Problem based learning in Italian universities
10.14601/TUTOR-15828
The goal of this paper is to describe how the educational approach called “Problem based learning” is applied in Italian Universities. First we define what Problem based learning is, when it was introduced into the University programs, how it was disseminated all around the world, which are its methodological characteristics and the underlying theoretical principles.
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1971-8551
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Antonella Lotti
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medical education
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2019-07-30
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Antonella Lotti
2015/03/12
10.14601/TUTOR-15828
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1971-8551
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medical education
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https://ojs.unito.it/index.php/tutor/article/download/4842/4425
15
tutor                                                                                                     Vol. 15, N. 1, 2015: 5-12
                                                                                                       DOI: 10.14601/Tutor-15828



           Problem based learning in Italian
           universities
                   Antonella Lotti
                   Dipartimento di Scienze della Formazione, Unversità di Genova. E-mail: Antonella.lotti@unige.it




        ABSTRACT
        The goal of this paper is to describe how the educational approach called “Problem based learning” is ap-
        plied in Italian Universities.
        First we define what Problem based learning is, when it was introduced into the University programs, how
        it was disseminated all around the world, which are its methodological characteristics and the underlying
        theoretical principles.

        Key words: problem based learning, medical education, instructional methods

        RIASSUNTO
        L’apprendimento basato sui problemi, problem based learning o PBL, è un metodo formativo introdotto nel-
        la Facoltà di medicina di McMaster University nel 1971 da Howard Barrows. Da allora ha creato una sorta
        di rivoluzione nel mondo accademico mondiale. Anche in Italia è stato introdotto in numerose università,
        in corsi di formazione per medici e infermieri, sino dalla fine degli anni Ottanta. Questo lavoro delinea le
        caratteristiche del PBL nella sua formazione autentica, evidenzia gli aspetti teorici partendo da John Dew-
        ey a Howard Barrows e Henck Schmidt, tratteggia i cenni storici, offre una panoramica delle riviste, dei
        congressi internazionali e della cattedra UNESCO dedicati al PBL. Illustra brevemente le sperimentazioni
        attuate in alcune università italiane: il Curriculum Parallelo Sperimentale del corso di laurea in Medicina
        dell’Università di Bari, il Curriculum Parallelo della scuola per infermieri di Foligno, il Canale Parallelo Ro-
        mano dell’Università La Sapienza di Roma, l’esperienza ancora attuale del Campus biomedico di Roma per
        la formazione di ingegneri, medici e infermieri, la sperimentazione al primo triennio dell’Università di Siena,
        il corso di infermieristica dell’Università di Genova, il master in management sanitario dell’Istituto Superi-
        ore di Sanità, la sperimentazione nel corso di laurea di scienze della formazione dell’università di Foggia, la
        doppia esperienza del polo Humanitas dell’Università di Milano: il corso in italiano e il corso in inglese della
        International School of Medicine in Milan.

        Parole chiave: PBL, educazione medica, strumenti didattici




        1. INTRODUCTION                                                 First of all we will try to define what Problem based
        The goal of this paper is to describe how the edu-              learning is, when it was introduced into the Univer-
        cational approach called “Problem based learning”               sity programs, how it was disseminated all around
        is applied in Italian Universities.                             the world, which are its methodological character-




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           © Firenze University Press      ISSN (print) 1971-7296
           http://www.fupress.com/tutor   ISSN (online) 1971-8551
  tutor Volume 15, Numero 1, aprile 2015

