Comparing the Views on Problem-Based Learning from Medical Education Students in Zhengzhou University in China and the University of Bristol in the UK

Problem-based learning (PBL), as a student-centred learning method, refers to students actively participating in a group scenario to solve open-end problems. This study aims to compare the students’ attitudes on PBL in Zhengzhou University and the University of Bristol. This study adopts qualitative methods. By conducting semi-structured interviews with eight participants, four from Zhengzhou University and the others from the University of Bristol. Overall, the results of the study indicated that students from both two universities are overall satisfied with PBL because of its contribution to deeper understanding of medical knowledge and skill development and they all think that the quality of group discussion and the efficiency of PBL classes need to be improved. In terms of the different views from two universities, when it comes to the biggest benefit of PBL, students from Zhengzhou University are more likely to choose clinical thinking, while students from the University of Bristol are more satisfied with the deep understanding on medical knowledge. Unexpectedly, although Zhengzhou University has implemented PBL for fewer years than the University of Bristol, students are more satisfied with and motivated in PBL classes than those of the University of Bristol.


Introduction
Student-centred learning means that learners actively and autonomously participate in learning (O'Neill & McMahon, 2005), which is opposed to traditional teacher-centred learning. Problem-based learning (PBL) as one of the student-centred learning methods refers to encouraging students to solve open-end problems in a group scenario (Hmelo-Silver, 2004).
Previous literature shows that PBL assessment is usually done on the basis of students' academic performance or views from teachers or institutions rather than on the opinions of students. It is crucial to explore the students' perspectives on PBL classes because students are the direct audience of experiential in the process of teaching. The purpose of this study is to compare students' views of PBL in Zhengzhou University and the University of Bristol, which are the leading universities in China and the UK respectively. The research question is what are the similarities and differences of students' perspectives on PBL at Zhengzhou University and the University of Bristol?

Rationale of the Research Topic
In China, teacher-centred approaches and high-stake and frequent examinations dominate the whole education system from primary schools to higher education institutes. Such a model makes students passive information receivers who learn by rote memorisation rather than with analytical and critical thinking. Even worse, it could baffle students' willingness to communicate and innovate, producing students with high scores but poor competence. As a student educator eager to make a difference to China's future generations, the researcher worries about the current situation and seeks change. Accidentally, the researcher researched a primary school which was conducting PBL method, and found that PBL helped boost students' motivation and academic performance. Studying in the University of Bristol deepened the researcher's understanding of student-centred learning and culminated in the idea that PBL could be a potential solution to China's education problem, hence this study explores the comparation of medical students' views on PBL in China and the UK.

Significance of the Study
The importance of comparing the students' attitudes on PBL is to address the research gap in previous literature. Recent literature mostly focuses on comparing PBL with traditional learning (Savery, 2006), with few articles giving thought to the effects of institutional culture on PBL operation. This research, however, considering different learning contexts, explores the views of students from China and the UK on PBL, which to some extent fills the void of geographical concern in PBL research. According to Levitt, McKeage, and Rangachari (2013) and Savin-Baden and Major (2004), it is important to evaluate students' voices in the process of learning and courses. However, in general, it is common to assess the results of PBL based on teachers' experience and students' academic performance rather than on students' views in the learning process which is missed a significant element on the courses evaluation. Overall, the significance of the study lies in its helpful and positive information to academic staff and universities that can be used to improve the implementation of PBL in the future curriculum.

