The implementation of PBL: problems and strategies

If faculty want to convert from a traditional method to PBL, they should be clear about the reasons for this change.

In this chapter we shall address the issues of justification for PBL, discuss the kind of problems one can expect with introducing PBL in a (new) curriculum. Finally we have a few suggestions for how these difficulties can be overcome.

Reasons for change

Maybe the most important reason for change can stem from an awareness of teachers and health care administrators of the lack of quality in the traditional learning environment. Most of these environments are not very stimulating. Students and teachers are the product of didactic teaching, caused by the teacher's faith in the formal lecturing method. This kind of learning environment fails to produce students capable of self-initiated study and critical thought who are sensitive to the evolving needs of the society. More and more teachers express their desire for students to be more responsible for their own learning. When students are active in the learning process by sourcing their own learning materials, guided by good facilitators, they are likely to be better prepared for self initiated and self directed life long learning.
For example Harvard Medical School in the USA. embarked upon a new pathway to General medical education for different sorts of reasons. We will quote their philosophy because it summarises the important reasons for change in a nutshell.
"The new curriculum (......) would feature equal emphasis on attitudes, skills and knowledge; careful selection of essential knowledge in order to avoid information overload; the perspective of a single faculty looking at the entire span of general medical education rather than the discrete, separately planned curriculum components; close student-faculty contact in smaller groups, in an environment in which students and faculty learn together; interweaving of clinical and basic science elements throughout the curriculum; use of active educational methods such as problem solving and information management, (.....) emphasis on skills enabling students to become lifelong learners."

A second reason to change a program is the awareness of teachers that there is a gap between the goals of the program (to eliminate for example leprosy in the community) and the actual skills and attitudes the students have in practice. Sometimes students know a lot about very particular topics but have little insight in more general problems. Or, they lack the ability to apply their knowledge in practical situations.
In evaluations of programs and courses many students report themselves a curricular overload, a cramming of knowledge, sometimes called curriculopathy by very critical evaluators.

After this sort of evaluations a teaching staff can start a conversion process by attempting, first, to establish desired student outcomes. Teachers might ask themselves "What is that we want our students to know, and know how to do, when they leave the program?"
For example at the "National Tuberculosis and Leprosy Control Program" Training Centre ( NTLCP) in Nigeria, this question has to be raised in order to combat the resurgence of tuberculosis and its association with HIV infection. Another question was: "Have students been adequately trained to recognise early signs of leprosy as to distinguish its lesions of those of other common skin lesions in the community?"
Moreover, a discussion of the educational objectives revealed that the teachers wanted the students to think and act more independently as well, to enable them to deal with a great diversity of often-unpredictable circumstances.

A third reason to introduce PBL arises in a situation where the course entails multidisciplinary subjects. A good example is a course in Tuberculosis and leprosy where the students have to deal with medico-surgical (treatment, surgery), physical (disabilities, deformities), psychosocial (stigma, rejection and destitution) and economic (loss of earnings occasioned by deformities). This complex problem as in Olumide's case requires an integrated approach to training, as in PBL. The PBL method provides the opportunity for an holistic approach to the understanding of the problem as against the fragmental approach in the traditional method.

The fourth reason has to do with the advantages associated with small group work. While working in small groups, students have the opportunity to help one another understand in an atmosphere of equal partners.
Team spirit and leadership development can be enhanced because all group members are expected to carry out tasks assigned to them and because leadership roles are rotated among group members.
Communication skills are enhanced since each member is expected to present his/her findings. Other students have then the opportunity to criticise such presentations. During professional life these skills are extreme helpful for working in different kinds of health teams.

Resistance to change

These reasons for change, however, can be a major source of resistance to PBL at the same time.
As was said before, teachers and students are so used to the didactic teaching method that both have to change their attitudes. In PBL a teacher (tutor) is not seen any more as an authority or an expert in the field, but as a facilitator to stimulate the learning of the students. This change of role of the teacher was nicely characterised by one of the contributors on PBL on Internet ( a change from being the "sage at the stage" to serving as "guide by the side"
Many teachers cannot accept this change easily. If they move into "untraditional" educational methods they may feel risky, scary and uncertain. Sometimes they cannot imagine that students can study in another way than they have studied themselves. Moreover they really like to show their expertise. One of their arguments can be that a lecture can deliver more information about a subject to more people. They ignore then the value of working in groups, communication skills and dealing with uncertainty, issues that the lecture based education has never excelled in. This brings many teachers back to a mode of interaction with the students that is completely the opposite of facilitation. If this resistance is great among teachers, a sort of institutional complacency may result in which critical discussion of teaching methods becomes difficult and tenacious.

