JAMDA xxx (2014) 1e6

JAMDA journal homepage: www.jamda.com

Original Study

Using the Jigsaw Cooperative Learning Method to Teach Medical Students About Long Term and Postacute Care Gwendolen T. Buhr MD, MHS, MEd, CMD *, Mitchell T. Heflin MD, MHS, Heidi K. White MD, MHS, MEd, CMD *, Sandro O. Pinheiro PhD, MA, MRE Geriatrics Division, Department of Medicine, Duke University School of Medicine, Durham, NC

a b s t r a c t Keywords: Educational models active learning long term care nursing homes

Since many of the frailest and most vulnerable Americans reside in nursing homes, medical students need focused education and training pertaining to this setting. A unique cooperative learning experience utilizing the jigsaw method was developed to engage and expose students to the institutional long term and postacute care (LTPAC) setting and the roles of personnel there. To accomplish these goals, small groups of medical students interviewed LTPAC personnel about their role, generally, and in relation to a specific patient case. These groups were then rearranged into new groups containing 1 student from each of the original groups plus a faculty facilitator. Each student in the new groups taught about the role of the LTPAC professional they interviewed. To assess the effectiveness of this learning experience, students and LTPAC personnel provided written feedback and rated the activity using a 5-point Likert scale (1 ¼ worst; 5 ¼ best). Students also took a knowledge test. The activity received ratings from students of 3.65 to 4.12 (mean ¼ 3.91). The knowledge test results indicated that students understood the roles of the LTPAC personnel. In general, the jigsaw exercise was well-received by participants and provided an effective means of introducing medical students to the nursing home environment. Ó 2014 - American Medical Directors Association, Inc. All rights reserved.

Institutional long term and postacute care (LTPAC) has become a critically important area of patient care, as many of the frailest and most vulnerable elders are cared for in nursing homes either for short or long periods of time. In 2010, there were 1.4 million older adults living in 16,071 nursing homes across the United States.1 Another 1.7 million persons experienced temporary or short stays in skilled nursing facilities (SNF)s for rehabilitation and 1.23 million older adults lived in other care settings such as assisted living or residential care.1,2 Unfortunately, there are far too few physicians and other health professionals with appropriate training in LTPAC to care for that population. Although the geriatrics content has increased in medical schools in the United States, students are still receiving insufficient LTPAC content. A survey of medical schools in

Heidi K. White and Sandro O. Pinheiro contributed equally to this work. The authors declare no conflicts of interest. * Address correspondence to Gwendolen T. Buhr, MD, MHS, MEd, CMD, Duke University Medical Center, 2508 Blue Zone Duke Hospital South, 201 Trent Drive, Duke University Medical Center Box 3003, Durham, NC 27710 or Heidi K. White, MD, MHS, MEd, CMD, Duke University Medical Center, 2515 Blue Zone Duke Hospital South, 201 Trent Drive, Duke University Medical Center Box 3003, Durham, NC 27710. E-mail addresses: [email protected] (G.T. Buhr), heidi.white@dm. duke.edu (H.K. White).

1999 and 2000 showed that a modest 69% of medical schools had a teaching nursing home, and 65% had curricular content regarding interdisciplinary teams.3 The 2013 American Association of Medical Colleges’ Medical School Graduation Questionnaire indicates that most graduating students believed that their instruction in the care of geriatric patients (84.8%), long term healthcare (81.4%), and teamwork with other health professions (89.5%) was adequate; however, only about one-third of students had any experience with home care or nursing home care during medical school, suggesting that students’ self-reported data on this questionnaire overestimate the adequacy of LTPAC education.4 In comparison, 95.8% believed the instruction in the care of hospitalized patients was adequate.4 Taken together, the data suggest that more emphasis on the LTPAC settings, especially the nursing home is needed in the medical school curriculum. In response to this need for medical student education about the institutional LTPAC setting, we employed a novel cooperative learning technique called the jigsaw method. The objectives were to define LTPAC posthospital care, the scope of services it entails, and to describe the roles of the various members of the nursing home interprofessional team. This article will describe the jigsaw method, and discuss the results of our evaluation of this innovative activity.

