Use of the Decision Case Method of Teaching in a Course on Death and Grief

This article was downloaded by: [North West University]On: 20 December 2014, At: 19:30Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Journal of Social Work in End-Of-Life & Palliative CarePublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wswe20

Use of the Decision CaseMethod of Teaching in a Courseon Death and GriefBarbara Anderson Head aa University of Louisville School of MedicinePublished online: 07 Apr 2009.

To cite this article: Barbara Anderson Head (2009) Use of the Decision Case Methodof Teaching in a Course on Death and Grief, Journal of Social Work in End-Of-Life &Palliative Care, 4:3, 229-251, DOI: 10.1080/15524250902822382

To link to this article: http://dx.doi.org/10.1080/15524250902822382

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness,or suitability for any purpose of the Content. Any opinions and viewsexpressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of theContent should not be relied upon and should be independently verified withprimary sources of information. Taylor and Francis shall not be liable for anylosses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly or

http://www.tandfonline.com/loi/wswe20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/15524250902822382

http://dx.doi.org/10.1080/15524250902822382

indirectly in connection with, in relation to or arising out of the use of theContent.

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan,sub-licensing, systematic supply, or distribution in any form to anyone isexpressly forbidden. Terms & Conditions of access and use can be found athttp://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

http://www.tandfonline.com/page/terms-and-conditions

Use of the Decision Case Method ofTeaching in a Course on Death

and Grief

Barbara Anderson Head

ABSTRACT. As a key professional and essential team member, socialworkers must be adequately prepared to address the complexities andchallenges inherent in palliative, hospice, and bereavement care.Decision case method teaching is one means of exposing students topractice situations they may face and stimulating collaborative deci-sion making in the classroom. This article explores the use of thedecision case method in a master’s level course on death and dying.The approach was well-accepted by students and a good fit for theuniversity’s academic focus on developing critical thinking abilities.

KEYWORDS. Death and grief, decision case, end of life, social workeducation

Development of the decision cases used in this class was supported in partby funding from the Soros Foundation’s Project on Death in America.

Barbara Anderson Head, PhD, RN, CHPN, ACSW, is AssistantProfessor at the University of Louisville School of Medicine, Division ofInternal Medicine and Adjunct Faculty Member at the Kent School ofSocial Worker. She is a Registered Nurse with a masters and doctorate inSocial Work.

Address correspondence to Barbara Anderson Head, PhD, RN, CHPN,ACSW, MDR Building, Suite 110, 511 South Floyd Street, Louisville, KY40202. E-mail: [email protected]

Journal of Social Work in End-of-Life & Palliative Care, Vol. 4(3) 2008# 2008 by Taylor & Francis Group, LLC. All rights reserved.

doi: 10.1080/15524250902822382 229

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

INTRODUCTION AND PURPOSE

In hospice and palliative care, the social worker has been identifiedas a key professional and essential team member addressing thepsychosocial issues of patients and families facing life threateningillness and the subsequent period of bereavement (Huff, Weisenfluh,Murphy, & Black, 2006; Jeffrey, 2003; Parker, 2005; Reith, 2005).In 2004, the National Association of Social Workers (NASW) publi-shed practice standards for palliative and end-of-life care notingthe increased need for social workers who are trained and skilled towork with such populations. Standard 2 in this document addressesthe areas of knowledge essential for effective palliative=end-of-lifepractice (National Association of Social Workers, 2004). Similarly,the Clinical Practice Guidelines for Quality Palliative Care callfor the hiring of appropriately trained social work professionals askey members of the interdisciplinary team (National ConsensusProject for Quality Palliative Care, 2004).

Using decision cases to prepare social workers for end-of-life andbereavement practice is a solution to both the need for relevant, effec-tive course content and the need to develop the student’s criticalthinking ability related to the situations and issues faced in the ‘‘realworld.’’ This article details the methods used in employing the deci-sion case method as a teaching approach in a master’s level deathand grief course and the students’ evaluation of the process. Most,if not all, of the knowledge content recommended by the aforemen-tioned NASW standards, is addressed by these cases including themultifaceted roles and functions of social work clinicians, biopsycho-social needs of clients and family members, the range of settingsfor end-of-life and bereavement care, use of community resources,end-of-life decision making, and the needs of special populations.

BACKGROUND AND LITERATURE REVIEW

Unfortunately, the preparation of social workers via effectiveeducation and training has not kept pace with the increased involve-ment and responsibility of social workers who provide palliative andend-of-life care (Brandsen, 2005; Huff et al., 2006; Parker, 2005;Zelinsky & Thorson, 1983). In a survey of 391 healthcare socialworkers, few felt that their educational preparation for providing

230 JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

competent end-of-life care was adequate and the discrepancy betweenthe content needed and that which was received left many practicingsocial workers with a sense of helplessness (Csikai & Raymer, 2005).Inadequate preparation for practice in this area could result in defi-cits in the psychosocial care of those facing life-threatening illness.

Throughout the literature related to social work education andtraining for end-of-life and bereavement care, the use of multipleteaching methods and inclusion of realistic case materials has beenrecommended (Brandsen, 2005; Goldstein, 1977; Kramer, 1998;Miller, 1977; Zelinsky & Thorson, 1983). Opportunities to process cli-ent situations in the classroom was an expressed need of social workstudents participating in focus groups related to their education onend-of-life and bereavement care (Huff et al., 2006). Effective edu-cational experiences related to death and grief must address theambiguity related to social work roles in end-of-life care and the chal-lenges of interdisciplinary communication and teamwork. So far,written documentation of the critical roles and responsibilities ofthe social worker employed in end-of-life settings is lacking (Kramer).

