European Journal of Education Studies ISSN: 2501 - 1111 ISSN-L: 2501 - 1111 Available on-line at: www.oapub.org/edu 10.5281/zenodo.154255 Volume 2│Issue 5│2016 PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS Salvador Ruiz Cerrilloi Health Science Department, University of the Atemajac Valley, León, Guanajuato, Mexico Abstract: Problem-Based Learning (PBL) method is based on activities that encourage several education competencies, making shorter the distance between real and hypothetical learning problems. To establish the relationship between clinical reasoning and PBL teaching, action research method was implemented in 32 Mexican second-year Nutrition Bachelor Students during a 16-week period. For measuring the level of clinical reasoning, the validated Comprehensive Integrative Puzzle (CIP) was applied in three different moments. PBL Teaching improves significantly clinical reasoning in Nutrition students (p <0.05) mainly on the identification of the Clinical-Nutrition File, at establish a Nutritional treatment and on the assertiveness to emit a Nutritional diagnosis. Keywords: clinical reasoning; comprehensive integrative puzzle; nutrition; problembased learning 1. Introduction Education competencies must be generated from the United Nations Educational Scientific and Cultural Organization (UNESCO,2002) requirements, strategies and standards, such as the Problem-Based Learning (PBL), Case Study-Based Learning and the Project-Based Learning, these methods try to reduce the distance between real life problems and the traditional learning method. (Tobón, 2015) The current issue of Didactic in Mexico according to Irigoyen et al (2011) falls at the research of a new definition of Knowledge, which is not consider static and Copyright © The Author(s). All Rights Reserved Published by Open Access Publishing Group ©2015. 1 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS reproducible at this point can be observed that PBL must encourage epistemic and anthropological models. According to the Pedagogical Thinking History, Traditional teaching seems to produced disputes in learning processes, making conflicts in the critical and effective curricular administration (Mbodila, 2015) A quality education as it is mentioned at the current Mexican educational politics, must be reached by teaching professionalization, so, from the perfection of the Didactic, it acquires a main position in the improvement of teacher´s practice, considering this, knowledge fields that can be structure and restructure by the professor, employing useful tools and strategies for a significant learning (SEP, 2016). This is how the importance of the following study come, trying to expose the results of PBL teaching in a Mexican Private University, where students need to be more likely to a real clinical environment, giving them tools and strategies to follow on their discover of their own professional practice for knowledge construction. Next sections of the article are going to define the most important elements of the theoretical framework, with a deepest point of view referencing different positions, interpretations and authors. 2. Background In Mexico the ITESM (Monterrey Institute of Technology and Higher Education, Instituto Tecnológico de Estudios Superiores de Monterrey in Spanish) System incorporates PBL as a didactic technique in the Faculties of Social Sciences and Medicine (ITESM, 2006). According to Martínez (2002) Medical School of the National Autonomous University of Mexico (UNAM), has been applying this strategy since 1993 with their Unique Study Planning in Bachelor and Postgraduate degrees as a main aspect for reaching the educational institute objectives in the same way as it has been applied into the Educational Quality Nucleus of the same University (Martínez, 2002) Through a research of the current Literature it was found that the University of Colima (Mexico) has been applying the PBL in the Faculties of Psychology and Medicine since the beginning of 2000 (Márquez, 2011), getting a good student satisfaction level. Otherwise, the University of Guadalajara (Mexico) has done the proposal of working PBL with B-learning, providing strength to a not related Health Science Knowledge (Santillán, 2006). In an official report file of The Autonomous University of Aguascalientes (Mexico) showed that it has been implemented PBL as a way to apply their Institutional Educational Model, but there are no research reports of PBL results in this University. (Universidad Autónoma de Aguascalientes, 2006) European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 2 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS This didactic and teaching strategy has been used also in basic education in Mexico, as it is mentioned by Morales and Pérez (2008) in a study realized in elementary at the Anahuac School (Villahermosa, Mexico), PBL was used in Math subject, getting an approval grade of the 56% with the maximal grade, this may show the effectiveness of this method. In the knowledge field of Nutrition, Olivares and Heredia (2012) applied a study at the ITESM (Mexico) in Health, Biotechnology and Food Bachelor Programmes, specifically on Medical Surgeon, Nutrition, Food, Biotechnology and BiomedicalEnginnering; according to the previously report, PBL has been implemented in Health Bachelor Programs since 2001, the aim of the research was to compare the Critical Thinking levels between students obtained with the CCTST test (California Critical Thinking Skills Test) validated by Facione (2000), they applied this instrument on students formed at Health Bachelor Programs comparing them with those who were not PBL intervened, results showed a better balance in development of inductive and deductive thinking in PBL students, which suggest that PBL ameliorate skills in Health Bachelor students. 2.1 Problem-based Learning (PBL) Problem based learning is a method of teaching and learning originated at McMaster University (Canada), Medical Program, in the mid-6 s. This method’s founding fathers were a group of physicians and basic scientists from Toronto-Hamilton area who were recruited by the McMaster School of Medicine. They all shared a negative view of their undergraduate experiences and thought they could do better (Norman, 1992). Based on McMaster University (2016) this method of teaching and learning spread fairly fast in the World, there were PBL curricula exists now days in the Netherlands, Australia, Israel and the United States. Now several hundred schools offer some form of problem-based learning, PBL has been used in America since 1968 and in Europe since 1974 (Martínez, 2002). In accordance to Woods (2006) from McMaster University, PBL is defined like any learning environment in which the problem drives the learning . McMaster University has long been internationally known for its problem-based learning approach in health science education. (McMaster University, 2016) There are different definitions for PBL, for this research it was used the DíazBarriga (2006) definition which is: PBL is an integrative focus activities-based that encourages thought, complex thinking, cooperation, and decision-making, that surrounds in front of authentic and significant problems. PBL has been used in America since 1968 and in Europe since 1974 (Martínez, 2002). European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 3 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS 2.2 Clinical reasoning According to Viesca (n.d) the terms: clinical reasoning, clinical making-decisions, clinical problem solutions and diagnostic reasoning can be considerate by professionals as synonyms and could be used in a similar context. It is important that all the terms for clinical reasoning mentioned before by Barrows (1980) referred to the same idea, standing out the concept, the author mentioned before define clinical reasoning as: the cognitive process needed for evaluate and manage the medical problem of a Patient. Clinical reasoning process is dependent of the attitude in front of critical thinking (Scheffer & Rubenfeld, 2000, in McCarthy, 2003) and it’s influenced by personal attitude, philosophical perspective and preconceptions (McCarthy, 2003). As stated by Morán (2010), clinical reasoning is the sum of thinking and cognitive processes of making-decision, associated with the clinical practice; is a critical skill of Health professionals with importance for acquiring an autonomous and professional practice, that allows a more assertive decision-making on Health Bachelor students, which implies a better action based on a judgment inside an Specific context. 2.3 Clinical reasoning process The clinical reasoning cycle, requires from a health professional that aware people´s health, with the goal of examine and discuss the included steps on the cycle model, the proposed model must be explained with clock hands order, with the objective to ease the decision-making, and enable a more precise treatment and screening. (LevettJonnes, 2010, in University of Newcastle, 2009). This cycle has been applied in common scenes that involve patients with different characteristics, with the aim of explore each one of the cycle stages, and in this way show how decision-making is useful at clinical practice (University of Newcastle, 2009). European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 4 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS . Reference: University of Newcastle, Australia (2009) With the theory exposed before, Figure 1 explains the clinical reasoning mechanism, representing each stage involved in the process that is related with:  3.  