Tutors face many challenges in applying basic principles of problem-based learning (PBL) (Azer, 2005; Chan, 2008; Maudsley, 1999; O’Doherty, McKeague, Harney, Browne, & McGrath, 2018), particularly if they are un-learning ‘teaching’ and ‘telling’. The contested minimum content-expertise and process-expertise required to be a good PBL tutor (Albanese, 2004) may well depend on the learning context, particularly the type of PBL enacted, and pressure from student preferences (Lin, 2005; Maudsley, Williams, & Taylor, 2008). Nevertheless, PBL is good for fostering the conceptual restructuring required to learn ‘science’ (Loyens, Jones, Mikkers, & van Gog, 2015).
In 2002, Dolmans et al. found the PBL tutoring evidence-base in medical education to focus on quantifying how tutor characteristics or learning environment affect tutoring behaviour or student outcomes. They recommended that research agendas should conceptualize PBL tutoring more as: ‘a process aimed at stimulating constructive, self-directed, situated or transfer-directed, and collaborative learning’ and be more qualitative for ‘detailed and in-depth knowledge concerning teachers’ conceptions of the tutor role and student learning’ (p. 178).
While such research remains scarce, O’Doherty et al.’s (2018) focus groups (after quantitative e-questionnaire) did seek understanding of tutors’ one to nine years’ experience with medical students. This illuminated how tutors addressed personal uncertainties about their content- and process-expertise and an idealistic tutoring ‘gold standard’. Others have explored the immediate dynamics of tutors’ interventions in PBL sessions rather than their outlook on the educational philosophy. For example, using phenomenography to explore short-term experience, cross-sectionally, Hendry’s (2009) e-questionnaire of three open questions found supportive (rather than directive) approaches atop a hierarchy of tutors’ conceptions of their role with medical students. Haith-Cooper’s interviews about their role with twelve tutors worldwide (nursing, allied health professions, basic science, medicine, veterinary) again illustrated difficulties balancing content-expertise vs process-expertise (2003a; 2003b). Lee, Lin, Tsou, Shiau, and Lin’s (2009) interviews with eight nursing, medicine, and psychology PBL tutors about their video-recorded interventions in sessions illuminated their intentions (to improve the quality of discussion, group-process, or reference-material used). Lastly, Chan (2008) reflected on ten years of PBL tutoring medical students, recommending how best to use process- and content-expertise.
Meaningful longitudinal qualitative research is a large evidence-gap though, particularly long-term follow-up. A rare example of follow-up was Wilkie (2004) interviewing very experienced nursing lecturers twice over three years as they set about PBL tutoring. Over time, most became ‘pragmatic enablers’, i.e. flexing their process-orientated approach for diverse students to reach their potential.
Medicine’s hidden curriculum (Hafferty, 1998; Lempp & Seale, 2004) from the tutors’ perspective is also under-researched. This is the ‘set of influences that function at the level of organisational structure and culture’ (Hafferty, 1998, p. 404).
In 1996, major reform of Liverpool undergraduate medical curriculum embraced an educational philosophy of:
problem-based, active, student-centred learning, with students using PBL sessions to word their own ‘learning objectives’ from triggers in clinically-relevant scenarios
horizontal and vertical integration of content respectively across conventional subject-boundaries and across the conventional pre-clinical−clinical divide into four themes (Structure and Function; Population Perspective; Individuals, Groups, and Society; Professional and Personal Development), revisiting topics progressively deeper, spirally
early clinical context and contact, with clinical and communication skills training
reduced assessment-load focused on core concepts.
Each two-week ‘module’ had three two-hour PBL sessions on a scenario. Tutor-groups mostly stayed together for a semester. The last Year 1 intake was in 2013/14 (before the problem-based curriculum was replaced). In the recent few years, students still had to word their own group objectives in PBL but could now access the indicative curriculum-map of all intended learning outcomes. Tutors were from diverse clinical and non-clinical disciplines, including for many years now numerous sessional tutors. Tutor development goals included improving tutors’ group-process expertise, self-awareness of effects of content-expertise, familiarity with content for non-content-expert tutors, and related role-modelling (Maudsley, 1999).
