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Research article

A comparison of problem-based learning andconventional teaching in

nursing ethics education

Chiou-Fen LinTaipei Medical University Shuang Ho Hospital, Taipei, Taiwan

Meei-Shiow LuTaipei Medical University, Taipei, Taiwan

Chun-Chih ChungTaipei Medical University Hospital, Taipei, Taiwan

Che-Ming YangTaipei Medical University, Taipei, Taiwan

Abstract

The aim of this study was to compare the learning effectiveness of peer tutored problem-based learning andconventional teaching of nursing ethics in Taiwan. The study adopted an experimental design. The peertutored problem-based learning method was applied to an experimental group and the conventional teach-ing method to a control group. The study sample consisted of 142 senior nursing students who were ran-domly assigned to the two groups. All the students were tested for their nursing ethical discrimination

ability both before and after the educational intervention. A learning satisfaction survey was also adminis-tered to both groups at the end of each course. After the intervention, both groups showed a significantincrease in ethical discrimination ability. There was a statistically significant difference between the ethicaldiscrimination scores of the two groups (P < 0.05), with the experimental group on average scoring higherthan the control group. There were significant differences in satisfaction with self-motivated learning andcritical thinking between the groups. Peer tutored problem-based learning and lecture-type conventionalteaching were both effective for nursing ethics education, but problem-based learning was shown to bemore effective. Peer tutored problem-based learning has the potential to enhance the efficacy of teachingnursing ethics in situations in which there are personnel and resource constraints.

Keywords

ethical discrimination ability, learning satisfaction, nursing ethics, teaching, peer tutor, problem-basedlearning

Corresponding author: Che-Ming Yang, 250 Wu-Hsing St, Taipei 11031, Taiwan.

Email: [email protected]

Nursing Ethics17(3) 373–382

ª The Author(s) 2010Reprints and permission:

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Introduction

It is widely accepted that health care professionals should strive continuously to strengthen their ethical

discrimination ability to enable them to make appropriate decisions when faced with ethical dilemmas. Nurses

are confronted with unique ethical problems arising from their involvement in patient care, and ethics has

therefore taken on an increasingly prominent role in nurse education.1 We were interested to find out whether

learning efficacy can be enhanced by the use of an innovative teaching method in nursing ethics education.

Background

Decision making by individual professionals and organizations can be influenced, either consciously or sub-

consciously, by the value systems embedded in the history of the profession concerned. The assumption is

that values are determinants of social behavior; and thus it is important to understand how values influence

job satisfaction, motivation and commitment, and consciously or unconsciously affect the way in which peo-

ple act in their personal and professional lives.2 Moral values have been defined as the distinction between

good and bad or right and wrong behavior. As such, moral values have great influence on the way nursesthink and act, and play a major role in patient care.2 Professional ethics education such as nursing ethics

is important because members of the profession need to know how they should behave.

Hosmer 3 points out that ethics education is not about clear cut choices, but more about multiple choices in

complicated situations. It does not aim to change people’s religion or customs, but instead to assist them with

their decision making. The objectives include: cultivating ethical aspiration, increasing sensitivity to ethical

issues, and enabling the ability to recognize ethical dilemmas, conduct ethical analysis and make decisions.

Similarly, the objectives of nursing ethics education should focus on the establishment of professionalism

and ethical thinking. The core course content needs to encompass such subject areas as theories of ethics,

ethical principles and their application, ethical codes and guidelines, critical thinking, ethical decision-

making skills, and the rights and responsibilities of patients and nurses.4

As indicated in the literature, ethics education provides nurses with the tools to reflect critically on their care practices5

and the inclusion of an ethics course in the nursing curriculum does increase student nurses’

moral reasoning abilities.6 There are primarily two approaches to ethics education for nurses: the first con-

sists of introducing nurses to the principles of right action and the second is a virtue ethics approach, which

places greater emphasis on attitude in caring.5 The first approach involves learning in a classroom setting,

whereas the second means learning from role models and mentors. There are also two models of classroom

ethics education: offering a separate course, or integrating ethics throughout the nursing curriculum.6

Although there is a consensus regarding the importance of positive role modeling for students,6 classroom

teaching is a convenient starting point, especially in undergraduate nursing education, and a separate course

can ensure that all the planned information is delivered in a systematic and coherent way. The question then

becomes: what is the most effective course design in terms of curriculum and teaching methods? Teaching

methods generally include formal lectures, seminars, classroom discussion, role playing and case analysis.6

