Institutional Support and Leadership Sustain Problem-Based Learning Across Medical Programs

A comparative qualitative study examining problem-based learning across two continents demonstrates that sustaining collaborative medical curricula depends fundamentally on continuous institutional resources, structured tutor development, and committed administrative leadership. Researchers evaluated the long-term enactment of problem-based learning curricula in medical schools at Linköping University in Sweden and Moi University in Kenya, both of which established problem-based learning models during the 1980s. Problem-based learning serves as an established instructional approach in health-professions education designed to foster active, self-directed learning, integrated clinical reasoning, and collaborative problem-solving rather than passive memorization from lectures. Despite decades of institutional experience at both sites, the investigation revealed that core educational principles face persistent risks of procedural dilution when medical faculties encounter systemic pressures such as inadequate instructional spaces, unmanageable group sizes, heavy staff workloads, and disconnected assessment practices. The authors identified system support for upholding the principles of problem-based learning as the central overarching theme across both institutions, demonstrating that educational viability requires coordinated institutional commitments rather than leaving instructional success to the isolated survival strategies of individual faculty members and student groups.

The study setting comprised two distinct medical education environments operating within markedly different socio-economic and structural conditions. Linköping University operates within Sweden, a high-income welfare state with universal healthcare, enrolling approximately 1,200 medical students across four distinct campuses affiliated with nine regional hospitals and 106 primary care centers. Moi University operates within Kenya, a lower-middle-income nation where healthcare provision confronts pronounced resource constraints and uneven regional access, enrolling approximately 800 medical students at a single campus affiliated with one teaching hospital and 16 primary care units. Both universities maintain instructional cohorts of approximately 100 academic faculty members connected directly to their medical programmes alongside 80 to 100 affiliated clinical educators. In both institutions, formal tutorials occur twice weekly for two hours per session utilizing structured stepwise problem-based learning models. However, group sizes differ substantially between the sites, as Linköping University organizes tutorials into small cohorts of six to eight students, whereas tutorial groups at Moi University frequently accommodate double that number, regularly ranging from 15 to 20 students and occasionally expanding to more than 30 participants.

To capture direct educational experiences, the research team conducted four focused group discussions involving a total of 24 purposively selected participants during 2023. At Moi University, academic recruitment for the first-term student discussion was coordinated through the student class leader, resulting in a focus group of seven first-year medical students, comprising four females and three males in their twenties, who met in November 2023 for 67 minutes. A separate educator focus group at Moi University involved six tutors, comprising five males and one female, held in August 2023 for 60 minutes, where all participating tutors possessed at least ten years of instructional experience in problem-based learning tutorials as lecturers, senior lecturers, or assistant professors. At Linköping University, seven first-year students, including four females and three males from a randomly selected tutorial group, participated in a 60-minute session held in February 2023. Four Linköping University tutors, consisting of two female and two male senior educators with at least ten years of tutorial facilitation experience as assistant professors or full professors, took part in a 65-minute focus group conducted in April 2023.

The collected qualitative data were examined through latent thematic analysis following the six-phase inductive framework established by Braun and Clarke to uncover recurring operational patterns and latent structural meanings. All focus group audio recordings were transcribed verbatim, after which three investigators conducted preliminary skimming and documented analytical ideas during an initial online meeting and an on-site brainstorming workshop. Detailed text readings followed, wherein the investigators collectively identified excerpts and systematically applied qualitative codes into a centralized analysis document for three of the four transcripts, while the fourth transcript was coded by the lead author and subsequently reviewed and validated with minor adjustments by the co-authors. Preliminary groupings of codes were developed into candidate subthemes and an overarching theme, with candidate categories further refined by splitting dense conceptual areas and clarifying definitions to generate robust representations of tutorial dynamics. The final analytical output resolved into one overarching main theme alongside five interlinked subthemes addressing participant understandings of educational principles, practical tutorial dynamics, the facilitator role, onboarding and continuous competence development, and the necessity of procedural clarity through leadership.

The first subtheme focused on participant understandings of problem-based learning principles, contrasting shared conceptual appreciations against the operational uncertainties encountered by junior trainees. Students and faculty across both campuses affirmed that problem-based learning promotes a significantly more active and intellectually engaged learning climate than traditional lecture-dependent formats, teaching students how to locate information, evaluate complex data collaboratively, and synthesize findings into coherent clinical reasoning. Nevertheless, first-year medical students at both sites encountered difficulties in calibrating their self-directed study, noting that they often felt as though they were fumbling in the dark while trying to separate essential concepts from extraneous medical literature. Tutors corroborated that learning how much reading is sufficient represents a universal challenge for beginners. To navigate this ambiguity, students relied heavily on the explicit learning outcomes contained in institutional course outlines, while tutors emphasized that written clinical scenarios must be intentionally drafted to stimulate curiosity, reasoning, and creative inquiry rather than serving as rigid reading checklists.

