Abstract
Online case-based discussions, parallel to theoretical dental education, have been highly valued by students and supervisors. This study investigated the relation between variables of online group discussions and learning outcomes. At Ghent University in Belgium, undergraduate dental students (years two and three) are required to participate in online case-based discussion groups (five students/group) in conjunction with two theoretical courses on basic periodontics and related therapy. Each week, a patient case is discussed under supervision of a periodontist, who authored the case and performed the treatment. Each case includes treatment history and demand, intra- and extraoral images, and full diagnostic information with periodontal and radiographic status. For this retrospective study, data were obtained for all 252 students in forty-three discussion groups between 2009 and 2012. Spearman’s rank correlations were calculated to investigate the relation among group dynamics (number of group posts and views), individual student contributions (number of individual posts, newly introduced elements, questions, and reactions to other posts), supervisors’ interventions (number of posts and posed questions), and learning outcomes (examination result). The results showed that learning outcomes were significantly related to the number of student posts (Spearman’s rho (ρ)=0.19), newly introduced elements (ρ=0.21), reactions to other posts (ρ=0.14), number of supervisors’ interventions (ρ=0.12), and supervisors’ questions (ρ=0.20). These results suggest that individual student contributions during online case-based discussions and the provided supervision were related to learning outcomes.
- dental education
- problem-based learning
- periodontics
- online discussion groups
- educational methodologies
- Belgium
In educational settings, clinical case simulations are typically used to create a bridge between knowledge and its application in a realistic clinical environment. An important advantage of case-based learning is the ability to align the degree of complexity to the expected student’s capacity to create an optimal learning environment.1,2 Furthermore, clinical situations can be offered without the need of patient contact. From a student’s perspective, cases offer the opportunity to engage in clinical reasoning without the pressure and responsibility related to patient care and safety issues.3,4 As a result, patient cases can be a useful educational strategy in preparing students for real clinical training or challenging students with rare (and complex) clinical situations.1
Discussing patient cases in small student groups adds another dimension as this cooperative learning strategy stimulates students to express their views, to reflect on emerging opinions of themselves or their peers, and to consider alternatives before reaching a collective conclusion.5 Technological developments now make available the opportunity for students to discuss patient cases on asynchronous forums. Online discussions have the advantage of being time- and place-independent, giving students the ability to participate at their own pace. Consequently, students have the time to individually think, reflect, and search for additional information in preparation of a contribution to the discussion, enabling deep learning.6
In search of a method of teaching information within its clinical context and as an approach to stimulate clinical reasoning and deeper learning,7–9 online case-based discussions were introduced in the undergraduate dental curriculum at Ghent University, Ghent, Belgium. A blended learning strategy was implemented in a periodontal course, combining traditional lecture-based teaching with small-group discussions on diagnostics and treatment planning based on presented patient cases. A previous study10 demonstrated that both students and supervisors considered this educational approach a valuable addition to the dental curriculum with high appreciation of feasibility and learning potential. These results are consistent with other studies in dental and other health professions education.4,5,11
Users’ perceptions are useful to assess the acceptance of teaching methods. To optimize this teaching method for dental education, however, increased understanding of the relation between case-based discussions and learning outcomes was needed to unravel its underlying mechanism. Although a considerable amount of research on online discussions has been performed, understanding their effects remains inconclusive due to divergence in educational approach and research focus and methodologies.12 Nevertheless, some influential factors have been identified. Social interaction in discussion groups relates to a constructivist approach of knowledge-building in collaboration with peers. This interactive process is characterized by the contributions that a participant makes and the (re)actions of others. On group level, the total number of posts and participants viewing the posts creates a dynamic environment that influences the outcome.13,14 Individual contributions, as an indicator of active participation, have also been related to learning gain.15 In addition to peer interaction, the supervisor’s role can raise a discussion to a higher level and affect the outcome.12,16
Our aim for this study was to investigate the influence of participation in online case-based discussion groups on learning outcomes in dental education. We sought to test the following hypothesis: group dynamics, individual student contributions, and supervision in online periodontal case-based discussions in undergraduate dental education are related to learning outcomes.
