Consideration of Problem-Based Learning in Athletic Training Education
Athletic training educators are faced with the tasks of assessing learning styles, preparing and delivering content, and assessing student learning. Within content delivery, some educators may subscribe to certain learning theories and teaching strategies. One teaching strategy that holds potential for athletic training education is problem-based learning, which is grounded in cognitive theory and aligns with the way in which athletic training students learn by constructing knowledge based on previous experiences. To describe problem-based learning, the theoretical basis for using problem-based learning in athletic training education, and provide examples of incorporating problem-based learning activities into an evaluation course. Problem-based learning was first introduced at McMaster University in an attempt to better transition between what medical students were learning in the classroom and what they were experiencing in their clinical settings. Problem-based learning has been studied and found to be effective in health care education and can be considered by athletic training educators. Problem-based learning is a philosophy as well as a teaching strategy that uses problem solving to learn both content and clinical skills. Students work independently and in small groups to acquire knowledge through problem solving. Problem-based learning challenges the idea that students need a reservoir of knowledge before being able to solve a complex problem. Based on theory and research in health care education, problem-based learning can be used in athletic training education to improve students' abilities to construct knowledge, to be active learners, to collaborate, and to give them the skills to be lifelong learners. Athletic training educators can consider implementing problem-based learning into their curriculums to integrate the learning of content and clinical skills.Context:
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INTRODUCTION
Athletic training educators have the responsibility to assess and adapt to students' different learning styles, prepare and deliver content, and evaluate student learning. Content delivery can take on a variety of forms, including traditional didactic lecture/lab, hybrid (a combination of classroom and online learning), or online learning formats. Within content delivery, some educators may subscribe to certain learning theories and teaching strategies, such as authentic learning, social learning, direct instruction, experiential learning, self-directed learning, or problem-based learning. The goal of this work is to present problem-based learning and how it can be used as a learning theory and teaching strategy within athletic training education.
Problem-based learning is an instructional method as well as an educational philosophy in which problem solving is the mechanism that enables students learning. Students work independently and in small groups to acquire knowledge through problem solving. Problem-based learning has been researched1–8 in other health care professions and found to have a positive impact. Koh et al3 found problem-based learning to be superior to lecture in learning teamwork, appreciation of social and emotional aspects of health care, and appropriate attitudes toward personal health and wellbeing. There is strong evidence4 that students who work in small groups within the classroom outperform their counterparts in knowledge development, thinking skills, social skills, and course satisfaction. Other positive impacts include improved clinical performance, improved faculty and student satisfaction and motivation,5,6 and improved application of knowledge.7,8 Problem-based learning is being used to various extents in athletic training education because it is aligned with the identified learning styles of athletic training students9 and methods that enhance learning by athletic training students.10,11 There is a need for continued research on the best educational practices for athletic training education; problem-based learning is a teaching strategy with theoretical implications for preparing athletic training students.
Researchers in athletic training education recommend the use of cognitive learning theory in developing curriculums.10,12,13 Cognitivism is described as an understanding of new information by relating it to information that is already understood and the ability to organize information to make it meaningful.14 From a cognitivist perspective, students will learn better when they can internalize information and make it their own through meaningful connections to their experiences. Given that problem-based learning is a teaching strategy grounded in cognitive theory,15–18 it stands to reason that athletic training students could benefit from the potential positive impact of problem-based learning.1–8
Principles of Problem-Based Learning
As previously stated, problem-based learning is an instructional method as well as a curricular philosophy that uses problem solving to drive learning.4,15,19 This teaching strategy has been used in medical education for several decades and become popular in professional education programs such as dentistry, mechanical engineering, social work, optometry, architecture and construction management, nursing, legal training, and business and management.20–24 Problem-based learning was introduced into medical education because traditional teaching methods (ie, classroom lecture/lab) were criticized for separating the basic and clinical sciences. Students felt the knowledge being taught in the classroom was irrelevant and difficult to retain; in addition, students felt learning was tedious, and they were unable to apply their acquired knowledge in their clinical settings.25
Problem-based learning was first introduced at McMaster University by Barrows, where it was called the “McMaster Philosophy.”26 The researchers perceived gaps and redundancy in the content taught in medical schools; therefore, their aim was to emphasize specific capabilities and characteristics of the learner rather than develop a reservoir of knowledge. Problem-based learning challenges the assumption that content must be learned prior to solving a problem.26 Problem-based learning allows for content and application to be learned at the same time,26,27 focusing on stepwise learning and a de-emphasis on the idea that the normal must be understood before exploring the abnormal.26 In other words, to use a puzzle as an analogy, students do not need all the pieces of the puzzle before they begin putting the puzzle together.
