INTRODUCTION:

The problem-based learning (PBL) is a student-centered teaching method in which students learn about a subject through the experience they provided with solving an open-ended problem given as triggering material. Problem-based learning is a pedagogical teaching approach employed in many medical schools. This approach includes the presentation of an applied problem to a small group of students who engage in discussion over several sessions. A facilitator in the session provides supportive guidance for the students. [1]

The discussions of the problem-based learning are structured, which enable students to the conceptual framework on the problem presented in the case. Here the students discover the limits of their knowledge; they identify learning issues by exploring their fund of knowledge. Also, between the PBL discussion meetings, learners able to research their learning issues shared in the next meeting. The application of problem-based learning (PBL) absorbed enormously and globally by many institutions in various fields of higher education, such as medicine, engineering, science, and economics [2]. The PBL emerging in the undergraduate curriculum, many universities encounter this curriculum reform and are exploring new ways to engage and teach the students more effectively. The goal of PBL is to prepare students for life-long learning by engaging them in an active learning environment in which the students are responsible for discovering the facts and learn the key concepts. The success or failure of PBL depends on the responsibility of students and proper guidance extended by the facilitators [3]. The PBL fosters the students’ ability to develop cognitive skills as well as soft skills such as critical thinking, problem-solving, leadership, teamwork, and communication. PBL is well-known for creating an active student-centered learning environment with a generation of soft skills [4].

However, the PBL also have an untoward effect on some students who merely receive content knowledge rather than the need to explore and apply the knowledge obtained. In this method, even facilitators have to adopt a shift in their mindset instead of simply giving information they have to facilitate students in developing cognitive skills and other soft skills. There were studies that have been published in favor of the strategy of PBL [5]. Various researchers reviewed articles regarding PBL implementation across the areas of higher education and found a positive effect on students’ skills; the pieces of evidence also show, negative tendencies regarding knowledge achievement [6, 7, and 8].

Another important and essential factor in conducting successful PBL is the role and responsibility of facilitators. Along with prior students’ knowledge and the quality of problems being discussed, the facilitators play a crucial role in all aspects of the PBL session. To fulfill the objectives, facilitators reinforce the activation of relevant prior knowledge, the attainment of new knowledge, the establishment of learning objectives for self-study, and the sharing of knowledge among peers via self-study ^[9]. Good facilitators allow students to propose hypotheses even if they are not accurate, permits learners to identify and correct misconceptions, and stimulate critical thinking. They also should motivate students to critically assess the information presented by their group members ^[10].PBL prepares students for lifelong learning in healthcare professions [11]. However, after so many years of successful PBL implementation across the world, many challenges and drawbacks have been identified from the literature, and the effectiveness of PBL being questionable [12,13,14].

In Malaysia, PBL was introduced in an education context, particularly in health sciences since the early 1970s [15]. The PBL is an upcoming pedagogical paradigm in Malaysia why conventional teaching methods are no longer applicable to today’s educational environment debated [16].Many studies regarding the student perception of the preclinical and clinical years on PBL were conducted in Malaysia and globally. There is no/ limited literature regarding the pre-housemen perception of PBL and facilitators. Pre-housemen have learned various teaching-learning methods throughout their medical program and experienced enough, to give feedback on the method of teaching-learning that is more advantages to them. Thus, the aim of this study was to determine the perceptions of clinical students and pre-housemen regarding the benefits and drawbacks of PBL and their opinion towards PBL facilitators.

THE OBJECTIVES OF THE PRESENT STUDY:

1) To assess the benefits of PBL,

2) To evaluate the drawbacks of PBL, and

3) To determine the opinions of clinical students and pre-houseman on PBL facilitators.

MATERIALS AND METHOD:

This study is a questionnaire-based, cross-sectional study conducted at Lincoln University College (LUC), Selangor state, Malaysia, during January and February, the 2017-18 academic sessions. The LUC PBL committee members design the PBL case and the facilitators with both medical and non-medical degrees, to guide the students to achieve the targeted learning outcomes. The participants from clinical year students comprise of year 3, year 4, and year 5, also the pre-housemen who exposed to problem-based learning methods earlier. Pre-housemen are those who have successfully finished their year 5 exams in medical school and waiting for the postings at the government hospitals as a houseman. Out of 275 clinical year students and pre-housemen, a total of 246 participants volunteered to be involved in the study. All participants clearly explained the objectives of the study and the assurance of confidentiality. Informed consent attained from all participants. The questionnaire was prepared using Google docs and distributed to students through social media like Whats app and emails. The questionnaire involved three areas of students’ perception and feedback.

