The effect of Problem-Based Learning on Care Management skills: A quasi-experimental study

Objective: to assess the preliminary effect of Problem-Based Learning on Care Management skills. Method: a quasi-experimental pre- and post-test conducted with students attending the Bachelor’s Degree in Nursing offered by an educational institution. The sample was comprised by 29 (Experimental Group) and 74 (Control Group) students. The Experimental Group solved four scenarios under the Problem-Based Learning method with the 7 steps proposed by McMaster University, in a Care Management program in distance mode. The self-reporting instrument assessed the pre- and post-test Care Management skills in both groups. Mean values were obtained and descriptive and inferential statistics were performed (Student’s t, paired t, linear regression). Results: the Experimental Group obtained higher scores in analytical, action-related and global skills than the Control Group (p<0.05). No differences were recorded in interpersonal skills or in use of the information. The Control presented no significant differences before and after usual teaching, whereas differences were in fact reported in the Experimental Group (p<0.05). Conclusion: despite the fact that there is little evidence on the development of Nursing Care Management skills, the current study shows that Problem-Based Learning is an effective and significant method in remote education.


Introduction
In the 21 st century, Nursing has positioned itself as one of the main disciplines that contribute to improving the health of the individual, the family and the population, due to its ability to perform the multiple roles and responsibilities required by current health systems: care, teaching, research, politics and, in recent years, in terms of management (1)(2) .
Care Management has been defined since 1996 as a heuristic process that implies a dialectical relationship between Nursing management and care knowledge, articulated with the help of administrative sciences to mobilize human and environmental resources to facilitate safe and timely care (3)(4) . However, the constant social, political, economic and epidemiological changes force its teaching from the undergraduate level to ensure the development of managerial skills in new novice Nursing professionals (5) , who should exercise the role of managers with specific skills to improve the quality of services and of care itself.
In this regard, some authors point out the skills that an undergraduate student should have in terms of management, in addition to providing background on which should be attributable to novice or beginner Nursing professionals. As an example, in Bosnia and after a study in various health institutions (6) , it was concluded that there are 4 main knowledge areas and basic skills that they should have, namely: 1) interpersonal, 2) use of the information, 3) analytical, and 4) action-related.
Following these arguments, a manager must know how to exercise leadership, work in a team, communicate openly and efficiently, lead health teams and users, have strategic thinking and make decisions (in a planned, organized, directed and controlled way) to improve quality of the health services (7)(8)(9) .
Despite the evidence on the main skills that a manager must have, several authors have concluded that Nursing professionals and beginner-level students who assume the new role of Nursing managers and have to put their skills into practice, and that they often encounter dilemmas, doubts, conflicts and conceptual misunderstandings, leading to deficient care management, which negatively affects the outcomes in the patients.
They also mention that some of the barriers are culture and organizational structure and lack of experience in the professional Nursing practice; as is the case with the government's public policies and precarious conditions of the workforce; but, above all, lack of education, formal and continuous training in educational institutions and the quality with which it is taught (10)(11)(12)(13) .
In this context, there are important challenges for the development of management skills in educational institutions in order to have highly trained Nursing professionals with experience in management of health services (14) .
To achieve the aforementioned, it is necessary that the professors use didactic strategies to promote the teaching-learning process and contribute to the development of skills in the students (15) and that these may be successfully used and adapted in the remote modality (16) . Different studies carried out with Nursing students assert that the Problem-Based Learning method is one of the didactic strategies that contribute to the development of critical thinking, increase theoretical and practical knowledge, improve specific and self-directed skills and prepare students to face unknown challenges for their professional practice (17)(18)(19) .

Problem-Based Learning (PBL)
PBL is an educational strategy based on the use of real or fictitious problems as a starting point, mainly centered on the students. Since 1986, the McMaster University has conceptualized PBL as "the learning resulting from the process of working towards understanding or solving a problem" (20) . The core value lies in employing a contextualized problem to motivate the students to actively seek the relevant knowledge using all the resources possible. Likewise, the PBL consists of posing a problem situation, where its construction, analysis and/or resolution constitute the central focus of the experience in the students, and where teaching consists of promoting the development of the inquiry and problem-solving process in an organized way (21) .

