Opportunities of a Problem-Based Learning

¶ … Opportunities of a Problem-Based Learning Approach in a Tertiary Healthcare Facility

Although there are countless opportunities for problem-based learning approaches in tertiary healthcare facilities, so too are there numerous challenges associated with the techniques that are used for these purposes. Clearly, providing effective and efficient evaluation of students in these healthcare settings represents an important and timely enterprise, but many healthcare practitioners may lack the skills and expertise needed to deliver these services or to effectively evaluate the students they observe. To gain a more in-depth understanding of the challenges and opportunities that are involved in using a problem-based learning approach in a tertiary healthcare setting, this paper provides a review of the relevant scholarly and juried literature, followed by a summary of the research and an identification of important points in the conclusion.

Review of the Literature

According to Distlehorst, Dunnington and Folse (2000), there are a number of clinical teaching improvement methods available for use in tertiary healthcare settings including (a) consultation with a professional educator; (b) peer evaluation; (c) feedback from students' ratings; (d) videotape review; (e) self-evaluation; (f) concept-based training; and (g) multicomponent methods (i.e., seminars and workshops). Each of these methods, of course, has its respective strengths and weaknesses depending on the setting and specific outcome that is desired. The growing body of evidence in this area indicates that there is a significant amount of variance in the following clinical teaching improvement areas: (a) instructional time; (b) needs assessment techniques; (c) format of programs; (d) content areas; (e) specialties; and (f) postgraduate years involved (Distlehorst et al., 2000). Taken together, these variances point to the need for more effective methods of delivering educational content to healthcare practitioners (Distlehorst et al., 2000).

Based on their analysis of the efficacy of various teaching methods intended to improve senior resident teaching skills, Distlehorst and her associates found that:

1. There are numerous resident teaching skills programs in use, but no standardized content or instructional method has been established.

2. Teaching skills programs have been conducted in numerous specialties, and residents' teaching skills needs may vary by specialty.

3. Teaching skills programs may involve residents from all postgraduate years, and content areas may need to differ by level of training.

4. Multiple approaches to define content areas are available.

5. Giving residents written feedback about their teaching may improve teaching (Distlehorst et al., 2000, p. 175).

One technique that has gained increasing acceptance by the medical community for clinical teaching improvement is the problem-based learning approach, and a number of studies have confirmed the positive effects of using this teaching method (Kwo, Moore & Jones, 2004). According to Smith and Katz (2006), "Problem-based learning is unique in that its major emphasis is on content as well as problem solving. As an instructional approach, problem-based learning focuses on content in any subject area" (p. 36). The underlying pedagogical rationale in support of using problem-based learning is that students are able to learn content more effectively by solving realistic problems and then apply this knowledge in real-world settings (Smith & Katz, 2006).

As the term implies, "problem-based learning" involves having students solve some type of "problem" and having their performance evaluated objectively (Alavi, 1999). In this regard, Albion (2003) emphasizes that, "Focusing on the solution of authentic problems as a context for learning accords well with theories of human expertise" (p. 243). While the problem-based learning approach can be applied to a wide range of disciplines, its use in healthcare applications typically involves scenarios that relate to the types of problems that healthcare providers will encounter in real-world settings. According to Alavi, "In the case of health-care professions, this could be a video of an incident; a simulated patient; written description of a presenting client and some symptoms; documents about a public health matter (e.g., a government health report, a memo from a director of nursing to agency staff)" (p. 165). Developed at McMaster University in the late 1960s, the problem-based learning approach has been increasingly applied to a wide range of healthcare settings (Lam, 2004). According to Lam, the problem-based learning (PBL) approach "is very well received in medical training programs: More than 82% of the medical schools in the United States teach the basic sciences using PBL to various degrees. It has since been applied to other health science curricula such as nursing, dentistry, and occupational therapy" (2004, p. 371).

