2014, 1–7, Early Online
Collaborative diagramming during problem based learning in medical education: Do computerized diagrams support basic science knowledge construction? BAS DE LENG1 & HANNIE GIJLERS2 1
Maastricht University, The Netherlands, 2University of Twente, The Netherlands
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Abstract Aim: To examine how collaborative diagramming affects discussion and knowledge construction when learning complex basic science topics in medical education, including its effectiveness in the reformulation phase of problem-based learning. Methods: Opinions and perceptions of students (n ¼ 70) and tutors (n ¼ 4) who used collaborative diagramming in tutorial groups were collected with a questionnaire and focus group discussions. A framework derived from the analysis of discourse in computer-supported collaborative leaning was used to construct the questionnaire. Video observations were used during the focus group discussions. Results: Both students and tutors felt that collaborative diagramming positively affected discussion and knowledge construction. Students particularly appreciated that diagrams helped them to structure knowledge, to develop an overview of topics, and stimulated them to find relationships between topics. Tutors emphasized that diagramming increased interaction and enhanced the focus and detail of the discussion. Favourable conditions were the following: working with a shared whiteboard, using a diagram format that facilitated distribution, and applying half filled-in diagrams for non-content expert tutors and\or for heterogeneous groups with low achieving students. Conclusion: The empirical findings in this study support the findings of earlier more descriptive studies that diagramming in a collaborative setting is valuable for learning complex knowledge in medicine.
Introduction
Practice points
Shared reasoning is essential for collaborative learning to be more effective than individual learning (Barron 2003). However, in problem-based learning (PBL) at medical school, we often see that this necessity of intensive discourse, negotiation, and collaborative construction of knowledge is not met. When addressing complex basic science topics discussion during the reformulation or reporting phase in PBL often lack the interaction and depth needed to make these tutorial group session effective learning activities. When learning complex basis science topics, for example, in immunology, students often find it difficult to verbalize the many detailed steps including their relationships in long immunologic pathways. The inability to effectively verbalize complex basic science topics during the reformulation phase of PBL can result in superficial and ambiguous statements about detail. This restricts the exchange of ideas, negotiation of shared meaning, and the construction of integrated knowledge in-group discussions. Matters can be made worse when poor communication and understanding are combined with limited motivation, causing groups to resort to a superficial conflictavoidance collaboration style (Fischer et al. 2002).
There is a shortage of research studies on collaborative concept mapping in general, and on the process factors involved in particular. Collaborative concept mapping and diagramming are subject to contextual factors dependent on the discipline or topics covered, group-learning characteristics, and the particular learning task at hand. Diagramming and concept mapping approaches share some characteristics, for example, common visual conventions including lines and boxes, but they are suited to different applications. Diagramming is better suited to step-by-step sequences, while concept maps are better suited to organising hierarchical information. Collaborative diagramming can alleviate often encountered problems in small group discussions on complex basic science topics.
Visual knowledge representations such as concept maps and diagrams might be valuable tools to alleviate some of the problems during small group discussions on complex basic science topics. Nesbit’s meta-analysis (Nesbit & Adesope 2006)
Correspondence: Bas de Leng, Institut fu¨r Ausbildung und Studienangelegenheiten, Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Medizinische Fakulta¨t, Malmedyweg 17-19, 48149 Mu¨nster, Germany. Tel: 49 251/83 53126; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.956053
1
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B. D. Leng & H. Gijlers
on learning with concept maps showed that across different knowledge domains, educational levels and formats, the use of concept maps was associated with increased knowledge retention. The positive effect on achievement and comprehension was especially clear when concept mapping was applied in groups (Horton et al. 1993) and when it was used for making activity-closing summaries (Moore 1984). Some studies in science education claimed that collaborative concept mapping supports sustained meaningful discourse and co-construction of knowledge (Boxtel et al. 2002; Gijlers & de Jong 2013). These findings and assumptions strongly suggest the potential value of concept maps and diagrams for the reformulation phase of PBL in which students report on the knowledge they acquired during self-study and in which they try to integrate and apply this knowledge. Concept mapping and diagramming are also increasingly used in medical education. In the medical education literature (Pinto & Zeitz 1997; Guerrero 2001; Daley & Torre 2010; Pudelko et al. 2012; Torre et al. 2013) one can find studies describing different types of maps (e.g., concept maps, mechanic diagrams, etiologic flowcharts) and different mapping techniques (e.g., making maps from scratch or filling in the blanks, single, or serial concept maps), used for different educational goals (e.g., applying basic science knowledge to clinical cases, fostering clinical reasoning, or critical thinking), and settings (e.g., teaching, assessment). Reports on collaborative concept mapping are however sparse. In a recent literature, review on concept mapping in medical education (Daley & Torre 2010) less than a quarter of the studies was situated in a collaborative setting. Furthermore, the few studies that took place in such a setting considered mainly outcomes at an individual level and did not fully consider the role of group interactions. When we view a learning event in an activity system framework (Engestro¨m 1987), we are forced to analyse and specify (1) the ‘subjects’ or participants in the event (in this case: students and a teacher), (2) the ‘object’ or matter participants act on (in this case: knowledge on immunologic pathways) and (3) the ‘community’ or social cultural context in which the event takes place (in this case: small groups in a
Problem Based Learning curriculum). In addition, we have to be explicit about the ‘tools’ or instruments that mediate the relation between the participants and the matter (in this case: interactive displays and a computerized mapping program with pictogram collections and pre-prepared half filled-in diagrams). Placed in such an activity system framework, it is immediately clear the current learning activity with collaborative concept mapping involves interacting factors that influence the final effectiveness of the learning activity. Daley’s literature review on concept mapping in medical education (Daley & Torre 2010) cites little empirical data on process factors. The scarce studies that do present such data either restrict themselves to very global process factors (Edmondson 1995; Moni & Moni 2008) or only relate to concept mapping and not to the construction of other visual representations like diagrams (Rendas et al. 2006). Some descriptive studies not included in Daley’s review suggest that linear diagrams have great value for small group learning in medicine (Engelberg 1992; Guerrero 2001). Although concept maps and linear diagrams have similarities, they also differ in several ways. In diagramming, key activities include identifying chunks of information in complex mechanisms, linking these chunks, describing their relations in terms of ‘causes and effects’, and building step-by-step story chains. In concept mapping, the focus is on formulating key ideas (concepts) in a knowledge domain, differentiating general concepts from detailed concepts, organizing concepts in a hierarchical structure with levels of inclusiveness, linking concepts, and describing these relations with propositions (Ausubel 1968; Novak 1998). Figure 1(a) and (b) shows for both visualization techniques an example. The aim of this study is to investigate how in undergraduate medical education the collaborative drawing of diagrams in tutorial groups during the reformulation phase of PBL affects the discussion and knowledge construction when complex basic science topics are addressed. By collecting process information of small groups involved in collaborative diagramming, we expect to obtain more insight in the conditions that make such diagramming effective for shared reasoning.
