Addressing Barriers to Implementing Problem-Based Learning

www.aana.com/aanajournalonline AANA Journal April 2021 Vol. 89, No. 2 117

Problem-based learning (PBL) allows students to address knowledge deficits by providing them with a clinical case so that they explore all aspects of patient care. The advantages of PBL for students include improving critical thinking skills, increased clinical rea-soning, and exposure to self-directed learning. Although PBL is commonly used in medical education, it seems to be seldom used in nurse anesthesia education. An evidence-based review was conducted to identify barri-

ers to implementing PBL and methods to address these barriers. Common barriers to PBL implementation were categorized as faculty resistance, student concerns, and resource limitations. Interventions to help address these barriers were presented to aid nurse anesthesia educators in incorporating PBL into the curriculum. Keywords: Active learning, nurse anesthesia educa-tion, problem-based learning.

Addressing Barriers to Implementing Problem-Based Learning

Kristin J. Henderson, DNAP, CRNA, CHSEElisha R. Coppens, DNAP, CRNASharon Burns, EdD, CRNA

Training future Certified Registered Nurse Anesthetists (CRNAs) presents the nurse anes-thetist educator with many challenges, includ-ing limited resources, staffing limitations, and time constraints.1 These factors limit the

CRNA educator’s ability to offer alternative teaching methods that foster development of critical thinking.2 Not only do educators face the demands of preparing students for the doctorate-level entry-to-practice, they also must consider the effectiveness of their educational methods. Despite these challenges, it may be possible to incorporate more innovative practices for teaching student registered nurse anesthetists (SRNAs).

McMaster University’s medical school in Hamilton, Ontario, Canada, introduced the problem-based learn-ing (PBL) method in 1969,3 in response to reports of unsatisfactory clinical performance by medical students.3 Educators desired to improve their students’ critical thinking skills and used this question-based problem processing to achieve that end.3 Before the utilization of PBL, medical education focused on memorization of frag-mented facts, which left many students unable to address pertinent clinical issues.3 In the PBL setting, learners evaluate multiple factors in a patient scenario including the differential diagnosis, laboratory testing, interven-tions, and selecting pharmacologic agents, which allows them to elicit connections earlier in their training.3

Active learning techniques such as small-group dis-cussion, case presentation, and high- and low-fidelity simulation scenarios are included in the framework of PBL.4 For example, a short case of an adult patient with a potentially difficult airway presenting for a laparo-scopic cholecystectomy could be be presented to the class (Figure 1). The class then could form into small groups

and formulate an approach to this case. The groups would then present their approach to the entire class. Nurse anesthesia practice requires acute critical problem solving, and PBL offers students a way to develop this skill. The authors examined the potential barriers to suc-cessful implementation of PBL in nurse anesthesia educa-tion and methods to address these barriers.

Materials and Methods• PICO Question. The PICO (problem, intervention, comparison, outcome) question was: “What barriers exist (P) to implementing PBL (I) in a traditional nurse anesthesia curriculum (C), and how can these barriers be addressed (O)?”

• Search Strategy. The search for evidence (1990-2017) examined PubMed, the Cochrane Database of Systematic Reviews, the Education Resources Information Center (ERIC), Google Scholar, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). The search terms applied both individually and in combina-tion were: PBL, problem-based learning, barriers, problems, implementation, nurse anesthesia education, and medical education. Inclusion criteria included research studies, systematic reviews, and case reports involving human participants published in English in a full-text form in peer-reviewed journals addressing the PICO question. We anticipated there would be little evidence describing implementation of PBL in nurse anesthesia programs, so we included evidence from other graduate-level health education specialties.

Individual studies included in an appraised system-atic review were not individually appraised. Studies included in more than 1 systematic review were noted. Reference lists of the included evidence were examined

118 AANA Journal April 2021 Vol. 89, No. 2 www.aana.com/aanajournalonline

for other evidence sources. Sources were included based on a review of the title, abstract, and finally the full text. The evidence was appraised using the method described by Melnyk and Fineout-Overholt.5 Attributes such as inclusion criteria and appraisal method were noted for systematic reviews and randomization and sample size determination for clinical trials.5 Evidence levels ranged from Level I (systematic review of randomized controlled trials) to Level VII (expert opinion).5

ResultsThe search resulted in 47 potential evidence sources, with 23 sources6-28 (Figure 2, Table 1) meeting the in-clusion criteria. The disciplines represented included medical education,6,7,9,10,17,18,20,21,24,25,27 dental educa-tion,25,26 nursing,8,14,16,19 physician assistant studies,12 biomedical engineering,28 pharmacy,15 and occupational therapy/physiotherapy.11,13 One source evaluated PBL comprehensively and provided insight into the wide ap-plicability of PBL in many educational settings.22

Mixed-methods studies were useful in identifying barriers to implementing PBL and ways to address the barriers.11,12,18 This shared experience across studies reveals that these barriers could be anticipated by

leaders of similar programs when implementing PBL.10-

14,16,18,20,22,25 Moreover, case reports provided valuable insight into the experiences of programs, educators, and students as they underwent the initial implementation of PBL curriculum.6,7,15,17,24,26-38 The inclusion of these sources provided valuable and applicable evidence re-garding methods to overcome barriers encountered along the process.6,7,15,17,24,26-28 Table 2 summarizes the po-tential barriers to successful implementation of PBL and ways of addressing those barriers, which are discussed in detail in the Discussion.

