Student selected components: student-designed modules are associated with closer alignment of planned and learnt outcomes

Abstract

Background: Student selected components (SSCs) are staff-designed modules selected by students from a menu of options provided separately from the ‘core’ curriculum. Students completing these do not always learn what teachers think they teach. Some medical schools also allow students to design their own modules. It is not known whether greater student input into planning of modules is associated with closer alignment of planned and learnt outcomes.

Aims: To compare student perception of learning outcomes addressed by student-designed (‘self-proposed’) SSCs, before and after completion, using the ‘Dundee learning outcomes’ template that we apply to all components of the undergraduate curriculum.

Methods: Students were required at the time of self-proposal, and subsequently as part of feedback on completed modules, to indicate which of twelve learning outcomes they felt were addressed by their self-proposed SSC. The χ² test was used to compare student perceptions of learning outcomes before and after completion.

Results: More students thought that learning outcome 10 (appropriate decision making skills, clinical reasoning and judgement) was addressed after completion than before (96.3% versus 90.0%, χ² 4.99, p = 0.02); for all other learning outcomes global perceptions were not significantly different after completion. Individual changes in perception ranged from 2.1% for outcome 12 (aptitude for personal development) to 19.6% for outcome 2 (competent to perform practical procedures).

Conclusion: Greater student input into planning of modules is associated with closer alignment of planned and learnt outcomes. Our findings provide further evidence for the benefit of student-directed learning.

Introduction

Most undergraduate medical courses in the UK now include student selected components (SSCs). The main driver for this was the publication in 1993 of Tomorrow's Doctors by the General Medical Council (GMC 1993); this document was subsequently updated (GMC 2002). SSCs are complementary to the ‘core’ curriculum, and encourage students to take more responsibility of their own learning (Harden and Davis 1999). The quintessential feature of an SSC programme is the exercise of at least some degree of student choice in the allocation of SSCs. In practice, the degree of student choice actually exercised varies significantly. Students may be given an opportunity to express preferences, but matching of allocations to preferences is rarely perfect, due for example to over-subscription of popular SSCs.

To allow students greater choice, some medical schools allow students to design their own SSCs (‘self-propose’) rather than, or as well as, selecting from a menu of organised SSCs. Such modules are similar to but distinct from medical electives: both involve substantial student input into the organisation of the module; however, in contrast with most electives, student-designed SSCs involve some form of summative assessment. Medical electives are often unstructured (Dowell and Merrylees 2009), and formal surveys of medical students before and after completing medical electives are rare (Houlden et al. 2004).

Table

Practice points

This is the first publication to provide data about student learning in student-designed (self-proposed) SSCs. Our findings provide evidence that self-proposed SSCs are associated with closer alignment of planned and learnt outcomes than staff-designed SSCs. This study provides further evidence for the benefits of student-directed learning.

Compared with staff-designed SSCs, the key feature of student-designed SSCs is that students who design their own SSCs are given much greater freedom to define the educational content of these modules than students who complete staff-designed SSCs. We have shown previously that students completing staff-designed SSCs do not always learn what their teachers think they teach (Murphy et al. 2008). Greater student input into the planning of teaching might be expected to produce closer alignment of planned and learnt curricular outcomes. We have examined this issue with reference to self-proposed SSCs in our institution, by comparing student perceptions of learning outcomes addressed by SPSSCs, before and after completion. We used a standardised learning outcomes template that we apply to all components of the undergraduate curriculum, both ‘core’ (Harden et al. 1999) and SSC (Murphy et al. 2008).

Background

General

SPSSCs completed in 2005/06 by medical students in Phase 2 of the Dundee curriculum form the basis of the current study. Phase 2 consisted of the second and third years of a five-year curriculum. Students were allowed to choose from a menu of staff-designed SSCs, or to design their own SSCs. Across the two years, sixteen weeks were devoted to SSCs/SPSSCs, all of which were either two or four weeks long. No restriction or obligation was placed on students in terms of proposal. Some self-proposed for all sixteen weeks, whilst others did not self-propose at all; a third group self-proposed for some but not all of the SSC blocks. SSC/SPSSC topics can be viewed at the following web link: http://www.dundee.ac.uk/meded/frames/SSCResearch.html.

