Knowledge Integration in a Veterinary Science
Degree Course. A Pedagogical Basis for a Revised
School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton, Bonington, Leicestershire, LE12 5RD, UK
Neil Foster, School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Sutton Bonington,
Leicestershire, LE12 5RD, UK, Tel: +0115 9516433; E-mail:
Received: April 01, 2015; Accepted: July 16, 2015; Published: September 30, 2015
Veterinary education like medical education consists of a
spectrum of disciplines, fundamental sciences (biology, chemistry and
physics), applied sciences (pharmacology, microbiology, immunology,
physiology, anatomy) and clinical courses (application of the combined
knowledge). The programme of learning adopted at Nottingham
School of Veterinary Medicine and Science is one of integrated
teaching to provide context specific delivery of fundamental sciences
within body-system-based modules. This could lead to a potential
fragmentation of certain core subject areas as they are integrated
into modules. This shift in educational philosophy was designed to
promote more independent learning by aligning fundamental topics
to their final use in the clinical environment. The aim of this study
was to investigate whether there are sound pedagogical reasons for
this new curriculum. We report that undergraduate performance
(in questions which tested different levels of knowledge) was not
altered by module integration and that most undergraduates stated
that they focused on the larger body-system-based modules rather
than integrated modules contained within them. Thus suggesting that
students are able to smoothly contextualise subject based disciplines
within the larger systems-based modules.
In conclusion, our study indicates that there are pedagogical
reasons to continue with the integrated curriculum adopted at
Keywords: Pedagogy; Veterinary; Integration
As with other clinical/vocational courses, the veterinary
curriculum, and its content, at Nottingham University are driven
by an outcome based education system . Decisions on the
course content are driven by the required end point, learning
outcomes based on the European Association of Establishments
for Veterinary Education (EAEVE) and Royal College of
Veterinary Surgeons (RCVS). As with a number of clinical
sciences the breadth of these requirements has led to conflict
between the volume of information delivered in clinical sciences
and the time students can allocate outside their timetabled study
to develop and learn the required concepts [2-3]. This has lead
to a constraint on study time, leading to lower order learning as students use rote learning to cope with the large volume of
factual information. The curriculum of the new Nottingham
vet school was designed to reflect an important report into
these current issues in veterinary education, the Pew national
veterinary education program , which was concerned with
veterinary education in the USA and Canada, and the foundation
statements of EAEVE in 1990. These outlined a need for a change
in how veterinary education is delivered with an emphasis on a
deeper understanding of the scientific principles which underpin
clinical training, rather than a passive recall of facts, an emphasis
on problem solving and professional and personal skills training.
A need for lifelong learning across the whole University sector
was also highlighted by other influential reports such as
the report of the National Committee of Inquiry into Higher
Education (Dearing report) in 1997  and the report of the
National Advisory Group for Continuing Education and Lifelong
Learning: Learning for the 21st Century (Fryett report) in 1997
. These reports also needed to be considered when developing
the Nottingham course.
The impact of increased course content on lower order
learning can lead to a reduction in both the retention of
knowledge and the ability to apply this knowledge in a clinical
setting, which is in conflict with the aim of generating lifelong
learners in clinical science, since poor self-learning skills are
promoted . Students can, however, respond to the increased
challenge of a course, with relevant resources in place, by
recognising that they are required to work as more independent
learners . This type of educational philosophy requires that
students learn how to learn and the role of a course organizer is
to facilitate this transition to educational autonomy, by providing
clear educational scaffolding . The Pew and Dearing reports
did not set out a prescriptive educational mechanism for the
achievement of its aims. In an attempt to achieve these aims, the
Nottingham veterinary course was developed along a radically
different pathway to other UK veterinary degree courses by
utilising vertical and horizontal integrations of subjects. In this
model the course is divided along body systems rather than
discipline-based modules and interwoven within these systems based modules are integrated modules which are subject based,
for example immunology or microbiology may be taught within
the larger systems-based Gastrointestinal system module (Table
1). The inclusion of integrated modules is designed to place
the learning of these subjects in context, which may promote
a deeper understanding of them. This format of teaching
represents a major shift from the traditional teaching philosophy
of established UK veterinary schools in which fundamental
science delivery is built on dedicated modules with signposting
lectures and practical classes.
The increasing workload and attempts to motivate and
deepen students learning has led to pressure for a more
integrative approach to teaching within medical sciences.