Materials and Methods
Ethical approval for this study was granted by the Ghent University Hospital Ethics Committee. The undergraduate dental curriculum at Ghent University is a five-year educational program (three years of bachelor-level study and two years at the master’s level). In years two and three, the curriculum incorporates two consecutive periodontal courses. These courses introduce students to a variety of periodontal-related topics from the basic principles to more advanced diagnostics, treatment planning, and various modalities of periodontal therapy.
The introduction of online case-based discussion groups to these periodontal courses was grounded in social constructivist learning theory, which considers that learners actively build their own knowledge, rather than passively receiving information via transfer.17 Consequently, educational strategies following social constructivist principles focus on creating an environment that stimulates this process in learners, including active participation,18 critical thinking and reflection,7 collaboration,19 and authenticity of content.20
The combination of theoretical lectures and online case-based discussion groups resulted in a course with a blended learning approach. Patient cases were introduced to present the course content in an authentic clinical situation, stimulating students to review their previous knowledge and seek additional information in the discussion process. Students were allocated to small groups of five to provide the best opportunity to fully participate in the case discussions.15 At the onset of the course, students received an in-class introduction about the online discussion groups. Subsequently each week, a new case was provided online in a structure proposed by Johnsen et al.;21 the case included a patient history and demands, intra- and extraoral pictures, periodontal charts, and radiographic status. Guiding questions that had to be addressed were incorporated to organize the student discussions.
Students were instructed to provide at least two contributions to the case discussion each week. Each group discussion was supervised by the author of the case, who was also the treating periodontist of the patient. This allowed students to ask questions related to the case in a broad sense. Online feedback was provided regularly by the author of the case, who could redirect discussions if necessary to stimulate students to critically analyze all elements in the patient case and to answer more specific treatment-related questions beyond the students’ current knowledge. The actual treatment of the patient was disclosed to all students during a seminar at the end of the course.
Evaluation occurred during an end course exam. Open-ended questions were used to evaluate students’ knowledge of periodontics. A patient case, similar to the one used in the discussion groups, was introduced to assess students’ ability to apply knowledge in a clinical context. After a written preparation, students had to discuss their answers to the questions and the patient case with an examiner.
To investigate the hypothesis of our study, a retrospective analysis was conducted. All students in the periodontal courses in years two and three and the online case-based discussion groups used during three consecutive academic years (2009–12) were identified and screened. To ensure a structured approach, a conceptual research framework (Figure 1) was developed to illustrate the relation among all variables in the hypothesis. Since group dynamics, individual student contribution, and supervision are important variables that influence the learning effect in group discussions, data on each variable were collected. The total number of posts in the discussion and the number of views by all participants were identified as indicators for group dynamics; these were the same for all participants in a discussion group. Individual student contribution was defined by the number of individual posts in the discussion group by a student, which could include introduction of a new element, a question, or a reaction to another post. Supervision was investigated by the numbers of posts by the supervisor and the supervisor’s questions to the students. These group discussion variables were related to the end course results as indicators of learning outcomes.
Conceptual research framework
Kolmogorov-Smirnov tests and Q-Q plots were used to evaluate the distribution of the data.17 As results showed an absence of normal distribution, Spearman’s rank correlations were calculated to analyze the relation between the group discussion indicators and learning outcomes.22 All statistical analyses were performed using SPSS 22.0 (IBM Corp., Armonk, NY, USA) with a significance level set at p≤0.05.
Results
Data from all 252 students in forty-three discussion groups were included in the screening process, containing 221 discussed cases and 3,370 posts. Descriptive characteristics of the data and Kolmogorov-Smirnov analysis, demonstrating the absence of a normal distribution, are shown in Table 1.
