Confidence as a Barrier to the Use of Problem-Based Learning in Veterinary Undergraduate Students
Publication: Journal of Veterinary Medical Education
Volume 38, Number 3
ABSTRACT
Problem-based or case-based learning is a popular method of instruction in clinical degrees such as veterinary science, nursing, and medicine. It is difficult, however, for students to adapt to this learning method, and this difficulty has been well described. The present study surveyed first-year undergraduate veterinary students at the University of Nottingham about the challenges they faced upon beginning problem-based learning sessions. A surprisingly large percentage of students (36% of females and 38% of males) reported a lack of confidence in speaking in front of the other students as a concern they experienced during their first term. Conversely, only 10% of the female students (and none of the male students) reported overconfidence as a problem. This is in contrast to the perceptions of the staff members who facilitated the sessions who reported that 14% of the students exhibited underconfidence and 14% exhibited overconfidence. The difference between the female and male students' responses as well as the difference between the perceptions of students and those of facilitators is statistically significant (G-test p<.05).
Introduction
Problem-based learning (PBL) is an independent approach to learning that involves students working through and solving a problem as a group by using resources such as text books and scientific literature rather than having a staff member give them the information. In this approach, students need to self-regulate a range of factors including time management, planning, monitoring and evaluating learning, and seeking help from peers and staff.1–4 The method has been criticized in that it can allow gaps to develop in students' basic science knowledge5 and, as a result, most medicine and veterinary courses (i.e., programs), including those offered at the School of Veterinary Medicine and Science (SVMS) at the University of Nottingham, aim for a hybrid experience whereby problem-solving tasks and self-directed learning are introduced early in the curriculum. The aim is to develop independent learning at a higher cognitive level, emphasize the clinical relevance of basic science knowledge, and improve interpersonal and communication skills. This is typically combined with more structured elements such as lectures and practicals to ensure students do not develop knowledge gaps.6,7
Good communication skills are regarded as essential to the ability to function as an effective medical or veterinary practitioner.7,8 Indeed, the veterinary defense society, which specializes in the legal defense of veterinarians in negligence claims, has highlighted that the bulk of its work is generated by poor communication.6 PBL has been demonstrated to enhance communication skills when compared with traditional curricula,9,10 partly because PBL requires effective communication between group members in order for the group to solve the tasks assigned to it. The flip side of this equation is that a lack of cohesion within the group is a common reason for the breakdown of this teaching method,11 and students who lack the ability to communicate effectively with their peers, either because of language or cultural barriers or a lack of personal confidence, might not be able to participate in this learning method in a meaningful fashion.12
The information presented in this article stems from a study into the problems that first-year university students at SVMS face with their initial PBL sessions. Students were surveyed three times during the first eight weeks of teaching of their first year of studies. The administered surveys used a mix of Likert-scale and free-response questions and were designed to ascertain whether the training provided by the veterinary school helped with the transition to independent learning, whether the students understood the purpose of the self-directed learning sessions, whether they were able to use them correctly, and what problems they faced in these sessions. The present article discusses the confidence-related issues that arose in students' responses to the surveys.
Methods
Course Structure
At SVMS, groups of eight or nine students carry out PBL sessions within a designated small-group teaching room with computer access, text books, electronic and normal whiteboards, and other teaching aids (skeletons, models, etc.). In the context of the present study, it is important to note that veterinary medicine is an undergraduate degree in the UK and the majority of students enrolled in the course have come straight from secondary school. As these students are generally unfamiliar with the teaching methods used in post-secondary education, many of their first few weeks at Nottingham are dedicated to introducing them to these teaching methods, particularly to PBL.
In the introductory weeks, the first group session is dedicated to introducing PBL as a teaching technique, emphasizing the difference between facilitation and teaching. Important behaviors for successfully working as a group are also discussed and students are encouraged to develop a set of group-work rules. At the end of the first two weeks, students review their group-work performance and discuss what worked well and what could still be improved. The students stay within their allocated group for PBL sessions for the first 12 weeks of the course, usually with the same facilitator.
Choice of Cohort
The veterinary course at SVMS is still new; those entering the course in 2008–2009 are only the third group of students enrolled in the course. The student cohort was made up of students coming straight from secondary schools, graduate students, and students from two different entry courses (a preliminary year at SVMS and a widening participation initiative at the University of Lincoln).
