The results from our analysis led to the identification of several common experiential threads that link individual facilitator’s experiences together. This coding tree included:
- Positive engagement and interaction with students
- Powerful educational tool
- Identity shift: educator to facilitator
- Time commitment relative to didactic teaching
- Shared space, planning and logistics
- Institutional approach to facilitator recruitment
- Concerns about standardized student experience/ anticipation vs reality
- Importance of the quality of supporting resources
Each thread is explored in more detail below, however in accordance with Smith et al. (18 (pg.117)) the results and discussion have been merged.
Positive engagement and interaction with students
Participants consistently reported enjoyment and fulfilment from their role as a facilitator. This was associated with the increased proximity and opportunity to interact authentically with students, which facilitators described resulted in positive engagement at both a personal and academic level. This fulfilment influenced their overall experience of the transition from didactic large group lecturing to CBL facilitating, and led to them narrating an overall positive experience, with the vast majority agreeing they would participate in CBL again.
Faculty spoke of a renewed appreciation of the learner’s perspective, student’s professionalism, and ability. They reported sessions as fun, enjoyable and interesting. They also commented on how enthusiastic, engaged and insightful the students were.
So I think it really brought home to me how enjoyable and how important teaching is. Getting to know the students, getting closer, and I enjoyed that’ (ID 2, male, non-clinical, 20+years teaching).
‘I love working with students and I love to meet them and I love the diversity... [sic], I really have faith in medicine when I see how smart they are... [sic]. And I always love engaging with them.’ (ID 6, female, non-clinical, 9 years teaching)
It’s nice to walk around campus and to see students [sic], that you recognize them and they’re not, you know, a tiny face, and from a large lecture theatre you cannot know who they are. (ID 1, male, non-clinical, teaching 17 years)
Powerful educational tool
Similarly to Burgess et al. (14), facilitators in this study acknowledged that for the system to work it was important to remain cognisant of their role being that of a facilitator, using facilitation methods as opposed to didactic methods. They reflected on the shift from large group lectures with mostly passive students to facilitating active learning and expressed their belief in CBL as an effective educational approach. Some suggesting they believed it was a stronger model from which to learn and others that it was complimentary to lectures. In our study most facilitators felt it was transformative for students and believed that active learning would promote retention of knowledge, this aligns with Thistlethwaite et al. (2), whereby teachers perceived CBL to motivate students. Two of the clinicians noted their sense that students benefit from earlier exposure to clinical terminology and healthcare practices and structures as a result of the authentic clinical narratives embedded early in the programme. Some facilitators described how the CBL experience allowed their own personal development with the opportunity to learn new or revisit content during the case also. They found that they came away with new or refreshed information, skills and insights.
‘The thing is, ... it was an [sic] active thing....I'm hoping that [sic] it should be easier to remember [sic] than something they heard in [sic] a half asleep lecture.’ (ID 1, male, non clinical, teaching 17 years)
‘It's about, you know, using all the methods you have and I mean, I still think, you know, there is a role for lectures....this (CBL) is certainly richer, I think they're more likely to get a deeper understanding of it.... I think they'd probably be more comfortable in the culture of practicing medicine than I think they would have been previously’ (ID 8, male, clinical, 30+ years teaching)
Identity Shift: educator to facilitator
Participants/interviewees found it difficult to answer if their role as facilitator resulted in an identity shift. The most resounding opinion amongst interviewees was that the role created benefits and opportunities which contributed to their perceptions of themselves as teachers.
Some facilitators felt a sense of increased confidence in their professional ability due to how well they transitioned and adapted to the new role. Some experienced staff also noted a greater awareness of teaching skills that they had forgotten they had. Facilitators with varying levels of experience discussed the new skills and techniques they had learned from this experience that they thought would enhance their teaching style for other academic and teaching roles. For some the experience of succeeding while initially feeling outside their comfort zone resulted in increased confidence in trying new pedagogical approaches. They did not acknowledge a shift in personal identity with this experience but did repeatedly express the positive benefits they felt from the social interaction with students. They believed that they would be aiding retention of knowledge for students also acknowledged that their CBL sessions were a reminder of how much they enjoy teaching and the skills and adaptability they have or acquired, which gave a sense of satisfaction and pride.
‘Overall I have learned new skills and learned more about anatomy and physiology… so new things are always good. You know you get bored of giving the same lectures and same tutorials.’ (ID 6, female, non-clinical, nine years teaching)
‘you know learn about each other and [sic] collaboration, respect… all that kind of stuff.
