Research Article

Analyzing the implementation of a new

curriculum: A qualitative study

Analyzing the new curriculum: a qualitative study

MARDIASTUTI WAHID1, AMITYA KUMARA2, TITI SAVITRI PRIHATININGSIH2,

GANDES RETNO RAHAYU2, RITA MUSTIKA1 & ESTIVANA FELAZA1

1Universitas Indonesia, Indonesia, 2Gadjah Mada University, Indonesia

Author for correspondence: Dr. Mardiastuti Wahid, MD, MSc., Department of Microbiology,

Faculty of Medicine, Universitas Indonesia, Pegangsaan Timur 16, Jakarta 10320, Indonesia.

Tel: +62 21 31922850, Fax: +6221 3100810, E-mail: mardiastutiw@yahoo.com

Presented in AMEE 2014 Conference, Milan, Italy

Abstract

The Faculty of Medicine, Universitas Indonesia has implemented the competency based

curriculum with student-centered learning as a learning strategy since 2005. Problem-based

learning (PBL) is one of learning approaches chosen. The aim of this study is to analyze the

preparation, implementation and evaluation of the new curriculum at institutional and faculty

level. This study is a single case study with a multiple unit analysis. Participants were selected

using the purposive sampling method. Participants were the former dean and vice dean, the

curriculum developers (5 persons), the program coordinator (1 person) and module organizers (3

persons). Data were collected by conducting a structured in-depth interview. Other supported

documents regarding students’ assessment and program evaluation were utilized. At institution

level, the organizational structure was more complex. Changes were focused on education

management and staff organization. At faculty level, education management was shifted to

multidisciplinary integration. The strong leadership and commitment of the leaders and medical

education unit members played an important role in a new curriculum development.

Nevertheless, some limitations were identified. However, based on students’ assessment results

and program evaluation, the outcomes of the new curriculum were in a good shape.

Introduction

The world is changing all the time, innovation and adaptation are required to overcome the effect

of globalization and information technology development. Changes on those aspects have an

impact on the educational system and administration. Educators are challenged to fulfill

communities’ need to renew the educational process. The competencies of principals as the

agent of change should be achieved to improve educational systems. (Gamage and Pang 2003)

Rapid changes in medical and health care services should be followed with the development of

medical education (Harden 2007). In developing countries where shortage of resources and

educational quality are becoming problems, higher education should be shifted from teaching to

training in obtaining information and applying knowledge to solve problems encountered at

national level (Majoor and Niemantsverdriet 2010).

To answer the challenge in medical education, competency-based curriculum was established

50-60 years ago worldwide. Curriculum is based on the outcome which should be achieved. As

mentioned by the International Competency-based Medical Education (ICBME), the definition

of competency-based medical education is (Frank et al. 2010):

“An outcomes-based approach to the design, implementation, assessment, and evaluation

of medical education programs, using an organizing framework of competencies.”

ICBME proposed the major principles of CBME which were primary focus on students’

outcome or competencies and students’ abilities, discourage time-based learning, and stimulate

student-centered learning. Curriculum is arranged based on competencies or abilities distributed

into educational objectives. Elements of curriculum were developed in a constructivist way

(Frank et al. 2010).

Problem-Based Learning (PBL) is one example of student-centered learning strategies. It is

established based on a new paradigm in medical education: constructive, collaborative,

contextual and self-directed learning (Dolmans et al. 2005). Students work together in a small

group discussion after being presented with a scenario or trigger. They learn how to build

knowledge, direct their own learning and link their knowledge obtained with their future

professional life. (Dolmans et al 2005) The implementation of PBL is a challenge for developing

countries since at senior high school students are mainly having lecture. Instead, if the students

accept the concept of student-centered learning which has more benefits, then it can replace the

lecture which is usually inefficient (Majoor and Niemantsverdriet 2010).

In response to these rapid changes in medical education globally, the Directorate General of

Higher Education, Ministry of National Education of the Republic of Indonesia instructed to all

higher education institutions to adopt competency-based curriculum (CBC) with emphasis on

student-centered learning. The Faculty of Medicine, Universitas Indonesia (FMUI) established

the CBC in 2005 along with PBL as the main learning approach. The aim of this study is to

analyze the preparation, implementation and evaluation of CBC in term of the change

management at institution and faculty level.

