The small group in problem-based learning: more than a cognitive ‘learning’ experience for first-year medical students in a diverse population

Abstract

In problem-based learning (PBL) curricula, first-year students need to adapt to a new learning environment and an unfamiliar new pedagogy. The small-group tutorial potentially offers a learning environment where students can become self-directed learners, collaborating with other group members to achieve individual and group learning goals. At the end of the first six-week theme in a relatively new PBL curriculum, new medical students were canvassed about coping with PBL (self-directed learning; content; time management; resources) and the value of the small-group tutorial, the latter of which is currently being reported. Almost 84% of students (n = 178) responded. The benefits of participating in small groups were categorized into three domains—cognitive, affective and social—as identified from student responses. Results were analysed in terms of gender and prior educational experience (secondary school vs. prior tertiary educational experience). For almost 94% of students, the small-group tutorial provided a conducive learning environment that influenced their personal development (i.e. tolerance, patience) and socialization into the faculty. Significantly more males indicated that they had developed social skills, while more school-leavers (matriculants) than mature students felt more receptive to the views of others. More mature students claimed to have made friends. Irrespective of some conflicting opinions in the literature, the present results suggest that the PBL tutorial may be important in facilitating student socialization into a new and unfamiliar academic environment, particularly when the pedagogy differs markedly from their past educational experiences. Through interacting with fellow students from diverse origins who hold different views in the intimate setting of the small group, students felt that they had not only increased their knowledge but had also developed personally and socially. It is proposed that the small group may be useful for integrating a diverse population of students into a new academic environment.

Introduction

Problem-based learning and the small-group tutorial

A principle element in problem-based learning (PBL) as implemented to date is the small-group tutorial. A search of the literature will yield many articles promoting the small-group sessions in student-centred curricula, ostensibly for learners to develop social skills to function as members of a multidisciplinary team and to learn cooperatively by sharing their newly acquired information and recently constructed knowledge (Holen, 2000; Dolmans et al., 2001; Eva, 2002). Notwithstanding the qualitative and quantitative evidence of cooperative learning in the small-group setting, some authors have challenged its value in PBL, particularly in terms of dysfunctional groups (Colditz, 1980; Norman, 2001), where poor group dynamics and intolerance of individual differences may hinder rather than promote learning (Colditz, 1980; Hitchcock & Anderson, 1997; Walton, 1997). For Eva (2002), the outcomes of a team in an educational setting may not always be greater than the sum of the parts. Despite considerable research into the learning and, to a lesser extent, the social aspects associated with group work in PBL, the variable outcomes in the literature arise partly from the many different ways in which PBL has been implemented (Miflin, 2004; Norman, 2004). In Miflin's (2004) view, in the light of challenges to PBL (Colliver, 2000; Rothman, 2000), “we need to sing from the same hymn sheet” (p. 444) and “Until shared understanding is forthcoming, research in any aspect of PBL is likely to add to rather than diminish the confusion that plagues this worthwhile innovation in medical education, and to contribute to its untimely demise” (p. 448). In order to reach a clearer understanding of the role of the small group, Miflin (2004) provides a meaningful debate on the role and value of the small group in PBL over the past three decades, in which she attempts to make sense of the variety of ways in which PBL has been implemented and the evaluations interpreted. The present study contributes to the debate on the small group in PBL by reporting on the value (cognitive, affective and social) ascribed by students to their experiences in small-group tutorials at the outset of their medical studies.

Table

Practice points

• The small-group tutorial in problem-based learning provides a conducive, collaborative learning environment.

• The small-group tutorial, in addition, facilitates student adaptation to a new and unfamiliar academic environment.

• Amongst culturally and educationally diverse student populations, the small-group tutorial fosters integration and socialization.

• The interaction of students in small groups promotes considerable individual personal development.