The complexity of practice with patients and families at the end oflife and beyond, including bereavement, points to the need for criticalthinking ability. This is best developed by employing a problem-focused approach such as decision case method teaching. The methoduses open-ended cases to stimulate and develop decision-makingskills. The cases depict actual situations recruited from practitionersand described in great detail. A good decision case is a well-written,engaging description of a real life situation in which the facts arenot changed although the identifying information is camouflaged(Cossom, 1991). Learners eagerly read the detailed scenario afterbeing drawn in by an opening ‘‘hook’’ or ‘‘trigger.’’ Rather thandepicting a situation and providing the outcome, decision casesrealistically portray the often messy, ambiguous reality of practicewithout providing answers. Readers receive the ‘‘raw data’’ and mustuse their professional judgment to resolve the dilemma or issuepresented.

The decision case method has been used successfully to prepareprofessionals in the disciplines of law, medicine, business administra-tion, public administration, management policy analysis (Lynn,1999), and education (Lundeberg, Levin, & Harrington, 1999). Theidea of using cases to teach preprofessional students most likely ori-ginated at the Harvard Law School around 1870; by 1910 all leading

Barbara Anderson Head 231

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

law schools used the case method of teaching (Kimball, 1995). Thedecision case method of teaching and learning was pioneered byHarvard University’s Business School which has used this pedago-gical approach since 1908 (Cossom, 1991). According to Cossom,social work literature has included examples of good case materialsbeginning with Mary Richmond’s work in 1917, but less has beenwritten about decision case teaching methods in the social workliterature than in business publications.

When teaching with decision cases, lectures about theory arereplaced by a Socratic method which facilitates in-depth discussionand encourages the use of analytical, critical thinking skills (Wolfer,Freeman, & Rhodes, 2001). The student is required to figurativelystep into the position of the decision maker (Leenders, Mauffette-Leenders, & Erskine, 2001) and confront the challenges of practice,including: conflicting statements by participants in a scenario, timeconstraints, resource limitations, ethical dilemmas, extraneous details,and incomplete information define problems, and make decisions.The success of the decision case teaching method is dependent onthe student’s ability to identify with the position of the decisionmaker or protagonist in the case and the data given (Leenders et al.,2001). When using the case method of teaching in a classroom setting,cases serve as a ‘‘site’’ to practice collaborative decision making(Wolfer & Runnion, 2008).

Wolfer and colleagues reported using the decision case method toaddress the following areas identified as needs for particular emphasisamong master’s level social work students: systematic thinking orlearning to think about cases in terms of the systems involved; move-ment from analysis to decision making; defining problems clearly andconcisely; directly linking interventions to problem definitions; anddeveloping more conditional ways of thinking (Wolfer et al., 2001).Attention is shifted from what the students know to how theycan use that knowledge ‘‘thinking as a social worker’’ (Wolfer &Runnion, 2008). According to Lynn (1999), the case teaching methodenables instructors to teach the art as well as the science of socialwork, ‘‘a decision case is to a social worker what a cadaver is to amedical student’’ (p. 6).

Challenges for instructors who want to use this method include:learning and practicing an approach very different from traditionalteaching methods; motivating and involving learners; insuringpreparation by both the teacher and learners prior to class


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

discussions; and evaluating student=teacherperformance (Lynn, 1999).Perhaps the greatest challenge to employing this teaching method islocating or developing current, relevant, well-written cases (Leenderset al., 2001). To inform those teaching social workers=students forpractice in palliative and bereavement care, a project to developdecision cases and related teaching notes for the express purpose ofpreparing social workers for effective practice with dying patientsand the bereaved was funded by the Project on Death in America(funded by the Soros Foundation). Wolfer and Runnion, from theUniversity of South Carolina, served as principal investigators.

METHODOLOGY

Case Development

Cases developed by the Project on Death in America grantees wererecruited from experienced social workers practicing in a variety ofvenues related to end-of-life and bereavement care most of whichwere in the southeastern United States. The case-writing process con-sisted of five steps: (a) the case reporter prepared a brief writtenaccount of the problem or dilemma; (b) during a team meeting con-sisting of the authors and a group of social workers, the case reportershared the case in detail and responded to team questions; (c) the casewriter prepared a draft of the case including the introductory ‘‘hook,’’a basic narrative, and the dilemma-posing ending; (d) the draft wasdistributed to other team members who asked further questions tocorrect, clarify, and amplify the case; (e) the case writer used the inputfrom the follow-up discussion to revise the case and prepare teachingnotes (Wolfer & Runnion, 2008). Teaching notes were subsequentlyreviewed and critiqued by topic experts, and suggested improvementswere made.

