Students’ experiences of clinic‐based learning during a final year veterinary internship programme

Abstract

This study investigated veterinary students’ experiences of clinic‐based learning (CBL) during a comprehensive final year internship programme. Open‐ended surveys (n = 93) were used to gather qualitative data about students’ conceptions of what is learned during CBL and their approaches to learning in clinics. Phenomenography was used for detailed analysis of the variation evident in students’ responses. Relationships between qualitative differences in students’ conceptions and approaches were then evaluated using quantitative statistical analysis. Links to achievement during final year were examined. Close associations were found between the quality of students’ experiences of CBL and achievement during the internship programme.

Keywords:

• higher education
• practice‐readiness
• professional autonomy
• student learning experience
• veterinary education

1. Introduction

Undergraduate internship programmes are considered to form a crucial component of preparing veterinary students for a successful transition to practice (Baguley, 2006; Farnsworth et al., 2008; Quality Assurance Agency for Higher Education, 2000). These innovative clinic‐based learning (CBL) programmes require significant investments of time, money and effort by veterinary education stakeholders. Ongoing support of such curricula relies on evidence of their effectiveness. However, little more than anecdotal evidence appears in the literature about the quality of students’ experiences of learning during internships. Critical links between students’ experiences of CBL and their readiness for independent practice as entry‐level veterinarians are unclear.

Seminal research in higher education (Biggs & Tang, 2007; Marton & Booth, 1997; Prosser & Trigwell, 1999; Ramsden, 2003) has shown that investigating the student perspective proves fruitful when evaluating the effect of curriculum innovations on students’ learning. This body of knowledge, referred to as student learning research, adopts the student perspective to explore factors contributing to variation in the quality of students’ learning outcomes (Prosser & Trigwell, 1999; Ramsden, 2003). Detailed analysis of students’ accounts of their learning experiences can be used to identify the variation that exists amongst a group of learners (Marton & Booth, 1997). This form of systematic analysis, known as phenomenography, allows judgements to be made about the quality of students’ learning (Marton & Booth, 1997; Marton & Säljö, 1976).

The study reported in this paper was part of a research project designed to investigate relationships between students’ experiences of CBL and their capacity for autonomous practice as new graduate veterinarians. Student learning research was used to establish students’ perspectives on an innovative internship programme in veterinary science. Phenomenographic analysis revealed the variation present in final year interns’ conceptions of the content of CBL and approaches to learning in clinics. Additional quantitative statistical methods were then used to link the quality of these components of students’ experiences of CBL to achievement during final year. This identified factors contributing to the success of students’ performance in practice as undergraduate interns.

1.1 Clinic‐based learning in veterinary education

The goal of veterinary education internationally is to prepare students for service to society as successful veterinarians. This encompasses a range of attributes required for veterinary graduates to perform effectively in practice. Successful veterinarians possess a sound understanding of the theoretical basis for veterinary science, demonstrate confidence in general professional abilities and are proficient in practically‐based veterinary competencies (Collins & Taylor, 2002; Royal College of Veterinary Surgeons, 2001). The extent to which new graduates demonstrate these attributes reveals their readiness for entry‐level practice as autonomous professionals. Graduates who meet only the minimum requirements for professional registration as a veterinarian demonstrate a lesser extent of practice‐readiness than graduates who rapidly make the transition to entry‐level professional autonomy. Graduates’ abilities continue to develop towards those of an experienced practitioner after entry‐level professional autonomy is attained. This continuum in veterinary practice‐readiness is depicted in Figure 1.

Figure 1 Development of veterinary practice‐readiness.

Comprehensive CBL programmes are intended to result in high quality learning outcomes that prepare students for entry‐level professional autonomy immediately upon graduation. Extensive and sophisticated internship programmes have been introduced into veterinary degrees worldwide to help achieve this goal (see, for example, Farnsworth et al., 2008; Jaarsma, Dolmans, Scherpbier, & van Beukelen, 2008; Walsh, Osburn, & Christopher, 2001). Although positive learning outcomes are commonly reported by students and alumni of veterinary internship programmes, variation in achievement is evident (Jaarsma et al., 2008; Walsh, Osburn, & Schumacher, 2002). Factors contributing to this variation in performance during veterinary internship programmes are unclear. This study aimed to address this gap in the literature by identifying relationships amongst the quality of students’ conceptions of what is learned during CBL, approaches to learning in clinics and achievement during veterinary internship programmes.