Gathering clinical clues or vignettes  For the correct Patient  Collecting the proper clues  In an appropriate time Take the correct decision Research Question and Hypothesis As the above, the main research question for this study is: How Problem-Based Learning (PBL) impacts the stages or clinical vignettes, in the clinical reasoning of Mexican second-year Nutrition Bachelor students? Based on the theoretical framework research, the hypothesis was: PBL Teaching in Nutrition Bachelor Students impacts the clinical reasoning at improving the diagnosis ability. European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 5 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS 4. Method 4.1 Context PBL was used in the subject of Nutritional Pathology I, during the 16 weeks course (May- August 2015), Nutrition Bachelor students were working in groups of 8 to 10 people according to the 7 steps PBL method of the University of Maastricht (Maurer, 2012) (Holland), sessions were divided in three phases: tutorial working, individual working and feedback. The programme is taught in Spanish but some of the resources provide by the tutor were in English. 4.2 Study Design Action research method was used, the teacher or tutor design the total intervention and defined the methodological line for PBL teaching. 4.3 Participants 31 Mexican students of second-year of Nutrition Bachelor from León, Guanajuato (Mexico) were included in the study (N=31; males, 5, Mage= 20.6; females, 26, Mage=20.4; SD= 1.07, RANGE= 19-23) 4.4 Instruments Assessment tools were used to evaluate the performance of the students during the PBL intervention, three different instruments were included:  Comprehensive Integrative Puzzle (CIP), has a format of an extended matching, it has rows and columns, columns contain clinical vignettes and rows different  medical diagnosis, validated by Ber (1997) with a Cronbach´s alpha value of 0.91. Student´s performance in problem-based learning tutorial sessions Questionnaire (Valle, 1999; in Martínez, 2007) a 24-item rating scale, divided into three categories: Independent study, Group interaction, and Reasoning skills, with  Cronbach´s alpha values of 0.96 for the total scale. Tutor´s assessment in Problem-based learning sessions Scale (Dolmans,1994), mixed scale with 16 items, from item 1 to item 13 there are different values, item 14 to 16 are open questions. 4.5 Procedure First two weeks of the course, the subject was managed with a traditional teaching style, then the first CIP was applied, after this, students were informed of the PBL project, and discussed the method that were used for the study (Maastricht University, 2016), at week 3 students started working with PBL method, the course was divided into 10 European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 6 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS clinical cases according to the content and topics established by the program. At week 6 was applied another CIP, and the last one was examined at the end of the course. Each clinical case was evaluated by the tutor, taking care of grading all the dimensions of each instrument, at week 16 the Tutor´s assessment in Problem-based learning sessions Scale was used. Every clinical case was involved in an auto-evaluation of students. 4.6 Data Analysis Data was first analysed with descriptive statistical, trough the help of the SPSS Software (v.20 for Macintosh). To prove the normal statistical behaviour of data, it was used the Saphiro-Wilk test, after the first analysis, data shown not to be normal, therefore to obtain the statistical significance of the relation between Traditional and PBL teaching with the Clinical reasoning, Friedman test was applied. 5. Results Results are shown by categories, ordered by the instrument applied in each time of the research. 5.1 CIP results Mean values of CIP are shown in Table, these results explain the data obtained in each measure during the course of Pathological Nutrition I, each clinical vignette had a total a maximal score of 20 points. Table 1: Mean values of CIP in each phase of application Clinical Mean Values in Mean values in Mean values in Vignette points of Pre-test points of Post-test points of post-test (Week 2) (Week 6) (week 16) Nutritional- 14.84375 7.8125 19.42810458 Laboratories 17.8125 6.25 14.00326797 Nutritional 14.375 9.09375 17.14052288 18.28125 12.5 18.85620915 18.7096 6.875 12.2875817 Clinical File diagnosis Nutritional Treatment Screening After organizing the information in Table 1, the hierarchy in each measure moment is exposed at Table 2. European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 7 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS Table 2: Hierarchy of clinical vignettes, after the CIP application Clinical Vignette Traditional teaching PBL Teaching PBL Teaching (week 6) (week 16) Nutritional-clinical file D C A Laboratories C E D Nutritional Diagnosis E B C Nutritional treatment B A B Screening A D E Based on data of Table 2, it can be inferred that after the intervention of PBL during the course, the clinical vignette of the Nutritional-clinical file improves at first place (19.42 points), in a second place the establish of a Nutritional treatment improved was outstand (18.85 points), then the skill of the nutritional diagnosis was found in third category (17.14 points) each clinical vignette had a total score of 20 points. Statistical significance given by the Friedman test in the SPSS was 0.000000007. 