Increasing student diversity and under-preparedness

Increasing pressure on South African tertiary institutions to widen access (to address previous marginalization and, in the case of medical faculties in particular, to provide doctors of indigenous ancestry) has resulted in South African medical schools increasing their intake of students from previously disadvantaged groups. The Nelson R. Mandela School of Medicine, in order to meet its internal targets, currently admits a large number of students with prior tertiary education experience, some with postgraduate degrees. To add to this increasing diversity in age, educational experience and ethnicity, through inter-governmental memoranda of understanding with various South African Development Community countries, students from Botswana, Namibia, Lesotho and Swaziland are also admitted. In addition, over the past 3–4 years, legal refugees from war-torn countries such as Rwanda and the Democratic Republic of Congo have also been admitted. In any one academic year, then, apart from the 11 official South African languages, four or five additional languages may be spoken on campus.

Despite national restructuring in higher education, a chasm remains between the quality of secondary education offered by private and by public schools. Public schools, particularly those in rural areas, are still largely under-resourced. Although a national matriculation examination exists (the minimum entry requirement for tertiary education), the differing quality of secondary school education translates into varying levels of student preparedness for tertiary education. Included in this under-preparedness are language skills. As English is the medium of instruction, many English second-language students experience difficulties. Starting points for tertiary studies amongst the diverse South African student population therefore vary greatly. While some may have personal experience of tuberculosis and HIV/AIDS, others will have greater academic knowledge (Connolly & Seneque, 1999). Tertiary institutions are therefore faced with the challenge of accommodating this diversity amongst students entering the many programmes offered, including medicine.

The role of the small-group tutorial in multicultural societies

Through national redress and equity, student demographics are changing rapidly, making for multicultural and multilingual populations of learners. The diversity of the small group in PBL (e.g. educational background, social, cultural, ethnic, language, gender and religion) will therefore increasingly reflect the truly multicultural nature of South African communities. In such culturally and linguistically diverse societies, the value of the small-group tutorial in a PBL curriculum may extend beyond its cognitive role to include some of the potential benefits identified by Walton (1997) and Eva (2002). In addition, in a non-threatening setting comprising a handful of probably equally unsure students, the small-group environment, overseen by a dedicated and trained tutor, may play an important role in exposing students to the diversity (colleagues and patients) they are likely to encounter in professional practice. In the South African context, where the repercussions of the historical racial and cultural separation and marginalization still pervade many spheres of our society, the small group may also be an important socializing element of PBL.

The authors initially set out to evaluate a diverse group of students’ ability, at the outset of their studies, to cope with different aspects of an integrated PBL curriculum and the personal impact of the content of a new first theme. It was, however, the unexpected results regarding the values this educationally and culturally diverse cohort of first-year medical students ascribed to the small-group tutorial that are presently being reported. In this regard, the results pertaining to the cognitive, affective and social benefits of the small-group tutorial have been analysed in terms of gender and educational background (matriculants vs. mature students). Since the “role of the small group in problem-based learning approaches has been the subject of unexplored assumptions based on unexplored assumptions about PBL” (Miflin, 2004, p. 448), there is much that still needs to be considered in terms of the role of the PBL tutorial group in students’ learning and development at different stages of their PBL programme. It is anticipated that the results of the present research will contribute to a better understanding of the role of the small-group tutorial in PBL at the outset of students’ studies.

Methods

Context of the study

In 2004, Nutrition became the first six-week theme of Year 1 in Curriculum 2001, a five-year PBL programme implemented in January 2001 at the Nelson R. Mandela School of Medicine (South Africa). Previously, Diabetes, a theme that curriculum developers believed would be contextually and locally relevant to South African students, was selected as the introductory theme. Evaluation from the past three years suggested, however, that many students, in part due to poor backgrounds in the foundational sciences (especially biology), experienced difficulty in the simultaneous introduction to physiology and pathophysiology in Diabetes. In Nutrition, on the other hand, students study the foundations of cell biology, chemistry, biochemistry and physiology to make sense of the clinical presentations encountered in the contextually relevant cases (e.g. kwashiorkor, pellagra, obesity, breast-feeding).

