The conceptual framework and the methodology

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This chapter presents a comprehensive review of the related literature and research regarding the problem of the study. The purpose of such review is to establish the conceptual framework and the methodology employed for the study. In doing so, the focus will be first on teaching and learning in nursing and then the most underpinning theories will be presented. The chapter then will review the PBL and related literature critically. It will be followed then by a description of the dependent variables in order to reveal the effects of instruction. The conceptual framework is also concluded in this chapter.

2.2 Teaching and learning in nursing

The traditional instructor-centered learning theory has dominated the world of education for many years. In that view, the teacher transfers knowledge to the students who have attained the class passively and have little or no input during the exchange (Prawat & Floden, 1994). Most recently, the suitability of such role for the learners is asked by the educators in professional practice schools i.e. education, medicine and nursing for some reasons (Rideout, 2001; Antepohl & Herzig, 1999).

Young and Patterson (2007) state that traditional educational strategies are characteristically teacher-centered which lean on note taking, lecture, and handouts inclined to bring out the rote learning. Thomas (1993) also notes that the traditional teaching methods just yield the students' minimal knowledge. It is believed by the researchers that such methods present low level demands on the cognitive processing ability of a student and do not bring the professional problem solving, lifelong learning and the chance of higher-level learning to occur (Young & Patterson, 2007; O'Shea, 2003; MacIntosh, MacKay, Mallet-Boucher, & Wiggins, 2002; Slavin, 1999). Creedy, et al. (1992) state that being prepared in the skills like analysis is proven among the graduates of traditional programs while in the skills of synthesis they are not equipped well. Hence, they show difficulties in understanding the contribution of the social context to health and illness problems and treatment. Shifting the center of teaching from the content and the teacher to the student by adopting student-centered learning pedagogies is the matter which is argued by some researchers (Young & Patterson, 2007; O'Shea, 2003; MacIntosh, et al., 2002; Slavin, 1999) in order to provide active learning, critical learning, co-learning, group process skills, creativity and higher-order thinking skills in the students. In order to reform nursing education and prepare students for better contemporary practice, lecturers are examining the new pedagogies in different parts of the world are . To achieve that, more research is needed. which directs how innovative pedagogies are experienced in nursing schools (Ironside, 2006). In the student-centered approach, the students are considered as active constructors who own knowledge in the context of social environment based on the tents of constructivism (Maclellan & Soden, 2004; Diekelmann, 2001). Another point of student-centered approach is its flexibility to design the content to the necessities of the students or to the styles of teachers and students which means the borders of the content and teaching methods are expanded to adapt students in a better way. This approach is consistent with client-centered nursing approach that is essential in health-promoting nursing practice. Using client-centered nursing approach, a nurse starts respecting to the live experience of the patients which is alike the nurse educator in student-centered teaching approach that begins with the students' experiences and their prior knowledge (Young & Patterson, 2007; Hardy, Garbett, Titchen, & Manley, 2002).

