Case-Based Authentic Teaching and Assessment
CONSTRUCTIVISM AND ANDRAGOGY
Constructivism, “a philosophy that people construct their own knowledge through interactions with the environment” (Rovai, 2004, p. 80), is the current instructional philosophy that aligns with the tenets of andragogy. Adult learning theory posits that adults are (a) intrinsically motivated and able to self-direct learning, identify learning needs, and resources; (b) utilize accumulated prior knowledge and experience to direct learning to benefit their future role; and (c) prefer learning to be problem-centered for direct application (Merriam, 2001). Grabinger and Dunlap (1995) operationalized constructivist principles for teaching that incorporate adult learning theory. These principles are as follows:
• Student responsibility and initiative: Students are responsible for their learning and are able to self-regulate, which involves reflection on learning.
• Authentic learning contexts: Authentic is defined as “realistic and faithful to the original phenomena” (p. 227), indicating that learning should occur within a context relevant to the student’s future role.
• Cooperative support: Learning within a supportive group teaches group processes, the respect for diverse opinions, brings to light faulty reasoning, and supports coconstruction of knowledge.
• Generative learning strategies: Active learning leads to the generation of a product, such as a solution to a problem or assignment.
• Authentic assessment: As assessment drives learning, learning should be contextualized and assessed from that context.
Traditional teaching methods, such as the lecture, cannot meet these requirements, but case-based teaching can. McCracken (2015) very aptly 126describes the case method as one that “combines the power of storytelling with critical discussion, shared experiences, and rigorous academic practice and theory . . . [that] enables the application and testing of theory, it encourages questioning of accepted practice, and it incubates essential dialogue between business practitioners and academics” (p. viii).
Value and Scope of Case-Based Teaching
Various approaches to case-based learning can be used, which range from providing a great deal of information for students to analyze to just a sentence or two indicating an issue that requires the process of inquiry to work through the problem. Which method is chosen depends upon the desired learning outcomes. What differentiates case-based learning from other formats in which readings are assigned followed by lectures and perhaps a test of some sort, is that case-based learning begins with a problem, mimics what the students might encounter in their desired roles, and lacks a road map toward resolution. Overall, cases have the potential to promote “(a) structuring of knowledge for use in clinical contexts; (b) developing of an effective clinical reasoning process; (c) development of effective self-directed learning skills; and (d) increased motivation for learning” (Barrows, 1986, pp. 481–482).
These outcomes are obviously clinically based. However, learning from cases can occur in any course, regardless of the content to be learned. The only limiting factor is faculty’s creativity when writing the cases. It is important to note that how faculty manage case-based teaching can make or break the process (discussed in Chapter 11). Case-based teaching must be student directed and not faculty directed; lengthy lectures have no place in case-based learning. If students are guided in identifying their specific learning issues, foundational knowledge and understandings will come to light when they conduct independent study. Also, assessment drives learning, so it is essential that what is assessed “must challenge problem-solving, clinical reasoning and self-directed learning and not primarily emphasize the recall and recognition of facts” (Frederiksen, 1984, as cited in Barrows, 1986, p. 485). This can be accomplished in online case-based teaching because online cases allow for both formative and summative feedback, and can double as teaching methods. In the process of discussing complex cases, students not only learn the content, but also use higher cognitive functions to think critically, which becomes evident from what they post.
Many types of case-based learning are available, but those particularly attuned to an online constructivist model include unfolding cases and problem-based learning (PBL). Before discussing how they differ, let us first 127look at the process for creating them, the 3C3R method, and what they have in common.
THE 3C3R MODEL
Hung (2009) developed a content and process model for case or problem design for PBL termed 3C3R. The three Cs represent content, context, and connections and are the focus of learning in PBL. The three Rs direct cognitive processing and include researching, reasoning, and reflecting. Incorporating these six variables when writing cases is discussed in detail in the sections that follow.