Descriptive statistics (median, interquartile range) and results of Kolmogorov-Smirnov analysis (D, degrees of freedom, significance) of group discussion variables-indicators and learning outcome
Spearman’s correlation coefficients between group discussion indicators ranged between 0.05 and 0.21. Significant correlations were present between learning outcomes and indicators of individual student contribution (total number of posts, introduction of new elements, and reaction to another post) and supervision (total number of posts and posed questions). An overview of the Spearman’s correlation analysis appears in Table 2.
Spearman’s correlation coefficient (Spearman’s ρ) and significance between group discussion variables-indicators and learning outcome
Discussion
In an attempt to unravel the underlying mechanism of learning in online case-based discussion groups, we conducted a study to investigate the relation among group dynamics, individual student contributions, supervision, and learning outcomes. The results could confirm the hypothesis only partially. Significant (albeit weak) positive correlations were found between learning outcomes and indicators of student contributions and supervision. Group dynamics, however, did not significantly relate to learning outcomes.
The absence of significant correlations between indicators of group dynamics and learning outcomes demonstrate that popularity and size of a discussion was not related to individual student learning. Instead, the results may suggest a need for students to actively engage in discussions, rather than passively observing the ongoing discussion from the sidelines.11 Individually contributing to a discussion forces students to analyze the previous messages and relate them to their own knowledge and possible external information sources to create a reaction. It stimulates them to actively engage in a learning process. Active learning is considered an efficient approach to learning and may have influenced the outcomes.18,23
Within this learning process, supervision was found to be an important facilitating factor. Next to providing confirmative feedback, supervisors in this study were instructed to enter into the discussions when students were introducing the wrong assumptions or incorrect quotes, when their reasoning led to the wrong conclusions, or when questions remained unanswered. The results suggest that, in addition to providing the correct information, supervisors also could ask thought-provoking questions, which is in support of the current view of supervisors as facilitators of student reflections.24 By asking the right questions, students are triggered to analyze their thoughts and engage in reflection.25 The relation between reflection and case-based clinical reasoning for medical students26 and portfolio learning for dental students27 has been previously suggested and could explain the influence of supervision. Consequently, it emphasizes the importance of supervisors’ being trained in reflection and coaching skills, rather than merely focusing on their clinical competence.28
The rather small correlations in this study (Spearman’s ρ 0.12–0.21) indicate the complex and subtle character of the underlying mechanism of learning during online case-based discussions. They also suggest the presence of other factors besides the variables included in this study, such as quality of contributions, motivation, self-efficacy, competence in clinical reasoning, or individual learning style. All of these factors are part of the rich educational environment in this study and are causing noise. Hence, the results have to be interpreted within this context. To filter out the noise, future research should integrate additional factors to investigate their influence on learning outcome and their relation to individual students’ contributions and supervision.
The scope of this study was directed towards quantitative rather than qualitative analysis. As a result, the findings are limited to interpretation of observed actions. The quality of students’ and supervisors’ contributions was not considered, which also could influence the depth of the discussion and consequently the outcome of a discussion group.
Furthermore, our findings are limited in identifying a causal relation between the indicators of online group discussions and learning outcomes. Establishing cause would require a research design with a control group with no individual contributions or no supervision, which could be considered unethical as students in the same course should receive the same learning content and instructional methods. To counter these ethical problems, one could consider a quasi-experimental design using multiple student populations29 or to offer additional education after wards to students in the control group. Although a causal relation remains to be confirmed by future research, our findings demonstrate a significant relation between learning outcomes and participating in online case-based discussion groups.
Conclusion
This retrospective study investigated the relation between variables of online group discussions and learning outcomes among all 252 dental students in a periodontal course at Ghent University in Belgium between 2009 and 2012. The results suggest that, in online case-based discussion groups, learning outcomes were related to a balanced combination of students’ individual contributions to advance the discussion and the supervision that was provided.
Acknowledgments
The authors would like to thank Maarten Glibert for his support during data collection.
REFERENCES
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