FACILITATORS' PERCEPTIONS OF PROBLEM-BASED LEARNING AND COMMUNITY-BASED EDUCATION

In 1997 the School for Nursing, University of the Orange Free State, changed from the traditional lechrre method of teaching to problem-based learning andfrom a curative to a community-based approach. Lect~rrerssfvom a traditional environment became facilitators and new skills such as listening, dialogue, negotiation, coztnselling andproblemsolving were expectedfiom them. Besides the role change, the environment changedfrom a stn~ctural classroom to an ttnstructitred community. The aim of this research was to determine theperceptions and experiences ojfacilitators in problem-based learningandcommunity-basededzrcation. In this ejlplorative anddescriptivestzrdy a qualitativedesign was followed. The study population of ten first and second year facilitators were included in the research. Data was collected by means of two focus groups by an independent person. Focus groups were tape yecorded and content analysis was done. Facilitators identifiedproblems and needs, butpositive aspects of the new teaching methodology were also emphasised. The research showed that a paradigm shift from the traditional teaching method to an innovative method leads to distinctive problems and makes more demands on facilitators. The re-education and continuous support of academic staff are essential for n problem-based learning and community-based ed~rcation programme.


INTRODUCTION
For a long time authors have voiced concern about the education of health care workers (Neame, 1984:699). The need for change was certainly augmented by the powerful global movement towards "Health for AN by the Year2000n and the necessity to reorientate national health care delivery systems toward primary care to serve that goal (WHO Alma Ata, 1978). Almost simultaneously a concept of integrated health services and manpower development emerged, which indicated that the quantity and quality ofhealth manpower had to be planned in response to specific needs of the national health system and through this, to the health needs of the population (WHO, 1978). The role of health professions education institutions in this process became clear. In an "Agenda for Action" the Universities are challenged to prepare health professionals for the prospective needs and demands of society (WHOAgendaforAction, 1991).
In South Africa, the new government emphasise the Primary Health Care Approach as the means to improve and maintain the health of the South African population (Official Policy Document issued by the Department of Health, 19965). The delivery of a co~nprehensive, high quality primary health care service is, however, restrained by substantial gaps in both the quality and quantity of suitably trained primary health care nurses, doctors, other paramedical staff and managers. The strengthening of the human resources capacity of primary health care facilities is thus a central component ofthe health care services.
At the beginning of 1996 the National Commission on Higher Education made recommendations in a working document that health education institutions revise their curricula in order to equip health care students and health personnel educators with the knowledge, competency and attitudes comprehensively to respond to the health care needs of the population of South Africa. It also reconnnended that higher education should play specific roles in the fields of continuing education for professional health care personnel and should ensure the relevance of courses to the health needs of the population, in order to produce appropriately skilled and orientated persons for the national health care services (National Commission on HigherEducation, 1996).
The call for change in the education of professional practioners caused the School of Nursing, University of the Orange Free State to reflect on theirprogrammes.
In 1997 the School of Nursing changed from the traditional lecture method of instruction to problembased learning and from a curative to a communitybased education approach. Problem-based learning (PBL) is seen as an instructional method characterised by the use of patient problems as a context for students to learn problem-solving skills and acquire knowledge, in a small group with a facilitator (Fichardt, 199659). Community-based education is a means of achieving educational relevance to community needs. The community is extensively used as a learning environment and the students, teachers and community are engaged throughout the educational experience (WHO, 1985:I)

PROBLEM STATEMENT
The role of the facilitator in an innovative programme is arathercritical one (Pallie & Can;1987:65). According to Barrows (1986:9) facilitators are an unplanned variable and this has a effect on the quality of education programmes. The facilitator is pivotal and actively coordinates the group and the process of learning. According to Bailey (1991:987) the facilitator does not primarily need subject expertise but the skills of listening, dialogue, negotiation and counselling.
However, the role of facilitating discussion rather than directing it, is foreign and even "good" teachers have difficulty adopting this new approach (Albanese & Mitchell, 1993:71).
Although facilitators in the School of Nursing, University of the Orange Free State, attended several international and national conferences and workshops, as well as training sessions in the School ofNursing on the role of facilitators and the process of facilitation, it became evident that the role change from lecturer, from a traditional teaching environment, to facilitator leads to anxiety, uncertainties and frustrations. These feelings were enhanced by the environmental change in which learning had to take place, the change from a structural classroomto anunstructuredcommunity.

AIM
The aim of this research was to determine the perceptions of facilitators in the problem-based learning and community-based education undergraduate programme of the School of Nursing of the University ofthe Orange Free State.
The objectives were to: ascertain the problems of facilitators in PBL and CBE; determine the needs of facilitators in PBL and CBE; and make recommendations regarding the preparation and future support of facilitators in PBL andCBE.

RESEARCHDESIGN
In this explorative and descriptive study a qualitative design was used and the research was contextual in nature. Focus group interviews were conducted with facilitators of first and second year students. All the facilitators agreed andwere eager to participate.

