Nurse Education Today 34 (2014) 829–835

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Exploring the relationships between teaching, approaches to learning and

critical thinking in a problem-based learning foundation nursing course
Julie Martyn a,⁎, Ruth Terwijn b, 1, Megan Y.C.A. Kek c, 2, Henk Huijser d, 3
a
Department of Nursing and Midwifery, University of Southern Queensland Fraser Coast Campus, 161 Old Maryborough Road, Hervey Bay, Queensland 4655, Australia
b
Department of Nursing and Midwifery, University of Southern Queensland, West Street, Toowoomba, Queensland 4350, Australia
c
Learning and Teaching Support, University of Southern Queensland, West Street, Toowoomba, Queensland 4350, Australia
d
Research, Teaching & Learning Division, Batchelor Institute of Indigenous Tertiary Education, Batchelor, Northern Territory 0845, Australia

a r t i c l e i n f o s u m m a r y

Article history: Undergraduate nursing programmes are responsible for providing teaching and learning that develops stu-
Accepted 26 April 2013 dents' knowledge, skills and attitudes in alignment with contemporary nursing standards and healthcare de-
mands. Problem-based learning (PBL) as a pedagogy uses authentic artefacts reflecting real-world situations
Keywords: for students to practice problem-solving skills through collaboration with their peers. PBL was introduced in
Nursing
a foundation nursing course delivered in a regional university in Queensland, Australia. This paper presents
Problem-based learning
Critical thinking
the findings of a study exploring the relationships between nursing students' individual characteristics and
Teaching problem-based learning perceptions of learning environments, teaching in PBL mode, approaches to learning, and critical thinking
Approaches to learning skill readiness. The study was guided by an ecological perspective designed to examine nursing students' eco-
logical environments and the influences of those environments on their approaches to learning, and on crit-
ical thinking skill readiness. The results, through hierarchical linear modelling, revealed that aspects of the
PBL approach to teaching influenced the approaches to learning students adopt, and thus their critical think-
ing skill readiness. Implications for teaching in undergraduate nursing programmes are discussed.
© 2013 Elsevier Ltd. All rights reserved.

Introduction
Enabling nursing students with essential 21st century skills such
as critical thinking and self-directed learning is important in prepar-
ing them to meet the future challenges in healthcare they need to be
creative problem solvers (Le Storti and Cullen, 1999, p. 62). These
essential nursing skills (Australian Nursing and Midwifery Council
and Council, 2006) were identified as important outcomes for teach-
ing and learning as early as 1985 in a higher education curriculum
for registered nurses education in regional Queensland, Australia
(Toowoomba Nurse Education Working Group, 1985).
Contemporary professional standards, such as the Australian
Nursing and Midwifery Council (ANMC) competencies for Registered
Nurses (2006), guide teachers of undergraduate nursing programmes
to deliver graduates that contribute to quality nursing care through
lifelong learning and professional development of themselves and
others, and who demonstrate professional practice aligned with the
health needs of the population (Australian Nursing and Midwifery
⁎ Corresponding author. Tel.: +61 7 41943161.
E-mail addresses: julie.martyn@usq.edu.au (J. Martyn), ruth.terwijn@usq.edu.au
(R. Terwijn), megan.kek@usq.edu.au (M.Y.C.A. Kek), henk.huijser@batchelor.edu.au
(H. Huijser).
1
Tel.: +61 7 46312367.
2
Tel.: +61 7 46312883.
3
Tel.: +61 8 89397140.
Council and Council, 2006). The ANMC competency standards are
constructed within a framework of four domains, and the critical
thinking and analysis domain “relates to self-appraisal, professional
development and the value of evidence and research for practice”
(Australian Nursing and Midwifery Council and Council, 2006, p.3).
Nurses are expected to be self-directed learners, be able to reflect on
their practice and the consequences of that practice for individuals
(Australian Nursing and Midwifery Council and Council, 2006, p.3).
Critical thinking is clearly part of an important skill set in the educa-
tion of nursing students to prepare them for contemporary practice
(Kek and Huijser, 2011a).
Problem-based learning (PBL) as a teaching strategy has the po-
tential to develop critical thinking skills (Kek and Huijser, 2011a).
PBL is used extensively in nursing education to facilitate critical think-
ing in nursing students attending generic and post-registration un-
dergraduate programmes (Worrell and Profetto-McGrath, 2007),
and as a self-directed learning pedagogy to engender learner charac-
teristics such as critical appraisal, information processing, communi-
cation and teamwork (Kassab and Abu-Hijleh, 2005, p. 524), which
are essential components of critical thinking. However, the develop-
ment of critical thinking and life-long learning skills as a specific out-
come of PBL for nursing students has received little attention in the
literature. This paper discusses the outcomes of a PBL teaching strat-
egy that was adopted by teachers of a foundation nursing course of a
pre-registration programme.

