1988; 68:522-527.PHYS THER. Harry V K Van LangenbergheProblem-based Physical Therapy CurriculumEvaluation of Students' Approaches to Studying in a

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Evaluation of Students' Approaches to Studying in a Problem-based Physical Therapy Curriculum

HARRY V. K. VAN LANGENBERGHE

The purpose of this study was to investigate the approaches to studying of first-and second-year students in a problem-based physical therapy program. The Short Inventory of Approaches to Studying was administered to 112 first-year students (66 female, 46 male) and 100 second-year students (62 female, 38 male). Ninety-nine first-year students and 88 second-year students responded to the inventory, representing a return rate of 88%. The results of both groups were compared. Further comparisons were made with reported normative inventory scores and with inventory results reported of first-year students in a medical problem-based school. All comparisons were made using two-tailed t tests. The inventory scores proved similar in both year groups of physical therapy students and were more desirable than the normative values. The first-year physical therapy students' scores were similar to those of the first-year medical students reported to be desirable. It was concluded that the physical therapy students possess desirable approaches to studying.

Key Words: Education: physical therapist, teaching methods; Learning.

Traditionally, physical therapy education has been based on the separate teaching of various disciplines. Increasingly, however, physical therapy educators have pointed out defi-ciencies in this curricular arrangement.1-5 The teaching fre-quently emphasizes the acquisition of large quantities of factual information, rather than critical assessment and ap-praisal of that information.1,6 The course content may not always be relevant to professional practice, and there may be little integration of subject matter. The students, thus, may have difficulty integrating information from various disci-plines. Additionally, evidence exists that students, when faced with large amounts of factual information coupled with a degree of perceived irrelevancy, may resort to rote learning or memorizing in an attempt to reproduce this information.7 Barr specifically pointed out that traditional forms of teaching fail to take into account the process of learning.1 The reported deficiencies may detrimentally influence students' approaches to studying, resulting in poor quality of knowledge.

Educational research has revealed numerous undesirable and desirable studying approaches. Rote learning is undesir-able because it can result in a superficial level of understanding and is considered detrimental to both the quality and the long-term retention of knowledge.7 Other approaches that are considered undesirable are a tendency to reach conclusions prematurely without sufficient evidence, an inclination to make implausible links between ideas, and a failure to seek relationships and analogies between concepts in the study

material. These approaches may impede the development of a comprehensive understanding of the subject matter.8 En-twistle notes that desirable approaches to studying include well-organized study habits, competitiveness, and a seeking of clues to what lecturers expect.9 Also desirable are efforts to obtain a general understanding of a topic by using analogies and examples, attempts to relate new information to knowl-edge already available, and a critical step-by-step examination of details and evidence. A combination of these approaches was found to enhance the quality and the long-term retention of what is learned9,10 and is reported to facilitate a deep level of understanding.9

Students' studying approaches vary widely among schools, depending on the learning environment.11-14 With regard to the quality of patient care, it is imperative that physical therapy students receive their training in an environment that facilitates desirable studying approaches, leading to the ac-quisition of a good quality of knowledge of a multidisciplinary nature with long-term retention and enabling them to contin-uously update their knowledge after qualification.

In medical education, problem-based curricula have emerged to provide such a facilitating learning environment. These curricula were designed as an alternative to the tradi-tional method of teaching, which was observed to have un-desirable effects on the way students learn.15,16 For similar reasons, problem-based (problem-solving) physical therapy curricula have been devised in the United States1,2 and in The Netherlands, where such a physical therapy program is cur-rently functioning in The Hague.6

PROBLEM-BASED LEARNING

The following description briefly outlines how problem-based studying is implemented in the preclinical part of the program at the physical therapy school in The Hague (the Haagse Academie voor Fysiotherapie). The description, which is based on my observations during a 14-day visit to the school

H. Van Langenberghe, BS, is Staff Physical Therapist, Physical Therapy Department, St. Joseph's Hospital, 555 E Market St, PO Box 1512, Elmira, NY 14902 (USA), and a doctoral candidate in life sciences, King's College London, University of London. He was a postgraduate student in rehabilitation studies at the University of Southampton, Hampshire, United Kingdom, when this investigation was conducted and Research Associate, Physiotherapy Re-search Unit, Physiology Department, King's College London, University of London, Strand, London WC2R 2LS, United Kingdom, when this article was written.