SAMPLE
The study population was the facilitators of first and second year students of the School of Nursing of the University of the Orange Free State. The total population often facilitators was included in the study.

ETHICAL CONSIDERATIONS
The Ethical Committee, Faculty of Health Sciences of the University of the Orange Free State approved the research. The facilitators were briefed in such a way thatthey understood the aim ofthe research. All ofthem consented orally to participate as they felt a need to discuss facilitation.
Confidentiality was ensured by not linking inputs to individuals. The interviews were conducted in private and all participants were aware of their freedom to disclose information.

DATA COLLECTION
Data was collected by means of focus groups because, according to Krueger (1994:3), this method is preeminently effective in gaining insight into people's opinions in order to design guidelines.
Two focus group were conducted: one with the frstyear facilitators and one with those working with the second year students.
The aim of the focus groups was explained to the facilitators and they were also provided with the following information: date and duration of focus groups, assurance of confidentiality and nature ofthe follow-up group after data analysis.
An expert in the facilitation of focus groups was approached beforehand to act as focus group facilitator. In this case it was apsychiatric nurse specialist who was skilled and experienced in focus group management. This person met the criteria of a focus group facilitator set by Krueger (1994: 102) and Morse (1994:229). The researchers acted as assistants to the group facilitator and took fieldnotes.
Aroom with comfortable chairs arranged around a table was reserved for the focus groups. Two tape recorders were setup andeach session lasted an hour anda half.
Only one open ended question was asked to enable the facilitators to share personal thoughts, perceptions and feelings in anunstructuredmanner.
The question was: "What are theproblems/challenges and needs you have experienced during your role as facilitator to students in PBL and CBE? " The facilitator led the focus groups and introduced the discussions. She also evoked questions about aspects requiring in-depth treatment. Discussions focused on relevant areas in an indirect way and the facilitator made sure that important questions were raised. Participation by the group facilitator was minimal although the respondents were encouraged to discuss their feelings without being pressurised by the situation -A (Kamfer, 1589:7).
The researchers transcribed the tapes to prepare for data analysis.
The researchers, who acted as assistants, documented the group process and dynamics during the focus groups. Afterwards the group facilitator compared her observations with those ofthe researchers.

Trustworthiness
According to Krefting (1991 :219) cross-examination is a strategy to ensure trustworthiness. This was done by having the researchers present at focus group sessions as assistants to the group facilitator. Sound recordings were made and field notes taken. After completion the categories, groups and themes were discussed and coufmed or amplified with the respondents at a follow-up group. Krefting (1991:220) states that qualitative contextual research cannot be generalised because it is so situation-bound and unique. The responsibility for transferability does not, therefore, rest with the researchers. There is, however, sufficient data accessible in the report for other researchers to judge the transferability should they so wish.

Consistency
The researchers preserved all recordings, notes and forms used in order to ensure that the research may be audited andto enhance consistency.
Neutrality refers to the degree to which research findings reflect the actual facts of the research and are not influenced by other parties, motivations or perceptions (Guba, 1998:80).
An independent person acted as group facilitator as she was not involved in the research at all except for her facilitation ofthe focus groups.

Choice of participants
Specific participants were not selected because, according to Kingry, Tiedje and Friedman (1990:124) the homogeneity of a focus group is important. All the respondents participated voluntarily.

Observation effects
These occur when the participants suppress or distort data to make it appear acceptable because they are being observed; the researcher interprets and presents data as a result of hisher own position (Woods & Catanzaro, 1988:137).
To prevent the above the aim of and need for the research were explained to the facilitators. Furthermore the researchers made sure that an independent theoretical analysis and cross-examination by the analysts showedup erroneous responses.

DATA ANALYSIS
The data was analysed by means of a combination of Kerlinger's (1986:477-483) method and Giorgi's (as HEALTH SA GESONDHEID Vo1.5 No. 2 -2000 quoted by Omery, 1983:57-58) basic steps of content The final product was submitted to co-coders for analysis.
The total experience (transcription) was described.

This included all verbal responses given by respondents in terms of the central question that was
The results of the focus groups will be expressed in posed. This was re-read to obtain a complete picture.
terms of categories, groups and themes. As the groups The transcriptions were read a second time.
were homogenous, that is, facilitators in a PBL and Summaries were identified in order to build them up CBE programme, the data of the two focus groups will to a whole.
be represented together (Kingry et al. 1990: 124). The The analysts eliminated superfluous data in the units following categories were identified after completion and used clearances and extensions of remaining ofthe content analysis: units by comparing the units with one another and Problems andneeds ofthe facilitators regarding: then with the whole. Facilitation They ensured that the insight ofthe researcher in the Coordinator interviews corresponded with the transcriptions.
Students Information was arranged in categories, groups and Clinicalpracticals themes according to recurrent trends.

