case study teachers perception

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• v.7; Jan-Dec 2021

Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country

Vidya seshan.

1 Maternal and Child Health Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Gerald Amandu Matua

2 Fundamentals and Administration Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Divya Raghavan

Judie arulappan, iman al hashmi, erna judith roach, sheeba elizebath sunderraj, emi john prince.

3 Griffith University, Nathan Campus, Queensland 4111

Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills. Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program. Methodology: A descriptive qualitative research design using focus group discussion method guided the study. The sample included undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018. The researcher used a purposive sampling technique and a total of 22 students participated in the study, through five (5) focus groups, with each focus group comprising between four to six nursing students. Results: In total, nine subthemes emerged from the three themes. The themes were “Knowledge development”, “Critical thinking and Problem solving”, and “Communication and Collaboration”. Regarding “Knowledge development”, the students perceived case study analysis method as contributing toward deeper understanding of the course content thereby helping to reduce the gap between theory and practice especially during clinical placement. The “Enhanced critical thinking ability” on the other hand implies that case study analysis increased student's ability to think critically and aroused problem-solving interest in the learners. The “Communication and Collaboration” theme implies that case study analysis allowed students to share their views, opinions, and experiences with others and this enabled them to communicate better with others and to respect other's ideas which further enhanced their team building capacities. Conclusion: This method is effective for imparting professional knowledge and skills in undergraduate nursing education and it results in deeper level of learning and helps in the application of theoretical knowledge into clinical practice. It also broadened students’ perspectives, improved their cooperation capacity and their communication with each other. Finally, it enhanced student's judgment and critical thinking skills which is key for their success.

Introduction/Background

Recently, educators started to advocate for teaching modalities that not only transfer knowledge ( Shirani Bidabadi et al., 2016 ), but also foster critical and higher-order thinking and student-centered learning ( Wang & Farmer, 2008 ; Onweh & Akpan, 2014). Therefore, educators need to utilize proven teaching strategies to produce positive outcomes for learners (Onweh & Akpan, 2014). Informed by this view point, a teaching strategy is considered effective if it results in purposeful learning ( Centra, 1993 ; Sajjad, 2010 ) and allows the teacher to create situations that promote appropriate learning (Braskamp & Ory, 1994) to achieve the desired outcome ( Hodges et al., 2020 ). Since teaching methods impact student learning significantly, educators need to continuously test the effectives of their teaching strategies to ensure desired learning outcomes for their students given today's dynamic learning environments ( Farashahi & Tajeddin, 2018 ).

In this study, the researchers sought to study the effectiveness of case study analysis as an active, problem-based, student-centered, teacher-facilitated strategy in a baccalaureate-nursing program. This choice of teaching method is supported by the fact that nowadays, active teaching-learning is preferred in undergraduate programs because, they not only make students more powerful actors in professional life ( Bean, 2011 ; Yang et al., 2013 ), but they actually help learners to develop critical thinking skills ( Clarke, 2010 ). In fact, students who undergo such teaching approaches usually become more resourceful in integrating theory with practice, especially as they solve their case scenarios ( Chen et al., 2019 ; Farashahi & Tajeddin, 2018 ; Savery, 2019 ).

Review of Literature

As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios ( Farashahi & Tajeddin, 2018 ; Hermens & Clarke, 2009). Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to experience teamwork and interpersonal relations as “they learn by doing” thus benefiting from possibilities that traditional lectures hardly create ( Farashahi & Tajeddin, 2018 ; Garrison & Kanuka, 2004 ).

Another merit associated with case study method of teaching is the fact that students can apply and test their perspectives and knowledge in line with the tenets of Kolb et al.'s (2014) “experiential learning model”. This model advocates for the use of practical experience as the source of one's learning and development. Proponents of case study-based teaching note that unlike passive lectures where student input is limited, case studies allow them to draw from their own experience leading to the development of higher-order thinking and retention of knowledge.

Case scenario-based teaching also encourages learners to engage in reflective practice as they cooperate with others to solve the cases and share views during case scenario analysis and presentation ( MsDade, 1995 ).

This method results in “idea marriage” as learners articulate their views about the case scenario. This “idea marriage” phenomenon occurs through knowledge transfer from one situation to another as learners analyze scenarios, compare notes with each other, and develop multiple perspectives of the case scenario. In fact, recent evidence shows that authentic case-scenarios help learners to acquire problem solving and collaborative capabilities, including the ability to express their own views firmly and respectfully, which is vital for future success in both professional and personal lives ( Eronen et al., 2019 ; Yajima & Takahashi, 2017 ). In recognition of this higher education trend toward student-focused learning, educators are now increasingly expected to incorporate different strategies in their teaching.

This study demonstrated that when well implemented, educators can use active learning strategies like case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. This study is significant because the findings will help educators in the country and in the region to incorporate active learning strategies such as case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. Besides, most studies on the case study method in nursing literature mostly employ quantitative methods. The shortage of published research on the case study method in the Arabian Gulf region and the scanty use of qualitative methods further justify why we adopted the focus group method for inquiry.

A descriptive qualitative research design using focus group discussion method guided the study. The authors chose this method because it is not only inexpensive, flexible, stimulating but it is also known to help with information recall and results in rich data ( Matua et al., 2014 ; Streubert & Carpenter, 2011 ). Furthermore, as evidenced in the literature, the focus group discussion method is often used when there is a need to gain an in-depth understanding of poorly understood phenomena as the case in our study. The choice of this method is further supported by the scarcity of published research related to the use of case study analysis as a teaching strategy in the Middle Eastern region, thereby further justifying the need for an exploratory research approach for our study.

As a recommended strategy, the researchers generated data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and cased-based teaching approaches. The focus group interviews allowed the study participants to express their experiences and perspectives in their own words. In addition, the investigators integrated participants’ self-reported experiences with their own observations and this enhanced the study findings ( Morgan & Bottorff, 2010 ; Nyumba et al., 2018 ; Parker & Tritter, 2006 ).

Eligibility Criteria

In order to be eligible to participate in the study, the participants had to:

• be a baccalaureate nursing student in College of Nursing, Sultan Qaboos University
• register for Maternity Nursing Course in 2017 and 2018.
• attend all the Case Study Analysis sessions in the courses before the study.
• show a willingness to participate in the study voluntarily and share their views freely.

The population included the undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018.

The researcher used a purposive sampling technique to choose participants who were capable of actively participating and discussing their views in the focus group interviews. This technique enabled the researchers to select participants who could provide rich information and insights about case study analysis method as an effective teaching strategy. The final study sample included baccalaureate nursing students who agreed to participate in the study by signing a written informed consent. In total, twenty-two (22) students participated in the study, through five focus groups, with each focus group comprising between four and six students. The number of participants was determined by the stage at which data saturation was reached. The point of data saturation is when no new information emerges from additional participants interviewed ( Saunders et al., 2018 ).Focus group interviews were stopped once data saturation was achieved. Qualitative research design with focus group discussion allowed the researchers to generate data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and case-based teaching approaches. The focus group interviews allowed the study participants to express their perspectives in their own words. In addition, the investigators enhanced the study findings by integrating participants’ self-reported experiences with the researchers’ own observations and notes during the study.

The study took place at College of Nursing; Sultan Qaboos University, Oman's premier public university, in Muscat. This is the only setting chosen for the study. The participants are the students who were enrolled in Maternal Health Nursing course during 2017 and 2018. The interviews occurred in the teaching rooms after official class hours. Students who did not participate in the study learnt the course content using the traditional lecture based method.

Ethical Considerations

Permission to conduct the study was granted by the College Research and Ethics Committee (XXXX). Prior to the interviews, each participant was informed about the purpose, benefits as well as the risks associated with participating in the study and clarifications were made by the principal researcher. After completing this ethical requirement, each student who accepted to participate in the study proceeded to sign an informed consent form signifying that their participation in the focus group interview was entirely voluntary and based on free will.

The anonymity of study participants and confidentiality of their data was upheld throughout the focus group interviews and during data analysis. To enhance confidentiality and anonymity of the data, each participant was assigned a unique code number which was used throughout data analysis and reporting phases. To further assure the confidentiality of the research data and anonymity of the participants, all research-related data were kept safe, under lock and key and through digital password protection, with unhindered access only available to the research team.

Research Intervention

In Fall 2017 and Spring 2018 semesters, as a method of teaching Maternal Health Nursing course, all students participated in two group-based case study analysis exercises which were implemented in the 7 th and 13 th weeks. This was done after the students were introduced to the case study method using a sample case study prior to the study. The instructor explained to the students how to solve the sample problem, including how to accomplish the role-specific competencies in the courses through case study analysis. In both weeks, each group consisting of six to seven students was assigned to different case scenarios to analyze and work on, after which they presented their collective solution to the case scenarios to the larger class of 40 students. The case scenarios used in both weeks were peer-reviewed by the researchers prior to the study.

Pilot Study

A group of three students participated as a pilot group for the study. However, the students who participated in the pilot study were not included in the final study as is general the principle with qualitative inquiry because of possible prior exposure “contamination”. The purpose of piloting was to gather data to provide guidance for a substantive study focusing on testing the data collection procedure, the interview process including the sequence and number of questions and probes and recording equipment efficacy. After the pilot phase, the lessons learned from the pilot were incorporated to ensure smooth operations during the actual focus group interview ( Malmqvist et al., 2019 .

Data Collection

The focus group interviews took place after the target population was exposed to case study analysis method in Maternal Health Nursing course during the Fall 2017 and Spring 2018 semesters. Before data collection began, the research team pilot tested the focus group interview guide to ensure that all the guide questions were clear and well understood by study participants.

In total, five (5) focus groups participated in the study, with each group comprising between four and six students. The focus group interviews lasted between 60 and 90 min. In addition to the interview guide questions, participants’ responses to unanswered questions were elicited using prompts to facilitate information flow whenever required. As a best practice, all the interviews were audio-recorded in addition to extensive field notes taken by one of the researchers. The focus group interviews continued until data saturation occurred in all the five (5) focus groups.

Credibility

In this study, participant's descriptions were digitally audio recorded to ensure that no information was lost. In order to ensure that the results are accurate, verbatim transcriptions of the audio recordings were done supported by interview notes. Furthermore, interpretations of the researcher were verified and supported with existing literature with oversight from the research team.

