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The Interdisciplinary Journal of Problem-based Learning • volume 3, no. 2 (Fall 2009)
43–62
Problem-Oriented Approaches in the Context of Health Care
Education: Perspectives and Lessons
Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
Abstract
The current study aims to explore and articulate some of the key issues in problem-ori-
ented learning (POL), in the context of health care education. Semi-structured interviews
were conducted with faculties representing four di erent health care disciplines around
common issues identi ed in a prior survey study. Thematic analysis of the interview data
revealed that POL practice among health care educators includes both problem-based
learning (PBL) in the strict sense, and a much broader integration of PBL components
into discipline-speci c curricula. In both cases, expertise was recognized as an important
requirement for an e ective tutor, although the range of necessary expertise was context-
dependent. Tutor guidance and feedback, as well as su cient autonomy for students, are
crucial to maximize learning in POL. In conclusion, POL was shown to have broadened
the instructional technique de ned by PBL. Although addressing the same underlying
principles, POL may represent a more exible and inclusive approach to achieve the
bene ts claimed by PBL.
Introduction
Howard Barrows (Barrows & Tamblyn, 1980) introduced the Problem-Based Learning model
into medical education 30 years ago. This multidisciplinary approach to critical thinking
has since expanded into other professional elds. PBL now represents a major, complex,
and widespread change within higher education, especially in professional education
(Savery, 2006). This increasing recognition and wide application of PBL lies in its theory-
based instructional strategy, which emphasizes that learning should be a constructive,
self-directed, collaborative, and contextual process (Dolmans, 2003).
The principles of constructivism emphasize that learning is an active process in which
students construct or reconstruct their knowledge networks (Ertmer & Newby, 1993).
The Interdisciplinary Journal of Problem-based Learning •
44 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
Competence is fostered not primarily by delivering knowledge, but by actively involving
learners in the teaching process. This involvement stimulates activation and elaboration
of prior knowledge networks in order to help students achieve deeper and richer under-
standing and better use of their knowledge (Harris & Alexander, 1998). Self-directed learn-
ing implies that learners play an active role in planning, monitoring, and evaluating the
learning process (Ertmer & Newby, 1996). This approach leads to lifelong learners who are
able to acquire new knowledge and skills more rapidly than those trained in the traditional
lecturing system (Dolmans, 2005). Transition from self-direction to collaboration requires
learners to be stimulated to interact with each other. As compared to a simple division
of tasks, collaborative interaction requires a common goal, shared understanding of a
problem, and shared responsibilities to make participants interdependent (Van der Lin-
den, Erkens, Schmidt, & Renshaw, 2000). This type of interaction may positively in uence
learning (Dillenbourg, Baker, Blaye, & O’Malley, 1996). Learning should also be a contextual
process, meaning that learners are exposed to a professionally relevant context while
confronted with cases or problems from multiple perspectives. Such a learning context
facilitates transfer of knowledge to future professional roles (Ertmer & Newby, 1993).
These guiding principles have the potential to prepare students e ectively for future
learning through the following seven core characteristics (Barrows, 1996; Dochy, Segers,
Van den Bossche & Gijbels, 2003):
Student-centered learning1.
Small group learning2.
The tutor as a facilitator or guide3.
Authentic problems as the rst step in learning4.
Problems that are representative of important and commonly occurring profes-5.
sional situations
Use of authentic problems as a vehicle to teach required knowledge and skills 6.
Acquisition of new knowledge through self-directed learning 7.
As PBL expands beyond health and medical education, each professional eld embeds
its own content within the PBL framework. While adhering to the essentials of PBL, which
include focusing on the application of course content to real-world problems while sup-
porting team-based and self-directed learning (Savery, 2006), each eld adopts speci c
elements associated with the profession into its own problems or projects (Jonassen &
Hung, 2008). Indeed, it has been acknowledged that there is no monolithic approach to
problem-based learning. Rather, the applications may vary in a number of ways, from
the problem format to the role of the instructor (Barrows, 2000). For example, within
engineering where the problem is often a project, Lehman, Christensen, Du, and Thrane
(2008) noted:
Problem-Oriented Approaches in the Context of Health Care Education 45
• volume 3, no. 2 (Fall 2009)
Engineers are today expected to master a combination of disparate capabil-
ities—not only technical competencies concerning problem solving and the
production and innovation of technology, but also interdisciplinary skills of
cooperation, communication, project management and life-long learning
abilities in diverse social, cultural and globalised settings. (p. 284)
Not only does the disciplinary expansion of PBL produce instructional variations, but
it also introduces a vocabulary shift across disciplines, resulting in a broader de nition of
the instructional technique, de ned here as problem-oriented learning. A campus-wide
survey was conducted to investigate the extent to which POL, as an approach to learn-
ing, existed and to explore the range of POL approaches that were being used across
di erent faculties within a large, research-intensive university. The ultimate goal of this
study was to increase our understanding of the current perceptions and conduct of POL
at the university level, in order to help promote e ective approaches across disciplines
and provide tailored support for further development.