1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2014.01.015

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Methods Jigsaw Method The jigsaw method is a cooperative learning strategy that is broadly applicable to many educational settings, working well for any material that can be segmented into equal parts among students. The basic procedure for orchestrating the jigsaw method involves dividing the students into ‘expert’ groups, with the same number of expert groups as the number of segments of material. The students in each ‘expert’ group study their assigned material, and discuss how to best communicate it to the larger group.5 When the discussions within the ‘expert’ groups are complete, 1 student from each ‘expert’ group forms a ‘jigsaw’ group. The members of the ‘jigsaw’ groups teach each other what they have learned.6 The instructor acts as a facilitator, monitoring the groups to make sure they are on task and do not have any gross misperceptions.5 Long Term Care Jigsaw Exercise

Evaluation Strategies The jigsaw exercise was assessed using a mixed-method approach. This approach is generally thought to yield a more

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Medical students early in their clinical training at Duke University took a weeklong required experience in geriatrics entitled the Clinical Core on Aging. In general, the experience was designed to introduce students to various aspects of the care of older adults, in different settings. As part of the week, students spent a half-day at a local continuing care retirement community interacting with residents and staff. The jigsaw exercise was employed during this half-day as a means of introducing students to the structure and function of the LTPAC setting. The objectives of the jigsaw exercise were to define LTPAC and the scope of services it entails, and to describe the roles of the various members of the nursing home team. To accomplish these goals, 10

key members of the LTPAC team were identified. A group of 50 students was divided into 10 ‘expert’ groups of 5 students. Each ‘expert’ group was given 30e45 minutes (Figure 1, step 1) to meet and interview 1 member of the LTPAC team. To facilitate the interview, the students were given a brief (1e3 sentences) description of the position and some suggested questions, as well as a clinical case to frame the interview. Each student in the group was to become an ‘expert’ in the role of their assigned member of the healthcare team. After the interview the students in the expert groups were allowed 15 minutes to confer with their members to discuss the main talking points about their professional’s role in general and in relation to the clinical case. Next, they would share these talking points as the case was discussed in the jigsaw groups. The groups were then rearranged into ‘jigsaw’ groups containing 1 expert student from each of the original groups along with a faculty facilitator (Figure 1, step 2). The ‘jigsaw’ groups met for 1 hour during which each student in the group offered insights into how the LTPAC professional that s/he interviewed would typically interact with the patient in the case during the various stages and problems encountered in the nursing home stay (admission, deconditioning, colostomy care, depression, lost hearing aids, lack of primary care physician that visits the SNF, and discharge planning). The goal for each ‘expert’ was to teach his/her peers about the role that the person s/he interviewed has in patient care, in general, and specifically with regard to the case. The faculty facilitator was given a facilitators’ guide to ensure that essential material/concepts were covered in each ‘jigsaw’ group. The entire exercise was repeated in order to accommodate all 100 students.

Fig. 1. Pictorial representation of the jigsaw method.

