Educational Approach and Quality: Does PBL support quality

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1. Educational Approach and Quality: Does PBL support quality learning outcomes? Tracey Winning School of Dentistry The University of Adelaide Hand-out 1Hand-out 1

2. Educational Approach and Quality Objectives To share knowledge and experience of learning and teaching in PBL ? review published outcomes of PBL

3. Why PBL? Quality Student Experience Student-centred focus 1, 2 Improve integration of basic science and clinical education 1, 2 Develop skills, understandings, qualities and dispositions appropriate to employment:3 life-long learning, critical thinking and decision making, independent working, teamwork, flexibility, oral communication, time management, planning and organisational ability Evidence-based decision making approach for patient management 4 Over the past 1-2 decades there has been a consistent call for improvements in the quality of the student experience and outcomes of higher education, including dental education. Changes that have been called for include: These various features will be familiar to you as your curriculum focusses on supporting these these features that are associated with quality higher education experience, including quality learning.Over the past 1-2 decades there has been a consistent call for improvements in the quality of the student experience and outcomes of higher education, including dental education. Changes that have been called for include: These various features will be familiar to you as your curriculum focusses on supporting these these features that are associated with quality higher education experience, including quality learning.

4. Why PBL? Learning Theories : Social constructivism Meaningful learning is most likely with: 5, 6, 7 authentic, real activities, modelling and coaching, ie, how to think and act as a practitioner, interactions: ‘inquiry and exploratory talk,’ 8 collaboration: students and staff, reflection: content and strategies, working independently: staff step back. Co-construction of new knowledge for ‘real-world’ contexts, linked to prior knowledge. These elements inform the design of problem-based learning (PBL) with the aim to support meaningful student learning. 9 The other support for the implementation of PBL are the close parallels PBL has with conteompoary theories of learning, These elements provide us with a framework to inform and help us understand the evaluation of our curricula.The other support for the implementation of PBL are the close parallels PBL has with conteompoary theories of learning, These elements provide us with a framework to inform and help us understand the evaluation of our curricula.

5. What is PBL? 10, 11 Principles Problem = organiser for learning Learner-centred Educational approach (not a method) Characteristics Problem = authentic professionally relevant situation Encountered first Student responds as practitioner Students involved in deciding what, how to learn Construct own knowledge & understanding Guidance/scaffolding provided by teacher as a ‘facilitator’ of learning Multiple learning and teaching methods Organised around problem: small groups, collaborative & independent research, peer learning and teaching, reflection and self-management PBL is presented in lots of different ways - so that we know we are talking from a similar view, Essential feature is: organiser and begins learning process. Authentic situation, often involving a patient, student need to respond as their chosen practitioner Learning centred: student decides on what/how to learn, develops own view and guided by teacher Approach (not method): Way of thinking about and organising learning methods to achieve a range of outcomes (broader than content) Reason done this way is to achieve certain educational goals/outcomes PBL is presented in lots of different ways - so that we know we are talking from a similar view, Essential feature is: organiser and begins learning process. Authentic situation, often involving a patient, student need to respond as their chosen practitioner Learning centred: student decides on what/how to learn, develops own view and guided by teacher Approach (not method): Way of thinking about and organising learning methods to achieve a range of outcomes (broader than content) Reason done this way is to achieve certain educational goals/outcomes