Although a "problem" is an integral part of problem-based learning, Alavi cautions that the problems used in problem-based learning opportunities typically involve a constellation of related problems in a specified context. In this regard, Alavi adds that, "No problem can be understood in pure isolation, so other matters are always implied. The phrase 'the problem' is useful as a brief way of referring to a complex phenomenon" (1999, p. 165). According to Neville and Britt (2007), learners who take part in problem-based learning opportunities "are presented with challenging and extended research scenarios that require them to synthesize their skills into a cohesive whole and develop operational schemata that could be transferred from an academic to a professional setting" (p. 226).

One of the challenges involved in developing and administering a problem-based learning curriculum relates to a paucity of comprehensive guidelines concerning what type of content should be presented. While there are no universal guidelines for conducting problem-based learning opportunities in healthcare settings, there are some commonalities involved in the approach as follows:

1. A problem situation, which is the basis for stimulating learning, is encountered.

2. The problem situation is presented to students in the same manner that it would be in the 'real world.'

3. Students work through the problem in a manner that challenges their ability.

4. Needed areas of learning are identified during the process and are used as a guide to individualized study.

5. The knowledge and skills that are learned in stages 3 and 4 are applied to the problem to evaluate the effectiveness of learning and to reinforce and contextualize learning.

6. The learning that has occurred through the process is integrated into the student's existing knowledge base (Maxwell, Bellisimo & Mergendoller, 2001, p. 74).

According to Edens (2000), the problem-based learning approach is "a constructivist teaching model that helps students learn to think and to solve problems -- skills too frequently not acquired in traditional university course work. This approach is implemented widely in medical school education" (p. 55). The problem-based learning approach uses realistic problems as the focus for learning and facilitates the acquisition of problem-solving skills as well as disciplinary knowledge (Edens, 2000). In contrast to traditional teaching practices such as lectures, the problem-solving learning approach actively engages learners (Edens, 2000). In this regard, Edens reports that the problem-based learning approach "engages students in developing a context-rich knowledge base and the skills for applying that knowledge, [and] can be applied in a wide variety of classroom settings and fields" (p. 55). Likewise, Hung (2002) notes that "Problem-based learning takes account of how students learn. It is becoming increasingly apparent that learning takes place most effectively when students are actively involved and learn in the context in which knowledge is to be used" (p. 394). There are a number of benefits that accrue to the use of the problem-based learning approach, including the following:

1. Adapting to and participating in change;

2. Dealing with problems, making reasoned decisions in unfamiliar situations;

3. Reasoning critically and creatively;

4. Adopting a more universal or holistic approach;

5. Practicing empathy, appreciating the other person's point-of-view;

6. Collaborating productively in groups or teams;

7. Identifying personal strengths and weaknesses and undertaking appropriate remediation, for example, through continuing, self-directed learning;

8. Fostering open-minded, reflective, critical, and active learning;

9. Respecting both students and teacher as persons with knowledge, understanding, feelings, and interests who come together in a shared educational process; and,

10. Reflecting the nature of knowledge -- that is, knowledge is complex and changes as a result of responses by communities of persons to problems they perceive in their worlds (Hung, 2002, p. 394).

Although the problem-based learning approach has been used in other disciplines besides the medical profession where the desired outcomes may vary (Simons, Klein & Brush, 2004), Evenson and Hmelo (2000) report that there are five fundamental goals for applying problem-based learning methods in healthcare settings: (a) construction of clinically useful knowledge; (b) development of clinical reasoning strategies; (c) development of effective self-directed learning strategies; (d) increased motivation for learning; and (e) becoming effective collaborators (pp. 1-2). Research has shown that two variables that influence the likelihood that any of the foregoing goals will be achieved are: (a) the nature of the case: whether it is a complete case, a vignette, or a full problem simulation; and (b) the locus of control of learning: whether it is teacher-centered, student-centered, or mixed (Evenson & Hmelo, 2000, p. 2).

The classic version of the problem-based learning approach has two primary attributes: (a) the use of a robust problem that provides free inquiry by students, and (b) learning is student-centered (Evenson & Hmelo, 2000). In addition, the classic version of problem-based learning "requires students to collaborate, formulate learning issues by determining factors that may contribute to the cause or solution of a problem, identify relevant content, and generate hypotheses. Most problem-based learning models also contain student reflection components as a means of self-evaluation" (Knowlton & Sharp, 2003, pp. 5-6).