For the past 4 years, seven of the cases developed by the SorosFoundation-funded project have been used as core content for agraduate level social work course, Death and Grief, offered at theKent School of Social Work at the University of Louisville. The casesused were those developed early in the course of the project, includingtwo written by the professor teaching this course. Five of these sevencases are briefly described and the related class topic(s) are displayedin Table 1.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

TABLE 1. Brief Description of Cases and Related Course Content

Title Description Related Course Content

The Request Mother of a severely

hydrocephalic child (now age 14

and unresponsive to stimuli)

requests hospice admission for

the child and assistance with

getting nursing home to honor

her wishes for no further

treatment including no

antibiotics for treating

chronic infections. Social worker

must decide best course of

action

Right to life=quality of life issues

Withholding=withdrawing

treatment

Family dynamics

Parental rights

Hospice care in nursing facilities

Interdisciplinary communication

Vulnerable populations

(children, the disabled)

Staff grief

Policy issues

A Painful

Predicament

Social worker documents patient’s

wishes to have no further

dialysis or artificial

nutrition=hydration on hospital

medical record. Patient’s wishes

are not honored by other

members of the health care

team and the social worker must

decide what action to take

Advance directives=end-of-life

decision making

Interdisciplinary teamwork and

communication

Withdrawing=withholding

treatment

Quality of life=good death

Professional boundaries

Role of dialysis social worker

Dying process

‘‘Till Death Do

Us Part

Elderly husband is not informed of

risks and consequences of a

research protocol to which his

wife consents. She is unable to

return home after the surgery

and he states he would not have

consented had he known her

probable post surgery condition.

Social worker must decide what

to do about breach of research

ethics related to the informed

consent process

Research ethics

Informed consent

Decision-making capacity

Quality of life issues

Vulnerable populations (elderly)

Family dynamics

Right Before

Their Eyes

School social worker must handle

consequences of a student’s

estranged boyfriend shooting

himself in front of a school bus

in route to school in the

morning. Students on the bus

had arrived at school and were

allowed to report to class as

usual

Traumatic death

Critical incident response

Children and grief=loss

School social work

Violence

Policy issues

Interdisciplinary teamwork

Suicide

(Continued)


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Curriculum Design

Death and Grief is offered during the spring and summer sessionsas an elective course contributing to the coursework requirements fora Masters of Science in Social Work degree. Both traditional andadvanced standing graduate social work students can enroll in thecourse. Completion of two required courses, Human Behavior inthe Social Environment I and II, is considered to be a prerequisitefor the course to assure that social work students have adequatebackground to benefit from the course content. The course is alsoopen to advanced graduate students from other disciplines after indi-vidual review and approval by the professor. Students pursuingadvanced degrees (masters and doctorates) in psychology, counseling,and nursing have comprised approximately 20% of the enrollees overthe past 4 years. Thus far, these students have indicated that decisioncases developed for social workers have also been appropriate fortheir learning. In fact, the involvement of other disciplines in the dis-cussions of the cases has been a learning experience for both thesocial workers in the class (as they are exposed to other disciplines’perspectives on their role in such cases) and the students from otherdisciplines who learn about interdisciplinary work and the socialwork role.

Each class meeting is focused on a topic related to end-of-life careor bereavement issues. Examples of class topics include: the dyingpatient; families and grief; children and grief; sudden, traumatic

TABLE 1. Continued

Title Description Related Course Content

I Don’t Want

Them to Be

Mad at Me

Widowed father of low

socioeconomic status with two

minor children does not want

them to know whom he has

designated to be their guardian

after he dies because he fears

their reprisal. As the patient

approaches death, the social

worker must decide how to

respond to the multiple needs of

this family

Rights of children

Family communication

Vulnerable populations

Policy=legal issues

Client competence

Confidentiality

Dying process


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

death and grief; ethical dilemmas; end-of-life care with marginalizedgroups; and cultural aspects of death and grief. Cases are assigned inaccordance with the class session’s focus. Cases could easily be inte-grated into existing class structures according to the class syllabuscontent.

Course objectives that speak directly to the use of decision casesare as follows:

Students completing this course will be able to:

1. Create, organize and integrate ideas and actions directed towardengaging dying persons and their families in effective copingduring death and bereavement.

2. Assess, conceptualize, and analyze theoretical, ethical, practice,and research problems from multiple perspectives and utilize criti-cal thinking skills to formulate appropriate interventions andactions when working with the dying and their families.

3. Analyze, synthesize, and evaluate the evidence available to guidepractice with dying persons and their families across the life span.

4. Demonstrate the ability to integrate knowledge and culturallycompetent skills into practice with dying persons and their famil-ies, including those persons marginalized by society.

5. Integrate into practice awareness and understanding of thefunctioning and roles of social and medical service providersand the resources available to assist dying person and theirfamilies.

6. Develop insight into one’s own attitudes and beliefs related todeath and dying and explore alternative paradigms; utilize this inc-reased self-awareness to more effectively relate to persons facingthe end of life and their families.

The decision case method and related expectations are explainedduring the first class session. Guidelines for effective participationin class discussions are provided to the students. One of the cases isread by the students and discussed during this first session to modelthe process. Since this class meets once weekly for 2½–3 hours (total-ing 10–12 class sessions depending on semester offered), a case isassigned for most class sessions. Decision case discussions constituteapproximately 1 hour of the 3-hour class session. Cases are posted onthe University’s instructional website at the beginning of the semesterso that students can access them throughout the course.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Instructor Preparation

Effective use of the decision case method of teaching requiresadequate preparation by the instructor. As detailed in Table 2, teach-ing with cases is quite different from traditional teaching approachesand using this approach often challenges instructors to move out oftheir comfort zone. According to Lynn (1999), the requirements forthe instructor include: psychological preparation; a thorough under-standing of the case and related issues; skill in discussion leadership; awillingness and readiness to remain neutral and set preconceptionsaside; patience; the ability to clarify and offer summations withoutcontrolling the learning; and a willingness to practice, experiment,make mistakes, and learn by doing.