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authentic assessment of an educational intervention,7 as well as a more holistic and valid picture of the impact of a program. In this case, the students evaluated the experience through a questionnaire, which included quantitative Likert scale questions and qualitative open-ended comments. Evaluation questions varied somewhat depending on the year since the evaluation was administered by the School of Medicine and was not completely under our control. In every year (2006e2010), the students were asked to indicate how successful the Clinical Core on Aging was in helping to achieve the learning outcome ‘define long term care and the scope of services it entails’ using the scale of 1e5 (1 ¼ extremely unsuccessful, 3 ¼ neutral, 5 ¼ extremely successful). In 2006 and 2007, they were also asked to rate the value of the jigsaw exercise in facilitating acquisition of knowledge and skills using the scale from 1e5 (1 ¼ unhelpful, 3 ¼ neutral, 5 ¼ extremely helpful). In 2008e2010, the students were asked “How much did you learn as a result of the jigsaw activity?” on a scale of 1e5 (1 ¼ none, 2 ¼ little, 3 ¼ a moderate amount, 4 ¼ a great deal, 5 ¼ exceptional amount). The qualitative prompts in every year were “The most effective/valuable aspect of the week was:” and “Suggestions for improving the course:” In 2007 there was an additional qualitative prompt that asked for specific comments on the jigsaw exercise. In 2009 and 2010, a qualitative prompt “Please indicate one thing you will do as a result of what you learned in this course:” was included. We searched responses to these general prompts for comments related to the jigsaw exercise. In addition, at the end of the week, the students took a 25-item knowledge test with items covering material learned throughout the week including an item about roles of LTPAC personnel. We also looked at the evaluation question of how successful the Clinical Core was in helping to achieve the learning outcome ‘integrate knowledge to solve problems outside the confines of a single discipline’ (2006e2007) or ‘develop clinical reasoning skills, integrating knowledge to solve problems outside the confines of a single discipline’ (2008e2010). We did this to compare the results of the Clinical Core on Aging to other weeklong required interdisciplinary professional development courses that were similar in structure and process during their same year of clinical training. The LTPAC personnel evaluated the experience the first 2 years the program was offered (2006 and 2007), through a questionnaire with quantitative Likert scale and qualitative items. The qualitative written feedback was in response to the following questions: “for next year’s program I would suggest the following changes,” and “other comments.” Additional feedback was also gathered through a focus group, which also served as a thank-you luncheon. All quantitative data from students and LTPAC personnel were summarized with descriptive statistics. The qualitative comments were read by 2 authors (GB and SP) and were categorized into positive or constructive comments. Then, constant comparative analysis was used to identify words or phrases that indicated key themes of how the participants perceived the learning experience.

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Results The jigsaw exercise was conducted annually from 2006 to 2010 with the same objectives. In each of these years, the curriculum was delivered to the entire class of medical students (approximately 100 students per year). Student Assessment Quantitative results The knowledge test results indicate that the students correctly identified the roles of members of the nursing home team following this experience. In 2007 and 2008, there were 4 questions that asked the students to match the role description with the titles of key members of the LTPAC personnel including medical director, certified nursing assistant, minimum data set nurse, and nursing home administrator. In both years, between 96% and 99% of students correctly matched certified nursing assistant and minimum data set nurse with their role description. However, in 2007 approximately 23% of students reversed the roles of the nursing home administrator and the medical director; the remaining students correctly matched the roles. There was a similar pattern in 2008 with 11% confusing the same two roles. In 2009 and 2010, with the nursing home administrator option removed, virtually everyone correctly matched the 3 role descriptions and titles in both years. The students self-rating of the success in achieving the learning outcome ‘define long term care and the scope of services it entails’ ranged from a score of 3.65e4.12 with a mean of 3.91. In 2006 and 2007, the students’ mean rating of the value of the jigsaw exercise in increasing their knowledge and skill development was 3.52 in 2006 and for 2007 was 3.56 (Table 1). In 2008 through 2010, the mean score for the question ‘how much did you learn as a result of the jigsaw activity?’ was 3.41 for all 3 years with the vast majority of the students reporting that they learned at least a moderate amount (Figure 2). The Clinical Core on Aging evaluation results were comparable to the Patient Safety, Critical Care, and Oncology courses (Table 2). Qualitative results Overall, the number of positive comments about the jigsaw exercise exceeded negative comments (71 positive and 34 negative). Each year, some students thought the jigsaw exercise was the most effective or valuable aspect of the week. One student wrote that the “Jigsaw puzzle was EXTREMELY HELPFUL.” Another said, “Jigsaw puzzle was unique and good way to learn different roles.” Another said, “Excellent and innovative activity. I thought that this was a tremendous learning exercise.” However, not all students have been enthusiastic about the activity. One student wrote “While the Jigsaw Exercise was informative, I did not feel that it was a particularly useful exercise. Several of the roles and positions discussed undoubtedly differ from retirement community to retirement community, while others could easily be discerned by their titles, or were

