity to ask questions. The freedom to choose whether or not to take part in the study was emphasised, both verbally and on the information sheet. Consent was therefore implied by completion of the questionnaire and/or agreeing to participate in an interview.
The data collection was then undertaken by the research assistant. In some ways, this was a clear advantage because the students could speak freely and honestly about their experiences and the risk of coercion was reduced. Confidentiality was assured, although it was acknowledged that anonymity was harder to completely guarantee; for example, the students who participated in a group interview may subsequently recognise comments from a fellow student in published material. Ethical approval was granted by the university's Institute Ethics Committee.
Methodology
A mixed methods design employing questionnaires, individual and focus group interviews was employed to maximise capture of the students' experiences and their perspectives of the new EBL curriculum.
Sample group
Participants were recruited from a purposive sample group of 113 midwifery students at the university. All 113 were invited to complete the questionnaire and 85 (75.22%) responded. Six midwifery student cohorts participated:
The 41 (48.2%) participants from the September cohorts had experienced between 12–14 months of the new EBL curriculum, while the 44 (51.8%) in the February cohorts had only completed 6–8 months of the new EBL curriculum. The 33 (38.8%) students from the September 2012 and February 2013 cohorts were at the end of their first year of midwifery studies at the time of completing the questionnaire, and therefore had not experienced the traditional lecture-based approach to midwifery education at the university. The remaining 52 (61.2%) students from the other four cohorts had all experienced the traditional approach at the university for either 1 or 2 years prior to the change to the EBL curriculum.
Methods
Standard Likert-type scale questionnaires were used, with five response possibilities ranging from ‘Yes, definitely’ to ‘Definitely not’. The middle possible response indicated ‘no preference’ or ‘not applicable’.
The first questionnaire contained 30 items relating to participants' views on how EBL affected their learning, development of skills, confidence in their own knowledge, how it links theory to practice, and how the curriculum had been implemented. All 33 (38.8%) students in their first year of study at the university (from the September 2012 and February 2013 cohorts) completed this questionnaire.
The second questionnaire contained 30 items relating to participants' views on EBL in terms of the categories listed above, together with 30 identical items relating to their views on the traditional lecture-based curriculum. All 52 (61.2%) students in their second and third years of study, who had previous experience of the traditional lecture-based curriculum, completed this questionnaire.
A repeated measures survey design was used to identify any variance between participants' views on the outcomes of the EBL curriculum and their views on the outcome of the traditional lecture-based method of learning. Internal consistency was achieved between items within the questionnaire sections. An independent groups analysis was used to compare the results between cohorts and investigate the possibility that previous experience of traditional lecture-based learning, or the amount of engagement with the EBL curriculum at the time of survey completion, may have influenced perceptions of the programme.
In addition to the questionnaires, all respondents were invited to participate in a one-to-one or focus group interview to discuss their experiences of the first year of the EBL curriculum. A small sample of six students responded in total, representing all three years of study. One final-year student participated in a one-to-one interview, two second-year students participated in a paired discussion facilitated by the research assistant, and three more final-year students from a different cohort participated in a focus group discussion. The recorded discussions were transcribed verbatim and analysed using framework analysis.
Data collection began in July 2013 with questionnaire distribution and interviews with students from the September cohorts as they approached the end of their first year of the EBL curriculum. In October 2013, the February cohorts completed the questionnaires and participated in interviews until November 2013, 8–9 months after the start of their first year of the EBL curriculum.
Findings
Analysis of the questionnaires revealed that the students perceived the positive aspects of the EBL curriculum to be increases in critical thinking (73%), problem-solving skills (68%), and leadership skills (66%). The most commonly recognised advantage of EBL across all student groups related to the development of team-working skills; 92% of the students agreed that this had improved, with only two respondents out of 41 (8%) disagreeing.
