Figure 1: Example of clinical case presented in Blackboard
| Australasian Journal of Educational Technology 2009, 25(3), 421-439. |
AJET 25 |
Do undergraduate paramedic students embrace case based learning using a blended teaching approach? A 3-year review
Brett Williams
Monash University
This paper presents the results of a descriptive longitudinal study which aimed to identify student paramedic perceptions of case based learning used in the clinical curriculum of the Bachelor of Emergency Health (BEH) degree at Monash University, Victoria, Australia. Case based learning and its integration within clinical curriculum is an important part of undergraduate paramedic education at Monash University. The study used self reporting questionnaires involving 247 students. The analysis provides an indication of the students' perceptions of case based learning in their clinical curricula during the 2005-2007 academic years. Quantitative and qualitative data produced encouraging student satisfaction scores and themes emphasising that case based learning was an appropriate, valuable teaching and learning approach. The data also highlighted that improvements are required surrounding student equity and communication between peers and lecturing staff.
Case-based learning is one of several PBL fusions (others include patient centred learning) that are modelled upon a student centred philosophy. As case based learning is derived from PBL, and as such has similar characteristics (working in small groups and independent study, etc), reference throughout the paper will include both approaches. These teaching and learning methodologies are conceptually supported by the same educational theories used in PBL, influenced by Dewey (1916), Piaget (1968), Bruner (1966), and Vygotsky (1978) and based upon cognitivism, constructivism and perceptions of social learning relationships. The basis for these theoretical frameworks allows students to discover learning that is meaningful to them, whilst scaffolding and constructing new information based on their new learning structures and resources provided by the teacher. The learning environment promotes an autonomous learning stance for students and allows teachers to encourage students to take responsibility for their learning. It also shifts the responsibilities of teachers, who now take an active role in listening and facilitating, not interrupting and directing the students, but instead providing sound advice and guidance with learning resources (Albanese, 2000).
The case based learning process used by the author has been adapted and modified from the Maastricht Problem Based Learning 'Seven-Jump' Process, summarised in the following terms:
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The success of teaching paradigms such as case based learning centres on the accomplishment of interactive tutorial groups as described in the 'seven-jump' process. In many cases, this is where the bulk of student learning takes place (as novices) - a place where students can assimilate, elaborate, debate and massage the theoretical content (thinking as experts) amongst themselves (Bennett, Harper & Hedberg, 2002). Jonassen, Mayes and McAleese (1993) believe that using a case based learning approach allows learners to immerse themselves in meaningful learning and improved metacognitive processes.
Contributions to the case based learning approach include writing authentic clinical scenarios that introduce students to a patient with a presenting clinical issue. This reinforces the notion of case based learning and enhances clinical praxis (Bowen, 1998; Herrington, Oliver & Reeves, 2003; Cook, Thompson, Thomas, Thomas & Pankratz, 2006; Silk, Agresta & Weber, 2006). Increasing clinical praxis for the paramedic discipline is presently important given the contraints being placed on the health sector (Willis, Pointon, O'Meara, McCarthy & Jensen 2009). It is hoped that the simulated cases will provide students with orientation and familarity with the cases they are likely to encounter during completing clinical placements. Each student undertakes approximately 4-6 weeks of clinical placements in a variety of health care settings, both acute and non-acute. This view is reinforced by Bennett, Harper and Hedberg (2002) who added, 'In designing learning environments to support these authentic activities there must be an alignment between the context in which learning is presented in the formal setting and the real life setting in which that knowledge can be called upon' (p.1). Further information about the clinical case is provided, including medical literature (supportive and controversial), vital signs, clinical manifestions and laboratory results.
