How-Students-Perceive-Problem-Based-Learning-(PBL)-DOI

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Szabó Z, Harangi M, Nylander E, Ljungman A, Theodorsson A, Ahn H and Davidsson B.
MedEdPublish 2015, 6: 17
http://dx.doi.org/10.15694/mep.2015.006.0017
How Students Perceive Problem-Based Learning (PBL) Group
Tutorials at a Swedish Medical College.
Zoltan Szabo, Marta Harangi, Eva Nylander, Anders
Ljungman, Annette Theodorsson, Henrik Ahn and Bo
Davidsson
Received: 21/09/2015
Accepted: 22/09/2015
Published: 29/09/2015
Abstract
Introduction: student perception of problem-based learning (PBL) group tutorials was investigated at a
Swedish University Medical College 27 years after the introduction of PBL into the curriculum.
Methods: a survey questionnaire comprising 43 questions answered on a Likert-type scale, together with one
open question was used. The questionnaire was distributed to all 821 students taking part in the Linköping
University medical program at the beginning of the Spring Term 2013. The results were subjected to
explorative factor analysis, descriptive statistics and ANOVA. Responses to the open question where analyzed
qualitatively by categorization.
Results: 84 per cent of the 821 students completed the survey. Four factors describing student perception
were identified: 1) PBL as a method of learning; 2) the tutor’s role; 3) PBL, stress and feelings of insecurity;
and 4) traditional teaching methods within the PBL curriculum. The Cronbach´s alpha value was 0,788
overall. Two hundred and seventy-six students answered the open question declaring that they would
appreciate more precise aims and objectives, smaller tutorial groups, and more formal lectures.
Conclusions: the results of this study on PBL group tutorials, as seen from the student’s perspective, stress
the importance of tutorial quality, tutor competence, tutorial group size and the quality and aims of the
curriculum. Too much emphasis on the teacher’s research merits against the educational ones, and the
inability to adapt to the needs and wishes of new generations of students seems a probable cause for the
erosion of PBL.
Keywords: Problem-based learning, group work, tutors, self-directed learning
Article
Introduction
PBL has its roots in the pragmatism of John Dewey claiming that knowledge is developed in relation to its
usefulness and practicality. This is expressed in the catch-phrase “learning by doing” as theory and practice
are closely interrelated(Dewey, 1928). The PBL method was developed by Howard Barrows and tailored for
medical education in 1980 (Barrows, 1980). Hammar Chiriac states that group work is used both as the
objective and the means in PBL (Hammar Chiriac, 2014). The principle of studying in groups assumes the
Article Open Access
Corresponding author: Zoltán Szabó zoltan.szabo@regionostergotland.se
Department: Dept. of Cardiothoracic Anesthesia, Linköping Heart Center, University Hospital, S-581
85 Linköping, Sweden.

