Case-based learning

Introduction

It is useful to think of case-based learning (CBL) as a teaching method that uses a set of events unfolding over time to stimulate an activity (Shulman, 1992). In clinical education cases make use of clinical narratives to create an authentic learning activity. CBL represents an approach to unstructured learning that can nonetheless be scaffolded in the sense that students choose the details of what they want to explore, while the case designer chooses the broad themes that must be covered. It is therefore an attempt to convey a balanced, multidimensional representation of the context, participants and reality of a clinical situation.

Cases are based on complex clinical situations or problems that should aim to stimulate discussion and collaborative groupwork among students (Flynn & Klein, 2001). They usually involve the interactive, student-centred exploration of those problems while being guided by facilitators. Since the cases are complex, students must analyse them as they try to resolve problems and answer questions that have no single, or simple, correct answer.

Case-based learning reduces the likelihood of students constructing inert knowledge that is decontextualised from how that knowledge will be used in the real world. If the case is an accurate representation of what can be expected in the real world, then the knowledge produced is more likely to be of use when they encounter similar events in the clinical context.

Benefits of CBL

CBL offers the following advantages (David, 1954; Flynn & Klein, 2001; Herreid, 1997; Lombardi, 2007):

  • It provides students with authentic situations in which to explore and apply a range of behaviors and information that can strengthen the learning of knowledge that transfers between different situations.
  • When students participate in the analysis and discussion of alternative solutions they come to better understand difficult or complicated issues and analyse them more effectively.
  • The emphasis on the process of decision making requires students to synthesise information from a variety of disciplines and subject areas.
  • Students can use the case as a base from which to launch their own, personally meaningful investigations into a topic or theme.
  • New technologies and resources can be integrated in order to solve problems. The use of images, video, audio and collaborative writing platforms can enhance the case, increasing the authentic context that promotes deep learning.
  • Cases can help students develop multiple perspectives, as opposed to hearing about patient management from only one point of view (usually the lecturer’s). Cases emphasise the value of interdisciplinary and collaborative approaches, skills that are increasingly important in health care systems.
  • In the process of finding solutions and making decisions through collaborative group work, students must sort out factual data, apply analytic tools, discuss issues, reflect on their experiences, and draw conclusions that can be related to new situations. Through this, they develop analytic, collaborative, and communication skills that are essential for the clinical context.
  • Cases provide students with the opportunity to see how to apply theory in practice. This can lead to graduating students who are more engaged, interested, and involved in the clinical environment.
  • CBL develops students’ skills in group learning, public speaking, and critical thinking.
  • Cases can be used effectively with both large and small classes or groups.

In summary, the benefits of using CBL in the classroom can lead to the development of knowledge that is not decontextualised, as well as skills that are relevant for working as part of multidisciplinary clinical teams.

Theoretical foundations of CBL

Collins (1988, pg. 2) described the idea of “learning knowledge and skills in contexts that reflect the way they will be used in real life”, as situated learning and cognition. When decontextualised material is presented to students (as it is during a lecture), they have difficulty deciding how to integrate that knowledge into their practice i.e. to bridge the gap between the classroom and clinical spaces. Being able to use information effectively requires that students learn it in the same, or similar, contexts as those in which they will be expected to use it. When knowledge and context are separated, knowledge is seen by learners as a product of education, rather than a tool to be used within dynamic, real-world situations. Authentic learning positions the task as the central focus for authentic activity, and is grounded in the situated cognition model (Brown et al, 1989; Herrington, Oliver & Reeves, 2003). In other words, meaningful learning will only take place when it happens in the same social and physical context in which it is to be used.

In addition, to situated learning and authentic learning, CBL also draws on elements of constructivism, in which students actively work to construct their own meaning from the learning opportunities presented to them. No matter what the intention of the teacher is, if students do not engage with the learning experience, they will have difficulty integrating the concepts that the teacher is presenting (Prideux, 2005). Social constructivism builds on this concept still further, and suggests that meaningful knowledge is only developed through discourse with a more knowledgeable other (Vygotsky, 1978). The teacher (or more experienced peer) helps guide the student through the zone of proximal development, the conceptual distance between what the student can do alone and what they can only do with the assistance of another (Vygotsky, 1978).