Evaluation of the Nutrition theme: survey instrument

In order to evaluate the Nutrition theme in terms of content and relevance, as well as its appropriateness as an introductory theme for a diverse group of students in a PBL curriculum, the 2004 Year 1 class (n = 213) was surveyed two weeks after completion of the theme. The survey was both open- and closed-ended, in that students had to explain their YES/NO responses to questions posed relating to the theme content, adapting to PBL, the value they ascribed to the small group, lifestyle changes they had made as a result of the theme and their most and least rewarding experiences during the six-week theme (Appendix 1). Data used for this discussion relate to student responses regarding the personal impact of the small-group tutorial, a new learning experience for the majority in the cognitive, social and affective domains. Additional information regarding the small group was extracted from an item relating to their ‘Most rewarding experiences’ during the theme. Anonymous biographical information was also collected (e.g. matriculation date; gender; previous tertiary studies) in order to analyse data in terms of gender and previous tertiary experience. Data collected on theme content, lifestyle changes and adaptation to PBL will be reported elsewhere. This document focuses on student perceptions of the value of the small group at the outset of their PBL studies.

Data analysis and statistics

To evaluate and analyse student comments pertaining to group work, one author (McLean) read through student responses to the question pertaining to their perceptions of the impact of the small group. A list of categories of positive outcomes relating to the small group was generated that could then be grouped into three broad domains: cognitive, affective (including personal development) and social. Independently, two authors (McLean and van Wyk) further refined and categorized student comments according to the list. Results were compared, and after some discussion agreement was reached on the interpretation of student comments. Categorical data (males vs. females; matriculants vs. mature students) were compared using a two-tailed Fisher's exact test. The level of significance was set at 95%. For the purpose of this research, matriculants are identified as students who enter medical studies directly from school, whereas mature students have at least one year of previous tertiary experience after leaving secondary school.

Results

Almost 84% (n = 178) of the first-year cohort returned their surveys. Their biographical details are provided in Table 1. Matriculants and mature students accounted for 56.7% and 43.3% of respondents, respectively.

Table 1.  Students (males vs. females; matriculants vs. mature) responding to a query (Did the small-group sessions impact on you personally or on your behaviour?) in the introductory theme (Nutrition) of the first year of a problem-based learning curriculum

Respondents	% Respondents
All survey respondents (n = 178)	Yes (n = 166; 93.3%)	No (n = 10; 5.6%)	No response (n = 2; 1.1%)
Females (n = 113): 63.5%	94.7 (n = 107)	4.4 (n = 5)	0.9 (n = 1)
Males (n = 65): 36.5%	90.8 (n = 59)	7.7 (n = 5)	1.5 (n = 1)
Matriculants (n = 101): 56.7% (i.e. matriculated in 2003)	95.0 (n = 96) 67 females:29 males	3.4 (n = 4) 4 females	1.1 (n = 1) 1 female
Mature (n = 77): 43.3% (i.e. matriculated in 1984–2002)	90.9 (n = 70) 40 females:30 males	8.0 (n = 6) 1 female:5 males	1.1 (n = 1) 1 male

Note: No statistical differences were recorded between males and females and between matriculant and mature respondents.

There was consensus amongst students (93.3%) that the small-group tutorials in the first theme of the first year of their studies in the PBL programme had had a meaningful impact in one or more of the three domains (cognitive, affective and social). For some, the tutorials had been conducive to their learning (e.g. filled in the gaps; gave them a better understanding), while for others, the group assisted with their integration into the Faculty (Table 2). Almost 39% of the respondents had made friends, while 27% indicated that they had found the small-group learning environment cooperative. Many students indicated that their experiences in the small group had also resulted in personal development (affective domain), ranging from becoming more tolerant and patient to developing confidence and becoming more self-assured. Within the social domain, significantly more mature students indicated that they had made friends (p < 0.01) and more males were of the opinion that they had developed social skills (p < 0.05) (Table 2). Of borderline significance (p = 0.054) was the fact that more female students were of the opinion that the small group had enabled them to interact with people from different backgrounds. In the affective domain, 11.9% of matriculants (vs. no mature students) indicated that they had learnt to respect or tolerate the views of others (p < 0.01). In the cognitive domain, the small-group tutorial ‘filled in the gaps’ for more matriculants than for their mature colleagues (p = 0.080). Table 3 provides some of the more descriptive comments of students as they relate to the different aspects of their experiences in the three domains.

