Problem-based Learning and Theories of Teaching and Learning in Health Professional Education

Rebecca E Gewurtz, Liliana Coman, Shaminder Dhillon, Bonny Jung, Patty Solomon,
McMaster University, Canada

Introduction

Problem-based learning (PBL) was developed within the medical program at McMaster University in the mid-1960s as an active learning approach to help students synthesise and integrate large quantities of information (Solomon, 2005). Subsequently, the PBL approach has become an accepted instructional approach (Saarinen-Rahiika & Binkley, 1998; Solomon, Binkley, & Stratford, 1996) and has been adopted by many health professional programs worldwide (Neville, 2009). The literature describes PBL in three ways: a process of inquiry, a learning-to-learn approach, and a method for acquiring new knowledge (Schmidt, van der Molen, Winkel, & Wijnen, 2009). It consists of the following elements: 1) small groups of students are presented with a scenario; 2) the instructor role transforms from imparter of information to facilitator of learning; 3) emphasis is on self-directed learning; and 4) students engage in a problem-solving process (Hmelo-Silver, 2004; Schmidt, Rotgans, & Yew, 2011; Solomon, 1994; Walsh, 2004)

PBL has been linked to several theories of teaching and learning. However, how these theories are applied in a PBL environment remains unclear. One theory alone may be insufficient to account for the complexities associated with PBL. In recent years, there have been several developments in theories of teaching and learning that have implications for PBL-based curricula. Developments in cognitive science and information processing, for example, have raised questions about the effectiveness of PBL in helping students acquire knowledge needed for practice (Hmelo-Silver, Duncan, & Chinn, 2007; Kirschner, Sweller, & Clark, 2006). Different perspectives of cognition have been applied to experiential learning and adult education, including the role of reflection, working through conflict, situated learning, learning through action and interaction, and resistance of power (Fenwick, 2000; Eames & Cates, 2011). Some evidence highlights the effectiveness of providing students with opportunities for choice and encouraging students to accept responsibility for their learning (Albanese, 2000); However, other evidence suggests that more structure and guidance is needed to help novice learners understand and integrate complex information (Kirschner et al., 2006). Thus, there is little agreement about the most effective way to support and guide student learning.

Evidence suggests that learning improves when theories of teaching and learning are implemented (Bergman et al., 2013). There is a need to understand how PBL should be implemented, what kinds of learning outcomes can be supported by PBL, and strategies educators can use to support student learning (Hmelo-Silver et al., 2007). The objective of this paper is to review literature on theories of teaching and learning associated with university-based adult learning and to describe if and how these theories relate to and can inform the PBL approach within university-based education programs.

Methods

Using the methodology described by Arksey and O’Malley (2005), we conducted a scoping review of the literature on theories of teaching and learning associated with university-based adult education and their relevancy to PBL. Scoping review methodology involves mapping the literature to identify “the current state of understanding” (Anderson, Allen, Peckham, & Goodwin, 2008, p. 10) by summarizing its extent, range, and nature (Arksey & O'Malley, 2005; Levac, Colquhoun, & O'Brien, 2010). It consists of six main steps, as outlined in Table 1. We identified relevant articles published between 1995–2014 by searching three electronic health sciences databases (MEDLINE, CINAHL and EMBASE) and an education database (ERIC). We identified 11 theories of teaching and learning relevant to PBL (see Table 2). We used these theories and the terms “problem-based learning” or “medical/health professional education” as keywords in our search. We excluded articles that focused on student attributes or outcomes, and those that were not related to university education. These searches yielded 368 abstracts that addressed a theory or theories of teaching and learning and university-based education. The abstracts were reviewed by the first two authors and were included if they addressed a link between theory and university-based education. From this process we identified 137 articles for full-text review.

All five authors contributed to the study selection and charting processes (Arksey & O'Malley, 2005; Levac et al., 2010). We excluded articles about clinical education and focused on broad curriculum design in the university setting. We developed a charting grid to extract, organize, and synthesize relevant information from each article including: theory of teaching and learning addressed; key principles pertaining to the theory; relevance to PBL as interpreted by the reviewer; and, any supporting evidence. Opinion papers that did not draw on the available literature, or advanced a new perspective, were excluded. Decisions about including or excluding articles were discussed in team meetings. The first two authors reviewed all extraction grids. From this process, 60 relevant articles were included in the data charting.