Transferability

The researcher provided a detailed description about the study settings, participants, sampling technique, and the process of data collection and analyses. The researcher used verbatim quotes from various participants to aid the transferability of the results.

Dependability

The researcher ensured that the research process is clearly documented, traceable, and logical to achieve dependability of the research findings. Furthermore, the researcher transparently described the research steps, procedures and process from the start of the research project to the reporting of the findings.

Confirmability

In this study, confirmability of the study findings was achieved through the researcher's efforts to make the findings credible, dependable, and transferable.

Data Analysis

Data were analyzed manually after the lead researcher integrated the verbatim transcriptions with the extensive field notes to form the final data set. Data were analyzed thematically under three thematic areas of a) knowledge development; b) critical thinking and problem solving; and (c) communication and collaboration, which are linked to the study objectives. The researchers used the Six (6) steps approach to conduct a trustworthy thematic analysis: (1) familiarization with the research data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes, (6) writing the report ( Nowell et al., 2017 ).

The analysis process started with each team member individually reading and re-reading the transcripts several times and then identifying meaning units linked to the three thematic areas. The co-authors then discussed in-depth the various meaning units linked to the thematic statements until consensus was reached and final themes emerged based on the study objectives.

A total of 22 undergraduate third-year baccalaureate nursing students who were enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018 participated in the study, through five focus groups, with each group comprising four to six students. Of these, 59% were females and 41% were males. In total, nine subthemes emerged from the three themes. Under knowledge development, emerged the subthemes, “ deepened understanding of content ; “ reduced gap between theory and practice” and “ improved test-taking ability ”. While under Critical thinking and problem solving, emerged the subthemes, “ enhanced critical thinking ability ” and “ heightened curiosity”. The third thematic area of communication and collaboration yielded, “ improved communication ability ”; “ enhanced team-building capacity ”; “ effective collaboration” and “ improved presentation skills ”, details of which are summarized in Table 1 .

Table 1.

Objective Linked Themes and Student Perceptions of Outcome Case Study Analysis.

Theme 1: Knowledge Development

In terms of knowledge development, students expressed delight at the inclusion of case study analysis as a method during their regular theory class. The first subtheme related to knowledge development that supports the adoption of the case study approach is its perceived benefit of ‘ deepened understanding of content ’ by the students as vividly described by this participant:

“ I was able to perform well in the in-course exams as this teaching method enhanced my understanding of the content rather than memorizing ” (FGD#3).

The second subtheme related to knowledge development was informed by participants’ observation that teaching them using case study analysis method ‘ reduced the gap between theory and practice’. This participant's claim stem from the realization that, a case study scenario his group analyzed in the previous week helped him and his colleagues to competently deal with a similar situation during clinical placement the following week, as articulated below:

“ You see when I was caring for mothers in antenatal unit, I could understand the condition better and could plan her care well because me and my group already analyzed a similar situation in class last week which the teacher gave us, this made our work easier in the ward”. (FGD#7).

Another student added that:

“ It was useful as what is taught in the theory class could be applied to the clinical cases.”

This ‘theory-practice’ connection was particularly useful in helping students to better understand how to manage patients with different health conditions. Interestingly, the students reported that they were more likely to link a correct nursing care plan to patients whose conditions were close to the case study scenarios they had already studied in class as herein affirmed:

“ …when in the hospital I felt I could perceive the treatment modality and plan for [a particular] nursing care well when I [had] discussed with my team members and referred the textbook resource while performing case study discussion”. (FGD#17).

In a similar way, another student added:

“…I could relate with the condition I have seen in the clinical area. So this has given me a chance to recall the condition and relate the theory to practice”. (FGD#2) .

The other subtheme closely related to case study scenarios as helping to deepen participant's understanding of the course content, is the notion that this teaching strategy also resulted in ‘ improved test taking-ability’ as this participant's verbatim statement confirms:

“ I could answer the questions related to the cases discussed [much] better during in-course exams. Also [the case scenarios] helped me a great deal to critically think and answer my exam papers” (FGD#11).

Theme 2: Critical Thinking and Problem Solving

In this subtheme, students found the case study analysis as an excellent method to learn disease conditions in the two courses. This perceived success with the case study approach is associated with the method's ability to ‘ enhance students’ critical thinking ability’ as this student declares:

“ This method of teaching increased my ability to think critically as the cases are the situations, where we need to think to solve the situation”. (FGD#5)

This enhanced critical thinking ability attributed to case study scenario analysis was also manifested during patient care where students felt it allowed them to experience a “ flow of patient care” leading to better patient management planning as would typically occur during case scenario analysis. In support of this finding, a participant mentioned that:

“ …I could easily connect the flow of patient care provided and hence was able to plan for [his] management as often required during case study discussion” (FGD#12)

Another subtheme linked with this theme is the “ heightened curiosity” associated with the case scenario discussions. It was clear from the findings that the cases aroused curiosity in the mind of the students. This heightened interest meant that during class discussion, baccalaureate nursing students became active learners, eager to discover the next set of action as herein affirmed:

“… from the beginning of discussion with the group, I was eager to find the answer to questions presented and wanted to learn the best way for patient management” (FGD#14)

Theme 3: Communication and Collaboration

In terms of its impact on student communication, the subtheme revealed that case study analysis resulted in “ improved communication ability” among the nursing students . This enhanced ability of students to exchange ideas with each other may be attributed to the close interaction required to discuss and solve their assigned case scenarios as described by the participant below:

“ as [case study analysis] was done in the way of group discussion, I felt me and my friends communicated more within the group as we discussed our condition. We also learnt from each other, and we became better with time.” (FGD#21).

The next subtheme further augments the notion that case study analysis activities helped to “ enhance team-building capacity” of students as this participant affirmatively narrates:

“ students have the opportunity to meet face to face to share their views, opinion, and their experience, as this build on the way they can communicate with each other and respect each other's opinions and enhance team-building”. (FGD#19).

Another subtheme revealed from the findings show that the small groups in which the case analysis occurs allowed the learners to have deeper and more focused conversations with one another, resulting in “ an effective collaboration between students” as herein declared:

“ We could collaborate effectively as we further went into a deep conversation on the case to solve”. (FGD#16).

Similarly, another student noted that:

“ …discussion of case scenarios helped us to prepare better for clinical postings and simulation lab experience” (FGD#5) .

A fourth subtheme related to communication found that students also identified that case study analysis resulted in “ improved presentation skills”. This is attributed in part to the preparation students have to go through as part of their routine case study discussion activities, which include organizing their presentations and justifying and integrating their ideas. Besides readying themselves for case presentations, the advice, motivation, and encouragement such students receive from their faculty members and colleagues makes them better presenters as confirmed below:

“ …teachers gave us enough time to prepare, hence I was able to present in front of the class regarding the finding from our group.” (FGD#16).

In this study, the researches explored learner's perspectives on how one of the active teaching strategies, case study analysis method impacted their knowledge development, critical thinking, and problem solving as well as communication and collaboration ability.

Knowledge Development

In terms of knowledge development, the nursing students perceived case study analysis as contributing toward: (a) deeper understanding of content, (b) reducing gap between theory and practice, and (c) improving test-taking ability. Deeper learning” implies better grasping and retention of course content. It may also imply a deeper understanding of course content combined with learner's ability to apply that understanding to new problems including grasping core competencies expected in future practice situations (Rickles et al., 2019; Rittle-Johnson et al., 2020 ). Deeper learning therefore occurs due to the disequilibrium created by the case scenario, which is usually different from what the learner already knows ( Hattie, 2017 ). Hence, by “forcing” students to compare and discuss various options in the quest to solve the “imbalance” embedded in case scenarios, students dig deeper in their current understanding of a given content including its application to the broader context ( Manalo, 2019 ). This movement to a deeper level of understanding arises from carefully crafted case scenarios that instructors use to stimulate learning in the desired area (Nottingham, 2017; Rittle-Johnson et al., 2020 ). The present study demonstrated that indeed such carefully crafted case study scenarios did encourage students to engage more deeply with course content. This finding supports the call by educators to adopt case study as an effective strategy.

Another finding that case study analysis method helps in “ reducing the gap between theory and practice ” implies that the method helps students to maintain a proper balance between theory and practice, where they can see how theoretical knowledge has direct practical application in the clinical area. Ajani and Moez (2011) argue that to enable students to link theory and practice effectively, nurse educators should introduce them to different aspects of knowledge and practice as with case study analysis. This dual exposure ensures that students are proficient in theory and clinical skills. This finding further amplifies the call for educators to adequately prepare students to match the demands and realities of modern clinical environments ( Hickey, 2010 ). This expectation can be met by ensuring that student's knowledge and skills that are congruent with hospital requirements ( Factor et al., 2017 ) through adoption of case study analysis method which allows integration of clinical knowledge in classroom discussion on regular basis.

The third finding, related to “improved test taking ability”, implies that case study analysis helped them to perform better in their examination, noting that their experience of going through case scenario analysis helped them to answer similar cases discussed in class much better during examinations. Martinez-Rodrigo et al. (2017) report similar findings in a study conducted among Spanish electrical engineering students who were introduced to problem-based cooperative learning strategies, which is similar to case study analysis method. Analysis of student's results showed that their grades and pass rates increased considerably compared to previous years where traditional lecture-based method was used. Similar results were reported by Bonney (2015) in an even earlier study conducted among biology students in Kings Borough community college students, in New York, United States. When student's performance in examination questions covered by case studies was compared with class-room discussions, and text-book reading, case study analysis approach was significantly more effective compared to traditional methods in aiding students’ performance in their examinations. This finding therefore further demonstrates that case study analysis method indeed improves student's test taking ability.

Critical Thinking and Problem Solving

In terms of critical thinking and problem-solving ability, the use of case study analysis resulted in two subthemes: (a) enhanced critical thinking ability and (b) heightened learner curiosity. The “ enhanced critical thinking ability” implies that case analysis increased student's ability to think critically as they navigated through the case scenarios. This observation agrees with the findings of an earlier questionnaire-based study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh, that showed 81% of respondents agree that case study analysis develops critical thinking ability and enables students to do better problem analysis ( Muhiuddin & Jahan, 2006 ). This observation agrees with the findings of an earlier study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh. The study showed that 81% of respondents agreed that case study analysis facilitated the development of critical thinking ability in the learners and enabled the students to perform better with problem analysis ( Muhiuddin & Jahan, 2006 ).

