Q 2009 by The International Union of Biochemistry and Molecular Biology
BIOCHEMISTRY AND MOLECULAR BIOLOGY EDUCATION Vol. 37, No. 3, pp. 137–143, 2009
Articles The Use of Contextual Learning to Teach Biochemistry to Dietetic Students* Received for publication, September 11, 2008, and in revised form, December 15, 2008 J. O. Macaulay‡¶, M.-P. Van Damme‡, and K. Z. Walker§ From the ‡Department of Biochemistry and Molecular Biology, Monash University, Melbourne, Australia, §Nutrition and Dietetics Unit, Department of Medicine, Monash University and Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia
This article describes the use of contextualized and ‘‘blended’’ learning to teach biochemistry to dietetic students during the second year of their professional training in a 4-year undergraduate degree (Bachelor of Nutrition and Dietetics). Contextualized content was used to engage students and motivate them to learn biochemistry, which many perceived as a ‘‘hard’’ subject. Contextualized learning presented via problem solving exercises, case-studies, and by the use of virtual subjects in laboratory class introduced content material through real life situations highly relevant to their later clinical practice. A ‘‘blended’’ curriculum where content was presented in a number of different modalities (on-line, on CD, or face-toface in small/large groups and in tutorials/lectures/laboratory class) further enhanced contextualized learning by providing a range of learning modalities catering to different student learning styles. The online and CD material also allowed student self-assessment of learning progress through interactive quizzes in varied assessment formats, where feedback was often immediate. Student responses to this biochemistry course have been positive with 89% finding it intellectually stimulating. Keywords: Blended learning, case studies, contextual learning.
University teaching has increasingly replaced the didactic lecture with more active learning modalities. These new modalities often require learning to be contextual, constructive, self-directed, and collaborative, and they engage students in the higher order thinking tasks of analysis, synthesis, and evaluation [1–4]. More active student-centered learning encourages deeper approaches to learning [5, 6] and can improve learning outcomes [7– 9]. Contextual learning greatly benefits students by placing their learning in relevant real life situations which is the way many of us learn best [3, 10]. Some common models used to contextualize learning are case-based and problem-based learning (PBL). In PBL students are presented with a problem that introduces content. This contrasts with more traditional ‘‘teaching by telling’’ approaches where presentation of facts and concepts occur before problem-solving is expected [11]. In PBL, the instructor offers guidance rather than knowledge during the learning process. As guidance fades with growing student confidence, student learning can be supported *This work is supported by Monash University, the Faculty of Medicine, Health Sciences and Nursing and the Department of Biochemistry and Molecular Biology. ¶ To whom correspondence should be addressed. E-mail:
[email protected]. This paper is available on line at http://www.bambed.org
by gradually adding realistic ‘‘real-world’’ components that are both authentic and complex [12]. Case-based learning (CBL) is a well-established variant of PBL, where a case study of professional relevance is presented to students. Case-based discussion provides an active learning strategy that engages students and fosters higher order thinking and problem solving skills [13–16]. PBL and CBL can readily be integrated with traditional teaching modalities including laboratory classes and data analysis exercises. Contextual learning can be additionally enhanced via a ‘‘blended’’ approach. ‘‘Blended’’ modalities bring together traditional face-to-face learning with on-line learning activities in authentic combinations that further facilitate student understanding. CBL and PBL are often integral components in ‘‘blended’’ modalities for science teaching [17–23]. Moreover, ‘‘blended’’ formats readily allow both collaborative group work and self-directed work, thereby improving students’ skills in teamwork, communication, leadership, organization, and time-management [18]. Online material can also help integrate in-class and outof-class learning and allows students to work at their own time and pace [18]. This article describes a 13-week single semester course (BND2021: Nutritional Biochemistry) that has been developed to teach biochemistry to second-year Australian dietetic students. Here, we describe the
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DOI 10.1002/bmb.20283
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FIG. 1. Placement of BND2021 within the four-year BND course. Subjects on a white background are linked most directly to teaching given in BND2021.
