Introduction

Problem-based learning (PBL) is an innovative instructional approach which is being increasingly used in many health professionals education world-wide (Schmidt 1993; Alshehri 2001; Bin Abdurrahman 2008).

This approach stimulates learning through small group discussions of a problem under the supervision of a tutor.

There are many reported advantages of PBL. These include increased knowledge retention, improvement of problem solving abilities and better integration of basic science and clinical skills (Hmelo-Silver 2004; Yaqinuddin 2013).

In addition, it has been assumed that PBL approach promotes utilization of the principles of social learning, which activates group discussion and hence contributes to the development of interpersonal, communication, and presentation skills (Wun et al. 2007; Bin Abdurrahman 2008; Yew et al. 2009).

Problem-based learning could also contribute to the provision of a good learning environment by promoting self-directed learning and increase students' enthusiasm and motivation (Kaufman& Mann 1996).

Many factors that could influence the effectiveness of PBL tutorials have been recognized. These include problems presented in the tutorials, tutors, students, and the process of the small group discussion (Dolmans & Schmidt 1994; Van Berkel & Dolmans 2008).

The problem utilized in the PBL sessions should be relevant, able to activate the students' prior knowledge, and complex enough to stimulate the students' discussion and motivation (Dolmans et al. 2001; Dolmans & Schmidt 2006).

Students, under the guidance of a tutor, conduct the PBL sessions according to predetermined process. This process involves clear role for every members of the group, known steps of discussion, and concluding learning objectives from the discussed problem (Dolmans et al. 1993, 2001).

Published research in Saudi Arabia demonstrated that undergraduate medical students are satisfied with the PBL method and believed to enhance many qualities of the learning process (Al-Damegh & Baig 2005; Shamsan & Sayed 2009).

However, there is a need to further investigate the perception of medical students regarding different components of this approach.

The College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) has been established in 2005 and adopted PBL curriculum. KSAU-HS is one of the leading universities in implementing this innovative instructional approach in Saudi Arabia. The present study was carried out to explore views of medical students about the relevance of PBL in the Kingdom of Saudi Arabia local settings, and their views regarding the concept and process of PBL used in the College of Medicine, KSAU-HS. Differences in students’ views were examined as well.

Participants and methods

This study is a cross-sectional, questionnaire-based study. The study was conducted in two major medicine colleges in Riyadh, Saudi Arabia, between April and June 2012. Both colleges have adopted PBL, system-based and community-oriented curriculum.

The curriculum in both medical colleges is delivered in three phases. In the first phase, which is also named as the pre-professional phase, basic courses like biology, biochemistry, principles of anatomy and physiology are delivered. Students are also taught principles of evidence-based medicine and PBL. The study in the second and third phase is conducted using PBL as the main instructional approach. To ensure students’ familiarity of PBL approach, only students who finish the two year pre-professional studies were invited to participate in this project.

The questionnaire is self-administered and anonymous. The questionnaire was developed in light of the stated objectives and purposes of the study. Methodologies of some relevant published researches were reviewed and relevant factors shown to affect the implementation of PBL approach were selected to be utilized in the questionnaire. A pilot study was conducted to increase its validity and clarity. Results of the pilot study were not included in the study.

The questionnaire consisted of three sections. The first section included characteristics of the participants as age, sex, study level, and name of the school. The second section included questions about the general views of students about the benefit of the PBL approach to their learning, their support, and whether they will recommend it for their friends. The third section contained questions about the features of the problems and the process of the PBL tutorials. Students’ views about the two main features of problems were sought; relevancy and stimulation to learning. Questions about the process of the tutorials include: the participation and cooperation of members, organization of the discussion, and acceptance of group members to feedback and comments on their behavior during the group discussion. The reliability of the questionnaire was assessed using the Cronbach’s alpha technique. The value of this test was 0.90, indicating a high reliability index.

Results

A total of 174 undergraduate medical students participated in this study. Mean age was 22.5 year (S.D + 2.8) and female students constituted 32% of the sample.

Details of other characteristics of the sample are shown in Table 1.

Eighty-four percent of the participants supported the concept of PBL and 85% thought that this teaching approach was beneficial for their learning.

Regarding the problems presented in the PBL sessions, 67% thought that they were stimulating for the group discussion. Only about half of participants (52%) perceived that used problems in the PBL tutorials were relevant to their culture, as shown in Table 2.

More than half of the participants perceived that the group discussions during the PBL tutorials were organized and the members of the group were cooperative. Sixty percent of the participants thought that the role of each member in the PBL session was defined and clear to them and were positive towards comments of each other during the feedback sessions at the end of the PBL sessions. The details of the students’ view regarding the process of PBL session are presented in Table 3.

About 65% of the participants indicated that they would recommend medical colleges that adopt PBL teaching approach to their peers. On the other hand, the reminder either indicated that they will not recommend this approach (15%) or they were undecided (20%).

Fifty-eight percent of the participants recommended the continuation of the PBL-based curriculum for them.

Table 2 shows the difference in students’ opinions regarding the features of the problems used in the PBL tutorials. Gender of students and their GPA did not affect their opinion about the stimulating effects and the relevancy of the problems to them.

Perception of the stimulating effect of the problems to the discussion of PBL tutorials differed significantly among students from school 1 and those in phase 2 of their study (p value = 0.01 and 0.02, respectively).

There was a statistical difference between the views of male and female students, regarding aspects of the process of PBL tutorials. Female students perceived that members of PBL tutorials were cooperative and knew their roles. Moreover, females tend to accept comments of their colleagues at the feedback session of the PBL tutorials.