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.04.023
830 J. Martyn et al. / Nurse Education Today 34 (2014) 829–835
Critical Thinking Readiness for Evidence-Based Nursing Practice
Critical thinking is a meta-cognitive skill, which involves think-
ing about one's own thinking, and is required as a two-level decision
making process if the nurse is to plan and judge the validity of nurs-
ing care activities (Seta et al., 2007). Safe practice includes gathering
patient data through observation, measurement and assessment and
critically thinking about that data to inform clinical decision making
through clinical reasoning (Levett-Jones et al., 2010). There is an
increasing focus on evidence-based practice suggesting a need to
engage nursing students in research processes and activities that
emphasise the relationship between evidence-based practice and
clinical outcomes (McCurry and Martins, 2010). Critical thinking is
argued to be crucial in evidence-based nursing (Profetto-McGrath,
2005), while evidence-based nursing is vital to patient-centred care
(Martin et al., 2010).
There is consensus in the literature that patient-centred care is based
on nurses' readiness to understanding the problems experienced by pa-
tients and the ability to implement individual and specific strategies to
reduce or eliminate those problems in a way that demonstrates respect
and care for that person (Dempsey, 2009). Understanding comes from
engagement with the problem, reflection on one's learning needs and a
preparedness to undertake research to resolve any knowledge deficits,
resulting in production of new knowledge and enhanced patient care
(Loth et al., 2007). This is an individualised process and Wells et al.
(2009, p. 194) identify the issue of variance in student readiness to en-
gage in the PBL process, different outcomes that PBL tutorials might de-
liver because of their learner-centeredness, and the unpredictability of
tutors who might modify the programme structure (Wells et al., 2009).
They conclude that the use of PBL can bridge the theory–practice gap
in nursing through the collaborative nature of the tutor–student rela-
tionship while respecting the student as “more than an empty vessel
needing informational cargo” (Wells et al., 2009, p. 199) and preparing
them to ‘hit the ground running’.
PBL as a Powerful Pedagogical Approach to Teach Critical Thinking
Profetto-McGrath et al. (2009) note that the role of teachers of re-
search skills is increasingly recognised as critical in stimulating the
use of research evidence in clinical practice. The challenge for nursing
education is how best to integrate research skills in an already busy
discipline and content laden curriculum, rather than treating it like
an added extra (Huijser, Kimmins and Galligan, 2008). Kek and Huijser
(2011a) propose that PBL is a particularly powerful pedagogy as well
as a teaching and learning system that, when used simultaneously to ac-
quire domain-specific content knowledge, can promote the develop-
ment of transferable critical thinking skills amongst higher education
students, including nursing students.
Traditionally, undergraduate nursing programmes have engaged stu-
dents through teacher-focused sessions (Lekalakala-Mokgele, 2010),
which do not encourage students to identify their individual learning
needs or develop skills in synthesising information (Creedy et al.,
1992). Traditional frameworks force educators to generalise teaching
methods and content to meet the variations in students' entry level
knowledge and skills. By contrast, the student-centred and dialectical
nature of PBL urges students to frequently undertake self-directed activ-
ities towards solving the ‘problem’ (Creedy et al., 1992, p.728). “PBL has
been identified as one approach to nursing education that supports
contextualisation of knowledge essential to nursing practice” (Applin
et al., 2011, p. 2). Aligning knowledge to practice works towards closing
the theory-practice gap that is a recurrent concept in nursing education