The results dispute previous findings that EBL as a method of learning leads to better retention of information. Only 17 (41%) of the respondents believed this to be the case. Interestingly, this figure represents the view of 60% of the first-year respondents, while only 30% of the second-year and third-year students agreed. A similar pattern of results emerged in response to the question asked relating to EBL triggering interest in specific topic areas. Overall, a majority of students agreed with this (68%), but this figure represents 87% of first-year student views. Only 58% of second-year and third-year students recognised this to be a benefit.
Results from the first set of questionnaires also highlighted the students' initial concerns with confidently interpreting triggers, and this was further explored in the group and individual interviews:
‘Yeah, it was that lack of guidance on, “You need to know X, Y and Z in this detail,” because without that we've all just sort of floundered around going, “Aargh, do we know enough about this?” or we've learned too much about that and not enough about that, and I think that's been the biggest problem with EBL…’ (Participant 002)
‘It's fine to teach yourself but there's no one watching what you're missing.’ (Participant 001)
One student observed that EBL may be valuable in ensuring that learning outcomes can be achieved regardless of the individual's learning style, and that this benefit may support students with learning difficulties:
‘When you're made to do the work it means that you can learn in a way that's more conducive to yourself. Rather than just lectures, you know for some girls—if you're dyslexic and you're sitting there in a lecture it's going to be really difficult for you, whereas if you can go and break it up into a way that is better for your own learning, whatever your learning style is, then you're going to get a lot more out of it.’ (Participant 003)
Some of these concerns were expressed in the context of the anatomical and physiological knowledge required as part of the enquiry. This is consistent with the findings of Barron et al (2008) and Fisher and Moore (2005); students in these studies believed that they lacked the required foundation knowledge before detailed discussion of the triggers could unfold. All of the students interviewed in this study acknowledged the value of the feedback sessions in affording them opportunities to explore alternative concepts and interpretations of the trigger with the whole cohort, especially if these had not arisen within their own learning set. Students from the September 2010 cohort observed:
‘There were a few times that it was actually really useful and you'd suddenly go, “Oh good, I didn't know that!” And you send each other your work so I've still got stuff now that I haven't read but I know I'm going to need it at some point and so it's there for me to refer to.’ (Participant 003)
‘When you present it back to the class you all do it in different ways so again, you're not just being lectured to. You'll see a poster presentation, you'll see a PowerPoint, you know they'll soon be doing games, all that sort of stuff.’ (Participant 001)
Conversely, the September 2011 students highlighted the benefits of learning within their small EBL groups:
‘We learnt a lot from each other.’ (Participant 002)
‘You learnt a lot from your own little group because you kind of share ideas.’ (Participant 002)
‘That's a positive, different people's way of working—we had one girl that used mind maps, which were completely new to me—I'd never used a mind map in my life, and I loved the way she presented her information, that was brilliant for me!’ (Participant 001)
All of the students stated that their perceptions of EBL and its outcomes became increasingly positive with time. This was a combination of tutor and student factors:
All of the interviewees agreed that they had developed appreciation of the benefits of EBL by the end of the academic year, and made some interesting comments regarding this. In particular, students believed that their own team-working and communication skills had been enhanced as a result of just 1 year of the EBL curriculum. One student said her confidence in her problem-solving skills had also increased. With regard to retaining information, all of the interviewees agreed that participation in EBL sessions had helped them to remember important information, although they varied in their explanations for this. For example, two believed that the process of finding information for themselves and presenting it to others was the cause of this benefit, while another suggested that it may have been due to the changed scheduling of modules:
‘With the EBL, one thing is, one topic is done in a week, and actually that's really good, whereas in year 1 we'd have one lecture on this, followed by one lecture on something completely different, followed by another lecture on something completely different—and it was just like, you were haphazard all over the shop, whereas now I think the topic-in-a-week thing does work much better, so instead of having lots of different things in a week, you've got one topic in a week so I think that has been better.’ (Participant 002)
These findings have provided valuable accounts of how the EBL curriculum has directly benefited students' learning, and particularly the development of important practical skills. It was expressed, however, that students were concerned about the rationale behind moving the curriculum entirely to an EBL approach. One student commented that the rationale for the introduction of EBL in higher education settings may not directly apply to midwifery programmes:
‘[The rationale is based] on 120 student nurses sitting in front of a PowerPoint, and yes, that isn't good, but our lectures were not like that, our tutors are fabulous.’ (Participant 001)
Other students agreed with this:
‘It was always very interactive and asking questions. It was never sat there in silence.’ (Participant 002)
‘They were brilliant because you'd ask questions and you could have somebody explain it to you, whereas if you don't understand something in a book and there's no tutor it's me on the phone to people going, “I don't understand it,” and they're going, “No, I don't either.”’ (Participant 001)
Overall, although some student concerns persist with regard to the teaching of anatomy and physiology, the students were appreciative of the process put into place by staff in response to concerns, and the same students agreed that these problems would likely disappear for later cohorts. The results from the questionnaires provide conclusive evidence of this, as 61% of the respondents agreed that they had witnessed improvement over the year and 67.7% of first-year students agreed that any issues they had at the beginning of term had been addressed.