It is clear then, that CBL as a teaching and learning method has significant theoretical support, offering more than a practical framework for the design of classroom activities. It is an approach that helps students develop the ability to apply abstract concepts and ideas to clinical situations, in an authentic context that leads to personally meaningful learning.

Common characteristics of cases

While cases can cover a broad range of topics, patients, conditions and environments, most effective cases have the following generic characteristics (adapted from Dolmans et al., 2009; Flynn & Klein, 2001; Herried, 1997; Wasserman, 1994):

  • Content should be closely aligned with one or more of the overall learning objectives for the course or module.
  • They tell a story and focus on a current issue that arouses interest. It should draw the reader into the story and enhance interest in the subject matter, helping to sustain discussion about possible solutions and encourage students to explore alternatives. The ending of the narrative could be open-ended, allowing students to develop their own conclusions.
  • It should be well-written and appropriate for the level of the students and could include direct quotes, using the characters’ dialogue to tell the story. It should be compelling and create empathy with characters, aiming not only to make it more engaging but because the attributes of the characters can influence the decisions that students make.
  • Include situations that students know about or are likely to face, therefore making it worth their while to complete. The content should adapt well to their prior knowledge and contain cues that stimulate them to use that knowledge.
  • Stimulate self-directed learning by encouraging students to generate their own learning outcomes and conduct literature searches in order to answer research questions that they come up with themselves.
  • Should provoke conflict and force decision-making, clearly presenting the dilemma but not resolving it. Include conflict or ambiguity so that students do not agree on the outcome, encouraging compromise and decision-making.
  • Collaboration and cooperation should be encouraged, rather than competition.
  • The case should be short. It is easier to hold someone’s attention for brief periods than long ones.

Designing effective cases

Before beginning to design the case, it’s important to determine what the objectives of the case will be. Begin by explicitly stating the purpose of the case and what specific knowledge and skills you’re trying to develop in the students (Dent & Harden, 2005). Provide some background for the case by inserting it into a larger health system context, which serves to inform students why they are going to be working on this particular case and why it is appropriate for them as part of their training. By making it more relevant, they are more likely to actively engage with it. Learning outcomes might need to be changed in order to reflect the idea that the knowledge gained should be used as a tool as part of a process, rather than an end in itself. In other words, it’s not enough to know a series of facts, but rather how those facts can be applied to solve real-world clinical problems. Designing authentic tasks is challenging, and readers are encouraged to review Authentic Learning as a framework to guide this process (Herrington, Oliver & Reeves, 2003).

It is useful to design cases that based on actual patients, which serves to increase its authenticity, as well as leaving less room for error (Marks & Humphrey-Murto, 2005). Place less emphasis on the volume of content to be covered and spend more time designing cases that facilitate the development of critical thinking and clinical reasoning. Pay attention to preparing resources for the case, including artefacts like policy documents, X-rays, referral letters, research papers, readings from textbooks, images of real patients, and videos. The range of materials is enormous and depends on the level of the students, complexity of the case, the creativity of the case designer and objectives of the module. These resources should be as authentic as possible in order to reduce the cognitive dissonance experienced by students when the classroom context is logically inconsistent with reality.

It should be noted that the key to success is the quality of the small group discussion, which is an integral aspect of CBL (Christensen 1987; Flynn & Klein, 2001; Wetley, 1989). Without the discourse associated with exploring new territory, students will not have the opportunity to analyse, generate and evaluate solutions, solve problems, or make decisions. These are the types of learning activities that give students an active role in the learning process, thereby helping them to develop and improve their higher-order thinking abilities. The content of cases and the process of discussion are therefore inseparable in CBL and designers should ensure that reasonable time is allocated for this activity.