By having distinct communication skills, providing client-centered care, and responding to the health care needs, a graduate nurse can reinforce the individuals. Having well-built problem-solving, critical-thinking skills, and undertaking a reflective approach to nursing is also needed for the graduate nurse to promote his/her personal and professional practice as well as the commitment to continuous learning. In an attempt to deal with some of the problems occurring in the more traditional practice-based programs, problem-based learning has been implemented as a student-centered teaching learning approach in nursing education (Creedy, et al., 1992). These problems which are highlighted by Streeton (1985; cited in Creedy, et al., 1992) are: 1) increasing the body of knowledge which are contributed toward the overloaded and fragmented curricula; 2) irrelevance of the subject materials from the students' perspective; 3) lacking the problem- solving abilities among studeunts; and 4) absence of positive attitudes towards the ongoing learning. In this regard, the superiority of PBL to conventional lecture-based strategy in nursing education is reported by some researchers (Vittrup & Davey, 2009; Wang, Zheng, & Meng, 2009; Hwang & Kim, 2006). Students who are involved in the clinical experience will investigate the situations of the clients in which health care setting utilizes the same PBL format as the one used in the classroom environment. PBL approaches encourage the students to be active creators rather than being passive receptors of knowledge. Thus, the opportunity to develop, apply and evaluate the students' own understanding of their concepts is studied in different situations (stimulated and actual clinical) which are provided for nursing students (Creedy, et al., 1992). If the imbalance between the already known and the new experience be great, the possibility of the new constructed structures will be very small. At the time of instructing to transmit information and accomplish correct performance, it can be seen that the traditional teaching strategies may suffice including the use of explanations.and if the explanations be used many times, a passive listener-follower role will be created for the students which might contribute to their dependence and reduce their thinking needs. Blais (1988) believes that such explanations carry on unsuccessful problem-solving strategies by the student; thus whenever a new situation happens in the clinical setting, the nurse is unlikely to expand alternative problem-solving ways and critical thinking skills (Creedy, et al., 1992). Doing so, the nursing students are expected to understand and apply the concepts of nursing, science and liberal arts in their specialized practices. The PBL's practical/clinical emphasis promotes the relevance of leaning, integration of nursing theory, and practice. Therefore, educators need to use strategies that advance self-directed leaning skills and are conducive to construct the students' knowledge into practice. These strategies encourage reasoning skills (Borrows, 1985; cited in Creedy, et al., 1992). Feasibilities for bridging the gaps between education, practice, and knowledge development are assured by SCL in professional nursing schools. According to Young and Patterson (2007), using teaching within the constructivist view opens the door of probabilities for nursing education in order to close the above-mentioned gaps by converting nursing education from teacher-centered activities to learner-centered activities.

The essential concepts taken from the theories of learning (constructivist learning theory, Vygotsky theory, and cognitive load theory) are explained in the following which provide the background bases for positive effects of using and integrating PBL as well as the Hybrid strategy in the process of teaching and learning of nursing.