The Core Components: The Three Cs
Content (Foreground Content)
Two types of information should be included in each case—foreground content and background information that creates context. Foreground content relates directly to the main problem to be solved in the case, represents core domain knowledge to be learned, and provides the trigger that will lead to learning in greater depth (Hung, 2009). Because the learners will entertain multiple hypotheses when working through the problem, the case must be designed so that the foreground problem comes to light as one potential hypothesis. However, in the process of researching the problem, students will encounter other potential causes or explanations, which Hung (2009) terms peripheral domain content, that create alternative pathways. If developing illness scripts is part of the course design and multiple cases are run simultaneously in different groups, each pathway must lead to a unique, yet plausible, diagnosis. This approach is explained in detail later in this chapter under the Illness Script Assignment section.
Barrows and Kelson (1996) differentiated between a problem and an instance of a problem. As an example, let us suppose your goal is for students to learn the differential diagnosis of ear pain in the adult, a problem most nurse practitioners (NPs) will encounter in clinical practice. Asking the question, “What causes ear pain in the adult?,” will result in all students posting the same information after consulting their textbooks. This is not an authentic problem. What is necessary is identifying an instance of this problem or specific issue that will occur in real life.
Several instances of ear pain can be introduced by the same brief chief complaint. Let us look at an example. Judy is a 22-year-old otherwise healthy woman who comes into your office complaining of right ear pain for the 128past 2 days. This complaint of ear pain occurs commonly in primary care practice, meets the definition of authentic, and will engage students as they think like an NP to discover its root cause. Potential causes for this problem include otitis externa, Eustachian tube dysfunction, serous otitis, and otitis media.
For the purpose of illustration, suppose there are four discussion groups responding to this brief chief complaint. If the solution to one case is otitis externa, students will encounter this pathology in addition to other potential diagnoses when researching ear pain, some likely and others less likely for a 22-year-old woman. Those other potential diagnoses are considered peripheral domain content (Hung, 2009) that students will learn about to some degree, but not in as much depth as the one potential hypothesis they will research. Once students review additional pertinent information found in the history, such as a history of recent swimming in a river and findings on the physical exam of a swollen left ear canal limiting view of the tympanic membrane, which appears normal from what can be visualized, they will lean toward a diagnosis of otitis externa. The other three groups will have a similar experience with different information on the history and physical exam (H&P), leading them down different paths in the direction of the other diagnoses. From this case, four instances based on one chief complaint leading to four different diagnoses will be explored in detail with other less common pathologies perhaps mentioned and discussed along the way.
Context (Background Information)
To make the cases messy and complex as well as create an authentic context, background information is added that may or may not be relevant to the problem at hand, yet helps to paint a real-life picture of the complexities of nursing practice. Background information may include socioeconomic status, secondary diagnoses (comorbidities), social issues such as alcohol or drug abuse or a history of smoking, and a complex family history. What this information does is make the patient seem real, adding depth to the case. Although not the main focus or learning outcome of the case, students will be expected to distinguish relevant from irrelevant background information, recognize the significance or salience of the information, and determine whether that data have an impact on the problem, the plan to address the problem, or the patient’s general well-being. For example, if the 22-year-old woman with ear pain also had a diagnosis of type 2 diabetes, and her blood sugars have been off baseline since shortly after the pain started, students must now address two issues. This additional data provides an opportunity for students to engage in holistic nursing practice. For nonclinical cases, the same purpose for background information holds true. Think of 129it as adding a creative touch to the cases to make them seem life-like and real for the student.
In addition, an authentic setting or context must be chosen in which the problem will reveal itself. Along with the background information for the case, the professional context sets the stage for the role students will take in solving the problem. An appropriate context or setting for the RN to bachelor of science in nursing (BSN) student might be within the acute care hospital setting or home health. For the nurse practitioner regardless of population focus, the context would most likely be a primary care setting and for the acute care NP, the setting is likely the hospital.