1) Student perception on benefits of PBL (Question 1 to 10)

2) Student perception on drawbacks of PBL (Question 11 to 15)

3) Students feedback on PBL facilitators (Question 16 to 20)

Information about demographic details such as age, sex, and study year was collected. Student opinions were graded based on five points Likert Scale (strongly agree, agree, neutral, disagree, and strongly disagree). Students were also asked an open-ended question on their preferences of teaching methods in preclinical and clinical years. Data were collected and analyzed by using SPSS version 21.

Table (1): Students’ perception on the benefits of PBL using Likert Scale

No	Question	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
		N (%)	N (%)	N (%)	N (%)	N (%)
1	PBL encouraged me for self-learning and problem- solving skills	80(32.5)	132(53.7)	28(11.4)	6(2.4)	0(0)
2	PBL helped me to build my ability to analyse and interpret knowledge	56(22.8)	142(57.7)	24(9.8)	2(0.8)	22(8.9)
3	PBL improved my ability to communicate with peers	94(38.2)	116(47.2)	34(13.8)	2(0.8)	0(0)
4	PBL improved my presentation skills	68(27.6)	132(53.7)	38(15.4)	8(3.3)	0(0)
5	PBL encouraged my understanding of basic sciences and its application to clinical scenarios.	66(26.8)	146(59.3)	28(11.4)	6(2.4)	0(0)
6	PBL improved my ability to perform tasks (allotted by team leaders/facilitators	60(24.4)	134(54.5)	46(18.7)	6(2.4)	0(0)
7	PBL motivated me to look for more information from additional sources relevant to the problem.	106(43.1)	120(48.8)	15(6.1)	3(1.2)	2(0.8)
8	PBL improved my ability to think critically.	66(26.8)	140(56.9)	32(13)	6(2.4)	2(0.8)
9	PBL improved my reasoning skills and to provide hypothesis.	52(21.1)	142(57.7)	46(18.7)	4(1.6)	2(0.8)
10	PBL gave a platform to build my skills on diagnosis.	72(29.3)	134(54.5)	31(12.6)	7(2.9)	2(0.8)

RESULTS:

MD year 4 students responded maximum (n=78), followed by MD year 5 (n= 70), pre-housemen (n=60) and least from MD year 3 (n= 38). Among 246 students responded 73.2 % were females and 26.8 % were males.

Table 1 shows student's perceptions of benefits of PBL 86.2% of participants have agreed that PBL encouraged them for self-learning and problem-solving skills (Q1). It helped them to build skills in analysis and interpret knowledge (Q2). It improved their ability to communicate with peers and their presentation skills (Q3/4). They have agreed that PBL encouraged them to understand basic sciences and their clinical applications (Q5). PBL has helped them to perform their tasks given by team leaders and their skills in searching for information (Q6/7). With the help of PBL, they have improved their critical thinking, reasoning skills to provide hypothesis and to derive diagnosis (Q8-10).

Table 2: shows the student's perception of the drawbacks of PBL among them 61% of the students agreed that dominant students gain more in PBL, but the remaining were either neutral or disagree (Q11). The mixed opinion was given by students for Q12, which states that PBL suppresses those students who are reluctant to participate and communicate with peers. The majority of the students have agreed that if the PBL facilitator did not debrief them towards the end of the session, they remain unaware that whether their information is right or wrong (Q15).

Table 3: shows student opinion on the PBL facilitator's role. Students have strongly agreed that PBL facilitators aware of PBL procedures, however few of them were neutral (Q16).

They agreed that facilitators helped them with ice breaking off the PBL session and also guided students to derive their learning issues (Q17-18). The students have given feedback that facilitators were ensuring that all students were actively participating in PBL discussions, and there was debriefing towards the end of PBL sessions (Q19-20).

Students were also asked an open-ended question on their preferences of teaching methods in preclinical and clinical years. Most of the students chose for the lecture (31.7%) and PBL (31%) followed by tutorials (28.9%) and CBL (8.5%), which is a preferred teaching method for preclinical years. But for clinical years, the majority of students preferred CBL (51%) and PBL (26.6%) over; lecture (13.3%) and tutorials (9.1%) as their preferred teaching methods.

Fig (1): Student opinion on preferred teaching method for preclinical years.

Fig (2): Student opinion on preferred teaching method for clinical years.

