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IS A BRIEF TUTOR TRAINING COURSE ADEQUATE?
HOLMBERG-MARTTILA, Doris & HAKKARAINEN, Kati & VIRJO Irma
Medical School, University of Tampere, Finland
ABSTRACT
The Medical School at University of Tampere has implemented a problem-based learning (PBL) method in undergraduate medical curriculum since 1994. In the beginning the tutors were trained by experts from McMaster and Maastricht Universities, and also from the Faculty of Education in Tampere University. As the experience in tutoring increased, the faculty decided to take the responsibility for basic tutor training. A first-degree tutor-education program consisting of two half-day introductory workshops has been developed. The course has been planned so practical-oriented that every medical faculty member has an opportunity to carry it through.
The aim of the study was to evaluate the adequacy of this training by observing how well tutorials adhere to the principles of problem-based learning.
Three tutor trainers observed nine tutorial groups’ sessions using a follow-up form in 1999. All interventions of the tutor were registered. Furthermore the tutors’ and the students’ experiences were asked by questionnaire.
Five groups applied the Linköping model, three applied it partly and only one group hardly at all. However, in every group systematic analysis and processing of knowledge could be seen. The variation between tutors was big. The interventions were mainly questions (0-24/tutor), but there were almost as many direct answers (0-35/tutor). The observers judged the tutors’ interventions to be mainly appropriate. All tutors and 91 % of the students reported that the information review succeeded well or moderately well, while 9 % of the students thought that there were shortcomings in this phase.
The teachers were mainly physicians without any pedagogical training. The brief intensive course given by experienced peers seemed to ensure sufficient basic readiness to act as a tutor. The need for further tutor training was also recognised.
INTRODUCTION
The Medical School at University of Tampere has implemented a problem-based learning (PBL) method in undergraduate medical curriculum since 1994 (Hakkarainen, 2000). The first three and a half study years consist of integrated blocks in which biomedical and clinical sciences and public health are studied together with social and behavioural sciences. During the first 3-week block “Introduction” students are also introduced to PBL method. In the remaining two and a half years the students work in clinical wards. Their studies have been organised into integrated entities covering a whole study year.
In the first years of PBL the tutors were recruited from among volunteer faculty members who were especially interested in the work. These faculty members were already learning the method during the traditional curriculum in a three-year problem-based study block “Early Clinical Studies” in 1991-1994. They were initially trained in courses on PBL given by experts from the Medical Faculties of McMaster and Maastricht Universities. The Tampere Medical Faculty also obtained practical and theoretical advice from the Faculty of Education in Tampere University. As the number of practical PBL courses given and experience in tutoring increased, the experienced tutors decided to take the responsibility for tutor training and started to call themselves tutor trainers.
At present, the training programme begins with a two-half-day introductory workshop for all new teachers (Tutor Training I), which initiates them into educational principles and their application in the new program. Two of the trainers run the workshop. First the curriculum design is shortly described. The main principles of PBL and how to apply it using the Linköping model is presented. The trainers simulate a tutorial with participants playing the role of students in small groups led by one of the participants. Two different cases are with. The experiences are discussed and evaluated. The main principles of working with a small group are described. At the end there is a “question hour” where the participants can ask anything about work as tutor with a student group. And finally there is a discussion evaluating the workshop. This course is run each semester. Tutor Training I is obligatory for all those who wish to act as tutors, and after the course most of the new teachers begin to act as tutors. Moreover, at the end of each semester there is a feedback session (Tutor ventilation) where the staff is able to share their experiences.