The study was performed in accordance with the British Educational Research Association (BERA) ethical guidelines, and the project was approved by the Ethics Committee of the SVMS, University of Nottingham. All data will be securely stored (and password protected) for at least five years or until all of the findings have been published.
Questionnaires
The 2008–2009 first-year students at the University of Nottingham were surveyed three times during the first module of their first year: they were surveyed for the first time at the beginning of teaching, for a second time four weeks into the module, and for the third time at the end of the eight-week teaching block. During this time frame, the students stayed in the same groups. However, it should be noted that over the whole year the PBL group composition changed three times. The questionnaires were coded by asking the students to provide their student numbers and the numbers of the rooms that they used for their PBL groups. The provision of the student number allowed individual responses to be tracked across the three surveys. The staff members that facilitated the problem-based learning sessions were also surveyed part way through the module and were asked to provide their PBL room numbers to enable matching between facilitator and students.
The full survey consisted of a mix of free-response and Likert-scale questions. The free-response questions were categorized and categorical scale questions were converted to numerical figures for statistical analysis.
The data presented here relate to the free-response question “What do you think the personal challenges are for you taking part in group learning activities?” from the first two surveys. This question was not repeated in the third survey. Students were instead asked “What problems did you encounter?” (in the PBL sessions, that is). The responses to these questions were coded by the themes mentioned. Students were classified as underconfident (too quiet) or overconfident (too loud/dominant) depending on whether they mentioned confidence as a problem in their participation in the sessions. Some students expressed this either in terms of an inability to stop dominating conversation (overconfidence) or an inability to speak up when necessary (underconfidence). Students who did not report confidence issues were assumed to not see it as a problem and were categorized as “neither.” The facilitators were asked the following questions: “What problems have the students had during their clinical relevance sessions?” and “What number of your individual students would you say were: a) Quiet/passive b) loud/dominant c) neither?”
Statistical Analysis
A G-test13 was used to compare the frequencies of students reporting themselves as too quiet, too loud, or neither with the facilitators' perception of the frequency of students in each category. Results were regarded as significant where p<.05.
Semi-structured Interviews
Ten students from this cohort were also interviewed at the end of the 2008–2009 academic year about their experience during the first year of the course. These interviews were semi-structured and included a section on PBL sessions.
Reflecting the gender imbalance and limited ethnic diversity that exist in veterinary medicine, 80% of interviewees were female and all interviewees were of white British background. Student selection for the interviews was based on voluntary participants who responded to an e-mail. Personal tutees of any of the researchers were excluded from the interviews (but not from the broader study) All students involved in interviews signed a consent form and were also given a written copy of the university support systems in case the need for those services arose during or after an interview session. All volunteers signed the form in advance and had no further questions or requests. The data present a snapshot of the students' experiences. As such, they are illustrative examples and are not representative of the student cohorts as a whole. It is also important to acknowledge that students who volunteer to participate in interviews are more likely to be those with a positive attitude toward the course in general and might not be representative of the student body as a whole.
The questions that were asked in the interviews included the following: “How do you think you have developed as a person this year?” and “How have your strengths and weaknesses developed over the course?”
The interviews were recorded and transcribed verbatim. The transcript was then reviewed once while listening to the recorded interview to correct any gaps or mistakes during transcription and to get a feel for the language used and the topics covered. The transcripts were analyzed using a narrative analytical approach, coding data broadly for various categories related to the first-year experience. For this publication, data coding to “problem-based learning” was conducted using QSR NVivo (version 8), and this category was then sub-coded according to the themes the students mentioned.
Findings
Out of a potential total of 98 student responses, 93 students returned survey 1, 84 returned survey 2, and 88 returned survey 3 (a>86% return rate). Of those who responded, 25% of the students were male and 75% were female. Fifteen percent of respondents had undergraduate degrees before entering the veterinary program and 3% had post-graduate degrees; the remainder were students starting their veterinary medicine degree straight after high school. This demographic makeup is typical of the intake at SVMS and is similar to that of other UK veterinary schools.
In survey 1, 34 out of the 93 respondents (37%)—including 9/22 (40%) of the males and 25/71 (35%) of the females (Figures 1 and 2)—indicated that a lack of personal confidence, most often expressed as a concern about speaking in class, was a personal challenge for them. Both graduate and undergraduate students reported this issue. Typical responses included statements such as “to be more confident in my opinions and to speak up when I feel I have a valid point.” Only seven students (8%), all of them female, identified themselves as being at the other end of the confidence spectrum, expressed as “not talking over other people.”