DiscussionThe evidence6-28 suggested that there are several barriers to successful implementation of PBL, including faculty, resources, and students.

• Faculty Barriers. Faculty engagement and enthusi-asm about the implementation of PBL is a crucial first step. Faculty often resist change, as some individuals may not want to deviate from the lecture approach.8,12,15,17,28 Equipping faculty with the skills to facilitate PBL is a vital part of successful change.6,7,10,14,16,26,27 The benefits of PBL are limited unless learners are guided by faculty who are skilled in PBL and its knowledge acquisition.21

Figure 1. Problem-Based Learning Case Script TemplateAbbreviations: BP, blood pressure; FB, fingerbreadths; ROM, range of motion; SpO2, oxygen saturation measured by pulse oximetry; TM, thyromental distance.

Patient Name: John Smith (fictitious name)

Patient Profile: 55-year-old man

Reason for Visit: Mr. Smith presents for a laparoscopic cholecystectomy.

History of Present Illness: Mr. Smith presented to the emergency department 36 hours ago with nausea, vomiting, and right-sided abdominal pain.

Weight: 88 kg

Surgeries: Anterior cervical discectomy 2 years ago

Anesthetic/Surgical Complications: Postoperative nausea and vomiting with prior surgery

Serious Injuries: None

Medications: Aspirin, 81 mg every day

Medication Allergies: No known medication allergies

Food Allergies: No known food allergies

Transfusions: None

Social History: Mr. Smith is an insurance salesman in Raleigh, North Carolina. He lives at home with his wife. He has 2 children, ages 21 and 24.

REVIEW OF SYSTEMSHead/Neuro: No seizures, strokes, or epilepsy

Eyes: No changes in vision, no eye pain or discharge

Ears: No pain, ringing, or change in hearing

Throat/Mouth: No trouble swallowing. No sores or dental problems

Skin, Hair, and Nails: No rashes, itching, or skin/nail changes

Cardiovascular: No arrhythmias, or heart murmur

Respiratory: No respiratory complications

Stomach: Last food intake: dinner last night around 8 PM

Liver: No history of jaundice, hepatitis, or liver failure

Kidneys: No history of kidney disease or failure

Endocrine: No heat/cold intolerance or excessive sweating. No diabetes, thyroid, pituitary, or adrenal problems.

Hematologic: No bleeding

Musculoskeletal: No history of muscle disease

PHYSICAL EXAMINATIONAirway: Mallampati class 3

TM Distance (FB): 3

Neck ROM: Very limited ROM (flexion/extension/rotation)

Oral Aperture (FB): 2

Vital Signs:

BP 120/80 mm Hg; Pulse 88/min; Temperature 36.7°C (98°F); Height 180.3 cm (5 ft 11 in); SpO2 98%

CASE OBJECTIVES1. Review Mr. Smith’s preoperative assessment and consider other questions to prepare for him during your preoperative visit.

2. Consider Mr. Smith’s history and scheduled surgery. Develop an anesthetic plan with rationale for each step.

3. What are your postoperative concerns for Mr. Smith?


cont

inue

s on

pag

e 12

0

Evi

den

ce s

ou

rce,

ev

iden

ce t

ype/

leve

l o

f ev

iden

ce,a

co

un

try

Nu

mb

erB

arri

ers

to P

BL

im

ple

men

tati

on

Oth

er fi

nd

ing

sC

om

men

ts

Gra

nd’M

aiso

n &

Des

Mar

chai

s,6

1991

Qua

litat

ive

case

rep

ort/L

evel

VI

Can

ada

1 m

edic

al s

choo

l (fo

llow

-up

of f

acul

ty w

ho a

tten

ded

PB

L w

orks

hops

); 20

7 m

embe

rs

• Fa

culty

did

not

ack

now

ledg

e ne

ed f

or c

hang

e

• N

eed

for

facu

lty d

evel

opm

ent

• Fa

culty

sat

isfa

ctio

n hi

gher

aft

er

impl

emen

tatio

n of

PB

L

• In

crea

sed

facu

lty in

tere

st in

ed

ucat

iona

l dev

elop

men

t

• R

espo

nse

rate

=80

%

• D

ata

colle

ctio

n to

ol n

ot e

valu

ated

for

re

liabi

lity

or v

alid

ity

Des

Mar

chai

s et

al,7

1992

Qua

litat

ive

case

rep

ort/L

evel

VI

Can

ada

1 m

edic

al s

choo

l (fa

culty

at

tend

ed 2

-day

PB

L w

orks

hop

befo

re im

plem

enta

tion)

• S

tude

nts

foun

d P

BL

dem

andi

ng

but

stim

ulat

ing

• A

dditi

onal

fac

ulty

tim

e an

d tr

aini

ng r

equi

red

• Im

prov

ed t

each

er a

ttitu

de t

owar

d P

BL

• P

rom

oted

inde

pend

ent

lear

ning

• N

o ad

ditio

nal c

ost

incu

rred

• B

efor

e P

BL,

thi

s pr

ogra

m s

uffe

red

from

exc

essi

ve c

ours

e co

nten

t,

lect

ure-

only

, and

poo

r co

ngru

ence

be

twee

n ev

alua

tion

and

cour

se

obje

ctiv

esC

reed

y &

Han

d,8

1994

Qua

litat

ive

surv

ey/L

evel

VI

Aus

tral

ia

1 pr

ogra

m (1

4 nu

rse

educ

ator

s w

ho a

tten

ded

PB

L pr

ofes

sion

al

deve

lopm

ent)