This article was submitted July 31, 1986; was with the author for revision 21 weeks; and was accepted June 10, 1987. Potential Conflict of Interest: 4.

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EDUCATION and on internal and external publications,3,6 was approved of by the school's educationist.

The first 2 years of the 4-year program are preclinical. They are followed by one year of clinical placements and then by half a year of preparation for the final examinations and the writing of a dissertation. Around 100 new students are admitted each academic year.

In problem-based education, the learning is structured around specific problems that the students study and must try to solve.15,16 In The Hague school, the problems take the form of case studies and are presented in a written or video-taped format. They comprise personal data, letters of referral, details of case history and clinical examination, and if rele-vant, radiographs and laboratory findings. After receiving the case presentation, students meet in small study groups (five or six people) to evaluate the information using the personal and professional knowledge they already possess. The students themselves determine what information must be gathered and studied to fully understand and solve the given problem. This information may be derived from the biomedical and behav-ioral sciences, as well as medicine and physical therapy.

A case study usually is completed within one week, and each study group generally is scheduled to meet three times during that period of time. In contrast to traditional curricula, no lectures are scheduled. It is the study group's responsibility to organize and define their own daily study activities and tasks. These activities may include consulting, on their own initiative, specialists among the college staff for specific help and information. The students may also gather information through library research, informative audiovisual media, and anatomical models. Hence, each study group may have a different itinerary each day. At the second group meeting, the information the students have collected is discussed, evalu-ated, and collated in the context of the problem case. If deemed necessary, additional information is subsequently sought. The third group meeting serves to revise the case and to devise a therapy program.

A tutor is present at each scheduled study group meeting. This tutor may be a specialist in any field, not necessarily in physical therapy. The tutor's task is not the teaching of a specialized subject, but the facilitation of an appropriate and systematic approach to the problem. The tutors regularly receive training to perform this task properly.

A final evaluation meeting is scheduled at the completion of the case study, when four or five study groups meet for a case evaluation session. The tutor present at this final gath-ering always is a physical therapist. A representative from each study group presents the group's approach to the case, the therapy program devised, and its rationale. Alternative approaches may be discussed. The tutor points out possible flaws and inconsistencies, corrects mistakes, and finally eval-uates the case.

During the course of the case study, the students also participate in scheduled practical classes in examination or treatment skills and may do various laboratory work. These "hands-on" sessions are problem-based in the sense that they focus on the case study problem of the preceding week. The students, thus, have the opportunity to integrate practical skills and knowledge into the theoretical construct they have developed. These sessions, which are compulsory, and the scheduled group meetings take up about one third of the time students generally spend on their studies.

Problem-based learning, such as that outlined above, is claimed to have educational advantages over traditional ways

of learning.1 -3,5,6,15,16 The relevance of what is learned is ar-guably self-evident because it is determined by what is needed to understand and solve real-life patient problems. Subject matter from many disciplines is studied and learned in an integrated manner, and students determine and implement their own learning tasks. These factors presumably facilitate desirable approaches to studying.

EVALUATION OF STUDENT LEARNING Evidence to suggest that problem-based curricula have ed-

ucational merit in terms of students' approaches to studying exists, but it is scarce. Coles found that medical students in a problem-based curriculum showed studying approaches su-perior to those of students in a traditional medical curricu-lum.1718 No study has been found in the literature addressing the studying approaches of students in a problem-based phys-ical therapy curriculum. Such an investigation might yield insight into the worth of problem-based learning for physical therapy education.

