Twelve tips for postgraduate interprofessional case-based learning

Abstract

Based on developing, implementing, and evaluating postgraduate interprofessional case-based learning, we have written these twelve tips for health education planners who wish to apply case-based learning in the clinical setting. Interprofessional case-based learning engages participants in a structured manner towards uncovering decisions processes and patterns of action that resemble the clinical reality in which various healthcare professionals handle multifaceted tasks related to the optimal patient treatment. Postgraduate interprofessional case-based learning has the potential to break down traditional hierarchical structures as interactions generate respectful behaviour. We present two models of case-based learning to assist in standardising, structuring, and systematising postgraduate interprofessional case-based learning. We have created 12 practical tips for the design, implementation, and evaluation of successful postgraduate interprofessional case-based learning integrated into the existing clinical setting.

Keywords:

• Design
• implementation
• evaluation
• method
• clinical

Introduction

Postgraduate interprofessional case-based learning has the potential to improve patient outcomes as a participatory learning method that engages participants in a structured manner towards uncovering decisions processes and patterns of action. These decision processes resemble the clinical reality in which various healthcare professionals handle multifaceted tasks related to the optimal patient treatment and care. Case-based learning is an enquiry-based learning method linking theory to practice, though there is no standard definition (Egidius 1999; Erskine et al. 2003; Thistlethwaite et al. 2012). Using authentic clinical cases, postgraduate interprofessional case-based learning involves interactive, facilitated group discussions with specific educational goals involving at least two different healthcare professionals working to improve patient care (O'Brien et al. 2017). Originating from the Harvard Business School in the 1920s, the case method formed the basis for participatory learning based on discussions (Erskine et al. 2003). As discussions are part of the complex clinical decision-making process in healthcare, the case-based learning method is ideal for healthcare professionals in continuing professional development (Thistlethwaite et al. 2012; O'Brien et al. 2017).

Postgraduate interprofessional case-based learning has the potential to break down traditional hierarchical structures as interactions generate behaviours that are ‘respectful of others regardless of their place in the system’ (Hammick et al. 2009). We adhere to the definition of interprofessional education as ‘Occasions when two or more professionals learn with, from and about each other to improve collaboration and the quality of care’ (CAIPE 1997). This assumes that interprofessional education improves how healthcare professionals work together, which in turn may lead to improved patient outcomes (Reeves et al. 2017).

The focus of these twelve tips is the planning (Tips 1–5), execution (Tips 6–10), and evaluation of postgraduate interprofessional case-based learning (Tips 11–12).

Tip 1

Define the need for postgraduate interprofessional case-based learning

Conduct a needs assessment as the first step in designing an interprofessional education (Harden 1986; Thomas et al. 2016). What gap needs to be filled? Is it a knowledge, skills or an attitude gap, or a combination of these? (Bass and Chen 2016). Education planners need to consider if the learning objectives are compatible with the educational strategy of case-based learning (Thomas and Abras 2016).

The purpose of case-based learning is to, for example:

• identify and describe interpretations of biological functions, diseases, psychological and social relations and propose courses of action;

• describe the problem (unsatisfactory events and states) and suggest known or plausible explanations;

• differentiate between biological, psychological, social, ethical, organisational, and political issues;

• have the possibility to expand reflectivity through discussion (elaboration of knowledge);

• become motivated to continue own studies in the future.

The purpose of postgraduate interprofessional case-based learning is closely linked to the definition of interprofessional education, as defined by the UK Centre for the Advancement of Interprofessional Education (CAIPE). This involves presenting learners to the different roles of healthcare professionals involved in patient care. Postgraduate interprofessional case-based learning involves concepts other than collaboration and should encompass any of the above mentioned purposes to be clinically relevant. Training real medical emergencies or frequently occurring incidents with the healthcare professionals involved can improve collaboration and their response (Siassakos et al. 2009, 2011). Focusing on the clinical problem by incorporating communication skills can make the purpose more compelling to a larger group of healthcare professionals (Topperzer et al. 2020a, 2020b, Forthcoming).