DISCUSSION:

Many medical schools have shifted traditional teacher-centered learning to integrated student-centered self-learning. There was a wide range of studies that considered PBL among the best educational strategies that empowered medical students in developing higher cognitive, communication, and research skills [17, 18]. PBL has many advantages to the learners, but there are also drawbacks, particularly in its conduction and facilitation. Therefore, how well a PBL was conducted and facilitated would be assessed by a questionnaire on student's perceptions and opinions that focus on the benefits, drawbacks, and facilitators. Our study demonstrates the majority of students agree on all soft skills are achieved by PBL. More than 80% of participants acknowledge that the self-learning skills, problem-solving skills, and analytical skills, application of basic science knowledge to clinical problems, and diagnostic skills improve by actively participating in PBL.

Previous literature study evidence that no PBL curricula result in any improvement in general, content-free problem-solving skills; learning in a PBL format initially reduces levels of learning but may foster increased retention of knowledge over a period of time. Evidence also advocate that PBL curricula may enhance both transfers of concepts to new problems and integration of basic science concepts into clinical problems, Evidence also advocates that PBL curricula may enhance both transfers of concepts to new problems and integration of basic science concepts into clinical problems, which enhances intrinsic interest in learning issues and PBL to promote self-directed learning skills. [19]

Facilitators and the chairperson play a very important role to overcome this dominant student problem by motivating others to contribute and cooperate. The PBL, students have to do self-study, gather information from various resources, read and digest the information, further communicates and share the information with group members. Active and attentive participation of the participants gathers a lot of information is during the PBL session. Furthermore, active self-directed learning motivated students to a proper understanding of the topic, which is not easily achieved by lecture-based learning. Similar findings reported by various researchers. [20, 21, 22] Interestingly many students agreed that there are drawbacks to PBL. Sixty-one percent of students commented that dominant students gain more knowledge, while 26% neither agree nor disagree.

Similarly, 51% of participants opted that PBL suppresses those students who are reluctant to participate, and communicate with peers while 30 % remained neutral on that question. It is noted that PBL is group work and active participation of team members to achieve the targeted learning outcomes, but there are some students who want to dominate the discussion by not giving a chance to others to contribute. At the same time, the chairman or facilitator can remind the dominant student to allow others to discuss in the PBL session. Surprisingly, we found that more than 81% of students commented on whether it is right or wrong regarding the information they discussed in PBL if the facilitators did not guide and debriefing. Facilitators encourage to debrief at the end of the PBL session confirm to provide all the relevant rightful information. These findings were consistent reports on PBL by Wong et.al, Lim and colleagues. [23, 24]

The majority of students at Lincoln University expressed positive opinions on the PBL facilitation, evidenced by their feedback. The percentages demonstrated college with facilitators’ awareness of PBL (75%), facilitators’ helpfulness in ice-breaking of PBL session (70.8%), facilitators’ guidance to achieve PBL learning issues (81%), facilitators’ encouragement to students’ active participation (78.8%) and facilitators’ feedback at the end of session (67.5%). One of the PBL objectives focus was to achieve the targeted learning outcomes by all students at the end of the session. Facilitators are required to drive the students to achieve such learning issues and to guide students if their discussion deviates from the main learning outcome. In the present study, most of the students agreed that the PBL facilitators drive them to achieve targeted learning issues. Schmidt and Moust, in their study, also concluded that tutor-related behaviours are a determinant of successful PBL sessions [25].The findings of this study demonstrate consistency with Nab shah M et.al study at University Kebangsaan Malaysia (UKM) [26].They found that facilitators understood the PBL process (99.1%), ice-breaking, and guiding to achieve learning objectives by facilitators (96.8%) and debriefing at the end of the PBL session (92.5%). Literature has evidenced one of the Pakistani studies evidenced that PBL sessions associated with Medical Biochemistry conducted by a content-expert facilitator. Their exam marks reflected well on their perception^. [27]

Giving feedback at the end of each PBL session is important for the students, whether they are on the right track or not. Debriefing would help the students to improve the discussions in future PBL sessions. In our study, the facilitators need to give more feedback at the end of the PBL session because only two-third of students consented that the facilitator did debrief which the lowest score among all five questions has related to the facilitator. The faculty should remind all the facilitators involved in the PBL session to give proper feedback to improve student's performance in upcoming PBL sessions and to make sure the information learned throughout the PBL sessions are true. In the present study, the student's preferred method of teaching for pre-clinical students was a lecture, tutorials, and PBL. Conversely, the participants preferred PBL and CBL to traditional lectures and tutorials in clinical years. To understand the intricate and complex basic science knowledge to deliver the information as a lecture and then discussed details during tutorial and PBL sessions. The expert knowledge from the lecturer could direct the students’ better understanding and correct information to be achieved. That is the reason most of the participants opted for lectures and tutorials for pre-clinical students. However, the participants perceived the CBL and PBL are better methods than lectures and tutorials for clinical year’s students. Clinical year students need to apply the basic science knowledge they have gained during preclinical years to real-life cases/patients. They use critical thinking, and problem-solving skills to get the correct diagnosis and its differentials. CBL and PBL are the best methods in inculcating those skills, and it is more suitable for patient/case-based learning. Problem-based learning (PBL) is commonly used by many medical schools to enhance learning that can improve open inquiry, teamwork, and critical thinking medical students. Previous studies reveal that PBL is not compared with other forms of discussion-based small-group learning, such as case-based learning that provides more structure during small-group sessions. [28]