POL was used as a global term for PBL instructional strategies in the current study,
in order to capture all users of PBL principles:
Problem-oriented approaches to teaching and learning focus on the applica-
tion of course content to real-world problems and issues. They encompass
traditional problem-based learning as well as approaches like team-based
learning, self-directed learning, case studies, project-based learning, design-
oriented learning, and problem-based service learning.
POL is supported at this university by a cross-faculty teaching center on the campus.
The center aims to promote collaboration among individuals and groups of PBL and
POL practitioners across the university through organizing meetings and seminars and
providing relevant resources. It does not provide speci c training in PBL or POL. This is
the responsibility of individual faculties. The center facilitated distribution of the survey
to instructors who had participated in activities at the center.
The Internet-based survey consisted of 10 open-ended questions regarding the
courses taught, the strengths of POL techniques in subject-speci c contexts, and limita-
tions or challenges identi ed by instructors and tutors in implementing POL within a
speci c faculty or department. The organization of the questions allowed respondents
to omit segments that didn’t pertain to their situations. For example, if the instructor
didn’t have tutors for the course, he or she was directed to another question. This format
allowed participants the exibility necessary to respond in ways that represented their
teaching situations in ecologically valid ways. Ten complete responses were received
from faculties of engineering, dentistry, medicine, nursing, and science. The health
care disciplines were particularly well represented (Jordan & Porath, 2008). Despite the
The Interdisciplinary Journal of Problem-based Learning •
46 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
low response rate, the breadth and depth of information given in the responses made
analysis and follow-up worthwhile.
Analysis of the survey responses revealed both the expected diversity of approaches
in di erent disciplines and a set of common themes. These included: 1) Whether tutors
should be content experts, 2) Whether tutors should provide answers or guidance, and
3) Who takes responsibility for learning during the POL process?
We believed that these issues re ected those which most commonly concerned
instructors across campus. They also comprised some of the central questions related to
POL practice. Thus, a follow-up interview study was conducted with respondents of the
survey in order to explore in further depth how individual faculty members from vari-
ous disciplines perceived these issues during their practice. We focused on faculty in the
health care disciplines who demonstrated a particular interest in regularly implementing
POL in their curricula.
Method
Responses to the survey questions were reviewed in detail to identify discipline-speci c
context and tutor-speci c practices. Open-ended questions were then constructed for each
potential interviewee according to his or her survey responses, in the three topic areas
of interest identi ed from the survey responses. For example, under the topic “whether
tutors should be content experts,” the starting question for an experienced tutor was,
“How do you feel your expertise helps you in preparation, guidance and evaluation during
POL?” For a tutor who did not have as much expertise, the question became, “You men-
tioned that you are not entirely a content expert, but from a related eld. In what ways
do you feel that this is bene cial, and in what ways can it make your work with PBL/POL
more di cult?” The interview questions were tailored to each participant. This provided
the advantage of allowing participants the opportunity to clarify their comments in the
original survey and to further address some of their main concerns. A complete list of the
questions drafted for each respondent can be found in the appendix.
After the approval of the proposed study from the University Ethics Board, respond-
ents who indicated an interest in being interviewed were contacted. The four participants
were from four di erent health care disciplines. Margery1 had introduced various forms of
case study to her class for more than 20 years. Steven had initiated a three-hour weekly
small group tutorial four years ago, which had become increasingly popular among his
students. Paula had brought patient care problems and a clinical situations approach to
her teaching for several years. Isabella was in her third year of tutoring for a PBL curricu-
lum. An hour-long interview was conducted with each participant. Responses to interview
questions made it clear that these educators spent additional time re ecting upon their
practice and were still in an active process of optimizing their approaches.
Problem-Oriented Approaches in the Context of Health Care Education 47
• volume 3, no. 2 (Fall 2009)
Interviews were tape-recorded and transcribed verbatim. A thematic analysis of inter-
view data was undertaken. In initial coding, common themes were identi ed. These themes
were then re ned, taking the speci c context of each discipline into consideration.
Findings
As a preface to the ndings, the two major forms of POL that were observed in this study
are described.
Models of POL in health care education
As discussed above, a number of principal characteristics are shared by di erent formats
of POL, for the same purpose of increasing student centeredness. The current interview
study revealed that POL practice takes at least two major forms within the health care
disciplines. This perhaps is related to historical reasons or the pedagogical preferences of
individual schools or departments.
One format leans toward the case-, problem- or project-component model, in which
real world issues are brought into the classroom. The aim is to allow students to apply
knowledge and techniques already acquired to a real problem or case in the subject areas
they have already learned about (Helle, Tynjälä, & Olkinuora, 2006). The objectives also
include developing problem-solving abilities and the capacity for independent work.
