Satisfaction of Health Educator Nurses Through an Ongoing Professional Education Program Using Two Instructional Methods

Table of Contents

Dedication

Acknowledgment

English abstract

Table of contents

List of tables

List of figures

List of appendices

Chapter 1 Introduction
1.1 Introduction & Background
1.2 Statement of the problem and its significance
1.3 Rationale
1.4 Research question
1.5 Research hypothesis
1.6 Aim
1.7 Specific objective
1.8 importance of the study

Chapter 2 Literature review
2.1 Introduction
2.2 Nursing in Saudi Arabia
2.3 Continuous Medical Education (CME)
2.4 Learning theories
2.4.1 Psychological foundations of Active learning:
2.4.2 Dewey’s experimental theory
2.4.3 Meaningful learning
2.4.4 Constructivist learning
2.4.5 Learning environments
2.4.6 Constructivist epistemology
2.5 Teaching methods
2.5.1 Traditional lecture method
2.5.2 Interactive teaching
2.5.2.1 Problem Based Learning
2.5.2.2 Case-based learning
2.6.1 Curriculum and health educators
۲٫٦٫۲ Peer teaching
2.7 Constructivism
2.7.1 Use of concept map
2.8 Cooperative learning
2.9 Lecture-based course versus group discussion
2.10 Summary

Chapter 3 Methodology
3.1 Study design
3.2 Study context
3.3 Study population
3.4 Sample size & Sampling technique
3.4.1 Sample size and response rate
3.5 Selection criteria
3.5.1Inclusion criteria
3.5.2 Exclusion criteria
3.5.3 Confounding variables
3.6 Pilot study
3.7 Methods used for data collection
3.7.1 Questionnaire
3.7.2 Demographic and professional variables
3.7.3 The English version of the questionnaire
3.7.4 The Arabic version of the questionnaire
3.7.5 Reliability and validity
3.7.6 Health education training program
3.8. Statistical design
3.8.1 Descriptive statistics
3.8.2 Primary analysis
3.9 Ethical consideration

Results
4.1Sample Size and Response Rate:
4.2Demographic Characteristics:
4.3Research question

DISCUSSION
5.1Sample size
5.2Reliability and Validity
5.3Demographic Characteristics
5.4 To answer the research question:
5.5 Discussion of significant questionnaire items.
5.4Study Limitations
5.5Conclusions
5.6Recommendations:

References

Appendixes

Aabic section(abstract)

Dedication

This work is dedicated to my dear parents: To my father, and my mother and all my family who gave me encouragement and were a source of motivation for me during the hard times of this work.

Acknowledgement

I would like to offer my special thanks to those who helped me complete this study, especially my supervisor, Professor Marwan Abu-Hijleh, for his sincerity, guidance, and encouragement throughout this research.

Also, I would like to thank all my teachers in the Health Professions Education Programme (MHPE), who inspired me to achieve more than I thought possible. In addition, I would like to thank Professor Mousa Al Nabhan for his much-needed advice on statistics.

My appreciation goes to my colleagues in the sector of Primary Health Care and to Dammam Health Administration Affairs, with special thanks to the Family Medicine consultant, Dr. Jamal Alhamed, Director of PHC Centers in Dammam. Thanks also go to Dr. Abdullaziz Al Sebiany of King Faisal University for his great help and advice, and to Ms. Ina, Secretary of MHPE.

Finally, I extend my deepest thanks to all the participants in this study for their cooperation during the process of implementing my study and to all those who did not hesitate to help me with their time and effort.

Abstract

Aim

The aim of the study was to determine whether the interactive teaching method is more effective than the lecture-based method with regard to the nurse educator’s satisfaction and learning. No local study has been conducted in this area in health educational training programmes in the primary health care setting. The results of this study will help administrators of health education programmes to evaluate the desirability of implementing interactive methods in health education and training.

Methods

The study was conducted between January and June 2008 in the Dammam area of the Kingdom of Saudi Arabia. The study was a cross- sectional study that sought to identify the perceptions of health educator nurses; of the 40 invited to participate, 34 nurse educators from 20 primary health care centers attended. The 34 participants were divided in two groups by simple random tables. This is due to that there is a shortage of nurses and workload in primary health care (PHC) centers. Each group was subjected to the traditional lecture-based method of instruction, after which participants’ perception was registered. One month later, each group attended another session which used the interactive teaching method with peer teaching, and then their perception was registered. Four medical cases were presented using the interactive method, and a fifth case was presented using the problem-based learning (PBL) method, to introduce some incremental change in the teaching process. All the cases use presented using interactive teaching method.