More recently, Suwono et al. (2017) found similar results in a quasi-experimental research conducted at a Malaysian university. The research findings showed that there was a significant difference in biological literacy and critical thinking skills between the students taught using socio-biological case-based learning and those taught using traditional lecture-based learning. The researchers concluded that case-based learning enhanced the biological literacy and critical thinking skills of the students. The current study adds to the existing pedagogical knowledge base that case study methodology can indeed help to deepen learner's critical thinking and problem solving ability.

The second subtheme related to “ heightened learner curiosity” seems to suggest that the case studies aroused problem-solving interest in learners. This observation agrees with two earlier studies by Tiwari et al. (2006) and Flanagan and McCausland (2007) who both reported that most students enjoyed case-based teaching. The authors add that the case study method also improved student's clinical reasoning, diagnostic interpretation of patient information as well as their ability to think logically when presented a challenge in the classroom and in the clinical area. Jackson and Ward (2012) similarly reported that first year engineering undergraduates experienced enhanced student motivation. The findings also revealed that the students venturing self-efficacy increased much like their awareness of the importance of key aspects of the course for their future careers. The authors conclude that the case-based method appears to motivate students to autonomously gather, analyze and present data to solve a given case. The researchers observed enhanced personal and collaborative efforts among the learners, including improved communication ability. Further still, learners were more willing to challenge conventional wisdom, and showed higher “softer” skills after exposure to case analysis based teaching method. These findings like that of the current study indicate that teaching using case based analysis approach indeed motivates students to engage more in their learning, there by resulting in deeper learning.

Communication and Collaboration

Case study analysis is also perceived to result in: (a) improved communication ability; (b) enhanced team -building capacity, (c) effective collaboration ability, and (d) enhanced presentation skills. The “ improved communication ability ” manifested in learners being better able to exchange ideas with peers, communicating their views more clearly and collaborating more effectively with their colleagues to address any challenges that arise. Fini et al. (2018) report comparable results in a study involving engineering students who were subjected to case scenario brainstorming activities about sustainability concepts and their implications in transportation engineering in selected courses. The results show that this intervention significantly improved student's communication skills besides their higher-order cognitive, self-efficacy and teamwork skills. The researchers concluded that involving students in brainstorming activities related to problem identification including their practical implications, is an effective teaching strategy. Similarly, a Korean study by Park and Choi (2018) that sought to analyze the effects of case-based communication training involving 112 sophomore nursing students concluded that case-based training program improved the students’ critical thinking ability and communication competence. This finding seems to support further the use of case based teaching as an effective teaching-learning strategy.

The “ enhanced team-building capacity” arose from the opportunity students had in sharing their views, opinions, and experiences where they learned to communicate with each other and respect each other's ideas which further enhance team building. Fini et al. (2018) similarly noted that increased teamwork levels were seen among their study respondents when the researchers subjected engineering students to case scenario based-brainstorming activities as occurs with case study analysis teaching. Likewise, Lairamore et al. (2013) report similar results in their study that showed that case study analysis method increased team work ability and readiness among students from five health disciplines in a US-based study.

The finding that case study analysis teaching method resulted in “ effective collaboration ability” among students manifested as students entered into deep conversation as they solved the case scenarios. Rezaee and Mosalanejad (2015) assert that such innovative learning strategies result in noticeable educational outcomes, such as greater satisfaction with and enjoyment of the learning process ( Wellmon et al., 2012 ). Further, positive attitudes toward learning and collaboration have been noted leading to deeper learning as students prepare for case discussions ( Rezaee & Mosalanejad, 2015 ). This results show that case study analysis can be utilized by educators to foster professional collaboration among their learners, which is one of the key expectations of new graduates today.

The finding associated with “improved presentation skills” is consistent with the results of a descriptive study in Saudi Arabia that compared case study and traditional lectures in the teaching of physiology course to undergraduate nursing students. The researchers found that case-based teaching improved student’ overall knowledge and performance in the course including facilitating the acquisition of skills compared to traditional lectures ( Majeed, 2014 ). Noblitt et al. (2010) report similar findings in their study that compares traditional presentation approach with the case study method for developing and improving student's oral communication skills. This finding extends our understanding that case study method improves learners’ presentation skills.

The study was limited to level third year nursing students belonging to only one college and the sample size, which might limit the transferability of the study findings to other settings.

Implications for Practice

These study findings add to the existing body of knowledge that places case study based teaching as a tested method that promotes perception learning where students’ senses are engaged as a result of the real-life and authentic clinical scenarios ( Malesela, 2009 ), resulting in deeper learning and achievement of long-lasting knowledge ( Fiscus, 2018 ). The students reported that case scenario discussions broadened their perspectives, improved their cooperation capacity and communication with each other. This teaching method, in turn, offers students an opportunity to enhance their judgment and critical thinking skills by applying theory into practice.

These skills are critically important because nurses need to have the necessary knowledge and skills to plan high quality care for their patients to achieve a speedy recovery. In order to attain this educational goal, nurse educators have to prepare students through different student- centered strategies. The findings of our study appear to show that when appropriately used, case-based teaching results in acquisition of disciplinary knowledge manifested by deepened understanding of course content, as well as reducing the gap between theory and practice and enhancing learner's test-taking-ability. The study also showed that cased based teaching enhanced learner's critical thinking ability and curiosity to seek and acquire a deeper knowledge. Finally, the study results indicate that case study analysis results in improved communication and enhanced team-building capacity, collaborative ability and improved oral communication and presentation skills. The study findings and related evidence from literature show that case study analysis is well- suited approach for imparting knowledge and skills in baccalaureate nursing education.

This study evaluated the usefulness of Case Study Analysis as a teaching strategy. We found that this method of teaching helps encourages deeper learning among students. For instructors, it provides the opportunity to tailor learning experiences for students to undertake in depth study in order to stimulate deeper understanding of the desired content. The researchers conclude that if the cases are carefully selected according to the level of the students, and are written realistically and creatively and the group discussions keep students well engaged, case study analysis method is more effective than other traditional lecture methods in facilitating deeper and transferable learning/skills acquisition in undergraduate courses.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

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Educators’ perceptions of technology integration into the classroom: a descriptive case study

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 14 June 2019

Issue publication date: 3 December 2019

The purpose of this paper is to supply an in-depth description of the educators’ values, beliefs and confidence changing from a traditional learning environment to a learning environment integrating technology.

Design/methodology/approach

The descriptive case study design was employed using descriptive statistical analysis and inductive analysis on the data collected.

Themes on a high level of confidence, the importance of professional development and training, self-motivation, and excitement about the way technology can enhance the learning, along with concerns over the lack of infrastructure and support for integrating technology, and about the ability of students to use the technology tools for higher ordered thinking surfaced.

Research limitations/implications

Additional research may include a more diverse population, including educators at the kindergarten to high school level. Another recommendation would be to repeat the study with a population not as vested in technology.

Practical implications

A pre-assessment of the existing values, beliefs and confidence of educators involved in the change process will provide invaluable information for stakeholders on techniques and strategies vital to a successful transition.

Social implications

To effectively meet the learning styles of Generation Z and those students following, educators need be able to adapt to quickly changing technology, be comfortable with students who multitask and be open to technology-rich teaching and learning environments.

Originality/value

This study filled a gap in the literature where little information on the humanistic challenges educators encounter when integrating technology into their learning environment providing insights into the values, beliefs and level of confidence of educators experiencing change.

• Educational technology
• Humanistic approach
• Integrating technology

Hartman, R.J. , Townsend, M.B. and Jackson, M. (2019), "Educators’ perceptions of technology integration into the classroom: a descriptive case study", Journal of Research in Innovative Teaching & Learning , Vol. 12 No. 3, pp. 236-249. https://doi.org/10.1108/JRIT-03-2019-0044

Emerald Publishing Limited

Copyright © 2019, Rita J. Hartman, Mary B. Townsend and Marlo Jackson

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

How students prefer to learn has changed dramatically since the introduction of the internet. Students no long prefer passive dissemination of information being delivered by a teacher. Students prefer to watch a task taking place, and then attempt to duplicate it instead of reading or being instructed about the topic ( Genota, 2018 ; Seemiller and Grace, 2017 ; Shatto and Erwin, 2017 ; Swanzen, 2018 ). For example, 59 percent of Generation Z, 14–23-year olds, access YouTube for learning and information, 55 percent believe YouTube contributed to their education and only 47 percent prefer textbooks as a learning tool ( Global Research and Insights, 2018 ). The findings indicate virtual applications integrated into the curriculum can enhance the cognitive and creative skills of students through a student-centered environment ( Steele et al. , 2019 ). Although the study indicated 78 percent of the Generation Z believed teachers were important to their learning, only 39 percent preferred teacher-led instruction.

During the last seven years, the number of technology devices has grown 363 percent in our public schools. However, the use of classroom computers that duplicate the passive pedagogy of traditional classrooms has become more common, and the percentage of educational professional development opportunities for technology integration has remained unchanged ( Genota, 2018 ). Most college courses, even those that use a learning management system (LMS), tend to be teacher centered and lecture based ( Vercellotti, 2018 ). Higher education tends to be slow at adopting innovations in part because of the risk and the time commitment involved in exploring new tools and ideas ( Serdyukov, 2017 ). Simply adding more devices into the classroom is not enough to change instructional practices.

To effectively meet the learning styles of Generation Z and those students following, educators need be able to adapt to quickly changing technology, be comfortable with students who multitask and be open to technology-rich teaching and learning environments. However, most educators do not have the adequate knowledge, skills and confidence to effectively or efficiently use the available technologies to support technology integration into the learning environment ( El Fadil, 2015 ; Ferdig and Kennedy, 2014 ; Somera, 2018 ). In order to generate a systemic and empathetic change that can be sustained over time, educational leaders would need to explore the humanistic aspect of the change process as experienced by the educators. Inherent in the shifting role of educators is an in-depth understanding of the values, beliefs and confidence educators bring to the integration of technology into their classrooms.

Accessing information

The creation of the internet in 1990 by Tim Berners Lee ( Patterson, 1999 ) greatly influenced how people accessed information, interacted socially and prefer to learn. Generation Z (those born between 1995 and 2010) have grown up with easy access to the internet and are accustomed to multitasking, accessing information with a few clicks and watching something being done before trying it themselves ( Seemiller and Grace, 2017 ). Generation Z students prefer working with peers in collaborative groups over lectures. These students desire active learning with demonstrations and hands-on participation ( Adamson et al. , 2018 ; Seemiller and Grace, 2016 ). The students are also known by the monikers Net Generation, iGeneration or digital natives. By the year 2020, digital natives will make up one-third of the population in the USA ( Seemiller and Grace, 2016 ). Technology is a dominant part of their existence.