The role of the tutor is essential to the success of the learning process (Moust, 1990, Schmidt, 1995, Wetzel, 1996). Research on effective tutor behaviour has focused particularly on the expertise of the tutor and its effects on student achievement (Schmidt, 1994). Only a few studies have identified important dimensions of tutor performance, which stimulate student learning. PBL requires the medical teacher to use facilitating and supporting rather than didactic, directive skills (Bligh, 1995). The tutor should facilitate the group’s self-directed generation of learning objectives from triggers in successive case scenarios (Maudsley, 1999). A tutor stressing the learning process in the tutorial group is seen to be as more effective than a tutor stressing content (De Grave, 1999). Also students expect a tutor to possess group-dynamic skills (Dolmans, 2001), and to be a skilled group facilitator who would guide them in their learning while helping to maintain a positive group climate (Kaufman, 1996). They do not want the tutor to teach content, as they perceive the task of learning to be their responsibility (Virtanen, 1999, Kaufman, 1996).
When the curriculum is totally changed from lecture-based teaching to student-centred learning, every teacher has to change her/his mode of action (Wetzel, 1996, Holmes, 1994). In many universities teachers undergo elaborate tutor study programmes of lectures on educational sciences, practical teaching sessions, seminars and workshops lasting months (Holmes, 1994, Vu, 1997, Hewson, 1999). In our medical school we would not have enough tutors if this kind of programme would be the prerequisite to act as a tutor. Thus we chose the approach using a short introductory course whish is possible for all medical teachers. Only a few faculty development programmes have conducted comprehensive evaluations and many of them lack clear objectives and criteria to define good teaching and tutoring (Nayer, 1995, De Grave, 1998).
The aim of our Tutor Training I course is that after it the teachers have basic knowledge about PBL method and model of tutor session applied in our school, and have readiness to act as tutors in real PBL groups. The purpose of the present study was to evaluate the adequacy of the course by observing how well tutorials adhere to the principles of PBL at the beginning of medical studies when students have also been initiated into the methods of PBL work. This paper describes the interaction and the utility of a systematic PBL method in the first-year medical tutor groups and the role of tutors in these respects.
MATERIAL AND METHODS
Three tutor trainers (the authors) followed up first-year tutorial groups in the Medical School in Tampere. Each followed single-handed one session of one group. In 1999 there were 80 first-year students, 30 male and 50 female, grouped into ten tutor groups. Due to practical problems the follow-up of one group could not be arranged. In the nine tutor groups observed there were present altogether 67 students; 6 in one group, 7 in three and 8 in five groups.
The follow-up was carried out during autumn 1999 in the middle of the block “The Cell”. This block follows the initial three weeks’ introduction to the principles and training of PBL. Its duration is eight weeks. The main objectives are to study the structure, function and regulation of cells. The groups met with a tutor twice a week for approximately two hours per a meeting.
To make the evaluation structured and provide a possibility to compare results we developed a follow-up form. One further purpose of the form was to help the observer to give feedback to the group and to the tutor at the end of the tutorial. In the form all important elements in a tutorial session were asked using structured and open questions. In our medical school the tutorial sessions followed the model used by the University of Linköping (Hard af Segerstad et al. 1997) to give an explicit framework to the tutorial. In practice, the group discussion was guided in 5 phases: brainstorm, review of the existing information, identification of learning objectives, self-study between tutorials and students’ review of the information gathered in the tutorial group. In the follow-up form, student participation, interaction, discussion of learning issues, the action of the tutor, student chairman and secretary, and the application of the Linköping model were grouped according to the course of the tutorial. The number and quality of all interventions of the tutor were precisely registered.
Moreover, at the end of the follow-up tutorial the tutors received a questionnaire mapping out their experiences and opinions using structured and open questions. The students were also given a questionnaire inquiring into their preparation for the tutorial session and an opinion of the session using structured and open questions. Finally, the observer provided informal feedback to the tutor and the group at the end of the session and privately to the tutor after the session.
RESULTS
The characteristics of the tutors according to faculty information are reported in Table 1. According the questionnaires, four of the tutors considered themselves to be content experts on the block, two almost expert and three non-experts. Only one of the tutors reported that he/she had made no study whatsoever of the medical substance of the block beforehand. Three tutors had done a great deal of work on it. All students reported that they had done their homework and were prepared for the tutorial; 37 % of them thought they had studied the learning issues well enough.
