Nurse Education Today 34 (2014) 52–56

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Effects of problem-based learning vs. traditional lecture on Korean nursing students'critical thinking, problem-solving, and self-directed learning

Eunyoung Choi a,1, Ruth Lindquist b,2, Yeoungsuk Song c,⁎a Chosun Nursing College, Gwangju, South Koreab University of Minnesota School of Nursing, Minneapolis, Minnesota, USAc Kyungpook National University College of Nursing, Research Institute of Nursing Science, Daegu, South Korea

⁎ Corresponding author at: Kyungpook National UnivDongin-dong, Jung-gu, Daegu 700-422, South Korea. Tel53 421 2758.

E-mail addresses: eychoi@cnc.ac.kr (E. Choi), lindq0asansong@knu.ac.kr (Y. Song).

1 Tel.: +82 62 231 7368; fax: +82 62 232 9072.2 Tel.: +1 612 624 5646; fax: +1 612 625 7180.

0260-6917/$ – see front matter © 2013 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2013.02.012

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 18 February 2013

Keywords:Problem-based learningCritical thinkingProblem-solvingSelf-directed learning

Background: Problem-based learning (PBL) is a method widely used in nursing education to develop students'critical thinking skills to solve practice problems independently. Although PBL has been used in nursingeducation in Korea for nearly a decade, few studies have examined its effects on Korean nursing students'learning outcomes, and few Korean studies have examined relationships among these outcomes.Objectives: The objectives of this study are to examine outcome abilities including critical thinking,problem-solving, and self-directed learning of nursing students receiving PBL vs. traditional lecture, and toexamine correlations among these outcome abilities.

Design: A quasi-experimental non-equivalent group pretest–posttest design was used.Participants/Setting: First-year nursing students (N = 90) were recruited from two different junior collegesin two cities (GY and GJ) in South Korea.Methods: In two selected educational programs, one used traditional lecture methods, while the other usedPBL methods. Standardized self-administered questionnaires of critical thinking, problem-solving, andself-directed learning abilities were administered before and at 16 weeks (after instruction).Results: Learning outcomes were significantly positively correlated, however outcomes were not statisticallydifferent between groups. Students in the PBL group improved across all abilitiesmeasured, while student scoresin the traditional lecture group decreased in problem-solving and self-directed learning. Critical thinking waspositively associated with problem-solving and self-directed learning (r = .71, and r = .50, respectively,p b .001); problem-solving was positively associated with self-directed learning (r = .75, p b .001).Conclusion: Learning outcomes of PBL were not significantly different from traditional lecture in this smallunderpowered study, despite positive trends. Larger studies are recommended to study effects of PBL on criticalstudent abilities.

© 2013 Elsevier Ltd. All rights reserved.

Introduction

Problem-based learning (PBL) helps students develop criticalthinking to solve problems in their clinical settings, and bridges thegap between theory and practice (Rogal and Snider, 2008). PBL is astudent-centered method of instruction; it is an educational strategyin which students take responsibility for their own learning and itappears to enhance self-directed learning skills (Dolmans et al.,2005; Lekalakla-Mokgele, 2010). The self-directed learning aspect ofPBL encourages the development of nursing students' ability tothink critically, and critical thinking enhances the nurses' abilities to

ersity, College of Nursing, 101.: +82 53 420 4978; fax: +82

02@umn.edu (R. Lindquist),

rights reserved.

logically assess and formulate interventions to impact patient care(Ozturk et al., 2008; Yuan et al., 2008b). Critical thinking has beenshown to be enhanced by PBL; it enables students to solve problemsin clinical situations and to provide rationale for their actions(Cooke and Molye, 2002).

Problem-solving abilities have been shown to be better in studentswho have received instruction with PBL relative to those who receivedinstruction by lecture (Uys et al., 2004). PBL resulted in the increase ofstudents' critical thinking and self-directed learning, which are neededto solve clinical problems.

Most studies of PBL have focused on its positive effects on criticalthinking (Jones, 2008; Yuan et al., 2008a). Published studies focused onPBL's effects on problem-solving ability and self-directed learning aresparse, and the findings of some of the studies were not significant ornegative. Choi's (2004) study of PBL versus traditional lecture with 76second-year nursing students showed that the critical thinking scoresof the students in the traditional lecture group were higher than thoseof the PBL group. Several other studies reported no significant differences

53E. Choi et al. / Nurse Education Today 34 (2014) 52–56

between PBL versus traditional lecture on self-directed learning orproblem-solving in first year college students (Lohman and Finkelstein,2002; Williams, 2004).