The quantitative method of data collection, through the use of a two-part questionnaire, was employed. The first part of the questionnaire asked for demographic data, and the second part contained 22 items regarding the perception of the nurses for the two methods of instruction. Data were analyzed using the SPSS program. The frequency and mean percentage of students' responses was determined. A paired t-test was used to determine if a significant difference existed between the students' responses towards the two methods of instruction.

Results

The mean age of the nurse educators was 35.2 ± 6.9 years. There was a statistically significant difference between the traditional and interactive methods in10 items out of the 22-item questionnaire (higher scores toward interactive method). There was also a significant difference in participants’ preference for the interactive method over the traditional lecture-based method. In addition, significantly better scores for course content and student satisfaction resulted from use of the interactive method.

No single factor among the demographic characteristics was found to significantly affect the total differences in score of participant`s perceptions.

Conclusions

Nurse educators in primary health care centers prefer an interactive teaching method and peer teaching over the traditional lecture-based method of instruction. There is a need to train nurse educators to become effective presenters using interactive methods. Updating nurses’ knowledge in interactive teaching and the use of peer teaching is, therefore, important in continuing medical education programs for health professionals.

List of tables

Table 1-1 lecture format :group 1

Table 2-1 lecture format :group 2

Table 3-2 Interactive method :group1

Table 4-2 Interactive method :group2

Table 4-1 Socio-demographic characteristics of the health educator nurses who participated in this study

Table 4-2 Comparison between nurse satisfaction scores towards traditional and interactive instruction methods of the course using paired t-test.

Table 4-3 Comparison between traditional and interactive instruction using students` perception scores towards the four domains of the course

Table 4-4 Linear regression Model 2 to predict student satisfaction from the other three domains relationship

Table 4-5 Demographic characteristics and the variables that affect the total score difference in the perception scores

List of figures

Figure Title of the figure

1 Organizational Structure of Health Education Unit in Dammam PHC centres.

2 A model of Dewey’s philosophy of experiential education.

3 An integrated instructional environment

4 Conceptual framework of cased-based learning

List of Appendices

Appendix No Title of appendix

1 Health Education Course design

2 English version of Questionnaire

3 Arabic version of Questionnaire

4-a Demographic data Form in English

4-b Demographic data Form in Arabic

5 Checklist of learning needs

6 Validity History of The Questionnaires

7-a Problem-based learning (case Diabetes mellitus)

7-b Problem-based learning (case Diabetes mellitus) in Arabic

8-a Medical Cases

8-b Medical cases (in Arabic) Approval letters

9 Approval letters

Chapter 1

Introduction

1.1 Introduction and background:

The purpose of this study was to explore the difference of learning using the interactive method in comparison to the traditional lecture-based methods presented in nurses’ educational health training programs. The focus of the study was on health educator nurses working in Primary Health Care (PHC) centres in the Eastern Province in the Dammam area of Saudi Arabia.

In total, there are 20 PHC centres in the Dammam area. Nurses in these centres are engaged in various activities including vaccinations, dressings and health education. Each centre has two nurses working as health educators who receive a three-day health educational training program twice a year. This program includes lectures, seminars, and workshops on various topics concerning nurse education such as diabetes, hypertension, and how to create brochures and pamphlets.

There are 40 health educator nurses in the PHC centres. The job description of these nurses includes holding community meetings and giving regular lectures to their patients thrice a week on different subjects in primary health care. They also conduct lectures on health topics at different schools in their area. They monitor the various educational activities among their patients according to individual requirements of health cases and document these in their files and records. They also create brochures and posters for their PHC centres.

The Unit of Health Education, under the direction of the investigator of the present study, is under the supervision of the Director of Dammam PHC centres (Figure 1). Another separate unit of Continuous Medical Education (CME) also offers some lectures to both doctors and nurses, but these are limited to just three hours per nurse per year. Thus, it is the educational training program organized by the Health Education Unit that provides consistent, continuous medical education to their nurses.

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Figure 1: Organizational Structure of Health Education Unit in Dammam PHC centres.