and literature (Andrews and Jones, 1996; Higginson, 2004). PBL encour-
ages deep approaches to learning through engaging students in self-
directed research to address real world problems, including analysis of
contextualised data applied to authentic discipline specific artefacts.
Thus, PBL is a highly structured and learner-centred approach that
makes the learning directly relevant to practice (Lin et al., 2010).
The literature suggests that tutor skills in facilitating student
learning processes are a critical success factor in PBL. For example,
Barrows (2002) insisted that the skill of the tutors is a crucial element
in PBL, to the extent that the effectiveness of a course or programme
is dependent on skilled and trained tutors. Kek and Huijser (2011a)
suggest that PBL is a powerful pedagogical approach to developing
critical thinking skills, and they identify that the deliberate design of
the PBL instructional process and the student-centred learning envi-
ronment, closely mirroring a social constructivist paradigm, are keys
to its effectiveness. Their framework has been adapted for this
study, as it provides a way to analyse and focus on different factors
impacting on the outcome of critical thinking skills for nursing stu-
dents, through an exploration of the relationships between teaching,
approaches to learning and critical thinking in a PBL context.
Method
A Conceptual Framework for Analysis
As noted above, this study has adapted Kek and Huijser's (2011b)
framework, which in turn was originally adapted from Bronfenbrenner's
theory of human development (1979), Bronfenbrenner and Ceci's (1994)
bio-ecological model of human development, and Biggs's (2003) 3P
model of learning. This framework has been used to explore the influ-
ences of individual characteristics, learning environments, and a PBL
teaching approach on student approaches to learning and critical think-
ing in a foundation nursing course.
Bronfenbrenner (1979, p. 16) asserted that “human development is
a product of interaction between the growing human organism and its
environment”, which is directly applicable to learning. Bronfenbrenner's
(1979, pp. 209–217) model of the ‘ecological environmental system’, de-
scribes four distinctly separate systems that are nevertheless inextricably
linked, and these can be broadly applied to a higher education context in
the following manner:
1. Micro system — students, classroom, and teachers/tutors
2. Meso system — study groups, family, laboratory, collegial support
3. Exo system — wider university structures and practices, teacher's
workplace and culture
4. Macro system — culture, social interchange, belief systems.
Kek and Huijser's (2011b) framework, adapted for this study, draws
on Bronfenbrenner's four systems and combines these with Biggs’ (2003)
3P – Presage, Process, Product – Model, because Biggs' model concen-
trates on higher education students, and the systems approach of his
model is consistent with Bronfenbrenner's (1979) ‘nested ecological en-
vironments’. Kek and Huijser's (2011b) framework can be applied to es-
tablish the interrelationships between students' individual characteristics
(presage), distal and proximal contextual factors (presage), approaches to
learning (process) and outcomes (products). The advantage of this model
is that it allows us to focus on the outcomes of a learning situation, for ex-
ample on whether critical thinking has been achieved as a measurable
outcome. Bronfenbrenner's (1979) systems allow for more depth in
terms of potential factors of influence in this process.
Kek and Huijser's (2011b) framework, when applied to this study,
leads to the three-fold process depicted in Fig. 1:
1. Presage
2. Learning Experience
3. Outcome
The distal elements in the Presage part of this framework include stu-
dents' personal characteristics such as age, race, Aboriginal and Torres
Strait Island descent, persons with disability, international status and
previous experience of PBL. The proximal elements in this case are the
classroom learning environment and the PBL teaching approach, or in

