Problem-based learning (PBL) is an educational strategy that has been used in medical and other health-care education since its development at McMaster University in the 1970s (Barrows, 1996). PBL facilitates the development of professional competencies required by health care practitioners (Neville, 2009) while developing the ability to communicate effectively within a group, thus equipping student midwives for practice within a multidisciplinary environment (MacVane Phipps, 2010).
The same educational theory that underpins PBL suggests that the creation of student-centred, rather than instructor-led learning increases participants' skills in communication, teamworking and critical analysis (Benson, 2001). This paper proposes that PBL, particularly the model used in midwifery education at the University of Bradford, contributes to safe practice by encouraging a holistic understanding of care within a woman-centred framework (Haith-Cooper et al, 1999). This approach facilitates the development of the 6 Cs recommended by the Chief Nursing Officer in response to the Francis report (Cummings, 2012); therefore, compassion, communication, commitment, courage, care and competence are all facilitated by educating midwives through the medium of PBL, using the Bradford model.
Developing the Bradford model
The Division of Midwifery at the University of Bradford has engaged with PBL as a teaching and learning methodology for the past 18 years. Following an introduction to PBL through a workshop at Maastricht University, one of the key European ‘PBL universities’, lecturers from the School of Health Studies brought this innovative educational philosophy to Bradford and began adapting it to their own needs. The Division of Midwifery was in the forefront of this experiment and within a few years had moved from using PBL as an isolated element in a small number of modules, to designing the first direct-entry midwifery degree as a fully-integrated PBL curriculum (Haith-Cooper et al, 1999; MacVane Phipps, 2010).
Teaching initially followed the classic Maastricht/McMaster model. This included use of the 7-jump process, facilitation of each PBL group by a dedicated PBL tutor and encouraging students to research individual topics which they then fed-back to the rest of the PBL group.
One of the first innovations made by midwifery lecturers was to alter the research and feedback stages of the process. By encouraging groups to identify a strictly limited number of learning outcomes or goals on which to seek information, each student was able to research all the identified questions. This quickly led to genuine discussion and debate as students evaluated the strengths and weaknesses of a variety of information sources including the library, online and human resources (MacVane Phipps, 2010). The midwifery educators perceive this as a major factor in encouraging students to model the 6 Cs of good practice (Cummings, 2012) in both education and clinical practice.
The educational arguments for PBL
While considering the implementation of PBL, it is important to acknowledge that PBL can present challenges to both students and academic staff as it reverses the traditional locus of control from educator to student (Price, 2003). Because an integrated PBL course combines knowledge from a variety of subjects, students sometimes find it hard to differentiate knowledge in relation to modules studied. This is beneficial in terms of PBL's replication of the ‘messiness’ of real life experience (MacVane Phipps, 2010) where psycho-social, cultural, clinical and physiological factors interact to create a unique experience. However, determining what information is required for which examination or assignment can be confusing for the student. It is the responsibility of educators to clarify module learning outcomes and specific requirements for assessments.
Educators can also find PBL difficult if they have learned their art in a didactic environment with a teacher-led model of knowledge transmission (King, 1999). To move from an instructor to a facilitator model of teaching requires commitment and self-reflection on the part of the educator (Haith-Cooper, 2003). However, students and teachers who work through the initial complexities of learning to learn and teach differently will be rewarded by enhanced skills and potentially a higher degree classification on graduation.
Communication and compassion
Effective PBL is dependent on good communication. As students develop communication skills, learning is enhanced. This models practice where communication with professional colleagues and with parturient women is a key midwifery skill. As midwives interact with women on a daily basis, communication on all levels is integral to the midwifery role. Technical skill unhitched from excellent communication limits practice, making it unsafe (Sloan and Watson, 2001). Technical skills are part of the science of midwifery; the communication that accompanies and enhances the skill illustrates the art of midwifery. Midwives use a variety of communication skills facilitating informed choice on the part of women. Technical skills and midwifery artistry need to both be evident in the provision of safe and skilful practice.