As we charted data from the articles, we also reviewed the theory descriptions offered by the original theorists to accurately describe each theory. There were overlap and commonalities between theories, making it hard to compare across theories. The principles of each theory were interpreted and described differently by different authors, and key principles were associated with more than one theory. For example, transformative learning theory (Kitchenham, 2008; Mezirow, 2003) was introduced as an adult learning theory (Knowles, 1990), described as “constructivist” (Forbes, Duke, & Prosser, 2001; Piaget & Inhelder, 1969; Vygotsky, 1962), and having much in common with experiential learning (Sewchuk, 2005). Consequently, we shifted our focus to the principles associated with the theories, and considered how these principles inform PBL. This focus provided a more fruitful way to synthesise the existing literature in order to develop recommendations for practice. Thus, we returned to the data extraction grids and identified eight distinct principles that emerged from our scope of the literature, crossed multiple theories of teaching and learning in university-based adult education, and were relevant for PBL in university-based education.

Table 1: Overview of the six-stage methodological framework for conducting a scoping study, as applied in this review (Arksey & O'Malley, 2005; Levac et al., 2010)

Findings

The eight principles that emerged from our review of the literature on the theoretical foundations of PBL are presented in Figure 1. A key finding from our review was the significant overlap between theories of teaching and learning, and the undefined boundaries and connections between theories. Some theories have clear links to PBL and were explicitly noted in relation to PBL. While other theories have not been described in relation to PBL, they have potential applications and relevancies. We noted that adult learning and constructivist learning theories were most dominant and together captured the central elements of the eight principles that emerged. We also noted that there has been an increase in empirical studies related to theories of teaching and learning published in the last five years.

Figure 1: Eight principles associated with theories of teaching and learning that can inform PBL

Principles that can inform PBL in health professional education

We provide a brief overview of the eight principles based on the findings from the scoping review. The associated theories of teaching and learning are outlined in Table 2.

Table 2: Principles associated with theories of teaching and learning that can inform PBL

1. Adult learners are independent and self-directed

This principle is one of the central principles of andragogy (Abela, 2009; Beckert et al., 2003; Bergman et al., 2013; Chikotas, 2008; David & Patel, 1995; Hean et al., 2012; Merriam, 1996; Taylor & Hamdy, 2013). However, it is also addressed within transformative/emancipatory learning (Johnson, 2000; Parker & Myrick, 2010), social learning (Bahn, 2001), and cognitive learning theories (Brandt, 1996). Learners are thought to become increasingly independent and autonomous as they transition from novice to expert learners (Brandt, 1996; Johnson, 2000; Parker & Myrick, 2010), and become more self-directed (Bahn, 2001; Shreeve, 2008). Thus, learners are able to take responsibility for their learning and actively construct their experience (Copp, 2002; Shreeve, 2008). As they become more independent, they can better evaluate their own learning needs.

Although this principle is mentioned in several articles, the papers draw almost exclusively on theoretical evidence. For example, Schumacher et al. explored how theories of teaching and learning inform the development of master learners (Schumacher et al., 2013). These authors note that the motivation to learn is driven in part by a sense of autonomy and competence, as posited by self-determination theory. Within the context of the PBL tutorial, tutors can encourage students to be self-directed by inviting them to articulate the next steps in their learning and ensuring that their ideas are valued. Regular affirmative feedback can foster a sense of competence and create a safe environment for the provision of constructive feedback.

2. Adult learners are goal-oriented and internally motivated

Also consistent with andragogy, this principle was discussed in several articles (Abela, 2009; Beckert et al., 2003; Bergman et al., 2013; Chikotas, 2008; David & Patel, 1995; Hean et al., 2012; Merriam, 1996; Taylor & Hamdy, 2013; Zigmont et al., 2011a, 2011b). It suggests that adults are ready to learn when they experience the need to learn (Merriam, 1996; Stagnaro-Green, 2004; Taylor & Hamdy, 2013). Although all learning environments have extrinsic motivators (e.g. grades), the focus in andragogy is students’ desire to acquire new knowledge. Some articles explicitly link PBL to self-directed learning and learning motivation (Mann, 2011; Taylor & Hamdy, 2013), suggesting that PBL tutorials can provide an ideal learning context to support student-directed learning.

While prominent in the andragogy literature, little empirical evidence is offered to support this principle. As an example of theoretical support, Stagnaro-Green (2004) reviewed the literature on adult learning principles in the context of medical education and highlights that time for self-reflection should be emphasised in order to stimulate self-directed goals and internal drive for learning. As an exception, Beckert et al. (2003) studied the effects of a voluntary, after-hours course designed in collaboration with medical students to address student identified study needs. In PBL tutorials, students identified learning objectives based on their learning needs. The findings highlight that student satisfaction with the course was high on value and relevance, and that performance on examinations was enhanced.