In the problem-based learning instructional method, students work independently and in small groups to solve problems before they receive formal didactic education. Problem-based learning uses patient problems, which are directly related to the desired learning competencies and outcomes, to allow students to learn problem-solving skills and acquire content knowledge about the basic and clinical sciences.27 Through this process, students must identify what they do not know and what they need to know in order to solve the problem. When students receive the problem, they analyze the problem as a group, collect information independently, share the information with the group, and then synthesize the information to arrive at a solution.15 Throughout the process, students construct new knowledge based on previous concepts and, in the process, become effective problem solvers.14 Through their independent information gathering and sharing, as well as the small group work in synthesizing the information, students acquire content knowledge.28
Theoretical Foundations of Problem-Based Learning
Cognitivism, or its more modern version, constructivism, is the ability to construct knowledge from information received. Problem-based learning focuses on the process of knowledge construction, is learner centered, and encourages collaboration.15 The basic premise of problem-based learning is that students are presented with a problem before they have the content knowledge required to understand or solve the problem. This requires students to be active and engaged participants in their learning and determine what information is useful.15,29 Problem-based learning has the ability to approach different learning styles and provides a more engaging environment.22 It does not focus solely on content or process, but through the process, content is learned. In addition, students acquire more than just content; they learn the importance of teamwork and collegiality.22,30–34
Benefits of Problem-Based Learning
The benefits of problem-based learning have been well documented. One is that it uses real-life problems as a vehicle to acquire disciplinary knowledge and problem-solving skills.35 Problem-based learning allows students to actively construct meanings through individual reflection and group interaction that leads to better retention and availability to recall information which is at the heart of cognitive learning theory.17,27 Problem-based learning is a more authentic learning36 method than traditional lecture methods because it uses real-life problems which more closely resemble what athletic training students will encounter in professional practice.
Problem-based learning also offers a high level of encoding specificity. Encoding specificity, as discovered by Thomson and Tulving,37 is the relation between storage and retrieval of memory. They found that memories are more easily retrieved when the context is the same as when they were stored. This is pertinent to athletic training education in which the cases used to learn should be similar to what will be experienced in professional practice. When there is a high level of encoding specificity, motivation increases and retention and transfer of knowledge improves.26
By participating in problem-based learning groups, students teach themselves the necessary skills to become autonomous and self-directed learners. In his study on problem-based learning, Harland38 found that students were more limited by metacognitive skills, or the awareness of their thinking and learning processes, not content knowledge. Students' metacognitive skills developed through group interactions which allowed students to recognize what they did and did not know and to seek out information about what they did not know. Problem-based learning also fosters autonomy; Harland38 recognized that, as the students became more autonomous, the tutors needed to do less guiding. In self-directed learning, the students set their own goals and self-evaluate their own level of achievement with the guidance of a tutor or adviser.27
An additional advantage is learning professionalism through problem-based learning. Hayes and Davies21 studied a hybrid model (a combination of situated and problem-based learning) and found that, although students were not initially comfortable with the process of problem-based learning, professionalism was learned. They also found that interprofessional learning and the adoption of a multidisciplinary approach had an impact on student engagement; students perceived a benefit of being valued in their contributions.21
Problem-based learning has been found to be well accepted by students in professional programs without negative differences in learning.5,25,39 Problem-based learning has, in some instances, been found to be superior to traditional (ie, didactic, lecture/lab) educational methods.1,5,17,27,40–43 Norman and Schmidt17 found that students who completed a problem-based learning curriculum had higher retention over time; in addition, students found learning to be more enjoyable, relevant, and stimulating than a traditional curriculum.27 Vernon and Blake5 found that program evaluations including student attitudes and opinions, as well as clinical performance scores, were significantly higher in students who completed a problem-based learning curriculum. Additionally, Blake et al41 and Hoffman et al42 concluded problem-based learning curriculums resulted in higher medical licensing examination scores, and Fincham and Shuler43 witnessed higher National Dental Boards scores following a problem-based learning curriculum.