• Fa

culty

and

stu

dent

s’ p

rior

belie

fs a

bout

eff

ectiv

e te

achi

ng

met

hods

• PB

L im

plem

enta

tion

impr

oved

w

hen

educ

ator

s pa

rtic

ipat

ed

in r

efle

ctio

n an

d ha

d ad

equa

te

supp

ort

• Su

rvey

res

pons

e ra

te=

21%

• W

ith s

uppo

rt, e

duca

tors

ado

pted

st

uden

t-cen

tere

d ap

proa

ch m

ore

easi

ly

Ber

nste

in e

t al

,9 1

995

Qua

ntita

tive

pret

est,

post

test

su

rvey

/Lev

el V

I

Can

ada

1 m

edic

al s

choo

l; 25

0 se

cond

-ye

ar m

edic

al s

tude

nts,

15

facu

lty t

utor

s

• St

uden

ts c

once

rned

abo

ut

know

ledg

e ac

quis

ition

• Ti

me-

cons

umin

g

• M

ore

stud

ents

agr

eed

that

PB

L w

as m

ore

effec

tive

than

tr

aditi

onal

tea

chin

g (3

8% p

rete

st

vs 5

2% p

ostt

est,

P<.0

2)

• Su

rvey

res

pons

e ra

te=

78%

for

pr

etes

t; 83

% f

or p

ostt

est

Dor

ing

et a

l,10 1

995

Qua

ntita

tive

surv

ey/L

evel

VI

Aus

tral

ia

3 pr

ogra

ms;

84

facu

lty

mem

bers

fro

m s

choo

ls o

f ar

ts,

nurs

ing,

and

edu

catio

n

• In

suff

icie

nt t

ime

for

PBL

sess

ion

• Su

ppor

t ne

eded

to

teac

h PB

L

• Fa

culty

agr

eed

stud

ents

att

ain

suff

icie

nt k

now

ledg

e th

roug

h PB

L

• Su

rvey

res

pons

e ra

te=

25%

Rey

nold

s,11

200

3

Mix

ed-m

etho

ds s

urve

y/Le

vel V

I

Uni

ted

King

dom

1 gr

adua

te m

edic

al e

duca

tion

prog

ram

; 157

occ

upat

iona

l th

erap

y an

d ph

ysio

ther

apy

stud

ents

• H

ighe

r le

vel o

f st

uden

t an

xiet

y w

ith P

BL

• St

uden

ts r

epor

ted

posi

tive

PB

L ex

perie

nces

(mea

n=62

, SD

=5.

6,

max

imum

sco

re=

80)

• Su

rvey

res

pons

e ra

te=

83%

• PB

L A

ttitu

des

Que

stio

nnai

re u

sed

• St

uden

ts w

ere

mor

e co

mfo

rtab

le

with

the

sub

ject

mat

ter

afte

r P

BL

impl

emen

tatio

n

Sco

tt e

t al

,12 2

005

Mix

ed-m

etho

ds s

urve

y/Le

vel V

I

Uni

ted

Sta

tes

All

PA

pro

gram

s ac

cred

ited

by

AR

C-P

A•

Fina

ncia

l sup

port

req

uire

d

• Fa

culty

res

ista

nce

• La

ck o

f ad

min

istr

ativ

e su

ppor

t

• 76

.2%

of

PA

pro

gram

s us

ing

PB

L at

the

tim

e of

the

sur

vey

• Su

rvey

res

pons

e ra

te=

75.4

%

• A

sses

smen

t sh

owed

str

ong

surv

ey

tool

val

idity

Foor

d-M

ay,13

200

6

Qua

litat

ive

surv

ey/L

evel

VI

Uni

ted

Sta

tes

1 ph

ysic

al t

hera

py e

duca

tion

prog

ram

(7 f

acul

ty m

embe

rs)