Methods

This study is a qualitative study, a single case study with a multiple unit analysis. Purposive

sampling method was applied to select the participants. At the institutional level, participants

were the former dean and vice dean (2004-2008), the curriculum developers (3 clinical and 2 pre

clinical staffs) including former manager of education, medical education chairman and

members. At the faculty level, participants selected were the program coordinator (1 person) and

module organizers (3 persons). A structured in-depth interview was conducted to collect data.

Interviews were recorded, thereafter transcribed, coded and analyzed according to the themes

emerge. Concepts were developed based on categories identified. To triangulate collected data,

we utilized other supporting documents such as students’ assessment results and program

evaluation reports.

Results

A. Institution Level

At institutional level, we identified 87 categories which were finally narrowed to 8 categories

which were policy (2 categories), leadership (1 category), experience on prior PBL

implementation (2 categories), management and organization (4 categories), planning (5

categories) , implementation (3 categories), evaluation (2 categories) and revision (3 categories).

Policies

In 2004, the DGHE instructed all higher education institutions to conduct competency-based

curriculum with emphasis on student-centered learning. Therefore, the dean (2004-2008)

appointed a curriculum team which consisted of the vice dean, manager of education, chairman

and members of MEU to develop a new curriculum namely competency-based curriculum or

faculty curriculum 2005 (CBC 2005).

Leadership

Leadership plays an important role in the new curriculum implementation. The dean showed a

strong leadership and commitment in implementing CBC 2005, as mentioned by one of

curriculum developers :

“ The most supporting aspect is the leader commitment” (WIAJ, lines 1-2, paragraph 27).

“ ...spirit building, it means that support by the faculty leaders was unbelievable”

(WIMR, lines 9-11, paragraph 10).

The dean supported and encouraged staff, showed enthusiasm and conduct medical education

training for staff development. He also supported staff members who are going abroad to attend

medical education conferences or other medical education workshop/training or short courses.

Without a strong leadership, the new curriculum will never be launched. As an outcome, faculty

resistance was minimal. The curriculum design members also showed their committment by

working hard, they showed enthuasiasm and motivation in developing the new curriculum.

Experiences of Prior PBL Implementation

PBL as a learning approach actually has been implemented at the FMUI since 1995. But, due to

the lack of preparation and socialization the program was terminated in 1996. Fortunately, in the

year 2000 FMUI received a grant from the DGHE to improve the quality of the undergraduate

medical education program through enhancing integrated and active learning, critical thinking

and clinical reasoning skill. In conjunction with this program, FMUI established a medical

education unit (MEU) in 2002. However, we also faced some other problems, such as mindset

of traditional education and understanding of PBL as recorded from a conversation below:

“The understanding of PBL is varies, so that it will give impact to the trigger

construction” (WIMD, lines 139-141, paragraph 2).

Organization and Management

The dean delegated and engaged the curriculum development team in designing the new

curriculum. He was the locomotive of a train consisting of faculties. Staffs not willing to

participate were left behind. The change management mostly occurred on the management of

education and organization. The academic vice dean directed all academic affairs such as the

manager of education, medical education unit, post graduate and undergraduate program

coordinators. Educational management shifted from departmental to integrated multidisciplinary

teaching. At faculty level, the staff from various departments took part in the module

development and implementation. Problems arose in uncertain job description of the

undergraduate program coordinator and MEU, also among MEU members.

Planning

The new curriculum was designed by a curriculum developer team. The team conducted some

intensive meetings among members, including members of the deans’ office. Students’

involvement was minimal. Preparation included developing the infrastructure such as a skill lab,

discussion rooms, a computer lab and also access to books as well as journals. The human

resources unit collaborated with MEU in conducting PBL facilitator training and other roles of

staff members as medical teachers. All staffs, including the Rector was obliged to participate in

the training of facilitators. It was decided that staff member could become a facilitator only after

completing the facilitator training. After the curriculum development was completed, the team

conducted a road show to almost all departments in order to socialize the CBC 2005. The

preparation process was smooth due to the strong support, leadership and commitment of the

deans’ office together with MEU members, although we found varieties on the perceptions of

PBL concepts among staff members.