Ecological Systems of Foundation Course
• Distal
Presage
• Proximal and Process
Learning Experience
• Product
Outcome
Source: Adapted from Kek& Huijser(2011)
Fig. 1. PBL ecological systems for teaching critical thinking.
short, the Learning Experience. The process is also part of this and is here
identified as students' approaches to learning; and finally, the product in
this study is represented by Outcome of critical thinking skill readiness.
Overall then, Kek and Huijser's (2011b) framework has been adapted
for this study to explore to what extent individual and demographic char-
acteristics, classroom environment, a PBL approach to teaching, and stu-
dent approaches to learning are associated with critical thinking.
Ethics
This study is approved by the human research and ethics commit-
tee of the University of Southern Queensland (USQ).
Research Design
This study was formulated as a descriptive research design using a
survey to gather data from a single cohort of students enrolled in a foun-
dational nursing course to determine the extent to which individual and
demographic characteristics, classroom environment, a PBL approach to
teaching, and student approaches to learning are associated with critical
thinking. The survey consisted of questionnaires to measure classroom
learning environment, PBL teaching, approaches to learning and critical
thinking. A free text area was also provided to obtain their written re-
sponses about what they liked most about PBL and suggestions for im-
provements. Demographic information was also collected from the
students related to gender, type of enrolment and Aboriginal and Torres
Strait Island status. Data was collected at the end of the semester when
the PBL sessions were completed.
Subjects
Surveys were administered to all first year USQ nursing students
enrolled in Responsible Nursing Practice in May/June of Semester 1
in 2010 (N = 301). The response rate was 72.42% (n = 218).
Data Analysis
The survey data were analysed using Predictive Analytics Software
Statistics (PASS) version 18. Correlational and hierarchical multiple
regression analyses were used to explore the research question. Hier-
archical multiple regression analysis was used to predict the relation-
ships between individual characteristics, distal and proximal learning
experiences, learning approaches (deep or surface approach), and
critical thinking skills. Within the hierarchical multiple regression
method, the importance of each predictor variable on the dependent
variables can be assessed (Tabachnick and Fidell, 2001). Thus, for the
J. Martyn et al. / Nurse Education Today 34 (2014) 829–835
• Age, Gender, ATSI, Disability,
International/Domestic
Student, Prior PBL
experience
• Classroom environment, PBL
teaching
• Deep and surface
approaches to learning
• Critical thinking
831
analyses of this study, each context's variables were added in blocks,
starting with the most distal to the most proximal learning contexts.
In this way, the earlier entered variables are controlled for, or held
constant.
The sequence for entering the blocks, as proposed in the theoreti-
cal framework is as follows:
1. Individual characteristics: gender, disability, Aboriginal and Torres
Strait Islander status
2. Distal context: enrolment type, previous PBL exposure
3. Classroom context: classroom-level learning environment, PBL ap-
proach to teaching
4. Learning process: approaches to learning (deep or surface ap-
proaches to learning)
In prediction, it is enough to know only something about “the
strength of association between variables, and not about how or why
variables are linked” (Russell, 1997, p. 508). Therefore, for all the regres-
sion models, R, R2, adjusted R2, R2 change, unstandardised regression co-
efficients (b), and standardised regression coefficients (β) are displayed
after the entry of each block of variables. In all the final models of the re-
gression equations, the semi-partial correlations (sr2), which indicate the
unique contribution of a particular variable to the dependent variable,
are shown (Tabachnick and Fidell, 2001). The effect size of the models
is also calculated using Cohen (1992 p. 157).4 Preliminary analyses
were conducted to ensure no violation of the assumptions of normality,
linearity, multi-collinearity and homoscedasticity.
Survey Questionnaire
The saliency of all the instruments guided the selection of scales
and items, and the re-wording of the items. The students completed
a questionnaire which asked for personal background information
and for their perceptions of the classroom learning environment
(using Johnson and McClure's (2004) Constructivist Learning Envi-
ronment Survey), approaches to learning (using the two-factor
Study Process Questionnaire (SPQ-2F) by Biggs, Kember and Leung
(2001)), PBL teaching (using six items from Wee and Kek's PBL eval-
uation questionnaire in Wee (2004)), and critical thinking (using
Castle's (2006) 12-item Critical Thinking Questionnaire).
Validation of Instruments
Prior to performing the statistical analyses, the validity and reliabil-