2.3 Constructivist learning theory

Conventional theory which is defined as the constructivist theory, underlies Problem-Based Learning (PBL) (Young & Patterson, 2007; Creedy, et al., 1992). Yilmaz (2008a) claims that constructivism is developed from dissatisfaction with traditional theories of knowledge. Accordingly, Fosnot (1996; cited in Yilmaz, 2008b) states that constructivism is a theory of learning which is also related to teaching. The traditional instructor-centered learning theory has dominated the world of education for many years. In that view, the knowledge transfers from the teacher to the students who have attained the class passively and have little or no input during the exchange (Prawat & Floden, 1994). The constructivist learning theorists, researchers, and practitioners who emphasize the dynamic nature of learning and construction of knowledge have kept the concept of active learning. The constructivist learning is rooted from the works of prominent psychologists, Jean Piaget and Lev Vygotsky. Piaget's focus was on the personal construction of knowledge while Lev Vygotsky highlighted the social construction of meaning. Piaget was an individualist constructivist since Vygotsky was a social constructivist. However, they both acknowledged the close relationship of individual and interpersonal learning and recognized the power of reflective abstraction and shared reflection. Reflection is an intentional, self-conscious analysis of life experience which can be individual or collective. From this perspective, the most important thing is the transition of teachers from "expecting listening" to "supporting learners" and changing the views of "planning for teaching" to "organizing for learning". Therefore, constructivists have a plan for knowledge which is a pattern of action that has dynamic process (Gagnon & Collay, 2006, p. xiv). Yilmaz (2008a) declares that there is no particular constructivist theory of instruction; rather so, the researchers are the ones who produce different aspects of a constructivist theory. To sum up, the constructivists assume that learners are the ones who build their own knowledge; thus the teachers are not transferring knowledge to the learners who are considered as active and intellectually generative ones. Accordingly, Maclellan and Soden (2004) claim that in a constructive situation, the focus should be on dialogue and debate between learner and others in order to develop the learners' thinking. As the learners construct their own understanding in this view, it is very favorable to build robust problem solving skills (Tajuddin, et al., 2009). Further, Prawat and Floden (1994) claim that the instructors must construct a model of learning which is more complex, mutual, and developing. In this regard, Most of the constructivism's proponents (i.e.Young & Patterson, 2007; Gagnon & Collay, 2006) believe that learners are not passive recipient of information since they get knowledge in an active process of constructing meaning. Therefore, the teacher is not only responsible to distribute information but to guide, facilitate, and coordinate learning by creating pleasant environments for the students' growth, development, and evolution. In addition, the constructivist pedagogy has focused more on the students' present knowledge as an initial point for the learning process and conceptual change teaching, since the work of Piaget is heavily concentrated on describing a model of cognitive functioning. From the view of constructivism, learners integrate new knowledge into the prior network of understanding in order to hold learning as a process of meaning making. Thus, teaching strategies should concentrate on the relationship between material and the things that learners know in order to be more successful in tent of constructive theory. This fact emphasizes on the implications for the nurse educator's role at the time of using PBL as a non-linear, conceptually-based construction by the student. Eliciting students' concepts and reasoning processes are focused on group facilitation and negotiation skills by teaching strategies. In addition, the ability to examine the students' leaning will be improved by the educator's knowledge. These factors play an important role in the required pedagogy for PBL approaches (Young & Patterson, 2007; Creedy, et al., 1992). The implication of constructivism in instructional design is laid out by Jonassen (1994) who claims that knowledge construction can be facilitated by utilizing tools proposing a view of reality (e.g. simulations and case studies), presenting tasks requiring critical thinking which should be employed, and presenting reflective practices. Another facilitated way to use constructivism into teaching practice is using techniques such as concept mapping, thematic organization, and categorizing in order to create a link between new and prior materials. Utilizing the constructivist frameworks for teaching is supported by nursing not just for developing problem-solving and critical thinking but for inserting diversity and adult individuality while learning (Young & Patterson, 2007; Peters, 2000).

Meanwhile, health-related problem will be discussed by the students in PBL and hybrid groups and they talk about different aspects of the problem and the essential interventions for the patient. Thus, the role of the instructor is only to confirm ideas and/or guide students into the proper ways which may lead them to find the answer looking for. Accordingly, the instructor discusses whatever they have done correctly and checks the utilized process in order to reach the correct answer after creating a finalized plan of care for the patient by them. Through this, the students are not given any answer but are guided in case of necessity. In learning process, the instructor serves as a link to knowledge rather than being dismissed and doing so, the students have dominance on whatever they have learned. According to Diana and Schemit (2006) in a PBL session, group discussion stimulates the previously activated knowledge and brings it to mind information, theory of construction, causal reasoning, collaborative learning construction, and cognitive conflicts which take place and lead to conceptual change. Nursing students who are involved in clinical experience will investigate the health care setting situations of the clients by using the same PBL format as that used in the classroom. Creedy, et al. (1992) claims that students are usually encouraged in PBL approaches to be active creators rather than being passive receptors of knowledge. Hence, nursing students have the opportunity to develop, apply, and evaluate their own understanding related to the concepts being studied for simulated and actual clinical situations.