The purpose of this investigation was to evaluate the study-ing approaches of the first- and second-year students in the problem-based physical therapy curriculum in The Hague by means of the Short Inventory of Approaches to Studying.9 The results of both year groups were compared with each other and with normative inventory values published by Entwistle.9 In addition, the first-year physical therapy stu-dents' scores were compared with inventory results reported by Coles18 of first-year students in a medical problem-based curriculum.

METHOD

Subjects The target population consisted of all first- and second-year

students in the physical therapy school in The Hague at the end of the academic year. According to the school's admin-istration, the first-year class comprised 112 students (66 fe-male, 46 male) with a mean age of 19.8 years (s = 2.4 years) and the second-year class comprised 100 students (62 female, 38 male) with a mean age of 21.1 years (s = 2.7 years).

Instrumentation

The Short Inventory of Approaches to Studying, developed by Entwistle and colleagues,9 contains 30 statements con-cerned with how students perform everyday academic tasks and measures eight learning dimensions.919 The dimensions entailed were derived from findings of several independently working investigators and have been confirmed by cluster and factor analyses. According to its authors, the inventory's internal consistency, validity, and reliability have been shown to be satisfactory after studies involving more than 2,000 students of various disciplines and year groups in higher education.919 It has also been used in medical education to evaluate the studying approaches of medical students.17,20 The Appendix presents the inventory statements and identifies the statements belonging to each dimension.

The students rate their response to each statement on a five-point agreement scale (4 = definitely agree, 3 = agree with reservations, 2 = uncertain, 1 = disagree with reserva-tions, 0 = definitely disagree). Dimension scores are calculated by addition of the scores on the relevant statements, in accordance with instructions by the inventory's authors.9

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The eight dimensions are: Achievement Motivation. A high score is desirable and

indicates well-organized study methods, regular and efficient study habits, competitiveness, desire to achieve, and an awareness of implications of academic demands by staff members.

Reproducing Orientation. A high score is undesirable; it relates to a preoccupation with memorizing and an interest in the course only for the qualification it offers, with reliance on the syllabus and on staff members to define studying tasks.

Meaning Orientation. A high score is desirable and indicates efforts to understand the subject matter and relate new information with what is already known and a motivation fed by interest in the topics to study.

Comprehension Learning Style. A high score indicates an inclination to "map out" the subject area, to think divergently, and to interrelate ideas.

Operation Learning Style. A high score indicates an inclination toward emphasis on facts, logical analysis, and use of evidence to reach conclusions.

Versatility. A high score is desirable, indicating an ability to use and adequately vary learning approaches depending on the learning task. This ability includes efforts to understand the subject matter, to relate new information to what is already known, to interrelate ideas, to think divergently, to map out the subject area, and to use logical step-by-step analysis procedures.

Learning Pathologies. A high score is undesirable, indicating the presence of one or more of the following poor studying approaches: 1) an inclination to rote learning, 2) an overcautious reliance on textbook definitions and on details in the study material, 3) a tendency to prematurely reach conclusions, 4) an inclination to ignore pertinent details or to focus on irrelevant details, or 5) a tendency to generalize without sufficient evidence.

Prediction of Success. A combination of the scores on Achievement Motivation and Versatility minus the score on Learning Pathologies. A high score is desirable, indicating good overall studying approaches that make academic success likely.

Procedure

The inventory was administered at the end of the academic year and on the first day of a new case study to ensure that the optimum number of students were reached. The students were asked to respond to the statements anonymously, indicating only their year of study. They were urged to respond as accurately as possible within the 20-minute time frame allowed.

Data Analysis

I used the Statistical Package for the Social Sciences software program on a VAX 11/785 computer for the statistical analysis. Numerous comparisons were made, all by means of two-tailed t tests.

The mean scores and standard deviations were calculated separately for the two year groups for each dimension. The significance of the differences between the mean scores of the two year groups was tested.

