Student Performance and Perceptions of a Lecture-based Course Compared With the Same Course Utilizing Group Discussion.

Lecturing is still, in my opinion, the predominant form of teaching in postsecondary[1] and health care professions education.[2,3] The greatest advantage of lectures in the opinion of faculties is the ability to share information with a large number of students.[4,5] Authors argue that the lecture method is as effective in communicating factual information as any other instructional method.[4-6] The major disadvantages of lectures are believed to be the passive nature of this form of information transmission and the lack of active involvement by students.[1,4,7-9] Cognitive theory has suggested that only active processing of information, and not just passive reception of that information, leads to learning.[8,9] Medical students' attention in lecture courses appears to be high only during the first 10 to 15 minutes and then declines abruptly.[10,11] Hammen and Kelland[12] gave further evidence indicating that very little learning occurs in lectures when they showed a weak correlation between lecture attendance and course grades in medical school courses. Both of these observations, however, came from studies of medical students, and whether they represent other students is arguable.

The Normative Model of Physical Therapist Professional Education, Version 97[13] (the Normative Model) states that the practice of physical therapy involves complex cognitive processes. Several authors of educational texts[6,14-18] have argued that lecturing is inappropriate for the presentation of complex, detailed, or abstract material and when that material must be understood at higher cognitive levels. Research data supporting this contention, however, are lacking. The Normative Model states that physical therapist professional education curricula should be "designed to foster active, self-directed learning,"[13(p13)] but it does not specify a method to be used or an underlying philosophy for clinicians.

Schon[19] has described the reflective practitioner as someone who reads new information, analyzes that information, and makes judgments about the relative merit of conflicting information within the pre-existing knowledge framework. This would appear to be the same type of practitioner that the Normative Model was designed to develop. Schon[19] contended that autonomous or self-directed learning is a key element in the development of the reflective practitioner. Therefore, in the opinion of many educators, central to the success of all health care professions education is the development of the autonomous learner who can acquire and integrate new information without the constant presence or supervision of an instructor.[20] The argument has been made that, in order to become autonomous learners, students in the health care professions need to accept personal responsibility for their learning.[21] The desire to develop self-directed learners in the health care professions has led to the increasing use of a variety of active learning methods.[1,4,6,7,20-31]

Active learning techniques that have been utilized in postsecondary education include interactive lectures or lecturing by questioning (the Socratic method),[1,4,7] whole class and group discussions,[4,6,14] peer teaching and collaborative group learning,[1,4,6,7,14] experiential or activity-based learning,[6] debates,[4,14] role-playing or simulations,[4,14] and interactive computer-based learning.[4,6,14] Problem-based learning is a form of active learning that appears to be increasing in use.[32-35]

Active learning methods are supposed to leave students with a greater level of knowledge and better learning skills compared with students exposed to other forms of learning. Whether they do in all courses, however, awaits further research. A commonly studied form of active learning is the small-group discussion. Greater learning in small discussion groups has been shown in engineering courses,[29] physiological psychology courses,[36] and anatomy courses.[30,31] Some investigators have reported that students working in groups were more likely to be able to generalize from specific observations,[29] were superior at applying concepts to new situations,[36] and had a greater ability to critically analyze what they read and synthesize information from a variety of sources.[37,38] Students working in groups also appeared to have increases in the attributes of self-directed learning and in obtaining relevant help for facilitating learning when compared with students in lecture-only courses.[39] More recently, no difference has been reported in scores on multiple-choice or essay examinations between courses with combined active learning and lecture methods and those courses with only lectures.[2,22,40] Students who had taken the combined lecture and discussion courses, however, were described by instructors in more advanced courses to be more aggressive learners who would ask and answer more questions in class discussion.[22]

Another important question about active learning courses is: How do students perceive active learning methods compared with lectures? Researchers have shown higher student course ratings[24,40] no difference in student course ratings[41] or instructor ratings,[40,41] and lower course ratings[22,42] in active learning courses when compared with courses using lectures. Some educators believe that students express concerns about their perceived lack of basic knowledge after completing active learning courses. This perception exists despite evidence that students who take these courses perform at the same level on examinations in advanced courses as students who take courses using the lecture format.[22]

The value of active learning and student perceptions of active learning remains unclear. The primary purpose of my study was to compare student learning and student perceptions of course and instructor effectiveness, course difficulty, and amount learned between a physiology course with group discussions and an active learning format and a physiology course with a lecture-only approach. A second purpose was to investigate whether a preparatory discussion about the rationale for using an active learning approach affected the students' perceptions of the course and the instructor.