Researchers and educators have stressed that knowledge about ethics and attitude learning should be based

on real situations and start from identifying problems.7 Some therefore argue that working with real cases in

small group discussions encourages students to apply their previous knowledge and new concepts learned in

the course, and thus helps them to bridge the gap between theory and practice.8

Problem-based learning is a highly structured and learner-centered teaching method. The principal fea-

tures include the following: problems are the starting point for learning; real problems are used; thinking

must be in terms of problems, not disciplines; orientated knowledge is acquired; learning is student initiated;

and there is an emphasis on group discussion.9 In this process, tutors merely facilitate learning. There are

374 Nursing Ethics 17(3)



generally five steps in the problem-based learning process: analysis of problems, establishment of learning

objectives, collection of information, summarizing, and reflection.

Two types of tutors are employed in problem-based learning: expert and non-expert. Some insist that

problem-based learning tutors have to be experts in the relevant field, whereas others support the use of

non-expert tutors such as peer tutors. Some propose that tutors must be equipped with both the ability to facil-

itate group discussion and professional knowledge of the related subject matter. However, financial and human resource constraints can limit the use of expert tutors.10 One study has shown that there is no signif-

icant difference between expert and non-expert tutors in terms of stimulating, leading, and controlling the

processes of group discussion.11 At times, non-expert tutors can concentrate more easily on facilitating the

group discussion process rather than controlling the academic content of learning,11,12 and learners often pre-

fer tutors to be non-directive.10,12 Especially in times of faculty manpower constraints, the use of peer tutors

appears to be a reasonable alternative.

The Economist’s Intelligence Unit ranked Taiwan second only to Sweden in its world health ranking in

2000.13 According to Taiwan’s 2005 National Health Statistics,14 more than 97% of the population of

approximately 22 million was insured through mandatory national health insurance. Cancer remained the

most common cause of death. Although Taiwan spent only about 6% of its gross domestic product on health

and the per capita health expenditure in 2005 amounted to USD942, there were ample health service provi-ders and health care professionals. There were 31.8 acute care beds per 10,000 people and 46.2 registered

nurses per 10,000 people in 2005, giving a total of 105,183 registered nurses.14

Modern nursing education in Taiwan started before the Second World War. Two tracks of nursing edu-

cation have evolved since then: junior college level and college level. Junior colleges enroll ninth-grade grad-

uates and provide a five-year nursing education course. Nursing colleges accept students graduating from

senior high schools and from junior nursing colleges, who must study for four or two years, respectively,

to gain a bachelor’s degrees in nursing. All these nurses can be licensed as registered nurses as long as they

pass the national licensing examination. With the rapid advance of nursing as a distinctive academic disci-

pline, we have also seen a rapid growth of graduate nursing programs in Taiwan. There are now 39 junior

nursing colleges and college programs, 19 master’s programs and seven doctoral programs. In order to mon-

itor and improve the quality of nursing education, the Taiwan Nursing Accreditation Council was established in 2006 to accredit nursing schools.

Aim

This study aimed to compare the educational results of peer tutor problem-based learning and conventional

teaching in nursing ethics education.

Methods

Participants

The study sample consisted of seniors in the Department of Nursing at Taipei Medical University. These

students were randomly assigned to two groups. They were informed about this research and given the oppor-

tunity to take other classes instead if they wished. Although nursing ethics was a required course, the students

were free to choose from other nursing ethics classes. Owing to withdrawals after registration, there were

72 students in the experimental group and 70 controls. There was no significant difference between these

two groups in terms of personal characteristics and discrimination of nursing ethics before the intervention.

Lin et al. 375



Ethical approval

This study was funded by the National Science Council, Executive Yuan, Taiwan, ROC, approved by the

curricula committee of Taipei Medical University, and conducted in Taipei, Taiwan in 2005. Confidentiality

of all records was strictly preserved according to the bylaws of Taipei Medical University regarding aca-

demic record keeping. According to the Medical Care Act of Taiwan, only clinical trials are required to

be referred to hospital ethics committees. The scientific value and ethical considerations of all the other kinds

of research are reviewed by the Taiwanese funding agencies as a whole.

Procedure

This study adopted an experimental design (Figure 1).

The peer tutor problem-based learning method was applied to the experimental group and the conven-

tional teaching method to the control group. Three tools used in this study were teaching plans, the nursing

ethical discrimination ability scale and the learning satisfaction survey. Three teaching plans to be used for

problem-based learning were conceived by an expert panel of seven. Each plan included learning objectives,

a clinical case exhibiting ethical dilemmas, and guidelines for peer tutors.