In 1997, post-semester 1 of 1996, all thirty-four of Liverpool’s inaugural (first-ever) PBL tutors had semi-structured interviews with the thirty-fifth tutor (me). They were generally positive about the major change in educational philosophy, albeit rather concerned at their own fallibility about how to intervene without ‘teaching’ (Maudsley, 2002). After sixteen years, the remaining inaugural tutors would likely have rich insights about maintaining that innovative curriculum.
The research question was therefore: what educator outlooks do inaugural PBL tutors develop after substantial experience in a problem-based curriculum?
Within the pragmatism paradigm (Creswell, 2003), this multi-methods (Fetters & Molina-Azorin, 2017), qualitative, longitudinal research followed up a ‘criterion sample’ (purposive) (Bryman, 2016; Patton, 1990) twice. Semi-structured interviews (DiCicco-Bloom & Crabtree, 2006) with me (summer 2013) involved inaugural PBL tutors from Liverpool problem-based undergraduate medical curriculum who had all had semi-structured telephone interviews with me about that role between February and June 1997 (Maudsley, 2002). At this sixteen-year follow-up, participants were those still engaged substantively with that curriculum to improve student learning, whether or not still PBL tutoring. Eighteen-year follow-up (summer 2015) used a two-page open-item e-questionnaire. The research received ethics approvals (School of Medicine Education Research Ethics Committee 201305138 and Institute of Learning & Teaching (ILT) Ethics Review Group (staff) 20130513-A-extension).
An invitation e-mail included an information sheet for reassurance about confidentiality and a pre-interview consent-form to sign. E-mail reminders ensued. A non-participating academic colleague checked for clarity the topic guide of broad questions and prompts. The domains were: how staff had experienced improving student learning; key features of PBL tutoring; reflections on their own 1997 comments about PBL; the hidden curriculum; and changes in outlook as educators. (A supplementary topic about the four curriculum-themes and one on the questionnaire about student epistemology are for exploration elsewhere.) Wording built on the 1997 topic guide (Maudsley, 2002), particularly about PBL and its tutoring, probing specific examples or using tutors’ previous wording and seeking ‘lived experience’ (van Manen, 1990) and critical incidents (Chitsabesan, Corbett, Walker, Spencer, & Barton, 2006).
The author interviewed and audio-recorded participants between June and September on campus. Each interview lasted long enough to explore all topics and clarify responses, i.e. for data saturation within interview (Saunders et al., 2018). Recordings were erased after transcripts (in Word) and analyses were checked.
Two years later (the academic year after the problem-based curriculum ended for new entrants), the open-item questionnaire was designed and e-mailed with study information and reassurance on confidentiality to the ten tutors, building on both previous topic guides. This explored: achievements of the curriculum worth institutional pride; its educational philosophy; personal reactions to its demise and actions that might have saved it; tutors’ previous ‘hidden curriculum’ comments; and their previous ‘outlook as an educator’ comments (for legacy of the curriculum and reasons for its demise). Reminders were e-mailed. Akin to an E-interview (Bampton & Cowton, 2002), several iterations of two-way clarification ensued specific to each responder’s queries and responses.
Analysis used QSR NVivo 10 and 12 to organize and code data, focusing particularly on participants’ notions of their own (and students’) knowledge and learning ‘then and now’, i.e. their personal epistemology (Elby, 2009), including reflections on their 1997 descriptions and concerns (linked by unique identifier). Re-reading transcripts and questionnaire open-answers identified concepts inductively to aggregate into themes (plus exceptions). ‘Supplementary counting’ (Hannah & Lautsch, 2011) of themes added further insight.
When revisiting tutors’ 1997 comments, analysis was iteratively inductive-deductive. For example, for key features of PBL tutoring, themes were either enhanced themes from 1997 or new. A then-vs-now tabulation focused on themes generated from at least one-fifth of tutors either time (7/34, 2/10), i.e. cut-off was two in the current interview-sample. This assumed that: single mentions were probably exceptions; that inductive thematic saturation (Saunders et al., 2018) was sufficient across responders; and that it was unexceptional to use such ‘cut-offs’ (Pratt, 2008).
Only quotations on improving student learning were attributed to tutors T1-T10, to show extracts from all. To maintain confidentiality, T-numbers were attached only sparingly to other quotations.