Detailed, well-developed teaching notes, such as those developedas part of the Project on Death in America grant, provide directionin teaching and stimulate thought about the teaching potential of

TABLE 2. Differences in Traditional Method and Case Method Teaching

Differences in Method

Traditional Method Case Teaching Method

Based upon lecture Discussion based

Lecture is the source of content Case is the vehicle for learning

Knowledge is seen as possessed

predominately by teacher and other

experts

Students contribute to learning

Knowledge flows from teacher to student Knowledge and skills flow back and forth

between and among students and the

teacher

Goal is mastery of didactic content Goal is student competence and

confidence in critical and analytical

thinking

Teacher is central Teacher is a facilitator and catalyst for

student learning

Students are receptive to content; may

become passive learners

Students are active and responsible for

their own learning

Results are most often measured by

exams and correct answers, papers

reflecting the content taught

No one correct answer; outcome is

critical thinking

Becomes routine, may be boring to

students and teacher

More work, but more fun


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

each case. The teaching notes developed for each case by Wolfer andRunnion (2008) follow this outline: (a) case synopsis; (b) course andlevels for which the case is intended; (c) learning objectives fromwhich the instructor may choose those most appropriate for thecourse or desired learning; (d) discussion questions and answersrelated to facts, analysis, and action; (e) teaching suggestions; and(f) references.

Teaching with cases requires ongoing preparation. As instructorfor this course, I came to the classroom with over 20 years of experi-ence in hospice and palliative care. While my understanding of thevenues and issues involved in providing end-of-life and bereavementcare was an asset, it did not offset the need to prepare for each andevery case discussion. Review of the facts is essential prior to the classsession, and review of the teaching notes facilitates awareness ofteaching possibilities and questions to be raised, especially if classmembers are not engaged or the session lacks energy. Each classhas its own personality and responds differently to the methodrequiring the instructor to consciously prepare to direct case discus-sions in a manner that is responsive to the group’s experience andtemperament.

One of the characteristics of the decision case method of teachingis that the teacher is a co-learner and allows the discussion to bedriven by the responses of the participants. While skillfully usinga combination of questioning, listening, and responding to directthe session toward defined learning objectives, the instructor mustavoid being too directive and discouraging the free flow of ideas.This ideal has been described as ‘‘controlled spontaneity’’—theright balance between free-wheeling discussion and control (Welty,1989).

By allowing class members the freedom of applying their knowl-edge as well as their practice wisdom and creativity, novel approachesand unique perspectives emerge. As an experienced professional, theinstructor may often find it difficult to refrain from directing thediscussion or attempting to teach content or theory as the classaddresses the case. Dominating or closely directing the discussioncan thwart the potential for class members to learn from each otherand develop synergy. It is important to emphasize that there is no onecorrect answer to the dilemma posed by the case and to encourage theless experienced and knowledgeable members of the class to activelyparticipate and offer their perspectives.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Student Preparation

It is essential that students come to class prepared for the casediscussion. Over the past 4 years, several methods have been usedby the instructor to assure students’ advance preparation. Initially,students were required to prepare a brief paper to be submitted atthe beginning of the class session answering a number of questionsrelated to the case and identifying the decision to be made by the caseprotagonist. In evaluating this preparation method, students expres-sed that they found it to be very repetitious and unnecessary. Theybelieved it was more like ‘‘busy work’’ that was insulting to thosewho took their personal preparation seriously.

A second approach used was to have the student write a brief dis-cussion of the decision to be made, the possible options, and theirrationale for the decision they would make based on the case content.This method assures that students read the case and gave someforethought to the decision to be made prior to class. One of thehallmarks of decision case method teaching is that students learnfrom each other during the discussion process. The ideas that stu-dents bring to class are often altered as they reflect on the decisionwith their classmates and are exposed to different perspectives viadiscussion and debate.

The third and currently used approach for preparation involvesreflecting on each case in a way that encourages use of the criticalthinking process. During the last 2 years in which the course hasbeen offered, a student journal experience has accounted for 50%of the course grade. This journal is used for both cognitive andpersonal reflections and reactions to a variety of experiential activi-ties completed both in and out of the classroom. In their journal,student reflections are expected to be related to identification ofthe decision and formulation of a response prior to the class meet-ing at which that case will be discussed. The instructor does notverify that this occurred each time as the complete journal is notsubmitted until the end of the course, but student participationeither verifies or negates such preparation. Subsequent to the classdiscussion of the case, students are to reflect in their journaldescribing what they learned via the discussion and the input oftheir fellow learners and whether the discussion altered their per-spective on the case or the decision they would make as the caseprotagonist.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Criteria for grading each decision case entry in the student journalare as follows:

Excellent (4 points)—demonstrates application of critical thinkingskills to formulate a response to the case decision. Response isbased upon the information available and reflects knowledge ofthe case and related readings. Several alternatives are explored.Postclass reflection indicates consideration of and reaction todifferent perspectives shared by fellow classmates.

Average (2–3 points)—responds to case offering a reasonablesolution and rationale based on information in the decision case.Briefly reflects on viewpoints offered during class discussion.