Table 1 Quantitative Results of the Jigsaw Exercise From the Students and Long Term Care Personnel in 2006 and 2007 Participant Type (n)

Question Asked

Average Rating on 5-Point Likert Scale (1 ¼ Worst; 5 ¼ Best) 2006

2007

Students (98, 100) LTPAC Personnel (14,13)

Value of session Was the exercise worthwhile? Were the students engaged? Did the students ask thoughtful questions? Was the time commitment manageable and appropriate? Was the discussion of appropriate depth and breadth?

3.52 4.7 4 4.29 4.57 4.43

3.56 4.77 4 3.92 4.25 4.50

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Fig. 2. Student responses to the question, “How much did you learn as a result of the jigsaw activity?” for the years 2008 through 2010.

already familiar to us as similar positions exist in other healthcare settings (ie, CNAs).” After reviewing students’ responses and identifying the positive and constructive comments themes emerged about learners’ perceptions of the jigsaw exercise. The first theme was centered around students’ perspectives on learning and the jigsaw method. Some students indicated their preference for a transmission (teachercentered) approach to learning. They seemed to have preferred a session where they would have been told about the roles of LTPAC staff instead of having to investigate and teach others about what they learned. For these students, the jigsaw method was ineffective because it took too much time and required much more work. One student wrote, “As much as the individual activities were interesting and helpful, and I recognize how much effort it takes to organize them, but they were varied in value and ‘bang-for-buck’ and I would have preferred for more concentrated lecture/panel time. which could have taught us the same amount, but led to more free time in advance.” Another wrote a similar comment. “While I appreciate the efforts made to not just give normal lectures, I don’t think the ways by which we were presented the material were very effective. Nor were they the best use of time. I think they only gave us a partial picture of the things we needed to know or that were the goals. Lectures covering the subjects comprehensively would probably have done a better job.” However, other students felt engaged and connected to what they were learning. One student wrote, “I really liked that we had many different types of activities so that we were not sitting in a lecture hall Table 2 Comparison of the Clinical Core on Aging to Other Representative Courses

Aging Patient safety Critical care Oncology

2006

2007

2008

3.79 3.74 Data Not Available 3.92

3.56 3.51 4.21 3.79

3.22 3.76 3.66 3.05 3.51 3.44 3.80 3.44 3.82 Course not offered

2009

2010

The data is the average rating on 5-point Likert scale (1 ¼ worst; 5 ¼ best) to the question how successful the Clinical Core was in helping to achieve the learning outcome ‘integrate knowledge to solve problems outside the confines of a single discipline’ (2006e2007) or ‘develop clinical reasoning skills, integrating knowledge to solve problems outside the confines of a single discipline’ (2008e2010).

all day. I also liked the personal aspect of meeting patients, meeting healthcare team members, etc.” Another said, “A wonderful activity because it allows us to speak with providers outside of our field and to understand the inner workings of the long-term facility.” For those students, the jigsaw exercise was effective in facilitating their exploration of the different staff roles in patient care in the LTPAC facility. The second theme was the students’ perspectives on the LTPAC learning environment. Students’ responses were mixed on how they perceived the effectiveness of this learning environment in teaching them about LTPAC. Some students perceived this to be a rich environment for learning. One said, “I really enjoyed visits to LTC facilities. It was very interesting and helpful for me to get some exposure to the experience of both patients and providers (of all types) in these settings.” Another said, “I actually did learn a lot about long term care facilities and the different services that go into taking care of elders. Going to the nursing home was helpful.” For others, the selected environment (a continuing care retirement community that included a nursing home) was perceived as not being representative of most LTPAC facilities, and therefore not an effective location to learn about LTPAC. One said, “I feel as though our vision of what LTC options are available was a bit skewed. It made me wonder what options patients who are not as financially stable have with respect to care.” Another echoed this sentiment. “I think that it is bad that we only visited upscale, expensive nursing homes. Many people in our class have never visited nursing homes before. I think that the facilities we saw skewed people’s opinions and people are likely to think this is how all facilities are. In reality, many of our patients will be in less than ideal, cheaper facilities. It would have been better to see one really nice one and one less nice one, so that we know what the reality is for patients.” The third theme involved students’ perspectives on what was learned through this activity/experience. Responses indicate that they learned about several aspects of LTPAC. As one student states, “I will be more confident about discussing LTC now with patients for whom it is a good option.” Another said, “I am now more aware of the general pathway that many geriatric patients follow, from living at home to assisted living to SNF to hospice. I was aware of these things before, but I still felt confused about how it all workedeI feel much more comfortable discussing these issues now.”

