Teaching Strategies Promoting Active Learning in Healthcare Education

Amy T. Russell, Tarrant County College, Texas, atrussell10@sbcglobal.net

Robert J. Comello, Midwestern State University, Texas, robert.comello@mwsu.edu
Donna Lee Wright, Midwestern State University, Texas, donna.wright@mwsu.edu

Abstract
Expanding technologies for clinical practice increase the amount of content that
healthcare programs, such as Radiologic Science programs, must cover.
Educational technologies provide opportunities for new approaches to education
delivery, including a shift to student-centered, active learning activities. This
literature review reveals that strategies such as questioning techniques, selfdirected learning, concept mapping, problem-based learning and case-based
instruction are used by educators within several allied health programs to promote
active learning and encourage students to become critical thinkers and problem
solvers. In cases with problem based learning curriculums, the instructor has a
minimal role in student direction. Radiologic science educators should consider how
to best incorporate these active learning strategies into their teaching.

Introduction
Over the past years, the health care system has undergone rapid and
unprecedented change because of a diminished life span of useful information and
an increasing complexity of practice.1,2 Specifically, many technological
advantages have been made in radiologic science such as digital and computed
radiography and Picture Archiving and Communication Systems (PACS). Because of
the increase in the amount of information to learn in a relatively short period of
time, educators have to reconsider their teaching strategies to meet the demands
of a new health care system.3,4 Educators agree lasting improvements in the health
care delivery system will ultimately depend on changes in the education of those
who provide the care.5-9 Radiologic Science Educators must help students develop
critical thinking skills and encourage problem-solving abilities through nontraditional methods of active learning.10 Active learning helps educators shift from
a teacher-centered to a student-centered approach,7 which can foster
independence in learning, creative problem-solving skills, a commitment to life-long
learning and critical thinking.8

The CINAHL, Medline and Health Source: Nursing/Academic Edition databases were
searched using the following key terms: active learning, self-directed learning,
teaching strategies and teaching techniques. Only articles from peer-reviewed
scholarly journals were included. Although very little research exists on active
learning in the radiologic sciences, the strategies and techniques reviewed from
nursing and other healthcare areas can be applied. Most articles were published
within the past five years, although older articles that had special significance to the
topic were also included. The final yield was over fifty relevant articles.

Active learning helps promote critical thinking and problem-solving abilities.8,11-19

Characteristics of active learning include student involvement through more than
just listening, emphasis on developing cognitive skills, student engagement in
activities such as reading, writing and discussion, and a greater emphasis on
exploration of a students own attitudes and values.19 Active learning means
students will take greater responsibility for their own learning and become more
involved in the educational process. Active learning methods help students move
away from being spoon-fed facts and figures to developing concepts,
understanding principles and applying knowledge in clinical work.20-21 These
methods leave students with a greater level of knowledge and better learning
skills.16

Lecture
Even with so many teaching strategies, the oldest and most widely used method in
classroom teaching today is the lecture.4,16 The lecture has many advantages
including the ability to provide information to a large number of students,16 the
ability to cover a large amount of material quickly,15 and provide cost
effectiveness and efficient use of class time.21 The lecture is a way to introduce
new material, continue discussion of a topic, and sum up course content, as well as
present large blocks of complex and confusing information.20 On the other hand,
lectures provide less opportunity for students to process information and develop
problem-solving skills, they lose students interest quickly and lack an opportunity
to provide feedback, do not allow students to skip content they know or work at a
self-directed pace and promote a teacher-centered environment instead of a
student-centered environment.18,22 Unfortunately, lecture allows students to be
passive learners, depending solely on the faculty to teach them information instead
of actively involving themselves in the learning process.11,15,16,18

Questioning Strategies
Educators can use questioning strategies to develop critical thinking, decision
making, and problem solving in students.23 Because questioning techniques are a
key part of active learning,17 Blooms taxonomy of the six levels of cognitive
learning can be used to provide a framework for constructing questions.24 Blooms

taxonomy moves from the simplest level of learning (knowledge) -- to the most
complex level (evaluation). The words used to construct a question will determine
the level of the answer. For example, asking a student to define Intravenous
Urogram, (IVU) would test his/her knowledge level. Asking a student to assess a
request to perform an IVU on a patient allergic to iodine, on the other hand, would
test his/her evaluation level. IVUs are x-rays of the urinary tract. The urinary
structures, including the bladder blend in with soft tissues in the abdomen; they are
not easily visible on regular x-rays. To better evaluate them, iodinated contrast
media must be injected into a vein. The contrast media travels through the venous
system and is eventually excreted through the kidneys. At this time, radiographs of
the urinary system can be obtained. Without upper level questioning, students
would not be prompted to think about or use material presented. For every
question posed by an instructor, feedback is possible from the student. According
to Lozano,25 Answering questions may show the instructor that the student
remembers the answer to a question or problem, but asking questions shows that
students are actively thinking. The progression of students in the course may be
evident in types of questions they ask, and a student asking questions is evidence
that he or she is thinking and assimilating information.