In addition, statistical comparisons were made between results of the current investigation and inventory results of two investigations reported in the literature. The dimension scores from each year group were compared with normative

data obtained by Entwistle9 from 2,208 students of various disciplines and year groups in higher education. A curriculum-specific comparison was made between the first-year physical therapy students' results and scores from 70 students at the end of their first academic year in a medical problem-based school, reported by Coles18 as being desirable.

RESULTS

Ninety-nine first-year students and 88 second-year students responded to the inventory, representing a return rate of 88%. Table 1 presents the mean inventory scores and standard deviations from year 1 and year 2, as well as normative scores. No significant differences were found between the two year groups (p > .05). The comparison with the normative data shows that the first-year students' mean score on Achievement Motivation is significantly higher than the normative value (p .05), but that the second-year students' mean score is not significantly different from the normative value (p > .05). The scores from both year groups on Meaning Orientation are not significantly different from the normative value (p > .05). The scores from each year group on Reproducing Orientation, Operation Learning Style, and Learning Pathologies are significantly lower (p .05) than the normative values, but are significantly higher (p .05) on Comprehension Learning Style, Versatility, and Prediction of Success.

In Table 2, the scores from the first-year physical therapy students are compared with those from first-year medical students in a problem-based school. No significant differences were found (p > .05).

DISCUSSION

The comparison with the normative scores provides evidence that overall the physical therapy students in the problem-based program in The Hague possess more desirable studying approaches than a large sample of other students in higher education. The differences found are highly significant. The studying approaches are not significantly different between the two year groups of the physical therapy school. Also, the return rates are high, indicating that these approaches are a common feature in the first- and second-year groups in this school. In this context, it may be relevant that the school does not screen students for their studying approaches. In The Netherlands, aspiring physical therapy students apply for admission to a central admissions office. Students are accepted for admission on the merit of their high school qualifications and expressed geographical preference. Some students may have expressed a preference for the school because it offers a problem-based program. Interviews that I conducted with 15 randomly chosen students, however, revealed that only 3 had expressed a preference for this reason.

Relative to the normative values, the physical therapy students' scores can be interpreted as follows. The first-year physical therapy students' mean score on Achievement Motivation shows that they have better-organized study methods, work more regularly and effectively, and show more drive to achieve than a large sample of other students in higher education. The second-year physical therapy students' mean score on this dimension is exactly midway between the first-year students' mean score and the normative value and is not statistically different from either. A possible explanation for this finding is that the first-year physical therapy students are more eager and anxious to do well than a large sample of

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EDUCATION

TABLE 1 Inventory Results from Year 1 and Year 2 of the Physical Therapy School and Comparison Between the Two Year Groups and with Normative Values

Learning Dimension

Achievement Motivation Reproducing Orientation Meaning Orientation Comprehension Learning Style Operation Learning Style Versatility Learning Pathologies Prediction of Success

Physical Therapy

Year 1 (n = 99)

13.6 11.0 15.0 14.2 12.3 31.1 21.3 71.3

s

3.0 3.4 3.6 2.0 2.1 5.6 5.4

10.1

Year 2 (n = 88)

13.2 10.9 14.6 14.7 12.0 30.7 21.4 70.5

s

2.9 3.6 3.1 2.1 2.1 4.9 6.1

10.4

Normative Valuesa

(N = 2,208)

12.8 13.5 14.3 13.1 13.3 29.6 24.6 65.9

s

4.3 4.4 4.5 3.6 3.7 7.0 7.2

13.0

Pb

.42

.84

.42

.09

.37

.62

.92

.55

Pc

.01

with, whereas a problem-based program may encourage them to continue approaching their studies in a desirable manner. A recent evaluation at The Hague provides some support for this suggestion. Inventory scores from first-year students on their day of entry to the program and again at the end of the academic year were not significantly different, but in both instances desirable (J. H. M. Tromp, personal communica-tion, November 1986).