Table 2.  Development students indicated they had undergone as a result of the group work in the Nutrition theme

Domain of development	% respondents (n = 178)	% Females (n = 113)	% Males (n = 65)	Fisher's exact p value	% Matriculants (n = 101)	% Mature (n = 77)	Fisher's exact p value
Social domain
• Made friends	38.8	39.8	36.9	0.751	33.7	45.5	0.0023
• Cooperative (sharing, etc.)	27.0	26.5	26.5	0.863	28.7	24.7	0.604
• Interactive	16.3	19.5	10.8	0.146	19.8	10.4	0.10
• Meeting different people	9.0	12.4	3.1	0.054	8.9	9.1	1.0
• Improved communication skills	5.6	5.3	6.2	1.0	6.7	1.1	0.178
• Exposed to different views	3.9	6.3	1.5	0.425	5.9	1.3	0.142
• Social skills developed	1.7	0	4.6	0.047	2.0	1.3	1.0
• Great facilitator	0.6	0.9	0	1.0	1.0	0	0.433
Affective domain
• Became more confident	12.9	12.4	13.8	0.819	10.9	15.6	0.375
• Developed tolerance	10.1	10.6	9.2	1.0	10.9	8.0	0.610
• Learnt to respect/more  open to other views	6.7	8.8	3.1	0.215	11.9	0	0.0013
• Learnt to speak my mind	5.1	7.1	1.5	0.158	3.3	6.8	0.503
• Learnt to listen to others	2.8	3.5	1.5	0.654	4.4	1.1	0.654
• Became more patient	2.2	2.7	1.5	1.0	4.4	0	0.135
• More disciplined	1.1	0.9	1.5	1.0	2.0	0	0.506
• Friendlier	0.6	0.9	0	1.0	1.0	0	1.0
• More considerate	0.6	0	1.5	0.365	1.0	0	1.0
*Self-evaluation	10.1	11.5	7.7	0.606	13.9	5.2	0.078
Cognitive domain
• Better understanding	15.0	9.7	9.2	1.0	9.9	7.8	0.793
• Learning took place	15.0	8.0	12.3	0.428	9.9	9.1	1.0
• Filling in gaps	5.1	5.3	4.6	1.0	7.9	1.3	0.080
• Broader view	2.2	2.7	1.5	1.0	3.0	1.3	0.635
• New ways of learning	2.2	2.7	1.5	1.0	3.0	1.3	0.635
• Clearing up misconceptions	1.7	1.8	1.5	1.0	3.0	0	0.260
• New ways of thinking	1.7	1.8	1.5	1.0	3.0	0	0.260
• Worked harder	1.7	1.8	1.5	1.0	3.0	0	0.260
*Self-assessment	9.0	11.5	4.6	0.174	8.9	9.1	1.0

Notes: Students’ comments were categorized into three domains. Bold p values indicate statistical significance. Underlined p values almost reached significance.

*These were categories largely assigned by the authors in response to student comments. Self-assessment refers to personal traits (e.g. become more of a leader) while self-evaluation refers to the learning context (e.g. identified my shortcomings).

Table 3.  Students’ comments pertaining to some of their experiences in the small-group tutorial during the Nutrition theme