Discussion
Although these results are generally encouraging and suggest that the decision to move completely to an EBL curriculum is largely justified, further studies are required in order to robustly assert this claim. The student numbers in this evaluation, and therefore the data generated, are small. Although an evaluation of the first cohort's entire 3-year EBL journey would have provided a broader range of data, the midwifery team was keen to assess the curriculum change after the first year in order to make any necessary major amendments. As part of the curriculum reapproval process, the students clearly articulated the same viewpoint, and this was supported by other key stakeholders.
Based on the midwifery team's growing experience of EBL and student feedback subsequent to the evaluation, we suggest that EBL clearly has the potential to develop students' cognitive skills at a higher level, thereby enhancing the practice–theory dynamic. However, this can only be fully assessed over time. Evaluation of the curriculum is ongoing at Worcester. Students give feedback at the end of each enquiry, and this enables an instant response to be made by the teaching team. This feedback may suggest that more or fewer resource sessions are required, or that they would actually be more relevant in a different enquiry altogether. For example, it took time to effectively balance the input of relevant anatomy and physiology sessions within the enquiries in year 1 as the needs of new EBL learners were explored. Ongoing review and mapping of the enquiries throughout the academic year enables the teaching team at Worcester to work closely together in a way that a traditional curriculum does not usually support, the most significant benefit of this being a unified approach to the application of the curriculum that greatly enhances consistency for students and staff.
The opinions and experiences of an important stakeholder, the sign-off mentor, also require exploration and would be an interesting line of future research enquiry. Sign-off mentors review students' performance in practice on a continuous assessment basis and, therefore, should be able to provide insight into the ‘preparedness’ of students as they undertake a practice placement. Sign-off mentors who have experience of overseeing the progress of students on a traditional programme would also have a basis for comparison of the two methods of curriculum delivery. Although they may have bias towards, or preference for, a particular type of course structure, they should be able to offer a valuable comparison of clinical competence that results from a traditional curriculum or EBL. Anecdotal evidence acquired during mentor update sessions, for example, suggests that an increased level of confidence among students has been noticed since the introduction of EBL. Further research is required to illuminate the perspectives of practice education partners.
‘Based on the midwifery team's growing experience of enquiry-based learning and student feedback subsequent to the evaluation, we suggest that enquiry-based learning clearly has the potential to develop students' cognitive skills at a higher level, thereby enhancing the practice–theory dynamic’
Conclusion
The development of an EBL curriculum has been a steep learning curve for the midwifery teaching team at Worcester, as well as the students. Yet, on balance, this small evaluation suggests that the decision to radically shift teaching methods has been justified. However, the move to an exclusive EBL approach can only be successfully achieved when a whole team is ready to make both the commitment and pedagogical shift that it demands. Ongoing review is also essential to ensure that midwifery students progress within the required NMC standards.