1.2 The experience of learning

The experience of learning can be analysed in terms of what students think they are learning and how they go about their learning (Marton & Booth, 1997; Prosser & Millar, 1989). What students think they are learning consists of their conceptions of the phenomenon being studied. These understandings form an outcome of learning (Prosser & Millar, 1989). How students go about their learning consists of their approaches to learning. These form part of the process of learning (Biggs & Tang, 2007; Prosser & Millar, 1989). Phenomenographic analysis can be used to identify the distinctly different ways that students conceive of and approach their learning (Marton & Booth, 1997). The result of a phenomenographic study is an outcome space that consists of the minimum number of categories required to describe the different ways that a phenomenon of interest is experienced (Akerlind, 2005; Marton & Booth, 1997; Prosser & Millar, 1989). The outcome space also details relationships between these categories (Akerlind, 2005; Marton & Booth, 1997). The categories and relationships can be used to systematically evaluate and draw conclusions about the quality of students’ learning experiences. These in turn are related to the quality of students’ learning outcomes (Biggs & Tang, 2007; Marton & Booth, 1997).

1.2.1 Conceptions of what is learned

Students’ conceptions of what they are learning vary according to differences in awareness of the phenomenon in question (Marton & Booth, 1997). Awareness of a phenomenon is comprised of awareness of the whole phenomenon, its parts and the relationships between them and the relationships between the parts and the whole (Marton & Booth, 1997). Different experiences of a phenomenon are associated with variation in awareness of these components. This variation in the structure of awareness is associated with variation in the meaning ascribed to the phenomenon (Marton & Booth, 1997).

Students’ self‐reports of what they are learning can be used to evaluate the quality of their learning experiences. More inclusive descriptions are indicative of awareness of more parts of a phenomenon, more relationships between the parts and/or more relationships between the parts and the whole (Marton & Booth, 1997). The inclusiveness and complexity of the structure of awareness revealed in students’ descriptions of what they are learning, together with the corresponding meaning attributed to this experience of a phenomenon, can be used to judge the quality of students’ conceptions (Marton & Booth, 1997). Differences in conceptions contribute to variation in students’ learning outcomes. Qualitatively different conceptions of what is being learned are commonly described as being either fragmented or cohesive (Crawford, Gordon, Nicholas, & Prosser, 1994; Marton & Booth, 1997; Prosser & Trigwell, 1999). Fragmented conceptions are characterised by limited awareness of a phenomenon. Although varying and sometimes numerous components of the phenomenon may be discerned by students, these are not integrated into a coherent whole. In contrast, cohesive conceptions are characterised by a more inclusive, complex and complete awareness of a phenomenon (Crawford et al., 1994; Marton & Booth, 1997). Awareness is evident of a range of interrelated aspects of the phenomenon and diverse linkages are discerned between these and the phenomenon as a whole (Marton & Booth, 1997).

1.2.2 Approaches to learning

The quality of students’ approaches to learning can be evaluated by examining differences in students’ self‐reports of their strategies and intentions in learning. The qualitatively different ways that students approach learning are commonly described as surface and deep (Biggs & Tang, 2007; Marton & Säljö, 1976). Students adopting a surface approach to learning often describe an intention to reproduce information without understanding it (Biggs & Tang, 2007; Prosser & Trigwell, 1999). This tends to be associated with a focus on meeting performance expectations and assessment requirements with minimal effort (Biggs & Tang, 2007; Marton & Säljö, 1976). In contrast, students who adopt a deep approach to learning seek to understand what is being learned (Prosser & Trigwell, 1999). They describe looking for underlying patterns and principles in material being learned so as to flexibly integrate new information with that which is already known (Biggs & Tang, 2007; Prosser & Trigwell, 1999). These qualitatively different intentions for learning have been related to differences in how the material being learned is treated by students during the learning process. Surface approaches to learning tend to be associated with atomistic learning strategies that involve sequentially ordering material for rote memorisation without regard to the relative importance of elements being learned (Svensson, 1977). Deep approaches to learning are often associated with holistic learning strategies that involve integrating what is being learned into a unified whole that incorporates its inherent frameworks (Svensson, 1977). These differences in students’ approaches to learning contribute to qualitative variation in students’ learning outcomes.