• Pe

er s

uppo

rt n

eede

d

• N

eed

for

lead

ersh

ip s

uppo

rt

• A

dmin

istr

ativ

e su

ppor

t re

quire

d

• C

urric

ular

cha

nge

to P

BL

had

been

est

ablis

hed,

and

the

tr

ansi

tion

was

occ

urrin

g

• 10

0% r

espo

nse

rate

• St

udy

note

d ch

ange

mus

t ac

com

mod

ate

indi

vidu

al n

eeds

Mat

thew

-Mai

ch e

t al

,14 2

007

Qua

litat

ive

surv

ey/L

evel

VI

Uni

ted

Sta

tes

3 un

derg

radu

ate

nurs

ing

prog

ram

s; 3

0 nu

rsin

g fa

culty

m

embe

rs a

tten

ding

fac

ulty

de

velo

pmen

t w

orks

hop

• R

esis

tanc

e to

cha

nge

• N

eed

for

facu

lty t

rain

ing

• Fa

culty

exc

ited

to d

evel

op

nurs

ing

PB

L

• PB

L he

lps

prom

ote

lifel

ong

lear

ning

• Su

rvey

res

pons

e ra

te=

100%

• Fa

culty

dev

elop

men

t pr

ogra

ms

incl

ude

ongo

ing

eval

uatio

n

Ros

s et

al,15

200

7

Cas

e st

udy/

Leve

l VI

Uni

ted

Sta

tes

1 pr

ogra

m (t

hird

-yea

r ph

arm

acy

stud

ents

); P

BL

curr

icul

um

impl

emen

ted

in 1

995

• Si

gnifi

cant

cos

ts

• In

crea

sed

teac

hing

spa

ce a

nd

time

• A

line

ar im

prov

emen

t on

as

sess

men

ts w

as n

oted

fo

llow

ing

PB

L im

plem

enta

tion

• Fa

culty

use

d P

BL

to p

rom

ote

com

pete

ncy

and

impr

ove

criti

cal

thin

king

and

pro

blem

sol

ving


Evi

den

ce s

ou

rce,

ev

iden

ce t

ype/

leve

l o

f ev

iden

ce,a

co

un

try

Nu

mb

erB

arri

ers

to P

BL

im

ple

men

tati

on

Oth

er fi

nd

ing

sC

om

men

tsV

ahid

i et

al,16

200

7

Qua

litat

ive,

pre

test

pos

ttes

t su

rvey

/Lev

el V

I

Iran

1 un

derg

radu

ate

nurs

ing

prog

ram

; 53

nurs

ing

facu

lty

mem

bers

• Fa

culty

rol

e ch

ange

s fr

om

teac

her

to f

acili

tato

r

• C

hang

es c

ould

cau

se s

tude

nt

stre

ss

• C

ost

• Fa

culty

sta

ffin

g

• La

ck o

f m

anag

emen

t su

ppor

t

• M

ajor

ity o

f st

aff

belie

ved

PB

L ef

fect

ive

met

hod

for

build

ing

prac

tical

ski

lls

• C

apac

ity b

uild

ing

and

crea

ting

supp

ortiv

e en

viro

nmen

t ar

e pr

ereq

uesi

tes

to P

BL

• Su

rvey

res

pons

e ra

te=

100%

• Th

e qu

estio

nnai

re w

as p

ilot-

test

ed

and

valid

ated

ass

esse

d

• C

ould

be

used

as

a to

ol in

fut

ure

rese

arch

Gw

ee,17

200

8

Qua

litat

ive

case

rep

ort/

Leve

l VI

Sin

gapo

re

4 m

edic

al s

choo

ls in

var

ious

pa

rts

of A

sia

• PB

L re

quire

s ad

ditio

nal

reso

urce

s

• Pa

radi

gm s

hift

to

stud

ent-

cent

ered

lear

ning

• St

rong

app

eal t

o A

sian

go

vern

men

ts s

earc

hing

for

a

new

edu

catio

nal p

arad

igm

• PB

L im

plem

enta

tion

requ

ires

care

ful

plan

ning

and

ded

icat

ion

Mau

dsle

y et

al,18

200

8

Mix

ed-m

etho

ds s

urve

y/Le

vel V

I

Uni

ted

Kin

gdom

1 pr

ogra

m (j

unio

r m

edic

al

stud

ents

enr

olle

d in

5-y

PB

L cu

rric

ulum

); 22

4 st

uden

ts

• S

tude

nts

unce

rtai

n ab

out

brea

dth

and

dept

h of

lear

ning

(4

3.4%

)

• C

once

rn a

bout

mis

sing

in

form

atio

n (1

8.4%

)

• PB

L en

cour

ages

inde

pend

ent,

ac

tive

lear

ning

(21.

2%b )

• C

ogni

tive

bene

fits

(17.

5%b )

• C

oope

rativ

e le

arni

ng (1

5.3%

b )

• R

espo

nsib

ility

and

con

trol

giv

en

to s

tude

nts

(12.

4%b )

• 2

surv

eys

give

n to

199

9 an

d 20

01

year

coh

orts

at

diff

eren

t po

ints

in t

heir

trai

ning

; res

pons

e ra

tes=

60%

-70%

c

Will

iam

s &

Bea

ttie

,19 2

008

Sys

tem

atic

rev

iew

of

qual

itativ

e st

udie

s/Le

vel V

Aus

tral

ia

5 qu

alita

tive

stud

ies

focu

sing

on

the

clin

ical

set

ting

of n

ursi

ng

educ

atio

n

• Fa

culty

do

not

unde

rsta

nd P

BL

• H

igh

staf

f tu

rnov

er

• La

ck o

f co

ordi

natio

n w

ith

clin

ical

and

PB

L te

achi

ng

• R

esea

rche

rs n

oted

impr

ovem

ent

in a

ttitu

des,

und

erst

andi

ng, a

nd

tole

ranc

e of

clin

icia

ns t

owar

d st

uden

ts

• C

ritic

al a

naly

sis

com

plet

ed u

sing

Jo

anna

Brig

gs In

stitu

te Q

ualit

ativ

e A

sses

smen

t an

d R

evie

w In

stru

men

t

• To

tal s

ampl

e si

ze u

nkno

wn

Al K

adri

et a

l,20 2

009

Qua

litat

ive

phen

omen

olog

ical

st

udy/

Leve

l VI

Sau

di A

rabi

a

1 m

edic

al e

duca

tion

prog

ram

•

Stud

ents

’ per

cept

ion

of le

arni

ng

was

low

er w

ithou

t us

e of

su

mm

ativ

e as

sess

men

ts

• A

nxie

ty le

vels

low

er w

ithou

t su

mm

ativ

e as

sess

men

t

• O

vera

ll st

uden

t pe

rfor

man

ce

impr

oved

• Su

rvey

res

pons

e ra

te=

100%

Pap

incz

ak e

t al

,21 2

009

Qua

litat

ive

surv

ey/L

evel

VI

Aus

tral

ia

1 m

edic

al e

duca

tion

prog

ram

• R

ole

conf

usio

n by

tut

ors

• Tu

tor

“sty

le”