Critical thinking and problem-solving abilities are skills viewed asessential for health professionals as the foundation for clinical reason-ing (Hendricson et al., 2006), and the ability to engage in self-directedlearning is important for success of the health professional studentwhile in school, and in their health career after graduation. Criticalthinking and problem solving are occasionally viewed as intertwinedabilities, and merged into a single construct such as reflective judg-ment or deliberative assessment (Hendricson et al., 2006). Optimalstrategies to promote the optimal development of these abilitiesin students remain elusive, and the inter-relationship among theseabilities that are targeted by nursing curricula remains of interest.

In Korea, PBL has been slowly adopted in nursing schools since theearly 2000s, however there have been few studies examining theeffects of PBL on nursing student learning outcomes. Members ofnursing faculties desire to have Korean nursing students receive thebest evidence-based instruction possible to prepare them optimallyfor careers as professional nurses. If PBL can be shown to result itsimproved learning outcomes in Korean nursing students relative totraditional strategies, then its adoption is ought to be continued oraccelerated. If, however, PBL is not demonstrated to have outcomessuperior to traditional instructional strategies, then traditional in-struction should continue and perhaps other alternative instructionalstrategies should be sought and tested. Therefore, the purposes ofthis study are to explore and compare the effects of PBL versustraditional education on critical thinking, problem-solving skills andself-directed learning ability of Korean nursing students, and to ex-amine the relationship among these learning outcomes.

Background

PBL is a process-focused instructional strategy as opposed tocontent-based; as a strategy, it employs small groups that are centeredon solving well-integrated clinical problems instead of large groups asin traditional instruction,with content deliveredmainly through lectureand limited self-directed learning (Uys et al., 2004). Most investigationsof the use of PBL in nursing have studied its effects on critical thinking,problem-solving, and self-directed learning (Yuan et al., 2008b;Lekalakla-Mokgele, 2010; Worrell and Profetto-McGrath, 2007).

Critical thinking is one of the essential core competencies of nurs-ing education to enhance clinical site-based learning and theoreticalknowledge (Ozturk et al., 2008; American Association Colleges ofNursing, 2007). PBL, as a method of instruction, has been generallyaccepted as a standard method of instruction to improve criticalthinking. Tseng et al. (2011) found among 120 nursing studentsthat the PBL group had higher scores in critical thinking than thenon-PBL group. Cooke and Molye (2002) established that instructionwith PBL motivated students to find new information, leading toa more critical thinking. Conversely, Choi (2004) showed that PBLhelped the students' problem-solving but not critical thinkingamong second year nursing students. Yuan et al. (2008b) reportedin a published literature review that the PBL instructional approachwas questionable for nursing education due to the lack of large highquality randomized controlled trials that have determined its effectson critical thinking.

Problem-solving is recognized as a critical outcome of importancewherever PBL is mentioned (Solomon, 2005), but studies of the effectsof PBL on problem-solving in the nursing literature are sparse. In onestudy by Uys et al. (2004), investigators reported that the PBL groupattained higher levels than the non-PBL group of problem-solving skillsin 128 graduate students enrolled in nursing school. Themajority of theresponses of students in the PBL group that were given to the problemsposed reflected highly constructive strategies (at the advanced begin-ner level or above), whereas responses of the students in the non-PBL

group's responses were more often at the novice level. Cooke andMolye (2002) reported that students felt more pressure to learn andto actively solve problems when instructed with PBL strategies. Thesetwo studies support that there is an increase in the problem-solvingability when PBL is used.

Self-directed learning is an outcome in which individuals take theresponsibility for one's own learning; self-directed learning has beenshown to be facilitated by PBL (Yuan et al., 2008b; Williams, 2004).Tseng et al. (2011) reported that nursing students who received in-struction that employed PBL strategies demonstrated significantlymore self-directed learning thannursing students in the traditional pro-gram. Dornan et al. (2005) found in their qualitative study that PBLinstruction fostered self-direction and lifelong learning skills.Self-directed learning outcomes of PBL have been shown to be affectedor related to the type of schooling students had prior to entering nurs-ing school. In one study of 135 first year nursing students enrolled in in-struction with PBL, students were separated and studied by level ofeducation including high school diploma, college, and baccalaureate de-gree. Students with high school diplomas scored significantly lowerthan those with college or baccalaureate degrees (Williams, 2004).In this study, many students reported that they experienced feelingsof uncertainty about PBL. In other words, as students transitionedfrom traditional high school education or traditional universityprogram to PBL instruction, they felt uncertainty about their learning.