The unit of health education is important unit in PHC centres, because it helps the health educator nurses to improve their performance in health education. It organise meetings to discuss the problems faced by them during their work. It also does for them training programs to update their knowledge.

The present study was undertaken to determine whether interactive learning or the lecture method is more effective in such an educational training program.

The traditional training given to nurse educators was undertaken by lecture as an instrumental method. It was provided by faculty members, who were family medicine consultants, and by head nurse advisers, who have no more time to prepare the lectures needed for the training.

To solve this problem, we must consider another method of instruction that can be given by the nurse educators themselves in the form of peer teaching. This research was conducted to determine whether this method is more effective than traditional faculty teaching. Peer teaching has been described as students teaching students, and was reported in various educational programmes in the United States (Iwasiw & Goldenberg, 1992). With increasing student-faculty ratios in university nursing programmes, two problems surfaced; the provision of sufficient supervision, and opportunities for students to develop leadership skills. Peer teaching among nursing students is one possible solution to these problems (Iwasiw & Goldenberg, 1992).

Also, peer teaching ensures the lecture is not simply a unidirectional flow of facts but one in which students interact with the lecturer throughout (Nasmith & Steinert, 2001). The investigator suggested that to make peer teaching more effective, try to encourage nurse educators to give interactive lectures to their peer students in the form of small group discussions.

Both peer teaching and interactive instruction are new trends in medical education. Notably, investigators into educational research found that these two methods of teaching can increase the learning among nurse students (Iwasiw & Goldenberg, 1992; Nasmith & Steinert, 2001).

1.2 Statement of the problem and its significance

The importance of this study is that it addresses a new trend in medical education (interactive teaching). At present, little information is available about the instructional method that improves learning and nurse educators’ satisfaction, the most during a Continuous Medical Education (CME) programme in primary health care.

To change the instructional method in CME from lecture to interactive and peer teaching, this study is needed to determine its effects on learning and nurse educators’ satisfaction in primary health care centres. This will lead to a better use of resources and improved training in health education programmes.

This study will help to encourage nurse educators’ participation through participating in interactive learning as opposed to strictly lecture- based instruction (Nasmith & Steinert, 2001). This also will help to increase practice skills and professional growth (Iwasiw & Goldenberg, 1992).

1.3 Rationale

1. Changing the lecture format of instruction to an interactive approach can increase satisfaction and learning amongst the nurses in an educational training program, which will eventually improve the quality of health care and education.
2. To the best of the investigator’s knowledge, no local regional study has been conducted into the satisfaction and learning of nurses involved in health educational training programs in a primary health care setting.

1.4 Research question:

Does the interactive teaching method increase the nurse educators’ satisfaction and improve learning more than the lecture-based method?

1.5 Research Hypothesis:

Interactive teaching methods significantly improve the satisfaction or learning of health educator nurses with CME.

1.6 Aim

The aim of this study is to evaluate and improve the quality of nurses' continual educational learning and performance as health educators during ongoing professional education program.

1.7 Specific Objective:

To determine whether nurses engaged with interactive teaching methods experience greater satisfaction with learning than with the lecture method.

1.8 Importance of the study:

Changing the lecture format of instruction to an interactive approach in the unit of health education can increase satisfaction and learning amongst the nurses in an educational training program, which will eventually improve the quality of health care and education.

Chapter 2

Literature Review

2.1 Introduction:

The purpose of this study is to find better ways of training and teaching educator nurses in order to increase their satisfaction in CME programs, and to assess any improvement in learning through changing the teaching strategy from traditional lectures to interactive methods of instruction. Methods such as interactive instruction are quickly gaining ground as effective alternatives to traditional lectures (Kumar, 2003). This will strengthen the future of nursing education, and it provides educators with evidence for use in discovering the most effective teaching methods and incorporating them into the curricula (Kumar, 2003).

2.2 Nursing in Saudi Arabia

There are 17 nursing health institutes that teach nursing in Saudi Arabia and graduate nurses with an institute certificate. The program is administered over a period of three years. Until recently, the teaching was delivered in Arabic; however, the instruction is now given in English. Notably, nurses began to encounter some problems with the English language in diploma courses, because their original language is Arabic (Al- Zahrani et al, 1991).