Method

The same advanced physiology course was taught in the fall and winter quarters to 2 groups of physical therapist students in the first year of their bachelor's degree professional program. Both groups of students were beginning the professional phase of the program after completing all liberal arts core courses and the prerequisite science courses. Students at this large, private university were admitted into the physical therapy program as first-year students based on their high school grade point average and Scholastic Aptitude Test scores. Previously taken courses were all taught in large lecture sections, and the students had little or no experience with small-group or discussion-oriented course work in the physical therapy program. The physiology course was taught in the fall quarter with 51 students as a lecture course with 4 one-hour lectures per week. In the winter quarter, the physiology course was taught with 78 students using an active learning format with a 1-hour "lecture" and a 1-hour small-group discussion. Students in both courses received weekly quizzes, a midterm examination, and a cumulative final examination. The same course topics were presented in both courses, and the same readings were used. The same study questions were used in both courses, and all quizzes and examinations in both courses were of a similar format, content, and difficulty. Questions used varied between semesters. Questions were drawn from a database of questions ranked by the instructor by difficulty and cognitive level (Bloom's taxonomy[43]). Similar numbers of questions from each level of difficulty and cognitive level were chosen. Because these determinations were done by the instructor based on student performance, the examinations and quizzes can only be described as similar, not identical. Both courses had an optional 2-hour question-and-answer session given by the instructor before the midterm and final examinations.

In the active learning course, students were given all reading assignments at the beginning of the course in the course syllabus and a reading packet, just as they were in the lecture course. Active learning is defined here as having the reading assignment combined with a discussion of that reading assignment without the benefit of a series of lectures that comprehensively cover all topics in the course. Students in the active learning course were instructed to read new material over the weekend. On the Monday following the weekend, a "lecture" was given in which the instructor discussed only those topics with which students in previous terms had the most difficulty understanding from the reading assignment and gave a quiz on the material discussed the previous week. The scheduled duration for this "lecture" was 50 minutes. Because the weekly quiz was administered during this "lecture" time, the actual time spent discussing course material was 30 to 35 minutes. Following the "lecture," students were instructed to read the assignment again in the context of a series of study questions. At midweek, students discussed the study questions for 1 hour in groups of 15 to 20 students facilitated by the instructor. A quiz on this material was given on the Monday of the following week.

The same instructor taught both courses. This instructor had received the university's excellence-in-teaching award 3 years prior to the study. At the time of the study, the instructor had been teaching physiology at the graduate and undergraduate levels for 14 years and had taught this particular course for 6 years. The lecturer used questioning, clinical examples, and humor to increase interest in the lectures. The instructor had not had any experience in small-group instruction prior to the initiating the active learning section of the course.

The points earned in both physiology courses were summed from the weekly quizzes, a midterm examination, and a final examination. The weekly quizzes had questions focusing on the knowledge level of Bloom's cognitive taxonomy.[43] The midterm and final examinations had most questions at the knowledge, comprehension, and application levels. There were a few questions on the midterm and final examinations that were at the analysis level, but there were no questions clearly at the synthesis level of Bloom's taxonomy.

Course grades were initially percentages of total points possible in the course. The final course score averages were compared between the lecture course and the active learning course. Because the percentages were not normally distributed (which, in my opinion, indicates a need to use nonparametric statistics), differences were determined with the Mann-Whitney U test, which is a nonparametric test for independent measures.

Student perceptions of the physiology instructor and overall course effectiveness, course difficulty, and amount that they had learned were measured with the teacher-course evaluation used at the university. This evaluation consisted of a Likert-style scale with scores ranging from 1 to 5, with 1 being the lowest score. The teacher-course evaluation results were compared between the lecture course and the active learning course.

Because the data from the teacher-course evaluations were ordinal-level data, a conservative method of analysis was done with a nonparametric statistical test. An analysis of student perceptions for each question on the evaluation (course difficulty, course effectiveness, instructor effectiveness, and amount learned) over the 3 student groups (lecture course participants, active learning course participants, and active learning participants from the second year given the rationale for active learning) was done using the Kruskal-Wallis test, with an alpha level set at .05. Individual post hoc analyses were done using the Mann-Whitney U test. With 3 post hoc analyses, the alpha level was corrected using the Bonferroni correction and set at .017 (.05 divided by the 3 post hoc comparisons).

The active learning format was again used in the physiology course the next fall quarter with 41 students. The positive academic performance results seen in the previous use of active learning were shared with the students during the first session of the course. Issues such as the importance of active learning and lifelong learning skills to the practicing clinician were discussed. Student academic performance and students' perceptions of the course and instructor were compared with the values obtained in the lecture course and in the previous active learning course. This comparison addresses the second purpose of the study, which was to investigate whether a preparatory discussion of the rationale for using an active learning approach would affect the students' perceptions of the course and instructor.