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student’s motivation to learn. Working in a PBL group has the advantage of social facilitation(Hammar
Chiriac, 2014).
In practice, however, working in groups may falter due to the students, the tutor or both. Common student-
related problems include: dysfunctional groups; shy individuals; dominant students; and non-attendance
(Tarnvik, 2007). Lack of self-discipline necessary for self-directed learning (Barrows, 1980), lack of
motivation, and personal problems lead to failure of the PBL method (Schwartz P, 2001). Recognition of
tutor-related problems and measures taken are at the heart of maintaining and improving the quality of PBL as
pointed out by Azer et al (Azer, McLean, Onishi, Tagawa, & Scherpbier, 2013).
In 1986 the Medical Faculty of Linköping University was amongst the first in Europe to employ PBL. The
exponential increase in knowledge in a rapidly changing world created the need to turn academic education
towards self-directed learning centered on the student (Rawlings, 2012). Although major revision of the
curriculum was made and implemented 2003, tutorial groups continue to perform suboptimal, not only due to
the students but also the tutors (Harangi, 2011).
A comprehensive survey of all medical college students was therefore carried out during the Spring Term of
2013 in order to investigate how they perceived working in tutorial groups. Our aim was to find out which
factors are important in influencing this issue as well how these factors change from term to term over the
course of the medical program from Term 1 to Term 11 (two terms a year).
Methods
The population studied consisted of all medical students at Linköping University Medical College
during the Spring Term of 2013. The study was approved by the Regional Ethics Review Board in
Linköping, Sweden (Dnr. 2012/298-31).
The medical program comprises 11 terms and PBL is used for all courses. The program is divided
into three stages; Stage 1 (Terms 1 – 2), Stage 2 (Terms 3 – 5), and Stage 3 (Terms 6 – 11). Tutors
are engaged in group work Terms 1 to 5. Thereafter the students conduct group work themselves.
This study included students from Terms 6 - 11 since they had a broad perspective and experience of
group tutorials in the first two stages.
The survey questionnaire comprised 43 questions answered on a Likert-type scale. Plain Swedish language
without negations was used. The Likert-type scale had four points: 1 = totally disagree; 2 = tend to disagree;
3 = tend to agree; 4 = totally agree. The questionnaire finished with an open question concerning student
perception of group tutorials and suggestions for improvement in the future. The total number of active
students at the time of the survey was 821. Of these 687 answered, i.e. a response rate of 84 per cent. SPSS
was used for statistical evaluation of the data (SPSS, 2012), and the results presented as mean with standard
deviation (SD). A standard variant of explorative factor analysis using Kaiser’s criterion followed by Varimax
rotation was used(Pedhazur E. J., 1991). To elicit any tendencies between terms in the program, the means for
each factor for each Stage of the program were analyzed using one-way ANOVA, combined with the
Bonferroni post hoc test (IBM SPSS statistic standard 20. 2012).
The answers to the open question were analysed qualitatively using categorization. As the number of
responses was large, we were forced to reduce the volume of the analysis and aim for overall tendencies rather
than depth. At the same time the analysis had to be sensitive to nuances. The analysis was therefore performed
in two phases. In the first phase the answers were read through repeatedly until a pattern of categories began
to emerge. All student statements were then coded into the three main categories and divided for each term. In
the second phase the statements in each of the main categories were sorted into sub-categories resulting in a
matrix (Bryman, 2011; Miles, 2013) of categories according to Term, making it possible to interpret the
responding students’ overall perception of PBL, as well as trends from Stage to Stage.

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Results
Factor analysis yielded four factors which reflected the logic of the survey. We named the factors: 1) PBL as a
method for learning; 2) The tutor’s role; 3) PBL, stress and feelings of insecurity; and 4) Traditional teaching
methods within the PBL program. Cronbach alpha reliability coefficients for the four factors were calculated
and found to be: Factor 1, 0,919; Factor 2, 0,919; Factor 3, 0,740; and Factor 4, 0,574, giving an overall
reliability of 0,788 for the four factors. The means and standard deviations for the factors covering the whole
group of respondents are presented in Table 1.
Table 1.
Factor N Mean Std. Deviation
Factor1. PBL as a method
of learning 562 3,222 ,541
Factor 2. The tutor’s role as
a help in learning 479 2,763 ,652
Factor 3. PBL, stress and
feelings of insecurity 618 2,753 ,613
Factor 4. Traditional
teaching methods 629 2,893 ,508
The results may be interpreted as follows: the mean for Factor 1, PBL as a method of learning, was 3,222, i.e.
slightly above the alternative “tend to agree”, implying that the students value PBL as a method based on
relevant cases that stimulates cooperation and learning. The mean for Factor 2, concerning the tutor’s role in
helping learning, was 2,763 implying that the students perceived their tutors as being helpful in PBL, but not
as much as the method itself. The mean for Factor 3, covering how PBL leads to stress, insecurity and
uncertainty caused by discussions in the group and difficulty in searching literature, was 2,753, implying that
although PBL is perceived as being positive, and tutor’s as generally supportive, PBL is also a source of
considerable uncertainty and stress. Finally, the mean for Factor 4, traditional teaching methods within the
PBL curriculum, i.e. lectures and clinical practice was 2,893, implying that the students rate traditional
teaching methods as good as PBL.
In order to elicit tendencies with time from Stage to Stage in the program, differences between the three stages
were calculated using one-way ANOVA, combined with the Bonferroni post hoc test. Details of the whole
model are presented in Table 2, the post hoc results are included in Appendix 1.
Table 2.
N Mean Std. Deviation
Factor 1. PBL as a method of
learning
Stage 1 145 3,431 ,414
Stage 2 156 3,323 ,429
Stage 3 261 3,046 ,605
Factor 2. The tutor’s role as
help in learning
Stage 1 136 3,050 ,623
Stage 2 155 2,746 ,670
Stage 3 188 2,571 ,635
Factor 3. PBL, stress and
feelings of insecurity
Stage 1 168 2,871 ,621
Stage 2 173 2,695 ,568

