Nurse Education Today 33 (2013) 791–795

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Comparison of problem-based learning and lecture-based

learning in midwifery
Gita Sangestani a, Mahnaz Khatiban b,⁎
a
Department of Midwifery, Member of Mother & Child Care Research Center, Nursing & Midwifery College, Hamadan University of Medical Sciences, Hamadan, Iran
b
Department of Medical Surgical Nursing, Member of Mother & Child Care Research Center, Nursing & Midwifery College, Hamadan University of Medical Sciences, Hamadan, Iran

a r t i c l e i n f o s u m m a r y

Article history: Background: Lecturing is the most common teaching method in the medical education. Problem-based learn-
Accepted 15 March 2012 ing (PBL) is one of the active and student-oriented learning strategies which have gained attention in the re-
cent decades.
Keywords: Objective: To compare the effect of PBL and lecture-based learning (LBL) on the satisfaction and learning pro-
Midwifery students gress of undergraduate midwifery students.
Problem-based learning
Design: Quasi-experimental study.
Lecturing
Settings: Hamadan University of Medical Sciences, Hamedan, Iran.
Participants: Fifty-six undergraduate midwifery students in two different classes participated in the study.
Methods: Randomly, one class (experimental group) received PBL in addition to LBL and the other one (con-
trol group) received traditional LBL. “Pregnancy and childbirth”, a 2-credit course, was selected for this pur-
pose. Scientific pre-test and post-tests were performed and satisfaction questionnaire was filled in for both
groups. A questionnaire to compare PBL and LBL was filled in only for the experimental group. The instru-
ments used in the study were “Demographic data form”, “Students' learning progress test”, “Student's satis-
faction of teaching method”, and the “Teaching method evaluation”.
Results: Learning progress in PBL group was significantly more than control group. PBL improved application
of theory lesson in clinical practice, increased learning motivation and enhanced educational activity in class.
There was more satisfaction with PBL method. There was no relationship between the students' satisfaction
and learning progress. 81.8% of students considered PBL the more suitable and better method.
Conclusion: PBL should be applied more in undergraduate midwifery courses. According to these advantages,
the quality of midwifery education can be improved via this method.
© 2012 Elsevier Ltd. All rights reserved.

Introduction assumed that student-centered methods can promote the students' com-
municating skills, team working, problem solving, responsibility for
In the 21st century, due to the universal social, economic, educa- learning, sharing information and respect for others (Rowan et al., 2008).
tional and Health challenges, there is demand for educated people Problem-based learning (PBL) is one of the active and student-
with high problem solving skills to work in complex situations. This centered instructional strategies which have gained considerable at-
can be accomplished through making changes in traditional educa- tention in the recent decades. PBL involves students' identifying of
tional strategy (Tiwari, 2006). their knowledge and skills and applying them in the new situation
Lecturing is the most common teaching method in the medical ed- or achieving to the definite goals. In fact the learners must discover
ucation. It relies on one way communication that mostly leaves the new methods to solve the problem by combining the previous knowl-
learners as passive participants only to take notes and probably ask edge or principles (Williams and Beattie, 2008).
questions after the lecture delivery, if and when time permits (Yuan Despite numerous studies about PBL in various disciplines in the
et al., 2011; Oladipo et al., 2011). In this method, students have no op- world, yet there is no enough evidence about this method in midwife-
portunity to contemplate which is necessary in learning process ry (McCourt and Thomas, 2001; Rowan et al., 2008). For example, in a
(Safari et al., 2006). So, it is important to revise traditional methods of study in Turkey, the knowledge scores of medical students in PBL and
teaching and take advantage of new, active and student-centered traditional curriculum on public health topics were compared. The re-
educational methods (Yuan et al., 2011; Oladipo et al., 2011). It is sults showed that the PBL group scores were significantly higher than
those in traditional group (Gurpinar et al., 2005). In another study in
Korea, PBL method was compared with the traditional lecture method
⁎ Corresponding author at: P.O. Box: 13185-1678, Tehran, Iran. Tel.: +98 811 8380150;
fax: +98 811 8380447.
in the cardiopulmonary nursing section of the Adult Health Nursing
E-mail addresses: [email protected], [email protected] course. The results showed higher level of knowledge and learning
(M. Khatiban). motivation in the PBL group than the lecture group but no significant