ity of the instruments were established. Tables 1 and 2 (see Appendices
A and B) provide the validation results for all the instruments used in
the questionnaires.
Findings
Table 3 (see Appendix C) displays the regression results indicating
the extent to which individual characteristics, classroom-level learn-
ing environment, PBL approach to teaching, and approaches to learn-
ing, are able to predict critical thinking skills amongst students.
The results in Model 1 (see Table 3) indicate that the individual
characteristics predictors of gender, disability and Aboriginal and
Torres Strait Islander status combine to form a small effect, but no sig-
nificant association with differences in critical thinking scores.
However, the results in Model 2 (see Table 3) show that the distal
context is significantly associated with critical thinking. This distal
contextual factor added another 4.4% to the variance in critical think-
ing scores. The significant predictor was enrolment type (β = 0.01).
This means that the domestic Australian students have higher critical
thinking skills scores than international students.
4
Small effects: 0.02 to 0.15, medium effects: 0.15 to 0.35, large effects: Above 0.35
832 J. Martyn et al. / Nurse Education Today 34 (2014) 829–835
In Model 3 (see Table 3), the results indicate that the classroom-
level learning environment, characterised by personal relevance, uncer-
tainty and critical voice, is related to critical thinking skills. These mea-
sures contributed nearly 22% to the variance in critical thinking scores
with a weight of 0.53 for controlling the individual characteristics and
distal contextual factors. The results indicate that students with high
critical thinking skill scores are those situated in a classroom envi-
ronment where learning is relevant (personal relevance), where op-
portunities are provided to determine that knowledge is dynamic
(uncertainty), and where a student is free to express his/her opinion
about the tutor (critical voice).
In Model 4 (see Table 3), the PBL teaching approach items were en-
tered and the results indicate a significant association with critical think-
ing. The PBL teaching items explain an additional 23% of the differences
in critical thinking skill scores, even when the individual characteristics,
distal context and proximal context of classroom learning environment
were statistically controlled. The regression weight was 0.46. That is, stu-
dents who reported high critical thinking skill scores were in classrooms
with PBL tutors who focused on real world problems and facilitated stu-
dents to inquire freely by generating, evaluating and synthesising ideas.
In Model 5 (see Table 3), the two approaches to learning were added.
These measures explained another 5% of the variance in critical thinking.
The results indicate that surface approaches to learning are negatively
and significantly related to critical thinking (p = 0.00). That is, students
who employ surface approaches to learning have lower critical thinking
skill scores than students who do not employ surface approaches to
learning. Overall, a PBL approach to teaching and approaches to learning
combined to have a large association with variance in critical thinking
(R2 = 56%, effect size = 1.28).
In the final regression equation, the results indicate that the strongest
predictor of critical thinking is PBL approach to teaching, characterised
by authentic facilitation skills that guided students to inquire freely by
generating, evaluating and synthesising ideas (β = 0.27). The other pre-
dictors are surface approach to learning (β = −0.23) and PBL approach
to teaching, characterised by a focus on real world problems (β = 0.18).
The total variance explained by this final model was 56.1%, [F(16,
196) = 11.81, p = 0.000], with unique contributions from each of
the predictors. The biggest unique contributor was the surface ap-
proaches to learning with 4% (sr 2 = 0.04). The final R of 0.75 dem-
onstrates that the PBL approach to teaching and approaches to
learning predictors have a large effect (effect size = 1.28) and
have significant associations with critical thinking skills.
Discussion
Traditional lecture-based teaching methodologies passively trans-
fer information from educator to student (Lekalakala-Mokgele, 2010,
p.638), and do not require active engagement from the student to re-
flect on the concepts being ‘delivered’ (Kek and Huijser, 2011a),
hence limiting teachers in developing their students' critical thinking
skills. This study adds support to Kek and Huijser's (2011a) proposi-
tion that when PBL pedagogy is used, students' critical thinking skills
are developed. Once the Presage elements (distal elements) of Kek
and Huijser's (2011b) model have been taken into account, the find-
ings in this study suggest that using a PBL approach to teaching, in
combination with approaches to learning (both of which are part of
the Learning Experience) together have significant associations with
critical thinking skills as an Outcome. Given these associations, the
role and skills of the PBL tutor take on significant importance.