Cognitive domain
A conducive and cooperative learning environment:
• Working as a group … stimulated my thought processes to a higher plane
• Working as a group helped me to understand the content better
• I wouldn’t have coped if I was working alone. Working in a group clarified the confusion I had during SDL
• My group mates were encouraging, nice and cooperative. They would sometimes give tips of how to read and understand something and be able to ‘narrate’ to others
• It's more stimulating, arousing your conscious (in terms of working), thus preventing intimidation/guilt of parasitism
• I learnt a lot of things during feedback sessions and got to acquire a lot of skills and grew as a person
The value of group work in learning:
• I actually learnt a lot, one being that one cannot know it all but need each other's input
• It made me realize that you can learn from other people
• I found I was able to contribute more in a small group (rather than a large group resource session)
• Made friends and felt very useful in my contribution
Affective domain
Personal development:
• I am a real introvert and the fact that we all had to input in our feedback session really got me talking and I actually realized that I am quite friendly
• I used to be a shy person who didn’t really talk, but now I’m getting used to it
• I used to be alone and I had a big problem with my English, even now I’m struggling but it is becoming better
• You get to know and understand different individuals and you are able to tolerate them as well
• I am more patient, interactive and friendlier
• It made me more of a leader than follower
• I realized that I have a wicked sense of humour
Social domain
Diversity and the small-group tutorial—making friends:
• I had an opportunity to befriend many of the classmates who I wouldn’t normally and I made lots of friends
• I made friends. I think the first theme will always be special to everyone because we all came into the group a little uncertain and left a little more confident
• You get to know people you would otherwise never talk to, and that sense of camaraderie never leaves, even in the next theme
Diversity and the small-group tutorial—broadening one's views:
• It allows me to listen to others and accept their opinions and respect them
• I’ve learnt to appreciate other people's views more openly
• I got the satisfaction of having people listen to all my views and opinions
• The varying and diverse views and opinions gave me a broader understanding of various issues
• By so many people airing their views, we were able to look at the situation from a wider view

Only 10 (5.6%) students, mainly mature students, felt that they had not benefited from the group work. Of these, seven provided reasons relating to prior group experience or that they were too shy or preferred to work alone. A single student indicated that conflict within the group had been a negative experience (Table 4).

Table 4.  Reasons offered by seven of the 10 students who did not find the small-group tutorials beneficial (seven mature:three matriculants; five females:five males)

Relating to the individual:
• I am used to group study (n = 2)
• I prefer learning on my own than checking with others later (n = 1)
• I didn’t talk much so didn’t make enough friends (n = 1)
Relating to group processes:
• I made enemies in terms of arguments about some things (n = 1)
• Made me feel uncomfortable and angry at the same time because I feel like I was contributing more to the group and the others were just keeping ideas to themselves (n = 1)
• People in the group remained quiet and did not want to fully examine the ideas (n = 1)

Additional evidence relating to the value of the small group for students new to the faculty and to PBL is provided by a number of either direct references to the small group, or indirect references to social aspects in their most ‘Most rewarding experiences’ section of the survey (n = 30) (Table 5; Appendix 1). There was overlap between these comments and the list provided in Table 2.

Table 5.  Student comments pertaining to the social aspects of the curriculum, mostly with reference to group work extracted from their ‘most rewarding experience’

Most rewarding experience	% respondents (n = 178)
• Congenial group atmosphere	7.9 (n = 14)
• Cooperative learning environment	3.9 (n = 7)
• Making friends	3.9 (n = 7)
• Meeting different people	2.2 (n = 4)
• Underwent personal development  (e.g. more tolerant)	1.7 (n = 3)
• Exposure to different views	0.5 (n = 1)

Note: Thirty students (16.9%) identified one or more social aspects (21 matriculants:9 mature students; 22 females:8 males) of the theme as their most rewarding experience.

Discussion

Students in the present study, representing many different cultural groups and from widely differing educational backgrounds, identified, presumably on reflection, numerous cognitive, affective and social benefits from their small-group experiences during the introductory theme of their first year of medical studies. Some recognized that this transition from the ‘old’ to the ‘new’ may not have been possible without collaboration with their peers.

