Advances in Health Sciences Education 6: 205–217, 2011.

205
© 2011 Kluwer Academic Publishers. Printed in the Netherlands.

Students’ Perceptions of Learning Outcomes From

Group-Based, Problem-Based Teaching and
Learning Activities
1 1 2
H. FORBES , M. DUKE and M. PROSSER
1 2
School of Nursing; Academic Development Unit, Faculty of Health Sciences, La Trobe University, Victoria,
Australia

Abstract. Objective: A study aimed at exploring the variation in perceptions of learning outcomes
reported by undergraduate nursing students enrolled in a problem-based learning subject in a pre-
registration Bachelor of Nursing course (BN).
Method: Students were asked to respond to four open-ended questions which focussed on their
learning outcomes in the different teaching/learning modalities of the subject. Data were analysed
in two phases using a modified phenomenographic analysis. In the first phase a set of categories of
description were developed from the student responses to questions related to the learning
modalities. In the second phase the individual responses were classified in terms of the categories.
Finally, correlations between the learning modalities were identified. In this paper the approach to
analysis, the process of category identification and the correlations between the learning modalities
will be described and the implications for further research and teaching will be discussed.
Results: The findings indicated that there were two distinct groups of student responses. Inward
focussed students who described outcomes in terms of their own learning and students whose focus
was outward i.e. describing learning in terms of patient care and how learning relates to that care.
Another important result shows the relationship between the learning modalities and outcomes.
From the students’ perspective, the most sophisticated outcomes of the lectures and laboratories
were ideas and skills to be used and applied in clinical settings. Whereas, the group-based activities
in which clinical problems were presented to the students in the form of Situation Improvement
Packages (SIPS) focussed their attention on the clinical setting which constituted a preparation for
the realities of clinical practice.
Conclusion: The findings from this study indicate that students perceive their learning in the group
based teaching/learning modality (SIPS) as effective in focussing them on the reality of their role
in the clinical practice environment while lectures and laboratories provided the skills and
knowledge required for this setting.

Key words: learning outcomes, perceptions, problem-based learning, undergraduate nursing

students

Introduction
The decision to implement a problem-based learning (PBL) curriculum in the
Bachelor of Nursing at La Trobe University is based on the belief that nurses of the
206 H. FORBES ET AL.

future need to be life long learners, with a flexible and adaptable knowledge
base. According to Finucane et al. (1998) PBL assists students to acquire and
retain relevant information by integrating basic and clinical sciences. They assert
that because learning occurs in context and builds upon what students already
know, retention, interest and motivation are increased.
The overall philosophy of the Bachelor of Nursing Course is process
orientated in line with Barrow’s (1985) conceptualisation of PBL at McMaster
university. However, the method of implementation of PBL in this course differs
from the McMaster model in that it is used as a teaching and learning method in
the clinical nursing subjects rather than as a fully integrated approach. At La
Trobe Univer-sity some modifications have been made in that, while students are
considered to be self-directed, direct instruction is available through supportive
lectures as are opportunities to work alone or in groups, with or without
assistance. Courses are also integrated where for example, psychology, sociology
and biological sciences provide theoretical input into nursing subjects.
In the La Trobe course clinical problems are presented to the students in the
form of Situation Improvement Packages (SIPS). The SIP triggers the student to
engage in the enquiry process and requires the use of clinical judgement in order
to improve the patient’s situation. Andersen (1992) notes that there is a correla-
tion between the quality of judgement and the quality of intervention. Horsfall
(1992) adds that fundamental to the learning process is the identification of
barriers which prevent resolution. These barriers are usually in the form of a
knowledge and/or skills deficit. With assistance from the group facilitator of
each small group, strategies are developed to assist the student to gain the
knowledge or skills required for improving the patient situation. In this way PBL
mirrors the decision-making process used by clinicians and facilitates the
bridging of the theory practice gap. A series of lectures are also provided to
support key concepts which emerge from the case. In addition, laboratory
sessions are available for students to develop their psychomotor skills, the need
for which emerge from the case. These three learning modalities (small group
work exploring SIPS, laboratory sessions and lectures) are seen to be preparatory
for the clinical practice component of the subject.
A study by Duke et al. (1998) showed that students studying in a PBL course held
qualitatively different conceptions of problem-based learning, and that these
different conceptions are systematically related to how they approach their studies in
those courses. Somewhat more tentatively, the findings suggest that students’
conceptions and approaches to learning become more complex over time. That study
has left unanswered, however, how such conceptions and approaches relate to
student learning outcomes in PBL, and how they relate to their perceptions of the
subject in terms of the quality of teaching, goals, workload and assessment. Finu-
cane et al. (1998) identify that it is difficult to detect learning outcomes because of
confounding variables such as concurrent changes in curriculum structure, student
selection, staff development and assessment. Given the established nature
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 207