Participation and cooperation of members of the PBL tutorials was perceived more by students from school 1 compared with school 2. Students from school 1 thought that group discussions were more organized and that each member knew and followed his/her roles and were open enough to accept comments and feedback from other group members. The differences were statistically significant as shown in Table 3.

Regarding the effect of the student academic level on the process of the PBL session, students in phase 2 appeared to accept the feedback from their colleagues more than students on the advanced study level (p value 0.02 as shown in Table 4).

Discussion

The reported advantages of the PBL led most of the medical colleges locally and regionally to shift their curricula to this instructional strategy (Azer 2001; Bin Abdurrahman 2008).

This study was carried out to examine the perception of medical students regarding the relevance and effectiveness of this approach in the setting of Saudi Arabia.

Majority of the participants were satisfied with PBL and think that this teaching strategy will enhance their learning and will contribute to their development. This view is in-keeping with previous local reports from Saudi Arabia and similar settings (Al-Damegh & Baig 2005; Habib et al. 2006; Shamsan & Sayed 2009).

Approximately half of the participants raised their concerns about the relevance of the problems used in the PBL tutorials. Relevance of the problem to the learners is significantly important in encouraging them to initiate the discussion and proceed in achieving the objectives of the tutorials and other learning benefits (Dolmans et al. 1993, 2001). Discussing well designed relevant problems will enhance learners’ reasoning strategies and help students to share their knowledge and utilize previous experiences in the process of problem solving (Hmelo-Silver 2004). Owing to the fact that this study is based on students’ views and perceptions, the issues of relevance and applicability of problems used in PBL tutorials to the local Saudi context should be further explored by reviewing the objectives of these problems to ensure that they address common and important local health priorities, and should be incorporated in future development of problems in order to improve students’ learning outcomes.

Despite this view on the relevance feature of the problem, students in phase 1 in school 1 perceived the stimulating effects of the problems to their discussion more than others. This is probably due to factors other than the problem itself. Indeed, this study also showed that students from school 1 felt that PBL tutorials were more organized and members of the groups were more cooperative compared with phase 3 students from school 2. This could partly explain the perception of students of school 1 about the stimulating features of the problem.

This study showed that female students seem to be more cooperative in small groups and open to the feedback of their colleagues at the feedback session. This is probably due to the fact that the communication and interpersonal skills of girls are probably more developed (Aspegren 1999), which are utilized in the effectiveness of the process of the PBL discussions. Undergraduate medical students showed a positive attitude and willingness to receive feedback on their performance (AlHaqwi 2012). Reports have shown that there are many barriers that could impediment and consequently reduce the practice and utilization of feedback in undergraduate medical education. These include inadequate skills for provision of effective feedback and students’ fear of insult due to inappropriately given feedback (AlHaqwi et al. 2012). Overcoming these recognized barriers is of remarkable importance to enhance students’ learning and development.

Evidence showed that PBL can be applied in different settings and cultures; however, culturally sensitive issues should be considered in implementing this approach (Franmbach et al. 2012).

About 35% of participants either were undecided or will not recommend PBL curriculums to their friends. This necessitates applying more measures in educating undergraduate medical students about this relatively new approach and periodically reviewing its process to overcome possible factors that could minimize its effectiveness.

In addition to the positive reaction and satisfaction of students toward the PBL approach, literature have showed that PBL could positively influence cognitive abilities and behaviors of learners (Dolmans 2003; Duchy et al. 2003; Al-Damegh & Baig 2005; Wun et al. 2007; Yew & Schmidt 2009). These abilities include better knowledge retention, long-term self-directed learning skills, communication skills, and better utilization of learning resources.

Conclusions

Majority of participants were satisfied with PBL approach and valued its importance in their learning process. Differences in gender, schools, and level of study have been identified in participants regarding the different features of problems and process of PBL tutorials. Participants, in general, raised some concerns on the relevance of the used problems in the tutorials.

This study addressed the reaction of students toward the concept and process of the PBL instructional approach. This is an important aspect in the evaluation of the PBL in the local setting; however, other levels of efficacy should be considered in future researches as demonstrated by Kirkpatrick’s model (Kirkpatrick & Kirkpatrick 2006). Different factors, especially those related to the local context should be further explored in order to improve the outcomes of PBL curriculum in the Saudi setting.

In addition, studies that compare the behaviors and skills of graduates of PBL and conventional curricula could help in evaluating long-term benefits and higher level of efficacy of both approaches. The comparison of patients’ satisfaction and their medical outcomes of graduates from both approaches could also be considered for advanced levels of evaluation.

Notes on contributors

ALI IBRAHIM ALHAQWI, MD, ABFM, MRCGP(UK), is an Associate Professor, Department of Family and Community Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

TARIQ AWAD MOHAMED, PhD, is a Lecturer in Department of Medical Education, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

ABDULAZIZ F. AL KABBA, MD, ABFM, is an Associate Professor, Department of Family Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia.

SULTAN S. ALOTAIBI, MD, ABFM, is a Consultant & Family Physician, Diabetic Center, Ministry of Health, Gurrayat, Saudi Arabia.

ALI M. AL SHEHRI, MD, FRCGP, is an Associate Professor, Department of Family and Community Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

HAMZA M. ABDULGHANI, MD, ABFM, MRCGP, is an Associate Professor, Consultant Family Physician, Department of Medical Education, College of Medicine, King Saud University, Riyadh, KSA.

MOTASIM BADRI, PhD, is an Associate Professor, Department of Basic Sciences, College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Riyadh Saudi Arabia.