In summary, in the literature, research results regarding the effectsof PBL on critical thinking, problem-solving, and self-directed learningaremixed. Also,when the effects of PBLwere examined,most investiga-tors studied its effects on critical thinking, problem-solving, and self-directed learning. However, studies were not found that examinedthe relationships among critical thinking, problem-solving, and self-directed learning. This study explored the effects of PBL on criticalthinking, problem-solving and self-directed learning among Koreannursing students and examined the association among the criticalthinking, problem-solving, and self-directed learning outcomes.

Methods

Design

A nonequivalent control group pretest–posttest design was usedin this quasi-experimental study. The research compared the effectsof instruction using PBL strategies versus traditional education oncritical thinking, problem-solving and self-directed learning abilityof nursing students in Korea.

Sample

Participants in two groups comprised first year nursing studentsfrom two junior college nursing schools at the different cities in Koreato prevent contamination. None of the students in either group hadbeen exposed to PBL previously. A power analysis determined that therequired sample size was 44 per group (Cohen, 1988): Significancelevel (α = .05), large effect size (Cohen's d = .70), and power (90%).There were no dropouts. Students who had incomplete data wereexcluded (2 in the PBL group and 4 in the traditional group). Theanalyses were done with 46 nursing students in the PBL group and 44participants in the traditional group.

Instruments

The Critical Thinking Ability Scale for College Students was devel-oped by Park (1999) to assess dimensions of critical thinking of collegestudents. The scale has 20 items in five sub-scales: Intellectual curiosity,healthy skepticism, intellectual integrity, prudence, and objectivity.Cronbach's alpha was found to be .74 (Park, 1999) and in our study aCronbach's alpha was .71. This scale is scored on a 5-point Likert-type

Table 1Demographics of students in the PBL (N = 46) and control (N = 44) groups.

Characteristic PBLn (%) or M ± SD

Controln (%) or M ± SD

χ2 (t) p

GenderFemale 38 (82.6) 44 (100) .006a

Male 8 (17.3) 0 (0)Age 18.67 ± 1.71 18.57 ± 1.31 .327 .744Prior high school

Academic 2 (69.5) 22 (50.0) .085a

Vocational 14 (30.4) 22 (50.0)

a Fisher exact test for least significant difference test.

54 E. Choi et al. / Nurse Education Today 34 (2014) 52–56

scale of 1 to 5 (1 = absolutely do not agree to 5 = absolutely agree).Total scores have a possible range from 5 to 100, with higher scoreindicating stronger critical thinking ability.

The Problem-solving Scale for College Students and the Self-directed Learning Scale for College Students were developed by Lee(2003) at the Korean Education Development Institute. Each scalehas responses assessed on a 5-point Likert-type scale (1 = absolutelydo not agree to 5 = absolutely agree). The tool for problem-solvingincluded 45 items and 5 subscales: Issue specification, cause analysis,counterproposal development, plan and practice, and evaluation.The total scores may range from 5 to 225; higher scores indicatebetter problem solving. Cronbach's alpha of the developed scalewas .94 (Lee, 2003) and Cronbach's alpha for our sample was .90.Self-directed learning had 40 items and 3 subscales: learning plan,practice, and evaluation. The scores may range from 5 to 200and higher scores reflected stronger self-directed learning ability.Cronbach's alpha of the developed scale was .93 (Lee, 2003) andCronbach's alpha for our study sample was .83.

Data Collection and Procedures

Prior to data collection, the protocol was reviewed and ethical per-mission for the study was received from the university human ethicscommittee in Korea. Written informed consent was obtained fromthe participating students. The PBL and traditional education programapproaches were conducted over one semester comprising 16 weeks.Students in both groups completed a demographic form, and criticalthinking, problem-solving, and self-directed learning questionnairesat the same time, prior to PBL and traditional lecture instruction.

For the PBL group, there were 46 students assigned to 10 PBLgroups; each PBL group consisted of 4–5 students. The PBL groupworked over 32 h with 4 learning packages developed by the KoreanNursing College. Each PBL session was 2 h per week for 16 weeks andwas facilitated by a faculty member who taught PBL with nursingstudents for 4 years. One scenario held 4 sessions. During the firstsession, students in each group read the clinical scenario (Koreanclinical situation) to identify the major concepts and meaning. Ascenario is provided as an example:

Mr. Park, 80 years old, has worn a long leg cast for 6 days due to aleft femur fracture, lies down in the bed. Mr. Park's daughterworries he does not move to frequently. She asks the nurse toexplain range of movement (ROM) and the method used to movehim into the wheelchair again.

