PROBLEM BASED

LEARNING
IMPLEMENTATION GUIDE

PREPARED BY
LALEM MENBER, IFAIMER FELLOW 2020
Contents
Background to Problem Based Learning................................................................................................. 2

Benefits of Problem Based Learning ....................................................................................................... 2

Learning principles in PBL ........................................................................................................................ 3

The Rationale of Developing the Guide ................................................................................................... 4

Guidelines for constructiong PBL Cases ................................................................................................. 5

Components of case specific tutor guide .............................................................................................. 9

Facilitating PBL Tutorials .................................................................................................................... 10

The 7 plus 1 steps in PBL tutorials ................................................................................................ 10

Roles and Responsibilities of Tutors and Students............................................................................. 12

Tutors’ role ................................................................................................................................... 12
Students’ role ................................................................................................................................ 13

Assessment in Problem Based Learning ................................................................................................ 14

Summative Assessment ........................................................................................................................... 14

Formative Assessment ............................................................................................................................ 14

PBL tutorial assessment rubrics ................................................................................................................. 0

1
 BACKGROUND TO PROBLEM-
BASED LEARNING
Nowadays’ a lot of information is available on the internet, then the real question that
needs to be answered is “should we continue providing all this information in our learning
environment or instead ask students to acquire all this information and discuss it with
themselves in small groups”? The answer should be, the role of the instructor should be
changed from information provider to a facilitator, supporting students to be self-directed
learners.

Problem-based learning (PBL) is a student-centered learning process in which the

problem acts as a stimulus to identify learning needs and increase the desire to know. The
problem will create a realistic context to show the relevance of learning for future
professional practice. Learning should be guided by the problem or case to make it more
authentic and inspiring. It is a paradigm shift from the conventional didactic approach to
more innovative ways of learning. The primary aim of the PBL process is not problem-
solving but to learn the basic concepts, principles, mechanisms, and other desired skills
for healthcare practice such as teamwork, collaboration, communication, leadership, etc.
In the PBL process, both content and the process of learning will be emphasized. PBL has
evolved through time and appears to have different shapes, however, some essential
features remain relatively constant. What is constant to PBL is that the problem comes
first without advance reading, lectures, and preparation on the PBL case objectives
(Mansur, Kayastha, Makaju, & Dongol, 2012).

Benefits of Problem Based Learning

The conventional way of teaching a course followed by assessment fundamentally
belongs to a conventional approach of learning called mastery learning. Problem-based
learning promotes a different form of learning in a more self-directed way. It is an
innovative way of teaching and learning strategy that fits into the current insights of
human learning. PBL promotes skills that are very important for the labor market (SDL,
functioning in a team, communication, collaboration, professional behavior, lifelong
learning, critical thinking, problem-solving). These kinds of skills are complex, not easy to
learn, and can be learned longitudinally (Dring, 2019; Guo et al., 2020). PBL allows students

2
to learn biomedical sciences, public health, ethics, and professionalism in a clinically
relevant context and hence improve retention of knowledge. Studies also showed that
PBL graduates had better-perceived learning experiences (Trevena, 2007).

Learning principles in PBL

Principles Description
Active - Learning is active and requires active engagement.
learning - Students take control of their learning; students will pose and
answer their questions
- Activation of prior knowledge and experience supports learning

Integrated - Different disciplines or sub-disciplines are not studied separately

learning - Knowledge, understanding, and skills are not seen as distinct
elements but integrated
- The problem is the focus of discussion
- Every attempt is made to link the classroom and the real world of
practice
Cumulative - No topic or problem is studied to the depth of the final learning
learning outcome in a single block; rather topics are revisited in
progressively greater depth
- The sophistication of the problem and the nature of the challenge
become progressively greater as students move through the
curriculum
- Topic become progressively more complex and problems more
indeterminate

Consistency in - Students are treated as responsible adults

learning - Adult learners are goal-oriented and internally motivated
- Assessment must be constructively aligned with the goals of PBL

Learning for - The processes of inquiry are more important than the facts
understanding delivered
- Knowledge must be tested by application
- Feedback and Reflection are an integral part of the learning
process

3
The Rationale of Developing the Guide
Universities are implementing the new innovative competency-based curriculum where
PBL is used as a major learning strategy. The hybrid PBL curriculum integrates the
advantages of the conventional and the innovative curriculum. PBL is used mainly to teach
biomedical sciences in a relevant clinical context and help students acquire generic skills
such as functioning in a team, communication, professionalism and ethics, synthesis,
critical thinking, problem-solving, and self-directed learning skills, etc. However, problem-
based learning implementation is inconsistent not only across institutions and programs
but also among instructors in terms of case presentation format, case writing format,
frequency, and duration of tutorials, the use of formative and summative assessments,
and the percentage account of PBL tutorials for summative value. Furthermore, PBL
experts have different experiences and understanding, lack consensus about PBL
problems, processes, and practices.