Student selected components

An extensive range of SSCs (n = 69) was offered, the educational content and context of which was varied, reflecting the gamut of clinical, teaching and research activity across the medical school; it included several ‘external’ SSCs (offered either by other university departments or, in a very small number of cases, by other institutions). Some covered core topics in more depth, e.g. clinical and basic sciences; others covered medical topics related to the core, e.g. sports medicine, history of medicine, health policies; yet others covered topics less directly related to medicine e.g. medical French or Spanish. The educational content of SSCs was decided by staff, without formal student input, although previous student feedback was taken into account.

Self-proposed student selected components

The range of topics proposed by students was varied, although clinical attachments were favoured. A minority of students proposed modules overseas. Self-proposing students were required initially to contact potential supervisors and, after consultation with them, to submit a written proposal detailing the educational objectives and learning outcomes to be addressed by their SPSSC. Proposals were subsequently modified as appropriate after discussion with the SSC Convenor and their SPSSC supervisor, in a series of ‘iterations’ of educational objectives in terms of detail and focus. The process of refinement and/or elaboration of educational objectives meant that self-proposing students had, before they started, invested substantial time and effort in establishing realistic, feasible objectives and, more generically, in defining the educational content of their SPSSC in terms of learning outcomes.

Methods

Study design

This study was a retrospective web-based survey of medical students at two time points, one before and one after completing their own student-designed (‘self-proposed’) SSCs. We took advantage of the fact that in our institution all students were required at the time of self-proposal (October 2005), and subsequently (February and May 2006) as part of feedback on completed SPSSCs, to indicate which of twelve ‘Dundee’ learning outcomes (see below) they feel will be/were addressed by their SPSSC.

Measures

A learning outcomes template (the ‘Dundee learning outcomes’) is applied to all parts of the curriculum including SSCs. We require all staff offering (and all students self-proposing) SSCs to specify which outcomes they think will be components of teaching and assessment. The same template is completed after completion of the modules; student feedback is compulsory. 194 self-proposed SSCs were completed in the academic year 2005/06.

The twelve learning outcomes are listed below.

1. Competent in clinical skills

2. Competent to perform practical procedures

3. Competent to investigate a patient

4. Competent to manage a patient

5. Competent to give advice on health promotion and disease prevention

6. Competent in communication skills

7. Competent to retrieve and handle information

8. Understanding of social, basic and clinical sciences and underlying principles

9. Appropriate attitudes, ethical understanding and legal responsibilities

10. Appropriate decision making skills and clinical reasoning and judgement

11. Appreciation of the role of the doctor within the health service

12. Aptitude for personal development

Analyses

McNemar's χ² test was used to compare student perceptions of learning outcomes addressed by SPSSCs before and after completion. Fisher's exact probability test was used where the number in individual cells being compared was small (<5). A separate analysis was also performed, where we calculated the percentages of students changing their perception from ‘not addressed’ to ‘addressed’, and vice versa. The purpose of this analysis was to reveal any changes in perception that may not have been apparent from the global comparisons; global comparison of student perceptions before and after completion of SPSSCs may conceal changes in perception if these act to cancel each other out.

The data reported here were collected as part of routine quality assurance of undergraduate medical training in our institution. Ethical principles were adhered to in the retrieval and analysis of the data, and a waiver obtained from the University of Dundee Research Ethics Committee.

Results

Table 1 illustrates global student perceptions of learning outcomes addressed, before and after completion of SPSSCs. The number of students completing the learning outcomes template before and after (thus allowing comparison) ranged from 187/194 (96.4%) in the case of learning outcome 7, to 194/194 (100%) in the case of learning outcome 12. Perception of learning outcome 10 (appropriate decision making skills, clinical reasoning and judgement) changed positively (i.e. more students thought it was addressed after completion than before – 96.3% versus 90.0%, χ² 4.99, p = 0.02); for all other learning outcomes global perceptions were not significantly different after completion.