Review articles and meta-analyses carried out in
Nursing and Medicine areas conclude that PBL increases students' performance and exerts a positive effect on theoretical and practical test scores (17)(18)22) . It also contributes to the development of critical thinking, increases Nursing knowledge and self-directed skills required for clinical, management and leadership hospital settings (19) ; however, there is little current evidence on the use of PBL to develop management skills in undergraduate students, although it is in fact suggested that this method should be implemented in Nursing programs to evidence its effectiveness (23)(24) .
It also improves analytical skills in relation to having a strategic vision, making use of technology and statistics, as well as human and material resource www.eerp.usp.br/rlae 3 Benítez-Chavira LA, Zárate-Grajales RA, Moreno-Monsiváis MG, Vite-Rodríguez CX, Hernández-Rosales CM, Brito-Carbajal CE.
planning skills (25)(26)(29)(30)(32)(33) . It also develops skills in continuous improvement topics (30,34) . In the same way, action-related skills are developed, but to a lesser extent, and are associated with being able to establish, organize and evaluate goals/objectives and make timely and risk-free decisions in problematic situations (27,(29)(30)32,35) . Finally, the least developed skill is use of the information, such as collecting and analyzing the hospital environment data (30,34) .
Despite the fact that there is conclusive literature on the development of management skills with the use of PBL throughout the world, in Mexico there are few or no recent studies on the effect of using this type of methodology on students in the remote modality of the Bachelor's Degree in Nursing to develop self-directed skills that are related to management (interpersonal, use of information, analytical and action-related) (36) and that contribute in the future to provide a professional practice

Period
The study was conducted during the 2022-1 school cycle: it was initiated on August 9 th , 2021, and ended on October 30 th , 2021, during the COVID-19 pandemic.
During such period, education was at a distance due to the temporary closure of educational institutions and the suspension of clinical practices in health institutions.

Population and sample
The research participants were students attending the Nursing Bachelor's Degree enrolled in the Care Management Program, the seventh semester (7/8)

Selection criteria
The eligibility criteria corresponded to students enrolled in the Care Management program, who completed the intervention (solution of 4 problem-scenarios) and with 90% attendance to the program. The exclusion criteria corresponded to students missing classes when the problem-scenarios were solved, as well as to those who dropped out from the program.

Study variables
The independent variable was the implementation and solution of 4 problem-scenarios based on the PBL methodology, conceptualized as "Learning that results from the process of working towards understanding or solving a problem" (20) .
The dependent or result variable corresponded to the Care Management Skills: The set of interpersonal, use of the information, analytical and action-related skills (9) , developed by the students attending the seventh semester in the Care Management academic discipline from the Bachelor's Program in Nursing (pre-and post-test).
The covariates were the demographic characteristics (age, gender, work, if work is related to Nursing) and the academic ones (shift, general mean, grade in the preceding discipline: "Management of Health and Nursing Services").