Literature Review
Traditional teacher-centred education has grown to be unsatisfied in motivating and developing students' knowledge and competences (Barrows, 1996;Silva, 2018). As a student-centred learning method, the first model of PBL was adopted by the McMaster University in Canada in medical education in the 1960s before spreading to the USA. In the late 1980s, this innovative method was noticed by British educators and gradually permeated other professional education programmes. Now it has become popular among educators and scholars from all over the world (Savin-Baden & Major, 2004;Prihatiningsih & Qomariyah, 2016). It is advocated that PBL is a learning method with which learners explore the answers of authentic problems and gain the upper-level knowledge and skills such as problem-solving and critical thinking (Colliver, 2000;Henk, Jerom, & Elaine, 2011;Ceker & Ozdamli, 2016). Barrows and Tamblyn (1980) hold that PBL encourages students to participate in problem scenarios actively. Those PBL pioneers, aiming at modifying and enhancing conventional curricula, emphasise on students' self-directed and collaborative learning to develop problem-solving and teamwork skills (Hernández et al., 2018;Chang, 2016).
According to relevant literature, PBL features open-end problems in real life, encourages collaborative work and self-directed learning (Savin-Baden & Major, 2004;Song et al., 2005;De Boer & Otting, 2011). White (2001 notes that problems as a crucial element need to be not only open-end, which means having multiple solutions, but also linked with the real scenario. Open-end questions in real-life not only stimulate creativity and flexible thinking (Savery, 2006;Levitt, McKeage, & Rangachari, 2013;De Boer & Otting, 2011), but also facilitate future knowledge retrieval as the knowledge can recall when the situation resembles the context in the class (De Boer & Otting, 2011;Bestetti et al., 2014). Although Bate et al. (2014) find that students feel their time is 'wasted' on unnecessary debates or on guessing answers with members who have similar level of prior knowledge, majority literature supports and encourages the collaboration on a team because it provides opportunities on students' in-deep understanding (Savin-Baden & Major, 2004;Tang et al., 2008). In specific, students who want to engage in the group discussion need to manage the answers of problems and evaluate members' response during the process of debate which leads to the deep understanding of professional knowledge (De Boer & Otting, 2011;Vernon & Blake, 1993). As an instructional student-centred learning method, self-directed learning has a significant characteristic which allows students to be active participants and to take responsibility for their learning (Bate et al., 2014;Hernández et al., 2018). While some students feel stressful about self-regulation (Pekrun et al., 2002), Bate et al. (2014) suggest that self-directed learning allows learners to identify their own learning needs, seek relevant information and determine the learning process to provide viable solutions in a team (Savery, 2006;Shin & Kim, 2013;Hartling et al., 2010).
By searching keywords such as 'PBL' and 'medical education' on academic websites and databases, 24 articles of authority and relevance are selected for analysis. In most articles, PBL is evaluated from two perspectives: academic performance and skills. Specifically, 18 articles focus on educational outcomes and 12 of them (66.7%) show that PBL is superior to traditional learning in academic performance and future career, while the rest (33.3%) show that there is no difference or even negative consequences on PBL compared with traditional learning (Savin-Baden & Major, 2004;Hande, Mohammed, & Komatil, 2015). In terms of skills evaluation, 18 articles all state that PBL is successful in enhancing students' capacity such as problem-solving skills, independent learning and interpersonal skills (Collard, Brédart, & Bourguignon, 2016;Ding et al., 2014). In conclusion, most literature holds that PBL is an innovative and positive teaching method to improve students' academic performance and skills.

Participants
This study uses a qualitative method to meets the need for an in-depth comparison of the medical students' perspectives in PBL class (Hammarberg, Kirkman, & De Lacey, 2016). The sample of this research consisted of eight students, with four from Zhengzhou University and four from the University of Bristol. The small sample of participants ensures that the researcher has enough time and experience to explore and interpret their perspectives in-depth (Matthews & Ross, 2010). Participants from Zhengzhou University are all-male postgraduates majoring in clinical medicine, with PBL experiences in their undergraduate years; while those from Bristol University are all-female medical undergraduates who had PBL classes very recently. As such, this program could potentially manifest both long-term and short-term influences of PBL. The necessary information of participants is displayed in Table 1.