According to Paula and Margery, this is the model primarily adopted by two schools of
health care education in the University. Paula further explained:
We do not really use PBL in its true form. Because we are [a] practice profession
and students are engaging with patient care problems all the time, [there is
the need to] talk about problems, cases or case-scenarios, clinical situations
we have been in [and] those become the focus for [our students to] gure
out [during their study]. [So] I do not particularly call them PBL. I would say
problem-oriented learning or case-based learning is the way I describe it.
The other form is the case orientation model, which refers to a curriculum entirely
devoted to the problem-based learning format. The cases that students complete form
the basis of their education, while instructional teaching is provided to supplement the
requirements of the case topics. In contrast to the prior model, what is essential here is
that students’ prior knowledge of the problem is insu cient for them to properly un-
derstand the phenomena in question. The students then decide upon learning goals,
after which they study the problems on their own (Boud & Feletti, 1999). This approach
shapes the template of the curriculum, the goal of which is to promote self-directed,
interdisciplinary learning.
The Interdisciplinary Journal of Problem-based Learning •
48 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
The small group tutorial conducted by Steven, however, includes characteristics of
both models. These case-based tutorials address the learning process more than the out-
come. Steven described himself as a tour guide who would guide students so that they
could see what they want to see. Meanwhile, the tutorial is conducted only once a week.
Instead of being the center of the curriculum, it serves more as an e ective component
tting well into the entire professional training program.
Although sharing a problem- or case scenario-based format, the rst model empha-
sizes knowledge integration, application, and transformation through provisions of case
opportunities along with other teaching methods. In Margery’s course, students “work
with speech-language pathologists to collect and analyze the data from children in the
community, and develop therapeutic plans with coaching from the instructor. [Through]
application of knowledge and techniques they learned from class in this problem-solving
process, students are expected to demonstrate nal products or outcomes in the form of
a report or a treatment plan.”
The same provision of case opportunities applies to Paula’s course, where the ultimate
goal of incorporating POL components into the courses is to “allow students to apply
their knowledge in real contexts, to link content knowledge to the situation and to think
through the problems they are going to encounter in their future practice. [This] very
explicit purpose of POL [allows them to] leave knowledge acquisition to other courses.”
In contrast, the second model (or PBL approach in the strict sense), which is conducted
in the undergraduate medical and dental curriculum, does not necessarily culminate in
an end product. The focus here is on the learning process, facilitated by a tutor, to en-
able students to navigate ways of learning. In other words, students’ activities during this
problem-solving process are directed to studying, with the ultimate goal being to foster
their development as independent, lifelong learners. Isabella compared the information-
loaded lecturing format of teaching to restaurant food: students receive well-organized
and structured knowledge that is already prepared. In contrast, the PBL process is like
teaching students how to prepare food themselves, starting with shopping for ingredients.
Tutors are like guides, telling them the types of stores they should go to and the recipes or
parameters for a good dish. Yet the tutors are not responsible for how tasty the nal dish
will be. The di erent features of the two models may help us understand the following
perceptions held by instructors and tutors from di erent programs.
Whether tutors should be content experts
Tutors’ competencies are recognized as one of the important factors in a successful PBL
program (Van Berkel & Dolmans, 2006). PBL tutors play a role that is di erent from the
role of a teacher in the conventional teaching format. It is a tutor's task to stimulate active,
self-directed, contextual, and collaborative learning and display interpersonal behavior
that is conducive to students' learning (Van Berkel & Dolmans).
Problem-Oriented Approaches in the Context of Health Care Education 49
• volume 3, no. 2 (Fall 2009)
Earlier studies showed that tutors can be grouped into those who rely more on the
use of expert knowledge, and those who rely more on their abilities to stimulate the
learning process in the tutorial group (De Grave, Dolmans, & van der Vleuten, 1999). De
Grave and colleagues also demonstrated that a tutor who stresses the learning process
was perceived as more e ective than a tutor who stresses content (expert tutor). Based
on results from Das, Mpofu, Hasan, and Stewart (2002), students’ and faculty’s perceptions
of the importance of tutor skills for guiding information management were di erent.
The students expected more support from tutors, whereas the tutors tried to emphasize
self-learning in the PBL curriculum. It therefore remains debatable as to whether a tutor
should be knowledgeable about the content area under study, or whether it is more
important for a tutor to be able to e ectively facilitate groups using certain techniques
(Lohfeld, Neville, & Norman, 2005).