of PBL in the nursing course at Latrobe University the confounding variables

mentioned by Finucane et al. (1998) are likely to be less problematic. Therefore,
it is intended in this study to explore students’ perceptions of learning outcomes
in the four teaching/learning modalities; small group work exploring SIPS,
laboratory sessions, lectures and clinical practice.

Methodology
This study was conducted in a problem-based nursing subject. This subject is the
first PBL subject in the Bachelor of Nursing course and is entitled Nursing
Therapeutics & Practice 1 (NR210). Students are introduced to concepts related
to meeting activities of daily living in aged care settings by the presentation of a
real clinical situation in which a nurse needs to intervene. Triggers in the form of
written case notes, doctor’s letter and drug order sheet, are provided. The case
was selected from an actual situation and was chosen for its capacity to trigger
acquisition of particular nursing knowledge and skill. It is expected that students
will identify relevant facts, form hypotheses and identify their own learning
needs in order to develop skill and knowledge which is then applied back to the
problem. This process enables the learner to evaluate the effectiveness of their
approach to learning and the quality of the outcome (Barrows, 1985).
In this study the intention was to distinguish emerging themes related to
students’ perceptions of their learning outcomes, and to identify correlations in
the various teaching modalities. The focus was on the variations and correlations
in students’ responses about learning outcomes in lectures as well as the group
based components of the subject.
A phenomenographic approach was chosen because, as Crawford et al. (1994)
have discovered, such an approach uncovers the meaning embedded in partici-pants’
perceptions. The questions were kept as general as possible so as to produce
descriptive data in the participant’s own words and from their own frame of refer-
ence. Themes emerged from the descriptive data that were unlikely to be revealed by
imposed categories of description or through usual methods of content analysis.
The data were collected through an open-ended response questionnaire,
distrib-uted to all students as part of the evaluation of the subject. The questions
included in that questionnaire were:
What did you learn in the NR210 lectures?
What did you learn by exploring the Situation Improvement Package in your
group?
What did you learn in the laboratory?
What did you learn in clinical practice?
The questions focussed on the students’ perceptions of their learning outcomes in
each of the learning modalities. In this paper we report on the analysis of
responses to all four questions and the correlations between learning modalities.
208 H. FORBES ET AL.

One hundred and fifty eight (158) questionnaires were distributed. Ninety one
(n = 91) responses were returned. This is equivalent to 58% of year 2 students.
The analysis is based upon 91 (out of 158) responses to the questionnaire. These
responses represent response rates of approximately 58% of year 2 students.
For each question the first stage in the analysis of the data was to identify a
set of ordered categories of description. From the responses to each open-ended
ques-tion, a hierarchical set of categories were identified which described the
variations in students’ responses. Two of the researchers independently identified
categories which each thought described the variation in the responses from a
sample of 20 responses. They met, compared and contrasted their categories, and
agreed on a revised set. They then independently classified the remaining
responses, met again, compared their classifications and found a high level of
agreement. Subsequently, some minor adjustments were made to the categories
and the descriptions to further improve the reliability of the classifications. It
should be noted that the categories are based upon an analysis of the responses
taken as a whole, and are not meant to represent any individual student.
Individual responses are conceived of as representing a fragment of a category.
In analysing the variation in the structural aspects of the students’ conceptions we
have drawn upon the categories of the SOLO taxonomy (Biggs and Collis, 1982).
According to Biggs and Collis learning occurs in ascending phases with each
becoming increasingly complex. The SOLO taxonomy describes five levels of
learning forming a hierarchical structure where the extended abstract category is at
the top of the hierarchy and the uni-structural category at the bottom. An extended
abstract is where the learner generalises and extends the coherent whole to include
more abstractions. On the other hand uni-structural responses indicate that learning is
pertinent but the focus is on one aspect of a task. We have used the same categories
identified by Biggs and Collis to describe variation in structure.

Results
The outcomes from each teaching modality fell into two distinct groups. An
inward focussed group in which the outcomes are described in terms of content
only. An outward focussed group described outcomes which focussed on the
content for care of patients in clinical practice.