Data Collection
Data collection was conducted through semi-structured interviews. In this regard, the choice of the semi-structured interview is in line with the purpose of the research, as it provides participants with the opportunity to share whatever they may think about PBL classes. Besides, the researcher could be inspired by participants' answers and put forward more relevant questions, thus acquiring an in-depth understanding of the student-centred approach.
Based on the research questions, interview questions were designed to investigate participants' attitudes towards PBL, such as the advantages or disadvantages of the PBL and challenges they faced in PBL classes. To maintain an objective assessment, Likert Scale was adopted in this part, where the intensity of participants' feelings for their PBL experiences was captured by a typical Likert scale, which in this case was formatted as very unsatisfied, unsatisfied, neutral, satisfied and very satisfied (Jamieson, 2004).
Participants from the University of Bristol were interviewed face to face. It is believed that face-to-face interviews could contribute to data of higher quality, as they enable intuitive communication between the interviewers and interviewees and mobilise their activeness (Holbrook, Green, & Krosnick, 2003). For students from Zhengzhou University, voice chat via WeChat was adopted due to the geographical distance in between. However, the remote interview can be tricky to handle without incentivisation.

Data Analysis
Data from both face-to-face interviews and WeChat interviews were analysed using thematic analysis methods, which is 'a method for identifying, analysing and reporting patterns within data' and is widely used in qualitative research analyses (Braun & Clarke, 2006).
After transcribing the recordings of the interviews, NVivo was used to generate codes out of all the transcriptions ies.ccsenet.org International Education Studies Vol. 14, No. 1; 2021 from the semi-structured interviews. Codes are the key or central ideas related to research questions (Braun & Clarke, 2006;Nowell et al., 2017). The researcher evaluated the codes and systematically divided them up into sub-themes via NVivo. Related the research question and literature, the researcher decided the final themes and selected some vivid and compelling examples of data for each theme. The final thematic maps and findings are presented in Finding.

Results
To answer the research questions: What are the similarities and differences of students' perspectives on PBL at Zhengzhou University and the University of Bristol? students' perspectives are divided into three categories, including the positive perspectives of PBL, the negative attitudes of PBL and the overall scores on PBL evaluation.

Students' Perspectives on PBL in Zhengzhou University
Students from Zhengzhou University gave both positive and negative perspectives on PBL. In terms of positive views, they mentioned that PBL gave them learning motivation, helped them in acquiring medical knowledge and skills and got them closer to tutors. However, they also pointed out that preparation for PBL classes took them too much time, and that the management of tutors need to be improved. The specific themes are summarised in Table 2, and accurate information will be explained later. Firstly, all participants from Zhengzhou University said that they preferred to study in PBL classes compared with traditional teaching classes as PBL provided with them an innovative learning experience and motivated them to learn more. Specifically, group discussions which were refreshing to them aroused their interests for classes, and patients' cases and problems related to reality boosted their enthusiasm for clinical practices. In contrast, in traditional education, teachers instilled a lot of knowledge that they were more likely to get bored with so as to resist in practices. Participant 1 supported the PBL: 'PBL was a vivid and interesting way of learning, especially in the process of group discussion. The debate was very fierce, including many brilliant ideas, which motivate us to actively share our opinions and allow me to find the shining points of other students.' Similarly, participants 4 said their attitude changed after PBL:

Students' Perspectives on PBL at the University of Bristol
Students from the University of Bristol demonstrated both positive and negative attitudes towards PBL. In terms of positive perspectives, they mentioned that PBL cultivated their learning skills and increased their medical knowledge as well as motivating their learning. However, they also pointed out the disadvantages and challenges of PBL. The specific themes and codes are shown in Table 3. Participant B and C majored in pharmacology mentioned that some PBL classes were held with students in physiology or neuroscience, which helped them to learn interdisciplinary knowledge during the process of discussion.
Secondly, all participants mentioned that PBL helped them to gain some learning skills such as collaboration and problem-solving. Participant B said that PBL improved her confidence in communication: 'In PBL classes, I learnt how to balance the roles of hearer and speaker in a group. At first, I was more comfortable listening to others and learning from their opinions in a group discussion. But after PBL, I got braver and contribute to discussion compared with the beginning when I don't really talk at all.'