Poor (1 point)—response to case lacks depth. Offers solution butrationale and relationship to details of the case are not explored.Postclass reflection is minimal or absent.

Absent (0 points)—neither preclass nor postclass refectioncompleted.

Students can receive a possible 28 points on their reactions to thedecision cases out of a total 128 points (22%) possible for theirjournal. The journal score is weighted with other assignments andaccounts for 50% of the student’s overall course grade. The majorityof students score very well on the decision case related points.

Classroom Discussion Process

Lynn (1999) offers the following scheme for organizing a class dis-cussion which is attributed to teachers at the Harvard Business School:

1. Fact confirmation: Who? What? When? Where?2. Analysis: Why? How?3. Challenge: So what?4. Action: What would you do?5. Hypothesis: What if?6. Prediction: What will happen?7. Lessons: Of what is this an example? This is a case of what? (Lynn,

1999, pp. 64–65)

Class discussions using this general format flow easily from the factsto analysis and application of the students’ critical thinking abilities.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Because students come to class prepared, less time is spent on factconfirmation than on analysis of the facts and the application of thatknowledge to problem solving. Clarifying and deciding how to struc-ture the problem or decision to be made is a critical step in problemsolving (Gambrill, 1997) and is a focus for the class discussion.

The cases used in this course expose students to a variety ofsettings in which social workers provide end-of-life or bereavementcare including hospice organizations, nursing homes, schools, andhospitals; and a variety of social work roles such as hospice teammember, school social worker, bereavement counselor, dialysis socialworker, and discharge planner. Because graduate level social workfield education is limited to one to three placements depending onthe student’s status, it is important that students are exposed to othervenues and roles, and this is indeed a benefit when using decisioncases. Each decision case provides background related to the agency,the involved social worker, and that social worker’s role. Discussingthese elements offers students exposure to various social work func-tions and settings. As additional teaching activities, students can beassigned to research specific agencies or roles and report findingsto the class, or a practicing social worker in a particular role canbe invited to come and share with the class about his=her role asbackground for the case discussion.

‘‘This cannot possibly have happened’’ or ‘‘is this for real?’’ arefrequent comments from students as they react to the cases. Suchquestioning of the factual nature of the scenario verifies that studentsare not always prepared for the complexity of practice and the chal-lenges they will actually face. To be able to tell them that the case isfactual with only the identities of the characters, location, and agencychanged, validates the situation and confirms the need for the studentto be able to apply critical thinking skills to each unique situation.The old adage ‘‘truth is stranger than fiction’’ often applies to thereality of the lives and experiences of those facing the end of lifeand their families.

Challenges for the instructor using decision case method teachinginclude managing content so that all important facts and issues areexplored during the allotted time and assuring that students are stimu-lated and engaged by the discussion. The teacher must both artfullyraise the appropriate question at the right time to guide without dom-inating the discussion and must respond appropriately to the studentcontribution. Participation problems (unmotivated or unprepared


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

students, compulsive talkers, quiet or withdrawn students, etc.) canbe particularly challenging. Ineffective participation can be avoidedby providing clear discussion expectations prior to using the methodand reviewing such expectations should problems arise.

Student participation can be an issue in that some may dominatewhile others offer little to the discussion. Dividing a large class intosmaller groups or dyads for the initial discussion and then havingthose smaller groups report on their decision to the larger group isone way to assure that all have the opportunity to participate at somelevel. Some recommend using a ‘‘call list’’ or calling on the quieterstudents especially in the beginning of the class session when factsof the case are discussed (Erskine, Leenders, & Mauffette-Leenders,1998). Because the class size for this particular elective is usually small(8–15), most students are comfortable with contributing at somepoint during the case discussion.

EVALUATION PROCESS AND RESULTS

Instructor Evaluation of Individual Sessions

It is important that the instructor reflect on each session and evalu-ate the discussion. Lynn (1999) suggested that the following questionsbe asked after sessions:

1. How much did the instructor talk versus how much did the stu-dents talk? (A high ratio of student to instructor talking is best).

2. How many students were voluntarily active in the discussion?(High levels of volunteering signify commitment).

3. How many questions did the instructor ask? How many follow-upor challenging questions were asked? (The instructor should askquestions, not answer them. Students should question each other).

4. How many times did students laugh? (Laughter is generally a signof high morale and a relaxed learning environment).

5. Was there a high level of ‘‘energy’’ in the discussion? (Energyamong students signifies engagement and concern about thematerial and the issues).

6. Did the discussion make sense? Was it coherent? (A logical flow ofdiscussion makes key points and insights clear).

7. Did the discussion conclude on an upbeat? (A discussion that diesat the end has less impact).


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Such evaluation can improve the instructor’s use of and comfort withthe method in the future with the same group or other groups oflearners.

Instructor Evaluation of Student Learning

Over the past 4 years, several methods have been used by thisinstructor to evaluate student learning. Initially, students were givenpoints for their preparation papers as described in the earlier section,student participation, and in addition, 10% of the student’s grade wasbased upon class participation obtained by averaging the student’srating of their own participation and the instructor’s rating of thatparticipation. When journaling was used as the method for prep-aration, part of the journal grade was based upon the reaction to eachcase in the student’s journal. In reviewing the student journals, itbecame apparent that some students who were quiet during the classdiscussion were nonetheless seriously considering and reflecting in-depth on each case. It became obvious to the instructor that activeclass participation was not always reflective of the student’s internalprocessing of the case or the learning that occurred.