The inventory results reveal that the students in the prob-lem-based physical therapy curriculum demonstrate numer-ous capabilities that clinically and professionally may be of importance. Entwistle concludes from his own studies and those by others that the presence of desirable studying ap-proaches and the absence of undesirable ones are prerequisites for a deep and "holistic" level of understanding of the subject matter. This level of understanding, in turn, leads to relevant and comprehensive knowledge with long-term retention.9 It seems logical to infer that if physical therapists can retain a high quality of knowledge, the quality of their patient care may directly benefit. The students' interest, their ability to identify and define deficiencies in their professional knowl-edge, and their use of studying approaches that enable them to efficiently and successfully obtain the lacking information also may predispose them to becoming good "life-long learn-ers." This attribute seems essential to keep abreast of the profession's rapidly developing scientific knowledge and clin-ical methods. Good studying skills may help practicing ther-apists to update and enhance their knowledge and skills, which ultimately is of benefit to the patient. In addition, similar skills and aptitudes could be deemed essential prerequisites for potential researchers; their development early in their professional education may stimulate therapists to pursue vital research activities, thus contributing to physical therapy's body of knowledge.

Firm conclusions based solely on this investigation cannot be drawn. Additional comparisons of the studying approaches of students in problem-based and traditional physical therapy schools are needed. Also, it will be necessary to investigate whether graduates from problem-based curricula have supe-rior professional skills and knowledge compared with gradu-ates from traditional schools. A further question to address is whether physical therapists graduating from problem-based schools retain their studying skills and have less difficulty updating their knowledge than those trained traditionally. In the meantime, physical therapy educators may find it worth-while to evaluate this type of curriculum critically, because the potential advantages are of utmost importance for mem-bers of an expanding health care profession.

CONCLUSION

The results from this investigation indicate that the students in the problem-based physical therapy school in The Hague possess desirable approaches to studying. These approaches are similar to those of medical students in a problem-based curriculum and compare favorably with those of a large sample of students in other forms of higher education.

Acknowledgments. I am very grateful to Dr. Colin Coles for his permission to reproduce data from his doctoral thesis, to Dr. Hans Tromp for his assistance in this investigation, and to Christine Van Langenberghe-Zryd and Sue Carter for their critical comments.

REFERENCES

1. Barr JS: A problem-solving curriculum design in physical therapy. Phys Ther 57:262-270, 1977

2. May BJ: An integrated problem-solving curriculum design for physical therapy education. Phys Ther 57:807-813,1977

3. Rietmeijer EFH, Tromp JHM: Een nieuw onderwijsmodel aan de opleiding fysiotherapie in Den Haag. Fysiovisie, December 1982, pp 7-8 (Dutch)

4. Beenhakker JC: Deficiencies in physiotherapy education. South African Journal of Physiotherapy 42(2):37-39,1986

5. Olsen SL: Teaching treatment planning: A problem-solving model. Phys Ther 63:526-529,1983

6. Tromp JHM: Probleemgestuurd onderwijs. Fysiovisie, April 1985, pp 11 -13 (Dutch)

7. Marton F, Saljo R: On qualitative differences in learning: 1. Outcome and process. Br J Educ Psychol 46:4-11,1976

8. Pask G: Styles and strategies of learning. Br J Educ Psychol 46:128-148, 1976

9. Entwistle NJ: Styles of Learning and Teaching: An Integrative Outline of Educational Psychology for Students, Teachers, and Lecturers. Chiches-ter, England, John Wiley & Sons Ltd, 1981

10. Svensson L: On qualitative differences in learning: 3. Study skill and learning. Br J Educ Psychol 47:233-243,1977

11. Fransson A: On qualitative differences in learning: 4. Effects of motivation and test anxiety on process and outcome. Br J Educ Psychol 47:244-257, 1977