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They also valued “learning about the responsibilities of the other members of the healthcare team, and the importance of adequate communication between physician and other members.” The students came away with a better understanding of their role in the interprofessional team and the importance of interprofessional teamwork in geriatrics. One student noted the importance of, “Understanding the complexity of caring for older persons and the roles of different healthcare workers to achieve that goal.” Another student wrote, “Really enjoyed hearing what other healthcare professionals do and how we can better incorporate their expertise into physician’s teams. Learned a lot from those individualseabout what they did and how systems work (in and outside of the hospital).” Another said, “The jigsaw puzzle exercise was critical at explaining the different aspects of care that MD’s need to know about in order to function within a healthcare team/hospital system that refers to outpatient services/facilities.” Finally, they indicate having a better understanding of how they will be able to apply the knowledge acquired through this experience in the future. Several stated they would, “consider everyone on the team” when caring for a patient. One student wrote, “I will remember to respect all members of the medical team from environmental services to interpreters to nurses as we all play a vital role in caring for and treating patients.” And another said they would “engage nonphysician healthcare workers in an effort to provide the most comprehensive care possible.” Long Term Care Personnel Assessment The quantitative survey results are summarized in Table 2 and indicate that the LTPAC personnel viewed the exercise overwhelmingly positively. Importantly, they thought the time commitment for the exercise was manageable and appropriate and the exercise was worthwhile. The feedback from the first year prompted the interview time to be lengthened from 30 to 45 minutes. In the second year, most thought 45 minutes was the right amount of time for the interviews. In addition, 1 person felt that the experience should be made more clinically relevant to the students. She said, “This is a young population many of whom had never been to a nursing home facility before. So this was an eye-opening experience for them. I think we have to make it more real for them. The one student in my group who was the most engaged had seen elderly patients in the clinic and had been asked by one of her patients how he/she should go about finding a nursing facility. So the information the student received through this process was directly related to an experience she had had.” The recommendation was addressed by adding a case to frame the discussions. Feedback from the LTPAC personnel also indicated that they enjoyed the experience and felt it was a valuable use of their time. Representative comments were, “Really enjoyed time with students;” “Thanks for the opportunity.” Discussion Medical students are receiving insufficient LTPAC content; in 2013 only one-third had any exposure to nursing home care in medical school.4 Focus groups of third and fourth year medical students and internal medicine residents expressed a need to know more about the different sites of care, specifically home care, nursing homes, assisted living, and hospice, as well as the level of care required for each patient.8 In that study, 1 student was quoted as saying, “I was very grateful for the opportunity in Medical School to go into a nursing