Implementation

The curriculum implementation was monitored continuously. To appreciate staff members who

were willing to get involved in education, the deans’ office developed a reward system, such as

remuneration. So far, the new curriculum was well conducted although there were some

difficulties discovered. Some aspects should be given attention such as staff members’

commitment, varieties in understanding PBL and resistance of participating members although it

was minimal.

Evaluation

Formative assessment was conducted twice, including a progress test, held twice a year at the

end of a semester. Summative assessment consisted of theory, laboratory practice, discussion

process, basic clinical skill plus a comprehensive test at the end of the final year. Remediation

test were taken by students who failed at a module.

Program evaluation was conducted by distributing questionnaires to students concerning the

implementation of the module. Facilitators were evaluated by the students by answering

questionnaires through internet. To know the students’ satisfaction on their learning

environment, we used DREEM.

Revision

Attention should be given to improve staffs’ performance on assessment, trigger construction

and understanding of PBL.

B. Faculty Level

By interviewing the program coordinator and module organizers, we identified 85 categories

which were compressed into 5 major categories: planning (3 categories), management and

organization (3 categories), implementation (4 categories), evaluation (4 categories) and

revisions (4 categories).

Planning

The plan for module arrangement had been done at institutional level. The module team was

assigned by the dean. The team was supported by 8-10 staff members as a team member from

multidisciplinary departments. Therefore, they worked to integrate knowledge and skill which

should be delivered to the students. Every year the team revised the instructional design book;

triggers were developed based on the 10th most common diseases in Indonesia. The instructional

design book was then reviewed by the medical education members. The preparation of all

resources was done along with the development of the instructional design book. In PBL

tutorial, one facilitator has the responsibility assisting 8-10 students. Extra effort was needed to

encourage faculties to be committed and having a sense of belonging of the new curriculum.

Obstacles which were found included trigger construction, infrastructures’ maintenance,

subjects’ coverage and staff commitment.

“Since the vice chairman is a clinical staff, she has never come to the modules’ meetings”

(WPNP, lines 13-15, paragraph 11)

However, an experienced chairman who was supported by a concerned vice chair contributed

to the success of the module preparation.

Management and Organization

Program coordinator delegated the program implementation to year coordinators. Modules’ team

worked under the supervision of the year coordinators. Leadership of program coordinator and

module chairman played an important role in mobilizing the organizational structure under their

jurisdiction. Program coordinator have a strong leadership, has the capability in making

decisions. Program coordinator held an annual meeting at the end of the year with the year

coordinator, module chairman and administrative staff. The chairman and secretaries of

modules’ team were appointed from preclinical departments, while the vice chair was selected

from clinical departments to help the team in developing triggers and has the responsibility in

organizing students’ assessment. The secretary was responsible in daily activities on module

implementation. During the development of the instructional design, the module chair held

several meetings and collected information from team members. However, some difficulties

arose concerning of coordination, communication, members’ commitment and authority

delegation from chairman to the vice chairman and secretary.

Implementation

Types of learning activities held were lecture, PBL tutorial, plenary, laboratory practice, basic

clinical skill, video conference, and special topics discussion. Students were not obliged to attend

lectures, but they have to attend other learning activities at least 80% of the total activities.

Facilitator led students’ tutorial using Brandas’ steps. They attended tutorial session on time, and

if they did not able to attend the tutorial, available staffs were provided by the module organizer.

Dean has an important role in supporting the curriculum change and faculty development in

medical education. Some faculties were sent abroad to learn more about medical education and

attend medical education seminars/conferences. Unfortunately, we still find lack of module

management and infrastructure development.

Evaluation

Evaluation design was written on instructional design and students’ guide book developed by

module team. Students have to take both formative and summative exams twice/module. If

she/he failed they have chance to take remedial test once. Facilitators were assigned to evaluate

tutorial process using an evaluation form contained activities, disciplines, dominances,

argumentation, and communication. Program evaluation was based on questionnaires concerning

the module performance, modules’ report, progress test, comprehensive test and National Exam.