3. Learning is most effective when it is applicable to practice

This principle is consistent with andragogy and constructivism. Adult learners want to see a clear link between what they are learning and what they want to achieve in practice (Abela, 2009; Beckert et al., 2003; Bergman et al., 2013; Hean et al., 2012; Hrynchak & Batty, 2012; Merriam, 1996; Rolloff, 2010). Kassirer (2010) states: “people learn new knowledge and skills most effectively when they are presented in the context of the application of new knowledge to real-life situations” (pp. 1118-1119). Hean et al. (2012) highlight that ensuring learning is relevant to practice should guide the selection of teaching and learning strategies.

Despite the lack of empirical evidence to support this principle, application to practice is addressed within PBL in health professional education. The PBL curriculum is planned around health care scenarios inspired by clinical situations. Learners are required to be explicit about their clinical reasoning and decision-making processes as they work through the scenario, explaining and providing rationale for what they would do if they encountered this situation in practice.

4. Cognitive processes support learning

This principle is derived primarily from information processing and cognitive load theories. It is concerned with strategies for reducing cognitive overload and promoting knowledge acquisition (Kaylor, 2014; Khalil, Paas, Johnson, & Payer, 2005a, 2005b). Cognitive load is affected by the nature of the material and strategies for information presentation (Hessler & Henderson, 2013; Kaylor, 2014; Khalil et al., 2005a, 2005b; Pociask et al., 2013). Learning is promoted when learners engage in strategies such as elaboration, abstraction, drawing inferences and combining simple ideas into more complex ones (Khalil et al., 2005a, 2005b; van Merrienboer & Sweller, 2010). Cognitive demands should challenge, but not exceed cognitive capacity (Schumacher et al., 2013). Furthermore, Khalil et al. (2005a) noted that novice and advance learners require different learning strategies. Specifically, novice learners cannot always distinguish between important and irrelevant information. Thus, novice learners may need more guidance to identify critical information and develop focused learning objectives and plans.

Schumacher et al. (2013) argue that giving learners “an optimal amount of developmentally appropriate work” will avoid cognitive overload, which is detrimental to learning (p. 1637). This perspective is supported by Pociask et al., (2013) who examined the effectiveness of instruction designed to improve learning among occupational therapy students in a gait analysis course. Findings show that students receiving modified instruction aimed at reducing cognitive load without altering content or total instructional time, performed significantly better than the control group and reported significantly less instructional difficulty. Their study suggests that matching cognitive demands with the learners’ cognitive capabilities and adopting instructional approaches to reduce cognitive load can optimize learning.

5. Learning is active and requires active engagement

This is a key principle of many learning theories including constructivism, experiential learning, social learning, information processing, collaborative/cooperative learning, cognitive learning and discovery learning. Active learning is considered fundamental to constructivism where learning involves a process of constructing knowledge, rather than acquiring it (Bergman et al., 2013; Brandt, 1996; Chikotas, 2008; Copp, 2002; Dolmans et al., 2005; Hrynchak & Batty, 2012; Mann, 2011; McCarlie & Orr, 2010; Terrell, 2006; Torre et al., 2006). This principle suggests that learners should have the opportunity to actively engage in the learning process (Rauk, 2003; Shreeve, 2008), work towards solving problems (Hrynchak & Batty, 2012; Lien & Hakim, 2013), discover new knowledge through active participation and cooperation (Lin, 2013), construct new knowledge in light of past experience or existing knowledge (Bergman et al., 2013; Mann, 2011), and hypothesise possible outcomes (Svinicki, 1998).

Although this principle is mentioned in several articles and is associated with multiple theories of teaching and learning, the papers draw almost exclusively on theoretical evidence. As an example, a review of the literature on PBL in nursing highlights the importance of constructivism and the need for active involvement of learners (Kantar, 2014). However, in a study conducted by Bergman et al. (2013), the findings highlight that active engagement in the learning process was one of the most preferred strategies among students in an anatomy course. Specifically, active engagement allowed for a more tailored learning experience, where students could progress at their own pace and create a personalized learning experience.