Figure 1. (a) Concept map with a hierarchical structure in which ideas with different levels of inclusiveness are linked by propositions. (b) Linear diagram with step-by step story chains in which chunks of information are linked with cause/effect relations. 2
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Collaborative diagramming
Methods
completed or diagrams can be drawn from scratch using pictogram collections (Figure 2).
Subject and setting
Data collection and analysis
In a pilot study in April 2011, first year medical undergraduate students (n ¼ 70) in tutorial groups (n ¼ 7) in a PBL curriculum were invited to construct diagrams on a board during the reformulation phase of solving an immunology problem. We used a computerized mapping program (SMART Ideas 5) on interactive displays (smartboards or touchscreens) to simplify collaborative drawing and sharing of diagrams. The program was tailored to the subject domain of immunology by importing pictograms of cells and diagrams of immunology processes from an abundantly illustrated textbook (‘Basic Immunology’; Abbas & Lichtman 2011). Students could construct diagrams by dragging the pictograms from a prepared collection of cells and processes to the working area of the board, add arrows to show their connections, and add text to provide more detail. In addition, students could use pre-prepared half filled-in diagrams as the starting point of their work.
To explore the effects of drawing shared diagrams using a computerized mapping program on the processes of argumentative knowledge construction, we videotaped the discussions in tutorial groups supervised by four different tutors. We then collected student perceptions using a questionnaire, while the perceptions of tutors were sought in the more interactive setting of focus group discussions. We used categories from a framework that was developed to analyse written argumentative discourse in computersupported collaborative learning (Weinberger & Fischer 2006) to construct the questionnaire and to analyse the videos. Within this framework the so-called social modes of co-construction describe to what extent learners refer to contributions of their learning partners. For example: ‘externalisation’, ‘elicitation’, and ‘quick’, ‘integration-oriented,’ and ‘conflict-oriented’ consensus building. These modes are related to knowledge acquisition (Fischer et al. 2002). The student questionnaire consisted of 11 statements with response options on a five-point Likert scale (1 ¼ fully disagree; 5 ¼ fully agree). Of these statements, four reified the social modes: (1) externalising task-relevant knowledge, (2) eliciting task-relevant knowledge, (3) integration-oriented consensus building and (4) conflict-oriented consensus building (Table 1). The other seven statements in the student questionnaire related to affordances of concept mapping that are frequently mentioned in the literature (Nesbit & Adesope 2006). During the focus group sessions, the principal researcher (BdL) invited the tutors (n ¼ 4) to talk about their experiences and to comment on fragments of video recording of their tutorial groups. In two interviews, pairs of tutors were presented with video fragments of both the tutorial groups led by themselves and those led by the other tutors. The fragments were selected
Task The task is a case describing a medical student receiving a vaccination for typhoid fever before he is going for an internship abroad. An immunology laboratory checks the result of the vaccination and the effects on mononuclear blood cells, cytokines, and T-cells are presented in a table. Based on this short vignette, students have to define problem statements and after an elaboration with available prior knowledge to formulate learning issues for their self-study. Expected learning issues might include ‘‘What has been the immune response to this vaccination?’’ and ‘‘What are the differences between the TH1 cell and TH2 cell pathways?’’. To help answer such questions, the tutorial group is equipped with a computerized mapping program. In this program, pre-prepared half filled-in diagrams (Figure 1) can be
Figure 2. (a) and (b) Left: pre-prepared half filled-in diagram with question marks indicating missing information for completion by the student. Right: an example of a complex diagram drawn from scratch by a tutorial group. The cells and processes were selected from the pictogram collection (left-hand side of the screen) and annotated by typing in text.
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Table 1. The social modes of co-construction (first column), their definitions (second column) and the way they were formulated in the questionnaire in response to the opening statement ‘‘Making diagrams using pictures from the textbook ‘Basic Immunology’ in the tutorial group:’’ (third column).
Process Externalising task-related knowledge Eliciting task-related knowledge Integration-oriented consensus building
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Conflict-oriented consensus building
Definition
Statement in questionnaire
Articulating thoughts to the group. Students explicate their knowledge Questioning or provoking a reaction from learning partners. Students use their partners as a resource Generating a shared solution or assessment of the facts by integrating differing interpretations and opinions. Students take over, integrate and apply the perspectives of their learning partners Generating a shared solution or interpretation of the facts by modifying prior knowledge, interpretations and opinions or by making choices. Students disagree, modify or replace the perspectives of the learning partners
Stimulated me to express my knowledge of immunology in the group Stimulated me to ask others to express their knowledge on immunology in the group Stimulated the group to compile all views discussed in a comprehensive diagram
to represent two themes that had emerged from the initial global analysis of the video tapes by the principal researcher (BdL): (1) the function of shared diagrams in the group discussions (defining the focus of the discussion, externalising knowledge, eliciting knowledge, structuring the discussion, and taking notes) and (2) the strategies used by the tutors to work on interactive displays with diagrams to scaffold shared reasoning and knowledge construction (stimulating participation, focussing on essential knowledge, increasing depth of discussion, fostering shared understanding). A second researcher experienced in analysing group processes (HG) was asked to verify the observations of the principal researcher. The software program Transana (‘‘Transana’’ 2013) was used to identify interesting fragments, assign keywords to these fragments, and to create a collection of interrelated fragments. The same software was used to present the video fragments during the interviews, without keywords and in a flexible manner. The interviews were audio recorded and transcribed literally. The tutors approved the summary of their interview.