Figure 1: Example of clinical case presented in Blackboard
Cases were presented in "web page" format to each e-tutorial group in Blackboard (see Figure 1). Students were given between 8-10 cases and additional learning resources per semester, organised around the students' 6 hours per week contact time. Weekly face to face lectures took place on Mondays and Thursdays. Each case reflected the theoretical content and was uploaded following the Monday lecture, allowing students to undertake the case based learning approach prior to the Thursday lecture. E-moderation was structured around the 'Seven-Jump' process, whereby responsive moderation of e-tutorial discussion threads and answering of queries and linkage to relevant learning resources could be made, thus providing scaffolding and individualised learning where possible. Each case was 'closed' on each Sunday, although students had online access to cases and discussions for revision purposes.
Figure 2: Screen picture - quarantined e-tute groups
Each group's discussion was quarantined from the discussions of other e-groups (see Figure 2), allowing each group to have private discussions amongst themselves. This strategy stemmed from the author's previous experience and student feedback, indicating that student saturation of questions and answers occurred on frquently and some students 'took over' or dominated their own e-tutorial group, with negative consequences for fellow learners. In theory (and practice), this process is identical to a small number of student/s consistently answering all questions in a face to face classroom situation. While student numbers increased over the 3 year period, cases and learning resources did not vary substantially.
This study was undertaken over a 3-year period, comparing second and third year BEH paramedic undergraduate students, guided by the following research questions:
| Demographic | % | n | |
| Gender | Female | 67.2% | 166 |
| Male | 32.8% | 81 | |
| Age | < 24 years | 54.7% | 135 |
| 25-44 years | 41.3% | 102 | |
| 45-64 years | 4.0% | 10 | |
The vast majority of students (97%) agreed or strongly agreed that the patient related cases were well organised and the efficacy of case based learning when presenting case related material was also well supported by the students, with the majority (78%) of students agreeing or strongly agreeing that case based learning was an effective way of presenting material, with the remaining students neither agreeing nor disagreeing with this statement.
The bulk of students (84%) also agreed or strongly agreed that case based learning helped to improve their diagnostic skills and lateral thinking abilities. In terms of the development of clinical treatment plans, 79% of students agreed or strongly agreed that case based learning improved the ability to develop treatment plans. Almost nine out of ten (89%) students agreed or strongly agreed that case based learning made their learning experience more enjoyable. A reasonable proportion (21%) reported that case based learning did not suit their learning style, in contrast to 78% of students, who agreed or strongly agreed that case based learning suited the way they learnt. The combined results and comparative data are presented in Tables 2-4.
| Strongly agree (%) | Agree (%) | Dis- agree (%) | Strongly disagree (%) | Mean rating score | SD | Sig. | |
| The cases were well organised | 40.5 | 56.7 | 1.6 | 1.2 | 1.64 | .582 | NS |
| The discussion sessions facilitated interaction between staff and students | 30.8 | 43.7 | 14.6 | 10.9 | 2.06 | .944 | ** |
| Case based learning made the learning experience enjoyable | 30.0 | 59.1 | 6.9 | 4.0 | 1.85 | .714 | NS |
| Case based learning was an effective way of presenting the material | 26.3 | 52.6 | 11.7 | 9.3 | 2.04 | .869 | * |
| Case based learning fostered more beneficial interaction between classmates | 23.9 | 56.7 | 12.1 | 7.3 | 2.03 | .808 | NS |
| Case based learning facilitated more communication between students and lecturing staff | 17.8 | 44.1 | 24.3 | 13.8 | 2.34 | .927 | NS |
| Case based learning suited the way I learn | 23.1 | 55.1 | 12.1 | 9.7 | 2.09 | .858 | NS |
| Case based learning helped to improve my diagnostic skills and lateral thinking | 30.4 | 54.3 | 10.5 | 4.9 | 1.90 | .772 | NS |
| Case based learning improved my ability to treatment plans | 21.9 | 57.9 | 14.6 | 5.7 | 2.04 | .769 | NS |
| This teaching method is a useful preparation in clinical problem solving | 37.2 | 56.3 | 4.9 | 1.6 | 1.71 | .634 | ** |