Some 87.5% of nurses in Saudi Arabia enter nursing schools because they believe the work done by nurses is a humanitarian job. Yet they face some problems during their studies, such as scoring low grades in the nursing schools (Al-Zahrani et al, 1991).

Al-Zahrani et al (1991) recommended increasing CME and training courses for nurses in general, and upgrading the knowledge of more experienced nurses to help them improve their performance.

There is a need to establish an effective network between various health sectors to share experiences and knowledge. The Saudi council requires CME for nurses to ensure that they maintain and improve their standards of practice.

By 2005, 11,324 female nurses had graduated from nursing health institutes. Today, rather than an institute certificate, nursing institutes award a diploma after the secondary school level. There is a recognized need to improve the performance of Saudi nurses (Al-Hussini et al, 2006). Notably, bachelor’s degrees are conferred only by some universities.

Training in the workplace is the best solution, and this can be divided into four types:

1) Training after graduation at a special hospital, which is still rare in Saudi Arabia.
2) Training in advanced programs, such as master’s degree programs.
3) CME and this having high shortage in Saudi Arabia. To carry out this training, Saudi medical council do not register the practitioner until the student complete 30 hrs of training.
4) Continuous training during night shifts, but this is not a requirement specified by the ministry of health (Al-Hussini et al 2006).

2.3 Continuous Medical Education (CME)

The process used by physicians and nurses to update their knowledge consists of participation in CME (Cervero, 1981). Most participants in such programs seek learning through CME in order to treat their patients more effectively (clinical attributes). As noted by Chan (2002), CME has changed to develop new practitioner skills in the areas of management, teaching, and communication skills, all of which are non-clinical features.

It has been suggested that effective CME must have the following elements (Lewis, 1998):

1- a motivated learner with professionally inclined incentives
2- a competent teacher
3- an effective intervention
4- removal of "barriers" to the behaviour change that is being sought

2.4 Learning Theories

2.4.1 Psychological foundations of Active learning

A body of theory exists that can inform practice when teachers are confronted with situations in which they are unsure about what to do (Kaufman, 2003).

Andragogy is defined as the art or science of adult learning, which was first used by a German educator, Alexander Kapp, in 1833 (Kaufman, 2003). This approach is distinct from pedagogy, which is the art and science of teaching children. Malcolm Knowles is a leading theorist in Andragogy (Harriett, 1998), and the approach is based on five assumptions:

1) Adults are independent and self-directing learners.
2) They have acquired considerable experience, which is a rich resource for learning.
3) They value learning that integrates with the demands of their everyday life.
4) They are more interested in the immediate problem-centred approaches than in subject-centred ones.
5) They are more motivated to learn by internal drive than through external motivation.

2.4.2 Dewey’s experiential theory

Dewey’s experiential learning theory states that everything occurs within a social environment (Grady, 2003). In Figure 2 below, the box represents the social environment.

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Figure 2: A model of Dewey’s philosophy of experiential education (Grady, 2003).

Within this box, the model begins with knowledge, which is organized by the teacher into logical content blocks. The teacher also facilitates the students’ experience with the content based on student readiness. The outcome of this experience is learning, which contributes to learning readiness and knowledge, thus allowing the process to begin again (Grady, 2003).

Problem solving is the major method of teaching in this model. The problems identified via student and teacher cooperation deal with what is relevant to their society (Marlow, 2000). Dewey (1938) argues that traditional education is a ‘pattern of organization’ that consists of schedules, rules, and procedures that inhibit student learning. Dewey recommends increased social interaction within schools (Grady, 2003).

By the 1980s, the research by Dewey and Vygotsky (1978) (cited in Powers, 2007) had blended with Piaget’s work in developmental psychology to produce the broad approach of constructivism (Powers, 2007). It stated that students learn best by doing rather than observing. From the constructivist perspective:

1) The teacher is viewed not as the transmitter of knowledge but as a guide who facilitates learning.
2) Learning is based on prior knowledge. Teachers should provide learning experiences that expose the current understanding and their new experiences.
3) Teachers should engage students actively in their learning using relative problems and group interaction.
4) If new knowledge is to be acquired actively, then sufficient time must be provided to allow an in-depth examination of new experiences (Kaufman, 2003).

