|Year : 2021 | Volume
| Issue : 1 | Page : 11-18
Qualitative analysis of student responses to survey questions investigating student perceptions of case-based learning
Katherine Fogelberg1, Micha Simons1, Stacy Anderson2
1 Center for Innovation in Veterinary Education and Technology, Lincoln Memorial University College of Veterinary Medicine, Harrogate, TN, USA
2 Office of the Dean, Lincoln Memorial University College of Veterinary Medicine, Harrogate, TN, USA
|Date of Submission||09-Nov-2020|
|Date of Acceptance||15-Dec-2020|
|Date of Web Publication||7-May-2021|
Dr. Katherine Fogelberg
Center for Innovation in Veterinary Education and Technology, Lincoln Memorial University College of Veterinary Medicine, 6965 Cumberland Gap Parkway, Harrogate, TN 37752
Source of Support: None, Conflict of Interest: None
Background: This qualitative study applied discourse analysis to open ended question responses of fourth semester veterinary students enrolled in case based learning (CBL) course. This was the first CBL course incorporated into the curriculum and was delivered via teams of two professors for each of eight sessions. Aims: Questions were designed to investigate student perceptions of CBL and determine how it impacted their learning. Results: Results were reported to faculty to help them deliver high quality, engaging, and challenging CBL sessions that pushed students without being discouraging. From a cognition and learning perspective, students felt that CBL helped with learning at all levels of Bloom's taxonomy, encouraged metacognition, and helped prepare them for clinical rotations and postgraduation careers. From a mechanics and delivery perspective, students desired resources to help them use cases to learn about species in which they have a particular interest beyond the classroom; wanted interactive sessions and in class assessments, primarily involving individual responses using audience response software (clickers); enjoyed class and small group discussions; and preferred little to no out of classwork or assignments unless explicitly related to the case and expectations for the assignment(s) is/are clearly laid out. Conclusions: Overall, most students wanted more CBL and found it engaging, fun, and supportive of their learning.
Keywords: Case-based learning, clinical reasoning, critical thinking, discourse analysis, qualitative research
|How to cite this article:|
Fogelberg K, Simons M, Anderson S. Qualitative analysis of student responses to survey questions investigating student perceptions of case-based learning. Educ Health Prof 2021;4:11-8
|How to cite this URL:|
Fogelberg K, Simons M, Anderson S. Qualitative analysis of student responses to survey questions investigating student perceptions of case-based learning. Educ Health Prof [serial online] 2021 [cited 2021 Jun 13];4:11-8. Available from: https://www.ehpjournal.com/text.asp?2021/4/1/11/315626
| Introduction|| |
Inquiry-based learning (IBL) methods have waxed and waned in health sciences education for decades, although there is much literature discussing their advantages and disadvantages.,,, One of the more popular IBL methods, problem-based learning (PBL), originated at McMaster University and was implemented in their medical school in the early 1970s. PBL had promising early results and was touted as a panacea for the challenge of teaching medical students the clinical reasoning and critical thinking skills required for successful patient care. Unfortunately, replication of PBL's success has been inconsistent, and its use is still somewhat controversial. [2,6-10] This is probably due to several factors, including the intense up-front workload, the lack of PBL training and resources, the student pushback, and whether the curriculum is completely or partially PBL delivered.,
While PBL's popularity decreased over the last few decades, its resurgence – along with other IBL methods - in professional school curricula is occurring as increasingly the idea of students as knowledge repositories has caused concern.,, Case-based learning (CBL), pioneered in the early 1900s at Harvard's Business and Law Schools, is somewhat easier to incorporate while generally retaining the reported PBL benefits.,, CBL is more structured than PBL and calls upon students' prior knowledge while simultaneously incorporating information that they have not yet been exposed to; it also requires students to engage in critical thinking, problem-solving, and research that aids them in coming to reasonable conclusions about the presented case., Faculty redirect students when they are getting off track and encourage students to ask questions. This method is particularly useful in clinically based programs such as psychology, social work, public health, and medicine. CBL is often also referred to as a guided inquiry pedagogical method.