Several factors might have been contributing to the inconsistency in the implementation
of the hybrid PBL curriculum. A survey at Debre Tabor University Midwifery program
revealed that the Lack of institutional or national standard problem-based learning
implementation guide is one of the hindering factors for the effective implementation of
PBL. The teaching and learning process is affected by socio-cultural factors. Having a
standardized PBL implementation guide is critical for the effective implementation of
competency-based curricula. So, Institutions may have their way of implementing PBL
based on the local context. The application of PBL as a unitary concept across different
contexts is being challenged by experts (J. M. Frambach, W. Talaat, S.Wasenitz, & M.A
(Tina). Martimianakis, 2019). Thus, scholars recommend adapting PBL into the local
context. Therefore, we prepared a contextualized guide considering international and
national practices to standardize the PBL implementation. It will help instructors and
students recognize their roles and responsibilities, frequency and duration of tutorials,
case qualities, assessment modalities, etc.

4
 GUIDELINES FOR
CONSTRUCTING PBL CASES
Well-constructed cases are essential for successful problem-based learning. PBL cases are
generally expected to be ill-structured, realistic scenarios that promote broader thinking
and inspire learning. The case will help to integrate clinical medicine, biomedical science,
behavioral/mental, population, professional attitudes, values, ethical issues, etc. which are
fundamental to medicine.

PBL Case construction involves four steps

I. Planning the Case: The planning phase is probably the most difficult and
critical element in the process of developing a case, requiring careful consideration
of the following questions:
o What are the learning goals and objectives of the course and how does this case
support them?
o What information and principles should the case embody to meet these goals?
o What common clinical scenario will provide a vehicle for the integration of the
intended concepts and serve as a model or prototype?
o How will biology, behavior/mental health, and population issues, as well as
professional attitudes, values, and ethics, be integrated into learning?
o What clinical skills are related to the case?
o How will other cases be integrated with this case?
o What keywords describe the case?
o How will the learning outcomes of the case be assessed?
II. Constructing the Case: PBL case writing should follow the following steps
a) Establish a multidisciplinary team to write and review PBL cases. Organize a
workshop to write a new case or review and update existing cases. The team will
- Discuss and identify case objectives that are aligned with module objectives
- Decide on how to turn objectives into events that foster discussion
- Research literature and collect resources to write cases
- Identify cues (problems) in the trigger text and design trigger images, video, etc.
- Outline major characteristics of the patient in the trigger like age and sex

5
 - Decide on the flow and key educational issues planned for each part of the case.
New information is provided as the case unfolds requiring students to test and
revise their hypotheses.
- Cases should be on priority health needs of the region/country
- Ensure the case is up-to-date and relevant for the level of students
b) Identify educational objectives of the case
- Derived and linked to module objectives
- 6 -7 objectives per case that can be feasibly addressed in the given period
- Objectives should cover different disciplines and perspectives
› Biological
› Psychosocial and population health issues
› Professionalism and ethical issues
c) Construct a template for cases: The case writing template may vary from disciple
to discipline. Departments/programs may have their case writing format. The case
is constructed to include some or all of the following elements.
› Patient and Visit Information
› Presenting problem/triggers
› History of Present Illness, Past Medical History, and Social History
› Review of Systems
› Ancillary Investigations and Results
› Differential Diagnosis/Hypotheses
› Treatment
› Patient Follow-Up
› Exhibits
› Mini Cases (Vignettes)
d) Think integration, logical flow, and authenticity of the case
› The case provides a focus for integrating a wide variety of learning activities;
Multiple categories of health and risk factors, different mechanisms of disease
› Reflect real practice thereby stimulating a wide range of realistic testable
hypotheses
› ill-structured
› Written from the patient’s perspective: The chief complaint and history are
written in patients’ own words
› Written for students and encourage student-centered learning
› Logical inflow and address objectives