In PBL, participants engage in the process of learning through interaction, sharing experience to explore knowledge and understanding. From this, questions are developed and then answered to expand and fill knowledge gaps. The group learning and the facilitation processes are both congruent with the essential educational constructs proposed by Rogers (1980) of mutual respect and positive regard. PBL utilises the basic helping skills (Egan, 2013) of attentiveness, active listening, and responding to non-verbal cues. According to Scarnati (1998) there are learned behaviours associated with active listening. These include attention to detail, maintaining eye contact, letting the speaker talk without interruption and watching for non-verbal cues. In this way, the listener is able to achieve a deeper perception of the speaker's intended meaning.
PBL is structured to maximise communication and group interaction, valuing the individual experience in order to enhance the knowledge of the whole group. All students bring with them a pre-existing capacity to communicate. While the quieter student may be challenged to speak, the over-confident one may come across as authoritative and domineering. Engagement in PBL can provide some insight into how to communicate effectively, helping students to develop their own voice. Participation and observation of group dynamics enhances individual reflexivity as students develop a level of self-awareness and emotional intelligence. This is facilitated by conscious appraisal of the impact that behaviour has on genuine interaction.
During a PBL session, the work achieved by the group is recorded by a scribe. This process involves rapid, accurate and contemporaneous recording of events. Students initially may find this stressful as they are required to actively listen, process and capture an accurate record of what is said. In an attempt to process and record the multiple perspectives presented, the scribe probes, questions and paraphrases, thus prompting further analysis and discussion until a collective consensus of ideas is achieved. The process culminates in the identification of knowledge gaps and the formulation of questions through discussion and negotiation. The skills used as scribe can help prepare students for active listening (Scarnati, 1998) and open questioning in counselling situations in practice. Recording of events directly mirrors practice skills required for professional record keeping, particularly during high-stress events such as an obstetric emergency. PBL also develops facilitation and group leadership skills (Haith-Cooper, 2003), building students' confidence to speak and present information to an audience.
Ground rules help students to explore the basics of good communication addressing the ethical issues of confidentiality and mutual respect, which underpin midwifery practice (Nursing and Midwifery Council (NMC), 2008). Acknowledging the need to value individuals and their contribution within the group, students reflect on their participation as they express thoughts and ideas as part of the decision-making process. Mirroring the midwife–woman relationship, this learning experience reinforces the positive outcomes of shared decision-making (MacVane Phipps, 2010).
Each student will take the role of Chair, developing skills through engagement in and observation of, others in the role. This requires skills of attentiveness, active listening, respect, positive regard and valuing all members of the group. Students acquire the skills of paraphrasing and summarising to check understanding and clarify meaning. Engagement with group dynamics helps to develop competencies in observation and facilitation, which are valuable skills for both clinical practice and career development. Through participation in PBL, students are able to identify their own strengths and weaknesses; this is an opportunity to learn with, and from, each other. Often a quiet student will express surprise at her ability to chair the group effectively, where the over-confident student can struggle to stand back and let others have their say.
The problem-based learning process
Developing compassion through PBL
Student midwives bring many varied personal experiences to the education arena; however, they have not always been encouraged to share these in the classroom. PBL provides this opportunity through the exploration of collective knowledge and understanding in a structured setting. During this process, students often reveal anecdotal and tacit knowledge through birth narratives and self-disclosure of personal experience. This can be highly emotive, for example when discussing pregnancy loss, disability, relationships, or domestic violence, thus requiring the expression of kindness, care and compassion. Working alongside each other, students demonstrate empathy through ‘being with’ each other. They are able to step into each other's shoes and understand their colleagues’ experiences. The skills of active listening, reflecting, paraphrasing and ‘being with’ (Freshwater, 2003) are skills that are demonstrated in PBL. These can be captured by the group and used to develop emotional intelligence through the recognition of collective feelings and emotions (Salovey and Mayer, 1990). Experiences of intelligent kindness can then be used to guide thinking and action in practice, mirroring what is required in clinical interaction where clients are needy, fearful or distressed.