EXPERIENCED OUTCOMES OF LECTURES

What did you learn in the NR210 lectures?
Of the 91 students who participated in this project 17 (19%) did not answer
this question. From the remaining responses four qualitatively different
conceptions of learning outcomes were identified. The responses ranged from a
focus on the content of the lectures alone to the application of the knowledge and
skills learnt in clinical practice.
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 209

Conception A: Content covered

In this category 27% of the responses focussed on content only. They followed a
set pattern which was found to be multi-structural. That is, the responses were
lists or descriptions of unrelated comments concerning their conceptions of
learning outcomes. One student described their conception of the learning
outcomes from the lecture program as;
elderly care, respecting patients
incontinence issues
laws in relation to nursing
communicating
The responses which fell into this category reflected a conception that lectures
provided content only. The respondents did not appear to recognise the purpose
of the lectures which was to provide additional support material to assist their
problem solving in the various group based activities.

Conceptions B & C: Theory for clinical practice

• theory and practice
• theory in practice
Here, the cluster of responses belongs in a broad category entitled theory for
clinical practice. However, within the broad category there were two sub-groups
in which subtle differences were noted. The conceptions were also structurally
different.
The responses in the conception B category (27%) were judged to be multi
structural. These respondents indicated that in lectures they learnt about theory
and practice as concepts which were not related to each other. For example one
student wrote;
incontinence
safety
dehydration
various topics in relation to elderly residents especially in nursing homes
In the conception C category, theory in practice, responses (42%) were
relational; that is, students linked lecture material to the clinical setting showing
that their focus was less on themselves and more on their professional role. This
conception shows that there is application of theory in practice. One student
wrote that she learnt;

all aspects of extended care of the aged, from making beds to Not for
Resuscita-tion orders. The lectures were extremely important for our clinical
practice as they reflected what we were doing and needed to know. Also we
were taught some specifics of gerontological nursing.
 210 H. FORBES ET AL.

Table I. Structural relationships between categories of description for conceptions

of outcomes of the lectures

Referential Structural
Multi-structural Relational

Content covered A (27%)

Theory for clinical practice
• theory & practice B (27%)
• theory in practice C (42%)
Content for further learning D (4%)
in the clinical setting

Conception D: Content for further learning in the clinical setting

In this category students (4%) recognised that the lecture content was a
component of the overall learning of the subject. In particular they saw lectures
as being valuable for generating further learning in clinical practice. These
conceptions were discussed in a relational manner. The following response is an
example of an outward looking student;
(I) . . . developed a knowledge base of the skills and knowledge required to
perform well on clinical placement. The subject gave information that was a
good starting point from which to work in developing a wider knowledge
base through self-directed learning
The structural relationship between these categories of description are shown in
Table I.

Experienced Outcomes of SIPS

What did you learn by exploring the Situation Improvement Package in your
group?
Of the 91 students who took part in this project 7 students (8.3%) did not
answer the question. From the remaining 84 responses four qualitatively different
approaches were identified in response to question 2. The responses ranged from
some students perceiving that they had learnt content only, through to concep-
tions which saw the learning outcomes from SIPS as involving integration and
application of knowledge in real situations.

Conception A: Content covered

Similarities were noted between student responses to questions 1 and 2. Both ques-
tions elicited responses focussed on content and were of a multi structural nature.
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 211

In relation to question 2, however, there were fewer students (15.5%) who were
inward looking. An example of this conception is as follows;
hazards of immobility on elderly and issues including
– pressure ulcer (skin integrity)
– respiratory function
– fluid balance/dehydration
– dementia

Conception B: Problem solving process as a task to complete

Once again the responses in this pattern were multi-structural. Respondents
(30%) identified that the SIPS involved a problem solving process that they
perceived to be a task to complete. One student presented the following list;
− how to look at a resident’s history/progress notes, put them into functional
health patterns, relate them to contributing factors
− correct definition of common terms i.e. dementia
− how to write up effective long & short term goals
− how to evaluate the interventions

Conception C: Problem solving which led to further learning

In this category 38% of students answering this question described a problem-
solving process which led to further learning. They described their learning
outcomes of SIPS in a relational way. That is, one student commented that as a
result of exploring the SIP;
I learnt the problem solving techniques needed to solve problems I may be
faced with. The SIP allowed me to explore learning issues and delve into
areas I hadn’t before. I found them both interesting & rewarding.