Generic content, or content that is relevant across a wide range of contexts, should be included in multiple cases in order to show students the different ways it can be used. For example, hypertension is a concept that is relevant for a range of cases that could involve heart disease, amputation, stroke and maternal health. The same is true of professional ethics, which can be explored across a diverse range of cases. In this way, the student is introduced to the idea that information can be used in many different ways, and that knowing the facts is less important than knowing how those facts can be used to solve problems in different contexts.

Finally, a multi-disciplinary team approach is recommended when designing cases. This has several advantages, including the increased likelihood of catching errors, more creativity, better resources, the inclusion of domain-specific expertise and ultimately, a more authentic case.

Preparing students for CBL

If this is the first time students are faced with CBL they will most likely have a few concerns. These can include the fact that they will be more responsible for their learning, the realisation that they are covering less content than friends from other classes or institutions (who are not using CBL), and general anxiety because the approach is new to them. These concerns can be addressed by discussing with them (as many times as necessary) the benefits of using CBL. You can also use one session to guide them through the process of completing a case, possibly with a topic that isn’t formally included in the course, to take the pressure off of getting the “right” answer.

While we may like to think that our students are capable of working collaboratively in groups, we often find that they work cooperatively as individuals. They split the work into smaller chunks and then assign those chunks to people in the group with one person taking responsibility for combining all the pieces at the end. The problem with this is that no single member of the group actively works on the project as a whole. Even the person who combines it all is only acting as an editor, giving a consistent aesthetic and voice to the content. Without actively engaging with all of it throughout the process, this form of cooperative groupwork has little value in CBL. Therefore, students will have to be taught and guided through a process of collaborative groupwork, including how to allocate roles, what those roles should be, how to negotiate group norms, setting consequences for failure to comply with group norms, resolving conflict, reporting what is learned back to the group and a host of other skills necessary for effective groupwork.

Designers should aim to create a space in the module for students to share and discuss their concerns, helping them to resolve any issues that arise. As they become more experienced with working in groups students will begin resolving their own problems.

Working through a case

Working through a case usually involves the following problem-based approach, although the specific steps used will likely be an adaptation of this. The following structure (or some variation of it) is usually used by groups when working through a case.

  1. One person reads the case out loud for the group.
  2. The group members identify words and phrases they don’t understand.
  3. They confirm what they do understand, and ensure that they all have the same understanding.
  4. Identify the clinical or functional problems (depending on the objectives of the case) that may arise as a result of the information presented.
  5. Brainstorm possible causes of the problems, taking on board every suggestion no matter how unlikely. This needs to be a safe space for students to be OK with sharing openly and without judgment.
  6. Structuring and hypothesis: students begin to systematically and logically explore relationships between concepts, narrowing down possible causes of the problems identified. They should create a list of statements that look something like “We believe that….because of….”
  7. Generate research questions in order to fill in the gaps in understanding and to “prove” the statements that they have made.
  8. Conduct research in order to find evidence to support (or refute) the statements.
  9. Finish with a set of notes that: i) Define words and phrases relevant to the case. ii) Present problems the patient is likely to have, possibly using the International Classification of Function (ICF), or another outcome measure that they would be expected to use in the clinical context. iii) Highlight relationships between clinical presentation and functional problems, supported by evidence. iv) Document the appropriate assessment and management of the patient. v) Note that the items presented above would vary significantly depending on the type of case, and the learning outcomes described at the outset.
  10. At the next session, each member of the small groups present to each other within the small groups. The purpose of this is to consolidate what has been learned, clarify important concepts and identify how the group is going to move forward (if the case is still not complete).
  11. At the end of each week each small group presents to the larger group. This gives them the opportunity to evaluate their own work in relation to the work of others, to make sure that all of the major concepts are included in their case notes, and the opportunity to learn and practice their presentation skills. Students could also be expected to evaluate other groups’ work.
  12. Note that students may begin moving between steps as they develop their clinical reasoning skills, which is only a problem if the process becomes one of unthinking, rote behaviour, in which case completing the activity will not have the desired impact on critical thinking.