2.3.1 Vygotsky theory

Vygotsky theory which was introduced by Lev Vygotsky has influenced the modern constructivists' thinking. According to this theory, the processes of higher order mental are initially co-constructed during shared activities between the learner and someone else. The processes are internalized by the learner afer that and become part of the learner's cognitive development (Woolfolk, 2008). This theory has some basic principles which are applicable in instruction. Some of these applicable principles are mentioned by Schunk (1996). According to Schunk (1996), the first applicable principle is to use instructional scaffolding, by guiding or controlling the process of task elements that are beyond the learner's capabilities. Thus, the learner can grasp quickly the task with scaffolding that fits nicely within the Zone of Proximal Development (ZPD) which is an important concept in this theory. ZPD is defined as a phase at which a learner can master a task if given appropriate help and support. Such support for learning and problem solving is named scaffolding. The support can be clues, reminders, encouragement, breaking the problem down into steps, providing an example, or anything else that allows the student to grow in independence as a learner (Woolfolk, 2008). Scaffolding is conceptualized as the process in which higher levels of initial support is provided for students while entering the ZPD with the gradual dismantling of the support structure as students move towards independence. Finally, the scaffolding will disappear and a new one will be built in order to help constructing the next stage of learning. Significantly, the idea of 'scaffolding in the ZPD' and the technique of 'facilitating PBL groups' are seen as the complementary processes. According to Harland (2003), teachers usually challenge to ensure that learners have the opportunity to reach their full potential within the context. At the time of increasing the learners' proficiency, their needs for facilitating of the task will be decreased. Thus, the role of the tutors will come in as they guide the learners by the instructional help in order to reduce the cognitive load. Doing so, the learner can solve the problems which need high mental effort that can be achieved by less effort. Such guiding or facilitating can only be positive or effective in the zone of proximal development (Schnotz & Kurschner, 2007). As learners gain skills, scaffolding will be gradually withdrawn. In conjunction with scaffolding, teacher and student initially perform tasks jointly and then the instructor decreases assistance gradually as the learner becomes more competent. Another form according to Schunk (1996) is apprenticeship which novice learners work closely with the experts in order to understand the process and develop their abilities.

The second applicable principle is to use reciprocal teaching. Based on Vygotsky's view, interaction between learners, teacher, and peers will lead to cognitive change if there will be a good deal of guided participation in ZPD (Rosenshine & Meister, 1994). By peer collaboration, the learners share responsibilities of the task to get a deeper understanding of concepts (O'Donnell & O'Kelly, 1994). In constructivist approach, learners are able to construct meaning by integrating their understanding and experiences in the context of social interaction by reflection on learning (Schunk, 1996). Vygotsky believed that cultural tools, including material tools and psychological tools or signs and symbol systems such as numbers and language, play important roles in cognitive development. Accordingly, he believed that the higher-order mental processes (like reasoning and problem solving) are mediated by psychological tools (Woolfolk, 2008). Cultural tools can be evident by themselves from a learner to another one through imitative learning, instructed learning, and collaborative learning (Tomasello, Kruger, & Ratner, 1993). Vygotsky's theory has also supported the instructed learning through direct teaching or structure experiences. accordingly, Das (1995) considers this theory as the one which is pertinent to the educators who use direct teaching in the classroom and make the environments suitable for learning.

This theory discusses that in the process of development, the learner faces certain problems at any given point which are vague to be solved. In this regard, the learner needs only some structures, clues, reminders, and some help (to remember the details or steps), encouragement (to keep trying), and so on. Some of these problems are surely beyond the children's capabilities even every step is explained to them clearly. Based on the Vygotsky's theory, the ZPD is defined as the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in dealing with more capable peers (Levykh, 2008; Woolfolk, 2008). Levykh (2008) believes that ZPD is a better indicator of the child's future intellectual development than the child's mental age calculated by IQ. Hence, it can be concluded that the greater the child's ZPD, the greater his/her potential learning.

As a dynamic process, the ZPD also reflects stable changes in emotional connections of all participants. The ZPD is practically a complex, creative collaboration between all and each of the members and through the environment. The ZPD process initiates new psychological formations in which a transition to the child's next developmental level occurs unavoidably. Besides, the ZPD process facilitates the formation of new knowledge that is based on affect and intellect. Thus, the ZPD is not just a process and a product but also a synthesis of intellectual and emotional functions (Levykh, 2008).