Note on my positionality
Being an inaugural tutor myself, a public health doctor, and PBL tutoring Year 1 every semester of the eighteen years will have influenced my framing of the research, design of items, interview technique, and analysis and interpretation, plus how participants responded to me - as a ‘passionate participant’ (Guba & Lincoln, 1994, p. 115) and colleague. To mitigate incorrect assumptions in interpreting dialogue, I summarized participants’ answers (from written notes) during interviews for them to agree, clarify, or expand. I clarified e-questionnaire queries by contemporaneous e-mail.
All ten tutors (three female; five medical, five basic science) responded. Only one had not undertaken PBL tutoring since the curriculum’s first few years. Interviews lasted 38-61 minutes (median=49 minutes).
Indicative questions are in italics.
Now vs then: Improving student learning
Asked about their ‘experience of improving student learning in this sort of curriculum’, seven tutors specified personal improvements underpinning such progress. Those tutors understood more now (or were more confident): that they could make PBL work; how to run sessions; or about crucial PBL concepts such as facilitating active learning, ‘not teaching’, ‘activating prior knowledge’ (T3), and ‘getting [students] to evaluate’ (T3). Tutoring PBL well involved the right breadth and depth and facilitating dysfunctional groups or reluctant students:
‘the [original] inclination … to sort of go into “lead-mode” and “teach” is less now … I’ve learnt a lot of ‘tricks of the trade” (T1)
‘more creative about … getting them to … review each other [end-of-session]’ (T3)
‘with experience, you derive better strategies [for reluctant or quiet students], which you hope will enable those students to get as much from it as the rest of the group’ (T2)
The other three tutors’ comments were more curriculum-focused. One urged a major curriculum rethink to maintain hard-won gains in student experience and achievement:
‘the principles of … getting students to become the masters of how they handle knowledge and all the uncertainties … still hold very true. … [but we] need to make another change, not because those principles are wrong, but because change itself brings people thinking about it again’
The second rued curriculum now drifting away from central oversight of content and process, which also gained another two incidental tutor-mentions. The third tutor focused on less enjoyment now, feeling ill-suited to a curriculum integrating so many subjects outwith that tutor’s own non-clinical discipline.
All other (nine) tutors were positive and confident in their personal epistemology now, relaxed about such integration and the effectiveness of PBL:
‘it’s not too important to clearly divide [their discussion] into four [curriculum] themes; as long as they’re covering a topic that’s relevant, then it doesn’t really matter’ (T8)
‘an excellent way of keeping the students engaged … if you can manage their anxieties then I think it’s good for the students; it teaches them all sorts of things around teamwork, as well [as] formal stuff’ (T10)
One tutor pondered: ‘I should imagine that I was quite an enthusiast at the time’ (T4). Four tutors reported still finding PBL tutoring stimulating, fun, or enjoyable: ‘I still find the same excitement that I did in the earliest days about seeing the “pennies drop” and seeing students understand something, and being able to make sense of it and explain it to others’ (T6). Three tutors highlighted tutor selection as crucial though:
‘when the process was done well and students were inspired and engaged, it’s second to none in [getting] students to really understand and know what they’re doing, but there lies the nub of the problem. To me, the big disappointment [was] that there were people doing problem-based learning that really wouldn’t have inspired anybody’ (T7)
Things were now ‘more solidified, and more routinized and predictable’ (T9). For experienced tutors, the original angst about intervening legitimately in group dynamics (Maudsley, 2002) had dissipated. Active tutor engagement had transformed from sin to respectable requirement:
‘I used to take very seriously the [directive] of “sitting offshore” … I get them to draw more on the boards [now] … I’ve talked a little bit more, but mostly … for clarification or to get them to think … “What do you mean by… ?” … open questions I’m asking rather than actually giving them information’. (T3)
As T5 said: ‘[PBL tutoring] turns out to be a lot easier than we might have thought … the students seem to understand what’s required of them very quickly [quicker than staff]’.