affe

cts

PB

L su

cces

s

• Tu

tor

has

larg

e ro

le in

ex

perie

nces

with

PB

L

• Im

pact

s en

joym

ent,

mot

ivat

ion

and

achi

evem

ent

• Su

rvey

res

pons

e ra

te=

42.4

%

• N

eed

for

tuto

r tr

aini

ng a

nd

prof

essi

onal

dev

elop

men

t

Wal

ker

et a

l,22 2

009

Qua

ntita

tive

syst

emat

ic r

evie

w

met

a-an

alys

is/L

evel

V

Uni

ted

Sta

tes

201

outc

omes

acr

oss

82

stud

ies;

add

ress

ed in

stitu

ting

PB

L ac

ross

sci

ence

edu

catio

n di

scip

lines

• Ti

me-

cons

umin

g

• R

equi

red

mor

e ef

fort

fro

m

stud

ents

and

fac

ulty

• PB

L st

uden

ts d

id a

s w

ell o

r be

tter

tha

n th

eir

lect

ure-

base

d co

unte

rpar

ts

• 68

pos

itive

out

com

es a

nd

21 n

egat

ive;

in f

avor

of

PB

L (P

<.0

01)

• Se

arch

con

sist

ed o

f m

eta-

anal

yses

an

d re

view

s

cont

inue

d fr

om p

age

119


Thom

pson

,23 2

010

Sys

tem

atic

rev

iew

of

qual

itativ

e st

udie

s/Le

vel V

Uni

ted

Kin

gdom

7 qu

alita

tive

artic

les

incl

uded

in

this

rev

iew

; prim

ary

focu

s w

as o

n IP

E e

xper

ienc

e w

ithin

con

text

of

PB

L

• R

equi

res

coor

dina

tion

acro

ss

curr

icul

a

• M

aint

aini

ng c

ontin

uity

of

the

PB

L gr

oup

• Fu

ndin

g ne

eded

• M

ore

faci

litat

ors

requ

ired

• St

uden

ts in

inte

rven

tion

grou

ps

deve

lope

d m

ore

posi

tive

attit

udes

tow

ard

diff

eren

t he

alth

pr

ofes

sion

als

than

tho

se in

co

ntro

l gro

ups

• R

evie

w o

f qu

alita

tive

stud

ies

exam

inin

g IP

E w

ith P

BL

• To

tal s

ampl

e si

ze u

nkno

wn

Dix

it et

al,24

201

3

Qua

litat

ive

case

rep

ort/

Leve

l VI

Nep

al

7 m

edic

al c

olle

ges

(inte

rvie

ws

of f

acul

ty a

nd s

tude

nts)

• Se

nior

fac

ulty

mem

bers

not

in

vest

ed in

cha

ngin

g th

eir

teac

hing

met

hods

• In

crea

sed

stud

ent

satis

fact

ion

afte

r P

BL

impl

emen

tatio

n

• Le

ss t

ime

spen

t in

cla

ssro

om

and

mor

e tim

e in

“se

lf-di

rect

ed”

stud

y

• Pa

rtic

ipan

ts r

epor

ted

low

er s

tres

s du

ring

PB

L cu

rric

ulum

Azi

z et

al,25

201

4

Qua

ntita

tive

surv

ey/L

evel

VI

Pak

ista

n

260

facu

lty m

embe

rs a

nd

stud

ents

fro

m m

edic

al a

nd

dent

al c

olle

ge

• Ti

me-

cons

umin

g

• A

dditi

onal

fac

ulty

tra

inin

g re

quire

d

• A

dditi

onal

sta

ff n

eede

d

• Fa

culty

(96%

) and

stu

dent

s (7

3.2%

) con

side

r P

BL

mor

e in

tere

stin

g

• PB

L pr

oduc

es b

ette

r re

sults

on

exam

inat

ions

• Su

rvey

res

pons

e ra

te=

87%

Nav

azes

h et

al,26

201

4

Qua

litat

ive

case

rep

ort/

Leve

l VI

Uni

ted

Sta

tes

1 pr

ogra

m (P

BL

taug

ht o

ver

2 y

usin

g 30

den

tal p

atie

nt c

ases

) •

Req

uire

s in

nova

tion

• Sc

hedu

ling

conf

licts

• La

ck o

f sp

ace

• Li

mite

d nu

mbe

r of

fac

ulty

• N

eed

facu

lty t

rain

ing

• C

ost

• Pa

ss r

ate

of b

oard

exa

min

atio

n fo

r fi

rst

PB

L cl

ass

(200

5)=

94%

vs

ave

rage

pas

s ra

te=

88.2

% f

or

trad

ition

al c

urric

ulum

(199

5-20

04)

• Tw

o-ye

ar m

ean

stud

ent

satis

fact

ion

ratin

g=4.

