The transition from passive to active learner: medical student experiences of Case-Based Learning (CBL) at a multicultural medical school: Structured Group Feedback Study

doi:10.21203/rs.3.rs-4713882/v1

Download PDF

Research Article

The transition from passive to active learner: medical student experiences of Case-Based Learning (CBL) at a multicultural medical school: Structured Group Feedback Study

https://doi.org/10.21203/rs.3.rs-4713882/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Educational research highlights that active approaches to learning are more effective in knowledge retention and problem-solving. Yet lectures are still the dominant form of teaching in most medical schools. For international students, active learning approaches can be both more challenging and less familiar. Gaining student engagement with active learning can be a significant challenge when there is an expectation for students to participate in a discussion or voice an opinion. Case-based learning (CBL), with its scaffolded form of learning, is an approach that could provide the support needed to help international learners adapt to their new learning environment in a low-stakes learning environment. The research question in this study was: what are the features of CBL that support active learning in an international student cohort familiar with a more passive approach?

Methods

Data was collected using Structured Group Feedback Sessions (SGFS) from 36 students in eight Structured Group Feedback Sessions, a method that facilitates structured discussions and is effective in curriculum evaluation and feedback. The experience-based Learning model was used as the conceptual framework to guide the analysis, which was completed using framework analysis.

Results

Themes were derived from the Experience Based Learning model: affective, pedagogical, and organisational and analysed according to the research question. The findings illustrated that students enjoyed the CBL teaching method but needed to feel psychologically safe to participate. They welcomed the facilitator's role in enabling them to participate and role model teamwork and problem-solving. They valued organisational support, the authenticity of the case, and the patient-centred approach to the clinical cases.

Conclusions

The students valued the transition to active learning using CBL. Prior learning was essential to providing the context, knowledge, and confidence to engage actively in the case discussion. Having a facilitator to summarise the session and provide assurance were important learning points.

Case-Based Learning

Active Learning

International

Student Perspective

Undergraduate

1.1 International students learning challenges

International university students face a multitude of learning challenges which stem from a combination of linguistic, cultural, and educational differences [1, 2]. Many are more familiar with passive approaches to learning and can experience significant challenges when expected to contribute to a discussion, work in a group, or voice an opinion. Yet, educational research highlights that passive approaches to learning are less effective than active approaches, which are a source of challenge for international students [3–5]. A more holistic approach to curriculum design, including active learning experiences for educational skill building, is advocated to facilitate a more effective, supportive and positive learning environment [6–9]. Case-based learning [CBL], with its scaffolded active form of learning, is one such approach that can be seen as supportive, helping international learners adapt to their new learning environment in a low-stakes learning context. According to Srinivasan et al., (2007) CBL can enhance student participation and knowledge retention, also highly beneficial to engaging an international learner group [10].

Case-based learning in medicine involves engaging students in the learning process through hands-on activities, discussions, and problem-solving within the context of clinical cases. This approach encourages students to apply their theoretical knowledge to real-life scenarios, promoting critical thinking, clinical reasoning, and decision-making skills. Case-based learning (CBL) has emerged as a prominent pedagogical approach in medical education, emphasising the integration of basic sciences with clinical reasoning and problem-solving skills. A review by Thistlewaite et al., (2012) defined CBL as a "learning and teaching approach that aims to prepare students for clinical practice, through the use of authentic clinical cases" [11]. This Best Evidence Medical Education [BEME] review also stated that CBL improves student engagement and learning outcomes [11]. Since Thistlethwaite et al., more evidence has emerged on the benefits of CBL; three meta-analyses all reported that CBL is an effective teaching method and helps improve student performance [12–14].

Research has shown the importance of structured facilitation during CBL sessions, with facilitators guiding students through problem-solving while encouraging active participation and reflection [15]. Moreover, cases should encourage active participation and collaboration among students, enabling them to apply theoretical knowledge to practical situations [16]. These studies provide evidence supporting the effectiveness of active learning within CBL for international medical students.

1.2. Study context and aims

CBL was introduced to first-year undergraduate students studying medicine at an international medical school, where students from over 100 countries attend. CBL was used to scaffold, frame, and integrate curriculum content and themes. Fundamental scientific concepts and principles and their clinical application were linked through cases, and students worked together in small groups (10–12 participants) to discuss cases that prompted the discovery of the biomedical, behavioural, and clinical sciences underpinning each case. A facilitator supported each group. Cases operated over a two-week cycle per module, and as part of this cycle, students had six hours of small group facilitated sessions. The sessions facilitated students to:

Work and actively learn in groups.