6
 e) Adjust cases to students’ learning needs and stages of the curriculum
f) Start the case with an engaging trigger
› Addresses key objectives
› Highlights 3-4 key problems
› Encourages broad discussion
› Reflects a realistic scenario
› Provides some background info (age, sex, place of a visit, etc.)
g) Think about students’ engagement with the cases
h) Ensure a deductive approach is applicable
i) Ensure learning objectives are well represented in the case
j) Design images and investigations
k) Mini case: mini cases should be included if the focus of the discussion is more on
clinical and small biomedical sciences. Creating what-if scenarios to help students
apply their knowledge in different contexts. These can be changes in risk factors like
ethnicity, age, sex, lifestyle, etc.

III. Formatting the Case: The format for the case is determined through
consideration of the following questions:
- What information will be provided to students initially?
- How will you provide additional information, if any, to students as they progress
through the case?
- At what point should case exhibits be provided?
- Do you want to include any supplemental activities such as role-plays, videotaped
patient interactions, visiting patients, simulated patients, etc.?

IV. Preparing for use of the Case/ proof reading the case

- Check the grammar and Spelling errors

- Ensure cultural, racial, and politically sensitive issues are not included in the case

7
 CONSTRUCTING TUTOR GUIDE
As most teachers lack experience in facilitating PBL, they are more likely to encounter
difficulties in planning, implementing, and assessing PBL. A tutor guide is an institutional
document that describes all necessary knowledge and skills which an effective tutor is
supposed to have. Each university/institution with a PBL curriculum creates its tutor guide
or tutor handbook based on global experiences and achievements in PBL implementation
and includes some details specific for a particular university.

The tutor guide consists of all the necessary information/ instructions regarding a
specific PBL case. During PBL tutorial a tutor watches, listen, directs, and helps students
with asking the questions, giving them hints (hint questions) if they need to go deeper or
more detailed in their discussion of the learning objectives. That is why each PBL case has
to have a tutor guide with precise instructions, explaining what exactly students are
supposed to know, understand, how deep they should study one or the other learning
objective.

A tutor guide has an explanation per each page of the scenario. So when the students see
a page, the tutor knows what exactly the students should discuss on this page, which
learning objectives they can create here, which new terms students are supposed to
understand.

Knowing from the beginning of the PBL case the final learning outcomes (official learning
objectives), and having precise notes a tutor can easily facilitate the discussion even if
she/he is not an expert in that area. That is the crucial part of a PBL tutor guide – a tutor
does not need and cannot be an expert in all topics of PBL cases. If students do have some
particular questions related to the specific areas, they are supposed to clarify them either
on the lectures (where a lecture is an expert in the exact area) or on the expert forum
(whole group session) which some universities include in PBL curriculum to give their
students opportunity to talk with the professional clinicians. Generally, there are not many
unanswered questions for the students if there are good PBL tutor guides.

8
Components of case-specific tutor guide
For facilitators to effectively lead the tutorial process and achieve the objectives, they need
to have the following information about the case before the date of the tutorial:
- A brief abstract of the case
- Location in the course: year, module, week
- The list of objectives (learning goals/ objectives): behavioral, mental health,
biological, population, professional attitudes, values, and ethics
- Overview of tutorials with a brief explanation of what exactly students should
concentrate on in this particular tutorial (Tutorial 1; Tutorial 2).
- Suggestions for facilitating the case (e.g., case progression, recommended
discussion points, prompting questions, what to avoid, etc.):
- Instruction for tutors per each page of the information given to students so that the
tutor knows what students will be discussing when they see a page.
- Information about other integrated educational activities (e.g., lecture, laboratory,
and clinical skills)
- Related and necessary investigations and exhibits, suggestions on how to use them
during the tutorial, and a thumbnail guide to their interpretation and what they add
to the understanding of the case.
- References: Supporting educational materials for the facilitator (e.g.,
articles/information to inform facilitators about the content of the case)
- The list of resources available during tutorials

9
 FACILITATING PBL TUTORIALS
PBL is a student-centered inquiry where the problems are the starting and ending points
of the PBL tutorial process. The problem creates a realistic context to activate prior
knowledge and experience. Students will be in small groups to learn collaboratively but
that doesn’t mean they are interdependent.