1.2.3 Relationships between conceptions of what is learned and approaches to learning

Logical relationships exist between qualitative differences in students’ conceptions of what is being learned and how they approach their learning (Crawford et al., 1994; Prosser & Millar, 1989). These differences are related to variation in the structure of students’ awareness of the phenomenon in question. The general tendency of relationships between the quality of students’ conceptions of what is learned and approaches to learning is that fragmented conceptions are associated with surface approaches and cohesive conceptions are associated with deep approaches. This is linked to the observation that students adopting atomistic learning strategies tend to delineate components of the phenomenon being learned without regard to their underlying structure, whereas students adopting holistic learning strategies integrate and relate parts and relationships into a coherent understanding (Marton & Booth, 1997; Svensson, 1977).

Figure 2 (adapted from Crawford et al., 1994, p. 333) summarises the logical relationships that exist between qualitative differences in students’ conceptions of what is learned and approaches to learning. Studies of students’ learning experiences have confirmed the presence of these associations between the quality of students’ conceptions and approaches in a range of disciplines (Marton & Booth, 1997; Prosser & Trigwell, 1999).

Figure 2 Logical relationships between qualitative differences in students’ conceptions of what is learned and approaches to learning.

2 Aims

This study seeks to provide evidence of factors related to successful performance during a veterinary internship programme. The hypothesis of this research is that variation in students’ experiences of CBL is linked to differences in achievement. The context for this research is the final year internship programme of the Bachelor of Veterinary Science degree offered by The University of Sydney. The following specific research questions are addressed in this research:

1. What is the nature of the student experience of CBL during the internship programme?

   1. What do these students think they are learning during the programme?

   2. How do these students approach their learning in clinics? What do they do? Why do they do it?

2. What are the associations between students’ conceptions of what is learned during CBL and their approaches to learning in clinics?

3. How does variation in the quality of students’ conceptions of what is learned during CBL and their approaches to learning in clinics relate to achievement during the internship programme?

3 Methods

This study uses the principles and methodologies of student learning research to investigate factors contributing to variation in performance during the final year internship programme. Phenomenography was used for detailed analysis of students’ experiences of CBL. Additional quantitative statistical analysis was then used to reveal relationships amongst the quality of students’ conceptions of what is learned through CBL, approaches to learning in clinics and achievement during final year. The intention was to reveal the types of conceptions and approaches that were strongly linked to success during the programme.

3.1 Context and participants

The internship programme that formed the context for this study is designed to immerse students in a series of intensive and authentic learning experiences. Students participate in 10 months of final‐year placements located in a range of veterinary work environments. The combination of workplace rotations is intended to develop the full spectrum of attributes expected of entry‐level veterinarians. Although favourable reviews of the programme have been received from students, employers and accreditation bodies (Baguley, 2006), variation in the quality of students’ learning outcomes is indicated by differences in achievement during final year. A detailed exploration of interns’ perspectives on their learning was expected to aid understanding of factors associated with variation in learning outcomes. The final‐year cohort of 2005 (n = 100) formed the student population for this study. All students in the cohort were invited to participate in this study and a 93% response rate (n = 93) was achieved for the survey results reported in this paper.

3.2 Instruments and analysis

3.2.1 Survey design and phenomenographic analysis

The open‐ended questions used for this survey were modelled on those used in similar investigations conducted in other content areas (Crawford et al., 1994; Ellis, Goodyear, Calvo, & Prosser, 2008). The questions used were kept as general as possible to avoid influencing students’ answers (Forbes, Duke, & Prosser, 2001):

1. During your clinic‐based experiences this year, what were you learning? What were the main things you got out of your clinic‐based learning?