Illustrating ‘something that sticks in your mind … a major highlight (a positive) … of trying to improve [student] learning’, five tutors described turnarounds in PBL-reluctant or PBL-sceptical students who, for example, skipped over activating prior knowledge straight to formulating learning objectives to study between sessions. Another tutor recalled a very sceptical student transforming:
‘becoming progressively more and more involved in the group discussions, so, not just their understanding (because they were a very good student) … increased, but their real understanding of how people learn and why it matters, and the enjoyment about talking about the subject flowered [that] first semester’ (T6)
‘A major challenge (a negative)’ was particularly students who did not engage with PBL, whatever the tutor did, or students who required much facilitation (n=3), but also that flawed curriculum design encouraged rushing over basic science (including pharmacology) in search of clinical application (n=2, medical tutors). The effect:
‘was to disenfranchise in a student’s mind, that the science wasn’t necessary. It was something that [just] happened, but it was a peripheral process to their medical knowledge, … [but] they’re all important’
About ‘changes in how students have tolerated uncertainty in the curriculum or knowledge base, like … they will meet in their everyday professional practice as a doctor’, tutors were ambivalent. Six intimated little change overall. Three reported improvement, because of students knowing what to expect now or senior students reassuring them, more plenaries, more guidance, or the now-published indicative learning outcomes, even if the last-mentioned disrupted active learning: ‘When the outcomes are known before the start, … that has to be carefully managed, but it does help with student uncertainty’ (T2). Only one tutor reported decreased student tolerance of uncertainty, attributing it to less ‘small-group and discursive learning’ (T6) in schools. Several tutors mentioned unchanged uncertainty levels but students objecting more, i.e. ‘gone from a lot of angst to moaning’ (T3).
One tutor disagreed with linking the uncertainty of clinical practice with learners’ uncertainty about their knowledge base because, in the latter, students: ‘see different groups covering different areas and it’s not clear to them whether they have covered the [right areas for] the curriculum and the final assessment’ (T9).
Now vs then: PBL tutoring
Tutors articulated more detailed, nuanced ‘key features of being a PBL tutor …’ than the whole cohort did in 1997 (
‘activating prior knowledge and being able to link the new information in with the existing knowledge base’ (T6)
Key features of problem-based learning (PBL) tutoring according to inaugural PBL tutors (n=10) who were still in the Liverpool medical curriculum (now) at sixteen-year follow-up, compared with similar features reported (then, 1997) by their inaugural cohort (n=34). Only themes where at least 2/10 or 7/34 tutors contributed are shown.
The 1997 top theme, ‘Knows when and how to intervene’, was joint third (with facilitating flexibly ‘to learn intended [and other] outcomes’) but now included ‘actively and confidently engaging with students’. Of the joint-second 1997 themes, empathizing with students no longer featured and enthusiasm received only one tutor-mention. Individual tutors’ answers now vs then prioritized what to do (or not do) to facilitate good learning. Seven tutors’ three answers differed from in 1997, one tutor highlighted two similar themes, and two highlighted one similar.
Now vs then: Essence of PBL
‘What do you think now about these comments of yours about “the essential characteristics of PBL”’: Faced with their own wording from 1997, tutors were intrigued albeit reticent, then relieved at coherent but long-forgotten answers: ‘To be honest, that’s quite good. I’ve deteriorated since then [*laughs loudly*]’. For one, the words prompted memories of novice exhaustion: ‘I couldn’t even contemplate doing anything for half-an-hour’ after PBL sessions.
Only one tutor disagreed with their previously reported description, which amounted then to ‘What it’s not, is it’s not problem-solving’. That concern had faded:
‘the worry at the time was that people perceived problem-based learning as essentially, “Here’s a problem-solving”, … they solve it, it’s done, and that’s it. … rather than, this [scenario] is … a coathanger around which you can dress a subject. That turned out to be not so much a problem.’
The other tutors agreed with themselves, but three would now emphasize things differently:
‘emphasize a bit more the element of self-awareness, what they, students need to be aware of: what they know and what they don’t know’
‘I’d frame them [differently] now, because I’ve done more about educational learning theory, but the essential characteristics I wouldn’t change’
‘ensuring that the standard’s high enough [for student achievement]. … It is about [us] stretching them … [and ensuring they] know exactly how high to jump’
All tutors agreed with their previous ‘main advantage of PBL’, although one-half refined their wording, e.g.
THEN: ‘they are going and finding the information… [for] understanding’
NOW: ‘with a little more understanding of the learning process now … because they’re finding out the information for themselves, they’re much more likely to remember that long-term, and the students always comment that that is a difference, that they are learning it as they go along’
Four tutors disagreed now with their 1997 ‘main disadvantage of PBL’ though, e.g.
THEN: ‘[sometimes] the case scenarios [in that inaugural semester] did not reflect the learning objectives… [sometimes they’re misleading, facile, or overcomplex]’
NOW: ‘I think the case scenarios have been updated and rewritten and refocused, and that was good’
Four of six tutors agreeing with their 1997 disadvantage also refined it, e.g.