The debate also involves a practical concern, given the di culties of recruiting and
retaining suitable educators for PBL or POL approaches (Maudsley, 2003). For example,
two of the programs represented in this study needed more than 60 PBL tutors at any
given time for their year-one and year-two PBL curricula. It is unlikely that such a need
could be met with content experts alone. Participants in this study reported that, based
on the belief that facilitation skills are more crucial in conducting e ective PBL, several
researchers in related elds were recruited to work as PBL tutors. To supplement these
tutors’ relative lack of content-speci c knowledge, they were provided with a number of
pre-drafted guiding questions along with each case. Tutors then used these questions
to explore speci c areas related to the case and learning objectives, and to stimulate
discussion in student groups. It is thus interesting to know whether these guiding ques-
tions helped noncontent experts to function as e ective tutors. According to Isabella,
“Guiding questions [in the Tutor’s Guide Book] are good. But sometimes if you do not
have su cient knowledge, you do not know what they are talking about and whether
they are only touching the surface or just memorizing [without real understanding].”An
experienced tutor of PBL, Isabella continued:
Every time if I have good information about the subject, I feel very con dent
and powerful, because I can ask more questions to probe them and to chal-
lenge them better. [Furthermore,] I feel empowered if I know more about the
topic. It helps me to prevent students from wasting their time and make sure
they cover everything they are supposed to know. [Therefore, I] will be a better
tutor and more helpful to them (students), if I know more about the subject.
[In conclusion] as a tutor, I would like to be the expert of the subject.
For those disciplines that do not adopt an entire PBL curriculum but rather incorpo-
rate case- or team-based approaches in each course, expertise of instructors apparently
The Interdisciplinary Journal of Problem-based Learning •
50 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
becomes more crucial for the success of their conduct of POL. For example, Margery has
a strong belief in the necessity for instructors to have the expertise, partly because she
views POL as serving the purposes of both the application of knowledge and a process to
facilitate students’ learning. She believes that the more experience an instructor has, the
more he or she knows if students’ ideas and solutions t the problem or not, and is able
to give students feedback. Margery’s pedagogical model is that it is important to learn
from people with experience. She values “human life feedback,” articulating:
You can go to a book, which is not life. The book does not talk to you. Engaging
with someone who does it for 25-35 years listening, thinking and debating in
this area, I feel PBL misses on that particular thing. That is what I feel PBL does
not do. [For example,] I am not a mechanic. [So] I would not feel comfortable
walking into a car maintenance class without being a content expert.
Meanwhile, Margery stated, “[I] do not mean I control it or I tell them everything. I
[just] felt my expertise is valid and valuable in the classroom.” She agreed “directed learn-
ing (facilitating skills) combined with expertise would be a powerful, powerful program.”
Echoing this perspective, Paula stated:
It is su cient [for nonexpert tutors] if it was a very rich and well-developed
guide for the tutor. It is possible to walk learners through the problem-based
approach. But it might not be ideal. Without some content knowledge, I think
it is more challenging to steer students, to provide guidance for them, or help
them if they get frustrated with the process or they are stuck with how to ad-
dress some part of the problem structure. With the expertise, you can have
the freedom to let them go far enough o [track], even before they need some
help to come back. If I did not have content knowledge, I might not be able
to do that as e ectively.
To further address the bene t an expert brings to POL, Margery added, “learners of
PBL do not have to know it all. The facilitator needs to be able to guide them to know
what they need to know, by asking the questions she needs to ask.”
According to Steven, a practitioner and an educator, “content expert” is not a rigid
but rather a relative term; PBL tutors do not need to be specialists in particular clinical
areas.
The facilitators do not have to know how to work with young kids or an injured
hand. [Instead,] what that person needs is the problem solving skills—how to
analyze questions, and to nd the best way to answer the [clinical] question.
The clinical reasoning skill should be the same [across] di erent streams in
medicine.
Problem-Oriented Approaches in the Context of Health Care Education 51
• volume 3, no. 2 (Fall 2009)
Steven therefore feels that it is necessary for tutors to be professional therapists with
basic clinical knowledge who also have problem solving skills and clinical reasoning skills.
The combination of the two, he stated, would allow them to facilitate students’ learning
and to guide them by asking the right questions.
Whether tutors should provide answers
It might be obvious that participants’ answers to this question varied depending on the
speci c teaching goals or approaches they took. As Margery put it, a facilitator does not
have to tell everything but should be there to provide feedback. This overarching principle
is seemingly appropriate to meet students’ learning needs in di erent settings.
Margery further identi ed two distinct types of situations that require di erent ap-
proaches. The rst one is about an analytical or technical procedure that leads to an incor-
rect outcome because students have not understood the underlying principle. This can
also include cases involving clear right and wrong dimensions or analytical knowledge as
the domain of inquiry. Experts need to provide timely feedback in these cases. Margery’s
justi cations were that she has considerable experience, whereas students have little.
So I can look at what they produce, and say, “You have missed the point here.
Here is how it works.” I cannot let them take away the wrong answers. It would
be unethical not to tell them that these answers are wrong. Sometimes feed-
back is for patients’ safety, that is when it is crucial for the expertise to come
in.