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.03.010
792 G. Sangestani, M. Khatiban / Nurse Education Today 33 (2013) 791–795

difference was found between the PBL and lecture groups in the level LBL was applied for the experimental group, whereas traditional LBL
of attitude toward learning (Hwang, and Kim, 2006). In Iran, the ef- method was performed for the control group.
fects of PBL were compared with lecture based learning (LBL) The two-credit Pregnancy and childbirth course takes 2 h/week for a
among nursing students. The level of knowledge, attitude toward semester (16 sessions). The course content includes: labor dystosia,
learning, and learning motivation in the PBL group were significantly IUGR (intra uterine growth retardation), multiple pregnancy, abruptio
higher than that of students in the lecture group (Dehkordi and placenta, placenta previa, post partum hemorrhage, birth canal injuries,
Heydarnegad, 2008). post partum infection, preterm labor, post term labor, abortion, mole,
Due to particulars of midwifery and lack of sufficient evidence on ectopic pregnancy, preeclampsia and eclampsia. The learning objectives
the usefulness and effectiveness of PBL in this subject, we decided to were definition, prevalence, clinical progress, diagnosis, complication
assess this teaching method in midwifery. To our knowledge, this is and management. The routine students' learning activities are class at-
the first study of PBL in midwifery in Iran and the first quasi- tendance, preparedness for the content according to lesson plan and
experimental one around the world. participation in reviewing the previous lesson.
The main objective of this study was to compare PBL and LBL in The two groups were taught in two separate schedules and settled
terms of satisfaction and learning progress in undergraduate mid- in two different dormitories, so the possibility of their interaction was
wifery students. very low.
The possible confounding factors like the features of the courses pro-
Materials and Methods vided, teachers and students were controlled by statistical comparing
demographic characteristic. Hence, the participants were chosen from
This was a quasi-experimental study with a control group and undergraduate midwifery students in the same semester in two differ-
pretest–posttest design performed in Hamadan University of Medi- ent classes. Learning progress was assessed before and after the study.
cal Sciences, Hamadan, Iran in 2010. Also, satisfaction of teaching method (in both groups) and evaluation
The possible confounding factors like the features of the courses of teaching method (in experimental group) were assessed after course
provided, teachers and students were controlled. Hence, the partici- presentations.
pants were chosen from undergraduate midwifery students in the
same semester in two different classes. A class was randomly chosen
Intervention
as the experimental group and the other as control. Learning progress
was assessed before and after the study. Also, satisfaction of teaching
LBL Group
method (in both groups) and evaluation of teaching method (in ex-
The control group received traditional didactic lectures through-
perimental group) were assessed after course presentations.
out the semester on the same content areas. Students had opportuni-
The study protocol was approved by ethics committee of Hamadan
ties to ask questions and use reference books and teaching materials.
University of Medical Sciences and each individual gave informed con-
Pre- and post-test assessments were done by multiple-choice ques-
sent before enrollment.
tion examinations in both groups.
Study Population
PBL Group
All midwifery students at Nursing and Midwifery School of Hamadan For the PBL group, the authors developed four PBL course syllabi
University of Medical Sciences were considered as study population. following the critical review of the “Pregnancy and childbirth” course.
According to the content, four clinical scenarios were developed from
Sampling Method actual patient records at a university hospital in Iran. Each of the four
clinical scenarios was evaluated by two faculty members.
To select study groups from the target population, Purposive Sam- A tutor guideline was also prepared by the investigators. Students
pling was used. Experts consider Purposive Sampling or Judgmental in the PBL group were divided into four sub-groups according to their
Sampling as a non-probability sampling to select subjects. The indi- desires. Each of the four PBL course syllabi was done in 2-hour class
viduals are selected deliberately based on the main criteria which sessions by one of the investigators. In the first session, students
are assumed by the researcher to be representative of the community identified the evidence and health problems in a scenario. In the
(Dempsey and Dempsy, 2000; Lobiondo-wood and Haber, 2006; Polit next session, upon completion of the self-directed learning, the stu-
et al., 2006). The main criteria consisted of, 1—being the midwifery dents delivered their answers on the given subject. During the last
student, 2—being at the same educational levels, 3—being at the 15 min of this session, a short feedback was provided to PBL students.
same semester, 4—having the same credit course, 5—having the Other topics were thought by usual lecturing method in the experi-
same instructor and 6—having consent to enroll in the study. Two mental group.
groups of students with above main criteria were selected who regis-
tered in “Pregnancy and childbirth” course.
Quality Control of Intervention
The “Pregnancy and childbirth course” was suitable for our pur-
pose because of its nature during which students encounter various
The PBL lesson plan was developed and approved by the Midwife-
clinical cases and diverse patient populations.
ry Department of Hamadan University of Medical Sciences. A faculty
member attended in the class randomly to supervise the quality of in-
Sample Size
tervention and its accordance with lesson plan.
All 56 first-year students of the two-year BS midwifery program at
the Nursing and Midwifery School of Hamadan University of Medical Ethical Consideration
Sciences were enrolled.
The study protocol was approved by Ethics Committee and Re-
Group Assignment search Council of Hamadan University of Medical Sciences and each
individual gave informed consent before enrollment. To consider
A class was randomly assigned as the experimental (22 participants) the ethical issues, the same course content was provided for both
and another as the control group (34 participants). PBL in addition to groups.
 G. Sangestani, M. Khatiban / Nurse Education Today 33 (2013) 791–795 793