Case-based learning differs from problem-based learning in essential ways. Both concern active learning and critical thinking, but problem-based learning focuses on explaining phenomena whereas case-based learning discusses appropriate actions to solve a problem (Azer et al. 2012). Applying enquiry-based learning assists healthcare professionals illuminate a case from the various viewpoints of the participants, making the method ideal for postgraduate interprofessional education, learning with, from, and about each other.

Tip 2

Plan ahead

Secure the physical space and material resources well in advance. These issues are often underestimated in education research (Erskine et al. 2003; Kitto et al. 2013; Boet et al. 2014; O'Brien et al. 2017). Organising postgraduate education can be a strenuous task that includes booking the right teaching facilities, ensuring that no competing courses are being held and planning a date that does not conflict with participants’ existing work schedules. Our research involved healthcare professionals from 14 various backgrounds in interprofessional case-based learning on childhood cancer (Topperzer et al. 2020a, 2020b, Forthcoming). Planning involved personally speaking with scheduling coordinators six months in advance to organise the dates and time. Staff turnover and participant cancellations on the training day nonetheless represented a challenge. Catering might seem a minor detail but providing hot beverages, fruit and biscuits can be an effective ice breaker for healthcare professionals who rarely have time to take informal breaks.

Prior to the case-based learning session, it should be considered whether participants should receive content or materials such as guidelines and standard operating procedures. We developed a website for the case-based learning where standard operating guidelines relating to the topic of gastro-intestinal side effects were uploaded and accessible for the participants (Centre 2019). We also emailed the participants the material two weeks prior to their participation in the case-based learning session (Topperzer et al. 2020a, 2020b, Forthcoming).

Tip 3

Write an interprofessional case

Write a case based on a real-world situation (Herreid 1998; Erskine et al. 2003; Herried et al. 2016). The case should originate from the participants’ professional background, involving one or more actual situations or a combination of situations where a problem needs to be solved and clinical decisions made. The situation needs to be relevant for all the participating professionals. Situational learning when the learners independently seek out the information they need to act on a realistic problem is more efficient (Egidius 1999). Writing and testing cases can be time-consuming (Herreid 1998; Erskine et al. 2003). Rewriting the case several times is necessary, to strike a balance between being adequately brief and simultaneously complex (Herried et al. 2016). Anonymise the case to protect patient confidentiality. Write a third-person narrative (Herried et al. 2016) using active voice, not passive, to clearly indicate who is doing what (Herreid 1998). Ensure that the case is explicitly relevant to all participants (Herried et al. 2016), for instance if physiotherapists participate, physiotherapists should be part of the case (Topperzer et al. 2020a, 2020b, Forthcoming). The research group developing the case should ideally comprise professionals representing the participants to ensure relevance of the case (Topperzer et al. 2020a, 2020b, Forthcoming) (see also Tip 5).

Use of jargon or profession specific language might make the text difficult to understand for all participating professions. If physicians or nurses have written the case, problems central to other professions may likely be omitted, which can be detrimental to the discussion and learning potential of all participants (O'Brien et al. 2017).

In addition to using clear, simple, and neutral language (Wood et al. 2019), keep the amount of information relatively small (Table 1). The text must aid in understanding what the problem is and must not act as a puzzle to be solved. Do not exceed more than a half a page of text per page as too many details shroud the problem rather than elucidate it (Herried et al. 2016). Use a single story or break it into two or three parts to reveal new information stepwise.

Table 1. Short extract from page 1 of 9 (Topperzer et al. 2020a, 2020b, Forthcoming).

Day one: Monday Larry, 14, has high-risk acute lymphatic leukaemia (ALL) and is being treated based on the ALL2Gether protocol. Larry arrives from home, accompanied by his mother, to receive day 22 of his chemotherapy. While the nurse is administering the chemo to Larry’s intravenous port, she asks how he feels. Larry tells her that he has a stomach ache.

For full case, please contact the first author.

Evoke critical thinking in the case (Herried et al. 2016) and include a scientific problem, narrative of normal reactions to extraordinary conditions, an illness story or similar. It is imperative to give as many interpretations as possible of what caused the problem and of potential solutions.