Results

The physiology course grades in the active learning courses were higher than those in the lecture course (Tab. 1). An overall analysis of student perceptions for each question on the evaluation (course difficulty, course effectiveness, instructor effectiveness, and amount learned) over the 3 subject groups (lecture course participants, active learning course participants, and active learning participants from the second year given the rationale for active learning) revealed changes in perceived course effectiveness, instructor effectiveness, and amount learned. There was no difference in student assessments of course difficulty. A post hoc analysis was done to compare active learning course participants and lecture course participants (Tab. 2). Two additional post hoc analyses comparing participants from the second-year active learning course who were given the rationale for active learning with the lecture course participants and the active learning course participants were done for each of these 3 areas of student perceptions (Tab. 3).

Table 1. Comparison of Final Median Percentage Scores and the 25th and 75th Percentiles for Those Students Participating in the Lecture-Only Mode of Physiology Instruction and Those Students Participating in the Active Learning Mode of Physiology Instruction(a)

Teaching
Mode                   Median   25%/75%     P

Lecture only             78      78/83
Active learning          84      79/88    <.001
Active learning with
  rationale              83      77/88    <.01

(a) Statistical significance determined by using the Mann-Whitney U test with [Alpha]=.05.

Table 2. Comparison of Student Perceptions for the Lecture-Only and Active Learning Modes of Physiology Instruction(a)

Evaluated                  Lecture   Active
Perception                  Only     Learning     P

Amount learned             4 (4/5)   4 (3/4)    <.0001
Course effectiveness       4 (3/4)   3 (2/4)    <.0001
Instructor effectiveness   5 (4/5)   3 (2/4)    <.0001

(a) Median score (25th and 75th percentiles) shown for each teaching mode and student perception. Statistical significance determined by using the Mann-Whitney U test with [Alpha]=.017.

Table 3. Comparison of Student Perceptions for the Active Learning Mode of Instruction Following Preparatory Discussion Explaining the Rationale of the Use of Active Learning Methods With the Lecture Mode of Instruction and the Active Learning Mode of Instruction Without the Preparatory Discussions(a)

                     Active                            Active
                    Learning      Lecture Only        Learning
Evaluated Student   Rationale
Perception          Explained    Score      P       Score     P

Amount learned       4 (4/5)    4 (4/5)    .015    4 (3/4)   .025
Course
  effectiveness      3 (3/4)    4 (3/4)    .04     3 (2/4)   .005
Instructor
  effectiveness      3 (3/4)    5 (4/5)   <.0001   3 (2/4)   .071

(a) Median score (25th and 75th percentiles) shown for each teaching mode and student perception. Statistical significance determined by using the Mann-Whitney U test with [Alpha]=.017.

As shown in Table 2, the active learning course students' perceptions of the effectiveness of the course and the instructor were lower than the perceptions of students in the lecture course. Although the grades were higher in the active learning course than in the lecture course (Tab. 1), the students in the active learning course perceived that they learned less compared with students who were taught in the lecture-only course (Tab. 2).

The second time the active learning course was taught, the students were given a 15-minute presentation at the beginning of the course showing the higher grades in the previous active learning course compared with the lecture course. Even with that preparation, the active learning course students' perceptions of instructor effectiveness and amount learned (Tab. 3) continued to be lower than the perceptions of students in the lecture course. The student perceptions of course effectiveness were not lower.

The perceptions of the students in the active learning course in which the students and the instructor discussed the rationale for using active learning methods were also compared with the perceptions of the students in the original active learning course (Tab. 3). The perceptions of the students in the active learning course with the rationale for active learning included were higher than the perceptions of the students in the original active learning course in the area of course effectiveness. However, there were no differences between the 2 groups of students in their perceptions of instructor quality and amount learned.

Discussion

Both times the active learning approach was used in the physiology course, student academic performance was higher than the academic performance of the students in the lecture course. However, the students in both of these active learning courses felt that they had learned less compared with students in the lecture course.

The students' perceptions of course and instructor effectiveness were also lower in the active learning courses than in the lecture course. A large number of the comments on the teacher-course evaluations among the active learning students were directed at perceived instructor effectiveness. A very common statement was that "he did not teach me anything."

When the active learning course was taught a second time and the students were given a rationale for the use of active learning methods, the students' perceptions of course effectiveness, instructor effectiveness, and amount learned were higher but continued to be lower than the perceptions of students in the lecture course. In the active learning course when a rationale was given, the students' perceptions of the effectiveness of the course were higher than in the original active learning course in which students did not receive a rationale.