Courage and commitment through PBL
Using PBL in a midwifery education setting facilitates the experience of both courage and commitment. This occurs when working through the steps of PBL. The first step to solving a problem (Pansini-Murrell, 1996) requires students to speak up when they do not understand specific terms or phrases used within the scenario. This allows engagement in the PBL process informed by a clear understanding of the concepts being discussed. Students often find it difficult in the early stages to ask questions or admit to a lack of understanding, especially within a group that has not yet developed a cohesive identity. During midwifery education, students will be exposed to working in groups of different compositions, often with academic and clinical colleagues they do not know well. Student midwives need to develop the courage to find a voice in such situations in order to extract the most from each new learning opportunity. This courage models the voice that is essential to enable a practising midwife to question policies or protocols unsupported by evidence or to advocate for women who may be denied authentic choice and autonomy. Because clinical enigmas form the core of PBL, learning through PBL facilitates problem recognition as well as problem solving and provides students with the opportunity to rehearse potential responses where courage may be required.
The importance of commitment
Students who learn through PBL are also exposed to commitment, another of the ‘compassion in practice’ core principles (Department of Health (DH), 2012). At the outset of the PBL process students are asked to set ground rules, which describe the way that they agree to work with one another. The Bradford model of PBL facilitates students gaining access to a wide range of information from a number of varying perspectives. This happens because all students review the entire set of learning goals or outcomes agreed on following the ‘brainstorming’ step of the PBL process. Access to information, through the use of IT, has developed substantially. Students are encouraged to review and access as many sources as possible to provide an answer to the group's negotiated learning goals, thus they may view the same goal, but from different perspectives. It is important that all of these perspectives are captured, setting the scene for rich discussion at the final feedback step of the process.
Commitment to participate in the group includes posting findings for each of the learning goals onto the university's virtual learning environment (VLE) before the next scheduled PBL session. Time to undertake research and write individual responses or interpretations of information retrieved is built into the timetable. This enables students to model the commitment that will be expected from them in professional practice following qualification. An effective midwife is one who is committed to her own ongoing education and who seeks to make a contribution to the wider service through sharing information.
PBL provides a good grounding in portraying commitment. Students maintain their obligation to the group's ground rules by participating in the entire PBL process, including doing their own research, posting information on the VLE, and taking a turn at the roles required to run the process successfully. Students therefore become accustomed to fulfilling their responsibilities to the group, once again modelling the commitment that is required in a clinical working environment or multidisciplinary team (MDT).
Students prepared for practice through the use of a PBL educational model should be able to acknowledge and action their responsibility for providing care to women, ensuring that the right care is given at the right time and in the right way. Hmelo-Silver (2004) suggests that students' learning is situated in complex problem-solving contexts, which are facilitated through the use of real-life scenarios. This enables students to experience a problem, and experiment with its solution in a safe environment. Students must consider what they know and what they need to know. Only then can a PBL group solve the problem under consideration by applying what they have jointly learned to the situation being explored.
Care
How does PBL encourage students to learn to care? This may be the most difficult aspect of the 6Cs to relate to PBL, as it provides an academic rather than a clinical, learning experience. Learning to care is often perceived as something that is either innate and cannot be taught (Costello and Haggart, 2008; Shrewsbury and Mohanna, 2010), or a skill that can only be acquired in clinical practice (Barnett, 2008).
‘Caring is our core business’: this opening statement from the core set of values issued by the chief nursing office is aimed at creating a shared vision for all those responsible for providing care (DH, 2012: 13). How caring is learned, or indeed whether it can be taught, has been questioned since the transfer of nursing and midwifery education away from the traditional apprentice-style training to higher education (UKCC, 1999). The use of PBL to facilitate the acquisition of caring skills at the University of Bradford challenges this.
Caring occurs when communication is good, mutual respect is nurtured and decision making about care is shared (Cummings, 2012). PBL introduces a number of these aspects of caring from early in the student midwife's educational experience. In addition, students use storytelling and reflection to further develop these skills.