Results Students’ perceptions Table 2 shows student responses to the statements about constructing diagrams in the tutorial group during the reformation phase of PBL.
Tutors’ perceptions The mean duration of the video recordings of the reporting phase of the PBL session was 66 min (SD ¼ 20.8). For the structured interviews with the tutors, we selected an average of 17 video fragments (SD ¼ 2.9) of each group, with a mean duration of 13 min (SD ¼ 1.9). This means that of the total of 265 min of video recording, 52 min (67 fragments) were shown during both interviews, which each lasted approximately two hours. During the focus group sessions, all tutors (n ¼ 4) expressed that they felt that the elaboration of complex 4
Stimulated the group to modify conflicting views to come to a common solution
Table 2. Mean scores and standard deviations for students’ perception.
Statements Making diagrams using pictures from the book ‘Basic Immunology’ in the tutorial group: Stimulated me to express my knowledge of immunology in the group Stimulated me to ask others to express their knowledge on immunology in the group Helped me to follow the group discussion Helped me to structure my knowledge Helped me to find gaps in my knowledge Stimulated the group to discuss conflicting views on the subject Stimulated the group to look at the steps of immunologic processes in detail Helped me to keep an overview of the complex subject Stimulated the group to compile all views discussed in a comprehensive diagram Stimulated the group to modify conflicting views to come to a common solution Stimulated the group to find relationships between different pieces of information Give a mark out of 10 (1–10) for how much you learned by making picture diagrams with a computer in the tutorial group
N ¼ 48 (70%)
Mean score1
SD
3.35
0.91
3.31
0.83
3.73 4.06 3.73 3.58
0.87 0.76 0.94 0.94
3.88
0.87
4.04
1.05
3.65
1.04
3.54
0.82
3.81
0.87
Mean mark2 7.04
SD 1.17
1 on a 5-point scale, 2 mark out of 10.
immunology theory by the tutorial group during the reformulation phase of PBL was improved by constructing diagrams with computerized mapping software. Two themes emerged; ‘the functions of computerized diagramming in tutorial groups’ and ‘the strategies in the use of computerized diagramming in tutorial groups’.
Theme 1: The functions of computerized diagramming in tutorial groups Tutors reported that working with shared diagrams seemed to have a positive effect on three aspects of group work.
Collaborative diagramming
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Tutor–student and student–student interactions Tutors felt that because students knew that the diagrams developed by the group using the mapping program will be saved and shared after the meeting, they tend to be less preoccupied with drawing and copying the diagrams for themselves during the discussion. This frees up students’ time and attention for active participation in the discussion. During tutorials, students left their seats (without written notes or laptops) to add their ideas to the diagrams on the smartboard. Tutors felt that opportunities for students to interact at the smartboard motivated them to participate and helps them to break free from their notes. The diagrams in the mapping program give both students and tutors an understanding on how to involve all group members in the discussion. During discussion, it is easier for all group members to follow the questions and answers, which stimulates active participation in the discussion. As a result, it is not just the inquirer but the whole group that engages in learning. Compared with female students, male students seem more likely to see the computerized mapping program as an exciting new gadget to play with.
The focus and detail of the discussion Tutors felt that because students have to build diagrams from scratch they are forced to think through and articulate every step of the process. Occasionally, this sparks discussion about information students would formerly have taken at face value. In-depth discussion of a topic often depends on the tutor or a student asking questions or inquiring about something. Noncontent expert tutors or student chairs are supported in this by the structure and content of the templates provided by the mapping program. Sometimes tutors fail to notice that all the students in a group do not properly understand basic knowledge. Since there are always some students that can demonstrate the desired level of knowledge, gaps in other students’ knowledge may go undetected. When asked, weaker students tend to confirm comprehension but this is hard to verify. The shared diagrams facilitate verification of comprehension by asking different students to explain parts of the diagrams. A potential drawback is that in weaker groups a relatively large amount of time may be taken up by explanations of basic knowledge, preventing in-depth discussion of the issue at hand. Tutors felt that shared diagrams make it easier for groups to return to and focus on specific parts of a longer story presented by one or more participants. This helps to structure the discussion. Pointing to visible parts of a diagram enables tutors to ask students to elaborate in detail on specific parts of information. Students easily forget their own and other students’ contributions to the discussion. The gradually evolving shared diagram makes it easier for students to ask other students questions about their contributions.
Reaching agreement on essential knowledge that is to be mastered Tutors felt that during the reporting phase students frequently spend too much time consulting their personal notes and collecting information to make these notes as comprehensive
as possible. Students seem to be looking for assurance that their notes are suitable to prepare for the examination. This preoccupation prevents students from engaging in meaningful discussion about the content of their notes or from verifying that they have a proper understanding of the material. Making a shared diagram of the available knowledge enables students to focus on constructing a shared story, on deliberately pursuing a detailed inquiry and on verifying that they have a good understanding of the material. The information in books on immunology is often fragmented. Students have difficulty in understanding the relationships between different parts of information and obtaining an overview of the whole process. The added value of making a shared diagram is that students do not end up with only bits and pieces of knowledge but with a coherent view of a topic. Making a diagram helps students to connect seemingly disjointed pieces of information. Tutors also felt that shared diagrams support both tutors and students in summarising what has been discussed. Without a jointly produced diagram, students tend to engage in laborious descriptions of isolated parts of information to reconstruct the story all over again. The diagram is also helpful for the tutor to identify gaps in students’ knowledge and to point out and clarify essential parts of knowledge.