12. Laurillard DM: The process of student learning. Higher Education 8:395-409,1979

13. Ramsden P: Student learning and perception of the academic environment. Higher Education 8:411-428,1979

14. Ramsden P, Entwistle NJ: Effects of academic departments on students' approaches to studying. Br J Educ Psychol 51:368-385,1981

15. Barrows HS, Tamblyn RM: Problem-based Learning: An Approach to Medical Education. New York, NY, Springer Publishing Co Inc, 1980

16. Schmidt HG: Problem-based learning: Rationale and description. Med Educ 17:11-16,1983

17. Coles C: Differences between conventional and problem-based curricula in their students' approaches to studying. Med Educ 19:308-309, 1985

18. Coles C: A Study of the Relationships Between Curriculum and Learning in Undergraduate Medical Education. Doctoral Thesis. University of South-ampton, Hampshire, England, 1985

19. Entwistle NJ, Hanley M, Hounsell DJ: Identifying distinctive approaches to studying. Higher Education 8:365-380,1979

20. Newble Dl, Gordon Ml: The learning style of medical students. Med Educ 19:3-8, 1985

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EDUCATION

APPENDIX Inventory Statements and Identification of Statements Pertaining to Each Learning Dimensiona

1. I find it easy to organise my study time effectively. 2. I try to relate ideas in one subject to those in others, whenever

possible. 3. Although I have a fairly good general idea of many things, my

knowledge of the details is rather weak. 4. I like to be told precisely what to do in essays or other set work. 5. The best way for me to understand what technical terms mean is

to remember the text-book definitions. 6. It's important to me to do really well in the courses here. 7. I usually set out to understand thoroughly the meaning of what I

am asked to read. 8. When I'm reading I try to memorise important facts which may

come in useful later. 9. When I'm doing a piece of work, I try to bear in mind exactly wha

that particular lecturer seems to want. 10. I am usually cautious in drawing conclusions unless they are well

supported by evidence. 11. My main reason for being here is so that I can learn more about

the subjects which really interest me. 12. In trying to understand new ideas, I often try to relate them to

real-life situations to which they might apply. 13. I suppose I am more interested in the qualification I'll get than in

the courses I'm taking. 14. I'm usually prompt at starting work in the evenings. 15. Although I generally remember facts and details, I find it difficult

to fit them together into an overall picture. 16. I generally put a lot of effort into trying to understand things

which initially seem difficult.

17. I often get criticised for introducing irrelevant ideas into essays or discussions.

18. Often I find I have to read things without having a chance to really understand them.

19. If conditions aren't right for me to study, I generally manage to do something to change them.

20. Problems fascinate me, particularly where you have to work through the material to reach a logical conclusion.

21. I often find myself questioning things that I hear in lectures or read in books.

22. I find it helpful to "map out" a new topic for myself by seeing how the ideas fit together.

23. I tend to read very little beyond what's required for completing assignments.

24. It is important to me to do things better than my friends if I possibly can.

25. Tutors seem to want me to be more adventurous in making use of my own ideas.

26. I spend a good deal of my spare time in finding out more about interesting topics which have been discussed in classes.

27. I seem to be a bit too ready to jump to conclusions without waiting for all the evidence.

28. I find academic topics so interesting, I should like to continue with them after I finish this course.

29. I think it is important to look at problems rationally and logically without making intuitive jumps.

30. I find I have to concentrate on memorising a good deal of what we have to learn.

Achievement Motivation: 1,6, 9,14,19, 24 Reproducing Orientation: 4, 8,13,18, 23, 30 Meaning Orientation: 7,11,16, 21, 26, 28 Comprehension Learning Style: 2, 3,12,17, 22, 27 Operation Learning Style: 5,10,15, 20, 25, 29 Versatility: 2, 7,10-12, 16, 20-22, 26, 28, 29 Learning Pathologies: 3-5, 8, 13,15, 17, 18, 23, 25, 27, 30 Prediction of Success: Achievement Motivation plus Versatility minus Learning Pathologies

a Reprinted with permission of John Wiley & Sons Ltd.9

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