The use of PBL as a teaching method enables students to work together in small groups using carefully constructed enigmas. Each enigma is written in such a way to encourage students to focus on the individual needs of a woman and her family.
Instead of limiting learning to the evidence and processes informing care, PBL is designed to engage students' emotions. The teaching and learning method aims to develop an understanding that individuals are complex and have rich social and emotional lives, thereby helping student midwives to consider, not only the physical requirements of the woman but also her emotional and spiritual needs. Thus students develop an appreciation of the significant impact that compassionate care, incorporating holism, has on the woman's experience of pregnancy and childbirth.
Developing competence through the use of PBL
Providing quality care, however, is dependent on more than compassion. It relies on the demonstration of competence by nurses and midwives at all stages of their education and practice (NMC, 2008). Although competence, a key requirement for entry onto the NMC register (NMC, 2008), is considered relevant mainly to clinical education, PBL has an important role in the development of key clinical competencies. Competence is acquired when core professional skills have been achieved; this depends on a number of elements including critical curiosity and self-awareness (Gruppen et al, 2012). Clinical competence is assessed formally in the practice area as education leading to professional registration is divided between clinical and academic settings. Fifty percent of the available curriculum hours must be spent in clinical practice and no less than 40 per cent as theory in UK midwifery education (NMC, 2008).
Competence is defined as ‘the combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and effective nursing practice and interventions’ (NMC, 2010: 11); it is a holistic concept that is neither taught nor learned solely ‘on the job’. Experienced practitioners who act as mentors to students assess their clinical knowledge and ability in the practice setting, where such evaluations are most appropriate as they involve real life situations (NMC, 2008). PBL enigmas or scenarios supporting clinical learning are developed to test clinical knowledge in a safe educational setting (Hmelo-Silver, 2004).
PBL equips learners with knowledge and abilities that can support the acquisition of clinical practice skills. Using tools such as reflection, students are encouraged to question practice from early in their midwifery education. Students are required to search the literature, find evidence and critique the research that informs contemporary practice. Students gain confidence through critiquing and sharing knowledge with their peers. Building on this, student midwives are then able to act as a resource for qualified staff.
There are a number of additional skills, fundamental to the PBL process that support competence in clinical practice. These include teamworking, communication, planning, and time management. Problem identification and creative problem solving are essential clinical skills for midwives in providing care in the ‘real world’ of clinical practice. This is an aspect of competence, which can be practised in the safe environment of the classroom through using PBL. On many occasions students have returned to the classroom to report ‘Do you remember that woman we discussed in Problem 6? Well, I met her in community yesterday!’ or ‘I knew exactly what to do when the woman I was caring for in labour experienced a post-partum haemorrhage because we discussed this in my PBL group last week’. Students are able to transfer problem identification and problem solving skills to the clinical environment, thereby improving situational awareness, which is essential in the provision of safe care (Cooper et al, 2014).
Providing safe care that fulfils the 6 Cs criteria requires thinking both methodically and laterally. Use of creativity, developing assertiveness to challenge outdated practice or false assumptions, and gaining confidence in one's own ability to practice reflexively are all skills developed through PBL. Developing these skills encourages practitioners who are innovators, able to be the managers and change instigators who can drive practice forward to meet the social, environmental and managerial challenges of the 21st century.
Conclusion
The ultimate goal in any health professional education programme is to prepare students who are fit for purpose (Henshaw et al, 2013), ready to be signed off as of good character and who understand the responsibilities inherent in entry onto the professional register as safe, confident, skilled and autonomous practitioners. The authors, lecturers at the universities of Bradford and Salford (which also has a BSc Midwifery PBL curriculum) agree that PBL has a unique capacity in helping to instil the 6 Cs into students' understanding and application of professional ethics. For this reason it continues to form the backbone of the midwifery education programme at Bradford and will do for the foreseeable future. PBL may also be an effective way of facilitating qualified staff to embed the 6 Cs within their own professional practice.