2. When you were learning in clinics this year, how did you go about it? What things did you do? Why did you do the things you did?

Three researchers were involved in establishing the phenomenographic categories that form the main outcomes of this study. Categories were developed from whole surveys rather than a collection of quotes extracted from their sources. Collaboration amongst researchers from veterinary science and tertiary education backgrounds was used to create categories that were both contextualised to the discipline of veterinary science and grounded in the broader themes of student learning research. An iterative process was followed during phenomenographic analysis (Prosser & Millar, 1989). All of the open‐ended surveys were initially categorised by Researcher 1 according to the complexity of responses given. Twenty surveys were chosen as representative of the variation in students’ answers. These were used as an initial sample from which to develop more defined categories. The preliminary classification of these surveys was discussed with Researcher 2 to establish probable categories for CBL conceptions and approaches. Researchers 1 and 2 independently classified the sample survey answers against these categories before discussing their allocations. Detailed descriptions for each category were developed once agreement had been reached on the classification of each sample survey. Researcher 3 then independently classified the sample surveys against the categories that had been developed. Differences in classification were discussed and used to modify category descriptions. Detailed outcome spaces for CBL conceptions and approaches were then developed by Researcher 1. The success of this process is indicated by the percentage agreement between researchers for classification of a final sample of surveys (n = 10) against the categories resulting from this analysis (Säljö, 1988). The average percentage agreement after consultation between researchers was 90% for CBL conceptions and 85% for CBL approaches. An agreement in classification of 80% or more after consultation between researchers is appropriate (Ellis, Goodyear, Prosser, & O’Hara, 2006; Prosser, Walker, & Millar, 1996; Säljö, 1988; Trigwell, Prosser, & Taylor, 1994).

3.2.2 Supervisor Report Form

A Supervisor Report Form (SRF) is used during final year placements to assess the extent of interns’ practice‐readiness and their progress towards attaining desired veterinary graduate attributes by the end of the year. Performance criteria evaluated by the SRF encompass a range of areas of clinical performance and professional behaviour relevant to new graduate practice (Baguley, 2006; Walsh et al., 2001; Zaki, Matthew, Baguley, & Taylor, 2008). These areas are captured in the SRF Aims listed in Table 1. Aims 1–8 are designed to assess eight different aspects of students’ performance during the internship programme. Aim 9 provides an overall evaluation of interns’ performance during the rotation. The final Aim requests that placement supervisors provide an assessment of students’ progress towards the standard of practice expected at graduation. These Aims were adapted from a model used by the School of Veterinary Medicine at the University of California, Davis (Walsh et al., 2001) in consultation with local veterinary practitioners and experts in veterinary education (Baguley, 2006).

Table 1. SRF Aims, related grading criteria and assigned numerical values.

SRF Aim	Grading criteria	Assigned numerical values
1. Basic knowledge and understanding}	Outstanding	100
2. History taking and data gathering	Very proficient	75
3. Communication and observational skills	Solid standard	50
4. Procedural skills	Marginal	25
5. Clinical problem solving and case assessment	Unsatisfactory	0
6. Case reports and patient management plans7. Professional attitudes and interest in learning8. Reliability, work ethic and humanistic values9. Overall clinical performance	Not observed	Average of all other grades awarded forAims 1–9 in that rotation
10. Progress towards graduation}	DefinitelyVery likelyPossibly of concernOf definite concern	10066.733.30

Grades earned on the SRF were converted to numerical measures in this study to aid analysis of achievement during final year. The numerical value assigned to each grade is presented in Table 1. Values were spaced equally to reflect the fact that grade descriptors were designed to represent relatively equally spaced points on the continuum of student performance. A wide spread of values was chosen to aid analysis of relationships between achievement and experiences of learning. An overall measure of SRF results, known as the aggregate SRF mark, was created for each individual student by aggregating the SRF grades earned for each rotation during the internship year. This facilitated investigation of associations between course outcomes and variation in learning experiences during the internship programme.