This view is echoed by Paula, who further emphasized that the bottom line is to
help students understand the professional standard of safe, ethical and e ective patient
care. That is why she will ask “what if ” questions on the y, to help students extend their
thinking in, and link theory to, real clinical situations. As a POL instructor in a clinical set-
ting, she also monitored her students all day to judge their performance and to provide
individualized feedback.
According to Margery, the second situation is around interpretations or discussions,
which are very open-ended. This might be more frequent in the case-oriented POL model
where tutors are not supposed to give information or answers but encourage students to
research and discuss themselves. Steven expressed his appreciation of creating a learning
community through the PBL process:
I believe that is the beauty of small group tutorial or PBL. We do not need to
give all the answers but let the students nd answers themselves. And even if
they make a mistake, they nd out among themselves—what kind of mistake
they make and how can you resolve that kind of problem by learning from each
other. [For example], if the treatment is full rest, that is the nding from the
The Interdisciplinary Journal of Problem-based Learning •
52 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
particular literature. And that is a wrong nding. The other seven students will
be nding answers that are very di erent, that you need to do these exercises,
that kind of mobilization, or take that kind of medication. It will be very dif-
ferent from this particular student’s nding. So when you pull all seven other
students’ ndings together, then you realize that that is not right.
The importance of allowing students to make occasional mistakes during their
learning in front of a group re ects Steven’s own honesty as a practitioner. He acknowl-
edged:
Sometimes I may make a wrong decision. And that is ne. Other team members
will remind me, “No, you are wrong.” That might not feel well. But that is the
reality that in our real clinical setting, we do not have the so-called mentor, or
a professor, to tell you that this is right, this is wrong.
It seems crucial to Steven that PBL brings the reality of future practice into the classroom.
Group dynamics are important in creating a learning environment where students can
have opportunities to learn from each others’ successes and mistakes.
Who takes responsibility for learning during the POL process?
Responsibility can mean a number of duties or self-perceived priorities for instructors,
depending on their goal for the speci c POL process. If the instructor designs the course,
his or her responsibility starts from drafting structured cases and guiding questions to
increase students’ critical thinking. He or she may also introduce a variety of teaching
methods, including group learning, lectures, and homework exercises. This variety of ap-
proaches helps to address students’ di erent learning needs and styles.
Instead of providing answers to students, participants all agreed that the provision
of guidance is one of their more important responsibilities. They realize that students
are new to the profession and often do not know what they need in the near future. As
teachers or professionals practicing in the eld for many years, they feel responsible to
tell their students the best way to get there, emphasizing the critical points in the process.
In particular, they adopt the role of guiding students to nd the knowledge themselves.
One approach to guidance, as Steven explained, is to give students very clear objectives
but leave exact learning goals up to them. Another approach suggested by Steven is to
provide students with guidance on what to look for. For example, he stated:
You will give them good textbooks. Tell them that those articles are over there,
and there is a journal that will help you here. [Or say] “Do your own search
using these few key words.” “Go to the library, look this book up.” [Or,] “Go to the
Internet, look for this information from this web site.” Or, “Use these words as
the key word and go to the data base and nd out from the journals.” And, “Go
Problem-Oriented Approaches in the Context of Health Care Education 53
• volume 3, no. 2 (Fall 2009)
to Google and nd out information. Go to certain clinics or talk to certain clin-
icians.” [That is] how we can guide them to nd information by themselves.
Providing timely and speci c feedback is another key responsibility recognized by all
interviewees. For students who practice in real clinical settings, individual feedback about
their performances can be obtained at the end of every clinical day from their instructors.
Students utilize and re ect on this timely feedback to know what they should be doing
next time, or what more to include. Interviewees shared a focus on the learning process
rather than the outcome most of the time, when providing feedback to their students is
critical. For example, they paid special attention to interactions among students, focusing
on their problem-solving processes, the logic of their arguments or interpretations, and
their e orts to ask good questions and to do so e ectively. To Isabella, feedback is also
very helpful in maintaining the e ciency of the learning process by keeping students on
track and focusing them on learning objectives. Isabella believed that providing this type
of feedback becomes one priority for tutors, when their students do not have much time
and yet have to cover a lot of material.
Interviewees saw themselves playing a big role in the development of students’
professionalism, which is one of the major goals of health care education programs.
They want to enable their students to become quali ed professionals and to be life-long
learners. To this end, they feel the need to provide individualized feedback dealing with
speci c issues such as participation, preparation, and the appropriate amount of research.
A responsible tutor tends to use di erent means to provide timely feedback to students,
through group-level feedback or e-mails to individuals whenever he or she sees something
important, including being respectful, supportive or caring for others’ needs. To help some
students to overcome shyness and speak up, Isabella would tell them that PBL is a good
opportunity for everybody to overcome their weaknesses, because the environment is safe
and supportive. In order to motivate them, she even went the extra mile to tell students
her own experiences and lessons learned.