Cognitive domain: a conducive and cooperative learning environment

The positive perceived educational benefits of the small group identified by students in the present study question Eva's (2002) view that, although teamwork has advantages in education, there is little conclusive evidence that it offers more learning opportunities than individual study. Students’ claims that interaction with members of the group and the sharing of ideas, resources and views exposed them to different ways of learning, that misconceptions were ironed out, that they were made to take a broader view on some issues and that this interaction led to a better understanding of some concepts support the findings of Qin and colleagues (1995). Following a meta-analysis of some 63 studies, those authors concluded that in a cooperative learning environment (vs. a competitive one), there was greater exchange of ideas, correction of misconceptions and better problem-solving ability (Qin et al., 1995). Furthermore, the list of positive learning outcomes identified by students in the present study is similar to that provided by Holen (2000). A glimpse at student comments in Table 3 provides rich qualitative evidence to support their claims of the benefits of the small-group environment, with many comments confirming elements of Vygotsky's (1978) proximal development theory. Students, by interacting with perhaps more skilled or experienced peers, were able to develop cognitively beyond what they would have achieved alone. Since it has been suggested that PBL assumes a degree of motivation and maturity more likely to be found in graduate students, undergraduate students may require more guidance and support in adjusting to the new pedagogy (Drinin, 1991), which their more mature colleagues may provide. This diversity in age and experience among students entering the faculty might translate into varying degrees of confidence and different strategies for coping with PBL. The support of the tutor/facilitator and peers in a small-group setting will certainly contribute to integrating students, in our case of varying ages and from many different backgrounds, into the cultural and academic environment where they will study for the next few years.

Affective domain: personal development

From the phenomenographic perspective of Marton and colleagues (1993), learning can be viewed as a number of hierarchical conceptions, ranging from the lowest reproductive conception (involving rote learning and recall) to the two highest transformative conceptions, where the student ‘sees things differently’ and perhaps ‘changes as a person’. One would anticipate that, if PBL lives up to its expectations, the learning should embrace the two highest transformative conceptions, which are likely to involve not only the cognitive domain but also affective and social elements. Considering the responses of students in the present study within this phenomenographic perspective, many students appear to have undergone considerable personal development and had seemingly changed as individuals (see Table 3). Their claims included becoming more tolerant, patient, confident, and more open to and respectful of the views and opinions of others (i.e. ‘seeing things differently’ and so ‘changing as a person’). Recognition of this personal development would have required reflection on their experiences, as well as self-evaluation and a sense of self-awareness.

Social domain

Value of group work

Through the small-group session, apart from the positive cognitive learning experiences, students also recognized important social and affective benefits, ranging from making friends, sharing ideas and resources to improving their communication and social skills by interacting with different people. Albanese (2000), in elaborating on theories that might be useful in supporting the PBL philosophy, uses the cooperative learning theory to explain the importance of the small group in PBL. In such situations, individuals perceive that they can reach their goals if and only if other group members do. Implicit in this theory is the notion that the successful attainment of the group's learning outcomes is dependent on mutual cooperation. This might explain the findings of Hendry and colleagues (2003) that students identified the quiet, shy group member who rarely participates as the highest ranking problem relating to group dysfunction. In the same vein, this might also explain why the domineering student who does not allow others to contribute was also ranked near the top of that list of problems (Hendry et al., 2003). A few students in the present study who did not benefit from the small-group tutorials (see Table 4) hinted at these aspects of group dysfunction, which we know, from experience, are unavoidable (Colditz, 1980; Walton, 1997; Norman, 2001; Hendry et al., 2003). This cohort, however, reported few conflicting or disruptive situations, which is probably best explained in terms of Tuckman's (1965) stages of group formation. Since this was the first theme of the year, with all students still finding their feet, not only in medicine, but also in PBL, the groups probably did not develop beyond the ‘forming’ or ‘norming’ stages, where conflict is generally avoided by members as they familiarize themselves with the process and with each other (Tuckman, 1965; Walton, 1997).

Diversity and the PBL small-group tutorial

Some students in the present study recognized that the small-group session not only provided an opportunity to interact with peers of different races, religions and cultural groups, but they were also able to befriend these individuals. For some, these friendships, fostered during a time when all students are new to the faculty and to PBL, may well persist for the duration of their medical studies (see Table 3): “You get to know people you would otherwise never talk to, and that sense of camaraderie never leaves, even in the next theme”.