The same expert panel developed the nursing ethical discrimination ability scale after consulting the rel-

evant literature.8,15 The final scale included nine situations and 41 questions measured on a Likert scale. The

learning satisfaction survey was developed by the 10 members of another expert panel after consulting the

literature.16

The whole research process was divided into three stages and seven steps (Table 1) as set out below.

Stage I:

1) Designing the curricula for peer tutor problem-based learning and conventional teaching: The

core components of the curriculum include basic theories of ethics and virtue, the four ethical

Problem-

based learning

Conventional

teaching

Nursing ethical

discrimination ability

Learning satisfaction

Student

characteristics

Control

Experimental

Randomization

Research participants Intervention Learning effect

Figure 1. The conceptual framework of the research design




principles of biomedicine, the nurse–patient relationship, rights and responsibilities of patients

and nurses, codes of ethics and ethical guidelines, the ethical issues surrounding artificial pro-

creation and organ transplantation, etc. Three teaching plans were conceived for use with

problem-based learning. Each plan included learning objectives, a clinical case with ethical

dilemmas, and guidelines for the peer tutors. The guidelines included details of the problem-

based learning steps, how to play the role of a facilitator in the process, and the potential ethical

issues for each clinical case.

2) Designing the nursing ethical discrimination ability scale: The content validity of this scale was veri-

fied by experts. The final scale included nine situations and 41 questions. The level of agreement with

the ethical statement enunciated in each question was measured using a Likert scale. The content valid-

ity index was set at above 0.86. Test-retest was conducted with 92 students and the reliability score

reached 0.95. A sample situation and associated questions from the ethical discrimination ability scale

is presented in Table 2.

3) Designing the learning satisfaction survey: This instrument was validated by experts for

content validity. The final version consisted of three open-ended and six closed questions mea-

sured on a 5-point scale. Learning satisfaction is measured by the respondents’ subjective feel-

ings not by objective observations. Internal consistency reached 0.8 and the split-halves

reliability was 0.76. The results of the closed questions of the learning satisfaction survey are

given in Table 3.

Table 1. The research process

Stage Step

I 1) Designed the curricula for peer tutor problem-based learning and conventional teaching2) Constructed the nursing ethical discrimination ability scale

3) Constructed the learning satisfaction surveyII 4) Administered the pre-test nursing ethical discrimination ability scale

5) Conducted educational interventionIII 6) Administered the post-test nursing ethical discrimination ability scale

7) Administered the learning satisfaction survey

Table 2. Sample situation and questions from the ethical discrimination ability scale: Johnny is 10 years old. He suffersfrom acute lymphocytic leukemia and has received treatment for two months without improvement. His attending phy-sician decides to prescribe a new drug that is still under investigation. Both parents have agreed to this trial and yetrequested the physician not to inform Johnny, to avoid increasing his anxiety.

Statement

Level of agreement

Comment1 2 3 4 5

1) Johnny is a minor with no autonomy;therefore, his parents can make medical decisions for him.2) Johnny is already 10 years old. If telling him will not increasehis anxiety, the physician should still explain to him andobtain his oral consent.3) In order not to increase Johnny’s anxiety, it is acceptablenot to inform him that this treatment is a clinical trial.

Lin et al. 377



Stage II:

4) Pre-test completion of the nursing ethical discrimination ability scale: All students were tested and scored on this scale before classes began.

5) Conduction of the educational intervention: Owing to space limitation, each group could be assigned

only one classroom. The whole course was taught or supervised by the same teacher over eight

weeks, for 1 hour 40 minutes every week. The teaching in the control group was lecture based and

complemented by question and answer sessions and discussions. These students had 20 minutes to

discuss course content with the teacher before the end of each class. The experimental group received

an introduction to the course in the first week. Then the students were divided into 10 groups of seven

to eight people each and small group sessions were held. Each problem-based learning case was dis-

cussed and studied for two weeks. The final week was used to clarify questions and share thoughts

with the whole group. Teaching of the experimental group was primarily by peer tutors, complemen-

ted by the teacher. One student was selected as the peer tutor for each case in every group. The peer tutors received relevant guidelines before each class, and were instructed not to disclose these to their

group members unless they failed to make progress during discussion. The teacher circulated among

the small groups during the discussion sessions and the tutors could seek advice from them at any

time. After each class, the teacher discussed the group sessions with the peer tutors, answering ques-

tions and clarifying ethical issues. The small group problem-based learning discussions comprised

five elements: (1) analysis of problems: the students read the teaching case within their own group,

asked questions and sorted out problems; (2) establishment of learning objectives: the students tried

to answer their own questions and identify learning objectives for the unsolved problems; (3) infor-

mation collection: the students sought information about the learning objectives after class; (4) sum-

mary: the students were asked to evaluate the information collected by each member during the

second discussion session; and (5) reflection: the group decided how the information could be

applied to solve the ethical problems.