‘‘blended’’ nature of this subject and the contextual, student centered style in which it is taught. In addition, we report students’ responses to this method of teaching. In BND2021, our aim was to use contextual learning through CBL to motivate dietetic students to study biochemistry. Cases were developed to present metabolic and/or biochemical problems in practical, ‘‘real-life’’ clinical settings, highly relevant to students’ later practice. In BND2021, each case was designed to illustrate how basic biochemical knowledge is relevant and often drawn upon in a work place environment. Moreover, each case is situated in a learning context that integrates a ‘‘blend’’ of teaching modalities. Thus on-line material complemented and enhanced face-to-face lectures and tutorials, and was further supported with distributable print media and CDs. In this way, a range of interactive multimedia learning modalities and face-to-face learning exposures sought to enhance students’ problem solving skills and promote interactive, active student-centered learning [4, 24–28]. SUBJECT PLACEMENT WITHIN THE COURSE
BND2021 is a single subject taught in the first semester (13 weeks) of the second year of a 4-year undergraduate course (Bachelor of Nutrition and Dietetics (BND)) at Monash University (Fig. 1). The BND has been designed to graduate students as dietitians trained to base-grade level and has been accredited by the Dietitians’ Association of Australia (DAA). The first 2 years of the Monash BND seek to provide a firm scientific basis for the clinical and community-based training and placements given during the third and fourth years. In recent years (2007/ 8), students have been mainly female (94%), largely enrolling directly after high school (82%), and they included 44% (2007) and 31% (2008) whose first language was not English. Enrolment includes many students either currently residing in Australia or from overseas who come from different cultures, particularly those of China and South-East Asia. BND2021 is designed to integrate vertically with subjects given in the first year of the course (specifically in semester one with BND1010: Human Nutrition, an introduction to nutrients; and BMS1011: Biomedical Chemistry; and in semester two with BND1022: Food Chemistry
and BMS1062: Molecular Biology). Students therefore enter BND2021 having gained in their first year, some basic concepts in nutrition, biology, biological chemistry, molecular biology, and food chemistry. They have a general appreciation of the structure and function of macronutrients and micronutrients and are familiar with the basic pathways for protein, carbohydrate, and fat metabolism. BND2021 also integrates with other Year 2, Semester 1 subjects (specifically BND2011: Nutritional Physiology; and BND2031: Health Psychology for Dietitians). Moreover, BND2021 provides a platform for skill development in CBL and essay writing that is built on in BND2042: Nutrition and Immunology during semester 2. REASONS FOR INTRODUCING BLENDED LEARNING AND COURSE CONTENT
The BND course caters to a diverse population group for which blended learning was introduced to accommodate for the range of learning styles [3, 10] and to engage students at a higher level of learning [17, 19–23]. In BND2021, learning occurs in face-to-face lectures and laboratory classes with the entire class, as well as faceto-face in small student groups for tutorials and case studies and as individual self-directed learning and research (Table I). Material for the latter is made available either through a CD-ROM or via Monash University Studies on Line (MUSO) based on the Blackboard Vista 4.0 Learning System (Blackboard, Washington D.C.). Learning sites on the web are therefore restricted to students enrolled in BND2021 and to BND staff. Self-assessment is also facilitated via material placed on the web or through interactive material on CD-ROM (Table II). In BND2021, the face-to-face lectures provide the main framework for delivery of the core curriculum content. Although there has been much criticism of the didactic lecture, the lecture format has well-accepted benefits for student learning [29]. To encourage deeper learning, lectures in BND2021 aim to be less didactic than a conventional lecture and more student-centered [5, 6, 30, 31]. Moreover, in this integrated course, the lectures often emanate from case studies and encourage active participation and problem solving. This combination of didactic lectures with case orientated teaching has been reported to be favored by students [32]. All lecture notes
139 TABLE I Teaching modalities used in BND2021 Modality
Frequency
Lectures Tutorials
2 per week 1 per week
Case studies
1 per week
Self-assessment quiz Critical analyses
1 per week 2 per semester
Laboratory practicals Research project
2 per semester 1 per semester
Comment Given face-to-face with extensive lecture notes posted in advance on-line (a) With a tutor present (b) Self-directed learning from CD-ROMs (a) Face-to-face gradual exploration of a case with a tutor. (b) On-line case presentation with later face-to-face class questioning by a tutor. Revision notes available on-line after the case. (c) On-line case study with on-line quiz plus feedback and additional revision material. Given on-line with immediate electronic feedback Face-to-face tutorial on interpreting scientific writing Critique of nutrition websites (on-line plus paper based) Laboratory biochemistry practical classes (samples from virtual patients) Self-directed learning plus class presentations