Based on their current level of knowledge, students and facultyreviewed the scenario together to confirm the significant conceptsand problems. During the second session, students in each groupdiscussed important factors in the nursing scenario and searched foradvanced information using textbooks and the internet and thenpresented their work and the faculty encouraged the students tothink critically and gave feedback. At the third session, each grouppresented a solution to the problem from the scenario. The facultyhad the students debate their approaches and solutions to the prob-lem to help the students increase their understanding of the issueswithin the scenario. Finally, during the fourth session, studentsin each group role-played the nurse in similar situations to that ofthe scenario. The faculty member then wrapped up the class andanswered any final questions the students may have had.

The 44 students assigned to the lecture group received didacticlectures for 2 h per week for 16 weeks on the same content as thatof PBL group: asepsis, safety, activity and exercise, nursing process,hygiene, vital signs, and environmental health.

Questionnaires were again administered to assess critical think-ing, problem-solving, and self-directed learning skills of students inboth groups when the semester was finished.

Data Analysis

SPSS was used to analyze the data. Chi-square (Fisher exactprobability) and t-test were employed to compare the baseline mea-surements of demographic characteristics and dependent variablesbetween the two groups. Analysis of covariance (ANCOVA) wasused to compare critical thinking, problem-solving and self-directedlearning scores between the PBL and traditional instruction groups,controlling for baseline differences in the abilities, because the base-line differences in the abilities between groups were statisticallysignificant.

Results

Table 1 presents comparisons of the demographics of the studentsin the PBL group versus the traditional group. The mean age was18.7 yr. (SD 2.01) in the PBL group and 18.6 yr. (SD 1.71) in the tradi-tional group. Nearly all participants were female (91.3%). In terms ofprior education, more students had attended an academic high schoolthan had attended a vocational high school. To compare the outcomesbetween the two groups, ANCOVA, using pre-test scores as the covar-iates was used (Table 2). Critical thinking scores increased 2.20 pointsfor students after PBL instruction and increased 0.82 points forstudents in the traditional group, however this difference was not sta-tistically significant (F = 3.364, df = 1, p = .070). Problem-solvingscores in the PBL group increased to 4.13, however scores in the tra-ditional group decreased to 1.30. There were no statistically signifi-cant differences between two groups (F = .604, df = 1, p = .439).Regarding self-directed learning ability, the post scores of who hadreceived PBL instruction increased to 2.65, and the traditional methoddecreased to 1.66. However, the differences between groups werenon-significant (F = 1.215, df = 1, p = .273).

The correlation coefficients (r) quantifying the relationships betweenlearning outcome scores were examined. The results revealed a positivesignificant correlation between critical thinking and problem-solving(r = .713, p b .001), between critical thinking and self-directed learning(r = .503, p b .001), and between problem-solving and self-directedlearning (r = .747, p b .001).

Discussion

Using the technique of PBL, students in previous studies havedemonstrated increased involvement in their learning and this ledto more improvements in critical thinking, higher levels of problemsolving, more motivation to find new information, and increasedconflict resolution skills (Seren and Ustun, 2008; Cooke and Molye,2002). The present study tested the effects of PBL on critical thinking,problem-solving, and self-directed learning skills with first yearnursing students in Korea.

In this study, finding no significant differences in groups in themeasure of critical thinking may have been due to a number of factors.

Table 2Outcomes of ANCOVA for critical thinking, problem-solving, and self-directed learning skills between the PBL group (N = 46) and control group (N = 44).

Variables Pretest Posttest Fa p

PBL Control PBL Control

M (SD) M (SD) Mean (SD) Mean (SD)

Critical thinking 51.21 (5.61) 56.72 (6.16) 53.41 (5.46) 57.54 (5.31) 3.364 .070Problem solving 112.15 (12.63) 126.95 (14.03) 116.28 (15.30) 125.65 (17.03) .604 .439Self-directed learning 107.78 (12.49) 114.72 (12.10) 110.43 (12.05) 113.06 (12.64) 1.215 .273

Note. PBL = problem based learning.a F score is from analysis of covariance with pretest scores as covariates.

55E. Choi et al. / Nurse Education Today 34 (2014) 52–56

First, it may be due to the limited duration of the PBL program. There islittle known regarding the length of time of PBL should be offered inorder to have an effect, and there are studies showing no significant ef-fects of PBL on critical thinking outside of Korea. However, most studiesof the effects of PBL on critical thinking in Korea have shown no signif-icant effects (Choi, 2004; Yang, 2006). It is likely that the duration of thestudy of the instruction using PBLwas too short, or themeasurement ofits effects on student abilitieswasmeasured in too short of a time frame.In our study, the duration of the PBL instruction was one semester(16 weeks). In contrast, research that has shown significant increasesin critical thinking has studied PBL programs having PBL instructionlasting for over one year with first year nursing students (Yuan et al.,2008b; Tiwari et al., 2006). Second, most first year nursing studentsare not accustomed to studying in group settings because most oftheir previous education in Korean high school has been done via lec-ture. Thus, it may be difficult to adapt to PBL teaching and learningstyles.