On the other hand, the professional context may be course-dependent. For example, in a policy course, the setting might be in a meeting room at the local nurses’ association headquarters where the student is part of a lobbyist group. Professional context is an important component of authentic cases and assists students with formation into the role they aspire to (Benner, Sutphen, Leonard, & Day, 1984/2010). Because it is role-driven, the professional context may be the same for all cases in a course or program.
The notion of connections is the final C in the 3C model. Connections made in the profession are difficult to articulate, as they are somewhat intuitive for nurses with experience. They arise out of domain knowledge from the basic sciences, the humanities, and upper division nursing courses, combined with multiple ways of thinking that include critical thinking and diagnostic reasoning. Because our students are RNs with known domain knowledge and varied clinical nursing experience, they will have some understanding of these connections. For example, from a complete history and physical exam of an obese 40-year-old male patient complaining of chest pain, most nurses will pick out potential health risks if additional information is provided that the man smokes two packs of cigarettes per day and lost his father as the result of a myocardial infarction at age 45. From the faculty perspective when writing cases, it is useful to think about past experiences with patient variables and specific diagnoses that students will likely encounter in practice. Including these variables in cases creates a rich, complex, believable context that represents the complexities that can occur in actual nursing practice and gives students the opportunity to connect the dots of provided data to arrive at the best solution given the situation.
130The Processing Component: The Three Rs
Once the problem has been encountered, the next step is research to obtain needed information to solve the problem (Hung, 2006). However, in order to approach the search for information strategically, the problem and goal or end-point must be clearly understood. In terms of a discussion question that may include relevant and irrelevant information by design so that students will gain practice in extracting the salient information from a situation, the problem itself must be clear in their minds. The plan to address or resolve the problem is the goal of an authentic discussion.
Context can influence research by providing a frame of reference that, by default, directs their problem-solving processes. Nursing is a broad field and nurses wear many hats. Context determines the hat the student will wear and the appropriate ways of thinking and methods of researching that go along with that hat.
Because we have not as yet agreed on a term broad enough to encompass critical thinking, diagnostic reasoning, clinical reasoning, or the multiple ways of thinking that nurses must employ, I think about the process of reasoning as “wrestling” with information to arrive at an understanding, as this seems to describe the complex, multifaceted cognitive effort required. Hung (2006) describes the steps of this process, which are:
• Analyzing the nature of all the variables and the interrelationships among them
• Linking newly acquired knowledge with existing knowledge and restructuring their domain knowledge base
• Reasoning causally to understand the intercausal relationships among the variables and the underlying mechanisms
• Reasoning logically to generate and test hypotheses
• Identifying possible solutions and/or eliminating implausible solutions (p. 64)
Reasoning is an iterative process that occurs during and after the process of researching. Thus, these two processes occur simultaneously.
Incorporating reflection as part of a case-based discussion will help students to develop metacognitive strategies. Hung (2006) suggested this occur as both formative and summative processes, a different conceptualization 131of Schön’s (1987) reflection-in-action and reflection-on-action. Formative reflection or reflection-in-action cannot be separated from researching and reasoning. To some degree, metacognition will guide reasoning.
On the other hand, summative reflection or reflection-on-action occurs at the end of the case and should be a faculty-guided activity, otherwise students may not take time to do it. Asking students to reflect on their research methods, resources used, what they did well, and what they could have done better will promote self-directed learning. Reflecting on the knowledge gained from the case, the reasoning strategies they employed, and what was learned from others in the process of the discussion will help to improve their problem-solving skills (Hung, 2006).
TYPES OF CASE-BASED TEACHING METHODS
Unfolding cases are well named in that the data about the case are given to students in stages, unfolding much like a real-life case in nursing practice in which all pertinent information is not available at the outset, changes with time, or new data are discovered. Each stage may require a shift in thinking and a need to reflect and reevaluate assumptions. These types of cases are well suited to the online environment and are very similar to PBL. How the case unfolds depends on the content, the time element for discussions, the desired learning outcomes, and whether resolution occurs within the discussion or the discussion ends prior to that stage so that students can turn in an individual assignment. For a case in a clinical course with the outcome being a plan of care developed during the discussion, the sequence is shown in Exhibit 6.1. For a nonclinical course, Exhibit 6.2 demonstrates the sequence of unfolding events that might occur.