                   istics and the underlying theoretical principles.          All around the world many medical schools tried to
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                   We also will try to identify how it is applied at the      convert their curriculum into a problem based one.
                   Italian University level.                                  In 1979 World Health Organization (WHO) facili-
                                                                              tated the creation of “The Network of community
                                                                              oriented educational institutions for health” which
                   2. THE ORIGIN OF PBL BY HOWARD                             grouped many schools of medicine, in each conti-
                   BARROWS                                                    nent, which were community-oriented and used
                   Problem based learning as a distinct educational           problem based learning as their main instructional
                   concept had its origins in the field of medical ed-        method.
                   ucation in the 1960s. At that time, clinical medi-
                   cal educators at McMaster University in Ontario,
                   Canada, became increasingly concerned with stu-            3. PBL AT THE INTERNATIONAL
                   dents’ ability to recall and apply in clinical settings,   LEVEL
                   biomedical content knowledge and skills taught in          In 2000 The Network was transformed in “The
                   previous biomedical coursework [1].                        Network: Toward unity for health” that today
                                                                              counts over 200 member institutions, organizations
                   In 1968, 4 years before the first class entered the new
                                                                              and individuals, with the vast majority from devel-
                   medical school at McMaster University, its educa-
                   tion committee undertook the design of the school’s        oping countries. The latter sought collaboration
                   curriculum. The physician who was the initial chair        with their health systems to adapt and integrate
                   of the committee indicated that all members were           health personnel’s education and health services
                   “frustrated with some aspects of traditional medical       in order to improve the health of the communi-
                   education…” (Spaulding 1991). Students were passive        ty. TUFH members also explore innovative educa-
                   and exposed to too much information, little of which       tional approaches (e.g. community-based education
                   seemed relevant to the practice of medicine. They
                                                                              and problem-based learning) to fulfil this mission.
                   were bored and disenchanted when medical education
                   should have been exciting. The committee noted that        Among those institutions we also find Harvard
                   medical education didn’t become exciting for students      University.
                   until residency training, when they were working with      Nowadays many Universities use PBL at the inter-
                   patients trying to solve their problems. They decided      national level; In particular in Europe there is an
                   that from the beginning of school, learning would oc-      UNESCO Chair for PBL, which is hosted by the
                   cur around a series of biomedical problems presented       University of Aalborg in Denmark, that organizes
                   in small groups with the faculty functioning as “tutors
                                                                              workshops, research activities, a Masters program,
                   or guides to learning”. No background in educational
                   psychology or cognitive science guided them, just the      and also a biennial research symposium on PBL.1
                   expressed hope that students would be stimulated by        Other conferences dedicated to PBL are the Inter-
                   this experience, would see the relevance of what they      national problem based learning symposium, held
                   were learning to their future responsibilities, would      every 2 years in Singapore, and the Pan-American
                   maintain a high degree of motivation for learning, and     Network for PBL that is held in North and South
                   would begin to understand the importance of respon-        America every 2 years.
                   sible professional attitudes. In this way, problem-based
                                                                              There are also 2 Journals dedicated to Prob-
                   learning, as a defined curricular method, was born
                   over 3 decades ago. [2].                                   lem-based learning:

                   The McMaster experiment was successful and
                   provoked a small revolution in the community of
                                                                              1   The first research symposium on Problem Based lear-
                   medical schools all around the world. Some new-
                                                                                  ning was held in Aalborg in 2008, the second one was
                   ly-established Universities in Europe adopted the              held in Melbourne, Australia in 2009, the third one
                   PBL method: the university of Limburg in Holland in            was held in Coventry, UK, in 2011. The following one
                   1972, the University of Aalborg in Denmark and the             it will be held in Kuala Lumpur in Malaysia next 3-4
                   University of Linkoping in Sweden in 1974.                     July 2013.




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                                                                       Problem based learning in Italian universities



1. Interdisciplinary Journal of Problem-based learning       lations, virtual reality, human simulations, models,
   which was launched in 2006 and published by               and actual problems.
   Teaching Academy at Purdue University, School
   of Education, University of Indiana, USA and in
   2010 jointly by the University of Memphis. The            Definition of tutor
   journal is an online, peer-reviewed publication,          The key idea is that the teacher in the tutor’s role is
   offered to the educational community as an                that of a facilitator or educational guide for learners
   open-access journal.                                      in aPBL. The tutor provides guidance as needed,
2. Journal of problem based learning in Higher Educa-        allowing the learners to assume responsibility for
   tion which will be launched in 2013 and published         the learning process and or their own learning. [2].
   by Aalborg University.                                    The tutor has the responsibility to guide learners
                                                             through all the phases of a PBL unit, to probe learn-
                                                             ers’ knowledge and understanding to be able to
4. THE AUTHENTIC PBL AND ITS                                 judge learners’ strengths, weaknesses and progress,
CHARACTERISTICS                                              to monitor and manage the group’s interpersonal
Before describing how PBL is applied in Italy, I would       dynamics, to encourage learners to take on respon-
like to give you a very short description of what            sibility for their own learning and evaluation. Mc-
PBL is, which are its main characteristics and its           Caughan pointed out similarities between Barrows’
underlying theoretical principles according to the           principles for the PBL tutor’s actions with Dewey’s
philosophy of Howard Barrows, who wrote a new                theories that address teacher behaviors and with
book in 2010 to re-define what authentic PBL is,             Carl Rogers’s conceptual frameworks that support
because he found that the application of his educa-          the therapeutic behaviors of the client-centered
tional approach, in some situations, showed some             therapist [3].
intended and un-intended “pollution” [2].
During the last decades, problem-based curriculum, as in-
troduced in its true state at McMaster University School
                                                             Definition of the educational setting
of Medicine in 1968, has mutated into many different         The common learning configuration in a PBL ses-
formats, each labeled as “problem based” or PBL. Most        sion is with a small group of learners, usually five to
of these mutations differ significantly from real prob-      seven, with a tutor. This allows the participants in
lem-based curriculum or problem based education [2].         the group and the tutor to get to know each other
                                                             as a team and adequate time for all the learners to
                                                             be able to express their ideas, knowledge and sug-
Definition of problem                                        gestions in the group [2].
In authentic problem-based learning, problems provide
the stimulus for learning. They are not narratives or case
presentations, but rather are presented to learners as
they appeared in the real work setting. They facilitate
                                                             Definition of evaluation
the development of problem-solving skills. They present      The key idea is that assessment drives learning. The
opportunities for the learners to acquire the integrated     assessment methods used in PBL need to measure
and relevant knowledge and skills needed for their next      learners’ progress towards achieving the outcome
stage of education or professional practice. Although        objectives, but in a way that is learner-centered and
written simulation formats are the cheapest and easiest      in the right context. The self and peer assessments
to create and to use, they have learning limitations that    carried out in the tutorial groups are complemented
need to be recognized. There are a wide variety of for-
                                                             by an end of unit formal assessment of the perfor-
mats that provide many advantages for the learner [2].
                                                             mance of the individual learners working with a prob-
The main formats are: written problems, prob-                lem. The pooled results of these assessment meth-
lem simulations, sequential management problem,              ods can assist in the evaluation of a curriculum [2].
problem-based learning module, computer simu-                Students are evaluated by formative and summative