| NS = not significant. * p < 0.05 ** p < 0.01 | |||||||
| 2nd years 2005 | 3rd years 2006 | Sig. | |||||
| N | M | SD | N | M | SD | ||
| The cases were well organised | 36 | 1.56 | .504 | 96 | 1.65 | .523 | NS |
| The discussion sessions facilitated interaction between staff and students | 36 | 1.67 | .756 | 96 | 2.43 | 1.02 | ** |
| Case based learning made the learning experience enjoyable | 36 | 1.97 | .845 | 96 | 1.76 | .707 | NS |
| Case based learning was an effective way of presenting the material | 36 | 1.86 | .798 | 96 | 2.47 | .951 | ** |
| Case based learning fostered more beneficial interaction between classmates | 36 | 2.11 | 1.03 | 96 | 2.04 | .739 | NS |
| Case based learning facilitated more communication between students and lecturing staff | 36 | 2.47 | 1.15 | 96 | 2.59 | .901 | NS |
| Case based learning suited the way I learn | 36 | 2.17 | 1.08 | 96 | 2.07 | .811 | NS |
| Case based learning helped to improve my diagnostic skills and lateral thinking | 36 | 1.89 | .887 | 96 | 1.99 | .840 | NS |
| Case based learning improved my ability to treatment plans | 36 | 2.03 | 1.00 | 96 | 2.06 | .751 | NS |
| This teaching method is a useful preparation in clinical problem solving | 36 | 1.69 | .624 | 96 | 1.69 | .701 | NS |
| NS = not significant. ** p < 0.01 | |||||||
| 2nd years 2006 | 3rd years 2007 | Sig. | |||||
| N | M | SD | N | M | SD | ||
| The cases were well organised | 45 | 1.58 | .543 | 70 | 1.70 | .709 | NS |
| The discussion sessions facilitated interaction between staff and students | 45 | 1.87 | .786 | 70 | 1.87 | .850 | NS |
| Case based learning made the learning experience enjoyable | 45 | 1.82 | .576 | 70 | 1.93 | .729 | NS |
| Case based learning was an effective way of presenting the material | 45 | 1.69 | .596 | 70 | 1.77 | .685 | NS |
| Case based learning fostered more beneficial interaction between classmates | 45 | 1.91 | .701 | 70 | 2.04 | .842 | NS |
| Case based learning facilitated more communication between students and lecturing staff | 45 | 2.07 | .720 | 70 | 2.10 | .854 | NS |
| Case based learning suited the way I learn | 45 | 1.93 | .654 | 70 | 2.16 | .911 | * |
| Case based learning helped to improve my diagnostic skills and lateral thinking | 45 | 1.82 | .535 | 70 | 1.83 | .742 | NS |
| Case based learning improved my ability to treatment plans | 45 | 2.07 | .618 | 70 | 2.00 | .761 | NS |
| This teaching method is a useful preparation in clinical problem solving | 45 | 1.78 | .471 | 70 | 1.70 | .645 | NS |
| NS = not significant. * p < 0.05 | |||||||
That it can be dominated by 1 or 2 people in a group setting (BEH 3rd year student [14])I really enjoyed smaller groups to discuss ideas with my colleagues (BEH 2nd year student [8])
Great interaction between the student and the lecturer and gave us an opportunity to raise any queries (BEH 2nd year student [17])
Usually one or two people with prior knowledge dominated the case and it was often difficult to contribute (BEH 3rd year student [20])
Too much to read sometimes" (BEH 3rd year student [4])Online CBL work was difficult to find time for and difficult to complete on time (BEH 2nd year student [4])
CBL had a very high demand on time and to be online (BEH 2nd year student [9])
Increased demands on my time and work also made it difficult to participate (BEH 3rd year student [12])
Time restraints also make it hard to participate in the online tute (BEH 3rd year student [8])
Should have allocated time during week for us to complete (BEH 3rd year student [10])
I don't have Internet at home and found it slightly difficult to access information (BEH 2nd year student [23])All on computer - without Internet access at home, often others had answered all questions overnight before I had a chance to look at the case at all (BEH 3rd year student [21])
Can disadvantage some students if no computer at home (BEH 3rd year student [1])
Limited access to Internet (BEH 2nd year student [30])
As I do not have access to the internet at home during the week it was often difficult to participate (BEH 2nd year student [33])
I personally found it a much more effective way of learning (BEH 3rd year student [11])It improves my memory for clinical knowledge (BEH 2nd year student [3])
Great way to remember theory learnt in class (BEH 2nd year student [12])
It suited my learning style to have the information first then to put it into context (BEH 2nd year student [17])