Though there are limited studies on CBL and PBL, various studies have proved the efficacy of PBL, over lecture-based learning. A previous study by Parisa Khoshnevisasl and et al, evidenced in their studies on medical students who preferred problem-based learning over lecture-based learning because of motivation boost, a higher quality of education, knowledge retention, class attractiveness, and practical use. [29] One of the evidence from the Pakistani study has focused on triggers; they revealed triggers should have planned clues that lead students to generate issues that correlate with faculty objectives. [30] The student's comments on PBL draw their perceptions of PBL. Observation of previous studies demonstrates, the efforts of van den Hurk et al., in developing an instrument, to study PBL processes emphasized on assessing student perceptions regarding different PBL processes. [31]

Table 4: The table depicts the examples of some comments given by LUC students on how to improve in conducting PBL for the future PBL sessions.

Sl.no	The students comments
1.	“In the PBL, everyone must participate in the discussion and answering the question. Not just dividing the question number and do it alone at home. And later discuss in the PBL, and they only focus on their part only”.
2.	“During my pre-clinical years in PBL, even though we covered a lot, discuss a lot regarding the topics given I failed to grasp the whole picture as we go too deep blindly and often unnecessary to know. When I entered my clinical years, then I could see how PBL could sharpen our minds into critical thinking without blindly shooting here and there. I know what I want to know to the extent of how I want to manage each problem. PBL in clinical years would be helpful to utilize both our theory and clinical knowledge”.
3.	“PBL facilitator should be cleared with discussing learning issues in order to guide students.”
4	“Members who participate actively should give chances to other members that haven’t had a chance to share his/her opinion.
5.	“I think both lectures and CBL/PBL are important. Both benefit us lectures give us an overview of the topics and CBL/PBL so that we can apply the knowledge. So, they work synergistically.”
6.	“Initially, the students are not aware of the benefits of PBL and may think PBL as a burden, but as time goes, they notice that PBL helps a lot.”
7.	“I prefer to have both PBL and CBL for the clinical year. But we still need lectures.”
8.	“Please do PBL; it is very helpfully for the student in the clinical year.”

The identifying key resources for students, students learning to identify and utilize learning resources on their own in PBL are lined with their attitude. Thus their comments are key notes for to bring advances in problem based learning and facilitation by their teacher.

CONCLUSION:

The study conducted in LUC has concluded that the acceptance of PBL among students was satisfactory. The findings suggest that the students have benefited from PBL sessions. They have also given positive feedback on PBL facilitators. Dominant students, deviation from the point of discussion and lack of debriefing were the key drawbacks of PBL mentioned by participants in our study. This finding also pointed out that a combination of traditional lecture and tutorial as well as PBL sessions would be better for pre-clinical teaching-learning processes. Contrariwise, PBL plus CBL with more bedside teachings is a preference given by participants in the present study. The study results would be useful in the assistance of future PBL programs at Lincoln University College; further, it can be applied by other universities.

ACKNOWLEDGEMENTS:

The authors would like to thank all the students who voluntarily participated in this study.

CONFLICTS OF INTEREST:

None declared.

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Received on 18.11.2019 Modified on 18.12.2019

Research J. Pharm. and Tech. 2020; 13(1): 323-329.

DOI: 10.5958/0974-360X.2020.00065.7

No	Question	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
		N(%)	N(%)	N(%)	N(%)	N(%)
16	Facilitators were aware of PBL procedures.	48(19.5)	136(55.3)	54(22)	8(3.3)	0(0)
17	Facilitators helped in ice breaking of PBL sessions.	50(20.3)	124(50.4)	54(22)	13(5.3)	5(2.0)
18	Facilitators guided students to derive learning issues.	56(22.8)	144(58.5)	40(16.3)	6(2.4)	0(0)
19	Facilitators encouraged students to participate actively in PBL sessions.	82(33.3)	112(45.5)	46(18.7)	6(2.4)	0(0)
20	Facilitators debriefed students regarding their performance in PBL towards the end of PBL sessions.	48(19.5)	118(48)	54(22)	23(9.4)	3(1.2)