6. Interaction between learners supports learning

This principle is explicitly identified within seven theories, including constructivism, adult learning theory, social learning, experiential learning, collaborative/cooperative learning, contextual learning and vicarious learning. It provides the basis for learning in small groups where discussion and debate occur (Albanese, 2000; Bergman et al., 2013; Copp, 2002; David & Patel, 1995; Dolmans et al., 2005; Horii, 2007; Hrynchak & Batty, 2012; Lin, 2013; Merriam, 1996; Rolloff, 2010). Learning is a collective and social process (Mann, 2011; Poore et al., 2014; Schmidt et al., 2011) where learners are encouraged to share knowledge and understanding, present and explore alternative perspectives, and explore the advantages and disadvantages of their perspectives (Baker, 2000; Chikotas, 2008; Dolmans et al., 2005; Jackson et al., 2013; McCarlie & Orr, 2010; Torre et al., 2006; Whitman, 1993). Working in a PBL context, learners support each other by identifying challenges related to the scenario, and clarifying concepts. Furthermore, learning is promoted through peer observation and feedback (Stegmann et al., 2012).

Lin (2013) compared the effect of technology-based cooperative learning with technology-based individual learning among nursing students. Although there were no significant differences in skill performance, cooperative learning led to improvements in critical thinking and knowledge enhancement. The authors suggest that encouraging students to work together and appreciate different perspectives through peer dialogue is critical to learning. Furthermore, Bergman et al (2013) found that students were more satisfied with a teaching method that relied on collaboration (in addition to other learning principles). Although not associated with strong empirical evidence, these findings suggest that interaction between learners is an important principle that can support learning.

7. Activation of prior knowledge and experience supports learning

Although most widely associated with constructivism (Baker, 2000; Chikotas, 2008; Terrell, 2006; Whitman, 1993), activation of prior knowledge is implied by many theories of teaching and learning and is fundamental to information processing (Albanese, 2000; Rauk, 2003; Terrell, 2006). Learners build upon their existing knowledge and experience as they explore new areas and acquire new knowledge and skills (Bergman et al., 2013; Chikotas, 2008; David & Patel, 1995; Horii, 2007; Mann, 2011; Merriam, 1996; Poore et al., 2014; Schmidt et al., 2011; Stagnaro-Green, 2004; Svinicki, 1998; Taylor & Hamdy, 2013; Zigmont et al., 2011a, 2011b). Building on their existing knowledge allows learners to challenge their beliefs, values and understanding of the world, and consider alternative perspectives.

Although identified as a key learning principle, the supporting evidence is almost exclusively theoretical. As an exception, Bergman et al. (2013) found that students preferred a teaching format that stimulated them to build upon existing knowledge when learning anatomy in a PBL course. The pervasiveness of this principle within the literature suggests that the link between activating prior knowledge and ongoing learning is widely accepted. However, further study is required to build the empirical basis for this principle.

8. Elaboration and reflection supports learning

Elaboration and reflection are key components of adult learning theories, providing opportunity for learners to analyze, synthesise and integrate newly acquired knowledge through application to a case scenario and to future practice (Albanese, 2000; Eisen, 2001; Johnson, 2000; Khalil et al., 2005a, 2005b; Milligan, 1999; O'Connell, 2010; Parker & Myrick, 2010; Williams, 2001). Learners can broaden their learning and take stock of the knowledge they have acquired by revisiting their learning objectives and reflecting on further learning needs (Bergman et al., 2013; Brandt, 1996; H. F. Hodges, 2011; Hrynchak & Batty, 2012; Schmidt et al., 2011). Other authors have highlighted the use of reflective journals (Lien & Hakim, 2013), peer observation with feedback (Mann, 2011; Stegmann et al., 2012) and debriefing (Poore et al., 2014; Zigmont et al., 2011a, 2011b) to provide a forum for elaboration on content, for enhanced learning.

Complexity science, within a PBL context, provides a framework for active learning and transformation by pushing students out of their comfort zones towards uncertainty (Fraser & Greenhalgh, 2001). It can specifically provide an approach that stimulates innovative problem solving by considering multiple questions and possible answers that vary under different conditions. As an example, H. F. Hodges (2011) conducted a pilot study of a PBL strategy guided by the principles of complexity science with nursing students. In this study, students were specifically prompted to elaborate and reflect on their learning and consider innovative problem solving to adapt to change and improve their performance. The findings revealed high levels of satisfaction among students, and stronger performance on the assignment. However, further study of the effects of elaboration and reflection are required in order to establish the empirical basis of this principle and its impact on learning.