THEN: ‘[need lots of external support and has been underresourced]’
NOW: ‘I would add … the, sort of cohort of tutors has changed … there’s a major problem with quality assurance around the tutors and the tutoring, [partly] to do with their experience. So … the underresourcing includes the tutors now’
All tutors agreed with their previously reported three elements of ‘what makes a good PBL tutor’, e.g.
THEN: ‘1−knowing when to speak and when to keep your mouth shut’, ‘2−not giving them lots of factual information’, ‘3−facilitating the process so that [they were happy to discuss and joke]’
NOW: ‘you have to create that right, comfortable learning environment, so … all three of those are still important to me’ (T2)
Only two tutors qualified their tutoring comments. One reacted that tutors being ‘broadly educated… a broad view of health issues’ remained useful if it translated into ‘facilitating’ not ‘teaching’. Another reacted that ‘knowing enough… to spot when they are deviating too far’ should become: ‘From experience, knowing roughly how much to go [into things] … [i.e.] general experience … not specific knowledge of the area’.
All tutors agreed with their own 1997 reasons for ‘why did you volunteer to be a PBL tutor’ - interest, curiosity, or personal development. One reflected on still PBL tutoring now: ‘at least … if you’re doing it, you’re entitled to comment on [*laughs*] what’s going on’.
Now vs then: Hidden curriculum
Asked about ‘a hidden bit of the [curriculum culture] that has affected substantially your role as an educator … “assumptions or activities” behind the scenes that crucially supported (a reinforcing message) or crucially detracted from (a mixed message) the educational philosophy’, only one tutor’s example was positive:
‘we don’t get this thing that … in ‘96 we got … where other tutors were blatantly giving out the learning objectives’
All tutors gave one or more diverse negative examples conflicting with the educational philosophy:
students being students (n=8): heeded mixed-message rumours from other students; easily reverted (unless challenged) to wanting to be told or colluding in ignorance; overvalued and underattended ‘the lecture’; were distracted by other groups’ learning objectives or the now-available curriculum-map; contributed misinformation from medical relatives or friends; undervalued the professionalism required when signing clinical log books
staff disagreeing with content (n=4): told students they did not know enough Structure and Function theme-content and dismissed the other three themes
staff lacking commitment, expertise, or united effort on ‘rules of the road’ for a high-quality problem-based curriculum (n=4): tutored variably (not activating prior knowledge); undermined maintaining and quality-assuring an active problem-based educational philosophy; talked divisively of ‘them vs us’ - School of Medicine vs students and hospital placement staff
staff not promoting sufficiently high standards (n=2): undermined student performance
impending curriculum change creating (n=2): uncertainty; mixed messages about PBL staying or not; erosion of educational philosophy
staff role-modelling negatively (n=1): ‘in the hospital, … [some] students are … seeing behaviours that perhaps aren’t [what] we would want them to think are good role models’.
Now vs then: Outlook as an educator
About ‘Other changes in your outlook as an educator of medical students’, eight tutors’ closing comments gave a positive reflective outlook, mostly about the effectiveness of the educational philosophy and PBL but laced with negative caveats. The tutor not enjoying resuming PBL after a break reiterated the intellectual discomfort:
‘I don’t think I can cope with the uncertainty around the depth as well as I could then [in 1996] [*laughs*]. I’m sort of more aware of it than I was, [and] found that quite frustrating and I have some sympathy with the students that they don’t know what the level should be. [For every module] you think, “ … there’s a lot in that”’
The remaining tutor was ‘professionally optimistic’ but lamented a wrong change management strategy when introducing the 1996 curriculum, which disenfranchised rather than engaged stakeholders, thus scuppering sustainable renewal of curriculum innovation:
‘[The one error was not giving] a clearer exposition of what was already in our minds [at the outset], because the curriculum was very, very carefully planned. … we needed to show, which we didn’t, how clearly we had put the [very complicated] jigsaw together, from the point of view of the student understanding it, and … [hospital] colleagues … the detractors, because (although in any system change you have detractors … we didn’t marshal our arguments clearly and forcibly enough in the beginning) we effectively ended up losing the long-term war. We won the battle by saying, “This is how it’s going to be”, [with] some very good cogent arguments, but we … chose the wrong strategy’.