Reports on IBL from the students' perspective across a variety of programs, including veterinary schools, are common. CBL is perceived as being easier to incorporate than PBL and less frustrating to students and faculty during sessions. Thus, for these reasons and those stated above, some conclude that CBL is preferred over PBL by large margins,,,,,,,,,,,,,,, and studies looking at CBL, whether in isolation or in comparison to PBL, generally confirm the positive effects it has on student cognition and learning.,,,,,, Our research supports the extant literature in this regard; suggests some specific ideas for faculty who wish to incorporate high-quality CBL into their curricula; and introduces evidence that the mechanics and delivery of such sessions impact student learning and engagement.
This study applied discourse analysis (da) to anonymous, end-of-session surveys completed by fourth-semester veterinary students as part of their course grade. We set out to determine how CBL impacted overall student learning and what they desired in a CBL session's delivery. Results were reported to faculty to help them deliver high-quality, engaging, and challenging CBL sessions that pushed students without being discouraging.
Why incorporate case-based learning?
Medicine is both art and science; it requires scientific knowledge and understanding of the physical world as well as creativity and willingness to follow your “gut” or “intuition” when warranted. As a discipline, medicine requires critical thinking, analytical skills, and an ability to reflect upon successes and failures in ways that allow the clinical practitioner to avoid making the same mistakes twice. This metacognition, or thinking about one's thinking in a critical, reflective manner, is one of the hallmarks of successful medical practitioners; it is a metacognition, in addition to critical thinking and clinical reasoning, that the inquiry-based methods such as CBL attempt to cultivate in veterinary and human medical school students.
However, as outlined in May 2016 article, healthcare professionals who teach must do better at understanding the mechanics of how we become experts at clinical reasoning. Without this understanding, delivering CBL courses may be more confusing than helpful to early-stage medical students because they have to grasp the concept of simultaneously thinking backward (deductive reasoning) and forward (inductive reasoning) and applying what psychology researchers might call metacognition.
CBL can aid students in learning and reviewing content while increasing their skills in critical thinking, clinical reasoning, and metacognition. While ideally facilitated by faculty who have both specific content matter expertise and a solid understanding of teaching and learning theories, even in the absence of the latter, CBL can still be effective. It is helpful that students appear to enjoy the process much more than they do with lectures, demonstrations, and even other active teaching methods.,
Approach to data and data analysis
The method and theory of da have been around for over 2000 years, coming into their own in the latter half of the 20th century, when it was applied to the structure of texts to determine how the linguistic and sociocultural dimensions created meaning. Other applications included identifying various forms of verbal exchanges to see how they manifest power and authority. French theorists and philosophers shifted back to written texts, but looked at the ways writing affects power structures within society. This evolution of da was perhaps natural, given that its many predecessors, such as semiotics and content analysis, were somewhat restrictive in their applications.
James Gee first differentiated between Discourse Analysis (DA) and da, with DA including “all parts of the communicative act, including the environment, the language, and the individuals' internal and external gestures and thoughts” and the latter taking into consideration only written or transcribed words. Gee additionally expanded the application of DA/da to looking at the intent of those uttering or producing the discourse, rather than only determining how the discourse expresses power or creates meaning. Discourse, Gee argued, implicitly expresses power or creates meaning; what was needed was a systematic way to map and analyze the D(d) iscourse that allowed researchers to study those utterances “between the lines.” It is Gee's da, which allows interpretations of the discourse presented and elucidation of the students' meanings from their responses, which is applied both theoretically and analytically here.
| Methods|| |
This study was approved by (Lincoln Memorial University) IRB, number 923.V.0. The Qualtrics survey (Qualtrics XM, Seattle, Washington, USA) consisted of seven questions that were identical for each session. A total of 121 fourth-semester students participated in each of eight case sessions and were asked to respond to a survey with identical questions after each session as part of their course grade. Results from the four open-ended questions [Appendix A] are reported here.
Eight different cases were presented by instructor teams of two; five were presented face to face and three virtually due to the COVID-19 pandemic. For each, a primary instructor was responsible for creating the case and course sessions, including activities, assignments, and assessments. Because the course focused on interpreting diagnostics, a board-certified clinical pathologist was the supporting instructor for all cases except Case 5, where a board-certified radiologist participated instead. Instructors had full control over their session except for species and required anonymous student surveys, which were graded as complete/incomplete based on submitted screenshots of the survey completion page. Each session is outlined briefly below; all materials and quizzes were made available to the students before, during, and after each session on the university's learning management system (LMS).