In both active learning courses, there appeared to be a small number of students who responded well to the active learning format. These students did well in the course and had very positive perceptions of the course, the instructor, and the amount that they had learned. On occasion, they even apologized to the instructor for the very negative attitudes of their classmates. The results of my study indicate that greater learning occurred with active learning approaches,just as greater learning with these approaches occurred in engineering,[37] anatomy,[30,31] and physiological psychology[36] courses.

DaFosa and colleagues[2] studied the performance on multiple-choice and essay examinations of medical students who were randomly assigned to surgical rotations that utilized either lecture or independent study. They reported no difference in the scores on the multiple-choice or essay examinations between the independent learners and medical students who had lectures. I question whether students who were assigned to the independent study group had time to adapt to this very different style of learning over the short time of a single clinical rotation. In my study, students in the active learning course for an entire 11-week term performed better on multiple-choice examinations than students in a lecture course. In my study, students in the active learning courses perceived that they had learned less than did students in the lecture course.

This was the students' impression despite the fact that their higher scores on examinations indicated that they learned more. This observation is similar to the results of Goodwin and colleagues.[22] They reported that students in basic biology courses with half lecture and half small-group discussions felt that they had learned less compared with students in previous lecture-only courses. This was their perception despite the observation that they did not do differently in subsequent biology courses than students in more conventional lecture-style courses.

In my study, I used groups of 15 to 20 students. Other researchers have reported that there is student dissatisfaction with learning groups of 8 to 15.[38] Goldschmid and Goldschmid[44] and Argyle[45] cited evidence in favor of a maximum group size of 6. Rangachari[41] and Lake[46] have reported positive student responses to use of an active learning method with group sizes of 5 to 6 students. However, limiting the size of discussion groups could be a problem with large class sizes such as those in my study.

A different approach to improving students' perceptions of active learning courses would be to have a slow, incremental introduction of active learning methods. Richardson and Birge[40] described a physiology course that had approximately 25% active learning exercises and 75% regular lectures. This course was compared with an all-lecture format course. Student perceptions were measured using the standard teacher-course evaluation instrument. Their results showed that course ratings for the combined active learning and lecture course were higher than those for the lecture-only course. The students' ratings for instructor effectiveness were similar in both courses. Goodwin and colleagues[22] reported that basic biology courses with half lecture and half small-group discussion were not well received by students. Students reported that they had learned less compared with students in other courses using only lectures. Many students expressed the need or desire for more lectures rather than the discussion sessions. The students expressed considerable concern about vagueness of assignments and lack of preparation for future courses. I had very similar results with almost all teaching done using active learning. I believe that the threshold of student acceptability may be between 25% and 50% active learning assignments, but data are lacking to support this conclusion. Thus, if courses that occur early in a curriculum could have 25% of the activities be active learning, with the percentage increasing as students move through the curriculum, the students, in my opinion, may be able to accommodate to this new learning style. This possibility needs to be investigated.

Another approach to gain student acceptance might be to incorporate active learning courses into the larger curricular framework of small-group, case-based, active learning methods such as problem-based learning (PBL). Rangachari[41] has reported positive student responses to the PBL method applied to courses in a pharmacy curriculum. Lake[46] reported that there were no differences in the evaluations of instructor effectiveness, level of course difficulty, and amount learned between a lecture course and an active learning course when the active learning course was taught in a PBL curriculum. The overall perception of course effectiveness, however, was higher in the active learning course in the PBL curriculum than in the lecture format course.[46]

Summary and Conclusion

Active learning methods were shown in this study to result in higher student performance in a physiology course for physical therapist students when compared with the lecture-only method. However, students in these active learning courses felt that they had learned less and had lower perceptions of instructor and course effectiveness compared with students in the lecture-only course. Discussion of the rationales associated with the use of active learning methods with the students resulted in higher student perceptions of course effectiveness, instructor effectiveness, and amount learned when compared with the active learning course when no rationale was provided, but these perceptions continued to be lower when compared with the perceptions of students who took the lecture form of the course.

I believe that 3 approaches to addressing the problem of student perception are possible and worthy of research: (1) expanding or strengthening the discussion of the rationale for active learning methods, (2) incremental introduction of active learning methods, and (3) curricular change to an all-active learning or all-PBL curriculum. Future research is needed to investigate each of these approaches.

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DA Lake, PT, PhD, is Professor and Department Head, Department of Physical Therapy, Armstrong Atlantic State University, 11935 Abercorn St, Savannah, GA 31419 (USA) ([e-mail]).

Portions of this research were presented at the Combined Sections Meeting of the American Physical Therapy Association, February 2-6, 1994, New Orleans, La, and at the 12th International Congress of the World Confederation of Physical Therapy, June 25-30, 1995, Washington, DC.

This article was submitted July 19, 1999, and was accepted September 11, 2000.