TABLE II Case material used in BND2021 Case type Face-to-face in class On-line with face-to-face discussion and on-line revision All on-line or on CD-ROM
Case name
Priscilla Templeton Mrs Barton Don Morris Mrs. Lyons Thang Peggy Beecham Chris Tyson
What’s wrong with Elisa? Amy’s case Type 1 diabetes Type 2 diabetes
Learning issues Metabolism in fasting and starvation Vitamin B12 deficiency and pernicious anaemia. Blood lipids in diabetes. Vitamin C deficiency Malnutrition in the elderly. Multiple vitamin deficiencies. Iron deficiency anaemia in a toddler; red blood cell metabolism. Osteoporosis. Vitamin D deficiency Chronic alcoholism and micronutrient deficiency; effects of alcohol on metabolism Relation between carbohydrate, lipid and protein metabolism. Biochemical basis of clinical tests. Metabolism of bilirubin. Zinc deficiency and copper toxicity. Fuel metabolism, glycaemic control and blood lipids in type 1 and type 2 diabetes
(in power point format) together with audio recordings are made accessible to students online via MUSO. Via MUSO each lecture topic is linked to multiple choice and short answer questions in a self-assessment quiz. This allows for both formative and summative assessment as well as for revision before exams. Feedback and model answers are provided after students have submitted their answers online. The online quizzes allow students to assess their developing mastery of biochemical concepts and to obtain prompt and direct feedback on their performance in a nonthreatening environment. The use of such formative assessment, if it is of high quality, can have a strong positive effect upon student learning [33–35]. BND2021 also provides laboratory practical classes. These have been included to introduce students to a laboratory environment and to biochemical assays relevant to nutritional assessment as well as to data analysis and interpretation of results. In one exercise (adapted from Sadighi et al., [36]), students determine urea and creatinine levels in urinary samples matching them to and determining nitrogen status for virtual subjects following high, medium, or low protein diets. Students also carry out a 6-week research project on dietary fiber. This builds food knowledge and introduces students to dietary intake analysis and food composition software. Students keep a 7-day diet diary based on
household measures and analyze nutrient intakes using Foodworks (version 5.00, Xyris Software, Australia), an analysis program based on Australian food composition tables. In a face-to-face tutorial, students then collate class data for fiber intake, comparing it to the recommended daily intakes. After a discussion of possible food sources of dietary fibers, students are given time to individually design a 7-day diet that alters their dietary fiber intake by 65 g per day. Students follow their diet prescription for 7 days, while keeping a diet diary. A report discussing the effectiveness of their dietary change and summarising their reading on the metabolism of dietary fiber in health and disease is then written. This project is linked to a concurrent assignment in BND2031: Health Psychology for Dietitians where students reflect on the practical difficulties and feelings when making a substantive dietary change. These may include purchasing different foods, eating meals that are different from others in the household and having to eat foods that are less palatable than usual foods. In BND2021, students engage in several self-directed activities that allow students flexibility of pace, time, and place of learning. These activities include two in-depth tutorials compiled on CD-ROMs: Biochemistry-A Metabolic Challenge and Nutritional and Hormonal Aspects of Diabetes. The CDs are given to students at the start of the semester, although the material can also be
140 accessed electronically on campus via the Monash University server. Biochemistry-A Metabolic Challenge is based on a series of highly interactive tutorials covering fat, protein, and carbohydrate metabolism and their use as fuel sources for the body. Nutritional and Hormonal Aspects of Diabetes includes three main menus: ‘‘Introduction to Nutrition,’’ ‘‘Biochemistry of Diabetes,’’ and ‘‘Dietary Therapy for Type 2 Diabetes.’’ All use animated demonstrations and ‘‘click and drag’’ reaction sequences. Students assess their understanding of each topic via a range of assessment formats (Multiple Choice Questions, ‘‘click and drag’’ the correct answer, True/ False statements). Many of the assessments provide immediate feedback. Problem solving exercises are also included on the CDs to enhance students’ analytical skills. One for example, explains how metabolism differs in the ‘‘fed’’ or ‘‘fasted’’ state, leading students step by step, through a series of highly visual interactive problem-solving activities to explore the effects of starvation on the metabolism of macromolecules. Inter-relationships between pathways occurring in liver, skeletal muscle, and adipose tissue during the fed or fasted states are then compared and contrasted with tissue metabolism in Type 1 and Type 2 diabetes. A major teaching/learning component of BND2021 is the extensive use of case studies. These are based on patients of varied age, ethnicity, gender, and socio-economic background. The cases, timed to integrate with the lecture program, aim to revise and enhance students’ content knowledge and to help students integrate and contextualize biochemistry within their wider clinical learning. This