Theme 2: The strategies in the use of computerized diagramming in tutorial groups The tutors noticed that they differed in the strategies they applied when working with the content-specific diagramming program in their tutorial groups. The best strategies seemed to be dependent on characteristics of the group and the tutor. For homogenous high achieving groups, diagrams that are partly completed by the mapping program offered little added value. The groups finished quickly and there were few issues that needed to be discussed. Interaction in this type of group could be intensified by asking the group to make their own diagrams from scratch. Students often managed to make great progress without much help from the tutor. In heterogeneous groups, diagrams with icons in the mapping program seemed to make it easier for low achieving students with scant prior knowledge to get involved in the discussion. A drawback related to using a collection of icons from one standard textbook for the discussion is that this strategy goes against the general principle of PBL that students should use multiple resources. Going against this principle, however, may be detrimental to high achieving students but will enable average and low achieving students to discuss essential material. Constructing diagrams from scratch with the mapping program gives high achieving students opportunities to demonstrate their higher level of understanding in a way that is still comprehensible to less advanced students. This motivates all students to participate and enhances the depth of discussions. Of the tutors we interviewed, two were content experts and two were non-content experts. The content experts mainly asked their groups to make diagrams from scratch, whereas the two non-content experts mainly used the partially completed diagrams provided by the mapping program. The pre-completed diagrams made the non-content experts feel
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more confident that they would not get stuck and that all the essential material would be dealt with in the discussion.
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Discussion and conclusion Both students and tutors experience positive effects of collaborative diagramming on the discussion and knowledge construction when complex basic science topics are addressed in the tutorial group during the reformulation phase of PBL. On one hand, students especially mention the support for knowledge construction (helping to structure their knowledge, helping to keep an overview of the subject, and helping to find relationships between pieces of information) and mention less the support of the discussion (stimulating to discuss the details of immunologic processes). Tutors on the other hand emphasize more support of the discussion (increase in-group interaction, increase in focus, and detail of the discussion) and less support of knowledge construction (increase of consensus building). The different emphases expressed by students and tutors on what processes in the learning activity are supported by collaborative diagramming might be explained by the difference in perspective inherent to their roles. During scaffolding of the tutorial group activities, tutors have to support the cognitive activities (cognitive structuring, reduction of degrees of freedom), the metacognitive activities (direction maintenance), and the affect (recruitment, frustration control) of students (van de Pol et al. 2010). During the elaboration of a task students, however, are mainly concerned with the cognitive activities. The tutors’ comments on the video-recorded tutorial groups gave us some indication of conditions that influence the effectiveness of collaborative diagramming in the reformulation phase of PBL. The shared board clearly served as a focal point for group discussion in which individual members were motivated to share their knowledge. The economical way to capture a complex story with a few keywords and\or pictograms and the assurance that the constructed diagram was shared as a record at the end of the discussion seemed to free students’ time and attention to participate in the discourse. To get the full potential out of the collaborative diagramming, it was important that both tutors and students exploited the affordances of computerized diagramming to adapt the support of diagrams to the different performance levels of students in a group. To support the scaffolding of students by non-content expert tutors during discussions on complex-specialized topics, it was to be valuable to constrain the degrees of freedom in the diagramming activity. Pre-prepared half filledin diagrams as a starting point of the task in the reformulation phase of PBL worked well for this purpose. The half filled-in diagrams had less value for homogenous high achieving groups and for content expert tutors. They benefited more from drawing diagrams from scratch. The small number of subjects (especially of tutors) involved and the indirect nature of process information inferred from the participants’ perceptions are limitations of this study that we will address in future research with larger scale 6
observational and more quantitative studies. The current empirical findings on processes within discussions and knowledge construction of small groups during the reformulation phase of PBL, however, support earlier claims of descriptive studies that diagramming in a collaborative setting is valuable for learning complex basic science knowledge in medicine.
Notes on contributors BAS DE LENG, PhD, is with the Department of Educational Development and Educational Research, Faculty of Health Medicine and Life Sciences, Maastricht University. HANNIE GIJLERS, PhD, is with the Department of Instructional Technology, Faculty of Behavioral Sciences, University of Twente.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Abbas A, Lichtman A. 2011. Basic immunology. Updated edition (3rd revised edition). Ausubel D. 1968. Educational psychology: A cognitive view. New York: Holt, Reinhart and Winston. Barron B. 2003. When smart groups fail. J Learn Sci 12(3):307–359. Boxtel CV, Linden JVD, Roelofs E, Erkens GS. 2002. Collaborative concept mapping: Provoking and supporting meaningful discourse. Theory Pract 41(1):40–46. Daley BJ, Torre DM. 2010. Concept maps in medical education: An analytical literature review. Med Educ 44(5):440–448. Edmondson KM. 1995. Concept mapping for the development of medical curricula. J Res Sci Teach 32(7):777–793. Engelberg J. 1992. Complex medical case histories as portals to medical practice and integrative, scientific thought. Adv Physiol Educ 263(6):S45–S54. Engestro¨m Y. 1987. Learning by expanding: An activity-theoretical approach to developmental research. Helsinki: Orienta-Konsultit. Fischer F, Bruhn J, Grasel C, Mandl H. 2002. Fostering collaborative knowledge construction with visualization tools. Learn Instr 12(2):213–232. Gijlers H, de Jong T. 2013. Using concept maps to facilitate collaborative simulation-based inquiry learning. J Learn Sci 22(3):340–374. Guerrero APSMD. 2001. Mechanistic case diagramming: A tool for problembased learning. Acad Med 76(4):385–389. Horton PB, McConney AA, Gallo M, Woods AL, Senn GJ, Hamelin D. 1993. An investigation of the effectiveness of concept mapping as an instructional tool. Sci Educ 77(1):95. Moni RW, Moni KB. 2008. Student perceptions and use of an assessment rubric for a group concept map in physiology. Adv Physiol Educ 32(1):47–54. Moore D. 1984. A quantitative and qualitative review of graphic organizer research. J Educ Res 78:11–17. Nesbit JC, Adesope O. 2006. Learning with concept and knowledge maps: A meta-analysis. Rev Educ Res 76(3):413–448. Novak J. 1998. Learning, creating, and using knowledge. Mahwah, NJ: Lawrence Erlbaum Associates. Pinto A, Zeitz H. 1997. Concept mapping: A strategy for promoting meaningful learning in medical education. Med Teach 19(2):114–121. Pudelko B, Young M, Vincent-Lamarre P, Charlin B. 2012. Mapping as a learning strategy in health professions education: A critical analysis. Med Educ 46(12):1215–1225. Rendas AB, Fonseca M, Pinto PR. 2006. Toward meaningful learning in undergraduate medical education using concept maps in a PBL pathophysiology course. Adv Physiol Educ 30(1):23–29. SMART Ideas 5 (Version 5.1.19.2). Calgary, AB, Canada: SMART Technologies ULC.