Case 1 covered ketosis in a dairy cow and was facilitated by a board-certified large animal internist; it was delivered through an interactive PowerPoint presentation consisting of informational slides, embedded TurningPoint questions (Turning Technologies, Youngstown, OH; commonly called “clicker questions”), and several think-pair-share activities.
The second case was focused on zinc toxicity in a dog and required individual pre-session work that asked students to assess provided patient information, formulate questions, project what might be found during physical examination, interpret physical examination findings, and work on a diagnostic plan. The session incorporated class and small group discussion, PowerPoint slides with additional case information, and periodic question/answer sessions. A postclass SOAP note group assignment served as their final assessment for the case.
Case 3 asked students to work through feline diabetic ketoacidosis; it also asked students to respond to a series of questions about the case embedded within the prework. The same format as Session 2 was used and the postclass assessment was a small group collaboration, resulting in consensus responses to the pre-session questions. Both cases were facilitated by the same experienced small animal clinician.
Case 4, facilitated by a veterinarian whose practice is limited to small animal surgery (residency trained), introduced ferret diseases and focused on adrenal disease. A PowerPoint presentation with integrated laboratory data, radiographs, and photographs, along with small group discussions and full class case workup, was used. The instructor also posed specific questions to ensure the objectives were met, and the session concluded with a group created document.
A veterinary anatomist explored canine myxomatous mitral valve disease with congestive heart failure in Case 5. PowerPoint with photographs, embedded videos, and clicker questions integrated throughout was used, and an individual quiz via the LMS was completed.
Cases 6 through 8 were fully virtual due to the COVID-19 pandemic. Case 6 was facilitated by the same instructor who facilitated Case 4. It was a prerecorded “choose your own adventure” style PowerPoint presentation exploring a feline foreign body; in it, students were encouraged to work in small groups and complete the case virtually during a set time period. At the end of the session, students completed a short individual quiz.
A board-certified large animal surgeon facilitated Case 7 addressing equine septic arthritis. The case and accompanying quiz-type questions, consisting of matching, ordering, multiple choice, multiple answer, fill in the blank, and true/false, were posted for students to attempt individually prior to reviewing the case as a class. Questions were designed to encourage clinical reasoning skills, and many used images that relied on important prior learning in courses such as anatomy, clinical pathology, and diagnostic imaging.
Case 8 introduced copper toxicity in a goat and was facilitated by the same board-certified large animal internist who facilitated Case 1. The instructor progressed through the case using PowerPoint that incorporated multiple-choice and word cloud clicker questions. The case concluded with a quiz delivered via the LMS.
Data organization and analysis
The data were organized by session, with each session having the questions and responses included sequentially (i.e., Session 1, Question 4, responses; Question 5, responses). Each group of responses was printed for manual analysis, resulting in 106 pages of data (19, 17, 15, 12, 13, 12, and 12 pages for Sessions 1 through 8, respectively).
da was completed only by the primary author (Fogelberg ) due to time constraints. Each reading analyzed all responses to a single question across the eight sessions (i.e., all responses to Question 4 were analyzed together, then all responses to Question 5).
The first reading yielded field notes in the margins of each data set to capture the coder's impressions; the second reading resulted in underlined and circled words and phrases labeled with the author's initial codes, yielding 20+ potential themes, such as “eliminate groups,” “improves clinical reasoning,” and “available resources.”
The third reading was a review of the data, codes, and potential themes, leading to chunking. This was the most complicated step, as the codes from each set of responses were re-evaluated to determine if the initial themes should remain, after which initial themes were cross-referenced across questions to determine whether similar themes emerged from other question sets. In Question 5, for example, there were several codes related to student thinking and learning (review/test prep, application, synthesis/transfer, and metacognition), which turned into “Bloom's taxonomy” and “metacognition.” Moreover, in Question 6, there were 13 labels noted: improves clinical reasoning, knowledge expansion, different thinking, improve critical thinking, reinforces previous learning, realistic so prepares for future careers, gain skills in working up cases, deeper/faster/better learning, knowledge application, knowledge review, knowledge synthesis, and metacognition. These turned into student benefits: skills and learning and student thinking.