Conception D: Integration and application in real situations

Students whose responses fell into this category (16%) were able to identify that
the problem solving process learnt in the SIPS was also useful in the clinical
setting. Additionally, these students also recognized the relationship between all
components of the subject. One student described her learning as being;
Everything! These were the most helpful class sessions for assisting our
learning for and during clinicals. I felt they should have gone on longer and
more frequently because they provided a great open forum for everyone to
ask questions, share information and bounce ideas around. Everything really
started coming together in the SIPS. Knowledge from Pathology, Physiology,
Anatomy, Professional Nursing Studies, Therapeutic Communication. SIPS
taught me how to use and apply both my knowledge base and resources.
212 H. FORBES ET AL.

Table II. Structural relationships between categories of description for conceptions of

outcomes of the SIPS

Referential Structural
Multi-structural Relational Extended abstract

Content covered A (15%)

Problem solving process B (30%)
as task completion
Problem solving leading C (38%)
to further learning
Integration and application D (16%)
in real life

Table II shows the structural relationship between the categories of

description. Therefore, category D (extended abstract) represents a more
complex conception than category A (uni-structural).

EXPERIENCE OUTCOME OF THE LABORATORY

What did you learn in the laboratory?
Of the 91 respondents 4% did not answer the question. From the remaining 87
responses relating to learning outcomes from laboratory sessions there was less
spread resulting in only three qualitatively different categories being identified.

Conception A: Skills
Skill development for its own sake was the basis for the identification of this
category. There was no evidence that respondents (56%) recognized a purpose
for the skills and the responses were multi-structural. An example of this
conception is as follows;
skills
– bedmaking
– lifting techniques
– transferring techniques
– showering (from video)
– bed-bathe (from video)

Conception B: Skills for practice

In this category 37% identified a purpose in that it was seen that the skills were
learnt in preparation for clinical practice. One student presented the following;
practising skills that would be used in clinical e.g. lifts
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 213
Table III. Structural relationships between categories of description for
conceptions of outcomes of the laboratory

Referential Structural
Multi-structural Relational

Skills A (56%)
Skills for practice B (37%)
Skilful care of patients C (7%)

Conception C: Skilful care of patients

In conception C (7%) identified that learning of skills in the laboratory was not
only related to being able to perform the skills in clinical practice, but that they
provided a basis for safely caring for people. One student described the learning
outcomes as;
How to lift a person without hurting them particularly in elderly care (due to
poor skin integrity). Basically how to care for a resident/patient hygiene and
grooming, transferring and lifting, bedmaking. The roles essential for a
nurse/carer in the extended care setting.
The structural relationship between these categories of description are shown in
Table III.

EXPERIENCED OUTCOMES OF CLINICAL PRACTICE

What did you learn in clinical practice?
While there was little spread in the responses to question 3, five categories of
differing conceptions were identified in response to this question. These concep-
tions ranged from relating to theory or to practice to understanding the clinical
environment.

Conception A: Theory or practice

Responses in this category (15%) were uni-structural that is, the responses
focussed on either theory or practice. A theory-focussed conception is a student
who reported having learnt;
. . . about formulating care plans and diagnosing
An example of a practice-focussed conception was learning;
. . . alot in clinicals everything from showering, lifting transferring etc. The
nursing home was a great environment to get a grasp on these skills
214 H. FORBES ET AL.

Conceptions B & C: Theory and practice

• theory is seen to drive practice
• practice is seen to generate theory
When analyzing the data related to clinical learning outcomes in this category,
two sub-groups were identified. Broadly, the category focussed on theory and
practice, but the sub-groups identified different perceptions as to the relevance of
theoretical content; that is, some students (31%) saw clinical practice as the
environment in which to apply theoretical knowledge whereas others (30%) saw
the clinical setting as generating theoretical knowledge. In the first sub-group
responses were multi structural;
Being able to put theory into practice
We were able to use real patients
In the second sub-group, while the responses focussed primarily on the activities
in practice rather than the application of knowledge, there was an indication that
knowledge needed to be reviewed or modified as a result of experiences. In this
sub-group the responses were relational. The following student wrote;
clinical practice taught me alot more about communication skills, and also
that things don’t always go like a text book. Expect the unexpected.
A second student commented;
I learnt the skills by having hands on experience because some text book
examples are not always used in extended care especially because of lack of
funding and staff.

Approach D: Application of theory and practice in the clinical setting

In this category 10% of responses indicated that the clinical setting was an
environ-ment where they could apply theory and practice. The responses in this
category were relational. One student described her learning outcomes in the
following manner;
On hand experience of real situations, and how to apply scholar knowledge
to such situations. Importance of self-directed learning on own development
as well as significance of clinical teaching for guidance.

