Nepal is a small landlocked country with a territory of about 1,47,181 square kilometers. It occupies only 0.03% of the total land of the earth. It is 800 km long from east to west. Nepal shares border with India in the east, west and south and with Tibet in the north. About 77% of the land are covered with hills, rivers, forests and the Himalayas. The highest peak in the world, Mt. Everest (8848 m.) is located in the north of Nepal. The country is divided into three ecological regions called the Mountains, Hill and Tarai.

The country is divided administratively into 5-development regions and 75 districts. There are 3,914 Village Development Committees (VDCs) at the lowest level of administration and 58 Municipalities in the country .Each VDC is composed of 9 wards, Municipality ward ranges from 9 to 35. Kathmandu is the capital city.(Nepal in Figures, 2000).

Total population in 1999 is estimated to be 22,903598. The urban population is expected to be about 12% of the total population. Even though the majorities of its people are Hindu (86.5%). Nepal is famous and rich for its multiethnic and multicultural heritage. The national per capita income is estimated in the order of US $ 242 ((provisional estimate) for 1999/2000). The economy is primarily agriculture-based. Total adult literacy rate is 39.6.5% for male, 54.5% for female 25.1%. As the current population growth is 2.4 percent per annum. Life expectancy at birth is 58.95 years, crude birth rate is 33.58 /1000, crude death rate is 9.96/1000,total fertility rate is 4.3, infant mortality rate is 64.1 /1000 live births(Nepal in Figures, 2000). Maternal mortality rate per thousand (MMR) has been found to be 539 deaths for 100,000 live births (Nepal Family Health Survey of 1996). The health status of the Nepalese people is that of a developing country. The under 5 mortality Rate (U5MR) is 116 per 1000 ( Dixit, 1999).

In order to respond to the growing health care needs of the people of Nepal through development of appropriate Human Resource for Health, His Majesty's Government of Nepal started professional nursing training in the year 1956.The first batch of nursing students under went the general nursing training Programme of 4 years. With subsequent introduction of the New Education System Plan nursing education was brought under the umbrella of the Institute of Medicine (IOM), Tribhuvan University (TU) in 1972.

The original idea was to produce different levels of nursing health professionals ranging from the grassroots, mid-level and the higher level, so that they could provide graded nursing care from the community to tertiary level under the National Health Service System. A system of professional and academic career ladder development had been inbuilt and ensured. In this context, the Proficiency Certificate Level (PCL) nursing programs was started in 1972 at Institute of Medicine (IOM). The curriculum subsequently underwent changes as per changing health care needs of the society, as well as changes in plan and policy guidelines in health and education sectors of HMG, Nepal. Hence, a major review of the curriculum was started in 1987. The review extended over a period of several years. Finally, as an outcome of several years of collective efforts a new Primary Health Care (PHC) need-based and community -oriented curriculum came into its present shape.

The main aim of the PCL nursing curriculum is to prepare a competent and self-reliant staff nurse who will be able to care for the health of the individuals, groups and communities based on the principles of primary health care (PHC) approach. IOM has defined following roles for PCL nurses: communicator, change agent, motivator, problem solver, planner, care provider, evaluator, advisor, teacher, supervisor and facilitator.

The education program consists of 3 years duration. The first year focuses on the health of the individual and family. In the first year, students study English, Nepali, Integrated Science related to Health, Fundamentals of Nursing (including practical), and Community Health nursing-I (including field exposure).

In the second year main focus is on health maintenance as it relates to the family, especially the mother and child. The students study Nepal Parichaya, Community Health Nursing -II (including field visit), Behavioural Science, Nursing Care of Children (including practical), Midwifery A (Theory + Clinical), Midwifery B (Theory + Clinical) and Midwifery C (theory + clinical).

The third year and the final year mainly focuses on ill client and the restoration of the client to optimum health. In the third year students study Nursing Care of Adults -I (Theory), Nursing Care of Adults -II (Theory + Clinical) and the, Leadership and management (Theory + Clinical and Field) according to Certificate Nursing Curriculum,1997.