But [sic] for my own teaching, I'm thinking this year to do a little bit more of…, maybe once, a flipped classroom.’ (ID 5, female, non-clinical, less than 1 year teaching)
‘I suppose, you know, regaining some confidence, maybe that I had lost myself’ (ID 10, female, non-clinical, 15+ years teaching)
Time commitment relative to didactic teaching
As with some previous studies mentioned in the introduction (11); (12); (13) facilitators reported concerns about the time commitment to CBL preparation and delivery. Each CBL case required four separate sessions of 90 minutes student contact time (totalling 6 hours per small group of students). Some facilitators felt it was an excessive workload, in terms of preparation time and session time. Some experienced faculty believed that due to their experience and resources which they had honed over their careers, didactic lecturing is much more efficient for large class sizes. Other comments focused on the length and content of a case which varied at times, raising concerns about standardization of cases and unnecessarily giving each case the same allotted time, regardless of need.
‘I was sitting there at home at 8PM [sic] checking emails and doing the tasks that I missed during the afternoon [sic] (due to facilitating CBL sessions).’ (ID 3, female, non clinical, 10 years teaching)
‘Sheer amount of time you have to devote to it.’ ‘You have to put a lot of preparation into teaching. Umm, but as you become more experienced, you kind of know everything off by heart and you don't. So I would say at this stage in my career, I had to put very little, very little preparation into teaching lectures.’
(ID 9, male, non-clinical, 15 years + teaching)
Shared space, planning and logistics
The teaching space available for CBL was not designed for small group teaching and therefore several groups shared a larger space, resulting in disruptions such as noise and movement from other groups. Some facilitators reported a sense of professional exposurein the shared space; being seen and possibly overheard by other colleagues making them feel vulnerable in their new, unfamiliar role, particularly at the start of CBL implementation. However, a positive aspect noted as a result of this shared communal space was a sense of support, collegiality and increased interaction with other facilitators. Many reported that through the shared experience of the training and the CBL sessions themselves they felt part of the ‘CBL club’.
Through increased student engagement there was a greater awareness of the impact of scheduling in relation to other programme commitments, and the need for more student-centered approaches to scheduling. Timetabling issues occasionally meant that some cases were on topics the students still had to cover later in the curriculum, such as the foundational sciences underpinning the disease or symptoms which some facilitators found made for more challenging sessions. Occasionally CBL sessions were scheduled on exam days where the student’s energy was focused elsewhere. Facilitators also commented on the need to balance out the sessions with some sessions requiring more time than others and some feeling repetitive.
Facilitators believed there was benefit to be gained from continuity of the facilitator for all sessions, believing it allowed the student–facilitator relationships to grow and meant both sides had clearer expectations of each other. There were occasionally last minute changes in facilitators availability due to other commitments which meant available facilitators had to combine student groups and work significantly harder with larger groups which they found challenging.
‘So it was quite, …,kind of, collegial and yeah.....there was also a sense that if you were running into trouble in whatever, since there was somebody that you could call on in the room and that was, that was good too’ (ID 10, female, clinical, 15+ years teaching)
' and the noise was very difficult with that quiet group....[sic] because you don't want to keep asking them to repeat.’ (ID 10, female, clinical, 15+ years teaching)
In relation to last minute changes and group increase in size, increased responsibility due to same: ‘I suppose it,… it disrupted my happy little life at the time.’ (ID 2, male, non-clinical, 20+ years teaching)
Institutional approach to facilitator recruitment
Recruitment of facilitators for the new CBL sessions consisted of voluntary sign-up of existing faculty and this approach was a common thread though with conflicting opinions from those engaged in the study. Some facilitators suggested there was a sense of obligation to participate, particularly those at earlier career stages. Some felt it infringed on time for other academic responsibilities. Some believed this commitment was potentially at the detriment of their own career’s progression as it took time away from writing grants or undertaking research. The voluntary approach meant some expressed a sense of unfairness that not all faculty had the same CBL teaching workload. However, these feelings were juxtaposed with a personal interest in exploring the teaching approach and describing enjoyment from the engagement. A belief was also expressed that embracing a new teaching approach may benefit future promotion prospects.
Concerns were expressed about the sustainability of the CBL model at the institution because it requires a large voluntary time commitment from the same cohort of dedicated faculty, resulting in some mixed feelings about involvement in the CBL approach.