6. What is PBL? Educational Outcomes 10 Systematic approach to patient and analysis of their situation Contextualised and integrated knowledge, skills, behaviours Self-directed (independent) learning skills, lifelong Team skills Motivating, enjoyable learning experience So Educational goals asssociated with PBL: Working in small gps to investigate patient situation, students will/need to develop a systematic approach to patient For the knowledge and skills that students learn - For context, consider setting and process setting is have a patient and process is that need to work with patient eg, to learn about caries, learning basic science aspects in connection with presenting signs and symptoms of real patient and linked to how they help to diagnose or manage (as opposed to trad - basic science micro/histology - later in clinic have to apply this material) Students should learn how to ID what do and don't know and how to go about filling gaps in their knowledge - to develop skills to understand/learning to find resources to enable therm to keep learning after graduate Team skills are developed within their small groups - again an aspect of their practicing life There is consistent evidence that students enjoy PBL Context/intergrated: literature refers to contextualised and integrated - learning across disciplines, using basic and clinical science for a specific patient. Patient situation is whole a patient (not just a heart for which the function needs to the worked out). This approach supports the development of integrated learning eg learning about caries in context of patient, is not simply learning about caries as disease in terms of the microbiology of caries or histology of disease in separate subjects/courses, but learning about in caries in context of presenting signs and symptoms of patient, that link to aetiology and pathogenesis as well as management and the patient's social aspects and practice context. Also the context of the process of clinical investigation of a patient ie systematic approach. So Educational goals asssociated with PBL: Working in small gps to investigate patient situation, students will/need to develop a systematic approach to patient For the knowledge and skills that students learn - For context, consider setting and process setting is have a patient and process is that need to work with patient eg, to learn about caries, learning basic science aspects in connection with presenting signs and symptoms of real patient and linked to how they help to diagnose or manage (as opposed to trad - basic science micro/histology - later in clinic have to apply this material) Students should learn how to ID what do and don't know and how to go about filling gaps in their knowledge - to develop skills to understand/learning to find resources to enable therm to keep learning after graduate Team skills are developed within their small groups - again an aspect of their practicing life There is consistent evidence that students enjoy PBL Context/intergrated: literature refers to contextualised and integrated - learning across disciplines, using basic and clinical science for a specific patient. Patient situation is whole a patient (not just a heart for which the function needs to the worked out). This approach supports the development of integrated learning eg learning about caries in context of patient, is not simply learning about caries as disease in terms of the microbiology of caries or histology of disease in separate subjects/courses, but learning about in caries in context of presenting signs and symptoms of patient, that link to aetiology and pathogenesis as well as management and the patient's social aspects and practice context. Also the context of the process of clinical investigation of a patient ie systematic approach.

7. PBL Package Purpose Package must provide opportunity for students to: 12 Think and act as practitioner develop new, professional knowledge, skills and behaviours apply new, professional knowledge, skills and behaviours Develop learning skills collaborative, independent study discussion and critique of learning ? Is there support that PBL can achieve these educational outcomes? From that background, or in summary, the purpose of our PBL packages, which include the case under analysis and the supporting learning activities, eg, seminars, labs, clinic etc, is to provide opportunities for students to think and act like a practitioner - naturally this involves them learning about new knowledge, skills and behaviours PLUS they need to be able to apply or use what they have learnt. So packages should not just be an exercise in learning knowledge, they need to require students to apply their learning - ie integrate their basic science with their clinic approach/ response *And of course, they need to provide opportunities to develop learning skills: *Ie collaborative, independent study which involves discussion and critique of learning done least well/not addressed often The next logical question of course is can we achieve these outcomes, what research has been completed to show that this is possible. There is a large body of research in PBL and a major focus over the past 2-3 decades has been about whether PBL students/graduates are different to students/graduates from conventional curricula. This has drawn on surveys for self-rating by graduates, clinical directors and co workers or students perceptions of their experience or preparedness as well as using a range of tests, some national tests or others specifically developed to test key outcomes from PBL. From that background, or in summary, the purpose of our PBL packages, which include the case under analysis and the supporting learning activities, eg, seminars, labs, clinic etc, is to provide opportunities for students to think and act like a practitioner - naturally this involves them learning about new knowledge, skills and behaviours PLUS they need to be able to apply or use what they have learnt. So packages should not just be an exercise in learning knowledge, they need to require students to apply their learning - ie integrate their basic science with their clinic approach/ response *And of course, they need to provide opportunities to develop learning skills: *Ie collaborative, independent study which involves discussion and critique of learning done least well/not addressed often The next logical question of course is can we achieve these outcomes, what research has been completed to show that this is possible. There is a large body of research in PBL and a major focus over the past 2-3 decades has been about whether PBL students/graduates are different to students/graduates from conventional curricula. This has drawn on surveys for self-rating by graduates, clinical directors and co workers or students perceptions of their experience or preparedness as well as using a range of tests, some national tests or others specifically developed to test key outcomes from PBL.