Instruments experimental and control groups. All statistical analyses were done
by SPSS Software for Windows. Significance level was set at 0.05.
Four separate questionnaires were used for data collection. Details
of these instruments were as follows:
Results
1) The “Demographic data form” consisted of student's age, marital sta-
tus, the number of children, the place of living, employment status, Students' Characteristics
and the GPA of last semester. It was developed according to Safari
et al. (2006) study's demographic data form. Mean (SD) ages of the experimental and control groups were
2) The “Students' learning progress test”: two parallel multiple choice 25.64 (±1.92) and 25.82 (±3.61) years, respectively. Mean total
questions pre- and post-tests. These tests were designed by the au- scores of final exams in the preceding semester were 16.27 (±.82)
thors based on the formal course objectives to measure the students' in PBL and 16.22 (±1.32) in control group (highest possible mean
achievements in the direction of the course objectives. Both pre- and total score is 20). Most students in the experimental (72.72%) and
post-test included 0–10 scores for PBL and 0–10 for LBL topics, so the control (67.65%) groups were single and most of them stayed in uni-
total scores of each student were calculated 0–20. Each correct an- versity dormitory facilities (95.45% of experimental and 76.47% of
swer and each incorrect answer were respectively scored 1 and 0. control group). No significant difference (p > 0.05) was found regard-
Range of possible scores for each PBL/LBL subjects was between ing the aforementioned features between the two groups.
0 and 10 (0–4 = unaccepted; 5–6 = medium; 7–8 = good; 9–
10= perfect scores). The total score of each student's pre- and
post-test was 0–20 (0–9 = unaccepted; 10–13 = medium; 14– Students' Learning
17= good; 18–20 = perfect scores). The content validity of this in-
strument was confirmed by expert panel. Its reliability was obtained The mean pretest scores were 4.97 ± 1.49 in the control group and
by test–retest, in which McNemar's test showed no significant 5.18 ± 1.6 in the experimental group. There were no significant differ-
differences. ences in the pre-test scores between the two groups. As shown in
3) The “Student's satisfaction of teaching method”: A self-administered Table 1, the mean post-test scores were 9.64 ± 0.56 in the experimental
questionnaire with 22 questions on five Likert's scale (from “very group and 6.88±1.07 in the control group. It means that the experimen-
low= 0” to “very high= 4”). Range of possible scores was from tal group was higher than the other group in this matter (t= −11.073,
0 to 88 (very low = b0.8; low = >.8–1.6; medium = >1.6–2.4; p b 0.001). The mean level of changes in total scores of pre and post tests
high= >2.4–3.2; very high= >3.2–4). It calculated the students' of the students' which demonstrated the learning progress in the exper-
satisfaction regarding applied teaching methods. Some examples imental group (12.32 ± 1.73) was significantly higher than that of the
of its questions are: “To what extent was the class enjoyable for control group (10.12 ± 1.61) (F = 23.55, p b 0.001) (Fig. 1).
you?” “To what extent did the teaching method attract your motiva-
tion toward to subject?” “To what extent did you involve in the
learning activities?” and so on. It was completed at the end of the Students' Satisfaction
course by both groups.
4) The “Teaching method evaluation”: A form containing 23 items to Although the students' satisfaction scores of the educational
compare the PBL and LBL methods from the students' viewpoints. methods were high in both groups, that of the experimental group
It was filled out at the end of the semester by the experimental [2.864 (±0.59)] was significantly higher than the control group
group who had 8 sessions with PBL and 8 sessions with LBL meth- [2.44(±0.37)] (t = −3.05, p b 0.01). The experimental group showed
od. The respondents were asked to mark the preferred method in- significantly higher scores than the control group in the students' par-
cluding PBL, LBL, or “no difference”. For instance, some of its ticipation in learning (t = − 010.49, p b 0.001), interaction among the
questions were: “Which of these methods was more enjoyable students in the classroom (t = − 10.1, p b .001), the clarity and under-
for you?” “In which methods there was more interaction between standability of course content (t = −2.26, p b 0.05), the more pro-
the students?” and so on. No score was calculated for this form. found learning (t = − 3.56, p b 0.01), preparation for final exams
(t = −3.91, p b 0.001) and for clinical activities (t = − 2.35, p b 0.05),
The two latest questionnaires were developed according to Safari while in control group, the learning of course content was more diffi-
et al. (2006) who compared the effects of lecture and discussion cult (t = −3.15,p b 0.01).
methods on nursing students' learning and satisfaction in Iran and According to the Pearson correlation analysis, no significant rela-
modified for midwifery students with the consensus of the authors. tionship (p > 0.05) was detected between student satisfaction levels
An expert panel verified content validity of the “Student's satisfaction and learning progress in either group (r = .41 in the PBL group and
of teaching method” questionnaire. Its Cronbach's alpha coefficient r = .33 in LBL one). In other words, without considering academic
was .82, and the two-week test–retest reliability coefficient was .86. progress, students in the PBL group had more satisfaction with the
applied teaching method (Table 2).
Statistical Analyses