contextualization of biochemistry by the use of integrated case studies was designed to stimulate interest in each case topic, motivating students to become actively engaged in their learning, and promoting better content retention. Three different types of case studies are used (Table II) all of which involve the students in active learning. The first comprise cases that are presented entirely face-to-face in small group sessions led by a tutor. Students receive parts of the case in sequential fashion, with time given between each to problem solve and discuss relevant issues. An example is the case of ‘‘Mrs. Barton’’ a 67 year old woman presenting with extreme tiredness. Part A outlines her medical history, dietary intake, and blood biochemistry results. Students are asked to identify abnormal results and suggest their possible cause(s). Part B presents Mrs. Barton’s biochemical results for several B group vitamins. After discussing these, students receive Part C outlining methods and results for a vitamin B12 laboratory assay which students are asked to interpret. Finally, Part D stimulates discussion on pernicious anaemia. The discursive nature of these case studies requires co-operative learning and allows tutors to readily uncover misconceptions and points of confusion. The second case type is made available to students in power-point format on MUSO. Each case includes a medical history, results of a physical examination, a diet history and nutritional analysis, anthropometric data,
BAMBED, Vol. 37, No. 3, pp. 137–143, 2009 results of successive biochemical tests, and a glossary of medical terms. Students are given 1 week to access the case online and to prepare responses to questions before attending a face-to-face tutorial. Again the discursive nature of these case studies allows students and tutors to uncover misconceptions and points of confusion. After the tutorial, detailed notes on all questions discussed in class are posted online allowing for thorough student revision and exam preparation. Formative self-review multiple choice questions relating to the case and to the review material are also posted for student self-assessment. In the third case type, case details and accompanying interactive activities plus formative or summative quizzes are presented either entirely on-line or on a CD. Model answers are provided after submission of answers. If students perform poorly, they are directed to relevant materials for further study. An example is ‘‘Amy’s case.’’ Part 1 introduces ‘‘Amy’’ a 42 year-old woman and provides an example of her strict vegetarian diet. Links then take students to Dietary Guidelines and articles on vegetarianism. Students are asked to comment on the diet and to complete a short on-line quiz. A nutritional analysis, given in Part 2, shows that Amy’s diet is deficient in calcium and zinc and students follow links to web resources on these nutrients. They also view an animation on zinc absorption and complete another on-line quiz. In Part 3, students find that Amy has addressed her zinc deficiency by taking zinc tablets in very large doses. Her symptoms after 1 year of self-therapy are presented in Part 4, with relevant biochemical results. After accessing further web resources and viewing an animation on copper absorption, students take a third on-line quiz. Part 5 then resolves and terminates the case. Students in BND2021 also complete two assessment tasks on critical analysis. The first aims to help students learn to read and evaluate scientific papers in the area of nutrition. Students are provided with edited sections (introduction, methods, and results only) taken from scientific papers published in high quality peer-reviewed journals. They are asked to explain in class discussion (without access to the abstract or study discussion) the study design, the ethical issues raised, and the results shown in various results figures and/or tables. In the second task, students visit designated websites on a single nutrition-related topic and apply a series of set criteria to assess them for: accuracy, authority, objectivity, currency, and coverage [37]. COURSE EVALUATION
Discussions with students and responses from questionnaires taken at the end of semester (Fig. 2) indicated that 89% of responding students found the unit to be intellectually stimulating and were satisfied (78%) with the quality of the subject. Student comments indicated that they found BND2021 relevant to their course as a whole and their profession and included: ‘‘this is a very exciting subject which will be very beneficial in the future for other subjects and in my career’’ and ‘‘this was a great subject very relevant to the course.’’ The majority
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FIG. 2. Responses (highly agree/agree) to BND2021 by students at the end of semester as revealed by a CHEQ questionnaire. (a) I found the unit [subject] to be intellectually stimulating; (b) Overall I was satisfied with the quality of the unit [subject]; (c) The content and objectives of the unit [subject] built upon previous units in the course; (d) I found the resources provided by the unit [subject] to be helpful. The questions are taken from unit evaluations performed on all courses taught at Monash University. They are collected at the end of every teaching semester by the Centre for Higher Education and Quality (CHEQ), Monash University and are available at the following URL: http://www.adm.monash.edu.au/cheq/evaluations/ unit-evaluations/index.html.