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                   assessment. Assessment can be carried out within               solving. He further believed that learning should be
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                   the tutorial group to evaluate problem-solving per-            situated within the context of community. Interest
                   formance, self-directed performance and the per-               in such open inquiry, activity-based and integrative
                   formance as a member of the group. At the end of               approaches in our classrooms has grown in recent
                   the unit each student should be evaluated to verify            years. These types of approaches are sometimes
                   that she/he has also gained specific knowledge ap-             called constructivism.
                   plied to these problems.                                       Problem based learning may be one of the best ex-
                                                                                  emplars of a constructivist-learning environment [8].

                   5. UNDERLYING THEORETICAL
                   PRINCIPLES                                                     6. PROBLEM-BASED LEARNING IN
                   Barrows writes that:                                           ITALY
                                                                                  Problem-based learning was introduced in Italy in
                   There are many antecedents to problem-based learning
                                                                                  several Universities and in some schools of Med-
                   in the writings of Bruner, Gagne and Dewey and it is
                   logical to think that their work inspired its development      icine, Engineering and Education. In some cases
                   as an educational method in medicine in the late 1960s.        PBL was part of action-research, which lasted only
                   The roots of problem-based learning can be traced to           some months or some years. In other cases, PBL is
                   the progressive movement, especially to John Dewey’s           maintained as the main instructional method until
                   belief that teachers should teach by appealing to stu-         today.
                   dents’ natural instincts to investigate and create [4].

                   There is a common underline thread that links
                   together PBL with John Dewey’s book “How we                    1. University of Bari, School of Medicine
                   think”, cognitivism and constructivism.                        In 1988 the University of Bari started a Parallel
                   Hencke Schmidt, a Dutch cognitive psychologist,                track 2 , which was both community-oriented and
                   led many researches to provide empirical support               problem-based. A group of teachers, led by a char-
                   for the cognitive underlying bases in PBL [5, 6].              ismatic dean and a small group of Faculty members
                                                                                  who very motivated to introduce a reform in med-
                   Problem-based learning is a relatively new form of in-         ical studies, were trained by WHO Experts and
                   struction with a long intellectual history. Its roots in the   collaborating centers. They planned all the educa-
                   philosophies of rationalism and American functionalism
                                                                                  tional activities before starting the new program.
                   (Dewey 1929) clarify why this approach to learning and
                   instruction emerged in conjunction with the cognitive          Each academic year, the parallel track admitted 20
                   revolution in psychology. It is not purely coincidental that   students who attended a program, which was com-
                   McMaster University admitted its first batch of medical
                   students in its problem-based curriculum a year before
                   Ulric Neisser’s now classic book Cognitive Psychology was      2    Parallel Track is a an approach to change involving the
                   published (Neisser, 1967). We have argued that in PBL, a           establishment of an innovative curricular track as a
                   number of principles of learning are implemented, con-             curriculum distinct from, but running parallel with, the
                   sidered to be basic to many forms of human learning,
                                                                                      already existing curriculum. In 1987 WHO published
                   comprehension and problem-solving. These principles
                                                                                      an offset publication dedicated to 8 parallel tracks:
                   can be summarized as: prior knowledge, activation and
                                                                                      National Autonomous University of Mexico; Upper
                   elaboration through small-group analysis; the construc-
                                                                                      Pensinsula Medical education Program , Michigan
                   tion of problem-oriented semantic networks, includ-
                   ing contextual cues derived from professional relevant             State University, USA; University of the Philippines;
                   problems; and the fostering of epistemic curiosity [7].            MESRAP Program, Chulalongkorn University in Thai-
                                                                                      land; Primary Care Curriculum, University of New
                   During the Progressive Era, Dewey saw the tack-                    Mexico, USA; Alternative Curriculum, Rush Medical
                   ling of significant problems as the ultimate way to                School, USA; New pathway Program, Harvard Medi-
                   engage learners in meaning making and problem                      cal School, USA; Problem Based Curriculum, Shangai
                                                                                      Second Medical University, China [9].