5.2 Student´s performance in problem-based learning tutorial sessions Questionnaire Total Score The instrument was applied by the PBL tutor in each clinical case, the total score of instrument was measured in each clinical case and with the SPSS software, statistical data was obtained. The results of each clinical case are present in Table 5. Clinical Cases were dealt according to the subject course, providing the properly time to each stage of the PBL method; 11 cases were evaluated during the PBL phase. At the end of the 16-week course, students improved some of the skills measured by this instrument. Table 3: Student´s performance in problem-based learning tutorial sessions Questionnaire Total Score Clinical Case N Minimal Maximal score score 93.00 138 125.4063 11.49996 Pancreatitis 93.00 138 123.7500 13.56704 Ulcerative Colitis 32.00 138 115.9688 22.36138 SPRUE 30.00 138 113.7500 22.09364 COPD 93.00 138 127.7500 12.67968 Cirrhosis 81.00 138 125.5625 16.91714 Chron Disease 68.00 136 117.8438 17.75662 Diverticulitis 85.00 137 121.6875 14.49680 Hypertension 93.00 138 130.8125 11.55753 IBS 31.00 136 112.8750 24.58789 Dyslipidaemia 32 Mean Standard Deviation COPD = Chronic Obstructive Pulmonary Disease, IBS = Irritable Bowel Syndrome European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 8 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS Based on Table 5 data, the highest mean value was for the clinical case of Hypertension (130.81 +/- 11.55) and the lowest mean value for IBS (112.87 +/- 24.5). Making a Synthesis of the exposed results on table 5, it can be inferred that the best evaluated case by tutor in PBL sessions was the Hypertension, standing out the different factors involved in the assessment, such as: course period, lacks of PBL method phases or strategies, and in this way, the evaluation of PBL by tutor, becomes a complex topic, because of the solutions that approach to the development of education competencies, and it´s necessary influence to include the ones that are related with clinical reasoning. 5.3 Tutor´s assessment in Problem-based learning sessions Scale The instrument is a mixed scale with 14 quantitative items and 2 open questions for item 15 and 16. The results are shown in table 4 were mean values were obtained through the help of SPSS. The tool is designed as a Likert scale with values from insufficient, neutral, sufficient and non-apply item 14 takes values from 1 to 10 in order to grade tutor´s PBL performance. Application was in pairs, which means that the 32 Mexican students were divided into pairs, all the pairs answered except one, considering at the end only 15 pairs. Table 4: Item mean values of the Tutor´s assessment in Problem-based learning sessions Scale Item N Maximal Minimal Mean Standard score score value Deviation 3 3 3.0000 0.00000 2 2 3 2.4000 0.50709 3 1 3 2.2000 0.56061 4 2 3 2.6667 0.48795 5 2 3 2.4000 0.50709 6 2 3 2.6000 0.50709 7 2 3 2.8000 0.41404 8 2 3 2.7333 0.45774 9 2 3 2.8000 0.41404 10 2 3 2.1333 0.83381 11 2 3 2.5333 0.51640 12 2 3 2.3333 0.48795 13 2 3 2.4000 0.50709 14 7 85 13.5333 19.78407 number 1 15 As it is exposed at table 4, the highest mean value was for item one that evaluates if the tutor is well-informed about PBL (3 +/- 0.0), which suggest that students were agree European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 9 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS about the performance and preparation of the teacher, and it is implied that tutor had a domain of the PBL method. Otherwise the lowest mean value was for item ten, that evaluate if the tutor contributed to a better comprehension of PBL sessions, what means that this was an important opportunity area for the tutor, with these result opportunities may be clearer for future PBL interventions. In case of item 15 and 16, answers were codified with the help of Nvivo software (V. 10.0 trial for Macintosh), they were registered and codified into nodes, and those nodes were measured trying to find the most common answer pattern. Nvivo showed the coverage percentage of each codified answer, taking this as the base of a qualitative analysis. Question of Item 15 is: What is the most valuable judgment of tutor´s behaviour? For this item, the codified nodes were: Knowledge, motivation, practice and responsibility. About item 16, the main codified nodes were: explanation, feedback and cases time; tutor´s work perception from students were synthesized in two main nodes explanation and feedback, students exposed a lack on a deeper feedback, noticing that the tutor must work in this phase or stage. Finally, a correct administration of contents bust me keep by PBL tutor, suggesting a better didactic planning, and trying to establish a better student´s performance, avoiding excessive perfection, and designing more specified purposes in each session. 