Collaborating to Create Narrative Case Studies

• By Elizabeth M. Torcivia, Meryl M. Picard, Paul Younghouse
• 12/21/01

Several disciplines use narrative case studies to enable students to explore professional roles and experience decision-making and case-based reasoning before entering their fields. Here, we learn how Seton Hall University’s Curriculum Development Initiative has fostered collaboration among faculty and instructional designers to create effective multimedia case studies for students in occupational therapy.

The skill of keeping clients at the center of medical problem-solving is critical for all health professions. To maintain humanism in medicine, foster patient compliance, and improve treatment outcomes, future health care providers must be exposed to “whole” people during their training. The pressures that reduce practice to diagnostic problem-solving are of special concern to occupational therapy practitioners, for whom client-centered treatment has historically been the norm.

Interactive Multimedia Case Studies

Thanks to funding made possible through the Curriculum Development Initiative at Seton Hall University, we are now developing four case-based scenarios to use in teaching clinical reasoning to entry-level occupational therapy graduate students. These case studies focus on multidimensional people rather than conditions. They involve clients who fall into specific diagnostic categories, and they can be used across a curriculum to build increasingly sophisticated clinical reasoning skills. By using multimedia tools to present clients as “whole” people, we can help students develop multifaceted reasoning skills.

The goal is to give students a sense of the underlying factors that affect health care intervention and outcomes. Because a multidisciplinary team of doctors, nurses, social workers, and therapists provides additional information about each client’s story, the cases have excellent potential to be used in other health care fields.

Using an interactive platform—such as HTML-based Web pages or pages created using an application such as Macromedia Inc.’s Director—provides an effective solution for developing learning materials that enhance a case-based approach. These enhancements are designed to keep the “whole” person at the center of our process for teaching clinical reasoning.

Narrative Reasoning as a Clinical Skill

Narrative reasoning, an important part of clinical reasoning, involves pulling together the threads of an individual’s life story. This process allows the practitioner to understand how the client experiences the illness or disability and to develop interventions that will improve client outcomes. Traditionally, text-based case studies have been used to promote the development of clinical reasoning in students. Instructors created cases from the literature of the profession or from their own clinical experiences. Text-based cases generally included diagnostic facts and data, as well as sample assessment forms and procedures for using evaluation tools.

However, relying on diagnostically oriented, text-based cases has led to a conflict between a diagnosis-based pedagogical method and the theoretical emphasis in occupational therapy on the client’s occupation, environment, and adaptation. Although education for health professions is typically based on scientific data about disease states and interventions to alleviate dysfunction, occupational therapy students are taught a holistic framework for using activities and daily life tasks (in self-care, work, and leisure) to promote wellness, lessen or eliminate dysfunction, and enable individuals to adapt to life changes.

An Interactive Approach to Teaching Narrative Reasoning

Text-based cases give students clinical information about the diagnostic features of disease and disability. Yet the clinical facts, even with a detailed written narrative, can’t substitute for an examination by students of the specific personal features of individuals with disabilities and how those features influence the outcome of medical or therapeutic intervention. Diagnostic information is also limited to the facts about the client; it d'es not allow students to examine their own beliefs or attitudes regarding the client.

Rather than attempting to describe all of the concrete details of a particular individual’s environment and daily activities, adopting a multimedia approach gives us a means to show places and moments in an individual’s life in sufficient detail to make them effective simulations of a person’s real situation.

We make such case studies interactive by presenting examples of a prototypical client performing daily activities in particular situations. To produce these scenes, we imagine situations in which several factors affecting the success of clinical intervention might come in to play, and then stage a series of vignettes, usually between the client and his or her family members, or between the client and a member of his or her health care team.

For example, in our first case study, one of the instructional activities addresses the self-care needs of a middle-aged man who is unable to use his legs due to multiple sclerosis. Clinical reasoning in this case g'es beyond the obvious need for a wheelchair; students must also incorporate knowledge and understanding about the roles of his caregiver and the changes necessary in his home environment. Body type and size, cultural expectations, income parameters, sources of help, and financial constraints all go beyond what can be conveyed effectively in a text-based case.

The vignettes have been developed to enhance the student’s understanding of the interpersonal and environmental impact of illness or disability in the context of the client’s relationships. We anticipate that each of the case studies will be incorporated into the teaching materials for multiple courses, with the portrayals of human interactions in the vignettes intended to “humanize” the concepts being taught.

The goal of using case study methods is to draw students into the role of therapist. The immersive aspect of interactive multimedia presents case information across multiple senses (sight and sound) and makes the case more compelling, because a multimedia presentation creates a convincing world in which, for example, this client and his wife might be having a discussion of their problems while eating lunch in a favorite restaurant. Students can “overhear” the client express his fears about recovery, his uncertainty about the progression of his disease, and his anxiety that life roles that are of special importance to him (teacher, traveler, gourmand) will be disrupted.