Integrate prior and newly acquired knowledge.

Develop problem-solving skills and critical thinking.

Use self-study to consolidate learning that occurs in groups.

A specific context of this study was that CBL was being introduced into a new medical curriculum as a key component of the overall Learning and Teaching Assessment Strategy. The rationale for introducing a CBL model to the medical curriculum underpins an approach to learning that is based on experiential learning models that encourage and facilitate small-group learning [11]. In addition, educational strategies that promote learning among diverse student groups from varied learning backgrounds, such as this demographic here, also benefit from the social constructivist characteristics that form part of the learning pedagogy in a case-based learning environment [17].

To our knowledge, most students would be more familiar and comfortable with lectures than with this active learning approach since it persists as the dominant pedagogy at most universities despite calls for a less passive approach to learning [18]. Therefore, a goal was to leverage CBL to support students in developing personal and professional socialisation, which could grow into a sense of belonging for them [19] and support students to transition from being a scholar to a medical student and then a future doctor [20]. Within medical education, social constructivist theories can provide valuable templates for learning, developing, and applying learner's professional competencies, where individuals learn through observation, modelling, and critical discussion [17, 21, 22]. This model of mediating the curriculum can create a supportive environment and provide opportunities for feedback and reflection where educators can facilitate the development of professional competencies among medical students.

This study aimed to explore students’ perceptions of their experience of CBL and address the following research question: What features of CBL support active learning in an international student cohort familiar with a more passive approach?

The methodology to elicit the student's voice was valued as a key factor. Therefore, the goal was to investigate student-generated elements that both promoted and detracted from an effective learning experience. The related sub-questions are:

What elements do students perceive as working well and contributing to the active learning process in CBL?

What elements do students perceive as potentially hindering the active learning process in CBL?

What elements do students feel could improve the active learning process?

1.3 Conceptual framework

Experience Based Learning [ExBL] model was the conceptual framework for this study [23–25]. Developed initially to understand clinical placements, it has been adapted and used more widely for medical students starting that journey via patient cases as used in CBL [26]. Three particular supports were identified: affective, pedagogic, and organisational support.

Affective support is about relating to others. It included emotions and feelings experienced during the CBL towards self, but also towards others and the patient case. This can be both positive and negative but also involves feelings such as anger, anxiety, empathy and compassion. Pedagogical support focuses on student support during the teaching process. This includes modelling good practice, engaging students in the clinical case and helping them think about the learning they have experienced by listening, asking questions, discussing the case and providing a structure. Organisational support brings all aspects of the case together: a real patient case, student learning and leadership. This might include developing the learning resources to support the case, organising the group activities, providing expertise as needed, encouraging students to present an aspect of the case to the group, identifying the intended learning outcomes, debriefing and summing up at the end [25, 26].

2.1 Study Design

A qualitative research design was adopted to explore the perceptions of the medical students regarding the effectiveness of CBL in promoting active learning. The study aimed to identify both supportive and inhibitive elements of CBL as experienced by the students. Specifically, we wished to investigate their perceptions regarding the features of CBL that either facilitated, obstructed or held the potential for enhancing active learning processes.

Regarding the fit of methods adopted as most appropriate for this study, we considered using focus groups rather than interviews as the latter are very resource intensive. However, being aware of the "dominant voice" and "groupthink", we decided to use a Structured Group Feedback approach. First described by Gibbs et al., Structured Group Feedback sessions [SGFS] are structured discussions which encourage students to consider and present their views first, then discuss their views with peers while allowing time for individual thought and reflection on the views of others [27]. This approach is often used in curriculum evaluation and feedback as it offers a three-stage process in which students develop their initial thoughts on a topic before being asked to consider other people's perceptions [28].

2.2 Participants and Recruitment

The study population consisted of first-year medical students who had just completed their first year of CBL. An invitation to participate in the study was sent to all first-year students via email at the end of the academic year (N = 344). This communication included a participant information sheet detailing the study's purpose and methodology. Thirty-six students (10.4% response rate) consented to participate. Participants were unknown to the research team and assured of their anonymity and the confidentiality of their responses. Two pilot sessions, each with a group of 5 students, were conducted to refine the questions, process, and timing, resulting in no alterations to the study. Following the pilot, sessions were conducted at the commencement of MED year two, immediately following a CBL case.