2.4.3 Meaningful learning:

Piaget (1952) and Ausubel et al (1968) described how meaningful learning occurs in interactive instructional strategies. Piaget posited that children’s minds organize experiences into frameworks known as schema. Assimilation is a process by which the individual incorporates new experiences into existing mental schemas. Ausubel’s assimilation theory described the process of connecting new and prior knowledge (Powers, 2007). That process is known as subsumption.

Derivative subsumption occurs when new learning is illustrative of a previously learned concept. The work of Piaget (1952) and Vygotsky (1978) has provided modern educators with a theoretical foundation for the development of teaching methods that foster active learning and the meaningful construction of concepts (Powers, 2007).

2.4.4 Constructivist learning

Bruner (1973) provides the following principles of constructivist learning:

1) Instruction must be concerned with experiences and contexts that make the student willing and able to learn (readiness).
2) Instruction must be structured so that it can be grasped easily by the student (spiral organization).
3) Instruction should be designed to promote extrapolation and/or fill in the gaps (going beyond the information given) (Huitt, 2003).

The constructivist approach suggests that educators first consider the knowledge and experiences students bring with them to the learning task. The school curriculum should be built so students expand and develop their knowledge and experience by connecting them to the new learning. On the other hand, advocates of the behavioural approach suggest deciding first what knowledge or skills the students should acquire, and then developing a curriculum that will facilitate their development (Huitt, 2003).

The root of the learning environment can be traced to early apprenticeship. Socratic and similar movements have sought to immerse individuals in reliable learning experiences in which meaning, knowledge, or skills are realistically embedded (Dewey, 1938; Land & Hannafin, 1996).

2.4.5 Learning environments

There are variouslearning environments according to their underlying foundations (Land & Hannafin, 1996):

1) Psychological foundations are about how individuals think and learn, and these derive from areas such as constructivism.
2) Pedagogical foundations stress that knowledge is conveyed to focus on the methods, activities, and structure of the learning environment such as student-centered learning environments.
3) Technological foundations highlight how the capabilities and limitations of available technology can be optimized.
4) Cultural foundations include increasing the priority of computer use in education.
5) Pragmatic foundations reflect the practical constraints of the environment and run-time needs and software.

These five foundations are integrated functionally. The better integrated the foundations, the greater chances of success will be in the setting for which it is designed (Land & Hannafin, 1996) (Figure 3).

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Figure 3: An integrated instructional environment (Land & Hannafin, 1996)

The 20th century has been marked the progression of educational philosophies and pedagogy through three primary movements, known as behaviourism, cognitivism, and constructivism. Later, there was a shift towards a fourth educational philosophy, known as “interactivism”. Interactivism assumes that reality is multiple; the truth becomes known when senses and emotions interact with cognition as we react to and act on our changing reality (Barbara, 2000).

2.4.6 Constructivist epistemology

The constructivist epistemology challenges traditional pedagogy in that it considers what individual students have learned and how they have learned it. In short, it values socio-cultural influences. Since nurses have knowledge as adults, building on that knowledge and comparing learning can be attained, and the constructivist theory may offer a framework that will allow this to occur more readily than when traditional educational frameworks are employed. The link between conservuativism/ metacognition and andragogy allows them to collectively support and encourage active learning and understanding (Peters, 2000).

Metacognition refers to the active self-managing, conscious act of thinking about thinking and learning. It is the focus one places on learning with an understanding of the grading and the quality of learning. This will improve learning, and part of active learning includes awareness and personal learning. Clearly, we need to train students in this method of learning (Peters, 2000; Baird, 1986). Constructivism as well as metacognitive development empowers students in the areas of problem solving, reflecting, and evaluating skills (Peters, 2000; Cust, 1995).

The works by Ausubel et al. (1968), Piaget (1952), and Vygotsky (1978) suggest that instructional strategies which involve the learner actively discussing and applying information with the instructor and peers are more likely to address higher level outcomes and lead to improved academic performance.

2.5 Teaching Methods

Do teaching methods affect student outcomes as well as retention? The results of various studies are in conflict about the influence of teaching methods on student competence (e.g., skill performance) and effective measures (e.g., satisfaction, self-efficacy). For example, research from nursing (Jeffries et al., 2002; Vaughan, 1990) and education (Kolb, 1984; Sadeo & Robinson, 2002) suggests that interactive teaching strategies significantly improve outcomes compared with traditional methods.