Each step of the case may span from 2 to 4 days, depending on the requirements of the step and the overall time allotted to the discussion. However, not all steps need be the same number of days. Allotted time must be adequate in order for students to complete their research, synthesize what they have learned, and compose a post. The beauty of this type of unfolding case is that the information provided to students in all steps can be prepared ahead of time. The list of questions provided in Step 2 will not be in response to the actual questions students asked, but instead what faculty deem should have been asked. The same is true for findings on the physical exam in Step 3. For Step 4, faculty will need to respond within the discussion to the final plan. Basically, this type of case study will run itself with faculty monitoring students’ posts to be sure they do not wander off track, have questions that no one in the group can answer, and 132meet the learning outcomes. In most learning management systems (LMSs), the documents for Steps 2 and 3 can be set to upload on a certain date and at a certain time, freeing faculty from meeting a midnight deadline, for example.
Unfolding Case Format for a Clinical Case
Information Given to Students
Questions Students Are Asked
The patient’s problem in the form of a chief complaint is briefly outlined, including the context
1. What is your initial impression of the problem?
2. What are potential explanations for the problem (diagnoses)?
3. What specific questions will you ask the patient (history)?
1. Answers to questions students should have asked are given in order to provide the necessary information for students to move on to the next step.
After reviewing answers to the questions, students are asked:
1. Reflect on the questions you asked and those you should have asked based on the information provided. This is a learning activity for you. No need to post what you learned.
2. Are there any changes in your initial impression based on new information provided in the history?
3. How does this new information impact ruling-in or ruling-out your initial diagnosis?
4. Based on the information in the history, what areas will you focus the physical exam on?
Findings on the physical exam
1. Are there any changes in your initial impression (diagnosis)? Include rationales as to why.
2. What is your final diagnosis (or differential diagnosis) based on available data?
Final diagnosis with rationales related to findings on the history and exam
What is your plan? Include evidence-based rationales for treatment (where available)
The downside of this type of unfolding case is that students must post within the time frame for each step. If they do not, they must suffer the consequence of losing points for that step, as once the information has been posted for the next step, the student will have an unfair advantage in constructing his or her post. If this is made clear to students at the outset of the case, they should be able to arrange their time to post in each step in a timely manner.
Unfolding Case Format for a Nonclinical Problem
Information Given to Students
Questions Students Are Asked
A picture of the problem, issue, or dilemma is painted that includes context (background information)
1. What is the problem? Initial description in their own words.
2. What areas of inquiry need to be pursued?
3. Are there any additional questions to be asked or information to be gathered?
4. Who are the stakeholders?
Additional information is provided in a narrative format that describes what was learned from inquiry and research
Stakeholders are identified and their perspectives stated
1. How has the information provided changed your initial impression of the problem?
2. What additional inquiry is needed?
3. Any additional stakeholders who should be involved?
4. What is your potential solution?
The case can unfold in as many steps as necessary to provide twists and turns, giving students additional data to consider
Repeat Steps 1 and 2 until enough information is provided/unveiled for students to come to a conclusion and plan. This will be limited by the allotted time for the discussion.
PBL is the most researched case-based teaching method to date (Albanese & Mitchell, 1993; Dochy, Segers, Van den Bossche, & Gijbels, 2003; Gijbels, Dochy, Van den Bossche, & Segers, 2005; Shin & Kim, 2013; Vernon & Blake, 1993). However, as Barrows (1986) noted, PBL is “a genus for which there are many species and subspecies” (p. 485). PBL, as described and employed by Barrows and his group at Southern Illinois University’s medical school, is considered authentic PBL from which modifications have been made over the years by others, serving to confound research efforts to determine the teaching method’s validity (Hung, 2011). In an effort to bring this issue to light and define the various types of PBL, a taxonomy was developed (Barrows, 1986), as was a continuum to create some order (Harden & Davis, 1998), and a framework for analysis of the variations of PBL (Charlin, Mann, & Hansen, 1998). Regardless of the version of case-based teaching employed, writing cases that meet the goals of PBL as originally outlined by Barrows (1986) are listed in the section Tips for Identifying Appropriate Problems for Study later in this chapter.