Stage III:

6) Post-intervention administration of the nursing ethical discrimination ability test: This test was admi-

nistered to both groups immediately after the whole course ended.

7) Post-intervention administration of the learning satisfaction survey: This survey was also administered

to both groups immediately after the whole course ended.

Table 3. Results of the learning satisfaction survey

Closed question

Experimentalgroup (n ¼ 72):mean (SD)

Control group(n ¼ 70):mean (SD) t-value P -value

Level of satisfaction with the teaching method 3.51 (0.73) 3.70 (0.69) 1.560 0.252Level of satisfaction with self-motivated learning 3.99 (0.68) 3.67 (0.70) –3.786 0.003Level of satisfaction with moral self-cultivation 3.84 (0.62) 3.76 (0.67) 0.729 0.954Level of satisfaction with understanding of nursing ethics issues 3.89 (0.64) 3.76 (0.65) 1.127 0.746Level of satisfaction with critical thinking 3.92 (0.60) 3.59 (0.48) –4.437 <0.001Level of satisfaction with intellectual stimulation 3.99 (0.49) 3.86 (0.67) –1.313 0.506




Data collection

In summary, as noted above, data were collected from the two groups by means of the nursing ethical dis-

crimination ability scale both before and after the intervention, and through the learning satisfaction survey

after the intervention.

Results

There was a statistically significant difference between the nursing ethical discrimination ability scores of the

two groups ( P < 0.05) after the educational intervention, with the experimental group on average scoringhigher than the control group. Moreover, the results of tests pre- versus post-intervention showed statistically

significant differences from each other for both groups, which indicates that both teaching methods had a

positive impact in terms of learning (Table 4).

A repeat measure analysis of variance was computed by applying the pre-intervention test results as a cov-

ariate, teaching methods as an independent variable, and the post-intervention test as a dependent variable so

as to eliminate the influence of the students’ original background on the post-intervention test results. After

the pre-test factor was controlled, there was a significant difference between the two groups for the results of

the post-intervention test of nursing ethical discrimination ability ( F ¼ 22.222, P < 0.001). The average for

the experimental group was significantly higher than that for the control group, which means that, in terms of

their nursing ethical discrimination ability, the students who received problem-based learning performed bet-

ter than those who underwent conventional teaching ( P

< 0.001).For the learning satisfaction survey (Table 3), the control group was more satisfied with the teaching

method than the experimental group; nonetheless, it was not statistically significant overall. The experimen-

tal group scored higher on questions of self-motivated learning, moral self cultivation, understanding of nur-

sing ethics issues, critical thinking and intellectual stimulation. The experimental group was significantly

more satisfied with self-motivated learning ( P ¼ 0.003) and critical thinking ( P < 0.001).

Discussion

According to a recent meta-analysis of 13 studies evaluating physician competency,17 when compared with a

control group who had studied using traditional curricula, newly graduated physicians showed a significantly

stronger appreciation of the legal and ethical aspects of health care and were more able to cope with uncer-

tainty if they had been exposed to problem-based learning at medical school. There was also evidence to sup-

port a beneficial effect on communication skills and ongoing self-directed learning. These findings

corroborate our hypothesis that problem-based learning is suitable for ethics education.

Our results show that nursing ethics education can strengthen students’ ethical judgment regardless of

whether they are taught by problem-based learning or conventional methods. This improvement was more

evident in the problem-based learning group than the control group. A similarly designed study conducted on

medical students produced comparable findings,15,18 although this was a cohort study in which peer tutors

were not used.