Integration reduces the isolation of component subject areas by
integrating them under applied and clinical themes [9-10]. In
fact, some commentators have suggested that the level of course
integration can be used to assess innovation in medical education
. This 'integration-ladder' ranges from the complete isolation
of subjects at its lowest level up to the complete interdisciplinary
integration of key concepts. This trend effectively links the
integration ladder to a more traditional learning taxonomy such as
that proposed by Bloom  or, more appropriately, the revised
taxonomy proposed by Anderson and Krathwohl , since
the latter includes evaluation and creativity as higher learning
levels which require a metacognitive awareness of subjects to
improve practice. Thus, the more we can integrate the deeper the understanding which can be achieved. However, although we
have a rationale for wanting to change we need to know if this
change in educational philosophy has a pedagogical basis, as John
Dewey suggested there is danger in developing a new education
simply because we wish to offer something different from the old
system . This may be the case as the integration of the course
may marginalise specific areas and lead to a more superficial
learning experience, discussed below. The aims of the study
were to analyse student perception of integrated modules and
assess and compare student performance in both body-systembased
and integrated subjects when taught together. Thus, to
ascertain whether the novel teaching programme at Nottingham
undermines or enhances delivery of basic sciences in a clinical
Materials and Methods
Student cohorts analysed in the study
Two student cohorts were chosen; these were cohort 1, which
consisted of 101 students, which had begun the third year of the
course and cohort 2, which consisted of 97 students which had
completed year two of the course but had not yet been assessed
in three year modules.
The performance of both cohorts were assessed against two
systems based modules which contained integrated modules,
these were the cardio-respiratory system (CRS) (Year 1) module
Table 1: Year 1 Immunology integration across systems-based modules.
Introduction to Vet.Sci.
Lecture (1) Introduction to innate immunology
Lecture (2) Adaptive immune responses
Identification of Mammalian and Avian Leukocytes by Microscopy
Lecture (1) Cartilage as a Living Tissue: Osteoarthritis, Joint Inflammation and Cartilage Repair
Joint Inflammation and Disease
Clinical Relevance (1) Degenerative Joint Disease
Clinical Relevance (2) Sole Penetration
Lecture (1) Developmental anatomy
Cells and Tissues of the Lymphoid system
Live animal anatomy and imaging – spleen and lymph nodes
Lecture (3) Lymphocyte maturation and immunity
Lecture (4) Adaptive Immune responses
DSL (1) Innate Immunity
Lecture (5) Cytokines
Practical (2) ELISA analysis
Lecture (6) Inflammation and cytokines
Bone marrow and Leukocytes
The Complement System
Lecture (1) Cardiovascular parasites
DSL (1) Lungworms
Lecture (2) Pulmonary Parasites
Lecture (3) Pulmonary defence mechanisms
Clinical relevance (1) parasite immunity
Table 1 shows immunology teaching in different systems-based modules in year 1 of the course. Clinical relevance = academic facilitated small
group learning, DSL = directed self- learning (un-facilitated small group learning).
and gastrointestinal system (GIS) (year 2) module and in addition
to these, the response of cohort 1 to short answer questions
was also assessed in the principles of veterinary science (PVS)
(year 3) module, which consists entirely of integrated modules
and is designed to consolidate and build on previous knowledge
of integrated modules prior to students entering the clinical
curriculum (at the end of year 3) (Table 2).
Quantitative analysis of student performance in
integrated and system-based questions
To assess the effect of module integration on learning, we
compared student responses to questions which assess different
knowledge levels, as proposed by Anderson and Krathwohl .
These are: level 1. Remember (recall); level 2. Understand; level
3. Application; level 4. Analysis; level 5. Evaluate and level 6.
Create. To study student performance at these cognitive levels
we analysed their performance in three types of assessment
format which broadly measure the different levels of knowledge
in both systems-based and integrated subject-based questions.
Therefore, analysed multiple choice questions (MCQs) which
have been described as promoting and reflecting lower order
learning , assertion-reason questions (ARQs), which have
been shown to be a good predictor of student performance in
essay work and reflect higher order learning , and finally we
analysed student performance in essays.
Equal numbers of questions were analysed when comparing
the student response to systems based and subject based
(integrated) questions. Therefore, direct comparison could be
made between the mean numbers of correct answers obtained
from each individual response in a cohort divided by the number
of systems-based or integrated questions. Thus, if a cohort
consists of 100 students and all students answer 5 systems
based questions correctly but only 50 answered 5 integrated
questions correctly the mean number of correct response would
be equal to 100 and 50 respectively. However, in some cases the
comparison of responses to ARQs could not be made due to the
large disparity between the numbers of systems-based ARQs
and integrated ARQs. Data obtained for student performance in
GIS essay questions was expressed as a percentage and was not
subject to statistical analysis.