Tip 4

Train facilitators

Initiate the learning and reflection process by facilitating rather than teaching. The facilitator guides the participants in clinical decision-making by posing questions, eliciting opinions and stimulating a discussion, enabling exploration of their existing knowledge, skills and attitudes, but also to uncover gaps (Mauffette-Leenders et al. 2001).

It is paramount that facilitator is trained in posing questions and reframing statements that may seem obvious to the participants to address assumptions, reflections, and suppositions (Erskine et al. 2003). Being an expert in one’s clinical field does not necessarily mean being an expert at facilitating the reflections of others (Davis 1999). Participants should leave wondering about and reflecting on the questions that they are supposed to address, and also have the motivation to do so.

Thus, facilitating postgraduate interprofessional case-based learning and leading an interprofessional team involves practice (Hammick et al. 2009). Healthcare professionals vary in terms of the length of their education, work experience, responsibilities, and learning style, which necessitates taking a variety of approaches to interaction. As a result, pay meticulous attention to avoiding the unintentional reinforcement of traditional hierarchical structures by starting, for example with medical questions (O'Brien et al. 2017).

Tip 5

Test the case

Test the case for three reasons. First, the test should be used to check if the learning objectives are addressed and the defined need for interprofessional learning is met.

Second, the case should be tested for flow and duration. Is it too long or too short for the time allotted? Rushing through an interesting discussion or limiting a lively one discussion is highly unsatisfactory for everyone involved.

Third, variability is inevitable (Erskine et al. 2003). As in all teaching processes, interprofessional case sessions vary in terms of activity level and intensity. Depending on which healthcare professionals are present, new questions emerge, which is why we recommend testing the case with different participants at least twice to see if the intended themes emerge consistently. We pilot-tested the case for a postgraduate interprofessional case-based learning session twice (Topperzer et al. 2020a, 2020b, Forthcoming). First, we selected a team of interprofessional healthcare professionals that resembled the final participants in terms of number of years of experience, age, professions, and gender. The issues that arose from this pilot-test were addressed and changes made to the case. Second, we pilot tested the case on all the facilitators role-playing a case-based learning session.

Tip 6

Organise the physical space

Ensure that everyone can see the board that displays the observations, questions and statements generated. To engage in beneficial debate and to understand one another’s perspectives, productive group dynamics are important for postgraduate interprofessional case-based learning (Hammick et al. 2009). To achieve optimal two-way communication, have participants sit comfortably and make eye contact (Erskine et al. 2003). Preferably, sit in a U shape with the facilitator in the open part to allow eye contact with everyone. A regular lecture hall is not conducive to this. A whiteboard at least 4 m wide or multiple sheets of poster-sized paper should be visible to everyone (Figure 1). Erskine et al. (2003) describe several possible layouts for seating alternatives.

Figure 1. Writing on the board, adding structure with coloured markers, copywrite Martha Krogh Topperzer. Permission to use photo has been approved by all participating healthcare professionals.

Online learning, such as webinars can also be a solution for conducting interprofessional learning in situations where healthcare professionals cannot meet in person (Topor and Budson 2020).

Tip 7

Create a participatory environment

Invite all participants to speak. The atmosphere should be conducive to learning, which entail inclusive, accepting discussions. Two issues highly affect the environment: group size and being heard. First, there is no objective evidence determining the perfect group size (Herried et al. 2016). O'Brien et al. (2017) recommend a group size of 10–20 (O'Brien et al. 2017) while Erskine et al. (2003) say 20–60 is the ideal class size. Lessons learned from our postgraduate interprofessional case-based learning in childhood cancer revealed that more than 15 interprofessional participants made managing equal involvement difficult (Topperzer et al. 2020a, 2020b, Forthcoming).