2.3 Data Collection

Data were collected using Structured Group Feedback Sessions (SGFS), a method that facilitates structured discussions and is effective in curriculum evaluation and feedback. The protocol adhered to the three-stage framework proposed by Gibbs et al. (1988), as illustrated in Fig. 1.

Each SGF session was scheduled for 90 minutes, during which students were provided with lunch and beverages as a gesture of appreciation for their participation. The facilitators began by welcoming the students and reiterating the session's purpose and plan. At the outset, students were informed of the session's objectives and structure. Subsequently, they were presented with three questions, each written on a separate flip chart sheet.

During stage 1, students worked individually for approximately 15 minutes, jotting down their responses to each question on Post-it notes, using a distinct colour for each of the three questions and noting only one point on each Post-it. In stage 2, students collaborated in pairs, sharing and discussing their comments to determine agreement and placing agreed-upon points onto the flip chart sheets while beginning to identify themes. They were encouraged to consider ranking their comments based on importance. Finally, stage 3 involved a group discussion where all students reconvened in their groups. Points from student pairs were discussed collectively, with facilitators guiding the grouping of Post-it notes and facilitating discussions around each comment's agreement, disagreement, and importance. Students in each group collectively ranked the comments in order of importance on each flip chart sheet.

2.4 Data Analysis

Data analysis was conducted using the five stages of Framework Analysis described by Ritchie & Spencer [29]. Framework analysis was facilitated by referring to the ExBL model developed by Dornan et al., [25] and used by Burgess et al., [26], which had been adapted to suit CBL for this study. This model provided a framework to identify how different elements of CBL influence the active learning process.

The "Post it" comments and rankings were analysed for all three questions using the five stages of Framework Analysis [29, 30], namely: Familiarisation, identifying a thematic framework, indexing, charting, and mapping and interpretation. Familiarisation involved all researchers reading and discussing the comments to agree on the framework. Each researcher then indexed the data under specific themes, followed by 2–3 meetings to finalise charting, mapping, and interpretation. All three questions were analysed using the ExBL model for affective, pedagogic and organisational themes [25] to identify aspects of support for active learning.

2.5 Ethical Considerations

Ethical approval

was obtained from the university Research Ethics Committee [REC]. Consent was sought from all participants, who were informed of their right to withdraw from the study at any time without any adverse consequences.

3.1 Descriptive data

In total, 36 students participated in 8 small group sessions between June and September 2023. This was 10.46% of the total cohort of the Year 1 class (N = 344; 100%). Students came from 11 nationalities (representing 77.7% of the nationalities presenting in the cohort). Students from Ireland / Northern (22.2%) were also included in the data set as group members of the discussion sessions. Table 1 displays participants' demographics for gender, region, and nationality.

Table 1

Population characteristics
Demographics	Cohort (n = 36)
Gender	n	%
Female	21	58.3%
Male	15	41.6%
Regions	n	%
Asia	7	19.4%
Australasia	1	2.8%
Europe	11	30.5%
Middle East	6	16.6%
North Americas	11	30.5%
Nationalities	n	%
Australia	1	2.8%
Canada	8	22.2%
India	1	2.8%
Ireland / Northern Ireland	8	22.2%
Kuwait	2	5.5%
Malaysia	6	16.6%
Portugal	1	2.8%
Romania	1	2.8%
Saudi Arabia	2	5.6%
United Kingdom	1	2.8%
United Arab Emirates	2	5.6%
United States of America	3	8.3%

3.2 Themes

Themes are presented as "organisational, pedagogic and affective support" for active learning as described in the conceptual framework above. The themes answer the research questions examining which elements students perceive as working well and contributing to the active learning process in CBL. Examining which elements students perceive as potentially hindering the active learning process in CBL and what elements students feel could improve the active learning process.

3.2.1 Affective

Affective support relates to feelings and emotions and comfort in expressing themselves while engaging with the learning material [25]. Our data highlights the importance of empathy, encouragement, and a sense of belonging in fostering positive attitudes towards learning.

"… It feels like a group learning opportunity that I am comfortable asking a question and voicing ideas" (Group 1).

"… I found I was able to identify my weaknesses and gaps in knowledge and improve my treatment plan" (Group 2).

"I learnt a lot from these sessions when everyone actually put in the effort to answer the questions. It feels like a group learning opportunity that I am comfortable asking a question and voicing ideas … Grow friendships and bonds with the other students due to repeated interactions." (Group 1).