Another difficulty in converting to PBL resides in the students being unfamiliar with this PBL methodology. They frequently express frustration when they first encounter PBL. Usually they have progressed through an educational system where knowledge is divided into arbitrary disciplines and brought to them through "talk and chalk" lectures. Memorising of information is their goal, as well as the regurgitation on Multiple Choice examinations. Their premise is that the teachers are responsible for the their learning, while in PBL all of the sudden they are expected to take responsibility for that themselves. Teachers are no longer telling them the correct answers.
This creates a very ambiguous situation for students. Many will react by saying:
"What are we supposed to do?"
"How do we do that?"
"If you only tell me what you want, I would do it"
To help the students to overcome this initial problem, a great deal of coaching is required. Every new group of students must be helped and encouraged as they start to take on responsibility for their own learning. The tutor should be available and respectfully guide them throughout this difficult process of transition.

Another reason for resistance to the PBL method may be also found in the double task of health personnel. Doctors or supervisors must see patients on the one hand, and they should work with students on the other hand. One of the problems is that in many institutions the first role, their contact with patients, is valued more highly than their role with students. And thus professional careers are more related to the first professional task.

Finally one can imagine that, many doctors and supervisors are afraid of extra workload when traditional teaching is converted to PBL. They have to adapt themselves to the student centred style. To function in small groups is seen as an extra burden in their professional lives.
Investigations show, however, that this is not true. In the very beginning of a new program, teachers have to familiarise themselves with the new method indeed. This does cost extra time, which cannot be ignored. But after some time this investment will pay off. Eventually, tutors find that there is no difference in the total amount of time they have to spend to the educational process, but they see a change in the way they spend time. In the traditional, teacher centred courses most of the time is spend in the preparation of the subject in absence of students.
In PBL however we see the converse. Most of the time is spend in the presence of the students.

Introducing PBL

If teachers want to introduce PBL it certainly can be introduced into an established school or program. It is a fallacy to think that only new schools or program's are able to introduce this new method. Schools using PBL in the "Network of Community of Educational Institutions for the Health Services" have described a large range of different approaches among institutions. Across all of these, success in the introduction of PBL appears to be depending on a common set of factors.
A first factor is the dedication among the teaching staff and their engagement in planning and implementing specific PBL components, as were described in this booklet. At the NTLCP Training Centre in Nigeria about ten years ago, an interdisciplinary group of 26 people were assembled by the Federal Ministry of Health who concentrated their attention on the tasks that supervisors would have to fulfil in the community.
This group was convinced of the necessity to change the old programme, and started enthusiastically with the preparations for the new programme.
This team was responsible for the defining of the desired skills and competencies and the planing of the new curriculum.
After that, workshops were organised for teachers who are assumed to participate in the programme. The purpose of these workshops was:

  1. to introduce the PBL methodology
  2. to train the tutors to facilitate small group learning, using the 6 steps in PBL, and,
  3. to construct problems in concordance with the needs of the community, and the tasks of the health workers.

Also introductory days were organised for students to allow them to become familiar with the ideas and methods of PBL, concentrating on the learning around problems, the self-directed learning and the use of the library

Second it is essential that the organisation supports these teams of teachers and health administrators by appointing an effective leader who can orchestrate all the different activities. The change tends to take place as the leader perceives his function as one of enabling the group to work together. He expresses this as he helps and encourages members to participate and assume responsibilities. The leader helps the group by:

  • Furthering definition of the group's purpose
  • Facilitation interpretation of this purpose into practical administrative, organisational and educational goals
  • Helping to clarify the assignments of responsibilities of the different faculty and administrators involved.
  • Guiding the process of planning of change
  • Keeping operations consistent with the goals
  • Sponsoring evaluation of efforts and results.

During this period of training and introduction it is very important that the leader and the members of the team promotes the acceptance of the PBL method. They must make it clear that the curriculum mission endeavour is an institutional priority to which all the teachers must contribute.

A third factor that will help to understand the purpose of the change is to illustrate the similarity of the different steps in PBL and the different steps in problem solving or medial reasoning. Users of PBL in different programmes had good experience during the tutor training with this comparison. Doctors and health workers are used already to the process of identifying problems with patients, and solve these by the gathering of necessary data of the patient, guided by hypotheses about these problems. The doctors and health workers as tutors were then better able to understand the logic of PBL, in which students study around problems. The table comparing contrasting PBL and Problem solving can be very helpful for this kind of training. See Table 11.

Becoming comfortable with PBL will take some time, and will consume a lot of teacher's energy.
But there is also a reward. The learning environment is exhilarating, meaningful, and rewarding. It may turn out to be one of the most exciting things teachers have experienced.
Many tutors may see that students will learn the professional work up in a more convincing way with the PBL method. Moreover, many studies indicate that while students in PBL courses may not score dramatically higher marks on their examinations then there counterparts in more traditional lecture-based programs, they do retain the information they learn considerably longer. In addition, they are more often flexible and better able to learn after graduation than their counterparts in more traditional programs.
Evaluation studies of problem based learning for tuberculosis and leprosy supervisors in Nigeria are also promising in this direction.