In survey 2, 16 out of the 77 (20%) (3/19 [16%] male and 13/58 [22%] female) students who returned this section of the survey still indicated that underconfidence was an issue. Six students (7%)—once again all females—reported overconfidence as an issue in this survey (Figures 1 and 3). It was not necessarily the case that the students who reported overconfidence or underconfidence in the first survey were same students to report these issues in the second one. For example, only six out of the 20 quiet students in survey 2 had also listed this as a concern in survey 1.
In survey 3, participants were asked about problems encountered in PBL sessions rather than about personal challenges. Out of the 88 responses received, several students (nine) in this section indicated that a lack of contributions by group members prevented the session from running smoothly. Other students (three) indicated that overly dominant group members also interfered with the sessions.
In contrast, the eight facilitators (out of 11 in total) who answered this question thought that 10 students out of the 70 for whom they were responsible (14.3%) were too quiet or passive, and the same number (14.3%) were too loud or dominant, with the remainder at neither of these two extremes (Figure 1). We had six clinical-relevance groups from which we received full returns of surveys from students and facilitators. In five of these groups, more students than their facilitator had indicated reported underconfidence as an issue.
When comparing facilitator with student perceptions of overconfidence and underconfidence, the difference was statistically significant (G-test p<.001) for both surveys, and when comparing the differences between males and females' responses the difference was statistically significant for survey 1 but not for survey 2.
In the free response sections both students and facilitators commented on students not contributing equally or not taking their classmates' opinions into consideration: “a few people don't put in as much effort as others”; “some of the students are keen to voice their own ideas and opinions but not so keen to listen to other people”; “wasn't too bad as my good students were active but not dominant (has been worse in other groups).”
In the interviews conducted at the end of the first year, when asked about their experience with PBL teaching sessions, students indicated that they generally enjoyed the sessions and liked the clinical context/relevance and consolidation of knowledge. However, they clearly struggle with uncertainty and they also struggle because they are not told what the correct answers are. All students commented on the ways in which the quality of their experience was dependent on how they got on as a PBL group and on the facilitation style. Not unexpectedly, most students preferred facilitators who provided more guidance rather than those who let them find their own way (and thus sometimes let them go down a sideline). If facilitators deflected their questions, some students perceived PBL as a “complete waste of time.” However, more mature graduate students generally appreciated that students benefited from a more hands-off approach:
I get quite annoyed if people are too hands-on being facilitators cos I just feel that a lot of the point of them is for us to work out things on our own and if people get too heavily involved, you almost feel like they're giving you the answers and what's the point of the session.
In interviews, when asked about their personal development throughout the first year, three students indicated that their confidence in PBL sessions had improved:
And also confidence and like speaking up opinions, I think that small group teaching has helped that.… At first I didn't want to say anything unless I was a 100% sure that it was right. Whereas now I'll say something whether if I think it might be right, if I think it might not be, just to make sure that I don't have that wrong idea in my head. I think that's got better over the year as well.I think I've got confident and a bit more outgoing, just because you have to be! If you're not then you just don't meet anyone and you don't have any friends for the rest of the year really, if you don't make an effort.Yeah I think so. I think I'm a lot more confident now at the end of the year and especially the people that I don't know and there's so many people that I've met over the year as well and that's really helped.
Discussion
PBL sessions, such as the ones in which these students have participated, have been reported to promote soft skills, such as communication and time management, and to apply and consolidate each student's knowledge base. They have also eased the transition to clerkship for medical students.14 This study indicates that a lack of confidence is a significant issue for students beginning PBL sessions. Some of the self-reported confidence problems may be more of a matter of beginner nerves, as the number of students reporting this issue had decreased by survey 2, and the students interviewed at the end of the year indicated that their confidence had improved over the year. In addition, the fact that only six students consistently reported underconfidence as an issue would indicate that their perceptions of their confidence varied from session to session and that, for many students, this is a transitory problem. This variability in response would also indicate that students were not merely filling in the same responses from one survey to another. The lack of confidence is, however, clearly something that causes them anxiety at the start of the course and it should be taken into consideration when training for, writing introductory sessions to, or planning PBL classes.