The starting point for instruction according to this theory (Vygotsky' theory) is the learner's zone of current development (ZCD), knowledge and skills which are visually illustrated in Figure 2. 1. What is the zone of proximal development today will be the actual developmental level tomorrow (Vygotsky, 1978, p. 87,cited in Harland, 2003). The lower bound of the ZPD is defined as the most difficult task the student can do successfully without help, whereas the upper bound of the ZPD is defined as the most difficult task that the student can do successfully with the best possible help. It means that the instructor should include the learning tasks within the boundary of ZPD in order to increase the learning (Schnotz & Kurschner, 2007).



Figure 2. 1

According to Figure 2.1, the learner can reach to the level of ZCD through independent problem solving. The learner can also reach to the potential distance (ZPD) with the help of more knowledgeable others (MKO). The limits of the new ZCD are defined by the outer edge of the ZPD and after a successful instruction (Harland, 2003, p. 265).

Correspondingly, this is the place that PBL begins. In both (ZPD & PBL), there is a common assumption in which every learner brings experience to the learning situation and the existing knowledge can be applied in solving the problems that will result in the formation of new knowledge. From the Constructivist perspective, there is always a strong relationship between what the learner know and what they can do, and what is to be learned. Thus, according to the strategies used by a, teacher, the students construct their own meaning based on the interaction between prior knowledge and current learning experiences. PBL has diagnostic self-assessment which is built into its curriculum structure. When a tutorial group is presented with a problem, the first task for the students is to discuss with other members of the group in order to be informed about the things that they know about the problem and to the things that they need to find out; thereby, they set their own learning objectives. Ideally, diagnosing one's own ZCD has become embedded in the learner's repertoire of skills. At the beginning of a PBL program, the task set should be within the range of the majority of students' ZCD's, and initial teaching strategies are aimed at encouraging students to probe deeply and identify what is genuinely known so that current learning can be applied to the problem. Experience has shown that the students are rarely limited by their disciplinary knowledge, but nearly always by their metacognitive skills and life skills such as communication and collaborating in groups. Both types of the skills need careful support at the beginning of the program, as they are meeting PBL for the first time. Becoming critically reflective about learning appeared to be the key to both successful diagnosis in the ZCD and progression through the ZPD. Through structured personal enquiry, students could learn to ask questions about their learning and test their learning against their own experience, or the accepted wisdom of more experienced peers or tutors (Harland, 2002). Achieving a high level of independence from tutors is the aim of the educators. At the time of seeing an evidence that shows they can work independently, educators begin the progressively 'let go'; so, responsibility for the PBL program will be handed over. Initially, diagnostic teaching roles are centered on questioning, casual testing, and listening in order to ascertain current learning and to see how close the educators' understanding of a task or problem is to that of the students. According to Harland (2003), such strategies require the frequent conversations between tutors and students.

The present analysis of ZPD has created a trustful and nurturing environment in educational (teaching-learning) contexts of cooperation and collaboration. Derry (2004) declares that Vygotsky's theory encourages understanding of the social development in the modern time, no matter that it was introduced to the world in the beginning of the last century. His theory support active learning in which social interaction is fundamental for suitable human development. Some of the reasons to consider collaborative and cooperative activities as the nucleus of affective establishment and maintenance of the ZPD are as follows:

Activities in which students feel secure and can express their individual concerns (cultural and social), create a safe and nurturing environment.

Their prior affective and intellectual knowledge and experience can be prompted.

The interaction and negotiation of how they use their ideas can become stronger.

Students' communicative skills can be constructed and developed.

Memorization of the whole chunks of authentic and idiomatic discourse can be assisted.

Newly learned information can be moved from the working memory to the long-term memory.

A positive learning experience and appreciation for the topic being taught in any subject can be used (Levykh, 2008).

Rideout (2001) also claims that knowledge is constructed by the learner's cognitive activity, in permanent interaction with participation in social community where the learner, himself, is a member. Active participation in the social interaction and with the learners who are knowledgeable leads to learning which happens at the time of individuals' involvement in a related and meaningful activity. Interactions characterized by activities like directing, modeling, questioning, providing cognitive structuring, and feedback, assist learners until they are able to perform by themselves and there is no need to be given any guidance or assistance. It is also believed that learning must be transformed to the individuals' level; doing so, self-regulation happens leading a higher level of movement for both competency and independence.