The observers considered the student participation to be uneven in almost every group: in 8 groups during the review of the information gathered, in 6 during the brainstorm phase and in 5 during the phase reviewing the existent knowledge and generating the learning issues. The actively participating students were the same during all phases of the tutorial in all groups observed. None of the students dominated. Four students subsequently reported that they did not have an opportunity to say everything they would have wished. There were withdrawals from the discussion in seven groups during the review of the information gathered, in six during the brainstorm phase and in reviewing the existent knowledge.
The observers felt that the students in all nine groups discussed matters with each other; none of the discussions was tutor-centred. According to the questionnaire, the students’ opinion was that the interaction in the group was moderate (37 %) or good (63 %). Correspondingly, one of the tutors described the interaction as poor, five moderate and three good.
Five groups applied the Linköping model, three applied it partly and only one group hardly at all. However, in every group systematic analysis and processing of knowledge could be seen; abundantly in 5 groups and in some extent in 4 groups. All except one group recorded the learning issues on the board, but all students felt they were very well aware of them. All groups had one student as a chairman, whose role was active. The chairmen mainly started up the conversation, but four also gave attention to the phases of the Linköping model and one to balanced participation. All groups had also one of its students as secretary, but two did not take any notes. Three secretaries made copious notes.
The observers described the tutors as facilitators of a safe and calm learning climate in seven cases, as solely authoritative in one, and clearly inspiring in one case. The tutor was too dominant during the review of gathered information in two groups and during the brainstorming phase in one group. The individual variation between tutors in the number and style of tutors’ interventions was big (Table 2). The interventions were mainly questions, but there were almost as many direct answers, and even a considerable amount of lecturing. The observers judged the tutors’ interventions to be mainly appropriate. However, the majority of the interventions dealt with the substance of the learning issues and were made during the brainstorming phase and the review of knowledge gathered. Only three tutors paid attention to the PBL model itself or to group dynamics. Only a few interventions were made during the review of existing knowledge and when learning objectives were formulated (Table 3).
In the written questionnaires filled after the tutorial session two tutors felt that they had made too many interventions and one too few. All tutors and 91 % of the students reported that the information review succeeded well or moderately well, while 9 % of the students thought that there were shortcomings in this phase. One of the tutors and 16 % of the students thought that the phases leading to the definition of the learning goals did not go well. One tutor and four students felt that the case itself was not optimal for the purpose. All the observers agreed that some of the cases were too difficult, too specific and had little contact to students’ existing knowledge, and this giving cause for tutor intervention.
DISCUSSION
By observing the tutorial sessions we sought to evaluate the quality of them and adequacy of tutor training in our faculty. We wished thereby concomitantly to emphasise to tutors and students the importance of the tutorials. Interestingly, the opinions of tutors and students as to the success of the tutorials were much more positive than those of the observers. On the whole, both tutors and students seemed to try to adhere to the principles of PBL. The students’ preparation for the sessions and participation in discussion was good. The interaction was not tutor-centred, indicating that the students had realised their own responsibility in the learning process, which supports our previous findings (Virtanen, 1999). Tutors for the most part refrained from teaching or lecturing. We saw systematic analysis and processing of knowledge in every group, although the Linköping model was not strictly applied. At the end of tutorials all students were clearly aware of the learning issues.
There were nonetheless obvious shortcomings in group work. Most of the tutors’ interventions dealt with matters of content. Interventions were made during the brainstorming phase and review of information gathered, only a few during the review of the existing knowledge and formulation of the learning issues, when they should be more appropriate and expected. However, although the interventions were mainly questions, there were many direct answers, and there was even a great deal of lecturing. Many tutor interventions during brainstorming, the content orientation and tendency to offer answers in interventions are against the principles emphasized in the tutor training course. Keeping in mind that the bookkeeping system of the observers was to draw a vertical line with every intervention and thus somewhat inaccurate, we conclude that the main reason for these abundant interventions was the tutors’ still too traditional conception of their role, attending mainly to the content of the block. This phenomenon is probably quite common. In a study by Kaufman (Kaufman, 1998) less than half of their tutors reported that they almost never presented / explained case content.