That was one of four tutors lamenting flawed strategy for maintaining a coherent overview, e.g.:
‘we should have been much more ruthless with how we structured, restructured the faculty and its financial restructuring … [We should have brought in the planned] whole costing model, … overt and just … To avoid all the political repercussions, people avoided bringing it in, but I would have gone for the pain then’
Asked to ‘give your  self some advice about the PBL tutor role’, seven gave (amongst negative and neutral comments) positive motivational advice, which aggregated to:
Enjoy yourself and go for it. Expect hard work (from you) and high standards (from students). It is fine to be flexible and not to know everything. PBL really does work for us in our setting.
The remaining three commented neutrally on holding fast with the educational philosophy, as did three others, e.g. focus on: activating prior knowledge; achieving learning objectives; end-of-session reflective evaluation; intervening actively enough and constructively.
A month after the last interview, major reform was announced, replacing the problem-based curriculum with a lecture-based curriculum for the 2014/15 Year 1 entrants and Year 3, and for the remaining year groups the next academic year.
For the e-questionnaire, 9/10 tutors responded, including some recently retired.
Educational philosophy and curriculum achievements
Describing ‘key features of the educational philosophy (an explicit expectation on the students about the way that they should be learning, i.e. the process)’ with three terms or phrases, tutors highlighted active learning concepts. Six tutors included ‘self-directed’ (including one also mentioning ‘through enquiry’) or ‘self-learning’ and the more accurate ‘directed self-learning’ (Harden & Laidlaw, 2017); the others did mention ‘student-centred’ (n=2) or ‘curiosity driven’ (n=1) though.
Each of seven concepts had two tutor-mentions. Besides curiosity driven enquiry and ‘student-centred’, learning was: challenging (but exciting); integrated (spiralling clinical and basic science together); about ‘critical self-awareness’; with and from others, as a group; and in context or relevant. From single mentions, the philosophy was: ‘encouraging thinking outside curricular confines’; ‘problem-based’; ‘intended to encourage deep learning’; ‘guided’; ‘adult professional learning’; ‘innovative’; and ‘experimental’.
Descriptions of three curriculum achievements ‘of which the institution should be proud’ focused on the product. Three tutors suggested well-prepared graduates to be ‘foundation year 1’ doctors (their pre-registration job). Receiving two tutor-mentions each were production of: independent learners/skilled thinkers; ‘lifelong learners’; good communicators and communications training; well-rounded fit-for-purpose doctors; and independent, questioning students, who queried procedures and instructions.
Demise [the end] of that curriculum: Reaction, reasons, missed actions
Showing their emotional investment, tutors reacted (with three words or phrases) to ‘the demise of the curriculum and its whole-system design’ with negativity, resignation, regret, relief, and optimism. One tutor reported ‘heartbreak, despair, and disappointment’. Another lamented ‘sadness’, ‘throwing out the baby with the bath water’, and ‘no recognition of past effort by those involved’. Another blamed misconceptions about: PBL costs; how to improve National Student Survey results; and adding more and more lectures. Nevertheless, two others felt relief: ‘no longer required to deliver it!’ and ‘[no longer having to try] to defend PBL to clinical colleagues’. The latter tutor was ‘resigned to the notion that it was becoming rather stale’ and was optimistic for subsequent improvements. Nevertheless, another mourned three losses: ‘team/groupworking’, ‘student-centred’, ‘coherence’.
Suggested ‘main reason(s) for the demise of that curriculum’ were perceived high costs (and that long-term investment did fall behind increased student numbers) and perceived acquiescence of leadership to vocal minority views not evidence-based rationale. Subsidiary suggestions were students protesting more about uncertainty in their learning (perceived as not matching the tuition fees or expectations from school experience), chasing National Student Survey results, increased research pressures on staff, losing high-level PBL champions to other institutions and relying on dwindling long-dedicated staff, and some clinicians undermining students’ knowledge.
‘Had the educational philosophy … been retained but with stronger, more consistent implementation, [three] actions that should have been taken’ generated three tutor-mentions each for:
selling the educational philosophy, rationale, and strengths better to doubters and stakeholders
engaging clinical or senior staff more meaningfully
resourcing and rewarding educational effort and specialist expertise better, consistent with curriculum recognition by external bodies.