Figure 1: Steps in the PBL tutorial process

The 7 plus 1 steps in PBL tutorials
1. Clarify: Read the case carefully, identify and clarify unfamiliar terms and concepts
that they don’t understand
2. Define: What is the main problem? [problems; biological, psychological, social]
3. Analyze the mechanisms: Students will try to explain the mechanisms involved
based on their prior knowledge about the problem.
4. Review: Students will try to arrange their ideas and explanations into tentative
solutions.
5. Formulate learning objectives: The team identify and agreed on the learning
objectives.
6. Self-study: Students individually gather information towards learning objectives
and prepare to share it with colleagues
7. Report: Students come together and share their results with team members. Tutor
check if learning objectives have been met

10
 Day 1 Day 2 Day 3 Day 4

Introduction Case 1 Case 2 Case 3

completion completion completion

• case 1 • case 2 • case 3 • case 4

started started started started

Figure 2: A 3-hour PBL tutorial will be facilitated every week. Every tutorial is divided into
two parts. In the first 2 hours, the case from the previous week will be completed. In the next
1 hour, the next case will be started

Frequency and duration of tutorials

PBL tutorials will be conducted once a week that will last for 3 hours. A problem/ case/
scenario will be concluded in two tutorials. The first day of the tutorials will start by
orienting students about the process and opening up a case. Then, the subsequent
tutorials will have two parts; the first part will run for 2 hours and the second part will
continue for the remaining 1 hour. In the first part, the synthesis of the past week's case
will take place in 2 hours and the remaining 1 hour will be used to open the new case and
discuss it till step 5 of the PBL tutorial process.

How to present a case to students during the

tutorial processes?
Based on the level of students we use three different ways of case presentation. These
are:
a) One step unfolding: At the early stage of the curriculum the whole case with
limited information will be provided to motivate students’ learning needs. The
students are expected to discuss the case following the 7 plus 1 steps.
b) Two-step unfolding: In the middle of the curriculum, we use two-step unfolding
of information; in the first step subjective data will be provided, and in the second
step objective data (P/E and Inx) will be given.
c) Multi-step unfolding: later in the clinical years’ PBL cases will be presented in a
stepwise progressive unfolding way (trigger, HPI, PE, Inx, management, mini case,
etc.)

11
Roles and Responsibilities of Tutors and Students
Tutors’ roles
In PBL the role of the teacher is shifted from a “sage on the stage” to a “guide by the
side”(Telang, 2014). Teachers are not expected to provide information, but to guide the
discussion in the tutorial process. A good tutor is like a football coach; he/she actively
listens while students discuss, understands the learning issues to be discussed, and knows
what and when to ask. Hence, instructors who received PBL training can facilitate PBL
tutorials as far as they are provided a well-prepared tutor guide. Tutors should stay in the
same group at least till the end of a module.

Tutors responsibilities

- Facilitate the tutorial process using the 7 plus 1 steps

- Manage time and process
- Facilitate group dynamics (create and maintain a positive learning environment,
ensure opportunity for equitable participation, etc...)
- Make sure that students will be able to address all the key points indicated in the
tutor’s guide.
- Allow students to share, debate, and discuss the learning issues
- Facilitates regular group and self-assessment/reflection.
- Evaluate students’ performance and document their behaviors and progress over
time.
- Make sure that students can organize all the identified learning issues and develop
an action plan for working or self-learning on the problem
- Guide students in the identification and critical evaluation of learning resources and
use them to research key learning issues

12
Students’ roles
A small group of 8-10 students will engage in enquire-based learning. Students will
identify their gaps (need to know) while trying to explain and manage the problem.
Students will assume different roles and responsibilities in PBL tutorials. In the first
meeting, students have to be oriented about the general principles of the PBL tutorial
process (ground rules, roles, and responsibilities of students & tutors).