Second, hierarchies exist even in the most egalitarian healthcare systems (Hammick et al. 2009; Freeman et al. 2010). While postgraduate interprofessional education has the potential to break down hierarchical structure, this needs vigilance and management depending on the context, country, and culture. Uniting healthcare professionals in an educational setting with the aim of providing high-quality patient care will not dissolve existing power structures, hierarchies, and conflicts (Lingard 2012). Simply conducting postgraduate interprofessional education does not lead to structural changes in the healthcare system. A peril in interprofessional education is that some groups may feel apprehensive about speaking up in settings other than a monoprofessional one. One way of mitigating power structures is to facilitate that all participating healthcare professions are heard. To facilitate equal speaking time, have participants introduce themselves before beginning the case. The facilitator, however, is responsible for promoting equity between the groups of healthcare professionals to allow everyone to be represented (Hammick et al. 2007; Boet et al. 2014). Reducing conflicts in postgraduate interprofessional collaboration requires vigilance towards use of condescending language or patronising verbal and non-verbal communication. Building egalitarian power structures requires representation in the facilitator team by all professions, especially the professionals that traditionally rank highest. Facilitators representing the highest hierarchy or status can act as role models. Mix where the various healthcare professionals sit and give them nametags stating their profession to dismantle power structures and help create an enquiring environment conducive to interprofessional teamwork (Hammick et al. 2009) (Figure 2). This type of seating permits pairwise discussions between healthcare professions who do not communicate regularly otherwise. As the facilitator meticulously invite participants not explicitly mentioned in the case to speak or call on individuals who have not spoken previously.

Figure 2. Mix healthcare professionals using u-shaped table and nametags indicating name and profession, copywrite Martha Krogh Topperzer, permission to use photo has been approved by all participating healthcare professionals.

Tip 8

Structure the discussion

Facilitate the discussion using a structured approach (Erskine et al. 2003). Case-based learning research indicates that case-based learning varies according to feasibility, purpose, and context (Thistlethwaite et al. 2012). A whiteboard can facilitate reflection, discussion, and synchronise the group’s work. Table 2 provides an example of a structured board that draws on Egidius (1999) and Erskine et al.’s (2003, p. 82) board plans.

Table 2. Example of how to set up headings on a whiteboard.

Important facts: This we know	Problems: We are not satisfied with this	Possible explanations:	Additional information required:	Suggestions for procedures, treatment, etc.:	Study questions:
		Prognosis if nothing is done:		Anticipated effect of measures and procedures:

The columns derive from heuristic clinical problem solving (defining problems, gathering facts, making a hypothesis, testing it, and providing feedback). The facilitator guides the thought process through clinical decision-making by posing questions, eliciting opinions, and stimulating a discussion, allowing participants to independently explore their knowledge and gaps.

We propose two models for setting up the board. Table 3, model A, where one case is discussed over two sessions, involves formulating questions as neutrally as possible by leaving out indicators and not asking leading questions.

Table 3. Model A: one case is discussed over two sessions with self-studies in between.

Model A
Session one		Session two
Working with the case Study questions are drawn up for completion at second session	Participants seek information, study independently, and prepare by answering the study questions	Case concluded by answering the study questions and the case is briefly re-examined (a third session can be planned if required by the learning objectives)

Table 4, model B involves handing out the case and questions in advance to give participants time reflect in, for example, small groups prior to a larger group discussion (Erskine et al. 2003). These questions should be directed towards action and not knowledge, e.g. ‘What problems should the healthcare professional take into consideration at present’ or ‘What course of action is required now?’.

Table 4. Model B: the case is distributed in advance and prepared individually or in study groups and discussed in one session.

Model B
Prior to the case	Case-based learning session
Participants receive the case prior to the session The case can include questions conducive to self-study Participants familiarise themselves with the case, and study the literature and other relevant sources of knowledge provided by the facilitator in advance	One session to conclude case New study questions can be drawn up Participants answer the study questions independently

Tip 9

Facilitate the discussion

Begin by setting the scene and presenting the purpose of the case-based learning. Provide a printed copy of the case for each participant with the instructions to not turn the page until instructed to do so (model A). Ask a participant to read the first page aloud to help achieve a common focus. Then asks them to discuss what it is about in pairs. When the discussion begins to slow down (after 2–3 minutes), initiate a joint discussion based on the headings on the board (Table 2) (Erskine et al. 2003).

