Nama : Muhammad Agung K.

NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

Case Based Learning, an easy solution to improve cognitive skills ?: Literature Review

Muhammad Agung Krisdianto*, Sri Sundari Purbohadi**

*Colleger Master of Nursing Consent in Nursing Education University of Muhammadiyah Yogyakarta
**Lecturer/Mentor of University of Muhammadiyah Yogyakarta

Author Contacts:
*magungkrisdianto@gmail.com
Ns. Muhammad Agung Krisidianto, S.Kep
**sundari_purbo@yahoo.com.sg
Dr. dr. Sri Sundari Purbohadi, M.Kes

Abstract
Background: Case Based Learning is one approach of the Problem Based Learning method where CBL is considered
capable of improving cognitive learners. There are several studies that argue that CBL is able to improve students' cognitive
competence.
Objective: The aim of study is to review the literature related to the influence of Case Based learning on cognitive
improvement
Methods: 12 articles obtained from two databases: National Library of Indonesia (PNRI) and Google Scholar with
screening process using title, abstract, and inclusion and exclusion criteria
Results: The results of this review literature found that Case Based Learning is able to improve the cognitive based
on the measurement of Bloom's taxonomy
Conclusion: CBL can be one of the effective learning method to improve students' cognitive in learning process,
especially in nursing profession

Introduce
Quality teaching process is a learning process that gives changes to the results better than ever1. Learning process is
considered successful if it can provide changes to students who are sedentary. . Bloom's Taxonomy divides learning outcomes into three
domains: cognitive, affective and psychomotor 2. Bloom's taxonomy was invented by Benjamin S. Bloom in 1949, Bloom
proposed his idea of a cognitive taxonomy division to simplify the preparation of the question bank so that it has the
same learning goal3. Bloom's cognitive taxonomy makes it easier for educators to define learning objectives. This
learning objective comes with verbs and nouns. The verb defines the depth of cognitive mastery desired, while the
noun indicates what knowledge is expected4.
The first publication of Bloom's taxonomy was conducted in 1956. The first publication divides cognition
into six levels: knowledge, comprehension, application, analysis, synthesis and evaluation. David R. Krathwohl, one
of Bloom's team proposed the Bloom Taxonomy Revision (RTB) after 45 years later, Krathwohl worked with seven
educational and educational psycho teams2. RTB adds meta-analytical domain into its theory5. The main purpose of
the RTB is to respond to the demands of the development of the educational community, including in the
developmental part of children, and the preparation of educators in composing teaching materials. Krathwohl's revision
provides significant changes, especially in the discussion of application and terminology of the learning process.RTB produces cognition
levels into six sections by remembering, understanding, applying, analyzing, evaluating and create2.
.
Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

Background
Case Base Learning (CBL) is one approach of Problem Based Learning. CBL is a case study / literature / story that
describes the message of learning / education in it6,7. CBL method is often applied by some business, law, medical,
and science education, but the most visible development and become very popular is the health science 8. The
application of CBL in health science is able to improve students' cognitive by solving cases / scenarios that have an
overview of the real state of clinical practice patients9.
CBL is considered capable of improving student cognitive 10,11,12 ,. CBL is also considered to be a good
method considering the many benefits generated during the teaching and learning process, some of which are
improving attitude and learning motivation13, improving critical thinking skills14, increasing knowledge15, providing
an overview of clinical practice16, triggering active learning17, favorite method of students in teaching and learning18.
Some researchers disagree in declaring CBL as a method that can improve cognitive abilities. Pre-Service
Teachers (PSTs) are considered to be better in improving students' cognition19. Human Patients Simulation (HPS) is
also claimed to be better than CBL20. Other researchers revealed that CBL would be better if combined with Small
Group Session (SGS)21. The initial implementation of CBL is also considered to provide a sense of stress to students22.
The CBL process should pay attention to such things as programmer qualification, classroom size, and service in a
computer laboratory (if used) to create a quality CBL method23. Some of the rebuttal in the effectiveness and obstacles
in the CBL learning method, making this method is still not able to be implemented optimally by some institutions
and has not been effective in improving students' cognitive.
The difference between the results of one study with another makes CBL as an evaluation material whether
this method can be used as one of the superior products in improving student cognition. Therefore, the authors are
interested to make CBL as a literature review material to determine its influence in improving students' cognitive.

Objectives

The purpose of this literature review is to identify between one study and another on the effect of Case
Based Learning in improving students' cognitive abilities.

