Nurse Education Today 34 (2014) 5256

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

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 Korea
b
University of Minnesota School of Nursing, Minneapolis, Minnesota, USA
c
Kyungpook National University College of Nursing, Research Institute of Nursing Science, Daegu, South Korea

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

Article history: Background: Problem-based learning (PBL) is a method widely used in nursing education to develop students'
Accepted 18 February 2013 critical thinking skills to solve practice problems independently. Although PBL has been used in nursing
education in Korea for nearly a decade, few studies have examined its effects on Korean nursing students'
Keywords: learning outcomes, and few Korean studies have examined relationships among these outcomes.
Problem-based learning Objectives: The objectives of this study are to examine outcome abilities including critical thinking,
Critical thinking
problem-solving, and self-directed learning of nursing students receiving PBL vs. traditional lecture, and to
Problem-solving
Self-directed learning
examine correlations among these outcome abilities.
Design: A quasi-experimental non-equivalent group pretestposttest design was used.
Participants/Setting: First-year nursing students (N = 90) were recruited from two different junior colleges
in two cities (GY and GJ) in South Korea.
Methods: In two selected educational programs, one used traditional lecture methods, while the other used
PBL methods. Standardized self-administered questionnaires of critical thinking, problem-solving, and
self-directed learning abilities were administered before and at 16 weeks (after instruction).
Results: Learning outcomes were signicantly positively correlated, however outcomes were not statistically
different between groups. Students in the PBL group improved across all abilities measured, while student scores
in the traditional lecture group decreased in problem-solving and self-directed learning. Critical thinking was
positively 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 signicantly different from traditional lecture in this small
underpowered study, despite positive trends. Larger studies are recommended to study effects of PBL on critical
student abilities.
2013 Elsevier Ltd. All rights reserved.

Introduction logically assess and formulate interventions to impact patient care

Problem-based learning (PBL) helps students develop critical
thinking to solve problems in their clinical settings, and bridges the
gap between theory and practice (Rogal and Snider, 2008). PBL is a
student-centered method of instruction; it is an educational strategy
in which students take responsibility for their own learning and it
appears to enhance self-directed learning skills (Dolmans et al.,
2005; Lekalakla-Mokgele, 2010). The self-directed learning aspect of
PBL encourages the development of nursing students' ability to
think critically, and critical thinking enhances the nurses' abilities to
Corresponding author at: Kyungpook National University, College of Nursing, 101
Dongin-dong, Jung-gu, Daegu 700-422, South Korea. Tel.: +82 53 420 4978; fax: +82
53 421 2758.
E-mail addresses: eychoi@cnc.ac.kr (E. Choi), lindq002@umn.edu (R. Lindquist),
asansong@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.
(Ozturk et al., 2008; Yuan et al., 2008b). Critical thinking has been
shown to be enhanced by PBL; it enables students to solve problems
in clinical situations and to provide rationale for their actions
(Cooke and Molye, 2002).
Problem-solving abilities have been shown to be better in students
who have received instruction with PBL relative to those who received
instruction by lecture (Uys et al., 2004). PBL resulted in the increase of
students' critical thinking and self-directed learning, which are needed
to solve clinical problems.
Most studies of PBL have focused on its positive effects on critical
thinking (Jones, 2008; Yuan et al., 2008a). Published studies focused on
PBL's effects on problem-solving ability and self-directed learning are
sparse, and the ndings of some of the studies were not signicant or
negative. Choi's (2004) study of PBL versus traditional lecture with 76
second-year nursing students showed that the critical thinking scores
of the students in the traditional lecture group were higher than those
of the PBL group. Several other studies reported no signicant differences