Encourage participants to share thoughts, ideas, and experiences (Hammick et al. 2009). Write all suggestions on the board – including any that the facilitator does not agree with. Remember to include all the different healthcare professionals’ perspectives. There are no right or wrong answers in case-based learning, all contributions are equally important (Erskine et al. 2003). Different coloured markers can be used to underline connections that can help participant understanding and facilitate, structure and summarise the process (Erskine et al. 2003).

At the end of the session (1–3 hours), ensure that there are questions to be addressed or study objectives. Let the participants formulate these themselves with the support of the facilitator (model A). In model B, the facilitator is responsible for achieving consensus, but if this is not the case participants will receive questions to answer for continuing studies. Study questions in an postgraduate interprofessional setting can cover, for example skill sets, knowledge of new guidelines or communication chains (Topperzer et al. 2020a, 2020b, Forthcoming).

Tip 10

Probe, pose, and reflect

Stimulate thinking by posing questions. In case-based learning the facilitators' role is Socratic (Mauffette-Leenders et al. 2001; Erskine et al. 2003). To assist in continuous reflection, make sure that the communication is two-way, which means encouraging participants to discuss among themselves by pointing to opposing points of view (Hammick et al. 2009). As case-based learning originates from the business domain, participants are expected to possess some degree of knowledge to be able to discuss with equals (Tärnvik 2007). By posing questions, the facilitator assists the participants in wondering about and reflecting on the problem, encouraging a process where they formulate study questions (Erskine et al. 2003) (Table 5).

Table 5. Examples of questions.

Specific questions	Clarifying questions	Open questions	Probing questions	Confrontational questions
What happened? What were the symptoms?	Do you mean that …? Can you be more specific? Am I to understand that you mean ….?	Would you care to elaborate your observations/viewpoints? How do you see the problem? What do you mean?	How does that fit with what you said before? Is that what you do for illness X?	When you say it like that, do you mean …?

The facilitator’s body language and facial expressions can be used to encourage individual participants or the entire group to continue reflecting or to stop. Hale et al.’s (2017) twelve tips for effective body language for medical educators mention using nodding, eye contact, facial expressions, exclamations, sounds (e.g. ‘hm’), and pauses to signal interest. During the case-based learning session, use all of the questioning techniques, not just nodding and listening.

Tip 11

Evaluate

Capture outcomes relevant to IPE. Evaluating what the participants bring back to their clinical practice is relevant and Kirkpatrick’s outcome evaluation model can assist in framing potential areas (2006). The purpose of the evaluation model, has been extended to capture outcomes relevant to interprofessional education (Barr et al. 2005).

Case-based learning engages participants often resulting in positive feedback and high satisfaction ratings from participants and facilitators alike (Thistlethwaite et al. 2012).

Postgraduate case-based learning can have a significant impact on patient outcomes. In a monoprofessional setting, Kiessling et al. (Kiessling and Henriksson 2002; Kiessling et al. 2011) used two methods to distribute new guidelines on the management of lipid levels in patients with coronary heart disease to practitioners divided into two groups. In one group, the information was disseminated via traditional lectures while the other participated case-based learning sessions. Patients treated by the latter group had markedly decreased lipid levels and reduced overall mortality, even 10 years after the case-based learning intervention (Kiessling et al. 2011). Draycott et al. (2015) also showed that local and interprofessional elements are essential in a postgraduate healthcare setting for effective education adapted to the clinical context.

Evaluating case-based learning is essential to continuously improve the format and its execution, returning to Tip 1, Define the need. Following the case-based learning session, the postgraduate interprofessional participants should evaluate the quality and duration of the session. Questions, to be rated on a Likert scale, can include: How was the level of professional content? And, would you recommend others to participate? (Topperzer et al. 2020a, 2020b, Forthcoming). Revisiting the learning outcomes and exploring whether everyone was active during the session is essential for planning of future courses. Facilitators should also reflect on difficult issues and potential conflicts to improve future sessions (Boet et al. 2014; Topperzer et al. 2020a, 2020b, Forthcoming), in addition to reviewing the content on the board to evaluate if all aspects were covered, and if not, how to directly assess this in future sessions.