During the past 3 years, the Kent School of Social Work, as partof a University-wide initiative, has focused on the development ofcritical thinking skills in learners. Evaluation of the student’s processtoward development of such abilities has been mandated as part ofthe outcome evaluation for each required or elective course. There-fore, a critical thinking assessment rubric was developed for overallevaluation of each student’s progress in this and all other graduatelevel social work courses. The rubric used in this course is containedin Table 3 and details the student evaluation criteria based upon theirreflections on each decision case and the related class discussion.Results of this rubric are reported to the Associate Dean for AcademicAffairs and used in the overall evaluation of the graduate schoolcurriculum and related outcomes. Use of the decision case method isextremely compatible with an increase in critical thinking abilitiesdesired by this academic agenda.

Student Evaluation of Participation

Students complete an in-depth evaluation of the class during thefinal session of the semester. Since the inception of the use of the


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

TABLE

3.RubricforEvaluationofCriticalThinkingBasedUponAnalysis

ofDecisionCasesCompletedasPart

ofClass

JournalAssignment

TheStudent

Not

Fulfilled

(1)

Minim

ally

Fulfilled

(2)

Partially

Fulfilled

(3)

Mostly

Fulfilled

(4)

Completely

Fulfilled

(5)

Score

Demonstrates

recognitionof

theproblem=

decision

Doesnotidentify

andstate

the

nature

ofthe

decision=

problem

Identifie

sthemain

decision=problem,

butdoesnot

explain

whyor

how

itis

anissue

Identifie

sthemain

decision=problem

andarticulatesan

understandingof

thescopeofthe

problem

and

relatedissues

Identifiesthemain

problem,articulates

andunderstandingof

thescopeofthe

problem

and

discusse

srelated

issuesandpossible

repercussions

Articulatesathorough

understandingofthe

scopeofthe

problem=decision

andtheissues

involvedand

identifiesrelated

issuesand

repercussions

Usesreasoning,

arguments,

andevidence

Doesnot

developa

solutionbased

onavailable

inform

ationor

evidence

Appliesreleva

nt

thinkingskillsbut

doesnotrelate

them

tocontext,

assu

mptions,

data,and

evidence

Appliesreleva

nt

thinkingskillsin

presentin

g

inform

ation.

Suggests

implicationsand

consequencesbut

withoutin-depth

development

Appliesreleva

nt

thinkingskillsin

assim

ilating

inform

ationwith

referenceto

context,

assumptio

ns,

data,

andevidence.

Developsatleastone

appropriate

solution=decisionand

discusse

s

implicatio

nsand

consequence

s

Appliesrelevant

thinkingskillsin

presenting

inform

ationand

developsmultiple

solutionsbyusingall

available

and

applicable

inform

ation.

Discussesmultiple

implicationsand

consequencesof

potentia

ldecisions

244

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Draws

conclusions

basedon

reasons,

arguments,

andevidence

Conclusionsare

notprovided.

Conclusionsare

providedbut

withoutdiscussion

ofim

plicationsor

consequences.

Little

orno

refle

ctivethought

isprovidedrelated

todecision

Conclusionsare

statedand

discussed.

Implicationsand

consequencesof

theconclusionare

refle

ctedin

context,relativeto

assu

mptionsand

supporting

evidence

Statedconclusionsare

basedonathorough

examinationof

evidence,aclear

explanationof

reasonable

alternatives,oran

evaluatio

nofpossible

consequence

s

Statedconclusionsare

basedonathorough

examinationof

evidence,reasonable

alternatives,and

possible

consequences.

Reflectio

ndevelops

andchallenges

solutionsbyusinga

variety

ofrelevant

inform

ationand

analysisofthe

consequencesof

conclusions

Shows

awarenessof

multiple

points

ofview

Doesnot

acknowledge

otherpossible

perspectives

orother

optionswere

consideredin

developingthe

decision

Acknowledgesother

possible

perspectives

althoughtheyare

notclearlystated

ordeveloped

Acknowledgesand

statesother

salient

perspective

sand

positions

importantto

the

decisionanalysis

Acknowledges,clearly

states,anddevelops

atleastoneresponse

toothersalient

perspectivesand

positionsthatare

importantto

the

decisionanalysis

Acknowledges,clearly

states,anddevelops

multiple

responsesto

otherperspectives

andpositionsthatare

importantto

the

analysisofthe

decision

StudentName:

FinalSco

re:

245

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

decision case method in this course, the course has been taught sixtimes and 103 students have completed this evaluation.

Evaluation of the decision case method as used in this course issummarized in Table 4. The results are supportive of the student’sacceptance of this method to teach social workers preparing for workin end-of-life and bereavement care.

Besides evaluating the use of the decision case approach, studentswere asked to rate each of the decision cases used. There was littlevariation in their ranking of the cases as not beneficial, somewhatbeneficial, very beneficial, or extremely beneficial. For each of theseven cases used in this class, 96% (98 of 102 respondents) of thestudents ranked the case as very beneficial or extremely beneficialto their learning.