Much better than individual learning in my opinion (BEH 3rd year student [9])
The findings in this study suggested that communication and interactions between instructors and students has room for improvement in the case based learning environment. Several conclusions could be drawn from this. The first is that students were not used to the nature of case based learning, and therefore they could have been confronted by the very real need to 'interact' with each other. The longer the students spend time with each other, so does the likelihood of interacting forces cooperating in an environment which promotes individual competitive performances and the potential for personality and learning clashes (Dolmans, et al. 2001). Such an issue was made explicit in the third year group where certain students were 'taking over' in the e-tutorial group, thus hindering their learning experiences. Similar perceptions were reported by the student groups studied by Atack and Rankin (2002) and Dolmans et al. (2001), who were dissatisfied with the interactions, motivations, and cohesion with others. Other possible factors include difficulties for the author moderating and maintaining an efficient online classroom presence given large e-tutorial group numbers and the computer and Internet access issues for some students.
The literature interestingly balances the negative and positive aspects of student and group dynamics in relation to PBL. Papers by Dolmans et al. (2001) and Visschers-Pleijers et al. (2005) state that no evidence exists with regard to PBL and dysfunctional groups, however a significant amount of literature is available on difficult groups described by teaching staff. Pang et al. (2002) found attributes such as a lack of cooperation amongst students and also an ambivalence about whom they should develop learning group partnerships with. Pang et al. (2002) also found that students tended to be too independent and spent too much time on self directed study, which offset their co-learning with fellow colleagues. They were also able to show that some students encountered difficulties in personality clashes. Of note, the descriptive study by Das Carlos et al. (2003) also highlighted that the most prolific tutorial groups consisted of female group members. This compared to the male groups who were considered less productive and even, in some cases, unproductive.
Case based learning and other educational philosophies require positive, engaged and supportive student to student interactions (Dolmans, et al. 2005). This allows the teacher to act in a facilitator's role, not a dictator role, and allows students to be proactive in their learning. Huda and Brula (1999) draw attention to the well documented literature (Knowles, 1970; Barrows & Tamblyn, 1980) supporting the significant benefits of small tutorial groups within PBL programs.
However it should be noted that the very notion of interdependence is not magically embedded nor embraced and supported in tutorial groups and has been strongly argued by Brown (1998) and Morris and Turnbull (2004). They argued that the elements of student centredness and interdependence cause conflict and tension amongst student groups undertaking such teaching and learning settings (Brown 1988; Morris & Turnbull, 2004). Carpio, Illesca, Ellis, Crooks,, Droghetti, Tompkins & Noesgaard (1999) support this, stating that 'self directed, small group learning is new to many students and may be inconsistent with their learning experiences or preferred learning styles' (p. 35). Dolmans et al. (2005) continue the argument and add that many staff and student groups have experienced dysfunctional colleagues or student groups, and suggest many studies have investigated this area supporting the view that dysfunctional group dynamics can and will occur.
Group interaction and dynamics has the potential to inhibit the effectiveness of PBL orientated group work. The pioneering work by Barrows (1986) on PBL described several key elements to ineffective group attributes: silence, sarcasm, free loading, arguments, and attempts at taking over group learning (Das Carlo, et al. 2003). In practice, group learning environments have been shown by other authors to be less successful (Dolmans, et al. 1996; Hitchcock & Anderson 1997; De Grave, et al. 1999; Stromso, et al. 2004). Of note, 'free loading' and 'taking over' were elements described by the third year student cohorts in this study.