Thus, the PBL tutor is an essential ingredient in any successful PBL
course. In this study, the skills of the tutor in guiding students in a PBL
session were found to be an important factor to the development of
critical thinking skills, perhaps more so than having good problems
(Hmelo-Silver, 2004). However, Moore (2009) warns that there can
be inconsistencies in the interpretation and application of the PBL
tutor's role, depending on pedagogical beliefs and values. Potential
issues that arise in courses in which a PBL approach is applied to develop
critical thinking skills can be addressed by providing sufficient training
on PBL facilitation, with a specific focus on critical thinking skills. Further-
more, an understanding of the philosophical underpinnings and frequent
teaching team meetings throughout the semester can establish continu-
ous engagement and opportunity for reflection to encourage consistency
in approaches and development of necessary skills (Lekalakala-Mokgele,
2010; Barrows, 2002; Moore, 2009). Techniques such as clarification and
cognitive questioning can be agreed upon to encourage students to think
about their practice and the clinical decisions embedded in the problems
(Moore, 2009). Furthermore, the findings of this study suggest that the
Presage elements of this process are important and should be carefully
considered during the team meetings, in order to adopt the appropriate
PBL approach (Learning Experience) for a specific cohort of learners, and
thus yield the strongest possible Outcome of critical thinking skills.
This study largely supports Barrows' (1998) PBL propositions of using
authentic problem-based artefacts, such as clinical records and case
notes, and their complexity progressively scaffolded in this course to en-
able students to become familiar with interpreting clinical documenta-
tion from their scope of practice and academic progression (Seta et al.,
2007). Seta et al. (2007) acknowledge the importance of developing
nursing students who can think critically, but note the difficulty for tutors
to externalise their tacit know-how (critical thinking) so that students
can be taught. Critical thinking within a PBL context is a collaborative
teaching and learning experience, and students in this study considered
that an outcome of the process. Therefore, it is important that the teach-
ing team is not only trained in PBL, but that the students are also suitably
inducted into the PBL learning process (Barrow et al., 2002, p. 61). Again,
this is a crucial part of aligning the Presage with the Learning Experience.
Successful introduction of any self-directed teaching method such as
PBL requires adequate student and teacher preparedness with a balance
of student and teacher directed learning (Levett-Jones, 2005, p. 366).
This study found that students who adopted surface approaches to
learning have lower critical thinking skill scores than students who do
not adopt surface approaches to learning, which is not surprising. Surface
learners focus on extrinsic or external motivation, and use strategies that
consume the least amount of time and effort to meet the requirements
(Biggs et al., 2001). By contrast, a deep approach to learning in general
focuses on an intrinsic intention to comprehend, and is characterised
by adopting strategies to maximise conceptual understanding. Even
though this study did not indicate with statistical significance that deep
learners are more likely to exhibit higher levels of critical thinking skills,
the question of how we can ensure the right balance in terms of student
approaches to learning in a PBL course is nevertheless warranted, and in-
deed is a key question to address with regards to the Learning Experience.
We suggest therefore, in addition to inducting students into PBL, that
they should also be introduced to learning approaches through which
they develop a greater self-awareness of their own learning (Hendry
et al., 2005). This is useful for learning in a PBL course where students col-
laborate in small groups to work together to manage real-life problems.
By explicitly focusing on it as part of the teaching process, PBL student
participants gain a greater understanding of other students' learning ap-
proaches and how and why deep approaches to learning are more effec-
tive, within their academic setting as well as in future nursing practice.
This is not only likely to contribute to a productive Learning Experience,
but also more likely to achieve the desired critical thinking skill Outcome.
Conclusion
This paper has focused on the use of PBL as a pedagogical approach in
a foundation year nursing course, and explored the relationships between
nursing students' individual characteristics and perceptions of learning
environments, teaching in PBL mode, approaches to learning, and critical
thinking skill readiness. The results support the use of PBL to facilitate the
development of critical thinking skills and the use of evidence in practice.
This is achieved through working on real-world problems in teams to
 J. Martyn et al. / Nurse Education Today 34 (2014) 829–835 833