One obvious explanation for the tutors’ content-centred interventions is their expertise. Tutors who are content experts find it difficult to maintain the facilitator role (Kaufman, 1998). Tutors with expertise tend to take a more directive role in tutorials: they speak more often and for longer periods, provide more direct answers to students’ questions, and suggest more of the topics for discussion (Silver, 1991). The fact that the tutors in the present study reported having studied the substance beforehand indicates a misunderstanding of the role of the tutor. Moreover, the tutors in the cell block were in any case content experts.
In general, tutors at Tampere Medical School are not expected to be content experts, as this responsibility is filled by other teachers via lectures, group work and exercises; and also as members of a group that plans a study block. This planning group prepares the cases and advice to tutors. This advice should give a medical teacher enough information for to function as a tutor. The strategy of our medical school in recruiting tutors is presently that every department has an obligation in relation to the number of its members to provide the tutors needed for the semester. Teachers can independently select the blocks according to their preferences.
In our study, only three tutors paid attention to the PBL model itself. To our knowledge there is no research on how the used PBL model contributes to learning. Anyway according to our experience there should be a structure in the work of a PBL group. Discussing something connected with the problem at hand cannot be regarded as PBL learning. PBL, above all, should promote the activation of prior knowledge and its elaboration, and the processing of new information, which is indeed facilitated by discussion (Schmidt, 1993). Thus, PBL emphasises the tutor’s role in facilitating collaborative and integrated learning.
In present study three tutors paid attention to group dynamics; no-one interfered in the work of the secretaries. This, however, would have been necessary since the observers noted uneven participation and rather passive and non-productive secretaries in the groups. The distorted quality and distribution of tutor interventions may also be largely due to the cases used, as all observers and some tutors and students pointed out. This undoubtedly leads to a situation where the tutor must intervene and be particularly active in order to lead the group forward. Planning of problem cases is prerequisite to the success of tutoring and tutorial work (Dolmans, 1993, Mpofu, 1997). In our medical school the faculty nominates for each integrated block a planning group, which includes several experts from different medical fields. The purpose of the group is to agree on the objectives and contents of the block, and among other things plan cases and guidelines for tutorials. To render the case problems more suitable for the Linköping model, we recommend tutor training be obligatory for all teachers in the faculty even when they do not intend to act as tutors. Moreover, the planning groups should better inform the tutors about cases and case objectives (Eagle, 1992).
The Tampere Medical Faculty has developed a short first-degree training program. It consists two half-day workshop and is obligatory for all tutors. This is a conscious strategy intended to underline the need for professional competence to act as a tutor. The teachers are usually physicians without any pedagogical training. With this in mind, the course has been planned to be so practical-oriented that every busy medical faculty member, regardless of other responsibilities, has an opportunity to carry it through. According to the observation of tutorials this kind of short intensive tutor training seems to ensure sufficient basic readiness to act as a tutor. Adults learn at work by experience, reflection, abstraction and experimentation (Knowles, 1980, Mezirow, 1981, Schon, 1983, Whitman, 1996). However, we also recognised the need for further advanced tutor training, an observation which supported our pre-existing impression. Topics requiring more attention might include: questioning techniques and facilitation of small group work, particularly how and when to intervene. We found observation to be such a good learning experience that it can be used in developing a strategy for tutor training. Moreover, there is an indisputable need for training in devising good cases.
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PBL IN CONTEXT – BRIDGING WORK AND EDUCATION
International Conference on Problem-Based Learning, 9-11 June Lahti, Finland
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