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Stage 3 277 2,718 ,628
Factor 4. Traditional teaching
methods
Stage 1 164 2,736 ,493
Stage 2 180 2,859 ,493
Stage 3 285 3,005 ,500
Regarding Factor 1, the overall tendency was that student appreciation of PBL as a learning method decreases
the further they progress in the program. This decrease in appreciation was significant (F=30,250; df=2:561;
p=.000). It must be emphasized that Factor 2, regarding the tutor’s role as supportive in learning, was only
directly relevant for the first five terms in the program, i.e. Stages 1 and 2, as tutors are not involved in the
PBL program during the last six terms. However students from Stage 3 had a general picture of the tutoring
system from previous Stages. Even here we saw a significant decrease in student appreciation with time
(F=23,356; df=2;478; p=.000). Regarding Factor 3, i.e. PBL, stress and feelings of insecurity, the student
ratings were highest during Stage 1, fell during Stage 2, and rose slightly again during Stage 3. The
differences between Stages were significant (F= 4,402; df= 2:617; p=.013). For Factor 4, i.e. traditional
teaching methods, there was a clear trend in student rating of importance between the three stages, lectures
and clinical practice being more and more appreciated as time went by; the difference was significant
(F=15,849; df=2:628; p=.000).
Student responses to the open question
The responses of the students to the open question were analyzed qualitatively using a method of
categorization. The three main categories were: 1. Overall appreciation of PBL tutorial groups, aims and
objectives; 2. tutor competence and involvement; and 3.
PBL organization. There were 299 statements, 151, 82 and 66 regarding Categories 1,2 and 3 respectively.
Category 1. Overall appreciation of PBL tutorial groups, aims and objectives In this category (Table 3)
nearly all of the answers were critical of PBL or how PBL is applied in the medical program. The most
common sub-category, namely that aims and objectives need to be better formulated, were roughly the same
for each of the three stages, indicating a rather uniform opinion. Other frequent statements concerned the large
size of the tutorial groups and the desire for more lectures. An interesting pattern was that the students’
perception, that PBL is not always a suitable method, became greater in the later stages of the program.
Table 3.
Stage Statements (N) Sub categories
1 34  Aims and objectives need to be better formulated.
 Tutorial groups need more time/longer periods.
 Lectures are better.
 Tutorial groups should be smaller.
 Lectures are better.
 Smaller tutorial groups.
 More lectures.
 PBL is better suited later in the program.
 PBL is not suitable for every course/moment.
 PBL should be optional.
 PBL and traditional teaching methods need to be balanced.
 PBL is not suitable for every course/moment.
 Smaller tutorial groups.
 More and better lectures.