"working in a small group, with the same classmates (was helpful) the psychosocial discussion questions." (Group 4).

Students reported challenges that hindered active learning, such as negative group dynamics, dominant personality, difficulty listening, passive participation, and passive facilitation.

"…there is a clear difference in personalities which leads to some people standing out more." (Group 1).

"Some facilitators overpower what you're saying … "let me be wrong" … "Don't jump in to fast", but "prompt me" for a clearer answer." (Group 3).

In relation to affective factors for improvement of active learning in CBL, there were some strong feelings in relations to aspects such as group dynamics. Additionally, keeping students in the same groups enhanced their feelings of psychological safety.

"CBL is a great reflection of real medical cases which I find extremely useful for applying and developing our current knowledge and ideas; I find group discussions allow me to dispel any uncertainties I have with particular topics; and grow friendships and bonds with the other students due to repeated interactions." (Group 1)

"There should be an award for best CBL group to promote better discussion and collaboration." (Group 2).

“Doing the questions in small group; working at presentation skills; describing pathogenesis helps to understand disease; the diagrams; working with the same group as last year as you're set to build a rapport." (Group 1).

Students also valued opportunities for greater diversity and exposure to wider range of different ideas and culture while consolidating their learning through deeper engagement and collaboration.

" Exposed to many different aspects in the medical field, emotionally, socially, and mentally, role of doctors actually deals with people instead of passively studying; gets us to explore different ideas/cultures from your classmates; get to have a more engaged student environment." (Group 1).

"The collaboration between the team mates to help consolidate our work. Easier to incorporate our work through this medium." (Group 4).

"We think it's a great way of to strengthen bond between groups. … ALSO it gives us the chance to meeting facilitators we would normally never get to meet … It offers diversity." (Group 6).

3.2.2 Pedagogy

Pedagogical support focuses on supporting student learning during the teaching process. This includes facilitators modelling good practice. Pedagogical support enabled active learning when facilitators posed questions and facilitated discussion in a structured approach, particularly around clinical problems, which students appreciated. Our data shows that from the students' perspective, they felt more encouraged to engage and reported taking a more in-depth approach to their learning as a result.

"Whenever we have very active facilitators, we learn a lot of useful information." (Group 2).

"Questions that were opinion based fostered better discussion among the group. Facilitators that answered questions and spoke about their own experiences in hospital as doctors, nurse, etc." (Group 4).

"Facilitators are excellent and a great way to stay focused on the talk. The wrap-up sessions are very helpful." (Group 5).

Students reported taking a more in-depth and active approach to their learning and being more engaged. They reported being able to apply what they learned and even consider treatments. They also acknowledged the use of empathy and understood the role of the multi-disciplinary team [MDT].

"Exposed us to real-life scenarios; allowed us to not only explore the clinical importance but also emotions of a health care profession, a patient and their family members; insights on MDT" (Group 1).

"I really enjoyed the framework of CBL in terms of the continuity of following a case. Being able to collaborate and work with students, I found I was able to identify my weaknesses and gaps in knowledge and improve my treatment" (Group 2).

They also reported that opinion-based questions fostered better discussion among the group and suggested that "very active" facilitators who answered questions and spoke about their own experiences in the hospital as health professionals (e.g., doctor, nurse) were particularly effective in helping them stay focused on the discussion. They noted that the wrap-up sessions, in particular, were very helpful.

Students reported challenges that hindered active learning including being very uncomfortable and being asked questions about topics or content that had not been covered (yet) in lectures. However, students acknowledged that the active learning process aims to foster more independent and self-directed learning.

"… [We] know it's to try to make us more independent, but we think it just makes it less helpful" (Group 3).

Repetition across cases and, or questions detracted from the overall experience. They felt that being expected to answer questions before the knowledge had been covered in the lectures was an issue that impacted their ability to engage (anxiety), and they linked this concern to grading and assessment.

"Add points into knowledge pillar as there is a lot of background medical knowledge that is required." (Group 3).

"The order of CBL cases in relation to lectures occasionally made CBL very frustrating e.g., being expected to read ECGs in cardio CBL before we learned how to read them." (Group 4).

"Some topics are new, seen for the first time in CBL. It would be better if we had a lecture on it before CBL." (Group 5).

Students suggested areas for improvements pertaining to pedagogical factors, including factors impacting the overall experience of CBL. Areas for improvement included further training for facilitators, the quality of learning experienced by participants working in CBL groups, the structure of the cases, and suggested improvements to the CBL tasks. Students also requested access to the same information on the cases that the facilitators had to focus their prior reading.

