Collaborating to Create Narrative Case Studies
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.