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                                                                   Problem based learning in Italian universities



pletely integrated and interdisciplinary, organized      ability and paradigmatic interest of the conditions.
in several blocks. PBL, role playing, early contacts     The educational process comprised three main sec-
with patients and skills lab were the main educa-        tions: Introduction to Medicine (years I-IV), Clini-
tional methods. OSCE and written essays were the         cal Sciences (years II-VI), Clinical Clerkship (years
main evaluation methods.                                 V-VI).
The Experimental Parallel Curriculum of Bari was         The initial results showed that, in comparison with
the first Parallel Track in Europe and its activities    a Control Group of similar size and characteristics
were analyzed and published at national and inter-       (CPR/CG), CPR students did not get higher scores
national level. Unfortunately the premature death        at the Semester exams, but a significantly higher
of the Dean resulted in the end of this challenging      percentage completed them. Problem-oriented
experiment in 1995 [10].                                 learning and the use of clinical cases as triggers for
                                                         learning basic sciences were well accepted. The
                                                         identification of core contents represented a ma-
2. University of Perugia, Pole of Foligno,               jor difficulty for those involved in the curriculum
School of Nursing                                        planning [12].
In 1988 a pioneering regional school of nursing de-      The premature death of Professor Torsoli also end-
cided to introduce a parallel track which was com-       ed this parallel track.
pletely community-oriented and problem-based.
When the Italian law transformed the regional
school of nursing into undergraduate university          4. Campus Bio-medico, Roma
program, only the teachers of nursing kept the PBL       In 1993 the Bio-Medical Campus, a new private
in their educational activities while the majority of    university, was established in Rome and proposed
other teachers od basic and clinical sciences didn’t     two programs: undergraduate programs for medi-
adopt PBL [11].                                          cal doctors and for nurses. In 1999 they added an
                                                         undergraduate program for nutritionists and an-
                                                         other one for engineers. All the programs declare
3. University of Roma, La Sapienza,                      the adoption of small group activities and prob-
School of Medicine                                       lem-based learning. PBL is used also for inter-pro-
In 1993 The University of Roma La Sapienza de-           fessional education activities: students coming from
cided to introduce a Parallel Track, called Canale       Medical program and nursing program are divided
Parallelo Romano (CPR) an experimental under-            into small groups and together discuss clinical cases
graduate medical course. Prof Aldo Torsoli led the       according to the PBL seven jumps as described by
planning of this initiative and created a group of 50    Hencke Schmidt in 1983 [13].
teachers and 5 students. The Roman Parallel track
started in March 1995.
The CPR was intended to provide students with a          5. University of Siena , School of
basic bio-psycho-social professional profile, with a     Medicine
change in the learning approach (active rather than      A Problem-based Learning course based on small
passive), a training to practice evidence based med-     group technology started in 2001. Over 20 teachers
icine, knowledge and abilities adequate to pursue a      were trained as small group tutors by experts com-
supervised practice of medicine, as well as a positive   ing from Smith Kline Foundation, WHO collaborat-
attitude towards multidisciplinary and multi-profes-     ing center, and University of Sherbrooke, Canada.
sional cooperation.                                      The integrated course entitled “Interdisciplinary ap-
The project framework included problem-based             proach to medical sciences” (AISMe) had the follow-
learning and core curriculum. Core contents of the       ing educational objectives: to develop problem-solv-
curriculum were identified for clinical sciences ac-     ing, critical thinking and team work skills. Students
cording to the prevalence, urgency, severity, cur-       are divided in small groups of 10-15 persons; each