Discussion

Our findings highlight that no single theory of teaching and learning can fully represent the complexity of learning in PBL. Our review highlights the diversity within the literature in terms of how theories of teaching and learning are described and applied. These findings are consistent with the literature that has emphasised the need to draw on multiple theories of teaching and learning in university-based health professional education (Albanese, 2000; Bergman et al., 2013; Dolmans et al., 2005; Hean et al., 2012). Recognising the complexity of the PBL environment and the fluidity between theories of teaching and learning, we propose eight principles from across 11 theories that can inform how PBL is operationalised in university-based health professional education. These key principles have much theoretical support and some empirical support.

The principles expand on existing literature and allow for recommendations for curriculum design that are relevant to PBL and can be operationalised within university-based education programs (see Table 3). Specifically, our findings suggest that active engagement and interactions should be encouraged, that students should be prompted to activate their prior knowledge and experiences, and that elaboration and reflection on learning is critical. The small group format of PBL can facilitate this engagement if students question each other, consider alternative perspectives and are actively involved in setting learning objectives. Although these are common steps in the PBL process (Walsh, 2004), the findings presented here highlight and reinforce their importance. Furthermore, these principles could be of use to those charged with curriculum design within university-based education programs. Specifically, the principles can prompt reflection about how to promote active engagement, provide multiple opportunities for student interaction, encourage students to draw upon their prior knowledge and experience, and support elaboration and reflection on learning within university instructional design. A PBL model based on these principles, rather than on a single theory of teaching and learning, can contribute to building a collaborative partnership for learning within the small student group and between students and faculty. This collaborative partnership can support students as they develop their capacity to recognize the unknown, respond to the unpredictability of the discussion stimulated by the problem, and participate in the discovery process, thereby enhancing their ability to function in a clinical environment.

A limitation of this review is that we did not examine learning outcomes; therefore, we are unable to make any claims about the effectiveness of PBL for promoting learning or operationalising these principles. Rather, the findings provide indication of the theoretical basis of PBL and highlight several key components of the PBL process. Another limitation is that we restricted our review to teaching and learning theories; it can be argued that other theoretical frameworks could guide the operationalisation of PBL in health professional education, such as socio-cultural or bio-scientific theories. Furthermore, we excluded papers related to clinical education in order to focus on teaching and learning in the university environment, which limits the suggestions in Table 3 to the university environment. However, one of the principles that emerged from this research highlights that learning is most effective when it is applicable to practice. This finding suggests that the connection between classroom-based learning and real-world application should be made explicit (Eames & Cates, 2011). All eight principles outlined in our findings could be applied to clinical education. For example, the implication of the fourth principle (cognitive processes support learning) in a clinical setting would focus on offering learners the optimal exposure to developmentally appropriate work. Further research could explore the extent to which PBL principles are used in clinical education and if the application of these principles in clinical education enhances performance.

Although we did not include a formal approach to stakeholder consultation as the sixth step in the scoping review methodology, the authors of this paper are university-based educators in health professional programs that utilise PBL. We engaged in regular and ongoing team discussions about how the emerging findings resonated with our experiences as educators in PBL programs. Furthermore, we brought our findings to our respective curriculum committees for further discussion.

Our scope of the literature also revealed that educational research has evolved over the 20 years. Theories of teaching and learning are becoming increasingly prominent in the literature and referred to in discussions about approaches, methods and strategies for health professional education. Recent literature also contains more robust studies about teaching and learning in health professional education. This trend is promising. However, our findings emphasise the need for further research exploring the relationship between theories and learning outcomes. Further research could also be directed at examining the effectiveness of PBL as a method of implementing these key principles and promoting learning.

Table 3: Recommendations for PBL curriculum in health professional education based on eight principles of teaching and learning

Conclusions

Our scoping review suggests that PBL is grounded in key principles that are common to many theories of teaching and learning that can guide how PBL is implemented in university-based health professional programs. While it has been argued that health professional education should be based on theory and evidence, (Bordage, 2009), B.D. Hodges and Kuper (2012) suggest that theories are “dynamic, evolving and always at risk of being disproven” (p. 32). Our findings address both claims by suggesting that there is an emerging theoretical basis for PBL grounded in key principles that represent multiple theories of teaching and learning. The eight principles, derived from multiple theories of teaching and learning, provide guidance for how PBL can be implemented and operationalised within health professional education. Further work is needed to develop the empirical basis for these principles and examine if PBL is an effective means of implementing them within university-based education programs. Research is also needed to identify how other theories could, more broadly, inform PBL (B. D. Hodges & Kuper, 2012).