Several studies have attempted to establish positive group dynamics and interactions with learning outcomes (De Grave, et al. 1999; Pang, et al. 2002; Wigen, et al. 2003). This has also led researchers to investigate whether these positive group interactions were related to specific learning styles and if these interactions lead to better academic results (De Grave, et al. 1999; Wigen, et al. 2003). Papers by Dolmans et al. (1998), Iputo (1999), Schmidt et al. (1989) and Slavin (1996) described several positive factors in 'good' group dynamics - motivation, elaboration, cohesion, withdrawing, independence, reasoning skills, and active interaction. Dolmans et al. (2001) stated that 'The studies conducted so far provide empirical evidence that PBL enhances intrinsic motivation in subject matter and is more enjoyable' (p. 886). Of note, Visschers-Pleijers et al's (2004) paper was the only article located that focused on the cognitive interface in student group environments rather than simple group collaborations. They surmised that processes such as elaborations and co-constructions of knowledge were found in small group learning undertaking a PBL tutorial.
With a positive team/group environment, the amount of interdependent learning that takes place may improve. It is therefore reasonable to conclude that group and interpersonal dynamics can facilitate or hinder co-learning and cross-pollination of information and previous educational experience. This is reinforced by Botelho and O'Donnell (2001) and Perrine and Logan (2004) who support this proposition with the view that student to student interaction allows greater motivation thus stimulating greater understanding of concepts and the ability to seek out clarification of ideas or misunderstandings.
So what is the answer? Perhaps teachers should be applying a learning/personality inventory such as the Myer-Briggs (Briggs & Myers, 1962) or Kolb (Kolb, 1984) inventories into student's personality traits prior to dividing students into random groupings? Could this reduce the likelihood of personality clashes and the development of such negative traits as highlighted by Barrows (1986) and Dolmans et al. (2001)? However, consideration should be given to the fact that this type of hostile environment may be considered the norm for the day to day paramedic work environment and thus this is providing them an opportunity to work, learn, and develop confounding ideas and arguments in a 'non-work' environment.
Student interactions between themselves and amongst teaching staff as discussed earlier is one of the hallmark attributes for a successful learning process. The literature indicates that the success of the respective programs and the amount of information retained by students is directly related to the dynamics of classroom/tutorial environments. This is also inversely proportional to the struggle associated with dysfunctional learner groups. The results of these specific data have highlighted one particular question - are student interactions/learner dynamics directly related to dissimilar learner styles or are they related to particular student cohorts progressing through the degree at the same time?
These findings are critical in the context of student centredness since the very success of its pedagogical values is shaped upon the very notion that students communicate effectively. They have the capacity to be self directed and motivated to learn individually or collaboratively with other students, whilst the teacher acts as a facilitator not as a knowledge dispenser. PBL and case based learning are rooted in a belief that communication between students, and between students and teaching staff is important, and that student centred strategies improve these processes. Interestingly, papers by Hay and Katsikitis (2001), Hubble and Richards (2006), Schmidt (1994) and Stromso (2004) identified that students within their study actually felt they required less interaction, communication and general expectations of their teachers as their PBL program continued through the semester. The student responses outlined above led the author to query whether this assumption is justified in all settings, and this question is worthy of further detailed examination.
The study undertaken by Pang et al. (2002) highlighted that students did not find teachers helpful in the PBL program and in many cases did not provide clear guidance and constructive and timely feedback. Positive teacher-student interaction has been identified as a key element to the PBL process. The studies by Choi (2003) and Atack and Rankin (2002) were able to highlight that students who received frequent feedback and communication experienced higher satisfaction levels. The balance between providing feedback and providing the direct knowledge and answers is fine, and is difficult within paradigms like case based learning.