Approach E: Understanding the practice environment

In this category 15% of students described their learning outcomes in the clinical
setting in extended abstracts. That is, their responses tended to relate a story
about their experiences. Through their descriptions theory and practice were
linked and understanding of the practice environment was evident. One student
described the learning outcomes in the following manner;
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 215
Table IV. Structural relationships between categories of description for conceptions of outcomes of
clinical practice

Referential Structural
Unistructural Multi-structural Relational Extended abstract

Theory or practice A (15%)

Theory and practice
• theory drives practice B (31%) C (30%)
• practice generates theory
Application of theory and practice D (10%)
in the clinical setting
Understanding the practice E (15%)
environment

Table V. Rank order correlation coefficients between the classifications of outcomes

Experienced outcome Experienced outcomes

SIPS Lectures Laboratories Clinical practice

SIPS 0.20 0.19 0.40∗∗∗

Lectures 0.46∗∗∗ 0.40∗∗∗

Laboratories 0.38∗∗∗
Clinical practice

∗∗∗ p < 0.001.

As well as applying the techniques and theory learnt, we also learnt to

commu-nicate with and to manage real people in real situations. This was the
most difficult and confronting part of clinical and also the most important.
The most satisfying part of successfully completing the placement was the
knowledge that I can cope. I can deal with people. I can help.
The structural relationships between these categories of description are shown in
Table IV.

Relationships between outcomes of group based SIPS and other teaching

and learning methods
Table V shows the Spearman Rank Order intercorrelation coefficients between
the classifications of the individual statements of the group-based SIPS, lectures,
laboratories and clinical practice.
Table V shows the experienced outcomes of the group-based SIPS are highly
correlated with the experienced outcomes of clinical practice (Spearman r = 0.40)
216 H. FORBES ET AL.

but are not well correlated with the experienced outcomes of the lectures and
laboratories. While the experienced outcomes of clinical practice are also well
correlated with the outcomes of the other experienced modalities the focus of this
paper remains on the relationship of the PBL modality to clinical practice.

Discussion
The aim of the research was to distinguish emerging themes related to the students’
experiences of learning outcomes in the four teaching/learning modalities used in the
subject. Review of the literature has identified that there has been much written
about PBL in terms of process, implementation and students’ perceptions. However,
as noted previously little is known about the learning outcomes from PBL courses.
The results of this study are ground breaking in that they point to positive learning
outcomes from studying nursing using a PBL process.
Lectures and laboratories are typically used to prepare students for the
practice setting. From a review of medical literature Finucane et al. (1998)
identified criti-cism of curriculum structures which utilize traditional approaches
such as lectures and laboratories. One criticism was that they create a false
division between theor-etical concepts and practical application. In this study the
students’ experience of the learning outcomes in the traditional modalities within
a PBL framework indicate that they were not focussed on clinical practice but
instead on theoretical concepts and skills required for that environment.
In contrast the faculties belief that a scenario based learning modality (SIP)
would assist students to link theory to practice was well rewarded. Results of this
study indicate that the SIPs, unlike traditional learning modalities, focussed
students’ awareness on problem-solving and integration of theory in clinical
prac-tice. The problem solving process used in a SIP better prepared students for
clinical practice reality.
In a study by Jasper (1996) nurses expressed their dissatisfaction with their
transition from student to registered nurse stating that they felt unprepared for the
reality of nursing work and what it means to be a nurse. Based on the findings of
this study it would seem to be important to offer students the opportunity to
integrate the realities of clinical work into the theoretical preparation for practice.
The SIP process mirrors the decisionmaking used by nurses in practice, through
use of a real life case study. Students work through the problemsolving process
in a supportive environment, thus building the critical thinking skills essential for
practice and reducing the reality shock.

Conclusion
In conclusion, this study has shown that students’ experienced various modalities
of learning in different ways. The aim of each modality is to prepare students for
practice however, the findings of this study indicate that it was only the SIPs that
STUDENTS’ PERCEPTIONS OF LEARNING OUTCOMES 217

focussed learners on the clinical setting. Therefore, a recommendation from the

study findings is that courses provide more case based material to allow students
to explore situations which alert them to the realities of clinical practice. Absence
of this material and reliance on traditional modalities means that students are
prepared in a limited way for the challenges of the practice setting.

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