Method
Search Techniques
A systematic search technique is used to obtain a good article qualification sourced from PNRI with reference
to the article column and Google Scholar. The search is done manually by entering the keyword "Case Based
Learning", then adding the keyword "Cognitive" with the word "AND". The results are detailed by entering the year
criteria from 2014 to 2018.
The searching process of PNRI database with keyword "Case Based Learning" got articles with the number
of 1235 articles, then added the keyword "AND Cognitive" then the number articles decreased to 551. Setting year
published from 2014 to 2018 produced articles amounting to 158 The search process at Google Schoolar with the
same process resulted in article depreciation from 22,000 to 10,400, and to 3250 articles
Selection Technique
Selection of articles is done to ensure that the articles obtained have good content . One of the screening techniques done
is to see the title as the focus of the study iterature. Titles that have been selected will be re-sorting by looking at the abstract as a
picture of the contents of the article. The results of abstract screening are then sorted back by adjusting inclusion and
exclusion criteria as reference to the selection of article articles. The inclusion and exclusion criteria include:
Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

Inclusion:
 Article are Original research
• Articles discussion about CBL and cognition
• The effect on cognition can be seen directly from the titles, results and conclusions contained in the
article.
• Articles published in 2014 to 2017
• Participants are health workers
• Articles / Journals in English or Indonesian
Exclusion:
• Articles not accessible
• Articles do not discuss cognitive or levels

158 articles obtained from the PNRI database re-screened using titles yielded only 16 elective articles, after which feasibility studies were
conducted by reading the abstracts from each articles, 10 articles were obtained accordingly. The final process is to apply inclusion
and exclusion criteria to the contents of the articles, leaving only two journal articles.
3250 journal articles obtained from the Google Scholar disconnected database returned using the title and
produced 83 selected journals, after which feasibility studies were conducted by reading the abstracts from each
journal, 49 journal articles were obtained. The final process is to conduct inclusion and exclusion criteria of journal
contents, leaving only 10 journals. The number of journal articles to be conducted literature review is 12 journal
articles.

Results
The main focus in this review literature is the CBL influence on students' cognitive abilities. Literature
review is done optimally by selecting articles from several journals and in the final stage of the classification to get
that CBL has uniqueness in some of the results, among others:
Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

Identification PNRI keyword “Case Based Google Scholar “Case Based

Learning” AND cognitive, years 2014 Learning” AND cognitive,
– 2018 = 158 years2014 – 2018 = 3250
Total 3408 journal articles at
identification stage
Screening PNRI = 16 articles Google Scholar = 83 articles
A total of 99 journal articles are gained
by screening titles
Elagibilty PNRI = 10 articles Google Scholar = 49 articles
A total of 59 journal articles obtained
by performing abstract feasibility
screening
Inclusion and PNRI = 2 articles Google Scholar = 10 articles
Exclusion The final total number of articles to
be conducted after the review
literature review inclusion and
exclusion process amounted to 12
journal articles.

• Research methods
Of the 12 journal articles obtained, six of them are quantitative research10,11,12,25,26,27,28,29. Three of them are
qualitative24,31,32. One research method mix31.

• State of Research
Of the 12 journal articles, five studies were conducted in India10,11,12,25,28. One study in Lebanon24. One study
in Canada26. One study in the United Arab Emirates27. Two studies of south korea29,30. One study in Pakistan31.
One study at United State32.

• Sample Research Criteria

From 12 journal articles, six journal articles with sample criteria for medical students10,11,12,25,28,31. Three
journal articles with sample criteria of nursing students24,29,30. One journal article with sample criteria for
biochemistry students26. One journal article with sample science sample criteria27. One journal article with
student nutrition sample criteria32.