Evaluation tools such as the Assessment of Interprofessional Team Collaboration Scale can be used in a postgraduate healthcare setting to assess self-reported team collaboration, including the perspective on patient involvement, before and after the CBL (Orchard et al. 2012, 2018). Another useful tool is the Readiness for Interprofessional Learning Survey, which measures self-reported assessment of readiness of interprofessional learning and is widely used in especially pre-graduate training (McFadyen et al. 2005, 2010; Marcussen et al. 2019). A comprehensive list of 18 quantitative tools referring to Barr et al.’s extended outcome evaluation model can be retrieved from the Canadian Interprofessional Health Collaborative (Kenaszchuk 2013).

Tip 12

Secure leadership buy-in for longevity

Implement educational interventions supported by leadership buy-in (Sunguya et al. 2014). If management or leadership is missing or unclear, committing time and resources is more difficult and possibly result in a lack of participation by some groups of professionals who do not prioritise the time in a busy clinical practice (Topperzer et al. 2020a, 2020b, Forthcoming).

Case-based learning is considered easier to implement than problem-based learning as participants are already familiar with the topic presented. As one facilitator can teach more participants than in problem-based learning, case-based learning is often popular in areas with limited resources (Tärnvik 2007). As time is often a limited resource in even the most affluent postgraduate healthcare settings, case-based learning is feasible and a sound choice for interprofessional learning.

Leadership buy-in also means having access to designated resources embedded in the organisation to address human resources issues and logistical challenges (Boet et al. 2014; O'Brien et al. 2017). Close coordination and monitoring of participants is essential for the execution of postgraduate interprofessional case-based learning (Topperzer et al. 2020a, 2020b, Forthcoming). As a result, we recommend convening meetings where clinical leaders explicitly accept and support the intervention. Subsequent meeting fora that include clinical leaders can be powerful in securing the participation and involvement of all stakeholders. Stakeholder involvement is highly pertinent to securing an ongoing postgraduate interprofessional education programme to improve patient outcomes.

Acknowledgements

We would like to thank Knut Aspegren for kindling our interest and introducing us to the field of case-based medical education.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Data availability statement

By contacting the corresponding author, materials related to the development of case-based learning can be shared.

Additional information

Notes on contributors

Martha Krogh Topperzer

Martha Krogh Topperzer, RN, MSSc, designed and evaluated an interprofessional education programme in childhood cancer comprising the design of a randomised clinical trial comparing interprofessional with monoprofessional case-based learning as part of her PhD thesis at the University of Copenhagen, Denmark. She has vast mono-and interprofessional teaching experience as a nursing specialist at the paediatric oncology unit at Rigshospitalet, University of Copenhagen.

Louise Ingerslev Roug

Louise Ingerslev Roug, RN, MA, in pedagogical anthropology also has extensive experience in teaching as a clinical preceptor at the paediatric oncology unit at Rigshospitalet, University of Copenhagen, Denmark.

Peter Pontoppidan

Peter Pontoppidan, MD, and Liv Andrés-Jensen, MD, both have clinical experience from the paediatric oncology unit at Rigshospitalet, University of Copenhagen, Denmark and regularly teach and tutor medical fellows. Andrés-Jensen teaches learning strategies to medical interns at Copenhagen Academy for Medical Education and Simulation, University of Copenhagen.

Marianne Hoffmann

Marianne Hoffmann, MD, PhD, has vast educational experience as the programme coordinator of the specialist medical education in paediatric haematology/oncology at the Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Denmark.

Hanne Baekgaard Larsen

Hanne Baekgaard Larsen, RN, MSSc, PhD, is an associate professor at the Department of Clinical Medicine, University of Copenhagen, Denmark.

Kjeld Schmiegelow

Kjeld Schmiegelow, MD, PhD, is a professor in childhood cancer at Rigshospitalet, University of Copenhagen, Denmark.

Jette Led Sørensen

Jette Led Sørensen, MD, MMEd, from Dundee University, is a specialist in obstetrics and gynaecology and a professor of interprofessional learning, University of Copenhagen, Denmark. She has extensive educational and research experience with various educational methods such as simulation and case-based method in a mono- and interprofessional setting.