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care facility or hospice care or go into patients’ homes.and see what happens at many different sites and therefore feel comfortable with the decision making process.”8 The authors concluded that there should be education in the process of care, which includes knowledge of a variety of care settings including home care, assisted living, and nursing homes.8 First-hand experiences with LTPAC settings such as the jigsaw exercise described here are one way to deliver this important objective. In addition, positive early exposure is important regardless of future specialization, as nursing home patients will interact with both generalists and specialists. In this application of the jigsaw method, informational interviewing as an instructional strategy was also employed, which has a number of advantages. Interviewing allows students to verbally interact with a direct source of knowledge, in this case enabling the students to directly assess the day-to-day tasks of LTPAC professionals. Interviewing also sensitizes students to cultures, attitudes, and beliefs of individuals and other professions that may not be accessed through a traditional lecture-based or textbook format, the increased value of which to an overall educational experience cannot be overestimated. In addition, interviewing puts students in an active rather than a passive role, thus enhancing learning.9 Finally, an informational interview assignment can achieve secondary goals of improving communication skills of the students, as well as their ability to organize and report data.10 In the application described here, the jigsaw exercise was generally well received by participants and provided an innovative and effective means to introduce medical students to the LTPAC setting. The comments and objective test items indicated that the students learned the concepts. Importantly, the students were motivated to remain engaged because of the structure of the jigsaw method. It is commonly said that one of the best ways to learn is to teach, and this seemed to be the case with the jigsaw exercise. Additionally, the nursing home visit was appreciated by the students and contributed to their learning. The addition of the faculty facilitator during the ‘jigsaw’ discussions was also found to be valuable. Because the exercise occurred during a single afternoon, the faculty facilitator was able to coach the students in the method, and to assess and correct any misconceptions. In this class of approximately 100 students, the jigsaw exercise proved to be an effective and feasible way to conduct small group discussions that engaged students and supported higher order thinking. Since each student and LTPAC professional was only required to participate in 1 interview, the method allowed the interview task to remain manageable for the LTPAC personnel and the students. In contrast, if each student had been required to interview each profession, the time commitment would have been burdensome for both the students and the LTPAC personnel. Beyond conveying factual knowledge concerning LTPAC, the scope of services it entails, and the roles of the various members of the nursing home team, the jigsaw exercise served to improve the students’ attitude toward teamwork, an important skill in today’s complex healthcare system. In fact, when asked what they would take away from the week, many students commented on respecting and engaging nonphysician members of the healthcare team. Cooperative approaches to learning as demonstrated by the jigsaw exercisedcompared with individualistic or competitive approachesdresult in increased student engagement, higher initial achievement and long-term retention of subject matter, more frequent use of critical thinking, and a greater likelihood of the transfer of learning from one situation to another.11,12 This is particularly important when the subject matter is unfamiliar to students (eg LTPAC topics). A strength of cooperative learning that makes it a particularly attractive teaching method for medical education, and in geriatrics and LTPAC in particular, is the emphasis on teamwork. In

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addition, cooperative learning promotes values central to professionalism such as a commitment to the common good, respect for others, integrity, compassion, appreciation of diversity, and a sense of responsibility to contribute one’s fair share.12 The importance of engendering these qualities in students is underscored by the standards that have been set by the Accreditation Council for Graduate Medical Education for physicians seeking postgraduate medical specialization.13 The competency of ‘interpersonal and communication skills,’ involves communicating and working effectively as member of an interprofessional healthcare team, an important skill in all of healthcare, but arguably even more important in geriatrics and LTPAC. The jigsaw method is one cooperative learning strategy. Just like a jigsaw puzzle, each student’s part is essential for the completion and full understanding of the final product. Each team member is valued by others because he or she provides a part of the lesson that is unattainable otherwise. Critical thinking and problem solving skills are fostered in the discussion portion of the jigsaw exercise that focuses on how best to communicate the material,5 leading to disclosure of each student’s understanding, as well as clarification of misunderstandings. The jigsaw method helps to develop a depth of knowledge not possible if students tried to learn all the material on their own. In addition, students are able to master the material in far less time, and experience the benefits of cooperative learning detailed above. Although the jigsaw exercise was evaluated with a mixed-method evaluation over 5 years, it still had a major limitation in lacking a control or comparison group. This precluded a definitive assessment of the exercise’s efficacy in imparting the LTPAC concepts, relative to that of a more traditional didactic educational approach. In addition, because of changes in the overall curriculum and evaluation strategies, the structure and content of evaluations questions changed over time. Our analysis also lacks measures of the ultimate impact of this experience on behaviors and practice of participating students. There were several students who participated in the jigsaw exercise who strongly objected to the seemingly inefficient use of their time, and in some cases expressed a preference for a traditional lecture. Research on cooperative learning shows that while it may be effective at increasing student engagement and increasing initial achievement and long-term retention of subject matter, it is critical that student buy-in is secured by clearly explaining the rationale for selecting particular teaching and learning approaches.11 Although we provided a 15-minute introduction to the retirement community structure and general aspects of LTPAC, we failed to provide the students with a specific rational for the jigsaw method, which might have dampened their objections.