The traditional educational setting no longer meets the needs of a generation of students who strive to design their own learning experience ( Office of Educational Technology, Department of Education, 2017 ). However, the change from a teacher-centered learning environment to a student-centered learning environment with the integration of technology creates challenges and creates opportunities for educators ( Nicol et al. , 2018 ). Some educators recognize the benefits of integrating technology into their classrooms, which includes the advantages over traditional teaching and additional opportunities for improving student learning. Educators also consider benefits such as the availability of equipment, ease of use and the interest the technology may spark in each student ( Porter and Graham, 2016 ).

The process of identifying and implementing instructional technology requires different levels of support. The transition from a traditional learning environment to a learning environment integrating technology requires a certain amount of self-education on the part of the instructor, and the change process may take years ( Nicol et al. , 2018 ). Some educators find the process of scheduling equipment and loading materials into online course shells frustrating, and others find professional development activities do not fulfill their needs. The professional development available to faculty may have the wrong instructional focus, may be the wrong type or format, or may not be at the appropriate instructional level of the learners involved ( Reid, 2017 ). Achieving the level of support required for educators to feel comfortable may be challenging to both the support staff and the educators.

Change process

Learning how to enhance teaching with technology can be difficult ( Reid, 2017 ). Some educators approach instruction with very traditional methods. Teacher-centered lectures, pages of notes and assigned readings represent traditional or old-school instructional practices. Few post-secondary instructors are taught how to teach and most learn by modeling the teaching style of others. Teachers have not been taught how to be a facilitator in a technology-rich classroom ( Nicol et al. , 2018 ). Those teachers who do not acknowledge the changes in learning preferences may find it more difficult to teach the new generation.

Not all educators have the ability to embrace change. They may approach change with a fixed-mindset attempting to use a new technology tool and giving up easily at the first sign of difficulty. They do not see themselves as capable of learning to use the new technology tools and fear the risk of failure when trying new things ( Dress, 2016 ). The transition from teacher centered to student centered is a significant change and may be seen as a relinquishment of control by the teacher. Educators who are most comfortable in a traditional approach to education need more support when changing to a student-centered approach.

Humanistic influence on technology integration

The humanistic approach is described as involving the whole person and is manifested in the values, beliefs, confidence and emotions of the individual ( Fedorenko, 2018 ). Teaching is a humanistic endeavor, and educators find joy in being able to interact with their students and in being able to share their knowledge directly ( Azzaro, 2014 ). Learning organizations need educators who can bridge the gap between human and technological cultures ( Dominici, 2018 ). However, changing from a teacher-centered approach to a student-centered approach to instruction and learning may be difficult, and requiring the use of technology may seem too impersonal for educators to accept.

The educators’ values, beliefs and level of confidence are factors in the adoption of new technologies and pedagogies. A positive attitude toward using technology was found to be a significant factor in the intention to use educational technology. Positive attitudes have a major influence on the acceptance or rejection of the new technology integration. The change may come in the form of an educational change initiated by the college or university.

An educator’s beliefs about using technology become a factor in the ability to adopt the new technology into their pedagogy. If the transition was smooth and the process was positive, educators may be more open to accepting the change. If the change was not positive, the announcement may produce negative feelings and doubt related to any new initiative. The change may produce resistance, self-doubt and uncertainties ( Kilinc et al. , 2017 ; Reid, 2017 ). The doubt causes them to question the change and their belief system. Past experiences may also influence educators’ ability to be successful with the implementation of a new innovation, such as technology ( Demirbağ and Kılınç, 2018 ; Reid, 2017 ). If the focus of the change contradicts the current belief system, teachers are less likely to put the reforms into practice; therefore, they become resistant to the change. Changes that align with core beliefs are more likely to be successful ( Demirbağ and Kılınç, 2018 ). The alignment allows teachers to feel confident about the change process and more likely to be a user of technology.

Educators produce resistance by using the technology superficially or not at all. The resistance builds when the educational technology seemingly does not contribute to their traditional teaching ( Demirbağ and Kılınç, 2018 ). Educators may perceive learning to use the newly adopted technology as a burden ( Cheung et al. , 2018 ). The educational technology may be meaningful, but the resistance prevents them from exploring further opportunities for using the technology.

Resistance to technology can also be in association with an educator’s efficacy. Self-efficacy is the belief in one’s own ability to succeed in a context-specific task or behavior ( Bandura, 1986 ; Alenezi, 2017 ). Confidence and knowledge with using technology and computers is known as computer self-efficacy (CSE). CSE refers to the ability and the application of skills to achieve a result ( Alshammari et al. , 2016 ). The importance of CSE increased since the implementation of computer-based learning at all educational levels ( Bhatiasevi and Naglis, 2016 ). Educators with limited exposure to technology in their everyday and personal lives or with limited or nonexistent support will be resistant to using technology ( Kilinc et al. , 2017 ). An educator who demonstrates higher levels of CSE will have less frustration and will increase their use of technology in the future ( Cheung et al. , 2018 ). Users of technology tend to believe in the value of technology if it is easy to use and makes completing tasks simpler ( Bhatiasevi and Naglis, 2016 ). Lower levels of CSE coincide with low motivation and the perception of the technology as difficult and useless ( Alshammari et al. , 2016 ). CSE is a major factor in the resistance of the change, but it is a barrier which is difficult to detect. However, when combining CSE with an educator’s background experiences, one may have the ability to determine an educator’s resistance to technology.

Educators who are comfortable with traditional teaching methods may feel more comfortable with a colleague or mentor easing them into the process of integrating technology. This mentor or colleague would be the change agent. The change agent would provide reassurance and support. It would not only require a change in an educators’ knowledge of pedagogy and technology but also in their self-efficacy ( Reid, 2014 ). These mentors can provide just-in-time support and help ease the educator into increasing the use of technology.

Purpose statement and research question

What were the values, beliefs, confidence and level of preparedness of educators making the change from a traditional learning environment to a learning environment integrating technology?

Method and design

Descriptive case studies provide insight into complex issues and describe natural phenomenon within the context of the data that are being questioned ( Zainal, 2007 ). The goal of a qualitative descriptive study is to summarize the experience of the individuals or participants ( Lambert and Lambert, 2012 ). The design is appropriate for this study as the researchers were seeking to gain a rich description of educators’ experiences transitioning from a traditional learning environment to a learning environment integrating technology (Harrison, 2017; Yin, 2013 ). A descriptive statistical analysis was conducted on the 12 Likert-type questions and an inductive analysis was conducted on the narrative data collected from five open-ended questions included in the survey.

Participants

The sample recruited from the membership of Association for Educational Communication and Technology (AECT) during the fall of 2018 were community college, university, graduate level educators and others who had experienced changing from a traditional learning environment to a learning environment integrating technology. AECT has a membership of about 2,000 individuals from 50 countries (T. Lawson, personal communication, September 10, 2018). This population was of special interest because of the value and experience that they place on technology as evidence by their membership in AECT. The members of this group are familiar with technology and embrace the use of technology leaving the move from teacher centered to student centered as the key challenge. An invitation was sent out to the membership through the AECT website, and members of the organization self-selected to take part in the survey by clicking on the Member Consent, “Yes, I agree to participate.” An informed Consent approval was electronically signed through the SurveyMonkey tool describing the purpose and intent of the research study and describing how the participant’s identity and responses would remain protected.

In total, 42 participants started the survey. Tables I–IV provide the demographic information collected from the first four questions of the survey.

Data collection

After an invitation was sent out to the membership through the AECT website, members of the organization self-selected to take part in the survey. Participants were provided with a link to SurveyMonkey where they were asked to complete 12 Likert-type items and five open-ended questions. Descriptive statistics were collected from the Likert-type items. Participants responded to a series of statements indicating he or she strongly agree, agree, neither agree or disagree, disagree, or strongly disagree ( Croasmun and Ostrom, 2011 ; Salkind, 2009 ). Three of the items (7, 10 and 17) were negatively worded requiring the participants to think about the statement avoiding automated responses to the items ( Croasmun and Ostrom, 2011 ). The three items and corresponding responses were translated to a positive wording for analysis purposes. The results of the Likert-type items are displayed in Figures 1–3 . In the final section of the survey, participants were asked to respond to five open-ended questions. SurveyMonkey generated a document with each participants’ narrative comments. Survey results retrieved from SurveyMonkey were anonymous with no participant names or identifiers, other than the demographic information collected was accessible to the researchers.

Procedure for analysis

SurveyMonkey site generated a graphic representing the responses of participants to the 12 Likert-type items. Due to the nature of the 12 items, descriptive statistics analysis was appropriate for describing the qualitative data in terms of percentages ( Hussain, 2012 ). A content analysis approach was used to analysis the narrative responses to the five open-ended questions allowing us to systematically describe the data surfacing descriptive codes leading to major themes ( Finfgeld-Connett, 2013 ; Miles and Huberman, 1994 ; White and Marsh, 2006 ). Researchers initially coded the narrative statements independently, then engaged in a process of reviewing and analyzing the codes through four rounds until consensus was reached on the cluster of codes leading to emerging themes. The codes were unique and used to describe the educators’ experiences and perceptions changing from a traditional learning environment to a learning environment integrating technology ( Hseih and Shannon, 2005 ; Merriam, 2009 ; Vaismoradi et al. , 2013 ).

Responses to the Likert-type questions were combined into three figures. The related questions are grouped together for easier analysis. The questions related to confidence are organized into Figure 1 . The questions that addressed beliefs are organized into Figure 2 . The questions that addressed the values of participants are organized in Figure 3 . A detailed description of each figure is provided below.

Likert-type items

Responses to the Likert-type items 6, 9, 10 and 15 focused on the confidence of level participants integrating technology. The results can be seen in Figure 1 . Combining the responses of strongly agree and agree, 97 percent of the participants indicated they had a high level of confidence in integrating technology into their learning environment. In total, 95 percent of the participants had confidence in their abilities to enhance the learning environment with the integration of technology. In total, 81 percent indicated they were prepared for moving from a teacher-centered learning environment to a student-centered learning environment. There was an 86 percent response to the participants’ confidence in technology to enrich and deepen the learning experience for students.