• Able to Increase Cognitive and Domain Deeper Levels

From 12 journal articles it was explained that CBL was able to improve students' cognitive ability10,11,12. CBL
is also even able to penetrate in cognitive abilities such as the ability to remember, understand, apply, analyze,
evaluate and create10,11,12,24,25,26,27,28,29,30,31,32.
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan
No Authors Tittle
(Year)
1 Bhattacharya et Early clinical exposure to first
al, (2016) year medical students through
case-based learning in
endocrine physiology
2 Bhattacharya et Case-based learning in
al, (2017) nutrition for first-year MBBS
students
3 Bhattacharya et Effect of case-based learning
al, (2017) in reproductive physiology on
cognitive domain scores of
first-year medical students in
Western India
Database Objectives
Google The objectives of this study
Scholar were to evaluate the cognitive
skills acquired by the
participating first-year MBBS
students after attending TDLs
on endocrine physiology
(using a pre-CBL test) and to
study the cognitive skills after
using CBL as the educational
intervention (using an
identical post-CBL test).
Google The objectives of the present
Scholar study were to compare the
cognitive domain scores of the
participating first-year MBBS
students after attending
conventional lectures on
nutrition (using a pre-CBL
test) and to compare these
with the cognitive domain
scores after using CBL as the
educational intervention
(using an identical post-CBL
test).
Google The objectives of the present
Scholar study were to assess the
cognitive domain scores of the
participating first-year MBBS
students after attending
lectures on reproductive
physiology (using a pre-CBL
test) and to compare these
with the cognitive domain
scores after using CBL as the
educational intervention
(using an identical post-CBL
test).
Method dan Sample Outcomes
Pre-Post (without controls), Statistically significant differences
59 first year medical were found in the student wise and
students question wise scores in the pre and
post tests.
Pre-Post (without controls), The mean score increased from
57 first year MBBS 5.39±1.51 (pre-test) to 7.11±1.19
students (post-test) with statistically
significant difference (P<0.00001).
Pre-Post (without controls), The overall mean score increased
55 first year medical from 5.36 ± 0.97 (95% CI: 5.11 –
students 5.62) in the pre-test to 6.49 ± 1.14
(95% CI: 6.19 – 6.79) in the post-
test. The differences between the
pre- and post-test correct responses
were statistically significant for
two questions.
Conclusions
Early clinical exposure
of a relatively larger
batch of students to CBL
by the same facilitator
was found to increase
cognitive domain scores.
The results of the
present study imply that
nutrition related case-
based learning enhanced
cognitive domain scores
of first-year medical
students.
The participating first-
year medical students
had adequate basic
knowledge of
reproductive physiology.
Gender differences in
correct responses were
statistically significant
for few questions. Use of
case scenarios enhanced
cognitive domain scores.
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

4 Kantar dan Case-based learning:What
Massouh, traditional curricula fail to
(2015) teach
5 Kartikayen et Retention of case-based
al, (2016) learning on infectious diseases
by third-year medical students
Google This study aimed at exploring
Scholar perceptions of nursing
students who had completed
two undergraduate nursing
courses using case-based
learning to be able to identify
professional skills that may be
gained by this instructional
approach.
Google The main aim and objective of
Sholar this complete-enumeration,
beforeand-after study (without
controls) is to employ case-
based learning (CBL) as an
adjunct to traditional didactic
lectures (TDL) for teaching
infectious diseases to third-
year undergraduate medical
students to study the retention
of knowledge by comparing
the cognitive domain scores in
pre- and post-tests.
Thematic analysis using
cross-group analysis and
inductive constant
comparison, 16 third years
nursing students
Pre-Post (without controls),
57 third years medical
students
The analyzed data converged on
three learning practices thatwere
developed by the case study
approach: (a) recognizing the
particulars of a clinical situation,
(b) making sense of patient data
and informing decisions, and (c)
reflection. Indepth analysis of these
practices helped unravel four
professional attributes that form the
tenets of case-based learning: (1) a
salience of clinical knowledge, (2)
multiple ways of thinking, (3)
professional self-concept, and (4)
professional caring.
The differences in the student-wise
and question-wise scores in the
pre-test and one-month post-test
and that between the pre-test and
six-month post-test were highly
significant. However, the
difference between the mean scores
in one-month and six-month post-
test were not statistically
significant
Since professional skills
are developmental in
nature, educational
programs may play an
active role in the skill
acquisition process. In
search of those ineffable
skills, four professional
attributes emerged from
the study findings.
Findings support
concerns of higher
education regarding the
ability of the traditional
curriculum to meet the
expectations of
employers at the
workplace
.
CBL modules using case
scenarios were found to
enable learning. The
marginal differences
between the scores in the
one-month and six-
month post-tests indicate
that a single post-test
administered six months
after the educational
intervention (CBL)
would be adequate.