A baccalaureate nursing program study determined what proportion of terminal

objectives for clinical nursing courses are high level objectives (analysis, synthesis,
evaluation), and are the kinds of questions asked by teachers and students during
clinical conferences of a high level also.26 Despite the fact that stated objectives
specified higher cognitive-level thinking, lower-level questions comprised 98.94% of
the total number of questions asked by teachers and students in the clinical
conferences surveyed.

Another study was performed within an Australian nursing program to examine

clinical teachers use of questioning strategies.23 The teachers years of classroom
and clinical teaching experience, years of clinical experience, and academic
qualifications were studied to see if an association between various qualifications
and levels of questions existed. Blooms taxonomy of the cognitive domain was
used as a framework for the study. The findings revealed clinical teachers asked
more low-level questions (91.2%) than high-level questions (4.4%).

Three Melbourne universities determined the level of questioning used by

undergraduate clinical teachers and preceptors.17 Both the clinical teachers and
preceptors asked a greater number of lower level questions than higher level
questions.

A Canadian baccalaureate nursing program compared the types and levels of

questions asked by nurse educators and their students in context-based tutorial

seminars.27 The largest percentage of questions asked by educators and students

were lower level. Only 4.1% of questions asked by tutors were framed at the highlevel and less than 1% of questions asked by students were rated as high-level.
These studies revealed that mainly factual and lower level questioning is being used
in the classroom.

Since questioning is an integral part of teaching that can assist students in applying
their knowledge,17 educators should know how to use questioning strategies
effectively. Lower level questioning does not promote critical thinking because
students rely mainly on recall of information. A simple recall of information does not
enhance students understanding of the information in a meaningful way. Higher
level questioning facilitates the development of critical thinking because it is aimed
at higher cognitive levels, which involves application, analysis, synthesis and
evaluation.24 Educators should take advantage of stimulating questions more
often to help create meaningful active learning instead of just prompting the simple
recall of knowledge from students.

Self-Directed Learning
Self-directed learning helps students take a more active role in their education and
can be defined in terms of the responsibility the learner accepts for his or her own
learning.12,14,28-30 How students set learning goals, locate appropriate resources,
decide on which learning methods to use and evaluate progress are all aspects of
self-directed learning.31 Self-directed learning in the health sciences can be evident
in the form of clinical logs, contracts, problem-based packages and distance
learning packages.29

Self-Evaluation
One form of self-directed learning is self-evaluation. Self-evaluation allows students
to assess their own performance, become more independent, and accurately
identify their strengths and weaknesses within the educational environment.
Students actively setting personal goals with the instructor are a key factor in the
self-evaluation process. A study conducted in a radiography program evaluated
whether student self-evaluation was a reliable and valid measure, if there were a
significant difference between student self-evaluation mean scores and clinical
instructor evaluation mean scores, and to what degree students expressed a
favorable attitude toward self-evaluation.28 Goals of the evaluation process
included developing skills to identify strengths and weaknesses independently,
setting goals associated with student performance and increasing student
satisfaction by empowering students to control their performance. The study was
limited to this one radiologic science program, so the results may not be
generalized to the radiologic science education population. Self-evaluation was
shown to be an effective method of clinical evaluation for both the students and

educators in this study. Although students tended to be slightly more critical of

their performance than the instructors, a high degree of satisfaction was evident
with the self-evaluation process. Self-evaluation helps students evaluate their own
performance accurately, which will be an asset in the clinical and work
environments.

Learning Contracts
Learning contracts are another form of self-directed learning that encourages active
learning. According to Chien, Chan, & Morrissey,32 A learning contract is a written
mutual agreement between teachers and students and states explicitly what a
learner will do to achieve specific learning outcomes. Students take an increased
responsibility for their own learning in academic courses and clinical education with
the use of learning contracts.33 Students set goals related to the course objectives
and determine the method of measurement and evaluation criteria.12,28,33,34
The clinical education portion of a baccalaureate radiologic science program
evaluated outcomes of its contract learning experiences post graduation compared
to those of two other radiologic science programs.34 The study explored career
satisfaction, lifelong learning skills and attitudes toward learning and learning
situations. Contracts included learning expectations, learning resources, learning
experiences, documentation and other information such as designated evaluators,
evaluation criteria and timelines. Results indicated students who employed learning
contracts during their course of study felt greater job satisfaction and a sense of
career accomplishment, were more involved in continuing education opportunities,
and had an overall positive attitude to the learning experience compared to the two
other programs.