Likert-type items 7, 12, 13, 14 and 17 addressed participants beliefs in technology integration into the classroom with the results displayed in Figure 2 . While the participant responses indicated confidence in technology integration, the beliefs of participations in how the technology contributed to student learning were more varied. In total, 86 percent believed technology contributed to the success of students. The responses to the extent to which technology engages students in higher order thinking indicated 69 percent either strongly agreed or agreed, while 29 percent indicated they neither agree or disagree. In total, 71 percent believed their value as a teacher was enhanced with the integration of technology, 72 percent believe the culture of their organization supports technology integration and 81 percent believed they had adequate training in technology integration.

Participants responses to the value of technology integration were high, at least 95 percent in each item as shown in Figure 3 . There was a 98 percent strongly agreed or agreed to the additional functions technology provides to monitor, adjust and extend student learning. In total, 95 percent of the participants value the opportunities technology integration provided them in creating and generating relevant lessons for students. In addition, 95 percent also valued ongoing training and professional development in integrating technology.

Open-ended questions

A systematic process was used for coding the responses to the open-ended questions. The process began with open coding in which similarities and differences in the responses were identified. Labels were created and examined for the emerging concepts. Axial coding was used to generate relationships between the categories, and these were tested against the theoretical framework. This process was repeated for each of the open-ended questions.

Participants reflected on some of the ways their personal values and beliefs were challenged in Question 18. Of the sample, 36 people responded to the question. Through the analysis of the question, several themes and subthemes were uncovered. These themes were: no impact, concerns about confidence and a change to student-centered instruction.

In total, 16 participants indicated a positive feeling toward technology or that there was no impact on their values or beliefs. One participant stated, “I’ve always believed in the value of technology.” Another said, “My personal beliefs were not challenged. I was one of the teachers leading the technology parade.” Under the theme of confidence, nine of the respondents indicated they had challenges to their beliefs due to concerns of their ability to use technology. One participant stated, “It took me several weeks to feel comfortable combining teaching and using the technology.” Another shared, “I was not sure I could truly deliver as engaging a lesson as I could face-to-face.” A similar comment was related to being able to manage students when technology was added, “My confidence in students’ ability to self-regulate has been challenged more than ever recently […] especially in terms of their unbelievable ability to distract themselves […].” In addition, nine of the respondents indicated the change to a student-centered approach brought about by the technology changes created challenges to their values and beliefs. One respondent shared, “The main challenge was in accepting a more learner-centered approach after decades of using the traditional approach to teaching.” This finding is significant, because it would be anticipated the participants would be comfortable with technology and yet, the move from teacher centered to student centered still held some challenges.

The ways participants were prepared for the change to a learning environment integrating technology was explored through Question 19. There were 36 responses to this question. Through the analysis of the responses, two main themes were uncovered. The themes were: prior experience with technology or formal training with the technology and being self-motivated to learn about the technology. Some of the respondents stated more than one thing that helped them prepare to use technology.

In total, 21 shared they had prior experience with the technology or formal training with technology that helped prepared them. “I was enrolled in technology classes that helped me in college and this opened many avenues for my learning.” Another subject stated, “I was a TA for two semesters for the course I taught. I attended the class and corrected papers, which helped me become familiar the Canvas, the LMS we use.” Other examples of formal training were, “Lots of grad school, at my own expense.” and, “My field is instructional design – it’s what I’m trained to do.”

In total, 18 of the respondents shared they were self-motivated to learn. Their responses included comments such as, “Trying out the technology before bringing it into the classroom.” Another participant stated, “Because of a personal interest in technology, I had been learning on my own.” Watching how-to videos on YouTube was another example of how participants were teaching themselves. There were some comments that were not common enough to merit a theme, but that still seemed worth mentioning. These referenced the importance of collaboration among peers. The comment, “Familiarity with the technology tools was important, but more important was the discourse with colleagues and former students about instructional strategies that allow students to grasp complexity,” reflected the value put on collaboration.

With Question 20, participants were asked to reflect on some of the challenges they encountered when moving to a learning environment integrating technology. In total, 34 provided responses. One major theme and two minor themes emerged. IN total, 19 of the participants indicated the greatest challenge was resources. Resources included those of time, financial and infrastructures. Time was needed for training, for development and redesigning of materials and lessons. One participant commented, “I need extra time on improving my digital capabilities, somehow add extra workload for me.” Specific to students, “when I ask them (the students) to use the technology. It consumes time, which is demotivating.” There was also concern about the “best use of time and resources when the technology may not ultimately be useful. ‘Knowing what will endure (and hence worth the effort) is difficult.’”

Financial support and a strong infrastructure to support the integration of technology was a concern. There were issues expressed about “access for all,” “reliability and expensive of technology,” “access to computer lab shared with other instructors” and “Tech support for things I can’t fix myself.”

In total, 11 participants expressed concerns about their lack of knowledge relative to technology resulting in a steep learning curve for educators and students. One participant was surprised at the “low technology skill level of students,” and another on the challenge of “becoming both subject matter expert and IT consultant to the students.” One participant was concerned about, “Learning new technologies and making sure that the activities and resources effectively help students learning,” and another mentioned a “Lack of knowledge about software/apps and ability to use them to enhance learning.”

Resistance surfaced in eight of the participants’ responses and reflected resistance on the part of students, teachers and administrators. Comments included, “student unwillingness to learn to use the technology,” the need for “opening people’s minds to a new learning style,” and “resistance from supervisors who are not forward thinking.”

Participants shared their level of confidence in the change process and any surprises or unexpected events they encountered during the transition in Question 21. There were 34 responses to this question. Through the analysis of the question, several themes and subthemes were uncovered. These themes were: confidence, attitudes and infrastructure. In total, 26 participants responded they were confident about the change process. One of the participants who identified confidence stated, “I am usually very confident because I am an avid technology user.” Another participant stated, “My confidence rests on the awareness that there is always more to learn about merging technology and instruction, and teaching and learning is a shared endeavor.” Few participants identified lack of confidence about the change process. The participant said, “I was not confident at first, but when I found students learning and enjoying the process my confident [ sic .] increase.”

The next theme which emerged was attitude. In total, 23 participants identified attitudes as surprising or unexpected about the change process. This theme was divided into two subthemes: teacher attitude and student attitude. One participant who mentioned student attitude said of his or her students were “very confident, student [ sic .] more creative, get more learning resources.” Participants also mentioned teacher attitude. One participant was “surprised by the jealousy of others who lacked knowledge and wanted to learn. Other teachers complained they couldn’t ever use the laptop cart, since I alwasy [ sic .] had it in my room and used it daily.”

Our last question was an open-ended question asking participants if there was anything else they would like to share that was not addressed by the previous questions. In total, 30 participants provided additional ideas. Comments related to instruction were made by 12 participants. The statement, “Although instructors should be cautious about the potential the extraordinary new technologies afford, there is much reason to excite our capacities to teach in ways that were not possible without these technologies,” reflects the participants views on the ways technology can and will influence their instruction.

In total, 11 participants expressed support for embracing technology and the potential technology holds for the learning environment with comments such as, “technology will be embraced by learners and it will enhance their learning and performance,” and “The potential of a learning environment with integrated technology is enormous.” Instruction and the importance of the designing the learning environment was expressed by eight participants. Respondents believed technology can enhance the learning, not drive the learning. “We must emphasize the design aspect in the learning environment as we do technology.”

Reflecting on their experiences transitioning from a traditional learning environment to one integrating technology, 42 participants shared their insights on the humanistic aspects of the change process leading to the generation of potential strategies and approaches for future change efforts.

The descriptive statistics indicated a strong level of confidence on the part of the participants in their abilities to integrate technology and a strong sense of the value technology brought to their educational setting. However, the beliefs on how technology contributed to student learning were more diverse. The results suggest there are still some questions about the extent to which technology engages students in higher order thinking and the degree to which technology enhances the role of the educator.

Three major themes emerged from the content analysis of the narrative responses: a sense of confidence and self-motivation in integrating technology in the educational environment, the importance of professional development/training opportunities, and a sense of excitement about the way technology can enhance the learning now and in the future. Approaching the humanistic aspects of change can lead to greater acceptance of the change and a deeper commitment to the change process. Efforts of resistance can be mitigated when the educators have a sense of self-assurance in the process, feel there is an alignment with their core values and have a sense of self-efficacy toward the ultimate goal. A parameter of the study was that the participants were members of the AECT and by membership, indicated an existing interest and awareness of the potential integrating technology into the educational environment.

In order to generate a systemic and empathetic change which can be sustained over time, educational leaders would need to explore the humanistic aspect of the change process as experienced by the educators, including the support and resources needed for the effective integration of technology into the educational environment. As anticipated, the participants in this study were more confident and comfortable about the change to technology. The challenge was the shift in emphasis from teacher- to student-centered pedagogies. Inherent in the changing role is an in-depth understanding of the confidence, beliefs and values educators bring to the integration of technology into their classrooms. A pre-assessment of the existing resources, needed resources and potential resources to support the change process, as well as, an assessment of the existing values, beliefs and confidence of educators involved in the change process will provide invaluable information for stakeholders on techniques and strategies vital to a successful transition.

Recommendations/limitations

The descriptive statistics and content analysis of the educators’ responses provided an awareness of the complex aspect of the change process when embracing technology as a tool to enhance the learning environment. The findings may provide schools, community colleges and universities, as well as graduate level educators, educational leaders and educational organizations moving to technology-driven learning platforms with valuable information on the humanistic aspect of designing strategies, techniques and support structures to assist educators in effectively and successfully embracing the innovation. Additional research may include a more diverse population, including educators at the kindergarten to high school level. Another recommendation would be to repeat the study with a population not as vested in technology as the members of the AECT.

Contributions

With the expanding capabilities of technology and ease of access to the internet, students at all levels are moving toward technologically driven approaches providing flexibility, active engagement and self-control over the learning experience ( Huh and Reigeluth, 2018 ; Utami, 2018 ). The informational age is moving education from teacher centered to learner-centered supported with the integration of technology. Research exists on the success of specific technology platforms and on the implementation of teacher training to support the integration of technology into the learning environment. However, there is little to no research on the values, beliefs and confidence of educators changing from a traditional learning environment to a learning environment integrating technology. Educators are entering into the new innovations with limited skills and knowledge to successfully implement the educational strategies needed for technology integration ( Somera, 2018 ). The findings from this study add to the literature on the complex issues educators encounter when integrating technology into their classrooms and providing additional insights into a humanistic approach to change.