Students also embraced the fact that with such diversity come different views and opinions, enriching their learning and personal experiences. In fact, Holen (2000) proposes that the small group in PBL serves to develop social skills that impact on a student's professional relationships with patients and colleagues. In the context of multiculturalism and multilingualism, the ability to work in such a diverse group from the outset will certainly be advantageous (see Table 3).

The comments of students in the present study highlight the value of acknowledging diversity in the educational setting. For Bollinger (2003), diversity is the educational core of what the university does and is central to the quality of students’ educational experiences. Since the intake into most medical faculties in South Africa should reflect the demographics of the population, it is advantageous to expose students to situations they might expect in practice. Like students in the present study, some American medical students recognized diversity as an important part of their education and training as medical practitioners (Whitla et al., 2003). These contacts with diverse peers enhanced the educational experiences of these American students and they strongly supported strengthening and maintaining affirmative action policies to ensure that this interaction took place.

On the importance of diversity in education, Bollinger (2003) takes a somewhat unconventional view: rather than viewing diversity as trying to understand differences amongst people, we should try to identify commonalities. It is only when we interact (such as in the small-group tutorial) with others that we can discover how much we have in common and where we might differ. Interacting with people of different backgrounds in a small-group setting, overseen by a committed facilitator, would certainly create an environment conducive to learning, understanding and empathy, allowing students an opportunity to understand how one's life experiences may influence one's opinions. In the South African context, by collectively exploring and discovering the past and the present from the experiences of different ethnic and cultural groups, students will have a broader perspective on the social and political issues that characterize our society today. It is to be hoped that this will provide them with the empathy and insight required to deal with the needs of the diverse communities they will serve.

Amongst the diverse student populations found at South African, like Australian educational institutions, cultural influences on the functioning of the small group in PBL cannot be overlooked. Although not within the scope of the current contribution, there is certainly sufficient information to warrant another discussion relating to the different behaviours associated with collectivist and individualist cultures in the context of learning in PBL (Hofstede, 1986; Tennant, 1997; Klimidis et al., 1997).

Implications and application to PBL curricula

While the authors accept that the present study examines the context of the small-group tutorial after only the first six-week theme for one cohort of students, it does provide a useful insight into the perceptions of an educationally and culturally diverse group of medical students regarding their experiences of group work in an unfamiliar PBL pedagogy. Notwithstanding these limitations, in all likelihood student descriptions realistically reflect a situation that might similarly exist in those medical schools committed to widening access. The study therefore provides a useful starting point for further research into the value of the PBL group at different stages of such students’ medical studies.

Students’ positive descriptions of their experiences challenge Norman's (2001) view that the small-group tutorial in PBL is an accident in history. Against the backdrop of educational and ethnic diversity, the authors would like to suggest that the small-group tutorial is a valuable cognitive, affective and social learning experience early in a PBL programme, and support Miflin's (2004) view that it is a more conducive learning environment at the outset of students’ studies than a lecture theatre filled with 200 or more students. Findings from the present study also support Miflin's (2004) opinion that the small-group tutorial is likely to be educationally more advantageous in the earlier rather than later years of PBL. Irrespective of factors that may be potentially disruptive, the first small group in a PBL programme provides a safe haven for new students at a time of uncertainty and anxiety. As self-directed learning or the field of medicine would be unfamiliar to the majority entering the faculty for the first time, it is proposed that the small-group tutorial may be valuable in introducing students to the faculty, and particularly to PBL, during a time of discovery, when they learn (often from each other) to take responsibility for their learning. It is likely that, in the first phase of the PBL curriculum, co-learners of the small group will support each other in making the transition from the old, teacher-centred learning paradigm to the new student-centred one. They might also support each other in terms of the insecurities they might feel with PBL, where a common complaint is the anxiety students experience in determining the required depth and scope of research (Colditz, 1980; Walton & Matthews, 1989; O’Hanlon et al., 1995; Miflin et al., 1999; Miflin, 2004). Connolly & Seneque (1999) have proposed that, irrespective of the different starting points of students in a PBL programme, the sharing and exchanging of information and ideas, including prior experiences, within the conducive learning environment of a small-group tutorial will contribute to the majority of students achieving the minimum learning outcomes. In this small-group setting, as new students are able to get to know some of their peers more intimately, it is likely that some of the friendships they develop during these first few weeks will persist throughout their studies. In this way, the small group becomes a social mechanism to familiarize students with their new learning expectations, and if overseen by a committed facilitator they will be provided with feedback to reflect on their group and individual progress. Some believe that such mutual support and cooperation lays the foundations for future teamwork (Colditz, 1980; Walton, 1997; Holen, 2000). In this context, it has also been suggested that it is the experiences of this small-group atmosphere that promote PBL graduates into professions where they are ‘affiliated’, such as in a group practice, in family medicine or in vocations with more contact with patients (Woodward et al., 1990).