0260-6917/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.02.012
 E. Choi et al. / Nurse Education Today 34 (2014) 5256
between PBL versus traditional lecture on self-directed learning or
problem-solving in rst year college students (Lohman and Finkelstein,
2002; Williams, 2004).
Critical thinking and problem-solving abilities are skills viewed as
essential for health professionals as the foundation for clinical reason-
ing (Hendricson et al., 2006), and the ability to engage in self-directed
learning is important for success of the health professional student
while in school, and in their health career after graduation. Critical
thinking and problem solving are occasionally viewed as intertwined
abilities, and merged into a single construct such as reective judg-
ment or deliberative assessment (Hendricson et al., 2006). Optimal
strategies to promote the optimal development of these abilities
in students remain elusive, and the inter-relationship among these
abilities that are targeted by nursing curricula remains of interest.
In Korea, PBL has been slowly adopted in nursing schools since the
early 2000s, however there have been few studies examining the
effects of PBL on nursing student learning outcomes. Members of
nursing faculties desire to have Korean nursing students receive the
best evidence-based instruction possible to prepare them optimally
for careers as professional nurses. If PBL can be shown to result its
improved learning outcomes in Korean nursing students relative to
traditional strategies, then its adoption is ought to be continued or
accelerated. If, however, PBL is not demonstrated to have outcomes
superior to traditional instructional strategies, then traditional in-
struction should continue and perhaps other alternative instructional
strategies should be sought and tested. Therefore, the purposes of
this study are to explore and compare the effects of PBL versus
traditional education on critical thinking, problem-solving skills and
self-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 to
content-based; as a strategy, it employs small groups that are centered
on solving well-integrated clinical problems instead of large groups as
in traditional instruction, with content delivered mainly through lecture
and limited self-directed learning (Uys et al., 2004). Most investigations
of 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 theoretical
knowledge (Ozturk et al., 2008; American Association Colleges of
Nursing, 2007). PBL, as a method of instruction, has been generally
accepted as a standard method of instruction to improve critical
thinking. Tseng et al. (2011) found among 120 nursing students
that the PBL group had higher scores in critical thinking than the
non-PBL group. Cooke and Molye (2002) established that instruction
with PBL motivated students to nd new information, leading to
a more critical thinking. Conversely, Choi (2004) showed that PBL
helped the students' problem-solving but not critical thinking
among second year nursing students. Yuan et al. (2008b) reported
in a published literature review that the PBL instructional approach
was questionable for nursing education due to the lack of large high
quality randomized controlled trials that have determined its effects
on critical thinking.
Problem-solving is recognized as a critical outcome of importance
wherever PBL is mentioned (Solomon, 2005), but studies of the effects
of PBL on problem-solving in the nursing literature are sparse. In one
study by Uys et al. (2004), investigators reported that the PBL group
attained higher levels than the non-PBL group of problem-solving skills
in 128 graduate students enrolled in nursing school. The majority of the
responses of students in the PBL group that were given to the problems
posed reected highly constructive strategies (at the advanced begin-
ner level or above), whereas responses of the students in the non-PBL
53
group's responses were more often at the novice level. Cooke and
Molye (2002) reported that students felt more pressure to learn and
to actively solve problems when instructed with PBL strategies. These
two studies support that there is an increase in the problem-solving
ability when PBL is used.
Self-directed learning is an outcome in which individuals take the
responsibility for one's own learning; self-directed learning has been
shown 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 signicantly
more self-directed learning than nursing students in the traditional pro-
gram. Dornan et al. (2005) found in their qualitative study that PBL
instruction fostered self-direction and lifelong learning skills.
Self-directed learning outcomes of PBL have been shown to be affected
or related to the type of schooling students had prior to entering nurs-
ing school. In one study of 135 rst year nursing students enrolled in in-
struction with PBL, students were separated and studied by level of
education including high school diploma, college, and baccalaureate de-
gree. Students with high school diplomas scored signicantly lower
than those with college or baccalaureate degrees (Williams, 2004).
In this study, many students reported that they experienced feelings
of uncertainty about PBL. In other words, as students transitioned
from traditional high school education or traditional university
program to PBL instruction, they felt uncertainty about their learning.
In summary, in the literature, research results regarding the effects
of PBL on critical thinking, problem-solving, and self-directed learning
are mixed. Also, when the effects of PBL were examined, most investiga-
tors studied its effects on critical thinking, problem-solving, and self-
directed learning. However, studies were not found that examined
the relationships among critical thinking, problem-solving, and self-
directed learning. This study explored the effects of PBL on critical
thinking, problem-solving and self-directed learning among Korean
nursing students and examined the association among the critical
thinking, problem-solving, and self-directed learning outcomes.
Methods
Design
A nonequivalent control group pretestposttest design was used
in this quasi-experimental study. The research compared the effects
of instruction using PBL strategies versus traditional education on
critical thinking, problem-solving and self-directed learning ability
of nursing students in Korea.
Sample
Participants in two groups comprised rst year nursing students
from two junior college nursing schools at the different cities in Korea
to prevent contamination. None of the students in either group had