Some difficulties identified were obtaining items for the test, items were mainly developed from

lecture and had a poor quality, too difficult, not appropriate with the learning objectives, only

tested superficial knowledge (factual) and exams’ schedule was too tight. However, from

documents analysis we found that students’ exam and National Board Examination results

showed that on average our students achieved good grades.

Revision

Interviewees suggested some aspects that need improvement such as management, learning

activities, evaluation and resources. The comprehensive test should be improved; staff has to be

aware that comprehensive test purpose is not for assessing the content. Learning methodologies

must be standardized. In addition, staffs have to be motivated to increase the quality of education

and implement coaching program before the remedial test. Other efforts that can be done

included developing good communication, a clear job description of the module team, strong

administrative staff, encouraging staff in using e-learning in their teaching-learning activities and

improving information technology and infrastructure maintenance.

Discussions

Davis et al (2007) has stated that never expected to be able to develop a curriculum for the first

time. Curriculum will be continuously changed and need to be renewed in order to respond

changes in medicine. There are ten steps in developing curriculum mentioned by Harden (2009):

1. The need of training program

2. Expected learning objectives

3. Content

4. Content and sequence organization

5. Educational strategy

6. Learning methods

7. Students assessment and program evaluation

8. Communication to all stakeholders, including students

9. Educational environment

10. Curriculum management

In our study we found that the curriculum developer team followed most of the steps above.

Furthermore, along with the new curriculum development, infrastructures were prepared to

support students’ learning. The dean office and medical education unit held in-house facilitators’

training and sent staff abroad to attend workshop on medical education, especially on PBL. Our

findings also aligned with Mc. Leod and Steinert (2014), who proposed the twelve tips for

curriculum reform. Some tips that we have done at our university, such as developed a strong

curriculum developer team; used evidence-based approach from prior experience; developed

remuneration system; ensured appropriate content and sequence of learning experiences;

evaluated the new curriculum and prepared learning resources.

In addition, as stated by Wong and Hubbal (2011):

“Curriculum reform is a complex and labor-intensive process requiring significant time,

energy, expertise and support (e.g. committed and influential leadership to foster a

curriculum learning community, faculty development and adequate resources)”.

It is evidence that curriculum reform needs a revolutionary change management, a complex

process from planning to evaluation and the most important thing are leadership, commitment,

communication and coordination. Our study found that without leadership of the dean, it is

impossible to mobilize staff to implement the new curriculum. At the faculty level, authority

delegation and clear job description were required to support the success of the change

management. According to Wolfhagen and Scherpbier (2010), a strong professional staffs’

support was needed to ensure the success of the curriculum governance. It is preferable to have a

multilayered organization with its clear tasks and responsibilities. The faculty has to consider on

staff carrier development. Human resources development, especially in context with the

continuing education has to be aimed to assure the quality of education and prepare staff

members in facing the environmental changes.

As mentioned before, our institution adopted PBL as one of learning approaches used in the

new curriculum. Achike (2003) proposed that the success of PBL implementation in a medical

curriculum is depended upon 3 major factors:

1. Administrative (top management) who understand and accept PBL philosophy and have

commitment in administrative, financial and politics matters;

2. Students who have the same perceptions and understanding of PBL. The success of

curriculum implementation is relied on graduates’ knowledge, attitude and skill.

3. Tutors who understand, accept and willing to implement PBL as its philosophy. Tutors

can influence students’ knowledge and attitudes.

From all factors described, the mayor factor should be considered is the management of the

medical school, so that one can minimize the problems arising from other factors (Achike 2003).

The departments’ involvement was shown by their participation and responsibility in giving their

expertise to the module related to their disciplines. In fact, the module organizer consists of

departments from multidiscipline. According to Wolfhagen and Scherpbier (2010), the

performance of each department was monitored by the educational board. Staffs and departments

received feedback of their performance through educational board. Instead of educational board,

we have a medical education unit who monitor and evaluate the implementation of the new

curriculum and gave feedback to the staff members.