It should be noted that there are students who do not prefer thedecision case method approach. Of the students completing the evalu-ation, nine students (9%) indicated that they preferred lecture to thisapproach and 26 (26%) reported themselves as neutral related to pre-ferring lecture or decision case method. Because course evaluationswere submitted anonymously, it is unknown which students preferredthe lecture method or if a certain type of student does not embracedecision case method learning. Those selecting the ‘‘neutral’’ responsemay see both methods as useful depending on the content type ofmaterial being taught. Cossom (1991) also reported that this methoddoes not appeal to all students. In his evaluation, 58% of the studentsviewed it as ‘‘better’’ or ‘‘much better’’ than other methods, while27% felt it was ‘‘worse’’ or ‘‘much worse.’’ His conclusion was thatit is useful as a modality in an eclectic approach (Cossom).

Since using the journal to prepare for and reflect on class discus-sions, 37 of 46 (80%) students responding to the class evaluation sta-ted that it was helpful to journal their reactions to cases prior to class,and 41 of 46 (89%) felt journaling to be an effective way to preparefor and react to the decision case discussions. When asked what theyliked best about the class in general, eleven students voluntarily statedthe cases and related discussions were their favorite aspect of thecourse.

When asked how use of the decision case method in this coursecould be improved, one student suggested the actual decision madeby the social worker in the case be shared at the end of the classdiscussion as an epilogue to the discussion. While this may be anappealing idea, decision cases are intentionally open-ended in an


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

TABLE

4.StudentEvaluation

ofDecision

Case

Method

Approach

as

Used

inDeath

and

GriefElective

With

Valid

Percentages

and

Mean

Ratings

(N¼103).

Students

Were

Asked

toRate

Decision

Case

Method

Teaching

as

Used

intheGraduate

LevelSocialWork

Class,Death

andGrief

Statement

Number

Responding

Strongly

Disagree

0

Disagree

1

Neutral

2

Agree

3

Strongly

Agree

4

Mean

Score

Decisionmethodteachingis

aneffective

methodto

teach=learn

socialwork

102

2(2%)

06(6%)

38(37%)

56(55%)

3.43

Thedecisioncaseschallengedmeto

think

differentlyaboutsomeissuesin

my

professionalpractice

101

1(1%)

2(2%)

6(6%)

29(29%)

63(62%)

3.50

Ilearnedfrom

theinputofothers

duringthe

discussionsofthecases

103

01(1%)

8(8%)

30(29%)

64(62%)

3.52

Iwould

recommendtheuseofdecisioncasesin

teach

ingDeath

andGriefto

socialworkers

101

2(2%)

1(1%)

4(4%)

27(27%)

67(66%)

3.54

Ipreferthelecture

methodasopposedto

decisioncasemethodteaching

100

28(28%)

37(37%)

26(26%)

9(9%)

01.16

Learningbythedecisioncasemethodwillhelp

mein

myprofessionalpractice.

101

1(1%)

2(2%)

9(9%)

42(42%)

47(47%)

3.31

247

Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

effort to replicate difficult decision making with limited informationand without the luxury of hindsight to critique decisions by otherprofessionals (Wolfer & Runnion, 2008).

Another student noted the need to engage all students in theprocess as some offered little during discussions. This is always achallenge for the instructor in that some students are not comfortablewith sharing or engaging in such discussions. Another suggestionmade was that students be assigned to develop a plan of actionrelated to a case, present it to the class, and defend their plan as analternative to open discussion. Such an approach, however, wouldnegate the value of collaborative decision making in which classmatesand the instructor challenge and learn from each other as a solution isdeveloped.

Unsolicited comments made on the overall course evaluationrelated to the decision case method included the following:

. ‘‘The cases gave me a different perspective through sharing of thepersonal experiences of others’’

. ‘‘I liked the discussions related to decision cases and the interactionbetween students and the instructor as well as students with otherstudents’’

. ‘‘I always learn more from discussion than reading or justlistening’’

. ‘‘I think more classes would benefit by using the decision casemethod because it requires use of crucial thinking skills and appli-cation of material being learned’’

. ‘‘I like the decision case method and would encourage its continueduse’’

. ‘‘The decision case method is a great way to think and learn’’

. ‘‘This class helped me to ’think outside the box’’’

Limitations

Student evaluation of the use of decision cases in this class was lim-ited to several questions on the final course evaluation and responsesabout the course in general. Directed questions focused on studentacceptance of this approach and their evaluation of the cases used.Evaluation of the impact of the cases and related teaching method onthe defined course objectives is needed to fully evaluate pedagogical


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

outcomes. In the future, students taking this class will complete anattitudinal survey before and after the class in an effort to evaluatethe impact of the use of decision cases on their thoughts related toend of life care.

Only seven of the cases developed by the SOROS Foundationgrant have been included as content for this class thus far. Withthe publication of all developed cases (Wolfer, 2008), a greater varietyof cases is now available for use adding more variety and better ‘‘fit’’of cases to the intended content for a specific class session.

CONCLUSIONS AND IMPLICATIONS

Student feedback related to the use of the decision case method inteaching this course indicated it to be well-accepted when used toteach end-of-life and bereavement care. Many students voluntarilystated that the decision case method was the component of the classthat they most enjoyed.