43 o

n a

5-po

int

scal

e

• PB

L ca

ses

and

mat

eria

ls r

evie

wed

on

a y

early

bas

is b

y cu

rric

ulum

co

mm

ittee

to

ensu

re q

ualit

y an

d co

nsis

tenc

y of

info

rmat

ion

Bes

tett

i et

al,27

201

4

Cas

e re

port

/Lev

el V

I

Bra

zil

1 pr

ogra

m; m

edic

al s

choo

l•

Res

ista

nce

to c

hang

e

• St

uden

ts c

an la

ck c

onfi

denc

e an

d m

atur

ity

• U

npre

pare

d st

uden

ts c

an

inte

rfer

e w

ith g

roup

lear

ning

• Te

ache

r tr

ansi

tion

to f

acili

tato

r

• Fo

r P

BL

to b

e ef

fect

ive,

stu

dent

s m

ust

be a

dapt

ed t

o so

cioc

ultu

ral,

econ

omic

, and

edu

catio

nal

cont

ext

of a

par

ticul

ar r

egio

n

• To

impr

ove

stud

ents

’ sel

f-gu

ided

st

udy,

tes

ts w

ere

give

n be

fore

and

af

ter

PB

L

• M

inim

ize

PB

L tr

ansi

tion

by u

sing

le

ctur

es, s

imul

atio

ns, a

nd v

isits

to

clin

ics

Cly

ne &

Bill

iar,

28 2

016

Qua

litat

ive

case

rep

ort/

Leve

l VI

Uni

ted

Sta

tes

1 pr

ogra

m; b

iom

echa

nica

l en

gine

erin

g co

urse

• Fa

culty

tra

nsiti

on t

o fa

cilit

ator

s

• In

crea

sed

facu

lty t

ime

• Fa

culty

and

stu

dent

s m

ay h

ave

a fe

ar o

f fa

ilure

in P

BL

• St

uden

ts r

ated

the

inst

ruct

or

and

cour

se h

ighl

y w

hen

taug

ht

in P

BL

• St

uden

ts f

elt

PB

L ex

pose

d th

em

to im

port

ant

know

ledg

e

• U

nive

rsity

to

enco

urag

e fa

culty

to

impl

emen

t P

BL

by p

rovi

ding

the

m

with

sup

port

suc

h as

wor

ksho

ps

Tabl

e 1.

Sys

tem

atic

Rev

iew

s an

d D

escr

iptiv

e S

tudi

es E

xam

inin

g B

arri

ers

to Im

plem

enta

tion

of P

robl

em-B

ased

Lea

rnin

g6-2

8

Abb

revi

atio

ns: A

RC

-PA

, Acc

redi

tatio

n R

evie

w C

omm

issi

on o

n Ed

ucat

ion

for

the

Phys

icia

n A

ssis

tant

; IPE

, int

erpr

ofes

sion

al e

duca

tion;

PA

, phy

sici

an a

ssis

tant

; PB

L, p

robl

em-b

ased

lear

ning

.a

Evi

denc

e ap

prai

sed

and

leve

led

usin

g th

e m

etho

d de

scrib

ed b

y M

elny

k an

d Fi

neou

t-O

verh

olt.

7 E

vide

nce

leve

ls r

ange

fro

m L

evel

I, (s

yste

mat

ic r

evie

w o

f ra

ndom

ized

con

trol

led

tria

ls)

to L

evel

VII

(exp

ert

opin

on).

b Pe

rcen

t of

stu

dent

res

pond

ents

.c 1

999

coho

rt s

urve

y re

spon

se r

ate=

61.2

% (n

=13

7) e

nd o

f ye

ar 1

; 77.9

% (n

=15

9) m

idye

ar 3

; 200

1 co

hort

sur

vey

resp

onse

rat

e=71

.0%

(n=

201)

sta

rt o

f ye

ar 1

; and

71.

0% (n

=19

8) e

nd o

f ye

ar 1

.d

Type

s of

fac

ulty

sup

port

pro

vide

d: w

orks

hops

, pee

r-to-

peer

inst

ruct

ion

in P

BL,

pro

vidi

ng a

sses

smen

t to

ols

and

expe

rtis

e, in

crea

sing

sta

ff, t

each

ing

assi

stan

ce, d

ecre

asin

g w

orkl

oad,

an

d le

ss r

elia

nce

on s

tude

nt c

ours

e ev

alua

tions


• Potential Faculty Interventions. Due to the many barriers tied to this group, faculty members are the key to a successful PBL implementation. Educating the faculty before beginning this process improves the success of bringing PBL to an institution.6,8,9-11,14-21,24,27,28 If faculty is given resources and examples of PBL outcomes in other programs, it is likely to increase their compliance and positivity.6,8,9-11,17,19-21,24,27,28

Faculty training and development has been found to be one of the most powerful interventions to ex-ecuting PBL.6,7,13,17,24-28 By providing PBL workshops and adequately training faculty, engagement in PBL flourishes.6-8,14,28 Providing the faculty with additional support during the time of implementation is para-mount.9,10,12,13,16,19,24 Institutional support will improve the use of faculty time as they engage in constructing PBL curriculum.9,10,12,13,16,19,24 Before the beginning of this process, the workload of each faculty member should be assessed.

• Student Barriers. Students may have difficulty tran-sitioning to PBL because it places the learner in the center of the process, which can lead to feelings of frustration and discomfort.8-12,18,21,25,28 It is not uncommon to en-counter resistance and anxiety from students toward the change in teaching styles.6,8-10,17-19,25,27,28 Students may have trouble adjusting to the new curriculum, as there is an increase in the amount of time spent invested in knowledge acquisition.9,25,27 This can be an unfamiliar approach for educators and learners, and there can be a fear of failure for both groups, resulting in hesitation with the transition.11,15,16,18,20,26,28

• Potential Student Interventions. Orienting students to PBL during the initial phase can be helpful in setting student objectives and expectations.6,8,9-11,15--19,21,24,27,28 Faculty should consider modeling a PBL case and explain the process in a step-by-step outline.3 A simple case should be used during the student’s first PBL session so that they understand the role of the learners vs the facilitator and experience the additional time that will be needed to explore knowledge deficits.9,25,27 It is im-portant for the facilitator to understand that the students may feel anxiety and frustration as they acclimate to this new learning environment. Student input should be en-couraged and positively reinforced during this process.6-