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Category 2. Tutor competence and involvement –The second category covered tutors, their competence and
involvement (Table 4). One sub-category predominated; that the quality of the tutor varies. The students also
described their tutors as not being involved enough. Some named that senior students might perform better as
tutors. In this category, as well as in the first, there was a tendency that the sub-categories became slightly
more diverse in the last two stages in the program.
Table 4.
Stage Statements (N) Sub categories
1 13  The quality of the tutors is uneven.
 Tutors need to be better prepared.
 Tutors are often unengaged.
 Tutors need to be more involved.
 Tutors need more competence.
 PBL requires good tutors.
 Vignettes/cases need to be updated.
 Senior students are better as tutors.
Total 82  The quality of the tutors is uneven.
 Tutors are often unengaged.
Category 3. PBL organization - The third main category concerned the organisation of PBL at our medical
college (Table 5). This category received the least number of statements and no clear pattern was seen
between stages. Even here, as in the first category, the opinion that PBL is not always a suitable method
persisted. Students desired better coordination between lectures and group tutorials in the program.
Table 5.
Stage Statements
(N)
Sub categories
1 6  Better overall structure.
 Better homepage.
 Frequent small examinations.
2 32  PBL is not suitable for every course/moment.
 Better connection between lectures and work in tutorial groups.
 Need for flexibility regarding participation in tutorial groups – not
punishment!
 PBL is good!
3 28  Better connection between lectures and work in tutorial groups.
 No PBL in the clinical term.
 More vignettes/cases.
 More lectures.
 Better feedback.
Total 66  PBL is not suitable for every course/moment.
 Better connection between lectures and work in tutorial groups.
Discussion
When sounding student opinion regarding PBL at our medical college, four major factors were defined: Factor
1, PBL as a method of learning; Factor 2, the role played by the tutor; Factor 3, stress and feelings of
insecurity resulting from PBL and Factor 4, traditional teaching methods in relation to PBL.

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Regarding Factor 1, the students ”tended to agree” that PBL is a useful learning method.
Regarding Factor 2, the students perceived their tutors as being helpful in PBL, but not as much as the
method itself.
Regarding Factor 3, PBL causes stress and feelings of insecurity. This agrees with the results of others in the
few papers published on stress and PBL. When Lewis compared traditional teaching methods with PBL, PBL
was found to be a source of considerable stress (Lewis et al., 2009). This was also described by Moffat in
first-year medical students (Moffat, McConnachie, Ross, & Morrison, 2004). We did not investigate coping in
this student group, as the study was not designed to explore that issue. However it is possible that
improvements in curriculum design and better formulated aims could give the students more security in
learning and consequently diminish feelings of stress.
Regarding Factor 4, lectures and clinical practice were considered the most important sources of knowledge.
The students perceived traditional teaching methods as being almost as good as PBL in the later stages.
The student commented that they needed better formulated aims and objectives, smaller tutorial groups and
more lectures. They also felt that the quality of tutors varied, and that their tutors were not involved enough.
Some considered that senior students might perform better as tutors, and others that PBL is not suitable in all
situations. In the students’ opinion coordination between lectures and tutorials needs to be improved.
At the beginning of the medical program PBL was regarded as a relevant and useful method of learning. This
held for the duration of the program, but appreciation declined as time went by. This decrease in appreciation
regarding PBL coincided with a decrease in the students’ faith in the role of the tutor and an increase in their
appreciation of traditional teaching methods, the latter being regarded as equal by the end of the program. This
trend is not necessarily negative as it may be a sign of a student´s intellectual maturation and increase in
autonomy during the years at the medical college. Of course this pattern can be interpreted in a number of
ways, but the tutor’s role, or rather the absence of tutors in Stage 3of the medical program, may be one
possible reason for the decrease in student appreciation of PBL and their increased trust in traditional teaching
methods. The exact explanation can only be elucidated by a qualitative study. Similar results led Moust to the
conclusion that this is a sign of PBL erosion (J. H. C. Moust, Van Berkel, & Schmidt, 2005) and proposed
new ways to revitalize PBL groups (J. Moust, Roebertsen, Savelberg, & De Rijk, 2005). In our opinion these
are very good suggestions based on pertinent analyses. We also suggest that better coordination between PBL
tutorials and clinical teaching could also revitalize trust in PBL later on in the curriculum at Linköping
Medical College.
Our results indicate that PBL during the early terms of a medical curriculum may increase student autonomy.
Students may change their behaviour when embarking on the clinical stage (Terms 6 and upwards) as they
have more contact with physicians and therefore develop role models on how to get information and how to
reflect on it. Most physicians in clinical practice still use traditional teaching methods for lifelong learning.
That role model may influence student behaviour and could at least partly explain our results. This may be one
of the reasons why Harvard Medical School has introduced a more structured PBL(Cardozo, Raymond, &
White, 2012). Even our students in response to the open question stated a lack of clearly formulated study
aims and objectives.
Developing curricula to better fit student requirements may diminish student stress and improve learning in a
medical program. In a mixed PBL curriculum where web-based learning was combined with PBL, the
students were very positive (Woltering, Herrler, Spitzer, & Spreckelsen, 2009) and this may well be one of the
ways to improve PBL in the future.
There are relatively few studies in the literature on student perception of the use of PBL in different contexts.
One studied the opinion of students at the time of introduction of PBL (Bernstein, Tipping, Bercovitz, &
Skinner, 1995; McCourt & Gail Thomas, 2001). Bernstein et al reported that “The students rated traditional
methods as better for knowledge acquisition, whereas PBL methods were rated better for improving teamwork
and doctor-patient relationships” (Bernstein et al., 1995). This implies that different aspects of medical
education can be handled with different methods of teaching/learning.