"as much as I value input from my peers, at times such as the wrap-up, input from people who have more knowledge and experience would be appreciated" (Group 4).

"writing the cases based on actual patient experiences, tying it in with the healthcare symposium (could promote attendance for wrap-up sessions + symposium)" (Group 6).

"Revising lectures by preparing to answer CBL questions … patients were realistic from GP point of view … helped me understand diseases and conditions from both the doctors’ and patients’ perspective" (Group 7).

Students also suggested changes to reduce the noise in the learning environment, which hindered their participation in and listening to the discussion.

"Facilitators are very different; some give great answers and help our learning, while others step back and don't answer and say it's up to us." (Group 4).

3.2.3 Organisation

Organisational support relates to when the learning activity sits appropriately within the curriculum and provides opportunities to participate actively. Organisational support allows for the use of real patient cases and authentic learning opportunities. This exposure to real-life scenarios aims to ze the conditions for learning and helps create effective learning [25, 26]. Active participation aligned with learning and curriculum outcomes and how CBL was delivered. The organisation domain reflects every level of a curriculum, including core learning and activities that contribute to learning about authentic clinical practice. Positive factors relating to organisation support included students reporting being able to apply what they learned and even consider treatments, using empathy, and understanding the role of the MDT.

"Helps me look at disease in a different way and real-life scenarios; group discussions; sitting with a specialised instructor who knows beyond the curriculum … Exposed us to real-life scenarios; allowed us to not only explore the clinical importance but also emotions of a health care profession, a patient, and their family members; insights on MDT." (Group 1).

"Reconsidering concepts from lectures ... Has opened my eyes to the psychosocial and ethical side of medicine. Has made me appreciate the value of MDTs." (Group 4).

"Helps give an essence of what we could expect in a clinical setting; improves knowledge of what we learn in lectures." (Group 5).

Features that could have worked better regarding the general content included consistent and timely access to the preparation material in advance, so they have more time to prepare, and access to the facilitators' script after the session for future references, including pre-class access.

"... Prep material is not posted on time / does not exist - we have to google / chat GPT half the questions." (Group 2).

The groups felt that the content of the cases, was often repetitive, resulting in boredom if everyone had the same case. For example:

"prefer if we didn't already know what the disease was. For example, sometimes the title of the case is literally the disease." (Group 2).

"In the modern day, some CBLs are quite repetitive (a culture of swiping up has reduced attention span). Having the same patient for 3 cases becomes boring & repetitive – similar plot a little different: too slow." (Group 6).

As regards the quantity and frequency of the CBL sessions, most groups felt that there were too many wrap-up sessions, for example:

"Having a wrap up session after each CBL is sometimes too much (especially if we are following the same patient)." (Group 3).

Students then expressed their thoughts and feelings regarding organisational factors that could improve their CBL experience. Organisation factors comprised a significant portion of the data analysed regarding suggested improvements. Over a third of participant responses highlighted areas linked to the organisation, specifically around the delivery of the CBL. Organisational factors highlighted included the learning environment, timing of sessions and planning.

"CBL is conducted with large groups of students, This creates a noisy environment which makes discussion difficult at times" (Group 1).

"maybe coordinate the dates and cases with our lectures so that we can discuss the topics after we have had exposure to them in class" (Group 4).

"Only 2 CBLs per module with a two-week break at the start of the module. Gives us a chance to learn" (Group 5).

4.1. Affective factors

Our principal aim was to support international students transitioning from passive to active learners using case-based learning as the intervention. Active learning is less familiar to international students, who are generally more familiar with receiving information passively via lectures [18, 31]. Yet research has shown that international students can benefit more than local students; not only does it facilitate deep learning [32], but it also provides opportunities to improve their language and supports opportunities for enculturation [31]. Active learning is underpinned by social constructivism, which emphasises the role of social interaction to encourage participation and support students to take part in discussions, gain confidence, share opinions and develop cognitive ability [33].