9,11,15,16,18,20,27

• Resource Barriers. The faculty-to-student ratio must change once a program elects to implement PBL.3 These sessions are taught in a small group setting of 4 to 8 learn-ers paired with a faculty educator. As a result, there will be a need for an increased number of faculty.15,16,19,23,25,26

There may be a need for supplemental support and ad-ministrative staff when considering an increased faculty workload.10,12,13,16,19 Each small group will also need space, and this can result in limited space availability.15,26 There is often an increase in cost associated with adding facility space, faculty, and staff members to facilitate PBL sessions.12,13,15,16,19,23,26

• Potential Resource Interventions. The physical re-sources required for a successful PBL program include providing faculty facilitators for each group, as well as room space.3 Program leaders could consider using clinical faculty to facilitate PBL sessions.15,16,19,23,25,26 A key benefit of using clinical instructors in this process is that these CRNAs will be eligible for Class B continu-ing education credits.29 Education credits could serve to motivate involvement by staff CRNAs. Once CRNAs have been trained in the process of facilitation, they could serve as a valuable asset in this process.6,7,14,17,24-28

It is important to seek institutional support at the start of this process.12,13,15,16,19,23,26 Educating the admin-istrative leaders on the benefits and process of PBL will likely improve access to additional resources. Providing a proposal estimating staffing and space needs may lead to increased support provided throughout this implementa-tion process.12,13,15,16,19,23,26 Systematically evaluating the impact of PBL can convince administration of the value of allocating additional resources to PBL.

ConclusionNurse anesthesia students and educators may gain many benefits from employing PBL, such as increased student engagement, improved performance, and rapid improve-ment in development of critical thinking skills.4 Although PBL has been successful in medical education, we found no evidence of its widepread use in nurse anesthesia education. This review helps educators by identifying common barriers and describes possible interventions to help ensure the successful implementation of PBL.

There are many opportunities for future research in this active learning style, which was pioneered in medical education. Although PBL has been in use since the 1960s, there are many avenues yet to explore, including the learner experience and the use of PBL in CRNA education. Problem-based learning can become an important tool in training the future generations of nurse anesthetists.

REFERENCES 1. Malina DP, Izlar JJ. Education and practice barriers for Certified

Registered Nurse Anesthetists. Online J Issues Nurs. 2014;19(2):3. doi:10.3912/OJIN.Vol19No02Man03

2. Chilkoti G, Mohta M, Wadhwa R, Saxena AK. Problem-based learning research in anesthesia teaching: current status and future perspective. Anesthesiol Res Pract. 2014;2014:263948. doi:10.1155/2014/263948

3. Walsh A. The tutor in problem-based learning: a novice’s guide. Pro-gram for Faculty Development, McMaster University, Faculty of Health Sciences. 2005. Accessed February 4, 2018. https://fhs.mcmaster.ca/facdev/documents/tutorPBL.pdf

Figure 2. Flow Diagram of Literature Search Examining Barriers to Implementation of Problem-Based Learning

Sources meeting criteria based on full text: 23

Potential sources: 416

Sources meeting criteria based on title: 47

Sources meeting criteria based on abstract: 026


4. Hung W, Jonassen DH, Liu R. Problem-based learning. In: Spector JM, Merrill MD, van Merriënboer J, Driscoll MP, eds. Handbook of Research on Educational Communications and Technology. 3rd ed. Law-rence Erlbaum Associates; 2008:1503-1581.

5. Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. 3rd ed. Wolters Kluwer/Lippincott Williams & Wilkins; 2011.

6. Grand’Maison P, Des Marchais JE. Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience [published correction appears at CMAJ. 1991;144(8):960]. CMAJ. 1991;144(5):557-562.

7. Des Marchais JE, Bureau MA, Dumais B, Pigeon G. From traditional to problem-based learning: a case report of complete curriculum reform. Med Educ. 1992;26(3):190-199. doi:10.1111/j.1365-2923.1992.tb00153.x

8. Creedy D, Hand B. The implementation of problem-based learning: changing pedagogy in nurse education. J Adv Nurs. 1994;20(4):696-702. doi:10.1046/j.1365-2648.1994.20040696.x

9. Bernstein P, Tipping J, Bercovitz K, Skinner HA. Shifting students and faculty to a PBL curriculum: attitudes changed and lessons learned. Acad Med. 1995;70(3):245-247. doi:10.1097/00001888-199503000-00019

10. Doring A, Bramwell-Vial A, Bingham B. Staff comfort/discomfort with problem-based learning. A preliminary study. Nurse Educ Today. 1995;15(4):263-266. doi:10.1016/s0260-6917(95)80128-6

11. Reynolds F. Initial experiences of interprofessional problem-based learning: a comparison of male and female students’ views. J Interprof Care. 2003;17(1):35-44. doi:10.1080/1356182021000044148

12. Scott Q, Lloyd L, Kelly C. Problem-based learning in physician assistant training programs. J Physician Assist Edu. 2005;16(2):84-88. doi:10.1097/01367895-200516020-00004

13. Foord-May L. A faculty’s experience in changing instructional meth-ods in a professional physical therapist education program. Phys Ther. 2006;86(2):223-235.