6 Kulak and Does the Use of Case-based
Newton, Learning Impact the Retention
(2017) of Key Concepts in
Undergraduate Biochemistry?
Google The present study determined
Scholar the effect of CBL vs. non
CBL on knowledge retention
in an undergraduate
Biochemistry course; it also
investigated associations of
We used the Revised Two-
Factor Study Process
Questionnaire, a retention
test, final exam grades and
other demographic
information to statistically
compare academic
The CBL group (M=12.65,
SE=0.79) performed significantly
better on the retention test than the
non-CBL group (M=10.59,
SE=0.54; p=0.007) as measured by
independent sample t-tests in each
pooled condition. When retention
Our findings suggest that
use of CBL in
undergraduate
biochemistry education
may confer benefits in
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

learning approach, age and
gender.
outcomes of students test scores were analyzed as a terms of retention of
subjected to either CBL or function of treatment condition and knowledge of key
non-CBL active learning gender, gender was non-significant concepts.
techniques. (p=0.856). Deep approach score
significantly predicted retention
test scores in the CBL condition,
and there was a moderate positive
correlation (r=0.324, p≤ 0.005,
R2=0.105). Deep approach score
did not significantly predict
retention scores in the non-CBL
condition (r=0.036, p≤0.005,
R2=0.001).

7 Shetty et al, Comparison of didactic
(2016) lectures and case-based
learning in an undergraduate
biochemistry course at rak
medical and health science
university, UAE
Google The study was conduct to
Scholar analyse the perception of first
year medical students about
dicdactic leacture and case-
based learning, teaching
learning methodology in
biochemistry course
Cross Sectional, 126 first The students expressed their
year medical students satisfication that CBL was useful
teaching methodology in
understanding the concept in
biochemisty. Majority felth this
method motivated them to
critically think in filling the
learning gaps and building the
concept. The also help and opinion
that this method facilitated
interaction between staff and
student from differenct culters and
backgrounds, which helped them
developing their inter and
intraprofesional relation.
Case based learning can
be good substitute for
teaching biochemistry for
first year MBBS
students, which can be
used alone or in
combination with
didactic lecture to make
the biochemistry more
interesting and
understandable to MBBS
students. We
implemented CBL of
method of teaching with
encouraging and positive
results.

8 Vora and Shah, Case‑based learning in
(2015)
pharmacology: Moving from
teaching to learning
Google The study aimed to find out
Scholar the beneficial effects of case
based learning (CBL)
compare to didactic lecture in
pharmacology and to evaluate
the perceptions of students
regarding the CBL
A total of 68 5th medical The Group 1 showed significantly Self learning approach,
students took part in the increased (P < 0.001) test score critical thinking with
study and were randomly in knowledge‑based and critical the integration of subject,
assigned to two equal and arousal of interest in
thinking (clinical application) as
groups: Group 1 (CBL the subject were positive
compared to Group 2. The
group) and Group 2 (lecture effects of CBL in the
perceptions of students were
group). Cases, test items, teaching of concepts of
quite positive regarding the CBL as
students feedback pharmacology.
a majority revealed that they has
questionnaires were
better understanding of concepts
developed and peer viewed
(82.35%), self-learning
by experts. Group 1
underwent the CBL and the
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

same topics were handled approach (91.17%), critical

as a didactic lecture in thinking with integration clinical
Group 2 concurrently. subjects (97.05%), and active
Written tests were participation in discussion
conducted after completion (76.47%) as well as interest in
of each session and the subject (88.24%) through the CBL
perceptions of students process
were evaluated

9 Yoo and Park Effect of case-based learning
(2014) on the development of
graduate nurses' problem-
solving ability
Google This study was carried out to
Scholar investigate whether case-
based learning (CBL) would
be useful in developing
problem-solving abilities in
graduate nurses.
Quasi-experimental design
using pre-test, intervention,
and post-test with a
nonsynchronized,non-
equivalent control group,
190 new graduated nurses
(94 used CBL and 96 used
LBG)
The research indicate that there
was a statistically significant
difference in objective problem-
solving ability scores of CBL
group demonstrating higher scores
The Research may
suggest that CBL is a
beneficial and effective
instructional method of
training graduate nurses
to improve their clinical
problem-solving ability.

10 Yoo and Park, Effects of case-based learning
(2015) on communication skills,
problem-solving ability, and
learning motivation in
nursing students
Google The purpose of this study was
Scholar to explore the effects of case-
based learning on
communication skills,
problem solving ability, and
learning motivation in
sophomore nursing students
Quasi-experimental study, At post-test, the case-based This finding suggests
we compared pretest and learning group showed that case-based learning
post-test scores obtained by significantly greater is an effective learning
the experimental group and communication skills, problem- and teaching method.
the nonequivalent, solving ability, and learning
nonsynchronized control motivation than the lecture-based
group. Participants from learning group
both groups were selected
using convenience
sampling from a population
of sophomore
undergraduate students
enrolled in a mandatory
health communication
course in the fall semesters
of 2011 (control group)
and 2012 (experimental
group) at a nursing college
in Suwon,Korea 143
nursing students (72
experimental from 77, 72
control from 74)
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