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van de Pol J, Volman M, Beishuizen J. 2010. Scaffolding in teacher–student interaction: A decade of research. Educ Psychol Rev 22(3):271–296. Weinberger A, Fischer F. 2006. A framework to analyze argumentative knowledge construction in computer-supported collaborative learning. Comput Educ 46(1):71–95.
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Torre DM, Durning SJ, Daley BJ. 2013. Twelve tips for teaching with concept maps in medical education. Med Teach 35:201–208. Transana (Version 2.5). 2013. University of Wisconsin-Madison Center for Education Research. [Accessed 18 December 2013] Available from http://www.transana.org/.
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Collaborative diagramming during problem based learning in medical education: Do computerized diagrams support basic science knowledge construction? BAS DE LENG1 & HANNIE GIJLERS2 1
Maastricht University, The Netherlands, 2University of Twente, The Netherlands
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Abstract Aim: To examine how collaborative diagramming affects discussion and knowledge construction when learning complex basic science topics in medical education, including its effectiveness in the reformulation phase of problem-based learning. Methods: Opinions and perceptions of students (n ¼ 70) and tutors (n ¼ 4) who used collaborative diagramming in tutorial groups were collected with a questionnaire and focus group discussions. A framework derived from the analysis of discourse in computer-supported collaborative leaning was used to construct the questionnaire. Video observations were used during the focus group discussions. Results: Both students and tutors felt that collaborative diagramming positively affected discussion and knowledge construction. Students particularly appreciated that diagrams helped them to structure knowledge, to develop an overview of topics, and stimulated them to find relationships between topics. Tutors emphasized that diagramming increased interaction and enhanced the focus and detail of the discussion. Favourable conditions were the following: working with a shared whiteboard, using a diagram format that facilitated distribution, and applying half filled-in diagrams for non-content expert tutors and\or for heterogeneous groups with low achieving students. Conclusion: The empirical findings in this study support the findings of earlier more descriptive studies that diagramming in a collaborative setting is valuable for learning complex knowledge in medicine.
Introduction
Practice points
Shared reasoning is essential for collaborative learning to be more effective than individual learning (Barron 2003). However, in problem-based learning (PBL) at medical school, we often see that this necessity of intensive discourse, negotiation, and collaborative construction of knowledge is not met. When addressing complex basic science topics discussion during the reformulation or reporting phase in PBL often lack the interaction and depth needed to make these tutorial group session effective learning activities. When learning complex basis science topics, for example, in immunology, students often find it difficult to verbalize the many detailed steps including their relationships in long immunologic pathways. The inability to effectively verbalize complex basic science topics during the reformulation phase of PBL can result in superficial and ambiguous statements about detail. This restricts the exchange of ideas, negotiation of shared meaning, and the construction of integrated knowledge in-group discussions. Matters can be made worse when poor communication and understanding are combined with limited motivation, causing groups to resort to a superficial conflictavoidance collaboration style (Fischer et al. 2002).
There is a shortage of research studies on collaborative concept mapping in general, and on the process factors involved in particular. Collaborative concept mapping and diagramming are subject to contextual factors dependent on the discipline or topics covered, group-learning characteristics, and the particular learning task at hand. Diagramming and concept mapping approaches share some characteristics, for example, common visual conventions including lines and boxes, but they are suited to different applications. Diagramming is better suited to step-by-step sequences, while concept maps are better suited to organising hierarchical information. Collaborative diagramming can alleviate often encountered problems in small group discussions on complex basic science topics.