Table 2: Student groups and subject types involved in the study.
Cohort 1 = third year students who have completed Cardiorespiratory
System (CRS); Gastrointestinal System (GIS) and Principles of Veterinary
Science (PVS) modules. Cohort 2 = second year students who have
completed CRS and GIS but yet reached PVS, which is studied in year
three. Cohort 3 = fourth year students who were asked their opinion of
module integration as part of an On-Line Focus Group (OFG) which also
consisted of year two students (cohort 2).
Statistical analysis of quantitative data
Minitab was used to analyse all quantitative data. Data
sets which required comparison of 2 means were analysed by
student t-test and data sets which compared more than two
means were analysed by Analysis of Variance (ANOVA) with a
one-way classification. Any significant difference determined
by the F test was further analysed post hoc by Tukey's test (to
determine where the significance occurred). All values obtained
from statistical tests were compared with tabulated values at P
= 0.05 (95 % confidence limit) to determine whether or not they
Qualitative assessment of student perception
An Online Focus Group (OFG) was used to investigate the
perception of integrated modules by undergraduates. OFGs have
previously been shown to provide comparable information to
conventional ('face-to-face') focus groups but with the added
advantage of convenience, since there is no time constraint, and
participants are more likely to honestly disclose their views [17-
20]. Twelve undergraduate students from year 2 and year 4 were
randomly selected for inclusion with the rationale that second
year undergraduates had experience of integrated modules from
their first year modules and that fourth year undergraduates
have experience of integrated modules from years one to three
and year four, which includes a much stronger components of
clinical academic learning and practical learning via Clinical
Extra-Mural Studies (CEMS). Fourth year undergraduates may,
therefore, have similar experience to second year undergraduates
regarding the use of integrated modules in non-clinical years but
have greater experience and possibly a broader opinion obtained
from CEMS and the deeper application of integrated knowledge.
Ten, second year students (including 2 males) and eight, fourth
year students (including 1 male) responded to the questions.
Two focussing on topics were included and both topics contained
two linked questions. No prompts were used (other than linked
questions) to minimize bias which may have occurred due to
the over-direction of student opinion. The following questions
for discussion were sent by email to all participants en-bloc to
ensure that each student had the names and email addresses of
other participants within the group:-
(1) Please express your opinion regarding the importance of
module integration in undergraduate teaching and learning.
(A) Do you recognise an integrated module when it is taught
within a larger system-based module?
(B) What is your view of module integration?
Please feel free to provide any information you wish and to
discuss these points with other participants.
Ten, second year students and eight fourth year students
responded to the questions.
Second year undergraduate opinion
Only two, second year undergraduate students said that they
specifically recognised an integrated module when it was being
delivered within a larger systems-based module, although all
students gave an example of an integrated module when they
expressed their opinion. The two who were conscious of an
integrated module being delivered stated that:
(1) 'The integration within the modules is very good and the
repetition helps with deeper understanding e.g. the immunology
lectures at the end of last term helped a lot and gave an excellent
chance to revise our understanding'.
(2) 'I think for many of the integrated modules fitting them
into the long modules is a better option than having them as
separate modules as they often involve a lot of memorising. For
example, I think microbiology would be too overwhelming if it
were all taught in one long module and it would be a lot harder to
remember all of the information'.
All other students in this group said that, they did not
specifically recognize an integrated module and regarded them
as being integral to the bodily system being taught (the larger
systems-based module). One student, who said that she did not
recognize independent integrated modules within systemsbased
modules, qualified her opinion as follows:
'I hadn't personally noticed integrated modules, but I
personally find it quite difficult not to think in module mode.'
Fourth year undergraduate opinion
There were some very interesting differences in the opinions
of fourth year undergraduates compared with second year
undergraduates. All students in this group stated that they paid
little attention to an integrated module other than in the context
of the larger systems-based module but, as with second year
students, all fourth year undergraduates gave an example of an
integrated module when expressing an opinion. In this regard
the opinion of fourth and second years was comparable, however
fourth year undergraduate students appeared to be more aware
of an integrated modules but chose to ignore them, as shown by
two of the testaments below:
(1) 'I don't really notice much integration, but I'm not looking
for it. I'm sure it's a good thing to do because it helps you in the
real world and helps revision of other subjects.'
(2) 'If asked to find the integrated modules then yes I could
probably point them out. However, I tend not to consider the
modules as distinct sections of the course, rather just knowledge
acquired during the course that needs to be applied.'