The data was analysed using EXBL as the conceptual framework (22, 23, and 24). This enabled us to break down CBL into the elements of affective, pedagogical, and organisational to identify how CBL supported the transition to the active learner. The analysis identified that the affective theme of the EXBL model was critical to its success as it was this theme that reflected students' engagement, energy, and enjoyment of CBL. In addition, the students reported having the opportunity to speak in English [34], as a strength, rather than talk mainly in their native language with peers from the same country. Clearly, students unfamiliar with active learning and managing the expectation of speaking up need to feel psychologically safe to do so. We noted psychological safety was an important element at this early stage in the transition to active learning, which was reflected in the student comments made about being in the same group with the same faculty member. Another element that made CBL work was prior learning, which enabled students to contribute with confidence.

Although CBL was viewed positively, there were some criticisms: when other students were allowed to dominate the discussion, when faculty failed to moderate the discussion; and when faculty failed to provide a structure that enabled all students to contribute. Our students, who were in the early stages of their transition from passive to active learners, required more from the facilitator to enhance their participation and support their perceptions of psychological safety. Managing group dynamics is an area that can help or hinder active learning and confirms the need for psychological safety faculty training before CBL learning begins as suggested by Gassim et al. [35]. These findings show a need for student preparation for group learning, which concurs with research for enhancing student performance and equipping students to deal with group challenges [36].

4.2. Pedagogical factors which impact active learning in CBL

The pedagogical theme reflected the interactions and the support provided by the facilitators as well as role modelling. Students were aware of the range of faculty who were moderating CBL. Understandably, students valued contact with medical staff, some of whom could provide more information about the case being discussed and on occasion, provide other examples from their practice. However, generally, students valued pedagogical support from faculty who drove up their engagement with the case and were not quick to provide the correct answer. Instead, they enabled them to explore options, consider the evidence, ask questions, and provoke both interest and engagement. Such faculty drove deeper thinking and required a greater level of cognitive ability.

This student was at the start of the journey to active learning and at this stage, preferred the guidance from the faculty to facilitate the discussion, rather than students self-directing the session. Other research has also identified the moderator role can strongly influence the CBL outcome [35].

Other suggested improvements from the data related to sharing information before the CBL session to enable prior learning to improve participation. Again, previous research has highlighted that this student population particularly benefits as they can take time to gain familiarity with the content before the session and feel more confident about their input to the session [34]. Many students said they would like to receive a copy of the facilitator information sheet after the session as a learning tool, reflecting the transition from passive to active learning and being given the 'right answers'.

Additional improvements suggested by the students included a preference for the final wrap-up session to be led by the facilitator to ensure all learning points were included. This preference for the facilitator to guide the wrap-up aligns with the early stage of active learning for this participant group. Typically, students in the early years of their training tend to prefer more input from those whom they perceive to be the "experts" [21, 37, 38]. This is also borne out across all the qualitative data analysed here.

Further suggestions relating to the theme of pedagogical improvements associated with the quality of learning experienced by students. Learners reported valuing the interactivity of the sessions. However, some more confident students preferred the challenge more, with the inclusion of an option to find the solution or uncover the differential diagnoses of the patient case where relevant. There were also suggestions for cases to be as closely based on real patient cases or aligned with previous real patient symposia, which is a feature of the curriculum. This is borne out in the research suggesting that the use of real-world tasks in active learning helps to increase knowledge and understanding in these contexts [39].

4.3. Organisational improvement factors which impact active learning in CBL

We agree with Burgess et al., that CBL enabled students to apply their knowledge and solve clinical problems within a small, safe group and through facilitator feedback [26]. We agree that our findings also represent these strengths of CBL and further enable international students to be more active contributory learners. In relation to the organisational theme, students were satisfied with this element of the CBL; however, some noted areas for improvement in the learning environment, such as the space used for CBL was noisy as other CBL groups were sharing a learning room, and this impacted negatively on hearing all the comments from within their CBL group. Additionally, there was consensus on a preference for round tables to help facilitate better active communication across their groups. Lastly, there were calls for better planning around timing, with many citing late afternoon CBL sessions as less enjoyable and more demanding to give energy and attention to at the end of a long day at college. Also, to ensure relevant lectures were timetabled before the CBL session and relevant to the case.

4.4 Limitations of this study

The current work has several strengths and certain limitations. Strength points include the application of CBL to a population of 12 nationalities. Limitations of this study were the small number of participating students, 10.4% representing the total cohort. Therefore, we recommend that more studies be conducted.

The students valued the transition from passive to active learners using CBL for international students. However, students new to CBL needed the facilitator to create an opportunity for them to contribute and ideally to remain in the same group to ensure psychological safety. Prior learning was important to provide both knowledge and confidence to provide an opinion or engage in a discussion, but the students preferred the facilitator to summarise the session and offer assurances that the important learning points were covered.