Visual knowledge representations such as concept maps and diagrams might be valuable tools to alleviate some of the problems during small group discussions on complex basic science topics. Nesbit’s meta-analysis (Nesbit & Adesope 2006)
Correspondence: Bas de Leng, Institut fu¨r Ausbildung und Studienangelegenheiten, Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Medizinische Fakulta¨t, Malmedyweg 17-19, 48149 Mu¨nster, Germany. Tel: 49 251/83 53126; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.956053
1
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B. D. Leng & H. Gijlers
on learning with concept maps showed that across different knowledge domains, educational levels and formats, the use of concept maps was associated with increased knowledge retention. The positive effect on achievement and comprehension was especially clear when concept mapping was applied in groups (Horton et al. 1993) and when it was used for making activity-closing summaries (Moore 1984). Some studies in science education claimed that collaborative concept mapping supports sustained meaningful discourse and co-construction of knowledge (Boxtel et al. 2002; Gijlers & de Jong 2013). These findings and assumptions strongly suggest the potential value of concept maps and diagrams for the reformulation phase of PBL in which students report on the knowledge they acquired during self-study and in which they try to integrate and apply this knowledge. Concept mapping and diagramming are also increasingly used in medical education. In the medical education literature (Pinto & Zeitz 1997; Guerrero 2001; Daley & Torre 2010; Pudelko et al. 2012; Torre et al. 2013) one can find studies describing different types of maps (e.g., concept maps, mechanic diagrams, etiologic flowcharts) and different mapping techniques (e.g., making maps from scratch or filling in the blanks, single, or serial concept maps), used for different educational goals (e.g., applying basic science knowledge to clinical cases, fostering clinical reasoning, or critical thinking), and settings (e.g., teaching, assessment). Reports on collaborative concept mapping are however sparse. In a recent literature, review on concept mapping in medical education (Daley & Torre 2010) less than a quarter of the studies was situated in a collaborative setting. Furthermore, the few studies that took place in such a setting considered mainly outcomes at an individual level and did not fully consider the role of group interactions. When we view a learning event in an activity system framework (Engestro¨m 1987), we are forced to analyse and specify (1) the ‘subjects’ or participants in the event (in this case: students and a teacher), (2) the ‘object’ or matter participants act on (in this case: knowledge on immunologic pathways) and (3) the ‘community’ or social cultural context in which the event takes place (in this case: small groups in a
Problem Based Learning curriculum). In addition, we have to be explicit about the ‘tools’ or instruments that mediate the relation between the participants and the matter (in this case: interactive displays and a computerized mapping program with pictogram collections and pre-prepared half filled-in diagrams). Placed in such an activity system framework, it is immediately clear the current learning activity with collaborative concept mapping involves interacting factors that influence the final effectiveness of the learning activity. Daley’s literature review on concept mapping in medical education (Daley & Torre 2010) cites little empirical data on process factors. The scarce studies that do present such data either restrict themselves to very global process factors (Edmondson 1995; Moni & Moni 2008) or only relate to concept mapping and not to the construction of other visual representations like diagrams (Rendas et al. 2006). Some descriptive studies not included in Daley’s review suggest that linear diagrams have great value for small group learning in medicine (Engelberg 1992; Guerrero 2001). Although concept maps and linear diagrams have similarities, they also differ in several ways. In diagramming, key activities include identifying chunks of information in complex mechanisms, linking these chunks, describing their relations in terms of ‘causes and effects’, and building step-by-step story chains. In concept mapping, the focus is on formulating key ideas (concepts) in a knowledge domain, differentiating general concepts from detailed concepts, organizing concepts in a hierarchical structure with levels of inclusiveness, linking concepts, and describing these relations with propositions (Ausubel 1968; Novak 1998). Figure 1(a) and (b) shows for both visualization techniques an example. The aim of this study is to investigate how in undergraduate medical education the collaborative drawing of diagrams in tutorial groups during the reformulation phase of PBL affects the discussion and knowledge construction when complex basic science topics are addressed. By collecting process information of small groups involved in collaborative diagramming, we expect to obtain more insight in the conditions that make such diagramming effective for shared reasoning.
Figure 1. (a) Concept map with a hierarchical structure in which ideas with different levels of inclusiveness are linked by propositions. (b) Linear diagram with step-by step story chains in which chunks of information are linked with cause/effect relations. 2
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Collaborative diagramming
Methods
completed or diagrams can be drawn from scratch using pictogram collections (Figure 2).
Subject and setting
Data collection and analysis
In a pilot study in April 2011, first year medical undergraduate students (n ¼ 70) in tutorial groups (n ¼ 7) in a PBL curriculum were invited to construct diagrams on a board during the reformulation phase of solving an immunology problem. We used a computerized mapping program (SMART Ideas 5) on interactive displays (smartboards or touchscreens) to simplify collaborative drawing and sharing of diagrams. The program was tailored to the subject domain of immunology by importing pictograms of cells and diagrams of immunology processes from an abundantly illustrated textbook (‘Basic Immunology’; Abbas & Lichtman 2011). Students could construct diagrams by dragging the pictograms from a prepared collection of cells and processes to the working area of the board, add arrows to show their connections, and add text to provide more detail. In addition, students could use pre-prepared half filled-in diagrams as the starting point of their work.
To explore the effects of drawing shared diagrams using a computerized mapping program on the processes of argumentative knowledge construction, we videotaped the discussions in tutorial groups supervised by four different tutors. We then collected student perceptions using a questionnaire, while the perceptions of tutors were sought in the more interactive setting of focus group discussions. We used categories from a framework that was developed to analyse written argumentative discourse in computersupported collaborative learning (Weinberger & Fischer 2006) to construct the questionnaire and to analyse the videos. Within this framework the so-called social modes of co-construction describe to what extent learners refer to contributions of their learning partners. For example: ‘externalisation’, ‘elicitation’, and ‘quick’, ‘integration-oriented,’ and ‘conflict-oriented’ consensus building. These modes are related to knowledge acquisition (Fischer et al. 2002). The student questionnaire consisted of 11 statements with response options on a five-point Likert scale (1 ¼ fully disagree; 5 ¼ fully agree). Of these statements, four reified the social modes: (1) externalising task-relevant knowledge, (2) eliciting task-relevant knowledge, (3) integration-oriented consensus building and (4) conflict-oriented consensus building (Table 1). The other seven statements in the student questionnaire related to affordances of concept mapping that are frequently mentioned in the literature (Nesbit & Adesope 2006). During the focus group sessions, the principal researcher (BdL) invited the tutors (n ¼ 4) to talk about their experiences and to comment on fragments of video recording of their tutorial groups. In two interviews, pairs of tutors were presented with video fragments of both the tutorial groups led by themselves and those led by the other tutors. The fragments were selected
Task The task is a case describing a medical student receiving a vaccination for typhoid fever before he is going for an internship abroad. An immunology laboratory checks the result of the vaccination and the effects on mononuclear blood cells, cytokines, and T-cells are presented in a table. Based on this short vignette, students have to define problem statements and after an elaboration with available prior knowledge to formulate learning issues for their self-study. Expected learning issues might include ‘‘What has been the immune response to this vaccination?’’ and ‘‘What are the differences between the TH1 cell and TH2 cell pathways?’’. To help answer such questions, the tutorial group is equipped with a computerized mapping program. In this program, pre-prepared half filled-in diagrams (Figure 1) can be
Figure 2. (a) and (b) Left: pre-prepared half filled-in diagram with question marks indicating missing information for completion by the student. Right: an example of a complex diagram drawn from scratch by a tutorial group. The cells and processes were selected from the pictogram collection (left-hand side of the screen) and annotated by typing in text.