Confidence level of participants integrating technology

Beliefs of participants in how technology contributed to student learning

Participants responses to the value of technology integration

Years teaching

Educational level currently teaching

Subject or field currently teaching

Age range of participants

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Acknowledgements

The authors acknowledge the support of Dr Mansureh Kebritchi research chair of the Center of Educational and Instruction Technology Research of the University of Phoenix.

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Case study teaching method improves student performance and perceptions of learning gains

Affiliation.

• 1 Liberal Studies, Faculty of Arts and Sciences, New York University, New York, NY 10003.
• PMID: 25949753
• PMCID: PMC4416499
• DOI: 10.1128/jmbe.v16i1.846

Following years of widespread use in business and medical education, the case study teaching method is becoming an increasingly common teaching strategy in science education. However, the current body of research provides limited evidence that the use of published case studies effectively promotes the fulfillment of specific learning objectives integral to many biology courses. This study tested the hypothesis that case studies are more effective than classroom discussions and textbook reading at promoting learning of key biological concepts, development of written and oral communication skills, and comprehension of the relevance of biological concepts to everyday life. This study also tested the hypothesis that case studies produced by the instructor of a course are more effective at promoting learning than those produced by unaffiliated instructors. Additionally, performance on quantitative learning assessments and student perceptions of learning gains were analyzed to determine whether reported perceptions of learning gains accurately reflect academic performance. The results reported here suggest that case studies, regardless of the source, are significantly more effective than other methods of content delivery at increasing performance on examination questions related to chemical bonds, osmosis and diffusion, mitosis and meiosis, and DNA structure and replication. This finding was positively correlated to increased student perceptions of learning gains associated with oral and written communication skills and the ability to recognize connections between biological concepts and other aspects of life. Based on these findings, case studies should be considered as a preferred method for teaching about a variety of concepts in science courses.

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Teachers’ Perceptions of School Behavior Support Systems: A Case Study

Laura N. Sarchet, M.S.Ed Niagara University

Teachers at a public middle school were given a questionnaire assessing the supports for student behavior and emotional needs in their school and district. Results show that teachers at this middle school perceive themselves as highly effective in forming individual relationships with students. Areas of growth include more clearly communicating and consistently implementing a Response to Intervention (RtI) process for behaviors, clarifying expectations of student behavior for both staff and students, and providing staff with more proactive professional development related to working with students with Emotional and Behavior Disorders (EBD). Relationship- and community-building RtI supports (Jones et al., 2004; Morrissey et al., 2010) fit well into a schoolwide Positive Behavior Interventions and Supports (PBIS) program (Fairbanks et al., 2008). One teacher is a single entity within the context of an entire system, they can be an advocate for change within the building and continue to support students’ social, emotional, and behavioral learning. 

Keywords: behavior, EBD, ED, emotional, middle school, PBIS, RtI, social skills

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Teacher Perceptions of How Attire Affects Student Behavior and Academic Performance: A Case Study

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Business school teaching case study: can green hydrogen’s potential be realised?

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Jennifer Howard-Grenville and Ujjwal Pandey

Roula Khalaf, Editor of the FT, selects her favourite stories in this weekly newsletter.

Hydrogen is often hyped as the “Swiss army knife” of the energy transition because of its potential versatility in decarbonising fossil fuel-intensive energy production and industries. Making use of that versatility, however, will require hydrogen producers and distributors to cut costs, manage technology risks, and obtain support from policymakers.

To cut carbon dioxide emissions, hydrogen production must shift from its current reliance on fossil fuels. The most common method yields “grey hydrogen”, made from natural gas but without emissions capture. “Blue hydrogen,” which is also made from natural gas but with the associated carbon emissions captured and stored, is favourable.

But “green hydrogen” uses renewable energy sources, including wind and solar, to split water into hydrogen and oxygen via electrolysis. And, because there are no carbon emissions during production or combustion, green hydrogen can help to decarbonise energy generation as well as industry sectors — such as steel, chemicals and transport — that rely heavily on fossil fuels.

Ultimately, though, the promise of green hydrogen will hinge on how businesses and policymakers weigh several questions, trade-offs, and potential long-term consequences. We know from previous innovations that progress can be far from straightforward.

Wind power, for example, is a mature renewable energy technology and a key enabler in green hydrogen production, but it suffers vulnerabilities on several fronts. Even Denmark’s Ørsted — the world’s largest developer of offshore wind power and a beacon for renewable energy — recently said it was struggling to deliver new offshore wind projects profitably in the UK.

Generally, the challenge arises from interdependencies between macroeconomic conditions — such as energy costs and interest rates — and business decision-making around investments. In the case of Ørsted, it said the escalating costs of turbines, labour, and financing have exceeded the inflation-linked fixed price for electricity set by regulators.

Business leaders will also need to steer through uncertainties — such as market demand, technological risks, regulatory ambiguity, and investment risks — as they seek to incorporate green hydrogen.

Test yourself

This is the third in a series of monthly business school-style teaching case studies devoted to responsible-business dilemmas faced by organisations. Read the piece and FT articles suggested at the end before considering the questions raised.

About the authors: Jennifer Howard-Grenville is Diageo professor of organisation studies at Cambridge Judge Business School; Ujjwal Pandey is an MBA candidate at Cambridge Judge and a former consultant at McKinsey.

The series forms part of a wide-ranging collection of FT ‘instant teaching case studies ’ that explore business challenges.

Two factors could help business leaders gain more clarity.

The first factor will be where, and how quickly, costs fall and enable the necessary increase to large-scale production. For instance, the cost of the electrolysers needed to split water into hydrogen and oxygen remains high because levels of production are too low. These costs and slow progress in expanding the availability and affordability of renewable energy sources have made green hydrogen much more expensive than grey hydrogen, so far — currently, two to three times the cost.

The FT’s Lex column calculated last year that a net zero energy system would create global demand for hydrogen of 500mn tonnes, annually, by 2050 — which would require an investment of $20tn. However, only $29bn had been committed by potential investors, Lex noted, despite some 1,000 new projects being announced globally and estimated to require total investment of $320bn.

Solar power faced similar challenges a decade ago. Thanks to low-cost manufacturing in China and supportive government policies, the sector has grown and is, within a very few years , expected to surpass gas-fired power plant installed capacity, globally. Green hydrogen requires a similar concerted effort. With the right policies and technological improvements, the cost of green hydrogen could fall below the cost of grey hydrogen in the next decade, enabling widespread adoption of the former.

Countries around the world are introducing new and varied incentives to address this gap between the expected demand and supply of green hydrogen. In Canada, for instance, Belgium’s Tree Energy Solutions plans to build a $4bn plant in Quebec, to produce synthetic natural gas from green hydrogen and captured carbon, attracted partly by a C$17.7bn ($12.8bn) tax credit and the availability of hydropower.

Such moves sound like good news for champions of green hydrogen, but companies still need to manage the short-term risks from potential policy and energy price swings. The US Inflation Reduction Act, which offers tax credits of up to $3 per kilogramme for producing low-carbon hydrogen, has already brought in limits , and may not survive a change of government.

Against such a backdrop, how should companies such as Hystar — a Norwegian maker of electrolysers already looking to expand capacity from 50 megawatts to 4 gigawatts a year in Europe — decide where and when to open a North American production facility?

The second factor that will shape hydrogen’s future is how and where it is adopted across different industries. Will it be central to the energy sector, where it can be used to produce synthetic fuels, or to help store the energy generated by intermittent renewables, such as wind and solar? Or will it find its best use in hard-to-abate sectors — so-called because cutting their fossil fuel use, and their CO₂ emissions, is difficult — such as aviation and steelmaking?

Steel producers are already seeking to pivot to hydrogen, both as an energy source and to replace the use of coal in reducing iron ore. In a bold development in Sweden, H2 Green Steel says it plans to decarbonise by incorporating hydrogen in both these ways, targeting 2.5mn tonnes of green steel production annually .

Meanwhile, the global aviation industry is exploring the use of hydrogen to replace petroleum-based aviation fuels and in fuel cell technologies that transform hydrogen into electricity. In January 2023, for instance, Anglo-US start-up ZeroAvia conducted a successful test flight of a hydrogen fuel cell-powered aircraft.

The path to widespread adoption, and the transformation required for hydrogen’s range of potential applications, will rely heavily on who invests, where and how. Backers have to be willing to pay a higher initial price to secure and build a green hydrogen supply in the early phases of their investment.

It will also depend on how other technologies evolve. No industry is looking only to green hydrogen to achieve their decarbonisation aims. Other, more mature technologies — such as battery storage for renewable energy — may instead dominate, leaving green hydrogen to fulfil niche applications that can bear high costs.

As with any transition, there will be unintended consequences. Natural resources (sun, wind, hydropower) and other assets (storage, distribution, shipping) that support the green hydrogen economy are unevenly distributed around the globe. There will be new exporters — countries with abundant renewables in the form of sun, wind or hydropower, such as Australia or some African countries — and new importers, such as Germany, with existing industry that relies on hydrogen but has relatively low levels of renewable energy sourced domestically.

How will the associated social and environmental costs be borne, and how will the economic and development benefits be shared? Tackling climate change through decarbonisation is urgent and essential, but there are also trade-offs and long-term consequences to the choices made today.

Questions for discussion

Lex in depth: the staggering cost of a green hydrogen economy

How Germany’s steelmakers plan to go green

Hydrogen-electric aircraft start-up secures UK Infrastructure Bank backing

Aviation start-ups test potential of green hydrogen

Consider these questions:

Are the trajectories for cost/scale-up of other renewable energy technologies (eg solar, wind) applicable to green hydrogen? Are there features of the current economic, policy, and business landscape that point to certain directions for green hydrogen’s development and application?

Take the perspective of someone from a key industry that is part of, or will be affected by, the development of green hydrogen. How should you think about the technology and business opportunities and risks in the near term, and longer term? How might you retain flexibility while still participating in these key shifts?