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Senevirante et al studied student perception of PBL in a new curriculum. The response frequency was high
and answers showed that the students perceived PBL as time-consuming. Half of the students felt that PBL
improved communication and problem-solving skills and almost half were satisfied with group tutorials
(Seneviratne, Samarasekera, Karunathilake, & Ponnamperuma, 2001). That study is not directly comparable
with ours as the numbers of responders was about a third of that in our survey, and the issues of that study
were quite different. Ragab in his study compared the preferences and learning outcomes of medical students
between PBL and traditional lectures and found that students preferred PBL. His conclusion was that
introduction of a hybrid-PBL curriculum was to be highly recommended (Ragab Ibrahim et al., 2014).
The main limitation of our study is the same as of all quantitative studies, but it does reveal the weakness of
PBL as practised at our Medical College, and raises issues which have to be examined using qualitative
methods. As the open question was answered by roughly one third of the students completing the
questionnaire, their responses do hint at the true situation but they have to be interpreted with caution. One
possibility, for instance, is that the students who answered the open question are those who chose to voice
criticism regarding PBL or the medical program, while positive or indifferent students chose not to answer.
Conclusion
We defined four factors which describe how students perceive work in PBL tutorial groups at our Medical
School, namely: 1. PBL as a method for learning; 2. the tutor’s role; 3. PBL,stress and feelings of insecurity;
and 4. coupling of PBL to traditional teaching methods.
One third of the students completing the survey questionnaire responded to the open question. They expressed
the wish to have better formulated aims and objectives, smaller tutorial groups and more formal lectures, and
they felt that PBL does not suit all courses/moments in the curriculum. The students also complained that the
quality of tutors varies, and described their tutors as not being involved enough, and suggested that senior
students might perform better as tutors. Finally coordination between lectures and tutorial groups throughout
the medical program must be improved.
Acknowledgements
We thank Mr. Olof Malm for his exemplary registration of data in the database. Those in the “Network for
lecturers at the medical college in Linköping” who, in collaboration with other teachers from the medical
program and the Institution of Behavioral Sciences, initiated the survey. Special thanks to the Dean of the
medical college for his support in distributing the surveys.
Disclaimer: none
Notes on Contributors:
Zoltán Szabó MD. PhD1, is part of the Division of Cardiovascular Medicine, Department of Medical and
Health Sciences, Faculty of Health Sciences, Linköping University, Department of Thoracic and Vascular
Surgery, Heart and Medicine Center, County Council of Östergötland.
Márta Harangi MS.2, is part of the from 2Linköping, Sweden.
Eva Nylander MD. PhD3, is part of the Department of Clinical Physiology and Department of Medical and
Health Sciences, Linköping University.
Anders Ljungman PhD6, is part of the Division of Neuro and Inflammation Sciences, Faculty of Medicine and
Health Sciences. Linköping University, SE-581 85 Linköping, Sweden.