Decision cases specific to issues of palliative and bereavement carecould be used in elective courses such as the Death and Grief coursewhich is the topic of this article and throughout the social work cur-riculum to assure that all masters prepared social workers receiveadequate exposure to the knowledge content and critical thinkingabilities required when working with patients and families facingthe end of life. As early as 1977, educators advocated for a moduleof learning related to death and dying to be included in foundationcourses in human behavior and the social environment and recom-mended using illustrative case material (Goldstein, 1977). Social workmethodology courses are another appropriate area within the socialwork curriculum to include death and dying content (Miller, 1977),and to employ decision cases. Capstone courses such as thatdeveloped by Wolfer, Freeman, and Rhodes (2001) at the Universityof South Carolina can be built using decision cases as the basisfor enabling graduate level social workers to apply their learning tochallenging end-of-life case scenarios.

Other potential opportunities to use such decision cases include theorientation and ongoing development of social workers in hospiceand home health agencies, hospital social workers providing dis-charge planning or palliative care consultation, social workers in can-cer clinics, and those in any setting where they frequently work with


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

dying clients and=or their families. The NASW practice standardscall for continuing education related to palliative and end-of-life care,and these cases could readily be included in continuing educationofferings.

Use of the decision case method and cases developed specificallyfor the teaching of end-of-life and bereavement care is a relevantand well-accepted approach that addresses the need for multipleteaching methods and realistic case materials. The decision cases pro-vide opportunities to process client situations in the classroom alongwith course content which includes the areas of knowledge necessaryfor such practice outlined in the NASW Standards for Palliative andEnd-of-Life Care (2004).

REFERENCES

Brandsen, C. K. (2005). Social work and end-of-life care: Reviewing the past andmoving forward. Journal of Social Work in End-of-Life and Palliative Care, 1(2),45–70.

Cossom, J. (1991). Teaching from cases: Education for critical thinking. Journal ofTeaching in Social Work, 5(1), 139–153.

Csikai, E. L., & Raymer, M. (2005). Social worker’s educational needs in end-of-lifecare. Social Work in Health Care, 41(1), 53–72.

Erskine, J. A., Leenders, M. R., & Mauffette-Leenders, L. A. (1998). Teaching withcases. London, Ontario, Canada: Ivey Publishing, Ivey School of Business Admin-istration, University of Western Ontario.

Gambrill, E. (1997). Social work practice: A critical thinker’s guide. New York:Oxford University Press.

Goldstein, E. (1977). Teaching a social work perspective on the dying patients andhis family. In E. Pritchard, J. Collard, B. Arcuth, A. Kutscher, I. Suland & H.Lefkloutz (Eds.), Social work with the dying patient and his family (pp. 301–312).New York: Columbia University Press.

Huff, M. B., Weisenfluh, S., Murphy, M., & Black, P. J. (2006). End-of-life care andsocial work education: What do students need to know? Journal of GerontologicalSocial Work, 48(1–2), 219–231.

Jeffrey, D. (2003). What do we mean by psychosocial care in palliative care? InM. Lloyd-Williams (Ed.), Psychososcial issues in palliative care (pp. 1–12).New York: Oxford University Press.

Kimball, B. A. (1995). The emergence of case method teaching, 1870s–1990s: A searchfor legitimate pedagogy. Indianapolis: Indiana University.

Kramer, B. J. (1998). Preparing social workers for the inevitable: A preliminaryinvestigation of a course on grief, death, and loss. Journal of Social WorkEducation, 34(2), 211–228.


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Leenders, M. R., Mauffette-Leenders, L. A., & Erskine, J. A. (2001). Writing cases(4th ed.). London, Ontario, Canada: Senton Printing.

Lundeberg, M. A., Levin, B. B., & Harrington, H. L. (1999). Who learns what fromcases and how? The research base for teaching with cases. Mahwah, NJ: LawrenceErlbaum.

Lynn, L. E. (1999). Teaching and learning with cases: A guideperiodic. New York:Chatham House.

Miller, R. (1977). Teaching death and dying content in the social work curriculum.In Social work with the dying patient and the family (pp. 289–300). New York:Columbia University Press.

National Association of Social Workers. (2004). NASW standards for palliative andend of life care. Washington, DC: Author.

National Consensus Project for Quality Palliative Care. (2004). Clinical practiceguidelines for quality palliative care. Brooklyn, NY: National Consensus ProjectSteering Committee.

Parker, J. (2005) Social work education for palliative care—Changes and challenges.In J. Parker (Ed.), Aspects of social work and palliative care (pp. 1–17). London:Quay periodics.

Reith, M. (2005). Social work. In M. S. Watson, C. F. Lucas, A. M. Hoy, & I. N.Back (Eds.), Oxford handperiodic of palliative care (pp. 665–666). New York:Oxford University Press.

Welty, W. M. (1989). Discussion method teaching. Change, (July=August) 41–49.Wolfer, T. A., Freeman, M., & Rhodes, R. (2001). Developing and teaching an M. S.W. capstone course using case methods of instruction. Advances in Social Work,2(2), 156–171.

Wolfer, T. A., & Runnion, V. M. (2008). Dying, death, and bereavement insocial work practice: Decision cases for advanced practice. New York: ColumbiaUniversity Press.

Zelinsky, L. F., & Thorson, J. A. (1983). Educational approaches to preparing socialwork students for practice. Death Education, 6, 313–322.

Date Received: 08/23/08Date Revised: 11/12/08

Date Accepted: 12/16/08


Dow

nloa

ded

by [

Nor

th W

est U

nive

rsity

] at

19:

30 2

0 D

ecem

ber

2014

Documents

Use of the Decision Case Method of Teaching in a Course on Death and Grief