Critical thinking is an ingrained trait and may be difficult to change(Ravert, 2008), and may take significantly more time to change criticalthinking through the use of PBL instruction thanwhat we carried out inour study. To address this, we suggest that longitudinal studies bedesigned over periods of at least one year and especially when PBL isapplied with first year nursing students. Further, PBL should be morecomprehensively and continuously employed in all nursing classes ina curriculum in a coordinated fashion instead of in individual classes.

Enhanced problem-solving ability affects the quality of nursing careand plays a vital role in the outcomes of the nursing care (Uys et al.,2004). In the present study, though self-directed learning was not sig-nificantly different, the post-test scores increased by 4.13 in the PBLgroup. However, in the control group, the scores for self-directed learn-ing decreased. A possible explanation for this result was the use of acase segmentation scheme. Lohman and Finkelstein (2002) found thatstudents' ability to solve the problems was changed in accordancewith the case segmentation scheme of the PBL. Long segmentationschemes comprise brief content (e.g., 4 parts), and short segmentationschemes comprise content details divided into many parts (e.g., 10parts). Students given a short segmentation scheme of 10 partsimproved their solving-problem ability more, relative to studentsprovided a long segmentation scheme of four parts (Lohman andFinkelstein, 2002). A short case segmentation scheme helps studentsefficiently solve problems. In the present study, PBL cases containedlong segmentation schemes. It is recommended that future PBL caseswould be formatted in shorter segments.

Self-directed learning is one of the ingredients comprising the the-oretical basis of PBL, consistent with modern theories on learning thatemphasize that learning should be self-directed (Dolmans et al.,2005). In this study, a difference in self-directed learning betweenthe two groups was not found. This outcome could possibly be attrib-uted to the fact that it was a hard time for first year nursing studentsto move from lecture (as in high school) to student-led tutorials inPBL (in college). Because first year students were accustomed tolecture and depended on faculty direction, it may be difficult to

engage in self-directed learning during their first year (Kassab et al.,2005; Lekalakla-Mokgele, 2010; Miflin et al., 1999). Conversely,senior students may feel discomfort if instructors control the learning(Lekalakla-Mokgele, 2010). That is reflected in the findings of previousinvestigators that students respond differently based on the level ofthe students' level or year in school. With advancing grade or level ofeducation, students may expect to gradually become better at self-directed learning, and may take more responsibility for their educationin a self-directed manner (Kassab et al., 2005).

The correlation analysis showed significant positive relationshipsamong critical thinking, problem-solving and self-directed learning.In order to promote critical thinking, we have to adopt proper educa-tional methods to simultaneously improve problem-solving and self-directed learning. Additionally, as self-directed learning is so fre-quently employed in nursing education, critical thinking to solveproblems also will and should be developed.

Limitations

This study has limitations. Results cannot be generalized to othersettings because it was employed with small samples of first yearnursing students at two junior colleges in Korea. Further researchwill be needed to more fully examine PBL as an approach to nursingeducation and larger representative samples will be needed. Anotherlimitation is the non-randomized design and lack of comparabilityin the two groups of students. Participants came from two juniorcolleges to prevent the contamination between the experimentaland the control groups. However, there were differences betweengroups in baseline dependent variables, and thus ANCOVA was used.

Conclusions

Although learning outcomes showed a trend to improve more inthe PBL group as compared to the traditional group, there were notstatistically significant differences between the PBL and traditionalgroups, suggesting no true differences. It is likely that the study wasunderpowered or that insufficient strength or time of instructionusing PBL strategieswere provided, or not enough time passed to assesseffects of PBL instruction on student learning outcomes. The correla-tions among critical thinking, problem-solving, and self-directed learn-ing were significant and positive. The higher the self-directed learningscore, the better the problem-solving and critical thinking ability. Webelieve that well-structured PBL holds promise for nursing educationto promote critical thinking, problem solving, and self-directed learningability.

Further research should, ideally, include larger more representativesamples, and employ randomization or other strategies to assure betterbaseline comparability between groups.

Findings of this study indicate that more research ought to beconducted on the effects of PBL on problem-solving and self-directedlearning abilities. Additionally, studies of the long-term effects of PBLare needed in nursing education.

56 E. Choi et al. / Nurse Education Today 34 (2014) 52–56

Acknowledgments

This study was supported by research funds from Chosun NursingCollege, 2010 and we would like to thank all student participants.

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