As a PBL tutor, helping students might be more indirect, sometimes subtle, without
providing the answer or information directly. Asking good questions and helping students
to know the elements of a good approach to problem solving might make a big di er-
ence to them in the end. Tutors can also remind students of the value of PBL, and help
them realize that the research they do will be useful to make them work as independent
professionals. As Steven summarized, “PBL is such a way to create a learning community
among learners—to learn from each other and to bene t.” To achieve this goal, instructors,
in general, agree that it is crucial for students to prepare by researching patients’ condi-
tions and medications, and synthesizing all pieces of information to know what’s going
on with their patients.
The Interdisciplinary Journal of Problem-based Learning •
54 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
POL-based curriculum provides students more autonomy by allowing students to
identify what they want to learn, how they are going to learn, and how members of the
group will contribute to learning. Steven’s belief behind this provision of autonomy is:
If I insist this (learning goal) in the tutorial, if that is not what they want to learn
or [are] interested [in], they will not be putting in their 100 percent interest
and e ort in it. [Instead], we believe that learners are all adults. They will learn
things that will be appealing to them, not appealing to us.
This entrusting of responsibility upon students also gives their instructors the con-
dence that if students are given choices, they will eventually learn what they need to.
However, it seems that even students in professional training can be irresponsible. The
instructors or tutors were concerned that such students might end up making unneces-
sary mistakes in their future practice. One solution is to bring rigor to the task, to tell
students if an answer is right or wrong. This may get the attention of students who seek
an easy path to learning. Alternatively, according to Margery, “It is probably better to have
a traditional educational system, which forces you (students) to do the right thing by ex-
ams and tests. . . . This kind of ‘discipline enforced upon’ students might be e ective.” She
acknowledged that groups vary in their need for this structure. Some can get the most
out of group experiences and learning activities, whereas other groups complain about
the workload. Margery concluded that a variety of activities would be helpful to address
the diversity of learning needs and styles.
Discussion
The current interview study portrays the diversity in approaches to conducting PBL or POL
and provides insight into teachers’ perspectives in di erent health care education pro-
grams. Being health professionals themselves, interviewees shared several commonalities.
They understand the requirements of professions that deal with people’s lives on a daily
basis. Thus they see the rigorous and comprehensive delivery of professional knowledge to
be crucial to guarantee technical or analytical correctness. Meanwhile, they share a passion
in engaging students in the learning process. They found that it is not enough to just talk
to students; rather something is needed to anchor people’s ideas. They consciously foster
integration and application of knowledge, and promote lifelong independent learning. To
this end, they bring real world situations to the class and actively transform them into a
whole variety of interactive learning approaches re ected in the curriculum. Direct contact
with patients or exposure to clinical scenarios are provided to students beginning with
their rst year in the program. Clinical considerations, including even basic knowledge,
can be addressed in a more relevant context, so that students learn to analyze and handle
practical scenarios early on. In addition, these educators make special e orts to cultivate
Problem-Oriented Approaches in the Context of Health Care Education 55
• volume 3, no. 2 (Fall 2009)
a positive group dynamic and encourage peer learning, features that mirror their own
professional practice. This early exposure motivates students’ learning by steering their
activities toward what truly matters in their future careers.
Taken together, it is evident that interviewees constantly encourage their students
toward constructive, self-directed, collaborative, and contextual learning. They consciously
apply these PBL or POL principles in teaching, which leads students to go beyond their
textbooks and to transfer knowledge into problem-solving abilities and e ective clinical
reasoning through practice in relevant, and often real, contexts. Our ndings also illustrated
that POL, with its greater exibility, may be a more advantageous approach in dealing with
potentially di erent learning styles among students than PBL in its stricter sense.
In agreement with Dolmans et. al. (2002), all interviewees in this study stated that the
combination of facilitation skills and appropriate levels of expertise (in content knowledge
or clinical reasoning) would lead to the most powerful POL approach. This conclusion is
based on their common recognition that facilitation skills and expertise complement and
support each other in the complex learning environment of POL. Both components were
perceived by the participants as crucial for an e ective and rich learning experience, al-
though the importance of the two can be situation-speci c and dependent on contextual
circumstances, such as the quality of the problems, the structure of the unit, and links with
students’ prior knowledge (Schmidt, 1994). For example, the value of rich expertise was
repeatedly addressed by interviewees in providing valid feedback on technical issues so
that students can grasp key concepts and skills of the profession more e ectively. Given
the di culties of recruiting suitable educators to serve as PBL or POL tutors and poten-
tial resource limitations, sta development strategies must be addressed to ensure an
adequate level of content knowledge among tutors. Meanwhile, individual tutors should
not be satis ed by walking the student through the guiding questions provided by the
tutor guidebook. Rather, tutors with relatively less expert knowledge should be encour-
aged to acquire su cient information through self-learning. As Isabella experienced, this
equipping exercise will provide tutors with stronger ability and increased con dence to
guide and probe students in desirable directions and depth.