Unlike Piaget who arrived to the final decision by saying that knowledge is constructed through the interaction of the individual with the world, Vygotsky led to a conclusion that development is primarily social in origin (Young & Patterson, 2007). In other words, this theory is contrary to many typical North American educators who believe that learning delays behind the development of a child, declaring that learning can cause the development of the child. Thus, cognitive development pivots on social interaction and development of language or communication skills (Levykh, 2008; Woolfolk, 2008).

Social constructivism has provided a dual theoretical rationale for PBL which are mentioned by Rideout (2001) and are going to be explained briefly in the following. . The first one states that learning is also placed within a social context in PBL. Learners meet together with a facilitator to work on momentous problems which are related to their selected area of practice and work collaboratively as they discuss issues and help each other in making links between the new idea and the previous knowledge to construct new meanings as they fulfill their tasks. According to the second one, the roles of tutors and students in PBL are harmonious with the constructivist paradigm in which people who are more capable or informed assist without taking over the activities and experiences of the learners. In PBL, each student is responsible for his learning and the tutor and peers are responsible for assisting each learner to attain the finest learning. An additional responsibility is also given to the tutor. This additional responsibility is to provide clear task and goal structures and to facilitate the learning process through consultation, collaborative interactions' assisting, and providing feedback for the participants.

As constructivists employ problem solving techniques in learning, multiple perspectives may be employed for solving problems. According to Young and Werner (2004), this approach to learning promotes critical thinking skills, assists in the growth of social skills, assists students to transfer their new skills to real-life situations, and motivates them in the process of learning as they possibly use their own style of learning for working through a problem later.

Moreover, constructivists propose that using social parameters makes learning more effectual, comparing to the situations in which learning is acquired through isolated learning techniques (Gagnon & Collay, 2006; Prawat & Floden, 1994). Their belief is derived from the principles of Vygotsky. Social interaction and meaningful learning focus on constructivist pedagogy. According to the proponents of the constructivist learning theory, learning takes place only if students are actively involved in learning. They also assert that meaning will be constructed through participation in the engaging learning activities. They further hold that knowledge must be related to the real-world settings and the students will succeed when they become part of a student-centered, social learning environment. They use prior knowledge and learn from each other as they interact socially. Vygotsky (1934/1986) found that a learner's intellectual growth is dependent to social means. However, traditional classroom practices do not provide a great deal of social interaction. These practices might actually hamper the development of thought, language, and intellectual growth (cited in Levykh, 2008). Von Glasserfeld (1997), a proponent of constructivism, also asserts that human mental functioning lies within social interactions. Hence, to increase such mental functioning, students must interact. Nevertheless, traditional methods of classroom instruction do not help increase the socialization and construction of new meaning and are mostly teacher-directed information delivery. Higher-order thinking may not appear if all instruction is teacher centered.

2.4 Cognitive load theory (CLT)

According to Paas, Renkl and Sweller (2003a), information processing theory is the origin of cognitive load theory (CLT) which has turned into a fundamental theory in learning and instruction. It began its practice in 1980s and experienced a considerable development and expansion in the 1990s by researchers' worldwide (Kirschner, et al., 2006; Paas, et al., 2003a; Sweller, Van Merrienboer, & Paas, 1998). According to this theory, instructional design efficiency will be determined by working memory (WM) constraints; thus, it is believed that some learning environments impose greater demands and consequently higher information processing load on limited cognitive resources in working memory (Sweller, et al., 1998). Hence, an instructional design that disregards working memory limitations is certainly incomplete. This is the central argument of CLT. There are some critical issues on that matter; the argument includes the relations between working and long-term memory (LTM) combined with cognitive processes that support learning. CLT is based on the structure of information and cognitive architecture that involve a restricted working memory interacting with a rather limitless LTM. It is also believed that the available knowledge structures in LTM are necessary in preventing WM overload and guide cognitive processes. Accordingly, the role of external instructional guidance in the process of knowledge elaboration can be defined as a substitute provider for missing LTM structures (Kalyuga, 2009b).