Other important factor is the tutors. Tutors should have internalization on PBL philosophy

and enthusiasm in order to implement the curriculum successfully. Students’ motivation is also

crucial. It can be enhanced by conducting a various assessment types. It is important to

encourage a mutual collaboration between staffs and students, so that the curriculum can be

implemented as has been planned (Achike 2003). Furthermore, lessons learn from prior

experience with PBL implementation showed that preparation of curriculum reform and

socialization of the new curriculum was critical. Some obstacles occurred due to staff mindset of

traditional curriculum and understanding of PBL. The poor understanding and various

perceptions on PBL were seen not only on staffs, but also on students. In addition, compare to

study held in Chinese medical school on curriculum reform identified problems on training and

organizing staff members, coordinating interdisciplinary departments, developing learning

resources and changing staff mindset (Huang et al. 2014).

Factors recommended that have to be improved including staff performance, quality of exam

item and the availability of qualified learning resources. Staff commitment plays an important

role in the quality of education. The institution in such a way must develop staffs’ sense of

belonging on the reformed curriculum (Wolfhagen & Scherpbier 2010). Therefore, they will

fully commit in implementing the new curriculum.

Conclusion

We have analyzed and established concepts on the curriculum change at institutional and faculty

level. Among factors influence the success of the new curriculum implementation, leadership,

commitment, communication and coordination were found to be the predominant factors.

Practice Points

A strong leadership and commitment of the leaders is the key of success of a new

curriculum implementation.

Various aspects should be considered when one would develop a new curriculum,

such as unclear job description, lack of staff commitment and understanding of PBL;

poor communication and coordination among modules’ organizers; and limited of

qualified resources availability.

Notes on contributors

MARDIASTUTI WAHID, MD, M.Sc, PhD, consultant clinical microbiologist, medical

education unit member, medical educator at Faculty of Medicine, Universitas Indonesia.

AMITYA KUMARA, Professor, M.Sc, Ph.D, vice dean at Faculty of Psychology, Gadjah Mada

University.

TITI SAVITRI PRIHATININGSIH, MD, MA, M.Med.Ed, Ph.D, chairman medical education

department, medical educator at Faculty of Medicine, Gadjah Mada University.

GANDES RETNO RAHAYU, MD, M.Med.Ed, Ph.D, medical educator at Faculty of Medicine,

Gadjah Mada University.

RITA MUSTIKA, MD, MEpid, medical educator at Faculty of Medicine, Universitas Indonesia.

ESTIVANA FELAZA, MD, M.Med,Ed, medical educator at Faculty of Medicine, Universitas

Indonesia.

Declaration of interest: There is no conflict of interests concerning financial and publication of

this study.

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•Aspects:

•Realization

•Ease (Remuneration)

•Consider:

•Staff

•Understanding of PBL

•Resistances

•Student assessment:

•Formative : formative test , progress test, comprehensive test

•Summative : process evaluation, summative test, remedial, competencies test

•Program evaluation: module evaluation, satisfaction on learning environment

•Aspects:

•Development process

•Infrastructure

•Ease

•Consider: Varieties in understanding of PBL

• Trigger

•Human resources

• Evaluation

REVISION PLANNING

IMPLEMENTATIONEVALUATION

Organization and managementAspects:

Change management Management of MEUManagement of module

Consider:

Job distribution

Policies

LeadershipCommitment

Experiences in prior PBL implementation

Consider : Mindset, understanding of PBLSocialization

Figure 1. PBL implementation at institutional level

PLANNINGResources

EaseDifficulties: trigger, staff,

infrastructure, material coverage

ORGANIZATIONA AND MANAGEMENTLEADERSHIP

Program CoordinatorModule Organizer

Obstacles: communication/coordination,,

authorities delegation, COMMITMENT

IMPLEMENTATIONLearning activitiesFacilitatorObstacles : resources, module managementEase: leader’s support

EVALUATION

Evaluation planStudent assessmentProgram evaluation

Obstacles: item quality, test implementation, learning

outcomes

REVISIONManagement

Learning activitiesEvaluationResources

Authorities delegation

PROGRAMCOORDINATOR

MODULECHAIRMAN

Figure 2. PBL implementation at faculty level