Potential limitations of our study deserve comment. They include those inherent
to interview studies. Both self-selection and the small number of participants may intro-
duce bias to the data and the analysis. However, participants of the current study are all
highly experienced educators representing four di erent health care disciplines, and
also demonstrated passion toward teaching and care for students’ learning. It was clear
during the interviews that these educators constantly spent additional time to re ect
upon their practice and were still in the active process of optimizing their approaches.
They were in a good position to share their experiences and opinions. Their insights and
suggestions will be valuable and bene cial to the healthy growth of the POL community,
which allows more students to bene t from diverse teaching and learning approaches.
The Interdisciplinary Journal of Problem-based Learning •
56 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
All four interviews taken at a single university might in uence the generalizability of the
ndings. Nonetheless, what seemed more important to us in this case study was that we
were able to construct a more complete picture of health care education via combining
perspectives from four subdisciplines. This illustrates more comprehensively the diverse
applications of PBL concepts under the broader umbrella of POL.
In summary, the current study helps us to understand more clearly how the principles
of PBL can be in uenced by a variety of practical factors when it is implemented across a
spectrum of disciplines. Our examples demonstrate the feasibility and possible approaches
of expanding the guiding principles of PBL. By increasing exibility and diversity, POL
practice gets more inclusive which can lead to increased e ectiveness, as well as innova-
tive means, to improve teaching and learning in a broad context.
Appendix
Problem-oriented learning (POL) interview questions for the four interviewees
The purpose of these questions is to further probe the three major topic areas of
our interest, which are also speci c to each interviewee based on his or her answers
to our previous survey questions.
Interviewee 1
Should tutors be content experts or not?1.
Why do you feel a general grasp of PBL techniques, that is, asking probing questions/a.
guiding questions, plus a tutor-guide book (that provides both guiding questions
and appropriate answers), are not su cient for a POL tutor?
Should tutors give answers/teach or not?2.
You emphasize the importance of guiding students using your own expertise. However,
one major purpose of POL is to foster students’ own problem-solving skills (PSS), which
needs them to both identify questions and search for answers/solutions.
In this case, how do you decide when to guide/provide answers, and when to allow a.
students to search in their own ways?
How do you balance the two to allow students to improve their own PSS, and make b.
good use of the instructor/tutor’s expertise?
What is the ultimate goal of your POL? c.
Whose responsibility is it during the POL learning process, the tutor’s or the students’? 3.
What do you think are the responsibilities of a POL/PBL tutor/organizer?a.
Preparation: i.
Strategic planning: 1.
Problem-Oriented Approaches in the Context of Health Care Education 57
• volume 3, no. 2 (Fall 2009)
Speci c goals for POL?a.
How to incorporate POL into the overall curriculum?b.
Drafting good cases to better convey learning objectives/goals, and to 2.
improve the e ectiveness of PBL?
Provide introduction session to explain the format and the purpose of POL, ii.
how it might be di erent from other forms of teaching, and your speci c
expectation?
Provide coaching: what exact content is included – to what extent is coaching iii.
needed? Why is coaching necessary?
Provide ongoing support, in and outside classiv.
Do you feel it is important for students in your class to fully understand advantages b.
of PBL? Does that help them realize and accept an increased responsibility from
their side during this process?
How do you adopt di erent learning styles of students? (i.e., those who are not c.
used to this type of learning and feel uncomfortable/unwilling/overwhelmed by
the increasing responsibility?)
By breaking POL into various components (i.e., funlab, literature review, team i.
presentation, WebCT discussion, tool assessment)?
Using evaluation? How do you use multiple grading systems to promote the ii.
goals you set for the course?
Do you feel PBL brings extra curriculum load to students? d.
How you adjust overall curriculum load? i.
Do you t PBL into the overall curriculum, in conjunction and coherence with ii.
other ongoing teaching activities?
Interviewee 2
Should tutors be content experts or not?1.
You are apparently an absolute content expert. How do you feel that expertise a.
helps you in preparation, probing, guiding and evaluation of POL?
Do you think non-content experts can work as tutors of the type of POL you are b.
doing? According to your experience, what might be some of the advantages/
disadvantages of using non-content experts as tutors?
Should tutors give answers /teach or not?2.
Your POL is mostly case-based, which needs students to brainstorm issues or a.
problems followed by solutions/action plans. During this process, in which cases
do you nd guidance and answers are helpful for learning?
Which seems the more e ective approach to you – providing guidance whenever b.
students tend to go “o track,” or allowing them time to further explore (along
The Interdisciplinary Journal of Problem-based Learning •
58 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
the “wrong” direction) and to gure out that they have gone down the wrong
path with evidence they found themselves – would this option better serve the
purpose of increasing their real problem-solving skills?