Ultimately, seven themes were identified. However, based on outside review, the original seven themes were revisited and ultimately condensed into two overarching themes: “cognition and learning” and “mechanics and delivery.” A similar process was used to reach the second theme; it is this theme that produced the suggestions for faculty who wish to incorporate CBL into their classrooms.
Throughout the analytic process, data saturation was reached at about halfway through coding. Cross-referencing of the data pre- and post-COVID further cemented the consistency of the final two themes, as the change from in-person to virtual teaching halfway through the semester did not appear to affect the results. Thematic consistency was revealed after continued review of the previous initial codes and early themes. Cognition and learning were strongly represented within Questions 5 and 6 responses, with mechanics and delivery being present across Questions 4, 5, and 7, indicating sufficient overlap to justify these large themes. Triangulation by a single coder was achieved via saturation, pre- and post-COVID cross-referencing, and consistency of themes across responses.
| Results|| |
The cognition and learning theme is addressed first, and it affirms that CBL helps students review, apply, synthesize, and evaluate their previous knowledge. It influenced some students to consider their learning as a whole: what they remembered, what they had forgotten, what was fuzzy, and where they might need to ask for help, indicators of metacognition. We also found that CBL helped students gain confidence in their knowledge and feel better prepared for clinical practice, all of which led to students desiring more CBL opportunities.
Cognition and learning
While there were a few concerns about incorporating content that had not yet been taught (e.g., radiology, ultrasound), this was quite rare. It is important to note, however, as faculty concerned about bringing in content that has not yet been taught should take comfort that this is not a big issue. Otherwise, as outlined here, the response to CBL was very positive.
Demonstrations of student thinking and learning spanned the gamut of Bloom's taxonomy [Figure 1]. CBL consistently helped with review and reinforcement of previous learning: “review of joints and laceration treatment” (Q5S7p6) and “allows us to put what we have learned to use and is a good reminder for some stuff we may have forgotten” (Q6S6p9).
Application of learning to “real-life” cases was also clear:
- This case was great because my group members and I were able to figure out what was most likely wrong with this case just based on the clinical signs and history. We came up with a great format for how to gather a full history, and we also came up with a really good diagnostic plan. I was really proud of how we were able to take all of our knowledge and put it to work on this case. These cases have been helping me apply my knowledge a lot, and I honestly have amazed myself with how much I actually know (Q6S6p9).
Strong indications of meaningful knowledge synthesis were apparent: “I really liked this case because it integrated two issues that we had learned about as their own issues but had not really discussed concurrently” (Q5S3p6); “Having practical clinical information presented in a way that connects all of the material we have learned” (Q5S2p8); and “It helps us keep our minds constantly connecting things we tend to compartmentalize” (Q6S1p14).
Integration, connection: two action words synonymous with synthesis that students used to describe their experience with CBL. This language indicates that Students saw how everything they had learned supported everything they would learn and be expected to do; they are beginning to think about their learning in new ways.
Improvements in critical thinking and/or clinical reasoning skills were clearly indicated: “...it gives us real-world problems and ways to think critically through them” (Q6S4p13) and “(cases) help students learn the thinking process for going through a case” (Q6S6p8). Such statements are important in supporting that CBL positively influences these necessary professional skills.
Although not quite as prevalent, it warrants mentioning that the concept of metacognition clearly emerged from the data:
I think that CBL is the best way for us to realize where our gaps are. For instance, in this case, I realized that I really need to go through horse anatomy, since that's what I had the most struggles thinking through, but I was surprised at how much of the diagnostics and medications I was familiar with (Q6S7p80).
Realizing knowledge gaps and strengths is a strong indicator that metacognition is beginning, which is an integral part of students learning to think inductively and deductively simultaneously.
Better self-understanding of knowledge strengths and gaps appeared to help students feel better prepared for clinical practice and, in some cases, increase self-confidence: “...it makes you think like a veterinarian in the real world” (Q6S5p9) and “...I think this class will make better vets, we'll have the confidence to make adequate decisions in our every day (sic) practice” (Q6S3p10).