Respondents' problems and needs regarding facilitation
As summarised in Figure 1 the facilitators singled out certainproblerns andneeds they experienced.
They stated that insufficient structure was provided and that they wondered whether the students obtained adequate information. Students were perceived as being demanding and conflict occurred in groups. They therefore found difficulty in moving from traditional hospital-based teaching to a community-based educational milieu.
Negative feelings such as frustration, tension, incompetence and scepticism were identified.
All the characteristics of a facilitator are represented in Figure 1. Facilitators must also be able to support one another and take the initiative.
One aspect highlighted under teaching was that facilitators wanted a framework indicating how to present the work. They also felt that objectives should be available. It is clear that the facilitators felt a need for structure. Neame (1981:86) also advised that facilitators should be provided with a guide which outlines the problem structure and flow. Several positive aspects were mentioned under teaching, for instance that they found that their students were better equipped than students who were taught conventionally. One facilitator remarked: "Yoti get backwhatyouput intongroup".

Respondents' problems and needs regarding the coordinator
It is important in PBL and CBE to have one person taking responsibility for the coordination of all the various aspects ofteaching for every year.
The facilitators were fully aware of the fact the coordinating is not an easy process. To have all the facilitators working together towards a common goal should be a challenge to the coordinator. It appeared that a coordinator must have good communication skills, be approachable and support facilitators. Problems with co-ordination and the characteristics of a co-ordinator as perceived by the facilitators are summarised in Figure 2.

Respondents' problems and needs regarding students
As illustrated in Figure 3 a number ofproblems relating to students were identified. It was found that seniors had a negative influence on the perceptions of the students of PBL and CBE. The following response was made: "When something goes wrong students attvibzrte it to PBL and CBE". Students also wondered whether PBL and CBE enjoyed international status. Some of the problems among the students may be illustrated by the following observation by a facilitator: "Students are negative because they were not wellprepared for PBL and CBE".

Respondents' problems and needs regarding clinical practicals
Facilitators remarked on the hospital and the community. The only negative aspect in the hospital appeared to be the fact that the facilitators felt that the ward sisters were not informed about PBL. However, the sisters had a positive perception of the students as indicated by the following responses: "The sisters are satisfied with the students". "Students are empathic to>vardspatients ".
In the community the facilitators found that the students became frustrated and that it was difficult to apply the principles of practical procedures in that milieu. Negativity was experienced in the community and it was difficult to find learning opportunities. However, . Students experienced problems when confronted with procedures in * Students were negative because they were not wall prepared for PBL the facilitators found that the "people" appreciated the The coordination of PBL and CBE was perceived to be students.
comprehensive. The greatest problem was perceived to be the fact that neither the students nor clinical practice Although problems were identified as shown in Figure  were sufficiently weliprepared. 4 under the group "community", the following positive response was recorded: "Community-based teuching Facilitators should have certain characteristics, such as was exciting ". presented in Figure 1, to meet the demands of PBL and CBE. They also have certain needs that must be met.

CONCLUSIONS
Interpersonal skills and support play an important role in this regard. The need was identified for a coordinator The data indicates that the facilitators had problems who acts as a democratic leader. with structuring the learning method. The fact that they were no longer faced with passive students but that their Re-education of academic staff must take place before teaching was questioned was experienced as a problem.
PBL and CBE commence. Support of facilitators The paradigm shift from hospital to community-based should be acontinuingprocess. education led to feelings of uncertainty among the facilitators. The adjustments required gave rise to Certain aspects of the data were identified that could negative feelings.
promote the facilitation process in PBL and CBE. The researchers singled these out in the following recommendations:

RECOMMENDATIONS Facilitation
To obtain facilitators of the type required for an innovative learning programme, academic staff responsive to the role should be recruited and should undergo carefill, in-depth training. This in-depth training should include aspects such as theoretical aspects and skills of facilitation of PBL and CBE, interpersonal skills and the steps by which communities are explored and access is obtained (Kaufmann, 1994: 179-1 83).
To help train new facilitators a co-facilitator programme where an inexperienced facilitator cofacilitated a group with an experienced facilitator should be introduced. Pallie and Carr (1987:66) support this co-facilitator training programme.
Regular group and individual support must be available to facilitators to relieve tension, to identify needs and to address uncertainties and problems.
* Continuing training in all facets of facilitation must be available.
Whoever acts as coordinator must be selected on the basis of a specific style of leadership and interpersonal skills. The coordinatormust provide good stn~cture. Clinical practicals as well as theoretical aspects must be coordinated.

Students
A great deal of emphasis must be placed on the preparation and orientation of students for a PBL and CBE programme.

Clinical practicals
An important factor to ensure the success of a PBL and CBE programme is thorough preparation of clinical practice forthis teachingmethodology. There must be a contact person available in the community to facilitate and promote liaison and communication.
This study was undertaken to describe the perceptions of the facilitators of a PBL and CBE programme. The research showed that a paradigm shift from the traditional teaching method to an innovative method leads to distinctive problems and therefore makes more demands on facilitators. Although the facilitators identified problems and needs, positive aspects of this method were also emphasised. Albanese and Michell (1993:69)  Facilitation is generally regarded by facilitators as a continuing learning process.
It has become necessary in higher education to pay more attention to the re-education and support of academic staff to meet the demands of a changed learning environment.