In addition to the more detailed steps listed above, students could also use a simpler, six step IDEALS approach when working through a case:

  1. Identify the problem (What is the real question we are facing?)
  2. Define the context (What are the facts that frame this problem?)
  3. Enumerate the choices (What are the plausible actions?)
  4. Analyse the options (What is the best course of action?)
  5. List reasons explicitly (why is this the best course of action?)
  6. Self-correct (What did we miss?)

Using the questions above, they begin to get a sense of the case and what it is about as well as situating themselves and their prior knowledge within that context. They identify the basic concepts and questions that will serve as a basis for progressing through the rest of the case. This approach helps to create a broad outline for the case before delving into the more complex aspects. For very simple cases students can also be guided by the following questions:

  • What do I know that will help me to solve this problem?
  • What do I think I know that I’m uncertain of?
  • What don’t I know that I need to learn more about?

A typical case is designed to be integrated with small group learning. However, it is also possible to create shorter, less complex cases that can be resolved independently as part of self-study. Note that students will need to be quite motivated to work through cases alone and the facilitator should still be available for short discussion and guidance. Remember that cases are a type of formative learning experience, where the process of working through the case is more important than the final product i.e the completed case.

Cases can also be distributed to students before or after a lecture, so that they can prepare for the work ahead, or to consolidate what has been covered. In these situations, the case would more likely contain more information, and leave fewer gaps because the objective is less about stimulating critical thinking, and more about revising content in an authentic, clinical context.

The role of the facilitator

Different facilitators take on different roles during the CBL process. They are, at various stages students, listeners, analysts, questioners, paraphrasers and lecturers, and it is important to recognise that this can have a significant impact on the students’ experience. Try to avoid having the facilitator take on the “teacher” role too often, providing students with the answers to all of their questions. The “all-knowing” facilitator who is the inquisitor, judge and jury can be seen as trying to extract wisdom from the student “victim”. In its worst form it can be a version of “I’ve got a secret, and you have to guess it.” But, in its best form it can bring about an intellectual awakening as insights emerge from a complex case.

The facilitator should aim to stay on the sidelines as the students take over the analysis but can begin the discussion by simply saying, “Well, what do you think about the case?” From then on, they may simply ensure that some semblance of order is kept and that all students in the group get to voice their views. They should also try to avoid being too far on the periphery and not providing students with the structure they need to not feel lost. Highlight the fact that they don’t have all the answers and that they are co-learners in the classroom.

The facilitator should aim to guide the discussion but not control it, which requires the confidence to give up control. This is the only way to get students to actively construct their own learning experiences by asking questions, gathering information, testing hypotheses, and convincing others of their findings. During this process, facilitators should work with the groups in order to make sure that students have not left out important concepts as they progress through the case.

It is important that the facilitator withholds personal or professional judgments and opinions during discussions. They need to guide the discussion in a way that generates as many different issues, perceptions and solutions as possible, which will be limited if they project their own opinions into the discussion. Using the basic questions, “who, what, why, when and where” helps to engage the students in the activity. Facilitators must also summarise the main concepts and ask questions that help students identify issues and stay on track, but that also do not lead them to a specific conclusion. Facilitating student discussion may appear to be simple but in reality it requires skill in helping students explore and discuss the case in ways that maximises their learning opportunities.

The facilitator’s work can be divided into two broad general categories: setting up the learning environment and facilitating discussion and exploration (Blackmon, Hong & Choi, 2007). They should provide the context for the class and the depth to which students should explore questions. They can also decide which questions are prioritised and which ones can be answered via different methods e.g. lectures, essays, or assignments. It is worth noting that CBL may not be appropriate for every aspect of the curriculum.

Finally, the facilitator needs to add additional information and be able to direct students to resources that are appropriate to the topic (Blackmon, Hong & Choi, 2007). Most practitioners of the discussion method prefer a middle ground, with the facilitator providing an introduction, directed but not dominating questioning, highlighting the essential issues, and an appropriate summary (Welty, 1989).