3.2.3 Quantitative analyses

Quantitative statistics were used in this study to explore associations between students’ conceptions of what is learned through CBL, approaches to learning in clinics and achievement during final year. After phenomenographic analysis had been completed, frequencies were calculated for responses consistent with different categories of CBL conceptions and approaches. Responses were then grouped into qualitatively different ways of thinking about the content of CBL and approaching learning in clinics. A chi square (χ²) test was performed to evaluate whether a relationship existed between qualitatively different conceptions and approaches. Relationships amongst different conceptions of what is learned during CBL, approaches to learning in clinics and student achievement during final year were investigated using independent samples t‐tests and measures of effect size (ES).

4 Results

The bulk of the results presented in this paper arise from phenomenographic exploration of interns’ conceptions of what is learned during CBL and approaches to learning in clinics. This is followed by additional quantitative analyses of relationships amongst CBL conceptions, approaches and achievement during final year.

4.1 Conceptions of what is learned during CBL

Categories for interns’ conceptions of what is learned during CBL are distinguished by differences in emphasis in students’ accounts of their learning experiences. These differences indicate variation in awareness of factors related to successful professional practice. Five different ways of understanding CBL were identified from students’ survey responses. Conception A focuses on individual veterinary competencies and topics of information without consideration of the case contexts in which these are applied:

Practical skills, e.g. taking blood, placing catheters, giving medication. Clinicians giving tutorials on various subjects.

Conception B emphasises protocols and formulae for dealing with standard ‘types’ of cases. This demonstrates limited awareness of contextual variation in veterinary case management and practice as part of what is learned during CBL:

Main things: how to communicate with clients, how to run/conduct consultations, watched a lot of different surgery and learned a lot about which treatments should be used for which diseases/conditions.

In contrast, Conception C demonstrates a rich understanding of the contextual variation inherent in veterinary case management and practice. It highlights the interdependence of theoretical principles and practical abilities in managing this complexity effectively during professional decision making:

Communication skills – talking with clients, understanding their decisions, how they interpret the info we give them etc. … Drugs – dispensing, doses and dose rates, how to work out what administration method is best for the patient.

Conception D emphasises students’ emerging preferences in professional decision making based on evidence and experience as key components of the contextual variation present in veterinary scenarios. This understanding of what is learned during CBL is illustrated by the following quote:

One of the main things I am learning this year is that there are many different ways of doing things, and I have to assess all the different ways and choose what I feel is appropriate.

Finally, Conception E highlights personal and professional factors related to sustainable practice as a veterinarian as a vital part of what is learned through CBL:

I think that I’ve also developed quite a sense of what things ‘cost’ in a practice, time, materials, staff, stress and lifestyle, which I hope will help me when I’m out in practice later.

Conceptions C, D and E represent the types of high quality understandings of the content of CBL that interns are intended to achieve by the end of final year. It is these types of understandings that underpin professional autonomy in veterinary practice.

The categories of conceptions form a hierarchy with Conception A at the bottom and Conception E at the top. Conception A represents the least inclusive and least complex conceptions contained in this hierarchy. Conception E represents the most inclusive and most complex conceptions reported in this study. The hierarchy is logically inclusive because the meaning attributed to what is learned through CBL in higher categories incorporates the meanings attributed to this phenomenon in lower categories (Crawford et al., 1994; Marton & Booth, 1997). The hierarchy is empirically inclusive because students describing more elaborate conceptions of the content of CBL also tended to describe aspects of the phenomenon characterising simpler understandings of what is learned through CBL (Crawford et al., 1994). A qualitative shift occurs between Conception B and Conception C. At this point, awareness shifts to emphasise the complexity and contextual variation inherent in veterinary practice and relevant to effective professional decision making in a wide range of scenarios. This is consistent with the shift between fragmented and cohesive conceptions that has been reported in other studies of students’ learning experiences (Crawford et al., 1994; Marton & Booth, 1997; Prosser & Trigwell, 1999).