CBL

Case-Based Learning p.3

SGFS

Structured Group Feedback Sessions p.3

BEME

Best Evidence Medical Education p.5

ExBL

Experience Based Learning model p.6

REC

Research Ethics Committee p.8

MDT

Multi-Disciplinary Team P.12

RCSI

RCSI University of Medicine and Health Sciences p. 19

Ethics approval and consent to participate

This study has been approved by RCSI [RCSI University of Medicine and Health Sciences] Ethics Committee (Ethics Ref. No. REC202301020)

Consent for publication

Not applicable

Availability of data and materials

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable

Authors' contributions

CB and JI led the facilitation but were joined by four others who supported the student groups (HK, CD, FM, RD). CB and JI were not involved in the CBL teaching and only three of the authors (RD, GO and FM) had any involvement in teaching, they acted as support rather than leading the session. CB, JI & HK conducted the data analysis and drafted the paper. All authors read and reviewed the final version of the manuscript.

Acknowledgements

The authors sincerely thank the students for their participation in this study. Our thanks extend to the staff members of the School of Medicine and Health Professions Education Centre their help in preparation and collecting of data for this study. We would also like to thank the members of the research team (Prof. Naji Alamuddin, Dr Sarah O'Neill, Prof. Maria Morgan, Dr Marie Mcllroy, Prof. Christopher Torrens and Prof. Clare Condron) for their support and guidance.

