The highest priority for the vast majority of studente when commencing a course is to immediately locate and consider the assessment requirements. Few, if any, students are concerned with the pedagogical intricacies of how the subject is constructed or the learning strategies embedded within it. Given this observation assessment therefore must surely be one of the leading strategies employed by academics to direct learning.
Demands on the time of the academic such as increasing student loads, less homogenous student cohorts, and research responsibilities impact on teaching commitments. Responding to these demands requires change in approaches to teaching, learning, assessment, and workforce preparation of nursing students. Strategies that reduce assessment preparation and marking time for the academic while concurrently enhancing learning outcomes for the student must represent a win/win solution for all. The use of case study class tests is one strategy that can satisfy these criteria while promoting the highly desirable deeper-level learning that Ramsden (1992) proposes is fundamental to higher education.
This article reports on the experience of the use of case study tests within an Australian baccalaureate program. The program runs over 3 years and comprises 24 courses each equivalent to 4 hours of face-to-face teaching for a 13-week period. In addition to the academic courses, 22 weeks of clinical experience (consisting of 4 weeks in first year, 8 weeks in second year, and 10 weeks in third year) is provided in a variety of health care settings.
ENCOURAGING DEEPER-LEVEL LEARNING
In Australia, as with a number of other countries, the movement of nursing from hospital-based training programs into higher education represented a major change in professional development. There was a potential quantum leap from a "doing" often ritualistic culture, which promoted surface level learning, to a "thinking" and "questioning" culture that could lead to deeper-level learning. However, one of the negative side effects of this movement was the lose of the potentially rich learning environment provided by the traditional clinical apprenticeship, which has not always been compensated by the relatively small blocks of clinical placements or internships. The use of case studies provides a virtual equivalent in a controlled and less threatening context, which may facilitate bridging the gulf between clinical theory and clinical practice.
A deeper-level approach to learning is where the intention is for the student to understand rather than merely complete task requirements (Ramsden, 1992). The defining features of a deep approach to learning include:
* intending to understand material for oneself;
* interacting vigorously and critically with content;
* relating ideas to previous knowledge/experience;
* using organizing principles to integrate ideas;
* relating evidence to conclusions;
* examining the logic of the argument.
Contrast this with a surface approach where:
* intention is simply to reproduce parts of the content;
* ideas and information are accepted passively;
* concentration is only on assessment requirements;
* purpose or strategies in learning are not reflected;
* facts and procedures are memorized routinely;
* guiding principles or patterns are not recognized. (The Council of Scottish University Principals, 1992)
The use of case studies in clinical education is not new. The approach described is sequenced and staggered, provides feedback on both performance and approach, and uses assessment as a learning strategy. This represents a package that is likely to provoke deeper-level learning.
THE FRAMEWORK FOR CASE STUDY ASSESSMENT
Second-year baccalaureate nursing students at Charles Sturt University (New South Wales, Australia) study an integrated clinical/theory subject in acute medical-surgical nursing that is divided into 5 modules (discrete topic areas) of study. A module of study involves the following face-to-face contact:
* Four, 50-minute lectures during which an overview of relevant general principles are included such as: a brief review of relevant anatomy and physiology, generic patient assessment data, diagnostic tests, generic nursing interventions, infection control issues, and pharmacology.
* Two, 2-hour tutorial sessions in which students work in small groups to problem-solve case studies (with directed questions), that apply the general principles in the lectures to simulated patient scenarios. Each group reports back to the class on their findings. This provides experience in the process of problem solving. The role of the academic during these sessions is to probe student responses and promote a deeper approach to learning. These sessions encourage student responsibility for learning rather than placing all responsibility with the academic (Gibbs & Habeshaw, 1997).
* A 2-hour clinical workshop in which the related clinical skills are demonstrated and practiced.
Each of the 5 modules is assessed by a case study class test valued at 5% of total available subject marks. Students are provided with a case study trigger to research at the commencement of the module. The following example is a case study trigger that accompanies a module of study on "shock and fluids."
John Walker, a 48-year-old pastry cook, has been admitted for investigation of malaena. When you first encounter this patient you note that he is very pale, and you make a mental note to check his hemoglobin, which you find in the notes is 9 gm/dl. His wife is present and you talk with her also as you assess your patient. You note that currently Mr. Walker is fit accept for some arthritis that he attributes to playing football when he was younger. He takes a nonsteroidal antiinflammatory drug for this and "aspirin." He no longer smokes but has a history of 30 a day before giving up 18 months ago. His wife claims that since he gave up smoking he has been very irritable and impatient with the children.