applying evidence-based nursing theory to practice. The results, through
hierarchical linear modelling, have revealed that aspects of the PBL ap-
proach to teaching influences the approaches to learning students
adopt, and thus their critical thinking skill readiness. Furthermore, the re-
sults show a significant relationship between teaching, approaches to
learning and critical thinking, if the teaching approach is PBL. Thus, PBL
enables students to develop critical thinking skills and is therefore
valuable in undergraduate pre-registration nursing courses, while
also aligning with the accreditation standards for nursing programmes
in Australia.
Acknowledgements
This study is supported with funding from Faculty of Sciences Re-
search Activation Incentive Scheme and Learning and Teaching Sup-
port Research and Professional Development Fund.

Appendix A

Table 1 nursing issues

identify from patient records and then by using self- directed learning and research to gather knowledge, and ultimately by
Summary of factor loadings.

Classroom learning environment (Five-component solution with a total 63.4% variance)

Item Personal Un-certainty Shared Critical Student

relevance control voice negotiation

I learn about the real world demands and practices in and outside of the university. 0.77
New learning relates to experiences or questions about the real world demands and practices in and outside 0.80
university.
I learn how the problems/cases are part of the real work demands and practices in and outside of my university life. 0.86
I learn interesting things about the real world demands and practices in and outside of university. 0.76
I learn that this course cannot always provide answers to problems/cases. 0.77
I learn that this course's explanations have changed over time. 0.78
I learn that this course is influenced by people's cultural values and opinions. 0.78
I help plan what I am going to learn. 0.74
I help to decide how well I am learning. 0.75
I help to decide which activities work best for me. 0.89
I let the tutor know if I need more/less time to complete an activity. 0.46
I feel safe questioning what or how I'm taught 0.82
I feel I learn better when I am allowed to question what or how I'm being taught 0.67
It's ok for me to ask for clarification about activities that are confusing. 0.66
It's acceptable for me to express concern about anything that gets in the way of my learning. 0.70
I learn that this course is a way to raise questions and seek answers. 0.60
I talk with other students about how to solve problems/cases. 0.81
I explain my ideas to other students. 0.90
I ask other students to explain their ideas. 0.87
I am asked by others to explain my ideas. 0.81

PBL teaching (One-component solution with a total of 65.8% variance)

Item Teaching

The PBL tutorial sessions focused on real clinical problems. 0.81

The PBL small group structure allowed both tutors and students to work together in the learning process. 0.82
PBL enabled me to work with and learn from my team members. 0.79
PBL enabled me to apply my learning to the challenges and demands of the working world. 0.82
PBL provided me with the opportunity to conduct self-directed learning. 0.82
PBL allowed me to inquire freely by generating, evaluating and synthesising ideas. 0.81

Approaches to learning (Two-component solution for motives with a total of 47.2% variance, two-component solution for strategy with a total variance of 48.5% variance)

Item Deep Surface

I find that at times studying gives me a feeling of deep personal satisfaction. 0.72
I feel that virtually any topic can be highly interesting once I get into it. 0.63
I find that studying academic topics can at times be as exciting as a good novel or movie. 0.72
I work hard at my studies because I find the material interesting. 0.73
I come to most PBL sessions with questions in mind that I want answering. 0.62
I find that I have to do enough work on a topic so that I can form my own conclusion before I am satisfied. 0.62
I find most new topics interesting and often spend extra time trying to obtain more information about them. 0.79
I test myself on important topics until I understand them completely. 0.67
I spend a lot of my free time finding out more about interesting topics which have been discussed in different PBL sessions. 0.73
I make a point of looking at most of the suggested readings or additional learning issues. 0.70
My aim is to pass the course while doing as little work as possible. 0.60
I do not find my course very interesting so I keep my work to the minimum. 0.60
I find I can get by most assessments by memorising key sections rather than trying to understand them. 0.69
I find it is not helpful to study topics in depth. It confuses and wastes time, when all you need is a passing acquaintance with topics. 0.70
I see no point in learning material which is not likely to be assessed or tested. 0.75
I only study seriously what's given out in PBL sessions or in the course outlines. 0.57
I learn some things by memorising, going over and over them until I know them by heart even if I do not understand them. 0.60
I generally restrict my study to what is specifically set as I think it is unnecessary to do anything extra. 0.75
I believe that tutors shouldn't expect students to spend significant amounts of time studying material everyone knows won't be examined. 0.66
I find the best way to pass examinations is to try to remember answers to likely questions. 0.73

(continued on next page)

834 J. Martyn et al. / Nurse Education Today 34 (2014) 829–835

Table 1 (continued)

Critical thinking readiness (Two-component solution with a total of 49.3% variance).