8. Outcomes: Systematic approach to analysis of patient situation Developing systematic enquiry skills: Graduates self-rated as better at problem-solving skills 13 Improvement in clinical reasoning strategy more accurate hypotheses and coherent explanations with basic science knowledge 14 Improved diagnostic ability with PBL using clinical contexts 15 Using educational outcomes that PBL was designed to achieve as a framework., beginning with the systematic approach to analysis of patient and their situation, this requires students to develop systematic enquiry skills. The research that supports that this can be achieved includes: A recent study of PBL graduates and graduates from conventional medical curricula, where PBL grad self-rated themselves as having better problem-solving skills Students in PBL program demonstrated improvement in clinical reasoning strategy as they progressed and this involved development of more acurate hypotheses and coherent explanations using more basic science knowledge than students who participated in only one unit that used PBL and their performance was better than students from a conventional curriculum. Using educational outcomes that PBL was designed to achieve as a framework., beginning with the systematic approach to analysis of patient and their situation, this requires students to develop systematic enquiry skills. The research that supports that this can be achieved includes: A recent study of PBL graduates and graduates from conventional medical curricula, where PBL grad self-rated themselves as having better problem-solving skills Students in PBL program demonstrated improvement in clinical reasoning strategy as they progressed and this involved development of more acurate hypotheses and coherent explanations using more basic science knowledge than students who participated in only one unit that used PBL and their performance was better than students from a conventional curriculum.

9. Outcomes: Contextualised and integrated knowledge, skills, behaviours Basic and clinical science knowledge Critical thinking, logical argument (eg explain, test, justify their assumptions, knowledge, reasoning) Communication/interpersonal skills Preparation for practice and clinical skills

10. Outcomes: knowledge, skills, behaviours 1 Basic and clinical science knowledge Several reviews have reported equivocal outcomes re basic science knowledge development 16, 17, 18 Better skills in applying knowledge 18 Significantly better performance on Medical Board exams (I & II) 19 Critical thinking Higher critical thinking disposition which was maintained (to a lesser degree over subsequent 2 y) 20 Older reviews have shown- no consistent benefit and in some cases signifi poorer performance, but method for comparing programmes is problematical due to test format used, ie MCQ -rarely will include the context and of course other key cognitiive outcomes besides basic facts. The medical board exams in US have changed (92-94) so these results may no longer be informative. More recent meta-analyses show students from PBL are better at applying knowledge And another more recent study, using current medical national boards exams, ie stage 1 and 2 (for graduation), show the outcomes of students from PBL programme to be consistently and significiantly better performance than the more trad programme and the national average (Hoffman et al., 2006). - this is over a 10 y period which I think is significant as as I am sure you are familiar with it is a major undertaking to develop and implement a PBL curriculum but maintaining this and continuing to develop the curriculum which you have done, eg recent changes related to Bologna agreemen is not an easy task and requires continual monitoring. But these results need confirmation as relate to one school so other analyses or meta-analyses are needed with the newer or different assessment formats Older reviews have shown- no consistent benefit and in some cases signifi poorer performance, but method for comparing programmes is problematical due to test format used, ie MCQ -rarely will include the context and of course other key cognitiive outcomes besides basic facts. The medical board exams in US have changed (92-94) so these results may no longer be informative. More recent meta-analyses show students from PBL are better at applying knowledge And another more recent study, using current medical national boards exams, ie stage 1 and 2 (for graduation), show the outcomes of students from PBL programme to be consistently and significiantly better performance than the more trad programme and the national average (Hoffman et al., 2006). - this is over a 10 y period which I think is significant as as I am sure you are familiar with it is a major undertaking to develop and implement a PBL curriculum but maintaining this and continuing to develop the curriculum which you have done, eg recent changes related to Bologna agreemen is not an easy task and requires continual monitoring. But these results need confirmation as relate to one school so other analyses or meta-analyses are needed with the newer or different assessment formats