The salient features of the PCL nursing program include emphasis on the health care needs of people of Nepal; early exposure to community and continued throughout the course, exposure to national health system from primary to tertiary levels, early exposure of students to practical nursing; integrated system-oriented approach to learning; and small group teaching. The conceptual framework is so arranged that teaching/learning proceed from simple to complex; from wellness to illness continuum. There is heavy focus on primary health care approach and utilization of the nursing process.

Different teaching strategies are mentioned in the PCL curriculum; Lecture, Role-play, Demonstration, Group Discussion, Field Experience, Written Exercises, Project work and case studies.

The program has actively promoted integrated approaches to learning in basic sciences. The Integrated Science course consists of Microbiology, Anatomy, Physiology, Pharmacology, Epidemiology, Nutrition, Applied Chemistry and Physics in relation to the organ systems of the body. The topics are integrated throughout the curriculum so that student would better understand and apply basic sciences in the provision of nursing care. The admission requirements for the PCL nursing programs are: School leaving Certificate (SLC) pass with a minimum of 50% aggregate mark and pass marks in English, Science and Mathematics. All applicants must sit for an entrance examination. Candidates will be selected on the basis of merit from only those applicants who secure the qualifying mark in the entrance examination. The program is open only for female applicants (The Profile of IOM, 1999).

The PCL nursing programs are run in seven campuses of the Institute of Medicine. Among them five are under the IOM, TU; the other 2 are academically affiliated to the IOM. For this research study Nursing Campus of Maharajgunj, which is located in Kathmandu, has been selected. The annual intake of students is 60 in the Maharajgunj Nursing Campus.

One of the main strengths of the program is its emphasis on community health, which occupies a total of nearly 23 percent of curriculum time out of a total of 673 hours in Community health nursing, 270 hours (40%) are allotted to practical field work, which clearly indicates the heavy emphasis on community field based education. The residential field practice provides real-life setting for learning. It has provided unique opportunity for the students to understand the bio-, psycho-, social dimensions of health and diseases. The emphasis on community-orientation endures from the basic sciences through all branches of clinical nursing, with a focus on the prevention and controls of common health problems.

The following are some of the notable weaknesses of the curriculum

• Time allocation is not adequate for some objectives.

• Some objectives are vague and the action verbs used are not suitable for different domains.

• Difficult to separate the least important content from the most important content.

• Curriculum places heavy emphasis on the lecture method.

• Teaching methods are not matched with objectives of the programme.

• Communication skills and attitude development are not adequately emphasized.

• There is focus on norm-referenced evaluation methods.

The topic diarrhoea has been selected for the study purpose because it is one of the commonest causes of childhood mortality in Nepal. A survey on Childhood Diarrhoeal Diseases (CDD) in 1991 revealed that on average, each child suffered from 3.3 episodes of diarrhoea per year. The number of deaths due to diarrhoea is estimated to be 45,000 per year (Annual Report 1994/95 & Dept. Health Services. MoH, 1996/97). During the PCL Nursing Progeramme, under the course Nursing Care of Children, students learn about diarrhoea and dehydration. The course Community Health Nursing II helps students to learn to identify common health problems of children in Nepal, and to provide nursing care management and plan strategies for prevention. Just one hour is available to teach the topic on diarrhoea. Lecture and group discussion methods are mentioned in the curriculum to teach this topic. Teachers and students' feedback over the years have shown that time allocated for the topic is grossly inadequate.

1. Informed interviews with the teachers and students revealed that the Nursing teachers most of the time used only lecture to teach the topic ' Childhood Diarrhoea'. It seems that research on comparison of the effectiveness of various teaching methods-lecture, small group discussion and 'mixed' (i.e. lecture coupled with small group) method has not been done in the past in Nepal.
   
   ii) Most of the teachers don't know about different types of knowledge, hence, they failed to select appropriate teaching methods for specific learning objectives. The results from this study could be useful for teachers in the classroom. They could have options to select the best method to teach appropriate of knowledge in the topic Childhood Diarrhoea.