(96%) also found that BND2021 built well upon previous subjects (Fig. 2). Students responded particularly well to the participatory (active learning) and ‘‘blended’’ nature of BND2021 as revealed by comments: ‘‘the variety of types of work were particularly good’’ and ‘‘the tutorials and small group sessions were very beneficial.’’ Many students commented favorably on the case studies. They indicated that cases enabled them to focus on the relevance of biochemistry to their future profession, developed their understanding of topics and enabled them to appreciate how information from the lecture component of the subject could be applied to
clinical issues (Table III). Comments included: ‘‘cases were extremely relevant’’ and ‘‘I found the cases to be important because they allowed us to apply knowledge that we learnt.’’ Cases were thus regarded as a positive component of the students’ learning (Table III). The computer-based case studies with accompanying face-toface tutorials were reported as very enjoyable learning experiences that encouraged self-directed learning and gave students confidence and satisfaction in their own abilities. Many (36%) preferred this case style for the opportunities given for more flexible learning. Another large group (50%) however, preferred tutorials given face-to-face with access to the expertise of a lecturer/ tutor while 14% displayed no preference for either case type. The difference in these responses points to the importance of catering for a range of learning styles within a student group. In considering the modes provided for self-assessment, students reported the online quizzes to be a valuable tool giving them the opportunity to test their understanding of the lecture content through multiple choice questions, short answer questions, and feedback comments. The quizzes also reinforced concepts that were particularly important to understand. Regrettably, as the BND is a new curriculum, we have not been able to assess whether there are improvements in learning compared with a conventional lecture course. DISCUSSION AND CONCLUSIONS
We all have preferred learning styles [3, 10, 38] but also use a range of different learning methods. The multiple modalities for learning provided in a ‘‘blended’’ course readily caters for different learning styles. In BND2021, we allow for diverse learning needs by varied methods of teaching delivery and by integrating in-class and out-of-class learning. Our use of an integrated blend of contextual components helps assist students to apply their knowledge, to master and integrate biochemical concepts that are fundamental to understand the metabolism and to appreciate the relevance of biochemistry.
TABLE III Student responses to questions related to learning in the case studies Case study Question
Response
Type 1 (%)
Type 2 (%)
The case studies enabled me to appreciate how information from the lecture component of the unit could be applied to clinical issues.
Almost always Much of the time About half of the time Occasionally Hardly ever Very broadly within the topic In most areas of the topic In two areas of the topic In one area of the topic Minimally within the topic I strongly agree I agree for the most part I am undecided I disagree for the most part I strongly disagree
24 59 10 3 3 14 55 31 – – 24 66 10 – –
17 59 10 10 3 14 52 24 10 – 17 66 14 3 –
After participating in the case studies, my understanding of the topic developed.
The cases have been a positive component of my learning experiences in the BND course so far.
Data are expressed as the percentage of students responding (26 students from a class of 30 students completed the questionnaire). Type 1 case study: entirely face-to-face in small group sessions led by a tutor. Type 2 case study: students are given one week to access the case online and prepare responses to questions before attending a faceto-face tutorial.
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‘‘Blended’’ learning thus motivates their knowledge acquisition and can deepen the quality of their learning. Acknowledgments— The authors are grateful for the input of all colleagues who have been involved in the development of the programs. Foodworks can be accessed at: http://www.xyris. com.au/professional/default.htm Readers interested in access to the CDs: Biochemistry – A Metabolic Challenge and ‘‘Nutritional and Hormonal Aspects of Diabetes’’ or any other resources described in the paper should contact the Corresponding Author.
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