Table 1: Roles and responsibilities of students in PBL tutorials

Roles Responsibilities
Chair - Lead the group discussion in the tutorial process
- Encourage active participation by asking questions
- Help group to order their thoughts by paraphrasing statements
- Maintain group dynamics
- Keep to time
- Encourage scribe to keep recoding of points and share learning issues
Scribe - Record points only upon consensus by the group
- Actively contribute to the group discussion
- Record resources used by the group
Members - Comply with ground rules set
- Select a group leader and a note taker and explain their roles
- Actively participate and contribute to the learning process
- Debate evidence related to the case and avoid personal attack
- Research key learning issues using a variety of resources
- Synthesize what you have learned and be prepared to discuss
- Participate in end-of-session reflection and assessment by giving and
receiving constructive criticism regarding self, tutor, and peers.
- Validate and summarize the key points about the specific case to be
addressed and link back to learning objectives

13
 ASSESSMENT IN PROBLEM-
BASED LEARNING
In a competency-based curriculum, the assessment drives the learning activities. It is the
motivating factor for students to engage in meaningful learning activities. Thus, in PBL
both the tutorial process and the contents covered are assessed. Student performance
assessment in PBL tutorials should be a continuous process. Assessment rubrics are used
to minimize subjectivity in assessing student performance during the PBL tutorial process
(Sim, Azila, Lian, Tan, & Tan, 2006). The content (knowledge) covered by the tutorial
process will be assessed in block exams like mid-exam and final exams.

Summative Assessment
PBL tutorial assessment should account for 15% of the summative value of the module
assessment. The tutor will do the summative assessment at the end of every second
tutorial (completion of the case). The average value of each assessment score will be
turned out of 15%.

Formative Assessment
The performance of students should be assessed at the end of every PBL tutorial.
Feedback and reflection are an integral part of the PBL tutorial process. Narrative
feedback is more important in the PBL tutorial processes. Students are expected to reflect
on their performance (strengths and gaps to be improved) followed by constructive
feedback from peers and tutors. Student assessment in the PBL tutorial should focus on
the PBL tutorial process (e.g. researching, collaboration, communication, etc.). Peers can
reflect on and assess the performance of other students. Self and peer assessment results
are more generous than teacher evaluation, and hence they should be used for formative
value only. Formative feedback should be assembled, reflected, and documented as a
learning portfolio.

14
PBL tutorial assessment rubrics
Module name……………………………. week……………………...tutorial #……………………………
Table 1: PBL tutorial assessment rubrics for assessing student performance during PBL tutorial

S. Name of please circle 1,2 or 3 based on their performance Other remarks

No student Participation and Cooperation/ Comprehensio Knowledge/ Professionali Total
communication team-building n/ reasoning information sm and marks
skills skills skills gathering ethics
skills
1. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
2. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
3. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
4. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
5. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
6. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
7. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
8. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
9. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
10. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
1= Unsatisfactory 2 = Satisfactory 3 = Outstanding

Signatures

Name of tutor----------------------------------------
 References

Dring, J. C. (2019). Problem-Based Learning - Experiencing and understanding the prominence

during Medical School: Perspective. Ann Med Surg (Lond), 47, 27-28.
doi:10.1016/j.amsu.2019.09.004
Guo, J., Li, L., Bu, H., Feng, M., Yang, Y., Zhang, Y., . . . Jiao, X. (2020). Effect of hybrid teaching
incorporating problem-based learning on student performance in pathophysiology. J Int
Med Res, 48(8), 300060520949402. doi:10.1177/0300060520949402
J. M. Frambach, W. Talaat, S.Wasenitz, & M.A (Tina).Martimianakis. (2019). The case for plural
PBL: an analysis of dominant and marginalized perspectives in the globalization of
problem‑based learning. Advances in Health Sciences Education, 24, 931-942.
Mansur, D. I., Kayastha, S. R., Makaju, R., & Dongol, M. (2012). Problem based learning in
medical education. Kathmandu Univ Med J (KUMJ), 10(40), 78-82.
doi:10.3126/kumj.v10i4.11002
Sim, S. M., Azila, N., Lian, L.-H., Tan, C., & Tan, N. (2006). A simple instrument for the
assessment of student performance in problem-based learning tutorials. Annals of the
Academy of Medicine, Singapore, 35, 634-641.
Telang, A. (2014). Problem-based learning in health professions education: An overview.
Archives of Medicine and Health Sciences, 2(2), 243-246. doi:10.4103/2321-4848.144363
Trevena, L. J. (2007). Problem-based learning in public health workforce training: a discussion of
educational principles and evidence. NSW Public Health Bulletin, 18(1-2), 1- 6.