Solving one problem often creates or obscures new ones. For example, many technologies that decarbonise (such as electric vehicles) have other impacts (such as heavy reliance on certain minerals and materials). How should those participating in the emerging green hydrogen economy anticipate, and address, potential environmental and social impacts? Can we learn from energy transitions of the past?

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International Edition

• Open access
• Published: 15 April 2024

Implementing spiritual care education into the teaching of palliative medicine: an outcome evaluation

• Yann-Nicolas Batzler 1 ,
• Nicola Stricker 2 , 3 ,
• Simone Bakus 4 ,
• Manuela Schallenburger 1 , 6 ,
• Jacqueline Schwartz 1 &
• Martin Neukirchen 1 , 5  

BMC Medical Education volume  24 , Article number:  411 ( 2024 ) Cite this article

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Metrics details

The concept of “total pain” plays an important role in palliative care; it means that pain is not solely experienced on a physical level, but also within a psychological, social and spiritual dimension. Understanding what spirituality entails, however, is a challenge for health care professionals, as is screening for the spiritual needs of patients.

This is a novel, interprofessional approach in teaching undergraduate medical students about spiritual care in the format of a seminar. The aim of this study is to assess if an increase in knowledge about spiritual care in the clinical context is achievable with this format.

In a mandatory seminar within the palliative care curriculum at our university, both a physician and a hospital chaplain teach strategies in symptom control from different perspectives (somatic domain – spiritual domain). For evaluation purposes of the content taught on the spiritual domain, we conducted a questionnaire consisting of two parts: specific outcome evaluation making use of the comparative self-assessment (CSA) gain and overall perception of the seminar using Likert scale.

In total, 52 students participated. Regarding specific outcome evaluation, the greatest gain was achieved in the ability to define total pain (84.8%) and in realizing its relevance in clinical settings (77.4%). The lowest, but still fairly high improvement was achieved in the ability to identify patients who might benefit from spiritual counselling (60.9%). The learning benefits were all significant as confirmed by confidence intervals. Overall, students were satisfied with the structure of the seminar. The content was delivered clearly and comprehensibly reaching a mean score of 4.3 on Likert scale (4 = agree). The content was perceived as overall relevant to the later work in medicine (mean 4.3). Most students do not opt for a seminar solely revolving around spiritual care (mean 2.6).

Conclusions

We conclude that implementing spiritual care education following an interprofessional approach into existing medical curricula, e.g. palliative medicine, is feasible and well perceived among medical students. Students do not wish for a seminar which solely revolves around spiritual care but prefer a close link to clinical practice and strategies.

Peer Review reports

Introduction

Education in palliative care was introduced in 2009 as a compulsory subject in German medical curricula. In the 1960s, Dame Cicely Saunders established palliative medicine and hospices as we know them today. Back then, Cicely Saunders propagated the concept of “total pain”, which means that pain or suffering in general is not solely experienced on a physical level, but also within a psychological, social and spiritual dimension (see. Fig.  1 ) [ 1 , 2 , 3 , 4 ]. Understanding the importance of spirituality in everyday clinical practice and what it entails, however, is a challenge for health care professionals (HCP) in all medical disciplines across the world [ 5 , 6 ]. Palliative care is a relatively young medical discipline which oftentimes is not sufficiently taught in medical curricula [ 1 , 7 ] and, therefore, knowledge regarding the importance of spirituality, which at many faculties is integrated into palliative care education, is scarce [ 1 , 7 ]. As a result, HCP tend to neglect the spiritual needs of patients [ 7 , 8 ]. But, if there is no fundamental knowledge in regards of spirituality and spiritual care among physicians, how can they target total pain adequately?

The European Association of palliative care (EAPC) describes spirituality as following:

“Spirituality is the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred.” [ 1 , 9 ].

It must be clear to all HCP that spirituality is a unique and subjective phenomenon that differs substantially from patient to patient [ 2 , 10 ]. Furthermore, to fully address the spiritual needs of patients, self-reflection, thorough consideration of one’s own attitude towards death, and finding meaning in life, are essential [ 8 , 9 ]. Several studies have shown the impact which the addressing of spiritual needs in the context of total pain can have on ameliorating the symptoms of patients, leading to a better quality of life and care [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Thus, once spiritual needs become imminent, it is necessary to engage in an interdisciplinary and multi-professional collaboration with specially trained professionals in the field of spiritual care [ 8 , 10 , 14 , 15 , 19 ]. Summing up, it is very important to raise awareness about the positive impact of spiritual care among HCPs [ 8 , 15 ]. To increase such knowledge and accrue such skills, the teaching of spiritual care in medical curricula is essential [ 20 ]. Throughout different regions in the world, in-person didactic teaching on spiritual care is the most commonly used technique [ 5 ]. Usually, the teaching is based on case studies and many include screening strategies assessing spiritual needs [ 5 ]. Often, education on spirituality and spiritual care is part of curricula in palliative care [ 5 , 21 ]. In German medical curricula, there is no compulsory subject solely revolving around spiritual care [ 22 ]. However, regarding the concept of total pain, implementing spiritual care into palliative care teaching, however, seems like a plausible proposition.

This study was conducted in order to assess the way medical students perceive the concept of implementing spiritual care into the teaching on symptom control in palliative care. Furthermore, we aimed to determine whether an actual increase of knowledge about spiritual care in the clinical context was achievable within this seminar.

Material and methods

This study is a single-centre prospective study conducted at University Hospital Duesseldorf, Germany. Ethical approval was obtained by the local ethics committee (reference number 2022–2274).

Curricular structure

At our facility, palliative care education is structured as followed: Five lectures (somatic symptoms, psychological symptoms, social symptoms and advance care planning, spiritual symptoms and end-of-life care and care for relatives, clinical ethics) and four seminars (symptom control, breaking bad news, clinical ethics I and II). Since 2022, the lecture on spiritual symptoms and end-of-life-care is held by both a physician and a hospital chaplain within the palliative care curriculum at Düsseldorf medical faculty. Beforehand, this lecture was solely held by a hospital chaplain. As internal evaluations implied, this concept was not well perceived by medical students as the relevance to daily clinical work was not apparent to them. They did not understand how spiritual care can support somatic strategies of symptom control and how both approaches are intertwined. Furthermore, they were unsure of how to assess patients’ spiritual needs. We therefore opted for the above-mentioned approach which allows lecturing relevant medical implications alongside spiritual care. As evaluations showed, this embeds spiritual care in a more clinical and tangible manner and students seem to better realize the relevance that spiritual care has in daily clinical practice. For example, students repeatedly stated that they were now able to understand the importance of ongoing collaborations for patients’ comfort care, e.g., in more sufficiently relieving anxiety or social distress.

Since this novel concept was perceived positively by medical students, we transposed it to our seminar titled “symptom control” which is now also held by a hospital chaplain and a physician. In the seminars, content from the lectures is further deepened and there is more room for discussions, e.g. concerning assessment of spiritual needs, possibilities of spiritual care, and inter-professional collaboration. There is also an emphasis on determining which patients might benefit from spiritual care making use of the SPIR tool (patient’s self-description as a S piritual person— P lace of spirituality in patient’s life – patient’s I ntegration in a spiritual community – R ole of health care professional in the domain of spirituality), which tackles different dimensions of spirituality [ 23 ].

In the seminar, a 33-year-old fictitious patient (inspired by a real patient) served as an example case. Her situation is used to address strategies for symptom control on both somatic and spiritual domains. To achieve this, a reflective question is discussed with the students followed by a joint development of possible therapeutic strategies on both the somatic and spiritual domain (see Fig.  2 ).

Case discussion in the seminar

Our approach can be described as novel, since training in spiritual care often involves the mere shadowing of chaplains [ 5 , 24 , 25 , 26 ]. An interprofessional, educational approach was mainly used with physicians or nurses in training [ 5 , 27 , 28 , 29 ], but not with medical students.

Evaluation methods

A structured, paper-based questionnaire was developed in repeated interdisciplinary and multi-professional discussions in the Interdisciplinary Centre for Palliative Care Medicine, University Hospital Düsseldorf, Germany. The basis for the questionnaire were the learning goals that are to be achieved within the seminar, as well as a didactic evaluation. The questionnaire was pretested among medical students, and unclear statements were altered. The questionnaire consists of two parts. The first part is made up of five statements regarding knowledge about total pain, assessing spiritual needs, and defining spiritual care (see Table  1 ) on both the knowledge and skills level. These statements cover the field of specific outcome evaluation. Making use of the comparative self-assessment (CSA) method to determine if a gain in knowledge was achieved, each student evaluated their knowledge before and after the seminar using the German school grading system (1 = “excellent” to 6 = “unsatisfactory”). The CSA gain is a well described and implemented method in evaluating actual knowledge gains in education [ 30 , 31 , 32 , 33 , 34 ]. This evaluation tool has the benefit of not taking into account experiences made beforehand as they are not contributing to the effect size [ 31 ]. CSA gain is calculated as followed:

Furthermore, CSA gain was calculated with a 95% confidence interval and standard error using individual learning gain (ILG) values. These values were calculated using the following formulas:

ILG = 0 if pre = post and

ILG = (pre − post)/(pre − 1) × 100 if pre > post [ 31 ].

The second part of the questionnaire consists of four questions regarding the perception of the seminar (structure, teaching spiritual care alongside symptom control in palliative care). A 5-Point-Likert scale was used for evaluation (1 = strongly disagree, 2 = disagree, 3 = neither, 4 = agree, 5 = strongly agree).

Study participation and analysis

Participation in the study was anonymous, voluntary, and could be withdrawn at any time without explanation. Eligible participants were undergraduate medical students at the beginning of their fifth year of medical education (Germany: total of min. six years), who completed the mandatory palliative care course. The purpose and content of the study were presented orally, and, furthermore, written information and consent documents were handed out. After completion of the seminar, the questionnaire was handed out making use of a post-then design in which the students were asked to retrospectively rate their knowledge before and after the seminar. There were no exclusion criteria other than refusing to participate. Due to the small number of students per seminar ( n  = 15–20), no demographic characteristics besides sex were assessed.

Data analysis was performed using Microsoft Excel 2020 (version 16.42, Microsoft Corp., Redmond, WA, USA) and IBM SPSS Statistic version 28.0.1.1 (IBM, Armonk, NY, USA).