Students recognized some gaps in experience and knowledge and wanted cases to help them address these: “I think it is important to learn about species that we don't learn a lot about and see more [exotic] cases like this” (Q7S4p14) and “Learning more about small ruminants [was helpful]” (Q5S8p4). However, regardless of species, students recognized that working through real-life cases helped better cement their recently acquired knowledge:
“This case really brought together my knowledge from every class, it made me use my clinical reasoning skills along with all the acquired knowledge from anatomy and physiology. I love this teaching method, it's as though we have a 'teaching hospital' within the classroom” (Q6S1p13).
One unexpected finding was that students appreciated the instructor team approach. They liked having multiple perspectives on each case and enjoyed each team's breadth/depth of knowledge: “I liked having both course professors give their expert opinion” (Q5S5p6) and “More cases with different professors...would be great!” (Q7S5p12).
While not overtly connected by the students, it seems reasonable to assume that for all of these reasons, students overwhelmingly wanted more CBL.
“MORE! MORE! MORE! I think we should have more cases, especially (large animal)...it gives us our 'passion' back and reminds us veterinary medicine is more than the challenging (sic) exams; that the information we're learning we will be using every day in practice” (Q7S1p17; emphasis original).
Mechanics and delivery
The mechanics and delivery theme provided some concrete information regarding our students preferred delivery methods and how the physical environment might influence their overall engagement. The results reported here start building a foundation for our faculty to help them obtain a clearer idea of the interactive techniques that our students found most engaging during CBL specifically. However, such information is also valuable to those considering using interactive techniques in their lecture-based classes.
A wide variety of interactive methods were employed by the faculty teams, including small group work, class and small group discussions, audio-visual aids, think-pair-share, and clicker questions. Interestingly, while students consistently failed to recognize these techniques as interactive except clicker questions, they did enjoy them. Clickers, however, were almost universally cited as being effective, useful, interactive, and preferred methods of class engagement, whether for an informal quiz or formal assessment. “More interactive potentially with clicker questions” (Q4S2p1) comments were typical, while “The audio clips of the heart murmurs were extremely helpful” (Q5S5p4) and “...It would have been great to have some anatomy photos scattered throughout as well for visualization purposes” (Q5S7p2) comments were occasionally woven in but never demonstrated understanding that such content was also interactive.
Students had strong preference for individual assessments and assignments, again using clickers. “...I love my clicker questions, it shows what you really know about the subject. Whereas (sic) in groups, you may be leaning on someone else's knowledge” (Q7S4p14); “I liked having clicker questions instead of being called upon, (sic) gave everyone a chance to think and answer/not panic/be more focused on the material” (Q5S1p6). This aligned with the idea that postclass assignments were not appreciated, whether as a group or individually: “No homework/busy work” (Q7S4p15), said one succinctly, while another was a bit gentler: “I enjoyed the clicker questions instead of a group postassignment” (Q7S1p16).
However, digging deeper into the data revealed that the homework itself was not necessarily the issue: “Giv(e) students an appropriate description of the assignment, or [be] more specific about what is wanted in the assignment submission” (Q4S2p1). Comments such as these indicate that homework is not negatively viewed when assignment instructions are clear and obviously related to the case at hand. Additional support for this idea is that many expressed appreciation and/or a desire for preclass readings/assignments: “Provide some information prior to class so students can prepare for case discussion” (Q4S1p3) and “A preclass assignment aids in our understanding of the case” (Q7S4p14).
Students also wanted more detailed PowerPoint presentations and subsequent access to them, more suggestions for specific textbooks and/or articles relevant to each case, and online links to high quality resources pre- and post-case: “...A lot info [sic] was given verbally...Lack of words on the slide made to [sic] harder to follow along/keep up with everything (Q4S8p1), and:
I really liked how this case had additional articles and resources to go along with it. This allowed me and my group to do some research and extra learning as we walked through the case. I would love to see more of the cases have those kinds of articles (sic) accompany them (Q7S6p12).
Thus, doing group work was acceptable if it explicitly related to the case at hand, and many students recognized the value in doing nongraded small group exercises during the sessions: “I liked having group discussions before having the class discussion” (Q5S2p9), and:
Working through this session within your own chosen group was very beneficial. It allowed us to work through it at our own pace and talk through some of the important concepts ...it also allowed for us to ask questions to our peers and get responses from those that knew. I think that this aspect was best because it allowed certain students to teach other concepts that they knew and vice versa(Q5S6p5).