The second subtheme revealed significant structural and cultural divergence in how problem-based learning is enacted daily during student tutorials. Tutorial sessions at both universities commonly operated with a designated student chairperson guiding group discussion and a designated student secretary recording notes. Within Linköping University, student groups practiced what educational researchers describe as learning as a group, wherein the entire tutorial cohort collectively examined shared learning objectives, relying on reciprocal trust, open dialogue, and peer feedback at the conclusion of sessions to refine gaps in understanding. Conversely, tutorial groups at Moi University tended to adopt a learning in a group model, dividing broad scenario objectives into isolated sub-topics allocated to individual students, who then conducted independent research and presented summaries during the subsequent session. Furthermore, students described deploying varied supplementary resources between tutorials, ranging from textbooks, digital videos, and lectures to memorization flashcards, with participants noting that individual accountability and shared responsibility remain imperative for effective peer-directed learning.

The third subtheme analyzed the pivotal role of tutors alongside the operational barriers that impede facilitators from upholding core student-centered learning methodologies. Facilitators are tasked with scaffolding group inquiries, questioning logic, fostering professional role modeling, and keeping students aligned with stepwise procedures without directly lecturing or providing pre-packaged answers. However, excessive workloads and resource shortages severely undermined facilitator practices, particularly at Moi University. Tutors reported that expanding enrollments and staff shortages created heavy operational strain, prompting some educators to abandon open exploration in favor of delivering mini-lectures on examination content to save time. At Moi University, severe scheduling conflicts occasionally led to tutors being unavailable, leaving junior students to navigate tutorials unassisted or creating an informal reliance on postgraduate students stepping in as co-tutors. Even at Linköping University, where faculty members articulated a clear commitment to facilitating rather than transmitting knowledge, tutors observed instances where specialists drifted toward lecturing, or where students established parallel curricula to manage examination burdens.

The fourth subtheme underscored the critical necessity of introducing new students and faculty to educational philosophies while establishing continuous competence development for tutors. Although Linköping University requires new educators to complete a mandatory training course in problem-based learning, faculty workshops offered once per semester attracted only approximately ten percent of teachers, predominantly drawing experienced facilitators rather than newer recruits who carried traditional lecture habits. At Moi University, an introductory course for tutors previously existed but was no longer mandatory, resulting in newer faculty members mistaking introductory topic overviews for standard lectures and reverting to didactic teaching. Both student and tutor participants at Moi University noted that formal student orientation to problem-based learning had been shortened over time, leaving first-year students initially confused regarding why faculty were not delivering direct lectures. Tutors across both settings advocated for recurring departmental forums where course coordinators, year coordinators, and facilitators could systematically align expectations, review learning processes, and formalize mentorship pipelines.

The fifth subtheme highlighted that maintaining procedural clarity across medical programmes demands firm administrative leadership and adequate institutional infrastructure. At Moi University, tutors described significant logistical friction, including mismatched room allocations where scheduled classrooms could not physically accommodate oversized tutorial groups of 20 to 30 students, compelling classes to spend tutorial time wandering campuses to secure seating. Severe timetable violations also occurred, resulting in tutorial sessions conflicting directly with scheduled examinations. Furthermore, Moi University tutors noted an institutional shift within their department of medical education, which had redirected its primary operational focus away from assisting wider faculty with problem-based learning implementation toward administering its own independent academic programs. At Linköping University, leadership challenges manifested around curriculum alignment and assessment policies; faculty reported that the widespread administrative adoption of multiple-choice examinations, driven by the labor required to grade open-ended analytical responses, conflicted with the holistic, reasoning-focused objectives of problem-based learning.

The authors evaluated several methodological considerations, noting that the study utilized purposive and convenience sampling among first-year cohorts and experienced tutors, which may limit generalizability across entire student populations or other institutions. Selection bias represents a recognized limitation in qualitative research, as voluntary participants may possess higher enthusiasm or stronger critique regarding curriculum dynamics than non-participating peers. Nonetheless, investigator triangulation reinforced analytical dependability, as three experienced educators conducted shared coding, discussed contextual terminology, and maintained reflexive review to balance personal familiarity with the two academic programs. Ultimately, the comparative findings demonstrate that problem-based learning cannot sustain its educational fidelity purely on historical momentum. Without robust leadership, protected staffing ratios, dedicated physical rooms, aligned evaluation methods, and institutionalized tutor development, medical curricula inevitably drift toward teacher-centered shortcuts, underscoring that active student learning requires systemic, well-resourced administrative foundations.

Subject of Research: Qualitative comparison of problem-based learning sustainability and institutional support in Swedish and Kenyan medical schools

Article Title: Sustaining Problem-Based Learning (PBL) in medical programs: insights from two continents

Article References: Karlsson, E., Mosol, P., Kågedal, K., Dahlgren, M. A., Appell, M. L., & Musau, P. (2026). Sustaining Problem-Based Learning (PBL) in medical programs: insights from two continents. BMC Medical Education, 26(1), Article 1830. https://doi.org/10.1186/s12909-026-10786-7

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10786-7

Keywords: Problem-Based Learning, Medical Education, Qualitative Research, Linköping University, Moi University, Medical Curricula, Health Professions Education, Thematic Analysis, Tutor Training, Curriculum Sustainability, Educational Leadership, Higher Education, Tutorial Dynamics, Faculty Development, Student Assessment, Comparative Education