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  tutor Volume 15, Numero 1, aprile 2015

                   group meets once a week with two tutors. Each se-           In 2010 PBL was used also as a starting activity
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                   mester a group meets around 12 times. The group             in a Ph.D. program about Migrations studies and
                   discusses problems following the “seven jumps”              it worked very well because students come from
                   process. In the first meeting group, students discuss       different graduate programs (anthropology, geog-
                   according their prior knowledge, then they go for           raphy, psychology, sociology, education) and dis-
                   self-directed learning to acquire identified learning       cussion in a small group around an interdisciplinary
                   goals; in the second meeting point students summa-          case is very challenging and values the participants
                   rize newly acquired information.                            ‘prior knowledge and their different points of view.
                   In 2000 the course started as an optional one, in           Ph.D. students appreciated PBL method and now
                   2001 the course became compulsory and involved              it’s used once or twice each academic year.
                   30 teachers. The “Interdisciplinary Approach to             In 2012 two Faculty members from the Dental
                   Medical Sciences” lasted three years: in the first          medical School decided to use PBL with first year
                   year students discussed dilemma problems, in the            students. After this first offering it was decided to
                   second year students discussed problems aiming to           offer it to students as a completely problem based
                   identify and retrieve scientific literature; in the third   elective course.
                   year they discussed problems aiming to critical ap-
                   praisal of papers concerning the accuracy of diag-
                   nostic tests, therapeutics and meta-analysis.               7. University of Milano, School of
                   In 2008 the course was reduced to only one year             Medicine
                   [14].                                                       In 2003 a parallel track was created in the univer-
                                                                               sity of Milan’s School of Medicine. The Humanitas
                                                                               Hospital parallel track has been led by a group
                   6. University of Genoa                                      of teachers, educationalists and the Dean of the
                   In 2002 the University of Genoa’s School of Med-            School under the supervision of the University of
                   icine started a PBL program for nursing education           Maastricht’s Faculty of Health, Medicine and Life
                   which continues to this day. The coordinator of the         sciences.
                   Nursing Program decided to introduce PBL into all           In 2010 the parallel track was transformed into the
                   nursing disciplines in all the three years. Almost 90       International school of Medicine, is taught in English
                   students are divided in small groups and learn led          and is a very attractive to foreign students. Cur-
                   by a tutor across the entire 3 year curriculum. The         riculum is divided in several interdisciplinary blocks
                   curriculum is divided in blocks around health prior-        (introduction to medical professions, from atom to
                   ity problems, and PBL cases propose relevant situa-         cells, human body, mechanisms of diseases, func-
                   tions In 2006 PBL was introduced also into continu-         tions and others). The main instructional methods
                   ing education activities for health personnel. (15).        are problem-based learning, investigating complex-
                   More recently PBL is used also in a Master program          ity, communication skills activities, observations in
                   for managers of health services and into graduate           outpatient clinics and clerkships.
                   program for nurses.
                   Nursing teachers from University of Genoa train
                   their colleagues from the University of Parma who           8. University of Foggia, School of
                   are willing to introduce PBL in the Piacenza pole.          Education
                   In 2010 PBL entered also in the Faculty of education        In 2005 a group of 6 faculty members of the School
                   where it is applied in one course “Planning of edu-         of Education, University of Foggia decided to in-
                   cational services”, an elective course. In this case it     troduce PBL for their 6 disciplines (anthropology,
                   is applied the PBL format for a large class: students       children literature, adult education, pedagogy, cur-
                   are divided in small group of 6 people and they dis-        riculum studies). They planned an interdisciplinary
                   cuss with the supervision of the tutor who moves            block lasting 4 weeks, wrote 4 cases, divided 130
                   from one group to another.                                  students in 10 groups and led small tutorial groups,



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                                                                       Problem based learning in Italian universities



planned and implemented integrative activities such       REFERENCES
as workshop, study visits, planned and implement-         [1]    Barrows HS & Tamblyn RM. Problem-based learning. An
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and other two cases were added.                                  Springfield: SIU School of Medicine, 2010.
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about their experience [16].                                     clinical psychology in PBL tutor guidelines. Interdisci-
                                                                 plinary Journal of Problem-based learning. 2013, 7, Issue
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                                                                 1, article 4.
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strengthen health systems in an interdependent world”.           itarie. Milano:McGrawHill, 2007: 161-183.
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                                                                 mazione come alleanza. Roma: Ma.Gi., 2004.
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                                                                 di esperienza dell’AISMe (Approccio interdisciplinare




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  tutor Volume 15, Numero 1, aprile 2015
                        alla Scienze Mediche): un corso triennale a piccolo            gestione dei servizi sanitari. Problem Based Learning
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                        gruppi basati sull’apprendimento per problemi nel              e formazione personalizzata in un modulo didattico
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