4.2 Approaches to CBL

Categories for students’ approaches to CBL are distinguished by differences in students’ self‐reports that indicate varying levels of engagement in professional learning. Five different ways of approaching learning in clinics were identified from students’ survey responses. Approach A is characterised by predominantly passive learning approaches directed towards meeting university assessment requirements. Veterinary information and skills are gathered and reproduced in a relatively unstructured manner:

I started to research in depth the cases for my case logs by using the books I have brought and searching for journal articles. Now I have moved to reading a little bit from my Vet Merck’s manual each night along with researching my case logs.

Approach B emphasises more active learning strategies aimed at attaining procedural competence to meet expectations for performance in practice. Emphasis is placed on accumulating and replicating veterinary knowledge and procedures:

I did things … animal handling, monitoring anaesthesia in surgeries, performed castrates and speys, helped take consults, … I did these things, and also the staff offered to let me do them as they are essentially part of what I’ll be doing after graduation.

Approach C indicates intrinsic motivation to understand the theoretical and practical considerations for veterinary case management as a basis for effective decision making. This is accompanied by consistently proactive, self‐directed and thorough learning efforts:

I mainly learned by actively participating in cases and consultations and looking things up in textbooks and databases during slower times. … I tried to actively discuss cases with veterinarians/specialists both at rounds and one‐on‐one to gain a holistic understanding of the cases.

In Approach D, independent and pre‐emptive clinical decision making is undertaken to develop the capacity for autonomous veterinary practice after graduation. Opportunities to share case management responsibility are readily accepted when available:

I took every practical opportunity possible to get in + do things myself. I worked things out on my own + then compare with the vet what they would do.

Approach E is characterised by proactively sharing case management responsibility to begin working as a novice veterinarian. Students seek to learn through working autonomously as far as possible within the parameters of the internship programme:

Watching, asking questions, taking on cases and doing reading/research further based on the case, practical doing (consulting, physical exams, minor surgery etc), formulating my own plan then discussing these ideas with clinicians.

Approaches C, D and E represent the type of high quality approaches to CBL that students are intended to adopt during the internship programme.

The categories of approaches to learning in clinics form a hierarchy with Approach A at the bottom and Approach E at the top. Approach A represents the least comprehensive approach to CBL and Category E represents the most comprehensive approach to learning in clinics. A qualitative shift occurs between Approach B and Approach C. Approaches A and B focus on reproduction of skills, knowledge and techniques and tend to emphasise atomistic learning strategies. Approaches C, D and E focus on understanding and applying veterinary theory as a basis for practice and tend to highlight holistic learning strategies. The hierarchy created by these categories is empirically inclusive because responses classified as consistent with higher quality approaches to CBL incorporate strategies and intentions typifying lower quality approaches to learning in clinics. The hierarchy is not logically inclusive because an intention only to unthinkingly reproduce what is learned is inconsistent with a desire to understand (Biggs & Tang, 2007; Crawford et al., 1994; Marton & Booth, 1997). This is consistent with the dichotomy between surface and deep approaches to learning (Biggs & Tang, 2007).

4.3 Quantitative analyses

4.3.1 Distribution of CBL conceptions and approaches

Table 2 shows the categorical distribution of students’ responses to qualitative survey questions about their conceptions of the content of CBL and approaches to learning in clinics. Just over half (54%) of the conceptions reported by students (n = 93) were classified as cohesive and just over half (54%) of the reported approaches were classified as consistent with a deep approach to learning.

Table 2. Distribution of CBL conceptions and approaches reported in qualitative surveys.

CBL Conception	n	%	CBL Approach	n	%
Fragmented	A	9	10	Surface	A	9	10
	B	34	36		B	34	36
Cohesive	C	39	42	Deep	C	33	35
	D	10	11		D	11	12
	E	1	1		E	6	7
Total		93	100	Total		93	100

4.3.2 Relationships between CBL conceptions and approaches

Table 3 identifies relationships between understandings of the content of CBL and approaches to learning in clinics. A strong and statistically significant relationship existed between the quality of conceptions of what is learned during CBL and approaches to learning in clinics (phi = 0.65, p < 0.001). More than 80% of interns who reported adopting a surface approach to learning (n = 43) also described fragmented conceptions of the content of CBL. A similar proportion of interns who reported a deep approach to learning in clinics (84%, n = 50) described understandings of the content of CBL that were classified as cohesive. This indicates that the quality of what students learn through CBL is linked to the quality of approach that is adopted to learning in clinics.