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Table 1. The social modes of co-construction (first column), their definitions (second column) and the way they were formulated in the questionnaire in response to the opening statement ‘‘Making diagrams using pictures from the textbook ‘Basic Immunology’ in the tutorial group:’’ (third column).
Process Externalising task-related knowledge Eliciting task-related knowledge Integration-oriented consensus building
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Conflict-oriented consensus building
Definition
Statement in questionnaire
Articulating thoughts to the group. Students explicate their knowledge Questioning or provoking a reaction from learning partners. Students use their partners as a resource Generating a shared solution or assessment of the facts by integrating differing interpretations and opinions. Students take over, integrate and apply the perspectives of their learning partners Generating a shared solution or interpretation of the facts by modifying prior knowledge, interpretations and opinions or by making choices. Students disagree, modify or replace the perspectives of the learning partners
Stimulated me to express my knowledge of immunology in the group Stimulated me to ask others to express their knowledge on immunology in the group Stimulated the group to compile all views discussed in a comprehensive diagram
to represent two themes that had emerged from the initial global analysis of the video tapes by the principal researcher (BdL): (1) the function of shared diagrams in the group discussions (defining the focus of the discussion, externalising knowledge, eliciting knowledge, structuring the discussion, and taking notes) and (2) the strategies used by the tutors to work on interactive displays with diagrams to scaffold shared reasoning and knowledge construction (stimulating participation, focussing on essential knowledge, increasing depth of discussion, fostering shared understanding). A second researcher experienced in analysing group processes (HG) was asked to verify the observations of the principal researcher. The software program Transana (‘‘Transana’’ 2013) was used to identify interesting fragments, assign keywords to these fragments, and to create a collection of interrelated fragments. The same software was used to present the video fragments during the interviews, without keywords and in a flexible manner. The interviews were audio recorded and transcribed literally. The tutors approved the summary of their interview.
Results Students’ perceptions Table 2 shows student responses to the statements about constructing diagrams in the tutorial group during the reformation phase of PBL.
Tutors’ perceptions The mean duration of the video recordings of the reporting phase of the PBL session was 66 min (SD ¼ 20.8). For the structured interviews with the tutors, we selected an average of 17 video fragments (SD ¼ 2.9) of each group, with a mean duration of 13 min (SD ¼ 1.9). This means that of the total of 265 min of video recording, 52 min (67 fragments) were shown during both interviews, which each lasted approximately two hours. During the focus group sessions, all tutors (n ¼ 4) expressed that they felt that the elaboration of complex 4
Stimulated the group to modify conflicting views to come to a common solution
Table 2. Mean scores and standard deviations for students’ perception.
Statements Making diagrams using pictures from the book ‘Basic Immunology’ in the tutorial group: Stimulated me to express my knowledge of immunology in the group Stimulated me to ask others to express their knowledge on immunology in the group Helped me to follow the group discussion Helped me to structure my knowledge Helped me to find gaps in my knowledge Stimulated the group to discuss conflicting views on the subject Stimulated the group to look at the steps of immunologic processes in detail Helped me to keep an overview of the complex subject Stimulated the group to compile all views discussed in a comprehensive diagram Stimulated the group to modify conflicting views to come to a common solution Stimulated the group to find relationships between different pieces of information Give a mark out of 10 (1–10) for how much you learned by making picture diagrams with a computer in the tutorial group
N ¼ 48 (70%)
Mean score1
SD
3.35
0.91
3.31
0.83
3.73 4.06 3.73 3.58
0.87 0.76 0.94 0.94
3.88
0.87
4.04
1.05
3.65
1.04
3.54
0.82
3.81
0.87
Mean mark2 7.04
SD 1.17
1 on a 5-point scale, 2 mark out of 10.
immunology theory by the tutorial group during the reformulation phase of PBL was improved by constructing diagrams with computerized mapping software. Two themes emerged; ‘the functions of computerized diagramming in tutorial groups’ and ‘the strategies in the use of computerized diagramming in tutorial groups’.
Theme 1: The functions of computerized diagramming in tutorial groups Tutors reported that working with shared diagrams seemed to have a positive effect on three aspects of group work.
Collaborative diagramming
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Tutor–student and student–student interactions Tutors felt that because students knew that the diagrams developed by the group using the mapping program will be saved and shared after the meeting, they tend to be less preoccupied with drawing and copying the diagrams for themselves during the discussion. This frees up students’ time and attention for active participation in the discussion. During tutorials, students left their seats (without written notes or laptops) to add their ideas to the diagrams on the smartboard. Tutors felt that opportunities for students to interact at the smartboard motivated them to participate and helps them to break free from their notes. The diagrams in the mapping program give both students and tutors an understanding on how to involve all group members in the discussion. During discussion, it is easier for all group members to follow the questions and answers, which stimulates active participation in the discussion. As a result, it is not just the inquirer but the whole group that engages in learning. Compared with female students, male students seem more likely to see the computerized mapping program as an exciting new gadget to play with.