Instrument used
The Self-Assessment Instrument for Care Management Skills was designed according to the skills described (6) .
The instrument had two parts, the first with variables identifying the students (ID number, name and group), as well as sociodemographic and academic data; all in scalar, ordinal and nominal measuring scales. In addition to asking, "Have you had any experience in solving problems with the PBL method?", with a dichotomous answer option.
It is worth noting that the sociodemographic and academic variables were not asked in the post-test.
The second section consists of 29 items divided into 4 dimensions: interpersonal skills: those that the student must develop in relation to leadership, communication and interpersonal relationships, with 10 items; skills in use of the information: those that the student must develop in relation to being creative in the search, collection and analysis of information from their environment to solve problems, with 6 item; analytical skills: those that the student must develop in relation to having a strategic vision, using statistical tools and making use of technology, with 6 items; and action-related skills: those that the student must develop in relation to being able to establish, organize and evaluate goals/objectives and making timely and risk-free decisions, with 7 items.
All the items were measured with a Likert-type scale containing the following answer options: 1=Never, 2=A few times, 3=Occasionally, 4=Almost always, and 5=Always.
Each of the items was added up by dimensions and the mean values of the global skills score and by dimensions were obtained, both in the pre-test and in the post-test.
Prior to its application, content validity was performed by 3 experts in topics related to quality, management models and education. They evaluated the clarity, comprehension and relevance of each one of the questions and the validity coefficient proposed by Hernández-Nieto was calculated (41) , obtaining a total validity of 0.87 (good to excellent coefficient).
After having applied the instrument, Cronbach's Alpha was calculated, obtaining a reliability of 0.91 (Excellent).
Such application was useful to observe viability of the application and the students' and researchers' understanding of the items.

Data collection
The

Ethical considerations
According

Participants
No statistically significant differences were identified between the students from the control and experimental groups in terms of their demographic characteristics (p>0.05). In relation to their academic variables, differences were found in shift, the mean in the Bachelor's course, and grade obtained in the preceding discipline (p<0.05) (

Care Management Skills
Regarding the baseline measurement of the mean corresponding to the Care Management skills obtained by the participants (pre-test), no statistically significant differences were found in the intervention and control groups (p=0.556). No differences were either found in the dimensions: interpersonal, use of the information, analytical and action related skills (p>0.05), thus being homogeneous ( Table 2). In the multivariate linear regression analysis (Table   4) with the total score of Care Management skills as the outcome variable after the use of Problem-Based Learning intervention, this proved to be associated with Type of student (regular-irregular), Academic performance (from excellent to poor) and Experience in PBL (r 2 =0.270, p<0.05).    Previous studies have shown that the skills that a Nursing manager or administrator should have are leadership and communication (43)(44) . Therefore, it is indispensable that professor teach and guide with significant didactic strategies (19,(26)(27) . However, skills such as leadership, teamwork and communication, as part of the Interpersonal skills dimension, did not present changes when using scenarios with the Problem-Based Learning method in this study. This could be due to the fact that development of these skills depends to a great extent on the interaction between students and teachers, which is why the remote learning modality might have affected the fact that there were no significant differences (45) , thus suggesting to encourage active participation of the students in digital spaces.
Likewise, it has been documented that nursemanagers must have the ability to be creative when looking for information, its collection and especially critical analysis to make informed decisions (6) with the purpose of improving the patients' health. Similar studies documented that PBL increases the ability to acquire independent information in undergraduate students when compared to traditional teaching methods (34,46) ; however, in our findings, use of the information did not have significant changes in the Nursing students. This can be attributed to the fact that students with two years of experience in remote education (due to the COVID-19 pandemic) learned to study autonomously and independently through documentary research.
Likewise, the results of our study in the pilot phase proved to improve the analytical skills. Similarly, previous studies have reported that problem-solving improves the analytical and critical thinking skills (25)(26)33) , which is in line with this research. This ability is related to the students' vision of being strategic in solving complex managerial Finally, the action-related skills were also improved.
These skills are manifested in the students when making decisions in the face of a particular situation or problem, whether real or fictitious; in other words, it is an eligible process of an option, taking into account the risks and benefits (35,(47)(48)(49) .

Conclusion
It is concluded that there is a positive effect on Care Management skills in Nursing undergraduate students with the problem-based teaching-learning method in distance mode. The students showed improvements in analytical and action-related skills; thus, PBL is considered as a powerful strategy to prepare students to assume the role of Nursing managers in their academic and professional practice. The preliminary results, as well as the identification of their strengths and weaknesses, suggest that the professors should implement this methodology for effective education for the professional world; however, in order to implement problem-based learning in remote education, teachers must be trained to effectively guide students and provide feedback for better coordination.