A further ‘hidden curriculum’ insight
Re-reading their answer from two years previously and providing ‘a further insight now about hidden aspects of the curriculum that worked against (or for) the intended educational philosophy’, tutors highlighted negative staff, institution, or system factors, including disengagement and disinformation:
‘due to a sense of disengagement between medical school and clinicians: The first was the difficulty in encouraging clinicians to help with “non-clinical” learning, such as PBL, clinical skills, or assessment. The second was a cadre of people saying that the curriculum didn’t work and that students didn’t like it, despite the evidence to the contrary.’
Only three tutors mentioned student examples, and only in passing, i.e. being demanding because of tuition fees; being ‘prone to … doing the minimum required to pass the exam’; and ‘[creating, with staff, given lack of explicit curriculum] their own versions of reality … of what was needed (to become a doctor) and influenced by those in previous years’.
Considering ‘From your outlook now as an educator (or recent educator) of medical students, the legacy of the curriculum is …’, tutors suggested good, resilient graduates, against a backdrop of advances in assessment and educators’ understanding of education. They highlighted that, unfortunately though, staff and student engagement and satisfaction were increasingly polarized.
What this study adds and so what?
With substantial experience in a problem-based curriculum, these inaugural PBL tutors viewed their role through a more discerning, reflective, and constructivist (von Glasersfeld, 1989; Savery and Duffy, 1995) ‘good educator’ lens. They articulated principles for facilitating active learning rather than a mechanistic approach. They thus resembled Wilkie’s (2004) ‘nurturing socializers’ (i.e. supporting socialization of students into good professional practice) and ‘pragmatic enablers’ - and without ‘toxic facilitation’, which undermines and turns students off PBL. They described facilitating students creatively in directed self-learning to:
say what they already know, expand on it (explore, explain, use the board), study to fill gaps, link new with prior knowledge (and expound again), link different types of knowledge, and say why things are relevant to learn
work with the uncertainty, which Weurlander et al. (2019) view as integral to negotiating professional identity formation, whether about their own knowledge and capabilities or about the sometimes detached medical culture and system
reflect on how sessions go and how to improve
aspire to excellence.
Tutors were therefore: role-modelling the epistemology; actively engaging but ‘not teaching’; intervening (without knowing everything) for integration (synthesis, application); monitoring achievement of intended outcomes flexibly without stifling other learning; expecting high standards; and maintaining a safe learning environment. When and how to intervene in-session remained prominent, as found elsewhere (Haith-Cooper, 2003b; Lee et al., 2009; O’Doherty et al., 2018), but without previous angst. As Woods (1994) outlined about McMaster’s PBL, intervening in-session should ensure that students tackle the scenario well and reflect on and justify their assertions and assumptions (plus ensuring end-of-session reflection (Maudsley, 1999)).
Tutors’ understanding of themselves, i.e. their identity (‘who I am and who I want to be’, van Lankveld, Thampy, Cantillon, Horsburgh, & Kluijtmans, 2020, p. 1) as ‘good educators’, was expressed confidently in constructivist epistemology, but collective concern emerged now about educational governance to maintain and quality-assure curriculum whole-system integrity. All were substantive staff (rather than the potentially underused resource (McLean & Arrigoni, 2016) of the latter-day sessional tutors). They were educationally literate and strategic about organizational structure and culture, recommending: transparent costing; challenging the hidden curriculum with transparency and better communication of the educational philosophy; and investing in well-selected tutors and a strong infrastructure of well-designed trigger-materials and supporting resources. They highlighted two domains that Hafferty (1998) considered worth exploring for hidden curriculum conflict: policy (‘rules of the road’, p. 404, as one tutor explicitly mentioned) and resource-allocation. They implied that a more consistent student experience (Maudsley et al., 2008) and a better change management strategy might have engaged stakeholders better with the evidence-based rationale, rewarded the educational expertise required, and embedded sustainable curriculum renewal.
With longevity, these tutors still defended the rationale behind a fading but evidence-based innovation that merited reinvigoration not replacement. Some were weary of continually countering erosion of its educational philosophy. They conveyed emotional and professional investment and ‘authentic pride’ (Tracy & Robins, 2007) in student achievement, with accomplished graduates being a worthwhile legacy. The tutor who now recalled PBL being so draining as a novice echoed a colleague in the 1997 study (Maudsley, 2002, p. 165): ‘very difficult to get down to concentrating on anything else like writing a paper after [PBL] … You’re just in a totally different mode’. Staying on-task in PBL tutoring can be very tiring and emotional, requiring specific attention in tutor development (Bowman & Hughes, 2005).