Throughout the course of one semester in 2023, the questionnaires were rolled out in each of six separate seminars. Out of 108 eligible attending students, 52 students participated in total (48.1%). 25% ( n  = 13) of the participants were of female, 75% ( n  = 39) of male sex. Within the answered questionnaires, there was no missing data.

Regarding the specific outcome evaluation, CSA gains showed a relevant increase especially in the field of knowledge (see Table  2 and Fig.  3 ). The greatest improvement (84.8%) was achieved in the ability of defining total pain and realizing its importance in clinical settings (77.4%). After the seminar, medical students were increasingly able to name tools such as SPIR in order to engage in spiritual needs assessment (CSA gain 68,8%). A lower increase in knowledge was achieved in realizing how spiritual care itself can benefit patients’ needs (66.7%). The lowest gain was detected in actually identifying patients who might benefit from spiritual care (60.9%), which represents a skill to be learned rather than knowledge to be gained.

CSA gains for each item

Statistical analysis using 95% confidence intervals confirmed the gains in knowledge, which were significant for all items (Table  2 ).

In regard to the second part of the questionnaire, students were overall satisfied with the new structure of the seminar (Table  3 and Fig.  4 ). The content was comprehensible and delivered clearly gaining a mean score of 4.3 (median 4, SD 0.6, min. 2, max. 5). The content was perceived as overall relevant to the later work in medicine (mean 4.3, median 4, SD 0.6, min. 3, max. 5). It seems as if medical students regard the implementation of spiritual care education into the seminar “symptom control”, which focuses on alleviating symptoms on multidimensional levels, as expedient. They feel that implementing education on spiritual care into this seminar makes sense (mean 4.2, median 4, SD 0.8, min. 1, max. 5). Furthermore, most students do not opt for a seminar solely revolving around spiritual care (mean 2.6, median 2, SD 1.3, min. 1, max. 5).

Perception of the seminar, Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither, 4 = agree, 5 = strongly agree)

Our data show that implementing spiritual care education into existing medical curricula, in our example palliative care, is feasible and well perceived among medical students. The timing of our seminar is in accordance to other studies that found that spiritual care should be implemented in mandatory undergraduate courses [ 6 ]. Students do not wish for a seminar solely revolving around spiritual care but prefer a connection to clinical practice and strategies in symptom management. This enables them to understand the relevance of spiritual care in a daily clinical setting.

To evaluate training programs, Kirkpatrick proposed a four-level approach (level 1: reaction, level 2: learning, level 3: behaviour, level 4: results) [ 35 ]. We followed levels 1 (reaction—satisfaction) and 2 (learning—gains in knowledge) making use of the conducted questionnaire. Level 3 (change in behaviour – acquired skills) was briefly addressed with item 5 in the first part of the questionnaire. As level 4 is an indicator of direct results of the training at an organizational level, we were not able to incorporate items on this level. A different study among undergraduate nursing students assessed the effectiveness of teaching spiritual care in mandatory classes: There was an increase in knowledge, e.g., in defining spirituality, compared to students who obtained no information on spiritual care [ 36 ]. This is comparable to our study, as there were gains in knowledge after completing the mandatory seminar. We reached higher individual learning gains on the knowledge level than on the skills level, as was also the case in a number of other studies we conducted [ 31 ]. This is mainly because, due to the format of the seminar, no bedside teaching takes place and scenarios that might occur in everyday clinical practice can only be discussed and serve as examples.

The concept of total pain is essential in palliative care; however, it should not only be taken into consideration in a palliative setting, but whenever patients experience high burdens on various dimensions such as pain, anxiety, grief or existential distress [ 2 , 4 , 17 , 37 , 38 ]. We were able to thoroughly educate students on total pain and its relevance in clinical settings. Spirituality plays an important role in a holistic approach. However, literature shows that HCP often don’t know how to implement spiritual assessments and how to deal with spiritual needs [ 1 , 5 , 6 , 8 ]. A systematic review on teaching methods found the usage of practical tools and the involvement of chaplains to be effective facilitators in the teaching of spiritual care [ 5 ]. A scoping review found that spiritual care should be taught in both mono- and multi-disciplinary educational settings [ 6 ]. With our multi-professional approach, we were able to introduce students to tools in assessing spiritual needs, such as SPIR [ 23 ]. Within this item, there was a definite gain in knowledge of these tools which make assessing spiritual needs of patients more feasible. This is in accordance with findings of a number other studies [ 5 ]. In our study, however, students are still unsure if they are fully able to determine which patients might actually benefit from spiritual care, even though this item still reached a learning gain of 60.9%. As concluded by other authors, there is need for ongoing education [ 5 ].

Even though our seminar entails many different aspects of the total pain concept (somatic symptom management, spirituality, and spiritual care) medical students found the content to be clearly structured and comprehensible. More importantly, they understood the relevance of spirituality for their future clinical work and perceived the multi-professional teaching as highly satisfactory. In sensitizing them in this, we hope that they keep in mind the importance of ongoing collaborations between different professions.

Our study has some limitations. Even though the questionnaire was pretested among medical students before the actual study, no validated questionnaire was used. The response rate of almost 50% is relatively low and it can be assumed that those who participated were mostly students who were interested in the topic. This might have led to bias as positive effects might have been overestimated. Due to the small study population and to protect the privacy of participating students, no demographic data besides sex was collected. Demographic data, however, might contribute to a better understanding of spirituality or palliative medicine beforehand such as age, professional expertise, or own spiritual resources. This also meant that adjusting for confounding factors was not possible. This study solely dealt with medical students and no patients were involved. It would be of interest to assess as to whether the content taught in this seminar ultimately impacts the wellbeing or stress levels of patients in everyday clinical practice. A study focusing on patients would complement the findings of this study, as suggested by other researchers [ 5 ]. Furthermore, the study was only performed in one centre; therefore, it can only serve as an example on how spiritual care education might be successfully implemented into medical curricula.

Spirituality plays an important role for many people and should always be taken into consideration when treating patients. This especially applies to palliative care where the addressing of spiritual needs is of crucial importance [ 18 ]. However, many HCP don’t know how to address topics revolving around spirituality which makes it hard to determine which patients might benefit from spiritual care. Therefore, education on the nature of spiritual care, on what it entails and on how it can support patients in everyday clinical practice should be thoroughly integrated into medical curricula. We opted to implement spirituality and spiritual care into an existing seminar and lecture within the medical curriculum at our faculty. This was well received among students. As a result, we found a clear increase in knowledge about total pain and about the tools one might use to assess spiritual needs. This knowledge needs to be further strengthened in practical clinical scenarios.

Availability of data and materials

All data and materials are available within this publication.

Abbreviations

Health care professional

European Association of palliative care

• Spiritual care

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Acknowledgements

We thank Dr Jessica JT Fischer for excellent English language editing.

Open Access funding enabled and organized by Projekt DEAL. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Interdisciplinary Center for Palliative Care, University Hospital, Heinrich Heine University, Duesseldorf, Germany

Yann-Nicolas Batzler, Manuela Schallenburger, Jacqueline Schwartz & Martin Neukirchen

Evangelical Church in the Rhineland, Duesseldorf, Germany

Nicola Stricker

Institut Protestant de Théologie, Paris, France

Evangelical Hospital Chaplaincy (Pastoral Care), University Hospital, Heinrich Heine University, Duesseldorf, Germany

Simone Bakus

Department of Anesthesiology, University Hospital, Heinrich Heine University, Düsseldorf, Germany

Martin Neukirchen

Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany

Manuela Schallenburger

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YB, NS, MS, JS, MN designed the study. YB analysed and interpreted the data. YB drafted the first version of the manuscript, which was critically revised by NS, MS, JS, and MN in several rounds of feedback. All authors have approved the submitted version and have agreed to be accountable for their contributions as well as for accuracy and integrity for any part of the work.

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Correspondence to Manuela Schallenburger .

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Ethical approval was obtained from the Ethics Committee of Heinrich-Heine-University Düsseldorf (Study No. 2022–2274). Written informed consent was obtained from all participants, which were all over 18 years and informed about the study before starting the questionnaire. Researchers assured participants that the contents of the surveys would be used solely for research purposes.

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Batzler, YN., Stricker, N., Bakus, S. et al. Implementing spiritual care education into the teaching of palliative medicine: an outcome evaluation. BMC Med Educ 24 , 411 (2024). https://doi.org/10.1186/s12909-024-05415-0

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Received : 23 August 2023

Accepted : 11 April 2024

Published : 15 April 2024

DOI : https://doi.org/10.1186/s12909-024-05415-0

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ORIGINAL RESEARCH article

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Destination Advertising in the Digital Age

A Study on the Construction of Destination Image for China's County-Level Integrated Media Centers: A Case Study of Four Counties in Fuzhou Provisionally Accepted

• 1 Communication University of China, China
• 2 South China University of Technology, China

The final, formatted version of the article will be published soon.

Today, as social media plays an increasingly important role in disseminating destination images, short videos have emerged as the primary channel through which tourists obtain information about their desired destinations. In comparison to traditional methods of using text and pictures, the new media accounts of local government agencies offer a means to convey more comprehensive local news and shape destination images that are more accurate and diverse, leveraging the potential of the short video platform. This study utilizes a combination of manual analysis (subject terms classification) and computer-assisted techniques (key-frame extraction and text mining) to examine the short videos posted on the TikTok (Douyin) platform by the integrated media centers of Minhou County, Yongtai County, Minqing County, and Lianjiang County in Fuzhou City, China. The objective is to explore the shared characteristics and variations in the dimensional aspects of destination images. The findings reveal that the short video contents released by the governmental new media accounts in these four locations primarily highlight three dimensions: stakeholders, urban infrastructures, and regional landscapes. These dimensions are evident in both descriptive texts and visual symbols.However, in terms of the presented destination image, a notable degree of homogeneity is observed, and there is a lack of emphasis on uncovering and presenting the cultural dimensions, thus failing to fully reflect the distinctive local characteristics.Consequently, it is essential for local integrated media centers to thoroughly explore the cultural uniqueness of their respective regions and enhance the development of thematic dimensions in creating short video content. This approach will effectively strengthen tourists' association with and perception of destination images.

Keywords: Short videos, Destination images, TikTok Platform, Governmental New Media, visual symbol

Received: 29 Nov 2023; Accepted: 23 Apr 2024.

Copyright: © 2024 Lin, Wen and Ma. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Hanzheng Lin, Communication University of China, Beijing, China

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