Items Positive Negative

I have learnt more about how to approach complex issues in a variety of ways. 0.74
I have improved my ability to judge the value of new information or evidence presented to me. 0.69
I have learnt more about how to analyse the learning issues. 0.75
I have developed a more open-minded approach in interpreting, analysing and judging alternative points of view. 0.59
My interest in learning issues and questions related to my subject area has increased. 0.76
I have developed a more focussed and systematic way of thinking. 0.78
I have learned more about how to justify why certain procedures are undertaken in my subject area. 0.82
The tutor has not demonstrated how to think and express myself in a more objective and evaluative way. 0.69
Most assessment have not stretched my intellectual abilities. 0.57
I have not improved my ability to give sound reasons for my beliefs, opinions and ideas 0.75
I have seldom found myself actively engaged in thinking about complex issues. 0.55

Appendix B

Table 2
Summary of reliability results.

Variables Cronbach alpha

Classroom learning environment 0.83

PBL teaching 0.90
Deep approach to learning 0.85
Surface approach to learning 0.81
Critical thinking readiness 0.77

Appendix C

Table 3
Results of hierarchical multiple regression analyses for critical thinking.

Variables Model 1 Model 2 Model 3 Model 4 Model 5

b β b β b β b β b β sr2

Presage
Individual characteristics
Gender (1 = Female) 0.07 0.33 0.07 0.31 −0.02 0.77 0.00 0.99 −0.02 0.70
ATSI (1 = Yes) −0.02 0.75 −0.02 0.74 −0.06 0.32 −0.04 0.47 −0.04 0.40
Disability (1 = Yes) 0.11 0.14 0.11 0.13 0.07 0.25 0.02 0.70 0.00 0.90

Distal
International student (1 = Yes) −0.19 0.01⁎ −0.17 0.08⁎ −0.14 0.02⁎ −0.10 0.08
Previous PBL exposure (1 = Yes) 0.09 0.21 0.08 0.21 0.04 0.46 0.02 0.66

Proximal
Classroom-level learning environment
Personal relevance 0.16 0.04⁎ 0.35 0.60 0.04 0.57
Student negotiation 0.01 0.90 −0.03 0.66 −0.03 0.62
Uncertainty −0.17 0.01⁎ −0.12 0.03⁎ −0.07 0.17
Shared control 0.14 0.06 0.12 0.06 0.08 0.19
Critical voice 0.25 0.00⁎⁎⁎ 0.15 0.03 0.12 0.06
PBL teaching
Focussed on real clinical/client problems 0.17 0.05⁎ 0.18 0.02⁎ 1%
Tutor and students worked together in the learning process 0.01 0.92 0.02 0.86
Working with and learning from team members enabled 0.09 0.29 0.05 0.54
Apply learning to real world challenges and demands −0.05 0.56 0.01 0.89
Provide self-directed learning opportunities 0.12 0.18 0.09 0.31
Allowed to inquire freely 0.31 0.00⁎⁎⁎ 0.27 0.00⁎⁎⁎ 3%

Learning approaches
Deep approach 0.05 0.44
Surface approach −0.23 0.00⁎⁎⁎ 4%
Multiple R 0.13 0.25⁎ 0.53⁎⁎⁎ 0.72⁎⁎⁎ 0.75⁎⁎⁎
R2 (%) 2.00 6.00 27.90 51.20 56.10
Adjusted R2 (%) 0.00 4.00 24.00 46.90 51.60
R2 change (%) 4.40 21.80 23.30 4.90
Effect size 0.02a 0.07a 0.39b 1.08c 1.28c

Effect size: a = small, b = medium, c = large.

⁎ p b 0.05.
⁎⁎⁎ p b 0.001.
 J. Martyn et al. / Nurse Education Today 34 (2014) 829–835
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