Conversely, other studies from nursing (Dougal & Gonterman, 1999; Jeffries et al., 2002) and management (Nadkarni, 2003) suggest that interactive teaching strategies do not significantly improve outcomes. This difference in conclusions could be because of lack of rigor and validity of the studies.

Dougal and Gonterman (1999) found that interactive studies do not significantly improve outcomes. They compare three instructional methods: lecture-discussion, self-study, and video group. Their study used a small sample size, and the self-study was limited by time and the physical constraints imposed by an oriented program. Other studies, such as those by Jeffries et al. (2002) and Miller (2003) observe no significant improvement in outcome by instructional strategy, but these studies must be tempered because of their lack of rigor in theme.

Many studies suggest that teaching methods affect both outcome and competence (e.g., cognitive gain, skills performance, critical thinking, and affective measures). For example, Jeffries et al., (2002) found that student satisfaction was significantly higher in interactive, student-cantered groups than in traditional groups.

Vaughan (1990) found that games and discussions were the most popular approaches among students while the lecture method was the least popular. Thus, students find learner-centred methods more acceptable. A constructivist teacher works as the link between curriculum and student to bring the two together in a way that is meaningful to the learner. He designs learning experiences that are active, where the learning is “doing”, and reflects an evaluation of students’ learning experiences and builds on their previous experiences to construct new knowledge and meanings (Yager, 1991).

Nadkarni (2003) found that students who were exposed to a hybrid method had more complex mental models than those exposed to either the experiential or the lecture-discussion method. This result does not support the traditional view on adult education that self-directed, experiential, instructional methods are the most suitable for adult learning.

Miller (2003) found no significant difference between two groups when following problem-based learning versus traditional lecture learning in a graduate pharmacology course. This suggests that both methods are equally effective course delivery methods. This was an experimental, post- test study of nurse students in a master’s degree program in the United States, where 12 students represented a control group and 10 students represented the experimental group. Group means on the exams were similar and satisfaction scores were similar as well. However, the sample size was small, which affected the generalizability of the study.

Sadeo and Robinson (2002) studied the utility of the three interactive teaching models: problem-based learning (PBL), case-based learning (CBL) and family-focused learning (FFL) (the direct involvement of family members in the teaching process with student presentations of research issues about the family). The researchers used person-focused learning to incorporate the teaching and learning methods mentioned above in a study that involved individuals with disabilities and their families. The students were from different universities. The results of the research revealed a change in students' attitude toward people with disabilities because of participation in the collaborative learning model.

Many studies in the literature compared different instruction methods, such as interactive and group discussions and lectures. The findings of these studies can be summarized as follows:

1. Students prefer to be taught by interactive lectures in which they participate actively in the learning session and preserve their engagement with the content (Ernst & Colthorpe, 2007).
2. Increased interactivity in the lectures leads to increased student satisfaction and better learning outcomes (Ernst & Colthorpe, 2007).
3. It is possible to introduce problem-based learning (PBL) in a traditional curriculum with a formal lecture-based program favoured by the students (Ghosh, 2007).
4. Interactive sessions with proper planning and organization enhance interaction and motivation, and promote active learning (Kumar, 2003).

2.5.1 Traditional Lecture Method

Although college educators continue to use traditional lectures as their primary method of instruction, Sousa (1995) noted that the average information retention rate for this method is only 5% for a 24-hour period, compared with alternative approaches, such as audiovisual aids (20%), demonstrations (30%), discussion groups (50%), practice activities (75%), and peer teaching (90%).

In the lecture method, factual material is presented in a direct and logical manner, and it may provide experiences that are useful for large groups. The traditional lecture format (defined as the continuous exposition by one person for approximately 50 minutes to a largely passive recipient audience) is the dominant method of teaching in most higher education courses. The continuous use of lecture comes from the advantages it offers:

1) One lecture teaches many students, and it is seen as being cost- effective
2) It is a method readily understood by both staff and students.
3) It affords a sense of “theatre”, which many lecturers enjoy (Butler, 1992).

At the same time, the lecture approach includes several disadvantages:

1. Expert oral skills are necessary
2. The audience is often passive
3. Learning is difficult to gauge
4. Communication is unidirectional
5. It is less effective than other methods when instructional goals involve the application of knowledge, developing thinking skills, or the modification of attitudes. Notably, educational research has shown that students who are involved in the learning activity will learn more than students who are passive recipients of knowledge (Butler, 1992).

