Does blended problem-based learning make Asian medical students active learners?: a prospective comparative study

Shimizu et al. BMC Medical Education (2019) 19:147 https://doi.org/10.1186/s12909-019-1575-1 RESEARCH ARTICLE Open Access Does blended problem-based learning make Asian medical students active learners?: a prospective comparative study Ikuo Shimizu1* , Hideyuki Nakazawa2, Yoshihiko Sato3, Ineke H. A. P. Wolfhagen4 and Karen D. Könings4 Abstract Background: Asian educators have struggled to implement problem-based learning (PBL) because students rarely discuss their work actively and are not sufficiently engaged in self-directed learning. Supplementing PBL with additional e-learning, i.e. ‘blended’ PBL (bPBL), could stimulate students’ learning process. Methods: We investigated the effects of bPBL on tutorial group functioning (discussion, self-efficacy, self-directed learning, active participation, and tutor’s perceived authority) and students’ level of acceptance of the e-learning elements. We compared PBL and bPBL in a medical university in Japan. In the bPBL condition, the tutor’s instructions were replaced with online materials and short quizzes. After the course, a 13-item questionnaire using a 5-point Likert scale was distributed regarding the tutorial group functioning of the tutorial group (influence of discussion, self-efficacy, self-directed learning, active participation, and tutors’ authority). The mean scores of subscales were compared with analysis of covariance. Knowledge levels were measured using a pre-test post-test design. A multiple regression analysis was performed to explore the association between e-learning acceptance and the subscales related to PBL. Results: Ninety-six students participated in the study (PBL: n = 24, bPBL: n = 72). Self-efficacy and motivation for learning triggered by group discussions was significantly higher for students in bPBL (p = 0.032 and 0.007, respectively). Knowledge gain in test scores was also significantly better in the bPBL condition (p = 0.026), and selfdirected learning related positively to the acceptance of blended learning (p = 0.044). Conclusions: bPBL seemed more effective in promoting active learning and improving knowledge, without affecting tutors’ authority. Implementing e-learning into PBL is suggested to be an effective strategy in the Asian context. Keywords: Blended learning, Health professions education, Problem-based learning, Quiz, Self-directed learning Introduction Problem-based learning as an example of cultural gap between west and east Undergraduate medical education in Asia was traditionally characterised by predominantly lecture-based, teacher-centred educational approaches and highly discipline-specific curricula until the late twentieth century, during which the West-inspired theories on learning have been introduced [1]. Problem-based * Correspondence: 1 Center for Medical Education and Clinical Training, Shinshu University, 3-1-1 Asahi, Matsumoto 3908621, Japan Full list of author information is available at the end of the article learning (PBL) is one of the typical examples of Western-inspired learning theories. It is defined as the learning that results from the process of working towards the understanding or resolution of a problem [2]. Important goals of PBL include supporting knowledge structuring in clinical contexts, development of clinical reasoning skills and self-directed learning skills, and increasing students’ learning motivation [3]. PBL has been proven equal to lecture-based education in terms of general success [4–8] as well as communication skills, and learning strategies [9–11]. The theoretical origins of the effectiveness of PBL have been variously explored. Among them, self-directed © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shimizu et al. BMC Medical Education (2019) 19:147 learning is one of key learning principles behind PBL [12]. It is the degree to which students metacognitively, motivationally, and behaviourally participate actively in their own learning process [13]. It refers both to a motivational, volitional component of being willing to engage in learning activities, as well as the ability to do so [14]. Since the amount of knowledge included in standard clinical performance increased rapidly [15], health professions have had to practice life-long learning. Therefore, PBL seems to be a more innovative pathway to learning in medical education, and seemed a convenient and obvious choice for educators to adopt [16]. It has thus been recommended in many countries, including Asia [17]. However, contrary to studies highlighting the success of PBL in Western countries, Asian medical educators have struggled to implement it [18], and Japan is no exception. In Japan, PBL was first incorporated into a curriculum in 1990. It was later suggested that PBL should be implemented in the ‘Model Core Curriculum’, which defined the essential core components of the undergraduate medical curriculum in Japan [19]; PBL was the prevalent educational method at 63 (80%) of the 79 Japanese medical schools in 2004 [20], and 70 in 2016 [21]. However, in 56 of those schools (80%) the implementation of PBL is considered problematic, mainly because of the high burden it places on faculties [22]. As a result, the latest research revealed that a growing number of faculties are avoiding PBL [23], underlining the necessity of coming up with solutions for the implementation problems which have arisen. Several characteristics of Asian students could be relevant in this matter and should be carefully considered when Asian medical schools are planning and preparing to implement PBL. Students are very deferential towards tutors as authority figures [19]; they fear confrontations with these authority figures and tend to be dependent. There are also vast differences between students’ learning attitudes and their prior knowledge, as well as a lack of passion for what they study during PBL [24]. Effective implementation of PBL builds on students’ prior knowledge and stimulates self-directed learning. Therefore, a lack of prior knowledge could hinder developing one’s own learning objectives in PBL [25]. Conversely, Asian students are so accustomed to the examination-oriented learning culture that they have difficulty applying their prior knowledge and collaborating with peers [26]. In addition, Asian culture predominantly pivots towards teacher-centred pedagogies. In such a prevalent culture, students gain self-efficacy through (...truncated)