The difference between male and female students in survey 1 was surprising as a lack of confidence is usually reported as a problem for female students.8 The small number of male students in this survey might be a factor; however, for a similar percentage of male and female students reporting overconfidence, we would have expected at least two males reporting overconfidence in a sample of this size. The reasons for the higher percentage of underconfident male students are not clear but might be related to the fact that they are outnumbered three to one by female students. Some of the male students might have been the only males in their clinical-relevance groups and might find the female-dominated groups to be intimidating. Alternatively, the interview process adopted by SVMS for the selection of veterinary students might bias against overconfident males. More controversially, the lack of confidence in this age group (mostly 18- or 19-year-olds) on the part of the male students may be a side effect of the fact that females in this age group in Britain regularly out-perform males academically, which may affect the students' perceptions of their ability and confidence.15
In this context, the issue may be quite different in British veterinary schools with their largely teenage, high-school student intake when compared with North American schools, where veterinary medicine is a graduate degree and students are on average three or four years older when entering the course than the student cohort in Britain. We did not see differences between students with prior tertiary education in this survey; however, we only had small numbers of such students in our cohort and it is possible that a study with larger numbers might demonstrate differences in confidence levels between undergraduate and graduate students. Interestingly, the students' perceptions of their confidence levels do not match those of an external observer (the facilitator). Clearly, some students have a false image of themselves as underconfident when they are actually performing quite adequately and other students who are actually over-dominant are not recognizing this characteristic in themselves. There are a range of potential reasons for this: Subjective perception of confidence is highly influenced by personal experience, personality type, and sympathy/antipathy between students and facilitators. In addition, behaviors shown in the session before the questionnaire might be subject or related to a specific case or problem rather than representative of PBL as a whole. The course at SVMS includes self-reflective exercises: a reflective essay about students' first-year experience (set in March) and a reflective portfolio. Quite a few students reflect on their experience in PBL and on how they develop throughout the year. These reflective exercises might help them develop a more realistic perception of their confidence as they progress though the course.
We asked the facilitators to classify their students' confidence levels based on their verbal interactions in class. This exercise might not accurately reflect the confidence levels of these students, but it is difficult for an external assessor to quantify what is in essence a combination of impressions of verbal and nonverbal communication between individuals.8 As many students had expressed verbal communication (rather than nonverbal) as an area in which they were not confident, in the context of their PBL classes we made the decision to use verbal communication as our measure of confidence, especially in light of limited resources for more detailed observational assessment of the students' confidence.
As to whether confidence affects the individual or group's learning experience, it would appear from both student and facilitator comments in the free-response sections that if students do not contribute to sessions or take their classmates' opinions into consideration their actions are disruptive to the sessions. Moust et al.16 have shown that students who did not contribute as actively as their classmates in discussions did not learn less than their more vocal peers. So, a lack of contribution might not be a problem for an individual student, but if it advances to an extreme where the group dynamic is affected, it might inhibit the group's learning experience.
It has also been shown in studies of medical students that those who appear less confident in practical examinations go on to have poorer career outcomes8 and do not inspire confidence in their patients. This is likely to be very similar for veterinary students and may have potentially serious implications for their post-graduation working lives. At present, it is not known whether perceived underconfidence within a PBL learning environment also correlates to future problems within a clinical setting. As documented elsewhere, it may be that while PBL students often initially struggle with the transition to the course as a result of less structured learning objectives and uncertainty about the appropriate depth of knowledge required, overall this style of learning leads to more intrinsic motivation to learn for learning's sake and effective transition to clerkship.14 It will be interesting to see how the vet students from this cohort will cope with and perceive the transition to fifth-year rotation, where they have to go into various clinical practices and work alongside vets dealing with diverse case loads (similar to a clerkship in medical school).
Overall, the findings reported here indicate that confidence levels need to be taken into account as a barrier to students' contributions to and benefit from PBL sessions, especially in the early stages of the course. Self-perception exercises focusing on confidence early in the introductory phase of the course may aid in the more accurate self-identification of confidence problems (whether a lack of or too much confidence) and should be considered in the design of PBL elements for undergraduate students.
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Information & Authors
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Published In
Journal of Veterinary Medical Education
Volume 38 • Number 3 • Fall 2011
Pages: 305 - 310
PubMed: 22023983
Copyright
© 2011 AAVMC.
History
Published online: 1 September 2011
Published in print: Fall 2011
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