Challenges of Problem-Based Learning
As with any educational method, there are advantages as well as challenges. Some of the reported challenges of problem-based learning include an increase in faculty time in developing the learning scenarios and the increase in time required of the faculty member to work through the problem in the small group settings.25 Another challenge found by Albanese and Mitchell27 reported that the problem-based learning curricula only covered 82% of the content that had been covered in a traditional curriculum. This fact must be weighed against the potential for greater knowledge acquisition and retention. A third challenge of problem-based learning is making students responsible for their learning.44 Hughes and Berry,45 however, suggest that today's athletic training students are capable of taking ownership of their work, and educators should consider incorporating activities which connect real life to course content.
Problem-Based Learning in Athletic Training Education
The empirical research related to problem-based learning within athletic training education is limited to doctoral dissertations and 1 peer-reviewed article.46 From these studies,47,48 it is known that problem-based learning is being used in athletic training education and considered a viable instructional method; however, there have not been significant differences in critical thinking when used over a short period of time.29,49 McLoda47 recommended “further research to investigate the effects of [problem-based learning] on athletic training students,”(p140) including the specific recommendation to compare problem-based learning to traditional (ie, lecture/lab) teaching methods using the results of the national certification examination. This recommendation to use the results of the national examination for comparison was also recommended by Catlaw,48 McGee,29 and Goodwin.34
McLoda47 was the first to investigate the use of problem-based learning in athletic training education. The aim of this research was to find out if instructors considered problem-based learning to be a viable instructional methodology, their level of interest in problem-based learning, and their interest in implementing problem-based learning. He found problem-based learning to be considered a viable instructional method in which there is interest in implementation.47
Similarly, Goodwin34 investigated the variables that influence athletic training students' attitudes towards problem-based learning as an instructional strategy. These results showed upperclassmen had a more positive attitude toward problem-based learning than underclassmen. The results34 further indicated students perceived participation in problem-based learning enhanced critical thinking and reasoning, problem solving, retention, and was more enjoyable.
McGee29 and Lesperance49 compared problem-based learning to traditional learning. McGee29 compared traditional learning activities with problem-based learning activities in an undergraduate athletic training pharmacology course. The program was 4 weeks long, and all students participated in both forms of instruction. McGee29 assessed critical thinking, problem solving, and content acquisition as well as student satisfaction. Critical thinking was assessed with the California Critical Thinking Skills Test. Problem solving was measured with an essay examination, and content acquisition was assessed with a multiple-choice examination. The results of this study indicated no differences in critical thinking or content acquisition, yet there was an increase in problem-solving scores, and there was no loss of content acquisition. This study was limited in the amount of time allowed for measureable change to occur due to the 2 forms of instruction implemented. Four weeks may not have been sufficient time to implement a problem-based learning curriculum with aims to improve critical thinking and problem-solving skills while acquiring necessary content and expect to see significant differences. However, this research provides a starting point in assessing the viability of problem-based learning in athletic training education, and it did demonstrate significant improvement in problem solving without a loss of content acquisition or critical thinking. The question to ask in applying this research is the aim of the educator; instead of focusing on content, the focus can shift to the ability to problem-solve.
Lesperance49 examined athletic training students' critical thinking disposition and critical thinking skills as well as the relationship between a student's critical thinking disposition and skills. In addition to critical thinking, Lesperance49 assessed content acquisition through course examination scores and measured students' perceptions of problem-based learning on critical thinking and problem-solving skills through an online survey. Problem-based learning was implemented for half of 1 semester, and students participated in either traditional learning or problem-based learning. Lesperance49 found that problem-based learning had no effect on critical thinking disposition or skills; critical thinking disposition did not predict critical thinking skills either. The researchers reported traditional learning students performed significantly better on the final examination, but there was not a statistically significant difference on lab examinations. Lesperance49 did find a positive significant difference in how students in the problem-based learning group subjectively perceived their problem-solving skills. The author concluded that, as a result of this study, problem-based learning will continue to be used, but in combination with traditional learning strategies. This study was also limited by the time between initial and final assessment; however, it expanded upon previous research by increasing the implementation time to half of a semester compared to the 4 weeks of implementation by McGee.29
Heinrichs46 states it is necessary to foster professionals who can think critically and want to be lifelong learners. The researcher described implementing a modified problem-based learning into a graduate program over a span of 4 semesters. The curriculum was modified following feedback and prompted the addition of lectures placed specifically to address basic concepts. While the researcher outlined how problem-based learning was implemented into the curriculum, there was no evaluation of its effectiveness.