Conclusions Exposure to LTPAC settings is currently insufficient and is important for medical students as the oldest old is the most vulnerable and fastest growing age segment of the older population and the population that will have an increasing need for LTPAC. Cooperative learning, of which the jigsaw method is a good example, is especially suited to medical education since it fosters teamwork, communication, critical thinking, and life-long learning, all essential characteristics of today’s physician. To ensure operative knowledge of the LTPAC setting, opportunities to dispel stereotypes, and appreciation for the interdisciplinary nature of care in this setting, the jigsaw exercise should be considered. Supplementary Data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.jamda.2014.01.015. References 1. Houser A, Fox-Grage W, Ujvari K. Across the states: Profiles of long-term services and supports. Washington, D.C.: AARP Public Policy Institute. Available at, http://www.aarp.org/home-garden/livable-communities/info-09-2012/acrossthe-states-2012-profiles-of-long-term-services-supports-AARP-ppi-ltc.html; 2012. Accessed September 13, 2012. 2. Medicare Payment Advisory Commission. Report to the congress: Medicare Payment Policy. Washington, DC; March 2012. Available at: http://www. medpac.gov/documents/Mar12_EntireReport.pdf. Accessed November 13, 2012. 3. Eleazer GP, Doshi R, Wieland D, et al. Geriatric content in medical school curricula: results of a national survey. J Am Geriatr Soc 2005;53:136e140. 4. Association of American Medical Colleges. Medical School Graduation Questionnaire 2013 All Schools Summary Report. 2013 [updated 2013]; Available at: https://www.aamc.org/data/gq/allschoolsreports/. Accessed August 9, 2013. 5. Aronson E, Patnoe S. The Jigsaw Classroom: Building Cooperation in the Classroom. 2nd ed. , New York: Longman; 1997. 6. Silberman ML. Jigsaw learning. In: Active Learning: 101 Strategies to Teach Any Subject. Boston: Allyn and Bacon; 1996. p. 111e112. 7. Shulman LS. A Union of insufficiencies: Strategies for teacher assessment in a period of educational reform. Educ Leadership 1988;46:36e41. 8. Drickamer MA, Levy B, Irwin KS, Rohrbaugh RM. Perceived needs for geriatric education by medical students, internal medicine residents and faculty. J Gen Intern Med 2006;21:1230e1234. 9. Stricklin D, Sharpless R, editors. The Past Meets the Present: Essays on Oral History. Lanham, MD: University Press of America; 1988. 10. Gaske PC. Informational interviewing: A targeted approach. Commun Educ 1984;33:404e407. 11. Millis BJ, editor. Cooperative Learning in Higher Education: Across the Disciplines, Across the Academy. Sterling, VA: Stylus; 2010. 12. Johnson D, Johnson R, Smith K. The state of cooperative learning in postsecondary and professional settings. Educ Psychol Rev 2007;19:15e29. 13. ACGME board. Common Program Requirements: General Competencies. 2007 [updated 2007]; Available at: http://www.acgme.org/outcome/comp/ GeneralCompetenciesStandards21307.pdf Accessed April 7, 2008.

Using the jigsaw cooperative learning method to teach medical students about long-term and postacute care.

Since many of the frailest and most vulnerable Americans reside in nursing homes, medical students need focused education and training pertaining to t...
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