The role of the student

Although some teachers will assign cases as the basis for individual work, many would argue that discussion in groups is at the core of the CBL approach. The group discussion in CBL can be an effective and motivating method of learning if students are well-prepared and given time for both individual preparation and group discussion (Flynn & Klein, 2001). You might even say that the student’s role is as important as that of the facilitator. Students who take their “jobs” seriously in CBL will prepare in advance by reading through the cases and describing the issues, perceptions, and possible courses of action. They could also review relevant materials in advance if the case is presented early enough.

In addition to preparation the successful student will continually evaluate the proposed solutions and reflect on what is learned and what still needs to be learned. In this process of evaluating and reflecting, they are able to take more responsibility for, and control of, their own learning. Finally, the student must commit to working collaboratively with their peers. Even students who reported disliking groupwork were more satisfied with their learning experience than those who worked alone (Flynn & Klein, 2001). While working through cases, students should aim to:

  • Engage with the characters and circumstances of the story
  • Identify and define the problems as they perceive them
  • Connect the meaning of the story to the clinical and professional context
  • Bring their own prior knowledge and principles to bear on the problem
  • Highlight relevant points and questions, and defend their positions
  • Formulate strategies to analyse the data and to generate possible solutions
  • Work with others to develop a collaborative solution to the problem

Case-based assessment

Initially, assessment and performance evaluation in CBL may seem daunting, as it can be more subjective than other methods and some teachers may be uncomfortable with that. However, with careful planning and preparation, assessment in CBL can be done efficiently, effectively and fairly. Students might also be uncomfortable with assessment, especially those who are accustomed to multiple choice or other forms of assessment that have clear right and wrong answers. This is one reason why the learning objectives need to be established at the beginning, and referred to regularly. Once those are clear and students understand what is expected of them, they should be able to keep track of their own progress and play a greater role in regulating their learning (Wasserman,1994).

The following questions should be considered when deciding how to evaluate a case (Schneider, 2010):

  • What parts of the process need to be assessed?
  • What parts can be graded as a group?
  • What can be submitted for individual assessment?
  • What are the time constraints for the grading?
  • How do you balance grading workload with the need to externally motivate student performance?
  • How will you ensure that the students actually know the content?

Assessing a student who has used a CBL approach can make use of something called key-feature approach questioning (Schuwirth & van der Vleuten, 2005). In this context, the assessor can use short cases that are followed by a limited number of questions aimed at addressing specific decisions that the student must make. Ensure that all of the information necessary to answer the question is presented in the case; not only medical information, but contextual information as well. Ensure that the questions are directly linked to the case, so that the correct answer is based on the students’ ability to integrate all of the relevant information in the case i.e. students should not be able to answer the question without comprehending the case. Ensure the question elicits important decisions where an incorrect decision would lead to incorrect management of the patient.

Teachers and students may both find scoring rubrics helpful, as these can help to establish a clear picture of successful behaviour or work quality, removing subjectivity and some of the ambiguity inherent in using CBL. Cases and group performance can also be assessed with case presentations, which are conducted at the completion of a case. Facilitators and other students can challenge the approaches and outcomes of the case, using a rubric that is distributed to students well before the presentations.

Conclusion

Case-based learning provides opportunities for the richer, deeper exploration of concepts and ideas in clinically-orientated teaching and learning. Students are able to develop experience in analysing ideas and applying concepts to solve problems, rather than simply acquiring abstract knowledge. It also requires students to engage with one another and their environment and facilitate the development of a wide range of social and cognitive skills. Case-based learning requires careful preparation and skilled facilitation on the part of teachers, as they aim to guide students towards personal learning, as opposed to providing them with content. Assessing student learning and evaluating their performance requires more than the traditional multiple choice or short-answer tests. Clear learning objectives, performance standards and relevant criteria can help enable teachers use a more holistic approach in order to better tailor the learning activities to students’ needs. Case-based learning is a valuable teaching and learning method that aims to develop contextualised knowledge and skills that will help students succeed in the clinical context.

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