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Annette Theodorsson MD. PhD4, is part of the Neurosurgery, Department of Clinical and Experimental
Medicine, Faculty of Health Sciences, Linköping University, Department of Neurosurgery, County Council of
Östergötland, Linköping, Sweden.
Henrik Ahn MD. PhD1, is part of the Division of Cardiovascular Medicine, Department of Medical and
Health Sciences, Faculty of Health Sciences, Linköping University, Department of Thoracic and Vascular
Surgery, Heart and Medicine Center, County Council of Östergötland.
Bo Davidsson PhD5, is part of the Department of Behavioral Sciences and Learning, Linköping University,
Linköping, Sweden 6 Division of Neuro and Inflammation Sciences, Faculty of Medicine and Health
Sciences. Linköping University, SE-581 85 Linköping, Sweden.

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Table legend
Table 1. Means and standard deviations for the four factors.
Table 2. Means and standard deviations for the four factors for the three stages in the medical program.
Table 3. Students’ overall comprehension of PBL tutorial groups, aims and objectives.
Table 4. Students’ overall appreciation of tutor competence and involvement.
Table 5. Student general opinion of PBL organization at our medical college.
Appendix 1. Post hoc test results

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Supplemental Digital Content
Appendix
Bonferroni post hoc tests
Multiple Comparisons
Bonferroni
Depend
ent
Variable (I) Stage (J) Stage
Mean
Difference
(I-J) Std. Error Sig.
95% Confidence Interval
Lower Bound Upper Bound
Factor 1 Stage 1 Stage 2 ,10832 ,05943 ,207 -,0344 ,2510
Stage 3 ,38562*
,05336 ,000 ,2575 ,5137
Stage 2 Stage 1 -,10832 ,05943 ,207 -,2510 ,0344
Stage 3 ,27730*
,05214 ,000 ,1521 ,4025
Stage 3 Stage 1 -,38562*
,05336 ,000 -,5137 -,2575
Stage 2 -,27730*
,05214 ,000 -,4025 -,1521
Factor 2 Stage 1 Stage 2 ,30342*
,07327 ,000 ,1274 ,4794
Stage 3 ,47887*
,07020 ,000 ,3102 ,6475
,07327 ,000 -,4794 -,1274
Stage 3 ,17544*
,06765 ,029 ,0129 ,3380
,07020 ,000 -,6475 -,3102
Stage 2 -,17544*
,06765 ,029 -,3380 -,0129
Factor 3 Stage 1 Stage 2 ,17663*
,06605 ,023 ,0181 ,3352
Stage 3 ,15302*
,05963 ,032 ,0099 ,2962
,06605 ,023 -,3352 -,0181
Stage 3 -,02361 ,05909 1,000 -,1655 ,1182
,05963 ,032 -,2962 -,0099
Stage 2 ,02361 ,05909 1,000 -,1182 ,1655

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Factor 4 Stage 1 Stage 2 -,12349 ,05360 ,065 -,2521 ,0052
Stage 3 -,26891*
,04866 ,000 -,3857 -,1521
Stage 2 Stage 1 ,12349 ,05360 ,065 -,0052 ,2521
Stage 3 -,14542*
,04727 ,007 -,2589 -,0320
Stage 3 Stage 1 ,26891*
,04866 ,000 ,1521 ,3857
Stage 2 ,14542*
,04727 ,007 ,0320 ,2589
*. The mean difference is significant at the 0.05 level.

How-Students-Perceive-Problem-Based-Learning-(PBL)-DOI

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