Demographic characteristics were compared between the experi-

mental and control groups using the chi-squared and independent
Table 1
sample t-test. Pre- and post-test scores were compared using paired Mean (and standard deviation) pre- and post-test scores in control and experimental
t-test. ANOVA was also used to control the effects of the pre-test groups.
scores on the experimental and control groups differed post-test
Topics Groups n Pretest scores Post test scores
mean scores as well.
To compare students' satisfaction mean scores in each experimen- M SD M SD

tal and control groups we utilized independent sample t-test. χ 2-test PBL Control 34 2.09 .99 6.88 1.07
was used to compare the PBL and LBL from the experimental group Experimental 22 2.25 .99 9.64 .56
LBL Control 34 2.09 .99 8.24 1.02
point of view. And finally, Pearson correlation test was applied to de-
Experimental 22 3.00 .86 7.86 1.30
termine the relationship of satisfaction and learning progress in two
794 G. Sangestani, M. Khatiban / Nurse Education Today 33 (2013) 791–795

peers (Szogedi et al., 2010). In Iran, Dehkordi and Heydarnejad

(2008) studied 40 second-year nursing students in a one-semester
course. The results showed that the PBL group's knowledge was sig-
nificantly higher than that of students in the lecture group. Former
studies in Iran (Dehkordi and Heydarnegad, 2008a, 2008b) are differ-
ent from ours in two aspects: first they were done among nursing stu-
dents. Second, they assessed attitude and critical thinking of nursing
students. However, here we decided to determine the effect of PBL
on satisfaction and educational improvement of midwifery students.
Mahdizadeh et al. (2008), also compared two methods of lecture
and PBL for teaching anatomy in 40 junior medical students. They
found that the post-test scores were significantly higher than the
pre-test scores in both groups but the mean differences for correct
answers to judgmental questions in post-test were significantly
higher in the PBL group compared with the lecture group. Such a pos-
itive effect on the students' higher levels of cognitive domain due to
the PBL in contrast with lecturing was also referred by Tiwari et al.
(2006) in Hong Kong. According to their findings PBL students
Fig. 1. Comparing learning progress in the PBL and control groups. obtained significantly higher scores in the nursing students' overall
California Critical Thinking Disposition Inventory (CCTDI) and in its
three dimensions including critical truth-seeking, analyticity, and
critical thinking self-confidence. In another study in Iran, the PBL stu-
Teaching Method Evaluation
dents showed significantly greater improvement in overall CCTDI
scores (Dehkordi and Heydarnejad, 2008).
The experimental group expressed that the PBL was more favor-
In our study, satisfaction scores of both groups were high in third
able than LBL method because of the following facts: more enjoyable
quartile, but the PBL students expressed higher satisfaction than did
(χ 2 = 14.72, p b 0.001); more enthusiasm to the course (χ 2 = 23.27,
their LBL counterparts. The higher sources of satisfaction in PBL stu-
p b 0.001), more participation in learning (χ 2 = 14.27, p b 0.001);
dents were supposed to be due to the students' participation in learn-
more interactions between students (χ 2 = 18.18, p b 0.001); more in-
ing, interaction in the classroom, more understanding of contents,
terest to the course content (χ 2 = 18.18, p b 0.001); better interpreta-
better preparation for final exams and for clinical activities due to this
tion of course content (χ 2 = 12.64, p b 0.01); deeper learning of
method. The finding that the midwifery PBL students were more satis-
concepts (χ 2 = 27.91, p b 0.001); lower work and time to prepare for
fied and motivated is similar to the results reported in previous studies
the final exam (χ 2 = 27.91, p b 0.001); more motivation to study and
(Hwang and Kim 2006; Safari et al., 2006; Mahdizadeh et al., 2008;
refer to additional literature (χ 2 = 6.64, p b 0.05); more preparation
Dehkordi and Heydarnejad, 2008; Lin et al., 2010). An interesting result