Although the positive effects of using a problem-based learning approach have been documented in a number of studies, the findings of other studies have indicated that problem-based learning may not compare favorably with more traditional teaching methods with regards to student's knowledge base, technical skills, or the resources expended; however, Dadd (2009) suggests that the benefits of using a problem-based learning approach justify the additional resources this method requires. Moreover, Simons et al. (2004) report that students using a problem-based learning approach "tend to develop more positive attitudes toward learning than students in more traditional environments" (p. 214).

There are also some other challenges to applying the problem-based learning approach in healthcare settings that must be taken into account when considering the adoption of this method and how it will be implemented and administered. In this regard, Dadd notes that these challenges include "development of further problems and the interaction of professionals in this development, the attitude of faculty to the teaching method" (2009, p. 2). Notwithstanding these foregoing challenges, many authorities agree that the problem-solving learning approach provides an excellent return on the investment of the resources expended (Lam, 2004; Alavi, 1999). Indeed, Simons et al. (2004) emphasize that the findings from a meta-analysis of problem-based learning models used in medical schools showed that although students who used traditional educational methods typically scored higher on standardized measures of basic science knowledge than those in problem-based programs, the students who used the problem-based learning approach appear to have acquired better long-term recall of the subject matter because of the deeper understanding they gained of the subject matter presented. This outcome is congruent with the observation by Albion (2003) that, "Because problem-based learning involves the learner in working with, rather than simply observing, a case, it ought to intensify the effect of a case on development of self-efficacy. Thus problem-based learning appears to offer particular benefits for developing both expertise and the capacity to apply it" (p. 243).

In tertiary healthcare settings, the objective structured clinical examination may be the most appropriate for evaluation purposes using a problem-based approach for advanced learners such as residents. According to Sweet, Huttly and Taylor (2003), "The objective structured clinical examination (OSCE) using simulated patients with video feedback is becoming widely used in the summative assessment of competence" (p. 47). Evaluation using the OSCE approach involves having students complete various tasks within a specified amount of time in a controlled environment which is frequently simulated (Sweet et al., 2003). Although they will vary in number, the OSCE approach uses numerous stations (typically between 20 and 40) to assess student performance on various realistic tasks (Sweet et al., 2003). Each station uses a real or simulated patient and the student's performance at each station is evaluated by the examiner using a checklist to provide objective assessment (Sweet et al., 2003). In addition, Wessel, Williams, Finch and Gemus (2003) report that, "Written stations may be included to evaluate the students' interpretation and application of findings or their ability to plan further assessment or treatment" (p. 266).

Yet another challenge in using this problem-based learning approach is how to maximize its effectiveness and student retention of the knowledge they have acquired. For this purpose, following the completion of the OSCE, Sweet and her associates emphasize the need for feedback to students in order to realize the greatest return on the investment of time and resources. In this regard, these authorities emphasize that, "To simply tell learners that they have either passed or failed and can or cannot progress to the next summative hurdle is of little value for their experiential learning. Feedback on knowledge, competence, performance and outcome should be given as soon after the assessment as is practicably possible" (p. 47). The evaluation criteria used by examiners should be made available to students and explanatory comments should be used to justify negative as well as positive evaluations (Sweet et al., 2003).

A final challenge involved in a problem-based learning approach in a tertiary healthcare setting relates to the manner in which teaching personnel are selected. According to Alavi (1999), in order to ensure the success of these initiatives, staff members who are selected for teaching problem-based curricular offerings must be provided with the information they need to make an informed decision concerning their abilities and desire for teaching these types of courses (Alavi, 1999). In this regard, Alavi notes, "Consistent with a problem-based learning approach, it is important that applicants be given opportunity to assimilate this information by having time to talk informally with the teaching team, and with students, and by attending problem-based tutorials and fixed-resource sessions" (1999, p. 125).