Table 1.  Learning outcomes addressed by self-proposed SSCs: student perceptions before and after completion

		BEFORE		AFTER
LEARNING OUTCOME	PERCEPTION	n	%	n	%	χ^2	p
What a student will be able to do
1. Competent in clinical skills	Addressed	168	87.0	169	87.6	0.23	0.88
	Not addressed	25	13.0	24	12.4
2. Competent to perform practical procedures	Addressed	146	75.3	154	79.4	0.72	0.40
	Not addressed	48	24.7	40	20.6
3. Competent to investigate a patient	Addressed	172	90.0	179	93.2	1.19	0.28
	Not addressed	20	10.0	13	6.8
4. Competent to manage a patient	Addressed	170	88.0	176	91.2	0.70	0.40
	Not addressed	23	12.0	17	8.8
5. Competent to give advice on health promotion and disease prevention	Addressed	166	86.5	160	83.3	0.51	0.48
	Not addressed	26	13.5	32	16.7
6. Competent in communication skills	Addressed	190	98.4	183	94.8	2.87	0.09^†
	Not addressed	3	1.6	10	5.2
7. Competent to retrieve and handle information	Addressed	177	94.7	182	97.3	1.11	0.29
	Not addressed	10	5.3	5	2.7
How the student approaches their practice
8. Understanding of social, basic and clinical sciences and underlying principles	Addressed	190	98.0	189	97.4	0.11	1.0^†
	Not addressed	4	2.0	5	2.6
9. Appropriate attitudes, ethical understanding and legal responsibilities	Addressed	175	90.7	182	94.3	1.34	0.25
	Not addressed	18	9.3	11	5.7
10. Appropriate decision making skills and clinical reasoning and judgement	Addressed	170	90.0	182	96.3	4.99	0.02*
	Not addressed	19	10.0	7	3.7
The student as a professional
11. Appreciation of the role of the doctor within the health service	Addressed	182	94.8	179	93.2	0.19	0.67
	Not addressed	10	5.2	13	6.8
12. Aptitude for personal development	Addressed	190	98.5	192	99.5	0.25	0.62^†
	Not addressed	3	1.5	1	0.5

*Significantly different perception

^†Fisher's exact test

1 degree of freedom applied in each case for χ² test.

Table 2 summarises the results of a separate analysis, where we focused exclusively on changes in perception, in both directions, i.e. from ‘not addressed’ to ‘addressed’, and vice versa. Percentages of students changing their perception from ‘not addressed’ to ‘addressed’ ranged from 0.5% for outcome 6 (competent in communication skills) to 11.9% for outcome 2 (competent to perform practical procedures). Percentages of students changing their perception in the opposite direction ranged from 0.5% for outcome 12 (aptitude for personal development) to 7.8% for outcomes 1 (competent in clinical skills) and 5 (competent to give advice on health promotion and disease prevention). Total percentages (changes in perception in both directions combined) ranged from 2.1% for outcome 12 to 19.6% for outcome 2.

Table 2.  Learning outcomes addressed by self-proposed SSCs: changes in student perceptions after completion

		PERCEPTION CHANGED TO:
	TOTAL RETURNS	ADDRESSED		NOT ADDRESSED		TOTAL
LEARNING OUTCOME	n	n	%	n	%	CHANGE (%)
What a student will be able to do
1. Competent in clinical skills	193	16	8.3	15	7.8	16.1
2. Competent to perform practical procedures	194	23	11.9	15	7.7	19.6
3. Competent to investigate a patient	193	10	5.2	5	2.6	7.8
4. Competent to manage a patient	192	14	7.3	7	3.7	11.0
5. Competent to give advice on health promotion and disease prevention	192	9	4.7	15	7.8	12.5
6. Competent in communication skills	193	1	0.5	8	4.2	4.7
7. Competent to retrieve and handle information	189	9	4.8	4	2.1	6.9
How the student approaches their practice
8. Understanding of social, basic and clinical sciences and underlying principles	193	4	2.1	5	2.6	4.7
9. Appropriate attitudes, ethical understanding and legal responsibilities	192	13	6.8	5	2.6	9.4
10. Appropriate decision making skills and clinical reasoning and judgement	191	13	6.8	8	4.2	11.0
The student as a professional
11. Appreciation of the role of the doctor within the health service	191	7	3.7	10	5.2	8.9
12. Aptitude for personal development	193	3	1.6	1	0.5	2.1