been exposed to PBL previously. A power analysis determined that the
required sample size was 44 per group (Cohen, 1988): Signicance
level ( = .05), large effect size (Cohen's d = .70), and power (90%).
There were no dropouts. Students who had incomplete data were
excluded (2 in the PBL group and 4 in the traditional group). The
analyses were done with 46 nursing students in the PBL group and 44
participants 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 college
students. The scale has 20 items in ve 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 a
Cronbach's alpha was .71. This scale is scored on a 5-point Likert-type
54 E. Choi et al. / Nurse Education Today 34 (2014) 5256
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 score
indicating 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 scale
has responses assessed on a 5-point Likert-type scale (1 = absolutely
do not agree to 5 = absolutely agree). The tool for problem-solving
included 45 items and 5 subscales: Issue specication, cause analysis,
counterproposal development, plan and practice, and evaluation.
The total scores may range from 5 to 225; higher scores indicate
better problem solving. Cronbach's alpha of the developed scale
was .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 200
and higher scores reected stronger self-directed learning ability.
Cronbach's alpha of the developed scale was .93 (Lee, 2003) and
Cronbach'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 ethics
committee in Korea. Written informed consent was obtained from
the participating students. The PBL and traditional education program
approaches were conducted over one semester comprising 16 weeks.
Students in both groups completed a demographic form, and critical
thinking, problem-solving, and self-directed learning questionnaires
at the same time, prior to PBL and traditional lecture instruction.
For the PBL group, there were 46 students assigned to 10 PBL
groups; each PBL group consisted of 45 students. The PBL group
worked over 32 h with 4 learning packages developed by the Korean
Nursing College. Each PBL session was 2 h per week for 16 weeks and
was facilitated by a faculty member who taught PBL with nursing
students for 4 years. One scenario held 4 sessions. During the rst
session, students in each group read the clinical scenario (Korean
clinical situation) to identify the major concepts and meaning. A
scenario is provided as an example:
Mr. Park, 80 years old, has worn a long leg cast for 6 days due to a
left femur fracture, lies down in the bed. Mr. Park's daughter
worries he does not move to frequently. She asks the nurse to
explain range of movement (ROM) and the method used to move
him into the wheelchair again.
Based on their current level of knowledge, students and faculty
reviewed the scenario together to conrm the signicant concepts
and problems. During the second session, students in each group
discussed important factors in the nursing scenario and searched for
advanced information using textbooks and the internet and then
presented their work and the faculty encouraged the students to
think critically and gave feedback. At the third session, each group
presented a solution to the problem from the scenario. The faculty
had the students debate their approaches and solutions to the prob-
lem to help the students increase their understanding of the issues
within the scenario. Finally, during the fourth session, students
in each group role-played the nurse in similar situations to that of
the scenario. The faculty member then wrapped up the class and
answered any nal questions the students may have had.
The 44 students assigned to the lecture group received didactic
lectures for 2 h per week for 16 weeks on the same content as that
of 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 in
both groups when the semester was nished.
Data Analysis
SPSS was used to analyze the data. Chi-square (Fisher exact
probability) and t-test were employed to compare the baseline mea-
surements of demographic characteristics and dependent variables
between the two groups. Analysis of covariance (ANCOVA) was
used to compare critical thinking, problem-solving and self-directed
learning 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 statistically
signicant.
Results
Table 1 presents comparisons of the demographics of the students
in the PBL group versus the traditional group. The mean age was
18.7 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 of
prior education, more students had attended an academic high school
than had attended a vocational high school. To compare the outcomes
between the two groups, ANCOVA, using pre-test scores as the covar-
iates was used (Table 2). Critical thinking scores increased 2.20 points
for students after PBL instruction and increased 0.82 points for
students in the traditional group, however this difference was not sta-
tistically signicant (F = 3.364, df = 1, p = .070). Problem-solving
scores in the PBL group increased to 4.13, however scores in the tra-
ditional group decreased to 1.30. There were no statistically signi-
cant differences between two groups (F = .604, df = 1, p = .439).
Regarding self-directed learning ability, the post scores of who had
received PBL instruction increased to 2.65, and the traditional method
decreased to 1.66. However, the differences between groups were
non-signicant (F = 1.215, df = 1, p = .273).
The correlation coefcients (r) quantifying the relationships between
learning outcome scores were examined. The results revealed a positive
signicant 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-directed
learning (r = .747, p b .001).
Discussion
Using the technique of PBL, students in previous studies have
demonstrated increased involvement in their learning and this led
to more improvements in critical thinking, higher levels of problem
solving, more motivation to nd new information, and increased
conict 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 rst year
nursing students in Korea.
In this study, nding no signicant differences in groups in the
measure of critical thinking may have been due to a number of factors.
Table 1
Demographics of students in the PBL (N = 46) and control (N = 44) groups.
Characteristic PBL Control 2 (t) p
n (%) or M SD n (%) or M SD
Gender
Female 38 (82.6) 44 (100) .006a
Male 8 (17.3) 0 (0)
Age 18.67 1.71 18.57 1.31 .327 .744
Prior high school
Academic 2 (69.5) 22 (50.0) .085a
Vocational 14 (30.4) 22 (50.0)
a
Fisher exact test for least signicant difference test.
 E. Choi et al. / Nurse Education Today 34 (2014) 5256