Caplan NA, Stevens SG. Step Out of the Cycle: Needs, challenges, and successes of international undergraduates at a U.S. University. Engl Specif Purp. 2017;46:15–28.
Fatemi G, Saito E. Unintentional plagiarism and academic integrity: The challenges and needs of postgraduate international students in Australia. J Furth High Educ. 2019;44(10):1305–19.
Sawir E. Language difficulties of international students in Australia: The effects of prior learning experience. Int Educ Journal: Comp Perspect. 2005;6(5):567–80.
Andrade MS. International students in English-speaking universities. J Res Int Educ. 2016;5(2):131–54.
Jabeen R. Multicultural Diverse Classroom Addressing the Instructional Challenges and Reflections, from a Teacher’s Perspective. Arab World Engl J 2019(1):127–36.
Sheridan V. A holistic approach to international students, institutional habitus and academic literacies in an Irish third level institution. High Educ. 2010;62(2):129–40.
Young TJ, Sercombe PG, Sachdev I, Naeb R, Schartner A. Success factors for international postgraduate students' adjustment: exploring the roles of intercultural competence, language proficiency, social contact and social support. Eur J High Educ. 2013;3(2):151–71.
Tang X, Collier D, Witt A. Qualitative Study on Chinese Students’ Perception of U.S. University Life. J Int Students. 2018;8(1):151–78.
Thompson G, Aizawa I, Curle S, Rose H. Exploring the role of self-efficacy beliefs and learner success in English medium instruction. Int J Bilingual Educ Biling. 2019;25(1):196–209.
Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S. Comparing problem-based learning with case-based learning: effects of a major curricular shift at two institutions. Acad Med. 2007;82(1):74–82.
Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Purkis J, Clay D. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide 23. Med Teach. 2012;34(6):e421–444.
Cen XY, Hua Y, Niu S, Yu T. Application of case-based learning in medical student education: a meta-analysis. Eur Rev Med Pharmacol Sci. 2021;25(8):3173–81.
Maia D, Andrade R, Afonso J, Costa P, Valente C, Espregueira-Mendes J. Academic Performance and Perceptions of Undergraduate Medical Students in Case-Based Learning Compared to Other Teaching Strategies: A Systematic Review with Meta-Analysis. Educ Sci 2023, 13(3).
Tsekhmister Y. Effectiveness of case-based learning in medical and pharmacy education: A meta-analysis. Electron J Gen Med 2023, 20(5).
Schmidt HG, Rotgans JI, Yew EH. The process of problem-based learning: what works and why. Med Educ. 2011;45(8):792–806.
Parmelee DX, Michaelsen LK. Twelve tips for doing effective Team-Based Learning (TBL). Med Teach. 2010;32(2):118–22.
Taylor DC, Hamdy H. Adult learning theories: implications for learning and teaching in medical education: AMEE Guide 83. Med Teach. 2013;35(11):e1561–1572.
Wolff M, Wagner MJ, Poznanski S, Schiller J, Santen S. Not another boring lecture: engaging learners with active learning techniques. J Emerg Med. 2015;48(1):85–93.
Chandran L, Iuli RJ, Strano-Paul L, Post SG. Developing a Way of Being: Deliberate Approaches to Professional Identity Formation in Medical Education. Acad Psychiatry. 2019;43(5):521–7.
Picton A, Greenfeld S, Parry JM. Correction: Why do students struggle in their first year of medical school? A qualitative study of student voices. BMC Med Educ. 2023;23(1):706.
Vygotsky LS, Cole M, Jolm-Steiner V, Scribner S, Souberman E. Mind in Society. Massachusetts: Harvard University Press; 1980.
Gryka R, Kiersma ME, Frame TR, Cailor SM, Chen AMH. Comparison of student confidence and perceptions of biochemistry concepts using a team-based learning versus traditional lecture-based format. Curr Pharm Teach Learn. 2017;9(2):302–10.
Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning. Med Educ. 2007;41(1):84–91.
Dornan T, Tan N, Boshuizen H, Gick R, Isba R, Mann K, Scherpbier A, Spencer J, Timmins E. How and what do medical students learn in clerkships? Experience based learning (ExBL). Adv Health Sci Educ Theory Pract. 2014;19(5):721–49.
Dornan T, Conn R, Monaghan H, Kearney G, Gillespie H, Bennett D. Experience Based Learning (ExBL): Clinical teaching for the twenty-first century. Med Teach. 2019;41(10):1098–105.
Burgess A, Matar E, Roberts C, Haq I, Wynter L, Singer J, Kalman E, Bleasel J. Scaffolding medical student knowledge and skills: team-based learning (TBL) and case-based learning (CBL). BMC Med Educ. 2021;21(1):238.
Gibbs G, Habeshaw S, Habeshaw T. 53 Interesting Ways to Appraise Your Teaching, 2nd Paperback edn: Technical & Educational Services Ltd; 1988.
McMahon S, O'Donoghue G, Doody C, O'Neill G, Barrett T, Cusack T. Standing on the Precipice: Evaluating Final-Year Physiotherapy Students' Perspectives of Their Curriculum as Preparation for Primary Health Care Practice. Physiother Can. 2016;68(2):188–96.
Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Analyzing qualitative data. 1st edn. Edited by Bryman A, Burgess R. London: Routledge; 1994: 173–194.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(117):117.
Marrone M, Taylor M, Hammerle M. Do International Students Appreciate Active Learning in Lectures? Australasian J Inform Syst 2018, 22.
McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. J Med Educ Curric Dev 2016, 3.
Carroll J, Ryan J. Teaching International Students: Improving Learning for All. London: Routledge; 2007.
Stillwell CG. Active Learning for International Student Users of English as a Second Language in Higher Education: Help or Hindrance? Doctorate Thesis. UC Irvine; 2018.
Gasim MS, Ibrahim MH, Abushama WA, Hamed IM, Ali IA. Medical students' perceptions towards implementing case-based learning in the clinical teaching and clerkship training. BMC Med Educ. 2024;24(1):200.
Edmunds S, Brown G. Effective small group learning: AMEE Guide 48. Med Teach. 2010;32(9):715–26.
Sanders D, Welk DS. Strategies to scaffold student learning: applying Vygotsky's Zone of Proximal Development. Nurse Educ. 2005;30(5):203–7.
Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363–406.
Prince M. Does Active Learning Work? A Review of the Research. J Eng Educ. 2013;93(3):223–31.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
16 Jul, 2024
Editor assigned by journal
15 Jul, 2024
Submission checks completed at journal
15 Jul, 2024
First submitted to journal
09 Jul, 2024

You are reading this latest preprint version

The transition from passive to active learner: medical student experiences of Case-Based Learning (CBL) at a multicultural medical school: Structured Group Feedback Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

1. Background

1.1 International students learning challenges

1.2. Study context and aims

1.3 Conceptual framework

2. Methods

2.1 Study Design

2.2 Participants and Recruitment

2.3 Data Collection

2.4 Data Analysis

2.5 Ethical Considerations

3. Results

3.1 Descriptive data

3.2.1 Affective

3.2.2 Pedagogy

3.2.3 Organisation

4. Discussion of findings

4.1. Affective factors

4.2. Pedagogical factors which impact active learning in CBL

4.3. Organisational improvement factors which impact active learning in CBL

4.4 Limitations of this study

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1