Negative Views on PBL
Although PBL contributes a lot to medical learning and skill development, there are some disadvantages and challenges according to students from the University of Bristol. Firstly, although most of the problems were related to the content of lectures, participants A and C mentioned that some problems could involve what students had not learned yet, which was difficult for students to solve and discuss. For example, participant A mentioned: 'One of the main problems for first-year undergraduates was the treatment of depression, which was intended for second-year schedule and thus increased a lot of workload for students.' Secondly, participant A and B said that some students felt confused and even resistant to PBL class when teachers failed to give a clear introduction of the purpose of the class.
Thirdly, participant B mentioned that PBL was not as effective as traditional teaching methods as it wasted a lot of time. She said: 'PBL takes quite a lot of time to prepare, but it only accounts for one per cent or less of our grade. So, it is hard for some students to get motivated to put their effort in especially when you have got a lot of other work.' Finally, participant A, B and D said that speaking in front of many people and working in group were big challenges for them. Participant D said the biggest challenge was expressing her opinions:

'I think the biggest challenge for me is to speak up and express ideas in a group because I am not really confident with my answers. Many thanks that the tutors and members help me to overcome it.'
In terms of group work, participant A mentioned that it was difficult to motivate all the members to contribute to a task: 'When our group worked on a presentation together, one of the team members failed to finish his part, which caused insufficient time for us to discuss how to present our work. Therefore, I think it was tough to control the progress of others, and if the cooperation of PBL was unpleasant, the efficiency was not as high as self-study.'

Overall Scores on Evaluating PBL
The average rating from the University of Bristol participants is 4.1/5. Participant A gave 3.5 points and said:   on the current medical knowledge learning. Therefore, the knowledge learned from PBL not only is beneficial to professional understanding, but also has a long-term influence on future work or study.
In terms of the motivation of PBL, all participants from Zhengzhou University stated that they enjoyed discussing with tutors and students. Some even mentioned that such discussions helped them find their future direction on career development. Compared with participants in Zhengzhou University, most participants from the University of Bristol do not think that the motivation of PBL have any important influence on them except keeping them awake in class. This difference may be caused by distinct cultural contexts of China and the UK. In British classrooms, students often develop a closer relationship with their teachers because of their frequent interaction in and after class. While in China, teachers usually distance themselves from students to maintain their authority, leading to less communication with students. In PBL classes, however, the traditional relationship between Chinese teachers and students are changed to resemble British style, thus causing greater implications on Chinese students and enhancing their motivation.
Finally, although the University of Bristol has a longer history of PBL implementation than Zhengzhou University which has PBL experience of only four years, more students from Zhengzhou university reported satisfied with PBL than from University of Bristol. According to the results on the Likert Scale, only two students from Zhengzhou University gave 'neutral' on the quality of group work and 'satisfied' or 'very satisfied' on other items. In contrast, students from the University of Bristol chose 'neutral' or even 'unsatisfied' on help from tutors, the quality of group work and the knowledge learned from PBL.

Conclusion
This study reveals that students from both universities are overall satisfied with PBL because of its contribution to deeper understanding of medical knowledge and skill development and they all think that the quality of group discussion and the efficiency of PBL classes need to be improved. In terms of the different views from two universities, when it comes to the biggest benefit of PBL, students from Zhengzhou University are more likely to choose clinical thinking because of its link with their current work, while students from the University of Bristol are more satisfied with the deep understanding on medical knowledge. Unexpectedly, although Zhengzhou University has implemented PBL for fewer years than the University of Bristol, students are more satisfied with and motivated in PBL classes than those of the University of Bristol. Due to the fact there is little literature focusing on the comparative attitudes of students in China and the UK, all the differences between the two universities are new evidence into the academic literature.
Based on the study, the two universities need to find how to motivate students' participation in group discussion to achieve better implementation results. With the high satisfaction of PBL among students, other universities should consider using PBL in medical education. A future study might be designed on more participants and comparison between genders differences.