In respect to working memory, there are two eminent features that include duration and capacity of the working memory which is very limited at the time of processing novel information. Because of these limitations, the instruction needs to be designed in such a way that working memory could be able to process it. Once multiple information elements interact, they must be presented concurrently. As Sweller, et al. (1998) state, such a task would impose a heavy cognitive load on the information learner and threaten successful learning. Accordingly, it is emphasized in cognitive load theory that instruction must be designed in such a way that facilitates the acquisition of knowledge in long-term memory whereas unnecessary demands on the working memory are reduced. Speed and accuracy of understanding would be improved and deep understanding of information content would be facilitated only if information is presented in such a way that cognitive load falls within the limitations of working memory. Therefore, limitations of working-memory capacity and measures that can be used for promoting learning that is the construction of schemata, by imposing sufficient levels of CL are the main concerns of cognitive load theory (CLT). At this time, the question which comes to the mind is "How can the instructional designer guarantee the limits of the learner's working memory load would not surpass when he or she is processing instruction?" . Instead of a group of rote learned facts, the contents of long term memory which are sophisticated structures let us perceive, think, and solve problems. These structures permitting us to treat multiple elements as a single element which are known as schemata. They are the cognitive structures that construct the knowledge base. Schemas apparent functions are to make mechanisms available for knowledge organization and storage because they are kept in long term memory. Schemata are acquired over a lifetime of learning, and may have other schemata contained within themselves. By increasing the lower level schemas into the higher levels schemas, skilled performance will expand. Consequently, this schemas acquisition is considered as an active and constructive process. Information contained in instructional material must first be processed by the working memory from an instructional perspective. If we want the schema acquisition to occur, instruction to decrease the working memory load should be designed. Cognitive load theory deals with techniques in order to decrease the working memory load in facilitating the changes in long term memory associated with schema acquisition. Schemas which are single elements in the memory, help treating complex generalized knowledge structures. The eventual justification for instruction is provided by the architecture of long-term memory and it is the desire of all instructions to change the long-term memory by schema construction. It is also claimed that if nothing has been learned, it means nothing has been changed in the long-term memory. Thus, it can be said that those instructional recommendations are ineffective if they cannot specify what has been changed in the long-term memory or that do not increase the effectiveness with which the related information is stored in or retrieved from long-term memory. Information processing is either consciously or automatically. After schema acquisition, automation is a significant learning mechanism which influences every learned item. Automaticity takes place after practice. If adequate practice is available, a procedure can be performed with minimal working memory load. A learner who has more automated schemas, has more working memory capacity available for solving sophisticated problems by using the schemas. Familiar tasks are completed precisely and fluidly if automation is available whereas unfamiliar tasks requiring the automated processes will be learned with maximum efficiency because of the availability of maximum working memory. There might be inadequate working memory capacity without automation for embarking on learning and performing the new task. To sum up, if the working memory limitations be ignored at the time of dealing with novel information or such limitations disappear while dealing with familiar information, instructional theory will be ineffective (Kalyuga, 2009a, 2009b; Sweller, 2004; Sweller, et al., 1998). It is hypothesized in this study that the use of PBL and Hybrid strategy in teaching and learning of pediatric nursing can increase both schema construction and automation for better learning outcomes. Therefore, it can reduce the cognitive load, leading to a better performance in learning and improves the students' metacognitive awareness levels.

Constructive theory

Construct Knowledge by Active Learning

Vygotsky theory

Scaffolding in ZPD by MKO

Cognitive load theory











Metacognitive awareness

Mental effort

Instructional efficiency

Communication skills