The focus and detail of the discussion Tutors felt that because students have to build diagrams from scratch they are forced to think through and articulate every step of the process. Occasionally, this sparks discussion about information students would formerly have taken at face value. In-depth discussion of a topic often depends on the tutor or a student asking questions or inquiring about something. Noncontent expert tutors or student chairs are supported in this by the structure and content of the templates provided by the mapping program. Sometimes tutors fail to notice that all the students in a group do not properly understand basic knowledge. Since there are always some students that can demonstrate the desired level of knowledge, gaps in other students’ knowledge may go undetected. When asked, weaker students tend to confirm comprehension but this is hard to verify. The shared diagrams facilitate verification of comprehension by asking different students to explain parts of the diagrams. A potential drawback is that in weaker groups a relatively large amount of time may be taken up by explanations of basic knowledge, preventing in-depth discussion of the issue at hand. Tutors felt that shared diagrams make it easier for groups to return to and focus on specific parts of a longer story presented by one or more participants. This helps to structure the discussion. Pointing to visible parts of a diagram enables tutors to ask students to elaborate in detail on specific parts of information. Students easily forget their own and other students’ contributions to the discussion. The gradually evolving shared diagram makes it easier for students to ask other students questions about their contributions.
Reaching agreement on essential knowledge that is to be mastered Tutors felt that during the reporting phase students frequently spend too much time consulting their personal notes and collecting information to make these notes as comprehensive
as possible. Students seem to be looking for assurance that their notes are suitable to prepare for the examination. This preoccupation prevents students from engaging in meaningful discussion about the content of their notes or from verifying that they have a proper understanding of the material. Making a shared diagram of the available knowledge enables students to focus on constructing a shared story, on deliberately pursuing a detailed inquiry and on verifying that they have a good understanding of the material. The information in books on immunology is often fragmented. Students have difficulty in understanding the relationships between different parts of information and obtaining an overview of the whole process. The added value of making a shared diagram is that students do not end up with only bits and pieces of knowledge but with a coherent view of a topic. Making a diagram helps students to connect seemingly disjointed pieces of information. Tutors also felt that shared diagrams support both tutors and students in summarising what has been discussed. Without a jointly produced diagram, students tend to engage in laborious descriptions of isolated parts of information to reconstruct the story all over again. The diagram is also helpful for the tutor to identify gaps in students’ knowledge and to point out and clarify essential parts of knowledge.
Theme 2: The strategies in the use of computerized diagramming in tutorial groups The tutors noticed that they differed in the strategies they applied when working with the content-specific diagramming program in their tutorial groups. The best strategies seemed to be dependent on characteristics of the group and the tutor. For homogenous high achieving groups, diagrams that are partly completed by the mapping program offered little added value. The groups finished quickly and there were few issues that needed to be discussed. Interaction in this type of group could be intensified by asking the group to make their own diagrams from scratch. Students often managed to make great progress without much help from the tutor. In heterogeneous groups, diagrams with icons in the mapping program seemed to make it easier for low achieving students with scant prior knowledge to get involved in the discussion. A drawback related to using a collection of icons from one standard textbook for the discussion is that this strategy goes against the general principle of PBL that students should use multiple resources. Going against this principle, however, may be detrimental to high achieving students but will enable average and low achieving students to discuss essential material. Constructing diagrams from scratch with the mapping program gives high achieving students opportunities to demonstrate their higher level of understanding in a way that is still comprehensible to less advanced students. This motivates all students to participate and enhances the depth of discussions. Of the tutors we interviewed, two were content experts and two were non-content experts. The content experts mainly asked their groups to make diagrams from scratch, whereas the two non-content experts mainly used the partially completed diagrams provided by the mapping program. The pre-completed diagrams made the non-content experts feel
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more confident that they would not get stuck and that all the essential material would be dealt with in the discussion.
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Discussion and conclusion Both students and tutors experience positive effects of collaborative diagramming on the discussion and knowledge construction when complex basic science topics are addressed in the tutorial group during the reformulation phase of PBL. On one hand, students especially mention the support for knowledge construction (helping to structure their knowledge, helping to keep an overview of the subject, and helping to find relationships between pieces of information) and mention less the support of the discussion (stimulating to discuss the details of immunologic processes). Tutors on the other hand emphasize more support of the discussion (increase in-group interaction, increase in focus, and detail of the discussion) and less support of knowledge construction (increase of consensus building). The different emphases expressed by students and tutors on what processes in the learning activity are supported by collaborative diagramming might be explained by the difference in perspective inherent to their roles. During scaffolding of the tutorial group activities, tutors have to support the cognitive activities (cognitive structuring, reduction of degrees of freedom), the metacognitive activities (direction maintenance), and the affect (recruitment, frustration control) of students (van de Pol et al. 2010). During the elaboration of a task students, however, are mainly concerned with the cognitive activities. The tutors’ comments on the video-recorded tutorial groups gave us some indication of conditions that influence the effectiveness of collaborative diagramming in the reformulation phase of PBL. The shared board clearly served as a focal point for group discussion in which individual members were motivated to share their knowledge. The economical way to capture a complex story with a few keywords and\or pictograms and the assurance that the constructed diagram was shared as a record at the end of the discussion seemed to free students’ time and attention to participate in the discourse. To get the full potential out of the collaborative diagramming, it was important that both tutors and students exploited the affordances of computerized diagramming to adapt the support of diagrams to the different performance levels of students in a group. To support the scaffolding of students by non-content expert tutors during discussions on complex-specialized topics, it was to be valuable to constrain the degrees of freedom in the diagramming activity. Pre-prepared half filledin diagrams as a starting point of the task in the reformulation phase of PBL worked well for this purpose. The half filled-in diagrams had less value for homogenous high achieving groups and for content expert tutors. They benefited more from drawing diagrams from scratch. The small number of subjects (especially of tutors) involved and the indirect nature of process information inferred from the participants’ perceptions are limitations of this study that we will address in future research with larger scale 6
observational and more quantitative studies. The current empirical findings on processes within discussions and knowledge construction of small groups during the reformulation phase of PBL, however, support earlier claims of descriptive studies that diagramming in a collaborative setting is valuable for learning complex basic science knowledge in medicine.
Notes on contributors BAS DE LENG, PhD, is with the Department of Educational Development and Educational Research, Faculty of Health Medicine and Life Sciences, Maastricht University. HANNIE GIJLERS, PhD, is with the Department of Instructional Technology, Faculty of Behavioral Sciences, University of Twente.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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