Instructional Use of Interactive Multimedia Cases

Instructors in other health care professions sometimes bring in either actual clients or actors hired to portray clients. Although this method may be effective for some aspects of developing therapeutic skills (such as interviewing), it also has limitations. Beginning students, for example, require additional time to reflect on how they apply their clinical practice skills as they listen to client responses.

Multimedia case studies open opportunities for instructors to model alternative queries, choices, and hypotheses. Further instructional opportunities come from exposing students to the decisions their classmates made about the case. How students approach each case is as critical as how they answer the assignment issues.

Each student is given a copy of the case studies, in Web page format, on a CD-ROM. They are taught the mechanics of searching the disc for the information. Each Web page has a series of navigation buttons that reflect the scope of occupational therapy practice for each client (see Figure 1, page 27). Case information includes areas such as self-care, work, leisure, documents, Web links, and “his story.” In our first case study, there is a vignette between the client and his wife, as well as an interactive floor plan of their home.

Figure 1: Using the case study CD-ROM, students can navigate through various aspects of the client’s life, including information about self-care, work, and leisure.

Students will be given assignments related to one of the case studies. For example, one assignment might be to assess the ability of the client in the first case study (J'e Remora) to return to his campus office. They will need to consider his ability to travel to campus or on campus (by manual wheelchair, power wheelchair, or motorized scooter); his fatigue level; how he will manage bathroom access and obtain his meals; whether his office, classroom, and meeting spaces are wheelchair-accessible; and whether the technology in his office and classroom needs to be adapted. Should he consider teaching his courses remotely, using distance learning technology? Although these issues could theoretically be conveyed in text format, the reality of looking at video clips of this individual and his ability to get in and out of his car will influence students’ choices of intervention strategies.

The CD format allows the use of the same case in different classes to explore various facets of the person’s life. For example, J'e’s case could be used in a first-year course on psychosocial occupational therapy so students can begin to address the facets of depression, adjustment to disability, and changes in family relationships and life roles. J'e might then be seen again in a rehabilitation course in the second year to address the medical issues of multiple sclerosis. Students at this level should be able to start integrating psychosocial and physical issues to create a more holistic view of the person.

A related assignment might focus on the occupational therapy needs that would be addressed by a home health therapist, including the potential time constraints imposed by a third-party payer.

In the third year, students might revisit J'e in an adapting environments course to focus on his low and high assistive technology needs at work, in his home, at leisure, and for his ongoing transportation. Each time students return to the case, instructors would require students to demonstrate increasingly complex clinical reasoning skills.

The Collaborative Process

Developing these complex case studies requires collaboration among several faculty members with appropriate professional training and significant clinical experience, as well as expertise in instructional design, information technology, multimedia production, and content. Seton Hall’s Teaching, Learning, and Technology Center, which administers our project, assigned a specific instructional designer/faculty consultant to the project for the life of the grant. Having one person committed to the project has been integral to its success.

The instructional designer’s role is to guide faculty members through the planning and production of the teaching materials, striking a balance between sound pedagogy and the allure of new technologies. The goal is to make appropriate use of technology to fulfill instructional objectives, using technology that is available on campus, even as it evolves. This approach keeps planning open and responsive to developments on both sides of the collaboration as the instructional designer learns more about clinical reasoning in occupational therapy and faculty members learn more about instructional uses of technology.

The instructional designer volunteered to become the actor in the first case study. As he immersed himself in the narrative details of the case, his involvement fostered a close working relationship with our team. In turn, this “insider information” prepared him to question the faculty about more specific learning objectives, suggest choices among possible media presentations to meet those objectives, and facilitate the decision to deliver the cases through a Web-based platform.

Subsequent cases have begun their life cycles during brainstorming sessions. Such sessions use the template developed in the first case to structure the narrative information that will be provided. Cluster diagrams, created with Inspiration software, are used to develop the key instructional issues for the cases, show relationships, and highlight character conflicts (see Figure 2). Decisions about multimedia use are made at this point, and a production schedule is established.

Figure 2: Cluster diagrams are used in the development of new case studies.

The production process is not scripted. Key issues, important relationships, and critical incidents are explained to the actors, but idiosyncratic character development and spontaneous dialogue are encouraged. Monologues and dialogues are created, rehearsed, and videotaped or audiotaped. In addition, we videotape environments and activities associated with those environments.

For the first case, we produced a floor plan of the client’s house and shot short video clips of those spaces. The video clips have been integrated with the floor plan in the resulting Web page. Clicking on the name of a room launches the media player to present a moving image of that room, or movement from room to room (see Figure 3).

Figure 3: Students click on a floor plan to activate video clips of the household.

The project has been shaped by a willingness to look critically at media materials as we generate them and to recognize when additional pieces are needed to present other features of the multidimensional character and his or her complex narrative. This has generated a collaborative partnership between two key segments of the academic community—faculty and instructional designers—to the benefit of all.