A Bachelor of Science Nursing degree program in Hong Kong undertook a study

implementing contract learning in a clinical context.12 Results of the questionnaire
survey and interviews recorded positive results including a greater sense of
autonomy and control, more individualized learning, an increase in motivation and
sharing in learning. Difficulties reported while using learning contracts included an
insufficient amount of time and knowledge as well as students learning attitudes.

Another study introduced fieldwork educators in an occupational therapy program

to learning contracts.33 Educators felt contracts would help facilitate students
learning and were willing to develop a fieldwork curriculum including learning
contracts. Positive attitudes were noted towards this self-directed learning
experience, and learning contracts have since been part of this program.

Learning contracts were used during mental health clinical placement with
baccalaureate nursing students in Hong Kong.32 Structured activities or specifically
arranged clinical situations related to their learning objectives were employed. A

questionnaire measured student perceptions and found learning contracts increased

their opportunities to apply theory to practice, enhanced their motivation to learn,
and promoted autonomy and control over their learning.

Concept Mapping
Concept mapping is another teaching strategy. Mapping can promote problem
solving and critical thinking by helping students process complex relationships.35
Plotnick36 defines a concept map as a graphical representation where nodes
(points or vertices) represent concepts, and links (arcs or lines) represent the
relationship between concepts. Edmondson & Smith37 describe a concept map as
a tool for representing the interrelations between concepts in an integrated,
hierarchical manner. The map provides a way to connect concepts, allowing the
student to visualize during the learning process. Many times, new meanings are
constructed about events or objects based on the students prior knowledge.38
Synthesizers, like concept maps, are graphic illustrations showing relationships
among content in a general to detail or simple to complex format.39 They show
major relationships between ideas, and the content may be concepts, procedures or
principles.

A study was conducted to examine the effects of concept mapping and synthesizers
as instructional strategies for nursing students encoding and recalling
pharmacology concepts in an undergraduate pharmacology course.39 Although
results cannot be generalized, this study showed that using concept maps and
synthesizers in the teaching environment is effective in increasing the students
learning experience. Another study completed by a nuclear medicine technology
program used concept mapping to correct misconceptions.40 This study
demonstrated concept maps were both efficient and effective for individuals and for
groups. A veterinary program in a different study found concept maps to be
instrumental in helping students to emphasize certain conceptual themes and
interrelations.37 The concept maps encouraged synthesis and integration as well
as provided the course instructor with insights into common errors and
misconceptions. A nursing program in Taiwan examined the effects of adopting
concept maps in problem-based learning scenario discussions. Students were
randomly assigned to a control or experimental group. Although the program found
concept mapping strategies useful for analysis of individual students thinking
processes, there was no significant difference in student scores between the two
groups within this study.35
The Vee diagram is a type of concept map named
because it is in the shape of a letter V.41 A nuclear medicine program study
described the effects of Vee diagrams and concept maps on laboratory learning.42
Diagrams were created by the students to show how their knowledge was
advancing. Instructors gave remediation and reevaluated the students
reconstructed diagram. This study supported the use of Vee diagrams and concept
maps for misconception identification and remediation.

Problem-Based Learning (PBL)

A method of teaching using patient situations or scenarios to stimulate students to
acquire and apply information to solve problems is known as problem-based
learning, PBL.35 In problem-based learning, problems encountered in clinical
settings are presented first before students learn clinical concepts.43 Educators
present realistic patient scenarios, ask questions, and require students to search for
holistic answers.18 Problem-based learning encourages active learning through selfdirected learning, self-appraisal, development of clinical problem-solving skills and
teamwork as well as requiring the student to have discipline and the integration of
information.11,44,45 PBL also improves clinical reasoning skills, increases the
retention of learned material and enhances self-directed study.46

An Australian radiation therapy program conducted a study with problem-based

learning.47 At the completion of the year, students were given a questionnaire
about problem-based learning, the teaching process, assessment, and the
availability of resources. Even though results showed students felt they had
become more independent learners, and the program met the aims of problembased learning, 69.2% of the students did not feel this was an interesting learning
experience. This result was surprising but may be explained by the fact that 84.6%
of students agreed with the statement, problem-based learning is a difficult way to
learn. Availability of resources was also a major concern with 57.7% of students
probably leading to frustration. This study highlights the importance of library
resources, improving access to the resources, and increasing levels of support for
the students involved in active learning. Problem-based learning is very interactive
and highly involved. It may need to be reserved for final year students who need to
be challenged intellectually.47

Another study involving problem-based learning compared test performances of

chiropractic students taught by traditional methods with students using problembased learning.11 Surprisingly, no significant difference was found between the
two groups. Frustrations were noted with problem-based learning such as confusion
regarding faculty-student expectations, insufficiency of faculty, student tutorials and
self-directed learning strategies, and a lack of curriculum integration, learning
context and provision of sufficient time to learn.