What is the ultimate goalc. of your POL – a more e ective vehicle to learn the
knowledge (in the form of learning objectives), or helping students to learn
practical skills such as teamwork, searching for relevant information, and problem
solving?
Do you think it would be possible to balance the teaching of knowledge and d.
of practical skills in your POL? If so, how do you balance the two? If not, do you
tend to address skills like problem-solving using POL approach, but address
knowledge using lectures?
Whose responsibility is it during the POL learning process, the tutor’s or the students’? 3.
How do you conduct your POL?a.
What do you think are the responsibilities of a POL/PBL tutor/organizer?b.
Drafting good cases to better convey learning objectives/goals, and to i.
improve the e ectiveness of PBL?
Provide introduction session: explain the format (how it might be ii.
di erent from other forms of teaching) and the purpose of PBL?
Provide coaching: Why is coaching necessary? What exact content is iii.
included? To what extent is coaching needed?
Provide ongoing support, in and outside class?iv.
Can all students realize and accept an increased responsibility from their side in c.
a POL process?
How do you motivate these students to engage into this interactive type of d.
teaching/learning process?
Do you feel PBL brings extra curriculum load to students? e.
Interviewee 3
Should tutors be content experts or not?1.
You told us that you are a content expert – in which way are you an expert a.
(practitioner working speci cally with community, or family doctor)?
How do you feel that your expertise has helped you in conducting PBL sessions, that is, b.
in planning, probing, guiding, or addressing certain issues you think are important?
Do you nd any negative e ect of being a content expert during your PBL c.
conduct?
Should tutors give answers/teach, or not?2.
During your tutorial, you used many open ended questions to discover unknown a.
concepts. Did you sometimes also provide students with answers?
And in what case do you do so, and when do you not? How do you balance the b.
Problem-Oriented Approaches in the Context of Health Care Education 59
• volume 3, no. 2 (Fall 2009)
two given that students had no prior knowledge and there was a shortage of
time?
How do you feel giving answers or not would a ect students’ learning? c.
Do you feel one of the strengths of PBL/POL is self-directed study? If so, would d.
providing answers help with it?
Whose responsibility is it during the POL learning process, the tutor’s or the students’? 3.
You mentioned that you tended to provide answers due to the lack of prior a.
knowledge and time constraints. Then what do you think would be students’
responsibility in this process (generating learning issues and conducting
research on them)?
Where do you think the right balance between students’ vs. tutors’ responsibility b.
would be?
From a health professional’s perspective, what useful (professional) skills do you c.
think need to be addressed during the PBL process?
Interviewee 4
Should tutors be content experts or not?1.
How do you feel that your expertise has helped you in conducting PBL sessions, that a.
is, in planning, probing, guiding, addressing certain issues you think are important?
Have you found any negative e ect of being a content expert during your POL b.
(i.e., do you tend to provide answers)?
Should tutors give answers/teach or not?2.
You mentioned that during your tutorials you tended to use many open-ended a.
questions. Do you also provide answers? In which cases do you do so, and when
do you not?
How do you feel that this would a ect students’ learning?b.
Do you feel one of the major strengths of POL is self-directed study? If so, do you c.
feel providing answers would help with it?
What is your purpose of incorporating a POL component into the curriculum, that d.
is, to promote independent learning or to promote acquisition of knowledge?
Whose responsibility is it during the POL learning process, the tutor’s or the students’? 3.
How do you conduct your POL?a.
What do you think are the responsibilities of a POL/PBL tutor/organizer?b.
Drafting good cases to better convey learning objectives/goals, and to i.
improve the e ectiveness of PBL?
Provide introduction session: explain the format and the purpose of ii.
POL, how it might be di erent from other forms of teaching, and your
expectations?
Provide coaching: Why is coaching is necessary? What exact content is iii.
The Interdisciplinary Journal of Problem-based Learning •
60 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
included? To what extent is coaching needed?
How do you provide ongoing guidance/support, in and outside class?iv.
Can all students realize and accept an increased responsibility from their side in c.
a POL process?
If some of them cannot, how do you motivate these students to engage in this d.
interactive type of teaching/learning process?
Do you feel PBL brings extra curriculum load to students? e.
Acknowledgements
We would like to thank our participants for their interest and insight into POL, and Alice
Cassidy and Judy Chan from the Centre for Teaching and Academic Growth for their sup-
port of the research.
Note
1. Pseudonyms are used for study participants.
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The Interdisciplinary Journal of Problem-based Learning •
62 Weiqun Courtney Kang, Elizabeth Jordan, and Marion Porath
Weiqun Courtney Kang is a candidate for Master of Public Health at The University of British
Columbia.
Elizabeth Jordan is Senior Instructor (Tenured) of Educational Psychology and Special Education at
The University of British Columbia.
Marion Porath is Professor of Educational Psychology and Special Education at The University of
British Columbia.