His job requires that he work from 2 a.m. until 9 a.m. He reports that when he comes home from work he usually has a few "beers" before he goes to bed because it helps him sleep better. As you are chatting John goes very pale and clammy and complains of nausea as he reaches out for vomit bowl on his bedside table. He then proceeds to vomit approximately 400 mis of bright blood.
A "test" on this case study is then conducted at the end of the module as an individual "in class" activity. Academic facilitated feedback on the class test is provided in a group discussion after the test has been marked (aiming for feedback within 24-48 hours).
Careful design of the questions for the class test is essential in promoting deeper -level learning. The questions require the student to relate theoretical principles to practical realities by providing an explanation for their actions rather than just a repetition of material presented to them in class. Students have to demonstrate that they understand the principles and can apply them to a real world situation.
Case Study Test Questions
Examples of questions related to the above case study trigger example are:
* Based on the case study information, identify two possible sources for Mr. Walker's bleeding. (2 marks)
* Describe the IV access (i.e., site/s); cannula/e (types and sizes) most likely to be used for Mr. Walker. Give reasons for your answers. (3 marks)
* What type of giving set would you select to commence Mr. Walker's fluid resuscitation? Why? (2 marks)
* Explain the term malaena and the potential relationship between the presence of this symptom and Mr. Walker's hemoglobin. (2 marks)
* Would a transfusion given to Mr. Walker in this instance be homologous or autologous? Explain the difference between the two types of transfusion and which would be the most appropriate in this case. (2 marks)
* Mr. Walker's blood group is found to be A positive. What blood types might be used for him? (1 ½ marks)
* Itemize factors to be checked before commencing Mr. Walker's blood transfusion. (5 marks)
Strengths of This Approach
The strengths of this approach lie in the sequential, staggered organization of the assessment that allows feedback on performance for both student and academic. The case study class test represents a method of formative evaluation, the purpose of which is to improve the quality of student learning (Meland, 1998). When researching the case study trigger in preparing for the class test, students need to anticipate the types of questions that may be asked. This in itself provokes problem-solving and critical-analysis skills. This process of testing then feedback is intended to lead to a spiraling process of refinement in both approach to the case studies as well as a deeper understanding of the clinical reasoning and decisionmaking processes involved. The importance of reflection on experience in learning has been identified by a number of theorists (e.g., Dewey 1938, Schon 1983, 1987). Other strengths include:
* providing active rather than passive feedback, i.e., a group discussion on the reasoning process as opposed to written comments on a returned assignment. Students can question at the time and any misconceptions can be rectified, while the academic probes for understanding of the critical aspects of each case.
* forming assessment to prepare for the summative end of the academic semester assessment.
* encouraging deeper-level learning rather than surface learning.
* administering and marking easily.
* assessing each case study directly related to a module of study that the student has just completed providing a structured approach favored by many students especially at a baccalaureate level.
* ongoing feedback for the academic on the student's grasp of the principles allowing clarification and, if needed, refinement of their educational practice at the time it is needed.
* providing a mechanism for the academic to set summative assessment questions based on the formative test feedback.
* ensuring the participation in, and assessment through, class tests are the student's own work given the potential black market in assignment writing.
* timetabling of the tests and followup feedback while reducing time available for teaching, is arguably teaching time well spent.
Weaknesses of the Approach
The emphasis for the entire subject is on students being able to explain the "why" of their actions, and in doing so moving beyond surface-level description towards a deeper-level integration of knowledge and understanding.
* students who prefer more passive approaches to learning and assessment, who react negatively to exams or who are poor exam performers may feel pressured (can be minimized by the small allocation of assessment marks for each test).
* student absenteeism for the class test requires alternative scheduling and ongoing follow-up that can be tedious for all.
Gibbs & Habeshaw (1997) identify assessment as the most powerful tool available for influencing student learning. Ramsden (1992) urges academics to promote deeper-level learning in the higher education sector. Case study class tests that are linked to a module of study, placed in a clinical context that uses feedback that is timely and interactive provide an assessment strategy well worth considering as a means of promoting positivelearning outcomes in nursing students.
- Committee of Scottish University Principals. (1992). Teaching and learning in an expanding higher education system (also known as The MacFarlane Report). Edinburgh.
- Dewey, J. (1938). Experience & education. New York: MacMillan.
- Gibbs, G., & Habeshaw, T. (1997). Preparing to teach: An introduction to effective teaching in higher education. Melksham: Cromwell Press.
- Melland, H.I. (1998). Classroom assessment: Linking teaching and learning. Journal of Nursing Education, 37(6), 275-277.
- Ramsden, P. (1992). Learning to teach in higher education. London: Routledge.
- Schon, D.A. (1983). The reflective practitioner: How professionals think in action. New York, Basic Books.
- Schon, D.A. (1987). Educating the reflective practitioner. San Francisco: Jossey Bass.