The results indicate communication between students and faculty could have been improved. This is a difficult area, particularly in a case based learning environment. On the one hand, students understand they are expected to learn as autonomous thinkers and communicate with their fellow peers to seek answers and resources, whereas on the other, some students obviously feel more dialogue with the teaching staff could have assisted the case based learning process. There appears to be scope to undertake some form of learner analysis prior and during their undergraduate years, perhaps this will allow teaching staff to better inform themselves on how much communication is actually enough and if students have learnt in a student centred environment before.
Whilst obvious benefits exist with distance education and e-learning approaches in terms of flexibility, timely feedback and possible cost savings to faculty and students, there is a need to be mindful that the technology does not 'drive' one's pedagogy and may in some aspects reduce the quality of teaching.
The BEH students' responses suggest that in many cases case based learning suited their learning styles. However, these data may simply be a reflection of the particular characteristics of these undergraduate paramedic students (for example, age and preconceived ideas about the structure and role of teaching and learning in higher education), and short exposure to case based learning principles do not allow the author to generalise findings to other disciplines and settings. Comparable results were found in research by McParland, Noble and Livingston (2004) who found student's learning styles were not altered nor completely embraced by the PBL curriculum.
The descriptive comparative study by Carpio et al. (1999) attempted to identify the learning styles of student and teaching staff. Their study concluded several key elements, which are parallel to this case based learning research project. Firstly, they suggested that with the changing student population in terms of age, gender, prior knowledge, it would be remiss for faculty staff not to re-examine their students' learning styles prior to engaging in their programs. This educational principle is supported by several authors (Cook & Dupras, 2004; Yang and Cornelious, 2005), who also encourage teaching staff to undertake learning style inventories on their student groups. Secondly, Carpio et al. (1999) conclude that identification of the students' learning needs allowed a greater perception from the students on the vital elements to group and independent learning. Finally, they discuss the importance of not only assessing their students' learning styles but their own teaching staff. They suggest that unknowingly, teachers will automatically teach according to their own learning style, which may be incongruent with the students' learning preferences. This is reinforced by the study by Schoenfeld-Tacher et al. (2005) who observed teachers vary their teaching styles according to their own learning styles.
Antepohl and Herzig's (1999) study of medical students found that the majority of students preferred PBL as it suited their learning styles. The meta-analysis by Vernon and Blake (1993) found that approximately 10% of students performed better academically whilst undertaking a PBL program, compared with standard students, although other studies (Albanese & Mitchell, 1993; Berkson, 1993) have suggested that little or no effect occurs upon students' academic achievement. Similar research (Coles, 1985; Newble & Clarke, 1986) reported that medically trained students educated under different teaching methodologies used a predominant inclination towards constructivism. Students tended to perform better and retain knowledge and skills when they could construct their own learning needs within the subject context (Wigen, et al. 2003).
This study did not formally assess students' learning style prior to teaching engagement. Based upon the literature and critical reflection as a teacher, perhaps teaching staff (including the author) should be assessing their own and students' learning styles prior to any teaching engagement. This is probably more important where teaching strategies use online environments (Cook & Dupras, 2004).
Overall, the findings of this study cannot be taken to be representative of lecturing staff teaching case based learning programs at large, rather they offer the experiences of this particular group of individuals, but they do provide new levels of understanding of paramedic programs which is important in this specific area of health science education.
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| Author: Mr Brett Williams, Senior Lecturer Department of Community Emergency Health & Paramedic Practice Monash University, PO Box 527, Frankston, Victoria 3199, Australia Email: brett.williams@med.monash.edu.au Web: http://www.med.monash.edu.au/cehpp/ Please cite as: Williams, B. (2009). Do undergraduate paramedic students embrace case based learning using a blended teaching approach? A 3-year review. Australasian Journal of Educational Technology, 25(3), 421-439. http://www.ascilite.org.au/ajet/ajet25/williams.html |