Table 4. Comparison of pre- and post-intervention results on ethical discrimination ability scale

Group Pre-test: mean (SD) Post-test: mean (SD) t -value P -value

Both (n ¼ 142) 3.45 (0.34) 3.62 (0.32) –4.729 <0.001Experimental (n ¼ 72) 3.45 (0.32) 3.65 (0.32) –4.569 <0.001

Control (n ¼ 70) 3.45 (0.37) 3.58 (0.32) –2.372 0.020

Lin et al. 379



Medical ethics core curricula can encompass a range of issues, including theories of ethics, ethical codes

and guidelines, informed consent, confidentiality, etc.19 Owing to time constraints, it is difficult for lecture-

based teaching to cover all of these. Many ethicists have therefore maintained that professional ethics edu-

cation should adopt the use of clinical case analyses through small group discussion in order to strengthen

ethical discrimination and problem solving ability, and cultivate a lifelong learning capability.8,20,21 Because

problem-based learning is based on analyzing clinical cases, the present study supports the assertion that stu-dents who participate in small group discussions for clinical case analyses perform better.

A statistically significant improvement was found for ethical discrimination ability in members of the

problem-based learning group after intervention in only four of the nine post-test situations. This finding

could be attributed to the use of peer tutors. Owing to the limited resources and time, the peer tutors used

in this study received only very limited preliminary training. Researchers have noted that expert tutors are

better at eliciting higher cognitive functions.11 However, administering proper training to tutors has been

shown to prevail over this shortcoming.12

There was also a statistically significant improvement in ethical discrimination ability in the control

group, indicating that conventional teaching is also effective. In addition, their level of satisfaction with the

teaching method was greater than the intervention group. This phenomenon could be caused by two possible

factors. First of all, most students in Taiwan are used to lecture-type passive learning. The demands of problem-based learning, such as previewing, class participation and expressing themselves publicly, could

have caused stress for the intervention group students. The other reason could be the relatively low number

of cases studies used for this research. Owing to time constraints, only three were used. Previous studies that

used 10–12 cases resulted in higher learning satisfaction rates, suggesting that more content could increase

satisfaction; on the other hand, it may mean that students respond better when more time is spent on problem-

based learning.22

Students taking part in the problem-based learning expressed higher satisfaction with self-motivated

learning and critical thinking compared with the control group. This finding is consistent with the character-

istics of problem-based learning described in the literature.7,22–24 Other studies have shown that the problem-

based learning format improves self-directed learning, critical thinking, communication and the ability to

work in a team.

25

Lecture-type teaching mostly focuses on conveying facts. The reason that problem- based learning was shown to be superior to conventional teaching is probably because this method is better

for achieving the ultimate goals of ethics education, that is, self-learning and critical thinking.

As noted earlier, there are two models of classroom nursing ethics education: either a dedicated course or

the integration of ethics teaching throughout the curriculum. Some studies have suggested that many schools

fail to offer a separate nursing ethics course because no-one is available to teach it.6 This, regardless of

whether it is universally agreed, reflects the fact that there are simply not enough qualified ethics teachers

in many countries, which is where peer tutor problem-based learning can be useful because it augments the

educational reach of the faculty. Qualified ethics teachers can supervise more in-depth discussions by apply-

ing problem-based learning than by running a whole course on a more general level. This approach allows

better use of the limited numbers of ethics faculty staff for reaching more students.

Limitations of the study

This study was conducted in only one university, which limits the generalizability of the research results. We

relied solely on the faculty members who were teaching the nursing ethics course when this research was

conducted. However, the differences in learning satisfaction may have been due to the teachers themselves.

Likewise, although the peer tutors had been given training in advance, this was not standardized, there was no

adequate evaluation of whether they were qualified to be peer tutors, and there was no assessment of how

they performed their tasks. Moreover, learning results can be affected not only by teaching methods but also




by teaching materials. Although our teaching materials were validated by an expert panel, they are still not

widely accepted in standard textbooks or teaching plans. Whether our research results were biased in either

direction by the teaching materials requires further validation.

ConclusionsThe findings of this study indicate peer tutored problem-based learning and lecture-type conventional teach-

ing are both effective for nursing ethics education in terms of improving ethical discrimination ability, but

problem-based learning is more effective. Students undergoing problem-based learning reported higher satis-

faction with self-motivated learning and critical thinking ability in comparison with the control group. When

there are faculty constraints, peer tutored problem-based learning can help to improve learning efficacy in

nursing ethics education.

Acknowledgement

Funding for this study was provided by the National Science Council, Executive Yuan, Taiwan, ROC. The

authors would like to acknowledge a research grant (NSC 92–2516-S-038–004) from the National Science

Council.

Conflict of interest statement

The authors declare that there is no conflict of interest.

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