However, students strongly preferred that groups be preassigned (as opposed to being assigned during the class session), and a few asked for “Smaller groups –...it was very difficult to hear people from one end of your group to the other with the size of our groups” (Q4S1p2).
Several comments about classrooms not being conducive to active learning were noted. While not prevalent, faculty should consider the activities they wish to incorporate and whether available learning spaces can accommodate them. It also indicates that students are influenced by their physical environment when learning, something that is often not addressed.
Finally, use of the LMS and technical connectivity issues within the classroom was mentioned as student learning disruptors. In particular, poor organization within the LMS was noted, although students were generally forgiving, especially after the COVID-19 pandemic began.
| Discussion and Conclusions|| |
Veterinary schools are once again investing in IBL methods, as there has been more widespread recognition that students merely being viewed as knowledge repositories are less than ideal.,, CBL is an IBL method that can be effective even in the absence of facilitator training, as long as the facilitator(s) have content expertise and a willingness to approach the session in a manner that engages and appropriately challenges students.
Many studies have demonstrated the value of incorporating CBL into health professions curricula, and we add to this body of knowledge, specifically within veterinary medicine.,,,,,, This study qualitatively investigated student perceptions of CBL to determine how it impacted their learning and to elucidate the types of teaching techniques they preferred. Our students were asked broad, open-ended questions about their experiences in CBL; their responses provided evidence of their cognition and learning and the types of activities they most desired.
Student responses ran the gamut of Bloom's taxonomy of learning and even spilled into the realm of metacognition, providing strong evidence that CBL can effectively support students' critical thinking, problem-solving, and research skills that help them come to reasonable conclusions about the cases, as stated in the literature., That students explicitly recognize the effects of CBL on their cognition and learning when given the opportunity to provide open-ended feedback is encouraging. In addition, and unexpectedly, students commented that CBL helped them feel more prepared for clinical rotations and practice. This finding had not been noted in the CBL literature by the authors and is another strong endorsement of CBL in veterinary school curricula.
We were also able to parse out what mechanics and delivery techniques our students preferred, and in an effort to help our faculty prepare for future CBL sessions, we gave them a summary of this information. We report them here as suggestions to faculty looking for guidance when hoping to create high-quality, engaging, and appropriately challenging CBL sessions.
Based on our study, we suggest the use of clicker questions for formal and informal assessment purposes; incorporation of a variety of audio/visual aids into the presentation; and using discussions both in small groups and as a full class. We caution against graded small group assignments, urge homework accompanied by clear instructions that are explicitly tied to the case, and suggest that ungraded pre-session work, along with high-quality resources, students can refer to before, during, and after each session, be integrated. Finally, when possible, we highly recommend team teaching during CBL. Understanding it is not always practical to have two faculty of different expertise/experience facilitate such cases, with the rapid changes that COVID-19 has wrought; we believe that this is achievable and can be highly impactful. Our program continues this technique and we look forward to seeing if our 1st-year students also remark upon this aspect of their CBL sessions.
Limitations and future work
The amount of data was considerable for a qualitative study; it consisted of 121 student responses to 32 open-ended questions (four per survey, eight surveys total). Thus, although it represents only one cohort of fourth-semester students at a single school, it provides good insight into our students' preferences when engaging in CBL. However, as with all qualitative data, it is not generalizable to other programs or even other students at different points in the curriculum. It would be interesting to survey students in other veterinary schools that use CBL and those in different semesters of the curriculum to see what differences, if any, might occur.
In addition, as with all qualitative research, the findings presented here represent the interpretations of the authors and, more specifically, the individual coder. However, they do provide a jumping-off point for further investigations into student perceptions of CBL on a broader scale, and we feel comfortable that our suggestions can help others using CBL create high-quality sessions that are challenging to students without being discouraging. We are currently collecting responses to an identical survey from first-semester veterinary students enrolled in a CBL course to determine if there is consistency across cohorts in our program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Appendix A: Open-ended survey questions
Question 4: Give us your suggestions for how to improve this session.
Question 5: Tell us what was particularly useful about this session.
Question 6: Tell us why you think there should or should not be more case-based learning.
Question 7: What else would you like us to know so that we can ensure you receive the best learning experience possible?
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