Table 3. Relationships between CBL conceptions and approaches reported in qualitative surveys.

	CBL Approach
CBL Conception	Surface(Categories A & B)	Deep(Categories C, D & E)	Total
Fragmented (A & B)	35 (38%)	8 (9%)	43
Cohesive (C, D & E)	8 (9%)	42 (45%)	50
Total	43	50	93
Notes: n = 93, χ^2 = 39.8, phi = 0.65, p < 0.001.

4.3.3 Relationships between CBL conceptions, approaches and achievement

Table 4 relates the quality of CBL conceptions and approaches reported by interns to achievement during final year as measured by aggregate SRF marks. Students who reported a conception of the content of CBL that was classified as cohesive tended to be assessed as performing at a higher level than students who reported a conception classified as fragmented. This relationship was statistically significant (t = 3.3, p < 0.05, ES = 0.70). Similarly, interns who adopted a deep approach to CBL tended to be assessed as performing at a higher level than interns who reported adopting an approach consistent with a surface approach. This relationship was also statistically significant (t = 2.3, p < 0.05, ES = 0.46). These are medium‐to‐large effect sizes for differences between means (Cohen, 1988; Crawford et al., 1994; Ellis, Calvo, Levy, & Tan, 2004). These results indicate that performance during final year against a range of indicators relevant to success in practice is linked to the quality of interns’ conceptions and approaches.

Table 4. Relationships between CBL conceptions, approaches and achievement based on qualitative survey responses.

	Aggregate SRF Mark
	Mean^**	SD	ES
Conception
Fragmented	67.0	6.3	0.70
Cohesive	71.4	6.2
T test: t =	3.3^*
Approach
Surface	67.7	5.2	0.46
Deep	70.7	7.4
T test: t =	2.3*
Note: n = 93, *p < 0.05, ** = aggregate SRF mark out of 100.

5 Discussion

This study sought to provide detailed evidence of students’ conceptions of what is learned through CBL and approaches to learning in clinics during a final‐year veterinary internship programme. It also sought to investigate relationships amongst CBL conceptions, approaches and achievement. Phenomenography followed by quantitative statistical analysis was used to achieve these goals. The backgrounds of the researchers and the proximity to graduation for participants need to be considered when applying the results of this study to other CBL contexts. The intensive learning environment that formed the context for this study also needs to be taken into account when applying the results to less intensive veterinary CBL programmes or CBL programmes in other disciplines (Marton & Booth, 1997).

5.1 Effectiveness of CBL programmes in veterinary education

Educators intend all students to attain the full spectrum of desired veterinary graduate attributes prior to graduation, but student progress towards this goal varies. This study has revealed that final‐year students experience CBL in qualitatively different ways. These different experiences of CBL can be summarised as shown in Figure 3 (adapted from Crawford et al., 1994, p. 343).

Figure 3 Relationships between conceptions of the content of CBL and approaches to CBL.

The outcomes of this research confirm that CBL has the potential to effectively prepare students for the range of skills, expertise and behaviours required for registration as veterinary professionals. The extent to which this occurs is related to the quality of students’ conceptions of what is learned and approaches to learning during the internship year. Some interns involved in this study reported relatively poorer quality experiences of CBL that were characterised by a focus on disparate elements of veterinary professional practice and an intention to satisfy perceived performance expectations with minimal effort. Others reported relatively richer quality experiences of CBL that encompassed awareness of the complexity inherent in real‐life veterinary practice and sought to understand the multitude of interrelated factors that influence professional decision making. These differences in the quality of students’ learning experiences were reflected in achievement during final year. Similar relationships between course achievement and the quality of students’ learning experiences have been established in other disciplines (Crawford et al., 1994; Marton & Booth, 1997; Prosser & Trigwell, 1999). The results of this study suggest that it is important for veterinary educators to consider not only students’ understanding of what is learned during CBL, but also their approach to learning in clinics, as they seek to improve the quality of learning outcomes associated with participation in comprehensive veterinary internship programmes (Crawford et al., 1994).