A study was conducted to determine if PBL was an appropriate learning strategy for
nurses in an ambulatory care setting using ethical dilemmas as problems.46 This
teaching strategy included shared knowledge and improved decision-making and
critical thinking skills as evidenced by the change in values from the pre to posttest scores. Participants agreed, without prior knowledge of their scores, PBL is an
appropriate learning strategy for ambulatory care nurses.

A Master of Nutrition and Dietetics program performed a study with problem-based

learning.43 Overall academic results and attitudes of students and hospital
supervisors were evaluated. Although no significant differences in final academic
results were noted, this program found the content in PBL to be more relevant and
in tune with contemporary practice. Also, a reduction in the number of students
requiring extra placement time to achieve competency was noted.

An occupational therapy program wanted to determine the effects of a PBL course

on the development of clinical reasoning skills.48 A quasi-experimental pretestposttest design was used with 48 senior students. Students participated in a PBL
course scheduled prior to fieldwork. The Self-Assessment of Clinical Reflection and
Reasoning (SACRR) was administered to measure changes in clinical reasoning
thought processes and behavior. This instrument relies on the subjects selfperception of clinical reasoning skills and behavior rather than an objective measure
of clinical reasoning performance and can be a limitation of this study. However,
statistically significant improvements were seen in this PBL course, and students
perceived that they increased their clinical reasoning strategies.

There are some disadvantages when considering a problem based learning

curriculum. Problem-based learning is time consuming. There is concern all of the
necessary and required material may not be covered.49 Some changes to the
existing curriculum will have to be made. Faculty will now have to re-evaluate the
curriculum in order to develop case scenarios and create new forms of
assessment.49

Case-Based Instruction (CBI)

Case-based instruction (CBI) is different from PBL in which students are exposed to
the content for the first time when they read the scenario. The scenario becomes
part of the explanation of the lesson in PBL. CBI, by comparison, introduces cases
after the students have completed lectures or lab units. They apply learned
theories to real-life situations.50 Hayward & Cairns13 state, The use of cases
allows students to integrate and apply developing clinical and basic science
knowledge and skills such as clinical reasoning, critical thinking, problem solving,
and interpersonal ability to hypothetical or real case scenarios. Case studies
provide a process of participatory learning that facilitates active and reflective
learning.51
A study of physical therapy students described how they perceived and approached
learning during case-based instruction.13 Students indicated cases served as a
stimulus for clinical thinking and promoting an in-depth thought process. Another
group of physical therapy students used case studies and role-playing to learn
clinical decision-making skills.52 This model for teaching clinical decision-making

could be incorporated into any of the health science education settings. Allied
health students were studied to see if they preferred Internet case-based instruction
to didactic lecture instructional strategies in a different study.13 The Internet
technique offered students an opportunity to apply their knowledge to solve case
scenarios using a widely available technology while working collaboratively. The
respondents viewed case studies as a valuable educational experience because
they were provided the opportunity to share expertise while learning from others.

Conclusion
A variety of teaching strategies can be used to provoke active learning in radiologic
science students. According to Hayward & Cairns,13 the goal of educators should
be to prepare students to become competent clinicians, clinical thinkers, critical
thinkers, problem-solvers and collaborators, team players, self-directed learners and
effective communicators. This applies to Radiologic Sciences as well as other
healthcare fields. Although the majority of studies within this article originate from
nursing techniques, these teaching strategies can be applied to Radiologic Science
as well. Radiologic Sciences should conduct more quantitative educational research
into active learning and other educational processes. More scientific studies
focusing on the radiologic sciences are desperately needed to validate the
successes of these teaching techniques as they would apply to our chosen field.
Until that time, a Radiologic Science educator can start by identifying appropriate
questioning techniques, employing self-directed learning, applying concept maps,
and adding problem-based learning and case-based instruction to current teaching
methods. Active learning is essential to help radiography students and other
healthcare students develop critical thinking and problem solving abilities.

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