Table 2
Outcomes 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
PBL Control
M (SD) M (SD)
Critical thinking 51.21 (5.61) 56.72 (6.16)
Problem solving 112.15 (12.63) 126.95 (14.03)
Self-directed learning 107.78 (12.49) 114.72 (12.10)
Note. PBL = problem based learning.
a
F score is from analysis of covariance with pretest scores as covariates.
First, it may be due to the limited duration of the PBL program. There is
little known regarding the length of time of PBL should be offered in
order to have an effect, and there are studies showing no signicant ef-
fects of PBL on critical thinking outside of Korea. However, most studies
of 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 the
study of the instruction using PBL was too short, or the measurement of
its effects on student abilities was measured 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 signicant increases
in critical thinking has studied PBL programs having PBL instruction
lasting for over one year with rst year nursing students (Yuan et al.,
2008b; Tiwari et al., 2006). Second, most rst year nursing students
are not accustomed to studying in group settings because most of
their previous education in Korean high school has been done via lec-
ture. Thus, it may be difcult to adapt to PBL teaching and learning
styles.
Critical thinking is an ingrained trait and may be difcult to change
(Ravert, 2008), and may take signicantly more time to change critical
thinking through the use of PBL instruction than what we carried out in
our study. To address this, we suggest that longitudinal studies be
designed over periods of at least one year and especially when PBL is
applied with rst year nursing students. Further, PBL should be more
comprehensively and continuously employed in all nursing classes in
a curriculum in a coordinated fashion instead of in individual classes.
Enhanced problem-solving ability affects the quality of nursing care
and 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-
nicantly different, the post-test scores increased by 4.13 in the PBL
group. However, in the control group, the scores for self-directed learn-
ing decreased. A possible explanation for this result was the use of a
case segmentation scheme. Lohman and Finkelstein (2002) found that
students' ability to solve the problems was changed in accordance
with the case segmentation scheme of the PBL. Long segmentation
schemes comprise brief content (e.g., 4 parts), and short segmentation
schemes comprise content details divided into many parts (e.g., 10
parts). Students given a short segmentation scheme of 10 parts
improved their solving-problem ability more, relative to students
provided a long segmentation scheme of four parts (Lohman and
Finkelstein, 2002). A short case segmentation scheme helps students
efciently solve problems. In the present study, PBL cases contained
long segmentation schemes. It is recommended that future PBL cases
would 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 that
emphasize that learning should be self-directed (Dolmans et al.,
2005). In this study, a difference in self-directed learning between
the two groups was not found. This outcome could possibly be attrib-
uted to the fact that it was a hard time for rst year nursing students
to move from lecture (as in high school) to student-led tutorials in
PBL (in college). Because rst year students were accustomed to
lecture and depended on faculty direction, it may be difcult to
55
Posttest Fa p
PBL Control
Mean (SD) Mean (SD)
53.41 (5.46) 57.54 (5.31) 3.364 .070
116.28 (15.30) 125.65 (17.03) .604 .439
110.43 (12.05) 113.06 (12.64) 1.215 .273
engage in self-directed learning during their rst year (Kassab et al.,
2005; Lekalakla-Mokgele, 2010; Miin et al., 1999). Conversely,
senior students may feel discomfort if instructors control the learning
(Lekalakla-Mokgele, 2010). That is reected in the ndings of previous
investigators that students respond differently based on the level of
the students' level or year in school. With advancing grade or level of
education, students may expect to gradually become better at self-
directed learning, and may take more responsibility for their education
in a self-directed manner (Kassab et al., 2005).
The correlation analysis showed signicant positive relationships
among 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 solve
problems also will and should be developed.
Limitations
This study has limitations. Results cannot be generalized to other
settings because it was employed with small samples of rst year
nursing students at two junior colleges in Korea. Further research
will be needed to more fully examine PBL as an approach to nursing
education and larger representative samples will be needed. Another
limitation is the non-randomized design and lack of comparability
in the two groups of students. Participants came from two junior
colleges to prevent the contamination between the experimental
and the control groups. However, there were differences between
groups in baseline dependent variables, and thus ANCOVA was used.
Conclusions
Although learning outcomes showed a trend to improve more in
the PBL group as compared to the traditional group, there were not
statistically signicant differences between the PBL and traditional
groups, suggesting no true differences. It is likely that the study was
underpowered or that insufcient strength or time of instruction
using PBL strategies were provided, or not enough time passed to assess
effects of PBL instruction on student learning outcomes. The correla-
tions among critical thinking, problem-solving, and self-directed learn-
ing were signicant and positive. The higher the self-directed learning
score, the better the problem-solving and critical thinking ability. We
believe that well-structured PBL holds promise for nursing education
to promote critical thinking, problem solving, and self-directed learning
ability.
Further research should, ideally, include larger more representative
samples, and employ randomization or other strategies to assure better
baseline comparability between groups.
Findings of this study indicate that more research ought to be
conducted on the effects of PBL on problem-solving and self-directed
learning abilities. Additionally, studies of the long-term effects of PBL
are needed in nursing education.
56 E. Choi et al. / Nurse Education Today 34 (2014) 5256
Acknowledgments
This study was supported by research funds from Chosun Nursing
College, 2010 and we would like to thank all student participants.
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