11 Bano et al, Case Base Learning and PNRI To explore the perceptions of
(2015) Traditional Teaching final year medical students
Strategies: Where Lies the about efficacy of traditional
Future? teaching methods and Case
based learning (CBL) and to
evaluate the effect of CBL on
students’ performance and
satisfaction level during their
clinical rotation in Obstetrics
and Gynaecology Department
Sequential mixed method 134 returned completed forms Although test
study, 134 students (from giving a response rate of performance was similar
141) 95%.Gender distribution was in both the groups,
similar in both the groups. There students expressed strong
was no statistically significant preference for CBL as
difference in performance compared to traditional
assessment. Strong preference for methods
CBL was expressed by 97% as it
improved their confidence (83%),
clinical and presentation skills
(91& 80%), attitude and student
teacher relationship (68 & 77%),
strengthened link between theory
and practice (90%), and integrated
basic and clinical knowledge
(92%). Seventy six percent stated
that all teaching should be
CBL. Qualitative data from SGD
strongly supported these views.

12 Harman et al, Case-Based Learning
(2014) Facilitates Critical Thinking
in Undergraduate Nutrition
Education: Students Describe
the Big Picture
PNRI This study examined student
perspectives of their learning
after immersion into case-
based learning in nutrition
courses.
The theoretical frameworks Four leading themes emerged.
of phenomenology and Story or Scenario represents the
Bloom’s Taxonomy of ways that students described case-
Educational Objectives based learning, changes in student
triangulated the design of thought processes to accommodate
this qualitative study. case-based learning are illustrated
Data were drawn from 426 in Method of Learning, higher
written responses and three cognitive learning that was
focus group discussions achieved from case-based learning
among 85 students from is represented in Problem Solving,
three upper-level and Future Practice details how
undergraduate nutrition students explained perceived
courses. professional competency gains
from case-based learning.
The skills that students
acquired are consistent
with those identified as
essential to professional
practice. In addition, the
common concept of Big
Picture was literated
throughout the themes
and demonstrated that
case-based learning
prepares students for
multifaceted problems
that they are likely to
encounter in professional
practice.
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

Discussion
The level of Bloom's taxonomy is initially in the form of knowledge, comprehension, application, analysis,
synthesis and evaluation, and then revised into level of remembering, understanding , applying, analyzing, evaluating
and create2. CBL is able to achieve learning targets in the form of better cognitive changes 10,11,12, even these changes
may occur in the old cognitive bloom model32, or revised33.
CBL is able to achieve higher levels of cognition domain. Some examples of cognitive abilities that can be achieved are able to
improve the long-term and short-term memory of a student16, facilitating in understanding each of the material topics,
especially the description of clinical practice experience21, facilitating in the application of learned execution23,
enhancing analytical and deep critical thinking32, facilitating students in self-evaluation30 and making new
breakthroughs in the learning process33. All the elements obtained represent every level of cognition based on Bloom's
taxonomy which is one of the assessment factors in cognitive measurement in various countries35,36,37, and one of them
is Indonesia.
Some articles reinforce the assertion that CBL is a good and practical learning method, especially in practice to
improve cognitive science and health actors35,36. Formerly CBL was performed as an alternative to clinical practice
because students were not allowed to hold patients during the education process, CBL now becomes the main approach
as a solution in providing an overview of clinical practice in improving cognitive health students2.

Limitless
The lack of this literature review is that not all samples were conducted on nursing students and no specific
research has been done to determine the effect of CBL on the cognitive improvement of health students (nursing)
especially in Indonesia

Conclusion
CBL is one of the learning methods that can improve students' cognitive. CBL is also considered feasible as one
of the methods dikarnakan learning can improve cognitive abilities in Bloom's taxonomy. Therefore CBL is suggested
to be one of the learning method that must be implemented especially in health sciences especially nursing education.
Funding : No funding sources
Conflict of interest : There is no conflict of interest

Acknowledge
My greatest thanks go to Dr. dr. Sri Sundari, M. Kes as a mentor who has taken the time to mentoring process
so that the literature review into a good paper

Author's Contributions
Designer and designer of learning concepts : MAK, SSP
Literature Review Analysis : MAK
Manuscript Writing : MAK
Advisor / Mentor : SSP
 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

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 Nama : Muhammad Agung K.
NIM : 20171050021
Peminatan : Nursing Education
Jurusan : Magister Keperawatan

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