From the limited information found in athletic training and other health care professions, recommendations for implementing problem-based learning into athletic training education would include using problem-based learning activities in combination with traditional learning methods and doing so in upper-level courses. Again, this is not without challenges; problem-based learning requires an investment from both students and instructors, but the return can offer tools for lifelong, self-directed learning. The following section describes how problem-based learning activities can be added to traditional methods.
Problem-Based Learning Activities
This section will provide examples of possible ways problem-based learning might be implemented into an upper extremity evaluation course. A problem-based learning purist would argue that true problem-based learning should span an entire curriculum; however, researchers recommend combining the best of both aspects of traditional and problem-based learning by starting with the basic sciences in an instructor directed environment and progressively adding more problem-based learning with increasing complexity.27 As the course is currently taught, these activities are integrated into a traditional (ie, lecture/lab) classroom setting. At the end of a class period, the students are given the problem and required to gather the information for the subsequent class meeting. Future research is needed to examine the impact of this integrated model.
Ideas for Implementing Problem-Based Learning Activities into Courses
Twenty Questions
A set of instructor-selected shoulder pathologies were printed on slips of paper. In this instance, 17 pathologies were chosen and printed 4 times, so in a class of 16 students, each student drew 4 pathologies to look up. This way, no 2 students had the same set of pathologies, but at least 3–4 of them were looking up the same pathology. The students were instructed to come to the next class meeting knowing the mechanism of injury, signs and symptoms, and treatments of their 4 pathologies. In class, 1 person was “it,” and the rest of the class was allowed 20 yes/no questions to guess the pathology. The person who correctly guessed the pathology was “it” next. This continued until all pathologies were guessed. By the end, students were better at asking questions of the “it” person, and the “it” person had to know their pathology well enough to be able to answer the yes/no questions. Sample questions included: Is it a boney injury? Is a mechanism of injury falling on an outstretched hand? Is it an injury to a muscle? Is it an acute injury? Is it a chronic injury? Is it treated surgically? Is it treated conservatively?
Guess the Injury
Students drew a number to determine what information they would collect about pathologies of the wrist and hand. The Table provides an example for a class of 16 students. In this example, the student who drew number 1 needed to return to the next class meeting knowing what a scaphoid fracture, pseudo-Boutonneire deformity, and subungual hematoma were, the mechanism of injury of a lunate dislocation and claw hand deformity, the signs and symptoms of Boutonniere deformity and Bishop's deformity, and the treatment for mallet finger and Dupuytren's contracture. During the next class meeting, the students divided into teams by those who drew 1–8 and another by those who drew 9–16. One team was given a pathology. They had to collaborate and combine their information to describe it to the other team, and the other team had to guess the pathology.
Both examples require students to gather information independently and work collaboratively to acquire knowledge. The instructor's role as content expert shifts to the role of facilitator, where faculty are no longer a knowledge dump. These are just a few examples, but there are others available in the literature.50
CONCLUSION
An athletic training education curriculum is intentionally sequenced to build upon basic knowledge. Athletic training students are continually required to build upon previously learned content and to make meaningful connections to the content so that it is more readily available for problem-solving situations. Building upon previously learned content and making those meaningful connections so they are more readily available in unique, problem-solving situations is germane to cognitive learning theory. Problem-based learning is a teaching strategy that is grounded in cognitive learning theory and applicable to the education of athletic training students. More research is needed to determine its efficacy in the specific context of athletic training education that might provide educators with more justification to implement problem-based learning into its curriculum.
It is known that problem-based learning is effective in health care education. The researchers have shown higher knowledge retention over time17; students find learning to be more enjoyable, relevant, and stimulating27; program evaluations including student attitudes and opinions as well as clinical performance scores were significantly higher5; and national medical licensing and dental board examination scores were higher.41–43 Research in athletic training education recommends the use of cognitive learning theory in developing curriculums10,12,13 and has indicated the specific use of problem-based learning47,51; therefore, theoretically, problem-based learning has the potential to be an effective teaching strategy in athletic training education. The challenges of problem-based learning, including increased faculty time,25 the potential for loss of content acquisition,27 and making students responsible for their own learning,44 should be weighed with the benefits. A possible solution is to integrate problem-based learning into traditional instructional methods to combine the positive aspects of each. Until there are more definitive outcomes, it is up to educators to determine the desired goals of their instruction and whether or not they find merit in this philosophy and strategy.
Contributor Notes
Dr Gillette is currently Assistant Professor in Exercise and Sport Science at the University of Wisconsin.