11. Outcomes: knowledge, skills, behaviours 2 Communication /interpersonal skills High levels of communication skills in PBL graduates (self 13 and clinical directors/co-workers 21, 22) Preparation for practice Graduates felt better prepared than their peers from conventional curricula 23 Graduates self-rated as better at professional skills (eg physical examination) 13 and were rated above average by clinical directors 22 Better clinical periodontics performance in OSCE (NS difference for examination of patient) 24 Improved communication skills - rolfe and pearson; Schmidgt et al., 2006(self-rating cf with convent) Preparation for practice: mennin et al 1996 Self-rated as better at professional skills and this was supported by clinical director ratings And this is consistent with similar studies for dental students at USC (Shuler and Fincham, 1998). Improved communication skills - rolfe and pearson; Schmidgt et al., 2006(self-rating cf with convent) Preparation for practice: mennin et al 1996 Self-rated as better at professional skills and this was supported by clinical director ratings And this is consistent with similar studies for dental students at USC (Shuler and Fincham, 1998).

12. Identifying own learning needs and resources Information literacy skills (eg identify, locate, evaluate and use information) Identifying and utilising appropriate learning processes (eg self-testing, concept maps, diagrams, teaching others, applying knowledge to novel situations) Developing time management and organisational skills Monitoring and evaluating learning processes and outcomes Outcomes: Self-directed learning

13. Identifying needs and resources: > 60% (average) learning issues match faculty-identified learning issues; identify other relevant learning issues 25, 26 plan and undertake research in own time, using self-identified resources 27 Information literacy skills Graduates self-rated as better at self-directed learning 13, 22 and using information resources 13 Outcomes: Self-directed learning 1 Disposition - tendency or inclination to act or prevailing quality of mind to actDisposition - tendency or inclination to act or prevailing quality of mind to act

14. Outcomes: Self-directed learning 2 Learning processes/approaches PBL associated with learning for meaning (deep) 28, 29, 30, 31 Developing time management and organisational skills Graduates self-rated as better at planning, efficiency and time management 13, 22 and rated highly by clinical directors 22 Monitoring and evaluating learning processes and outcomes: Updating of current knowledge for practice 32

15. Outcomes: Team Skills Group function: Group dynamics Working relationships (eg respect, trust, valuing, etc); Communication (eg negotiation, discussion, giving and receiving feedback); Conflict management, (eg trouble-shooting dysfunctional groups: domination, non-participation, exclusion, ‘short-cutting’, ‘sponging’) Group process Roles & responsibilities (eg leader, scribe, researcher, recorder/ administrator); Monitoring and evaluating group functioning; Organising

16. Outcomes: Team Skills Group dynamics Graduates self-rated as better collaboration skills 13, 22 Group process Graduates self-rated as better at skills required for running meetings 13

17. Outcomes: Student satisfaction improved enjoyment, student interaction, and flexibility in their programs 16, 30, 33, 34 overall satisfaction strong for PBL experience 35 and better cf with conventional curricula (CEQ) 31

18. Conclusion Evaluation of PBL indicates achieving some of educational outcomes; these link to quality higher education learning outcomes Issues in interpreting results due to variable implementations of PBL and limited use of theoretical basis: need clear definition of programme processes to assist in interpretation 10, 11 Research needed to identify key elements of context that are required to achieve PBL outcomes 9

19. References 1 Albanese MA, Mitchell S. 1993 Problem-based learning: A review of literature on its outcomes and implementation issues. Acad Med 68(1): 52-81. Barrows H. 2000 Problem-based Learning Applied to Medical Education. Springfield, Illinois: Southern Illinois University School of Medicine Blumberg P. Evaluating the evidence that problem-based learners are self directed learners: A Review of the literature. In: Evensen D, Hmelo CE, eds. Problem- Based Learning: Research Perspectives on Learning Interactions. Mahwah; Lawrence Erlbaum Assoc, 2000:199-227 Brown JS, Collins A & Duguid P. 1989 Situated cognition and the culture of learning. Educational Researcher 18: 32-42 Brophy J. 2002 Introduction. In: Social Constructivist Teaching: Affordances and Constraints. Ed: Brophy J. JAI: Amsterdam pp ix-xxii. Charlin B, Mann K, Hansen P. 1998 The many faces of problem-based learning: a framework for understanding and comparison. Medical Teacher 20:323-330. Coles CR. 1985 Differences between conventional and problem-based curricula in their students’ approaches to studying. Med Educ 19(4):308-309. Dean SJ, Barrett AL, Hendry GD, Lyon PMA. 2003 Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. MJA 178:163-167.