The tutors’ perceived progress corresponds with evidence from elsewhere about PBL tutors gaining role-confidence with experience. O’Doherty et al.’s (2018) experienced tutors reported better facilitation of group dynamics and student engagement, e.g. countering student attempts to short-circuit active learning from using official learning objectives rather than generating their own. Slattery and Douglas’s (2014) experienced tutors understood better the PBL philosophy and need to ensure participation (in a speech-language pathology Master programme). Liverpool tutors conveyed a similarly supportive (process-orientated) role to the seven Linkoping PBL tutors in environmental science in Dahlgren, Castensson, and Dahlgren’s (1998) phenomenographic interview-study. Hendry’s (2009) 29 PBL tutors of Sydney medical students viewed their role as educators in increasing order of complexity, as: facilitating equal contribution; guiding in the right direction, following steps; facilitating easier learning to achieve intended objectives; and guiding high-quality learning, thinking, and reflection. These Liverpool tutors now particularly conveyed the last of these.
Strengths and limitations
A study strength was gaining rich insight from all inaugural PBL tutors who were still immersed in the curriculum at lengthy follow-up. Revisiting their own novice words prompted exploration of their development of expertise (Dreyfus & Dreyfus, 1984). Semi-structured interviews allowed much probing and clarification (Hinton & Ryan, 2019; McGrath, Palmgren, & Liljedahl, 2019). Further reactive follow-up elaborated the story in the context of curriculum replacement. Even the basic e-questionnaire allowed meaningful continuation of topics from two years previously. While evaluation surveys of tutors’ views of how PBL fares in health professions education are informative (Galukande et al., 2015), exploring how tutors conceptualize their experience requires such qualitative research.
Exploring pride arguably used a vicarious, curriculum-focused, and open-item version of such Ipsos MORI-style questioning as ‘Which… of the following [characteristics] makes you most proud …’ (2016). The focus was on curriculum achievements though rather than its being, i.e. akin to ‘authentic’ rather than ‘hubristic’ pride (Tracy & Robins, 2007). It seemed important to acknowledge the generally sombre and apprehensive mood amongst such long-serving educators during curriculum replacement, hence exploring reactions to, reasons for, and ways to have avoided this demise. This reflected the zeitgeist of their (our) everyday practice, not a preformed agenda or feigned ‘objectivity’. Questioning and clarifying iteratively by e-mail, i.e. ‘the E-interview’ (Bampton & Cowton, 2002), suited these busy staff, compensating for potential loss of data-richness. Posing all questions together was risky but allowed cross-linking between answers and simultaneous progression of all E-interviews, which also self-transcribed.
Despite this being a one-institution and one-curriculum study, these educators highlighted challenges that many other curricula, disciplines, and settings encounter. Having a PBL tutor colleague as sole researcher allowed rich discussion with these educators, but potential perils accompanied such positionality. Using a clear topic guide and contemporaneous notes (to clarify key points in-session) improved credibility of interpretation. While data interrogation by a lone researcher might challenge dependability, more important might be data immersion, seeking alternative interpretations conscientiously and systematically, and transparent reporting (Barbour, 2001). Subjecting early extracts to wider scrutiny at several conferences contributed alternative perspectives.
Reporting contradictory exceptions (not just prominent views) also enhanced confirmability of findings. Although quantifying instances in small qualitative research samples can be criticized, it can supplement the emerging picture and acknowledge ‘multiple audiences’ (Dutton, Ashford, O’Neill, & Lawrence, 2001; Hannah & Lautsch, 2011; Monrouxe & Rees, 2020; Pratt, 2008). The sample size appeared sufficient for ‘cross-case generalities, [not] being bogged down in data, and permitting individuals … a defined identity’ (Robinson, 2014, p. 29).
Implications for broader practice
These educators expressed an identity of both their ‘being’ and ‘doing’ (van Lankveld et al., 2020) from long-term socialization into the active learning system of this innovative curriculum. Emotional attachment to their self-understanding and their perceived shaping by the sociocultural context were evident. Sharing their personal epistemology and strategic insights should inform educator development in other settings, prompting critical reflection on ‘the good educator’ identity, the related enthusiasms, discomforts and uncertainties, and the impact of curriculum shifts.