2.5.2 Interactive teaching

Interactive teaching is a method of instruction that is becoming popular in many parts of the world. It is defined as “a two-way process in which students are expected to play an active part by answering questions, contributing points to discussions, explaining and demonstrating their methods to the class” (Department for Education and Employment, 1999; Sadeo & Robinson, 2002). It is also defined as focused teaching, with the educator being a cognitive coach, highlighting the facilitative nature of the educator-student relationship (Biddulph & Osborne, 1984). For focused teaching to be of value, it requires sensitive educators to challenge the students’ thinking interactively. They must expose students to new ideas, yet value the students’ past experiences while empowering them to be independent learners. Educators are encouraged to learn along with their students by being active listeners and challenging any misconceptions that arise. The students are encouraged to reflect on their own experiences to make sense of them, evaluate their work, and set future learning goals by determining which learning style suits them best (Biddulph & Osborne, 1984).

All interactive teaching strategies have evolved to meet the students’ needs, so they are viewed as student-centred, where students are willing to take an active role in their own learning. Examples of interactive teaching include problem-based learning (PBL), case-based learning (CBL) and peer teaching (Biley, 1999; Miller, 2003).

2.5.2.1 Problem-based learning (PBL)

PBL is defined as an educational method characterized by patient problems that represent a context in which students learn problem solving skills and acquire knowledge about the basic and clinical sciences in an integrated manner (Finucane et al., 1998).

PBL offers some positive priority to traditional methods (Norman & Schmidt, 1992). No significant differences were seen in academic achievement as noted by Vernon and Blake (1993), where the PBL group gained better examination performance. Students claim that PBL provides a more satisfying and enjoyable learning experience than traditional methods. It increases retention, interest, and motivation (Dehkordi & Heydarnajad 2008). In addition, it is compatible with modern theories of adult learning, and offers evidence of efficacy in some areas. Further, PBL students had significantly higher scores in learning attitudes than those of traditional lecture students (Arthur, 2001).

PBL programs place more emphasis on “meaning” (understanding) than “reproducing” (memorization) (Vernon & Blaker, 1993). Students engaged with PBL curricula integrate their knowledge better than students in a traditional curriculum, which means the former students can solve problems more effectively (Norman & Schmidt, 1992).

The disadvantages of PBL include the following:

1. It is costly with respect to staff time and teaching materials, and other physical resources. Significant energy and resources are needed over several years to develop the curriculum and train tutors and students in the PBL process (Finucane et al., 1998).
2. Practitioners might be tempted to use old cases blindly, relying on previous experiences without validating them for the new situation (Eshach & Bitterman, 2003).

2.5.2.2 Case-based learning (CBL)

A case study is a presentation of a real or simulated patient, with at least a chief complaint, selected history, and symptoms. A more complicated case may have several chief complaints, each with a full history, laboratory results, and treatment plans (Thomas, 1993).

Kim et al. (2006) reviewed themes related to case development strategies and organized them into a conceptual framework using the following categories: content, structure, attribute, and process. There were five core attributes (Kim et al., 2006) (Figure 4):

1. Relevance: Cases should reflect the learning needs and diversity of the learners
2. Realistic: Approximate real-world settings
3. Engaging: Rich content to allow multiple levels of analysis
4. Challenging: Increasing degree of difficulty
5. Instructional: Ask students to study what they remember from prior cases before learning the new case.

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Figure 4: Conceptual framework of cased-based learning (Kim et al., 2006)

Advantages of case-based learning include:

1) Develops analytic and problem solving skills
2) Allows students to apply new knowledge and skills.

Case-based teaching has been found to be more effective than the lecture-based approach in promoting students’ critical thinking and decision making skills (Kim et al., 2006). With the growing importance of the Web for teaching with cases, there is an acute need to develop the knowledge base on how to translate guidelines for constructing cases into an online working environment (Kim et al., 2006).

Limitations of the Case-based teaching include:

1. The difficulty in constructing cases. Each should have a real background and trigger willingness to discuss and concomitantly fulfil scheduled the learning objective.
2. Need for teachers capable of chairing case sessions. Faculty development, retraining, and supervision are thus required (Tarnvik, 2007).
3. They are not suitable for elementary level instruction (Kizlik, 2008).

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