‘It's a very good opportunity for people early in the(ir) [sic] career to actually get a bit of teaching experience, even though it's not, you know, classic teaching, but at least you can build up your skills and … can actually say…I've done a couple of cases’ (ID 5, female, non-clinical, <1year teaching)
‘(Others) [sic] don't put themselves forward for these things… and that's very unfair. And if you're somebody like me who would like to progress and be promoted and so on, you feel you have to do these things and you have to say yes…, but there's other staff that just are ‘Let's not do it.’ And that's very frustrating as well because you're kind of saying, well, I don't get time to do research or write grants because I'm teaching for no real recognition.’ (ID 6, female, non-clinical, 9 years teaching)
Concerns about standardised experience: anticipation vs reality
Facilitators’ awareness of their diverse backgrounds and differences in breadth of expertise, led them to express concerns about the potential impact on the student experience. One non-clinician believed that not being a subject matter expert may have been beneficial because they felt more likely to ask open questions which they believed opened up student interactions. Another discussed how students did not look to them to answer questions, and having a broad fundamental science background meant they were not concerned about their clinical status. However, the vast majority of non-clinicians commented that lack of expert knowledge of the case impacted their confidence to guide or draw boundaries on discussions. Occasionally the cases covered clinical skills, such as interpreting an ECG, a concern when facilitators were non-clinical. One facilitator reported overhearing a clinical expert working with a group nearby, which left them feeling the student experience was varied and potentially unfair for students.
On the other hand, faculty with clinical backgrounds had concerns about students having higher expectations of them. Overall, both clinicians and non-clinicians described an initial sense of discomfort at the potential of not being a good enough facilitator.However, as their experience with CBL increased this concern reduced. The greater their experience of CBL the more they came to appreciate the core skills and knowledge they did have to offer. They were aware they gravitated towards their own specialty when the session allowed, but also noted their overall confidence improved with increased experience of facilitating sessions.
Prior to commencing facilitation, there was a recurring theme of concerns and potential discomfort about managing student engagement and interactions or dealing with group dynamics which echo similar concerns highlighted by Nordquist et al. (4), but for the most part when actually facilitating sessions these concerns did not come to light with the interviewees and any that did were manageable. They expressed awareness of the need to sensitively deal with different students and to use prompts and silences to encourage engagement. Facilitators believed having the same group of students repeatedly worked well and, enabled references to be made to earlier cases and previous discussions, resulting in stronger relationships and deeper student insights.
‘You don't need to be a subject matter expert, but I actually found as you go in not being a subject matter expert actually is probably a benefit here because you can throw out hypothetical questions and get discussions started when there is seemingly a lag in discussion.’ (ID 4, male, non-clinical, 3 years teaching)
‘I suppose I was conscious that you've got these undergraduate students who think that everybody who's teaching them knows everything [sic]. You know, there was a lot around one of my areas of specialty. So I kind of was really getting into my groove there in terms of the content, but also the fact that I was more relaxed as well.’ (ID 10, female, clinical, 15+years teaching)
‘I think my biggest concern was what happens if you’re there for 90 minutes with a group who just don’t do anything and then how do you keep the momentum going for that length of time?...but you know, I couldn’t have been more wrong.’ ID 1, male, non-clinical, 20+ years teaching
Importance of the quality of supporting resources
The case materials and documents that supported CBL implementation were highly valued and helped to ensure clarity on the direction of discussions as well as standardised outcomes. Facilitators gave tips for successful facilitation that included following the brief, completing the training and using the handbook. The ‘Facilitators Case Handbooks’ in particular were noted as often relied upon for knowledge content and were for the vast majority highly rated and valued. One facilitator mentioned relying on the Facilitators Handbook heavily, at times allowing the students to view it when this facilitator did not feel they had the expertise, knowledge or understanding to verify the students’ answer. This same facilitator mentioned the importance of the key learning outcomes summarised for each session, which they believed was important to increase confidence that the most important content was sufficiently covered. Interviewees also commented on the benefit of the pre-implementation in-person facilitator training sessions, particularly the training workshop where participants role-played a typical CBL session.
‘Reading the handbook was really my go to.’ ‘And I actually found myself showing the students the handbook, so saying, you know, OK, well, you don't seem to get this.
This is the answer I have and you know, so maybe this is what you need to know.’ (ID 6, female, non-clinical, 9 years teaching)
‘…the high-level things are the quality of the documentation that really supported the facilitation. You know, I was blown away by that…. You know, if I ever have to develop something, … I feel that I have a gold standard against which to (compare) [sic], so from a learning perspective, for me that was really, really good.’ (ID 10, female, clinical, 15+ years teaching)
Commenting on the facilitator training workshop where participants role-played a typical CBL session: ‘You know, it became life for me, and I think I got it then, that really changed my perspective on it (ID 2, male, non-clinical, 20+ years teaching)