The PBL process, which was originally carried out in small groups of students who met face to face, will further the understanding of teaching 134with cases in general, as it is the prototype of case-based teaching (Barrows & Tamblyn, 1980). The steps of the PBL process are as follows:
1. An authentic problem is presented to students without any prerequisite study, that is, reading assignments.
2. Individually, each student reflects on the problem and discusses his or her thoughts with the group so that they may be challenged and evaluated. The scribe takes notes on a whiteboard, listing them in four columns: hypotheses, information synthesis of what is known, learning issues, and action plan.
3. Next, learning issues are identified and assigned to individual students for independent study. Potential resources are identified.
4. When the group reconvenes, each student discusses findings from his or her independent study and relates them back to the problem to evaluate the fit. Hypotheses are revised, new learning issues are identified, and additional information and actions needed are determined. Specific information from the casebook that contains the particulars of the entire case can be requested.
The result of this process is learning from individual study and group work that is then summarized and becomes integrated with the student’s prior knowledge and skills. This process may go through several iterations of identifying learning issues, researching them, and reporting on the results to the group before potential solutions are identified.
The PBL process is facilitated by a faculty member, called a tutor, who asks probing questions without assuming the role of a teacher (i.e., lecturer) and prevents students from researching unfruitful issues. Two additional final steps are valuable for learning that include students reflecting on their reasoning process, providing rationales for their choices, and completing a product, such as a clinical note or other authentic deliverable dictated by the problem.
Online PBL follows much the same process and is quite suited to nursing education for RN–BSN or graduate nursing student for several reasons. Our students’ educational backgrounds are quite similar, in that all have completed a basic nursing program and have similar foundational knowledge. Thus, case-based teaching should not be as much of a stretch for our students as for medical students, for example, who come from heterogeneous educational backgrounds. Our students have enrolled in a program because they have a goal or desire to change roles—they want to learn. They are intrinsically motivated, for the most part, and understand being responsible for their learning. They have some measure of clinical experience, have used clinical and diagnostic reasoning, and know what it takes to think like a nurse. They have knowledge, skills, and attitudes on which to build.
135However, Barrows (2002) was skeptical that distributed PBL (dPBL) was a realistic expectation, finding online LMSs “cumbersome” (p. 120). However, after completing the PBL tutor training at Southern Illinois University’s medical school, visions of creating online PBL flashed through my mind. I knew it could be done. The process is a bit different because students readily identify learning issues and research them independently without being assigned to do so. Also, the casebook is provided. Because of these changes, the process becomes somewhat truncated. Nevertheless, dPBL or online PBL adhere to the original intent and learning outcomes of PBL, especially for the groups of nursing students taking online courses.
Online PBL Process
The online PBL cases unfold in a similar fashion to what occurs in the face-to-face version and mimics how problems evolve in real life, adding to the realism. The path is uncovered as nurses ask questions, analyze data, and use multiple ways of thinking. For clinical cases for NP students, the steps are listed in Box 6.1. The major difference between classroom-based and online PBL is the step of identifying potential hypotheses for the chief complaint and learning issues. Students post their list of potential hypotheses, identify the one they will work on, and begin independent research. Faculty should be vigilant during this step to avoid problems. If two students indicate in separate posts that they plan to work on the same potential hypothesis, an e-mail to both students is necessary to communicate which student should proceed and which should choose another topic, so no confusion occurs. In the process of that research, they will identify areas that they do not understand. These will become their own personal learning issues that they will continue to look into until they reach understanding or post an inquiry to the group. Alternatively, after posting their initial perspectives, feedback may be forthcoming from other students and faculty to help the student connect the dots.