Ethical approval

The study has received ethical approval from the Biomedical Ethics Research Unit, University of KwaZulu–Natal. No. R200/04.

Acknowledgements

Tonya Esterhuizen is thanked for the statistical analysis and the 2004 first-year students for their enthusiasm in assisting the authors with this evaluation.

Additional information

Notes on contributors

Michelle McLean

MICHELLE MCLEAN is a Professor and Histologist who has developed a strong interest in student learning. She is particularly interested in issues relating to diversity and multiculturalism.

Jacqueline M. Van wyk

JACQUELINE VAN WYK has been involved in evaluation of the Nelson R. Mandela School of Medicine's problem-based learning curriculum that was implemented in January 2001.

Edith M. Peters-Futre

SUSAN HIGGINS-OPITZ, PhD and EDITH PETERS-FUTRE, Professor, are both Physiologists. Susan served as the founding theme coordinator, while Edith was involved in the theme design and undertook many of the hands-on experiences within the theme.

Susan B. Higgins-Opitz

SUSAN HIGGINS-OPITZ, PhD and EDITH PETERS-FUTRE, Professor, are both Physiologists. Susan served as the founding theme coordinator, while Edith was involved in the theme design and undertook many of the hands-on experiences within the theme.

Appendix 1: Questionnaire administered to first-year medical students two weeks after completion of their first six-week theme, Nutrition

Student Survey: Theme 1.1—Nutrition

Table

Please spend a few minutes reflecting on your experiences in the Nutrition theme. We need to know how you feel, how you coped and how the theme impacted on you. Please tick (✓) the appropriate box. We thank you in advance for your cooperation
Gender: Female _ Male _	Date of birth: ______
Year matriculated: __	School matriculated: ____
Previous tertiary studies: YES _ NO _	If YES, give details: ____
1. Were you able to cope with the content of the Nutrition theme? YES _ NO _
If NO, explain
2. Were you able to find suitable resource material to answer your learning goals? YES _ NO_
If NO, explain
3. Were you able to manage your time and activities during this theme? YES _ NO _
If NO, explain
4. Were you able to cope with the self-directed learning expected in PBL in the Nutrition theme? YES _ NO _
If NO, explain
5. Did working in a group impact on you as an individual or on your behaviour? (e.g. more tolerant, made friends, etc.) YES _ NO _ If YES or NO, explain______
6. Did the Nutrition theme impact on your awareness of your personal dietary intake? YES _ NO _
If YES, explain
7. Did the Nutrition theme result in any lifestyle changes for you? YES _ NO _
If YES, explain
8. Did the Nutrition theme result in you advising anyone about their dietary habits or their lifestyle? YES _ NO _
If YES, explain
9. What was your most rewarding experience during this theme? Explain_____
10. What was your least rewarding experience? Explain
11. During the theme, you worked out some statistics for yourself. Please indicate if you cannot remember.
Can you remember a. Your body mass?_kg □ Cannot recall
b. BMI? _ □ Cannot recall
c.% body fat? _ □ Cannot recall
d. Total daily kilojoule intake? _ □ Cannot recall

Your cooperation is appreciated.

Prof McLean, Dr Peters-Futre (Physiology) and Mrs van Wyk (SUME)