20. References 2 Dochy F, Segers M, Van den Bossche P, Gijbels D. Effects of problem-based learning: a meta-analysis. Learning and Instruction 2003;13:533-568. Dolmans DH, Gijselaers WH, Schmidt HG, van der Meer SB. 1993 Problem effectivenss in a course using problem-based learning. Acad Med 68(3):207-213. Dolmans D, De Grace W, Wolfhagen IHAP, van der Vleuten CPM. 2005 Problem-based learning: future challenges for educational practice and research. Med Educ 39:732-741. General Dental Council 2002 The First Five Years. General Dental Council, London. Hmelo CE 1998 Cognitive consequences of problem-based learning for the early development of medical expertise. Teach Learn Med 10(2):92-100. Hoffman K, Hosokawa M, Blake R Jr, Headrick L, Johnson G. 2006 Problem-based learning outcomes: ten years of experience at the University of Missouri - Colombia School of Medicine. Acad Med 81(7):617-625. Institute of Medicine 1995 The mission of education. In: Dental Education at the Crossroads: Challenges and Change (Report by Committee on the Future of Dental Education, Division of Health Services). Ed: Field MJ. National Academy Press, Washington. pp 88-143.

21. References 3 Institute of Medicine 2003 Health Professions Education: A bridge to quality. (Report by Committee of the Health Professions Education Summit). Eds: Greiner AC, Knebel E. The National Academies Press, Washington. http://www.nap.edu/catalog.php?record_id=10681#toc (accessed 11-9-07). Lyon PMA, Hendry GD. 2002 The use of the Course Experience Questionnaire as a monitoring evaluation tool in a problem-based medical programme. Assessment & Evaluation in Higher Education 27(4): 339-350. Mennin SP, Kalishman S, Friedman M, Pathak D, Snyder J. 1996 A survey of graduates in practice from the University of New Mexico's conventional and community-oriented, problem-based tracks. Acad Med 71: 1079-89. Newble DI, Clarke RM. 1986 The approaches to learning of students in a traditional and in an innovative problem-based medical school. Med Educ 20:267-273. PROBLARC 1994 Constructing a Problem. Workshop papers: Designing and Writing PBL Packages, June 30th and July 1st, 2001, Adelaide. Newcastle, NSW: Problem Based Learning Assessment and Research Centre, The University of Newcastle. Rich SK, Keim RG, Shuler CF. 2005 Problem-based learning versus traditional educational methodology: a comparison of preclinical and clinical periodontics performance. J Dent Educ 69(6): 649-662.

22. References 4 Richardson J 2007 Medical Teacher 29: in press Rohlin M, Petersson K, Svensbter G 1998 The Malmo model: a problem-based learning curriculum in undergraduate dental education. Eur J Dent Educ 2:103-114. Rolfe I, Pearson S. 1994 Communication skills of interns in New South Wales. MJA 161:667-670. Savery JR & Duffy TM. 1995 Problem-based learning: An instructional model and its constructivist framework. Educational Technology 135:31-38 Schmidt HG, Machiels-Bongaerts M, Hermans H, et al. 1996 The development of diagnostic competence: comparison of a problem-based, an integrated, and a conventional medical curriculum. Acad Med 71(6): 658-664 Schmidt HG, Vermeulen L, van der Molen HT. 2006 Longterm effects of problem-based learning: a comparison of competencies acquired by graduates of a problem-based and a conventional medical school. Med Educ 40:562-567. Sigrell B, Sundblad G, Rönnås P-A. 2004 To what extent do students generate learning issues that correspond to pre-set faculty objectives? Med Educ 26(4): 378-381.

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