14. Matthew-Maich N, Mines C, Brown B, et al. Evolving as nurse edu-cators in problem-based learning through a community of faculty development. J Prof Nurs. 2007;23(2):75-82. doi:10.1016/j.prof-nurs.2006.07.004

15. Ross LA, Crabtree BL, Theilman GD, Ross BS, Cleary JD, Byrd HJ. Implementation and refinement of a problem-based learning model:

a ten-year experience. Am J Pharm Educ. 2007;71(1):17.

16. Vahidi RG, Azamian A, Valizadeh S. Opinions of an Iranian nursing faculty on barriers to implementing problem-based learning. East Mediterr Health J. 2007;13(1):193-196.

17. Gwee MC. Globalization of problem-based learning (PBL): cross-cultural implications. Kaohsiung J Med Sci. 2008;24(3 suppl):S14-S22. doi:10.1016/s1607-551x(08)70089-5

18. Maudsley G, Williams EM, Taylor DC. Problem-based learning at the receiving end: a ‘mixed methods’ study of junior medical students’ perspectives. Adv Health Sci Educ. 2008;13(4):435-451. doi:10.1007/s10459-006-9056-9

19. Williams SM, Beattie HJ. Problem based learning in the clinical setting—a systematic review. Nurse Educ Today. 2008;28(2):146-154. doi:10.1016/j.nedt.2007.03.007

20. Al Kadri HM, Al-Moamary MS, van der Vleuten C. Students’ and teachers’ perceptions of clinical assessment program: a qualita-tive study in a PBL curriculum. BMC Res Notes. 2009;2:263. doi:10.1186/1756-0500-2-263

21. Papinczak T, Tunny T, Young L. Conducting the symphony: a quali-tative study of facilitation in problem-based learning tutorials. Med Educ. 2009;43(4):377-383. doi:10.1111/j.1365-2923.2009.03293.x

22. Walker A, Leary H. A problem based learning meta analysis: dif-ferences across problem types, implementation types, disciplines, and assessment levels. Interdisciplinary J Problem-Based Learning. 2009;3(1):1-43. doi:10.7771/1541-5015.1061

23. Thompson C. Do interprofessional education and problem-based learning work together? Clin Teach. 2010;7(3):197-201. doi:10.1111/j.1743-498X.2010.00381.x

24. Dixit H, Vaidya S, Pradhan B. PBL implementation of Kathmandu University curriculum—is it quo vadis? JNMA J Nepal Med Assoc. 2013;52(192):652-658. doi:10.31729/jnma.2445

25. Aziz A, Iqbal S, Zaman AU. Problem based learning and its imple-mentation: faculty and student’s perception. J Ayub Med Coll Abbot-tabad. 2014;26(4):496-500.

26. Navazesh M, Rich SK, Tiber A. The rationale for and implementa-tion of learner-centered education: experiences at the Ostrow School of Dentistry of the University of Southern California. J Dent Educ. 2014;78(2):165-180.

27. Bestetti RB, Couto LB, Romão GS, Araújo GT, Restini CB. Contextual considerations in implementing problem-based learning approaches

Area Barriers Potential interventions Faculty • Lack of buy-in to the value of PBL

• Lack of training

• Need to commit additional time during transition period

• Resistance to change

• Education about the value of PBL

• Provide training

• Discuss concerns with experienced PBL instructors

• Built-in additional planning time, especially in the transition period

• Evaluate faculty workload Students • Fear and discomfort due to inexperience

with PBL

• Increased time spent on PBL assignments, especially during transition

• Deliberate instruction about the PBL method

• Start off with basic cases

• Faculty-provided exemplars

• Discuss concerns with students who were or have been enrolled in programs successfully using PBL

• Facilitator-provided positive reinforcement

• Encourage students’ input early and throughout the introduction of PBL

Resources • Instructors to facilitate small groups

• Support personnel to help coordinate the larger number of faculty and increased faculty workload

• Private rooms for PBL groups to meet

• Train adjunct instructors in PBL

• Train support personnel

• Stagger meetings of PBL groups so all the groups do not meet at the same time

Table 2. Summary of Barriers to Implementing Problem-Based Learning (PBL) Into Curriculum and Potential Interventions6-28


in a Brazilian medical curriculum: the UNAERP experience. Med Educ Online. 2014;19:24366. doi:10.3402/meo.v19.24366 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058778. Accessed Dec 3, 2017.

28. Clyne AM, Billiar KL. Problem-based learning in biomechanics:advantages, challenges, and implementation strategies. J Biomech Eng.2016;138(7):070804-070804-9. doi:10.1115/1.4033671

29. National Board of Certification and Recertification for Nurse Anesthe-tists. Continued Professional Certification (CPC) Program. AccessedApril 15, 2018. https://www.nbcrna.com/continued-certification

AUTHORSKristin J. Henderson, DNAP, CRNA, CHSE, is an assistant professor and education innovator at the Wake Forest School of Medicine Nurse Anes-thesia Program, Winston-Salem, North Carolina, and the director of simu-

lation at the Bowman Gray Center for Experiential and Applied Learning, Winston-Salem. Email: [email protected]

Elisha R. Coppens, DNAP, CRNA, is a clinical CRNA and clinical coordinator in Maine.

Sharon Burns, EdD, CRNA, is a professor at Midwestern University, Glendale, Arizona, and adjunct faculty at Texas Wesleyan University, Fort Worth, Texas.

DISCLOSURESThe authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request.

Documents

Addressing Barriers to Implementing Problem-Based Learning