Discussion

Differences between the “planned”, “taught” and “learnt” curriculum are well recognised (Lowry 1992), and we have shown previously that students completing SSCs do not always learn what their teachers think they teach (Murphy et al. 2008). This is true both at the level of individual SSCs, and globally (across the entire SSC programme) for certain outcomes, e.g. outcomes 2 (competent to perform practical procedures), 6 (competent in communication skills) and 7 (competent to retrieve and handle information). The use of two complementary tools (individual and global comparisons) provides a powerful tool to examine this important issue. Given the absence of student input into staff-designed SSCs, and given that students who design their own SSCs are given substantial input into the planning and design of their modules, it seems reasonable to hypothesise that these student-designed modules might be associated with closer alignment of “planned” and “learnt” outcomes. We therefore sought to perform a similar analysis with reference to student-designed (self-proposed) modules, to the one we performed with reference to staff-designed modules (Murphy et al. 2008), to test this hypothesis. Comparing SSCs (staff-designed) with SPSSCs (student-designed) in this way might provide evidence of closer alignment between “planned” and “learnt” curriculums if we could demonstrate smaller pre versus post differences in student perceptions for SPSSCs than for SSCs.

Global comparison of student perceptions of learning outcomes before and after completion of SPSSCs revealed just one significant difference: more students perceived appropriate decision making skills, clinical reasoning and judgement (learning outcome 10 in Table 1) to be important after completion than before. For all other learning outcomes global perceptions were not significantly different after completion. By comparison, the analagous comparison for staff-designed SSCs – between supervisors’ perceptions pre and students’ perceptions post completion – revealed discrepant perception for several outcomes; more students than supervisors thought that outcome 2 (competent to perform practical procedures) was a component of teaching and assessment, whereas more supervisors than students thought that outcome 6 (competent in communication skills) and outcome 7 (competent to retrieve and handle information) were (Murphy et al. 2008). Similar pre-post comparisons at the level of individual SPSSCs revealed very few differences in perception (data not shown). Taken together, our findings suggest that students largely realise their educational expectations. Our study demonstrates that greater student input into curriculum planning can also be achieved by allowing students to design their own SSCs.

We performed a separate analysis, focusing on changes in perception (Table 2). Global comparison of student perceptions before and after completion of SPSSCs may conceal changes in perception if these act to cancel each other out. The results of this supplementary analysis confirm that for all twelve learning outcomes, perceptions remain unchanged in most cases (>80%). However, the percentage of students whose perception of the role of individual learning outcomes changed varied from 2.1% for outcome 12 (aptitude for personal development) to 19.6% for outcome 2 (competent in practical procedures). Higher percentages were observed for some but not all of the outcomes relating to what students will be able to do, like clinical skills and practical procedures, but the data do not permit generalisation. For example, only 4.7% changed their perception of the role of outcome 6 (competent in communication skills). In a similar way, we did not observe any systematic differences between outcomes in the direction of changed perception. In some cases, more students changed their perception from ‘not addressed’ to ‘addressed’ than vice versa; in others the reverse was true; while in yet other cases, similar numbers changed in both directions. (In the absence of student input into staff-designed SSCs, it was not possible to perform this analysis for SSCs).

Limitations of the analysis

This study does not allow judgements to be made about the role of student input in the attainment of learning outcomes in specific modules. We have reported on perceptions, and not on objective measures of attainment. In addition, we have not reported here on how important students perceived individual learning outcomes; that is beyond the scope of the current report. Finally, we have only compared SSCs and SPSSCs here with reference to the pre-post differences in perception (alignment of “planned” and “learnt” outcomes), and not the post-post differences in student perceptions of SSCs and SPSSCs. That important analysis is the subject of another paper.

Conclusion

In conclusion, we have found that greater student input into planning of modules is associated with closer alignment of the “planned” and “learnt” curriculum; students mostly realise their expectations. Our findings provide further evidence for the benefit of student-directed learning.

Acknowledgements

The authors wish to acknowledge the contribution of staff and students at the University of Dundee Medical School without whose co-operation this study would not have been possible.

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

Additional information

Notes on contributors

Michael J. Murphy

Michael J Murphy, BA(Mod), MB BCh BAO, FRCP Edin, FRCPath, is Senior Lecturer in Biochemical Medicine, and SSC Convenor, at the University of Dundee, Scotland, UK.

Rohini De A. Seneviratne

Rohini De Alwis Seneviratne, MD, MBBS, MMEd, FCCP(SL) is Professor in Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka.

Olga J. Remers

Olga J Remers, BSc, MSc, is Assessment Administrative Assistant (SSCs) at the University of Dundee Medical School.

Margery H. Davis

Margery H Davis, MD, MB ChB, FRCP is Director of the Centre for Medical Education and Professor of Medical Education, University of Dundee.