for clinical activities and work with clients (χ 2 = 27.91, p b 0.001);
of this study is that regardless of academic achievement, PBL students
more adherence to course schedule (χ 2 = 8.27, p b 0.02); and allowing
stated more satisfaction with this teaching method. This increase in stu-
better communication between teacher and students (χ 2 = 19.73,
dent satisfaction can confirm the effectiveness of PBL in the classroom
p b 0.001).
for midwifery students.
Experimental students preferred PBL method to LBL. This prefer-
Discussion
ence for PBL was prominent due to factors such as being more enjoy-
able, enthusiasm to the course, participation in learning, interactions
Niemer et al. (2010) stated that PBL is a strategy which improves
between students, interest to the contents, interpretation of contents,
students' learning to use scientific knowledge for real problem solv-
deep learning, encourage to study, preparation for clinical practices,
ing in clinics (Niemer et al., 2010). We found that the learning pro-
observance of course schedule, communication between teacher
gress of students in the PBL group was more rapid than in the
and students and lower necessary work and time to prepare for the
control group. This is the only study performed in midwifery students
final exam. This finding is in contrast with the findings of Hwang
and shows a positive effect of PBL on their learning. This finding is
and Kim (2006) who found no statistically significant difference be-
comparable with that of the Korean study (Hwang and Kim, 2006).
tween the PBL and lecture groups in the level of attitudes of nursing
They compared the effects of PBL with the lecture on 71 second
students toward learning. But there are two studies which showed
year students in “Adult Health Nursing” course. They found that the
positive attitudes in Iranian nursing students to PBL method com-
level of knowledge in the PBL group was significantly higher than
pared with the traditional one (Mahdizadeh et al., 2008; Dehkordi
that of students in the lecture group. In another study, in Turkey,
and Heydarnejad, 2008; Hassanpour et al., 2006). Yuan et al. (2011)
the mean knowledge test scores achieved by medical students in
also showed that the students judged PBL to be moderately effective.
the PBL group were significantly higher than the traditional group
Students in small PBL groups with expert mentors were also rated it
in public health topics (Gurpinar et al., 2005). Hungarian nursing stu-
favorable at the State University of New York (Trappler, 2006). In
dents who received PBL had better final CPR exam grades than lecture
the studies conducted in Turkey (Alper, 2008), Pakistan (Khan et al.,
2007) and Bangladesh (Rahman et al., 2004), the medical students
had positive attitudes toward PBL.
Table 2
Mean scores of the students' satisfaction and their learning progress in the test and
control groups. Study Limitations and Suggestions for Further Researches
Topics Groups n Learning Satisfaction
Progress The students' satisfaction and preference could have been affected
by the researcher, who also was the tutor. In addition, the sample size
M SD M SD
was small, and the study period was only 16 weeks. The effect of PBL
Topics of PBL Control 34 10.12 1.61 2.44 .37 in clinical midwifery education and practice is recommended to be
Experimental 22 12.32 1.73 2.86 .59
studied in future studies.
 G. Sangestani, M. Khatiban / Nurse Education Today 33 (2013) 791–795 795

Limitations Hassanpour, A.D., Kheiri, S., Shahrani, M., 2006. The effect of teaching using, problem
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dents. Shahrekord University Medical Science Journal 8 (3), 76–82.
Despite the instructor's efforts to involve the LBL students through Hwang, S.Y., Kim, M.J., 2006. A comparison of problem-based learning and lecture-
questions and answers, the full participation of LBL students was not based learning in an adult health nursing course. Nurse Education Today 26 (4),
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learning and conventional teaching in nursing ethics education. Nursing Ethics 17
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