5.2 Improvements in veterinary curriculum design and teaching

The results of this study suggest ways in which veterinary curriculum design and teaching can be altered to improve the quality of students’ learning experiences. A key element of these changes is to constructively align veterinary internship programmes in ways likely to promote high quality learning outcomes and a successful transition to veterinary practice (Biggs & Tang, 2007; Prosser & Trigwell, 1999). This study has revealed the characteristics of cohesive understandings of what is learned through CBL and deep approaches to learning in clinics. These findings can be used to shape the overarching goals, stated learning outcomes, teaching and learning activities and student assessment during an internship programme in ways likely to foster high quality learning experiences (Biggs & Tang, 2007; Prosser & Trigwell, 1999; Ramsden, 2003).

For example, intended learning outcomes for CBL programmes can now be defined by using themes drawn from high quality experiences of CBL reported in this study (Biggs & Tang, 2007). Grading criteria for performance assessment during internship programmes could be modified to guide students more effectively and consistently towards higher quality conceptions of what is learned during CBL and deeper approaches to learning in clinics. Placement supervisors can expand interns’ awareness of the content of CBL by explicitly asking students to consider a range of perspectives on veterinary case management and practice as they solve veterinary problems. The importance of this in real‐life practice can be highlighted by prompting students to consider the likely consequences of each potential solution (Lane & Strand, 2008). Active and self‐directed learning strategies can be stimulated by asking interns to formulate and justify independent opinions about options for managing veterinary cases (Barnes & Taylor, 1999; Lane & Strand, 2008). This can be achieved by asking students to conduct self‐directed research about case management options after interviewing veterinary clients, then evaluating the quality of resulting diagnostic and treatment plans (Lane & Strand, 2008). The combination of these efforts would help interns to develop the range of attributes, attitudes and skills associated with professional autonomy in practice.

5.3 Outcomes assessment of veterinary degree programmes

A range of quantitative statistics and measures of satisfaction are currently commonly used to evaluate veterinary degree programmes. While an important part of outcomes assessment, this data alone provides insufficient evidence of the quality of students’ learning. Exploring students’ conceptions of what is learned through CBL and approaches to learning in clinics is crucial for evaluating associations between veterinary internship programmes and a successful transition to practice. A number of options exist for outcomes assessment of veterinary programmes using student learning research principles and methodologies. As reported in this study, open‐ended surveys can be used for extensive data collection to ascertain the different ways that students experience CBL. Semi‐structured interviews could be used to complement these with intensive data collection that investigates students’ learning experiences in greater depth. A less labour intensive option is to administer closed‐ended surveys that enable identification of qualitatively different conceptions of the content of CBL and approaches to learning in clinics. Items for these surveys could be developed from qualitative data arising from students’ open‐ended survey responses about their CBL experiences (Crawford et al., 1994, 1998).

New graduate veterinarians’ experiences in practice provide a valuable source of outcomes assessment data for veterinary degrees (Heath, 1997; Riggs, Routly, Taylor, & Dobson, 2001). Student learning research principles and methodologies could be used to generate insight from the graduate perspective into what constitutes a successful transition to practice. Linking these results to students’ experiences of CBL during final year may reveal critical factors associated with early attainment of entry‐level professional autonomy after graduation. If consistent results were obtained from a range of universities using these methods, it would be feasible to administer a standardised graduate survey on a national and/or international basis. This would facilitate outcomes assessment comparisons between veterinary degrees worldwide.

Acknowledgements

This study was supported by Scholarships Index funding provided by the Faculty of Veterinary Science at The University of Sydney. The project proceeded with approval from the Human Research Ethics Committee of The University of Sydney (Project No. 8025). Sincere thanks go to all the final year interns who participated in this research.