6. Conclusions and Discussion After a teaching intervention with PBL method in Mexican Nutrition Bachelor students can be concluded that, PBL may improve Clinical reasoning mainly at the clinical vignettes of Nutrition-clinical file, nutritional treatment and assertiveness of establishing a nutritional diagnosis, therefore PBL must be an effective tool that ameliorates skills in Health Bachelor students. One of the challenges on the study was the definition of PBL method, because of the current theoretical framework, it exists many authors, Universities and theories with varieties of PBL methods and applications, differing at the number of stages, the knowledge field, and number of students in classrooms. Finally, and keeping these characteristics Maastricht University method was choice. PBL interventions in Nutrition students must be done in other countries and in several study designs, even it must be in different academic grades. Longitudinal studies have to be done, where PBL may show other skills approaches and development. Sample size could be an important issue; thus reliable population should be included in future researches of PBL. European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 10 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS The quantity of study reports about PBL in Mexico is still low, so it could be convenient to amplify the number of investigations and a deepest research about the skills developed by PBL, such as critical thinking, self-direction, creative thinking etc. Some of the professionals are agree with the usage of PBL with other knowledge fields such as the Social Sciences, so and opportunity area could be standing out in those. Different contexts may be consider as another limitation, considering the teaching experience of tutor, the planning of PBL lessons, registration of evidences, data sources, curriculum, age, country and subjects.  From the present study the next suggestions were generated: It is recommendable that the PBL tutor, spend more time with the feedback method part, as it is reflected on the results, this area may provide strength  resources for future PBL interventions. To invite other Universities for applying PBL in different knowledge fields, not just in Health grades, even in Social Sciences such as Law students, and in Math, with the purpose of improve the professional education competencies in each  different profile. A common proposal is exposed about PBL effectiveness in Schools where teachers does not have the knowledge or preparation in this kind of methods, so, teaching skills may be created by experiencing PBL such as: critical and creative  thinking, and more didactic abilities. Promote PBL researchers in other similar contexts must be a current issue to work on, especially in Mexico where education may still improve in many different aspects. Finally, the students experience was acceptable, but it was shown some resistance to work with PBL method, Higher education Mexican teachers must train to this kind of methods, this would change the way of students in Higher Education prospect. References 1. Ber, R. (1997) Design of an integrative course and assessment method: the CIP (Comprehensive Integrative Puzzle), in: .A.J.J.A. Scherpbier, C.P.M. van der vleuten, J.J. Rethans & A.F.W. Van der Steeg (Eds) Advances in Medical Education. 84-86 (Dordrecht, Kluwer Academic Publishers). Retrieved from 8th August 2016 from: http://link.springer.com/chapter/10.1007%2F978-94-011-4886-3_23#page-1 2. Díaz Barriga, F 6 . Reseña de: “prendizaje basado en problemas. De la teoría a la práctica de Carlos Sola “yape. Perfiles Educativos. XXVIII (111), 124European Journal of Education Studies - Volume 2 │ Issue 5│ 2016 11 Salvador Ruiz Cerrillo PROBLEM-BASED LEARNING (PBL) AND CLINICAL REASONING IN NUTRITION BACHELOR STUDENTS 127. Retrieved 19th of June 2016 from: http://www.redalyc.org/articulo.oa?id=13211107 3. Dolmans, D., Wolfghagen, I. y Snellen-Belendong, H. 994 . Improving the effectiveness of tutors in problem-based learning . Medical Teacher. 16 (4). pp.369377 4. Facione, P. (2000). Test California de Destrezas en Pensamiento Crítico CCTST-2000 versión española (translated by Guisado, S. J). Berkeley: Insight Assessment/The California Academic Press 5. Irigoyen, J. Jiménez, M. Acuña, K. (2011). Competencias y Educación Superior. RMIE. 16(48).pp.243. 6. Jones, M. 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Retrieved 14 July 2016 from: http://www.facmed.unam.mx/sms/seam2k1/2006/ago_02_ponencia.html 25. Woods, R. (2006) Preparing for PBL. McMaster University. (3rd ed.). Canada. Creative Commons licensing terms Author(s) will retain the copyright of their published articles agreeing that a Creative Commons Attribution 4.0 International License (CC BY 4.0) terms will be applied to their work. Under the terms of this license, no permission is required from the author(s) or publisher for members of the community to copy, distribute, transmit or adapt the article content, providing a proper, prominent and unambiguous attribution to the authors in a manner that makes clear that the materials are being reused under permission of a Creative Commons License. Views, opinions and conclusions expressed in this research article are views, opinions and conclusions of the author(s). 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