However, one student also expressed a preference for
integration of some modules rather than the traditional way
these are taught (as stand alone block modules) in other UK vet
schools. This student believed that integration of some modules
helped to contextualise them within body systems and stated
'I think we all accept that, everything is integrated so we tend not to appreciate it as much! I like the fact that parasitology
and microbiology are introduced at the relevant points in the
course rather than stand-alone modules because it highlights the
relevance of them.'
The effect of module integration on low to medium
To assess whether module integration affected the
retention and comprehension of knowledge, we examined
student performance in both CRS (year 1) and GIS (year 2) and
compared these with the performance of students in integrated
modules, delivered within the systems-based modules. Student
performance was assessed by the numbers of correct responses
to MCQ (knowledge retention; level 1) and ARQ (knowledge
understanding and application; levels 2-3) and essays (which
can actually assess all 6 levels of Anderson and Krathwohl's
taxonomy, depending on the information they require).
Cohort 1 CRS
For this group only MCQ data existed since only one ARQ
from an integrated module was used during the examination and
therefore, comparison could not be made between the responses
of students to ARQs from the systems-based module and the
integrated modules contained within this systems-based module.
Means were calculated from 5-16 questions per integrated
module (depending on the number of questions chosen from
each module to be used in the examination). However, when
integrated modules were combined the mean responses were
calculated from 16 and 15 questions respectively. The data shows
that there was consistency between the numbers of students
who responded correctly to MCQs from the systems-based
module and from all integrated modules. When this latter group
was taken as a whole and the responses to MCQ questions was
compared to responses to MCQs from the systems-based module,
or when each integrated module was compared independently
to each other and to the systems-based module, there were no
significant difference between the groups (P > 0.05) (Figure1).
Figure 1: Cohort 1 (cardiorespiratory system): Student response
to MCQs . No significant difference (P > 0.05) was measured between
the mean responses of students to MCQ questions associated with any
of the groups shown. Data was analyzed using an Analysis of Variance
(ANOVA) with a one-way classification. Note, only MCQs could be compared
due to a lack of inclusion ARQs from integrated modules in the
final examination papers.
Cohort 2 CRS
The data sets generated from the second student cohort
contained fewer questions overall from integrated modules (5
MCQ and 5 ARQ) but the inclusion of some ARQ questions allowed
some comparison between the systems based module and the
integrated modules with respect to higher knowledge levels. In
this data set all of the integrated questions actually came from
one module (microbiology) (Figure 2).
Although the data collected showed a trend towards reduced
correct responses in systems based ARQs compared to ARQs
from the integrated module, and conversely increased number
of correct responses in systems based MCQs compared to MCQs
from the integrated module, there were no significant difference
(P > 0.05) between the numbers of correct responses by students
when comparing between ARQs or MCQs in the systems-based
module or ARQs and MCQs in the integrated module, or between
different modules (systems-based compared to integrated)
Cohort 1 GIS
The next part of the study was designed to compare the
responses of students to short answer questions from systemsbased
and integrated modules in the second year (gastrointestinal
system) module but the two student cohorts analyzed were the
same cohorts analyzed in the CRS. Data from 8 systems-based
MCQs and 11 integrated MCQs (3 parasitology; 6 microbiology
and 2 immunology) were analyzed. Only two integrated ARQs
were included in the examination, therefore, comparison of the
student response to ARQs from systems-based modules and
integrated modules could not be performed. In this data set
there were significantly fewer (P < 0.05) correct responses to
Microbiology MCQs compared with systems-based MCQs, but
there was no significant difference between the mean response
to parasitology or immunology MCQs. However, in some cases
the standard deviation of mean responses was very high and, as
previously stated, some integrated modules were represented
by only 2-3 MCQs. Nevertheless when combined, the response
to integrated modules was not significantly different to those
for the systems-based module and the difference was closer if
Figure 2: Cohort 2 (cardiorespiratory system): Student response to
ARQs and MCQs. No significant difference (P > 0.05) measured between
the mean responses of student ARQ or MCQ from systems-based versus
integrated module questions. Data was analyzed using an Analysis of
Variance (ANOVA) with a one-way classification.
Figure 3: Gastrointestinal Cohort 1 (gastrointestinal system): Student
response to MCQs. A significant difference (P < 0.05) was measured
between the mean responses of students to Microbiology MCQs
compared to the systems-based MCQs. No significant difference was
calculated between systems-based module and other groups (other integrated
module or all integrated modules combined). Note, only MCQs
could be compared due to a lack of inclusion ARQs from integrated
modules in the final examination papers. Data was analyzed using an
Analysis of Variance (ANOVA) with a one-way classification. * = Significant
difference between microbiology MCQs and systems-based MCQs.
microbiology questions were removed. The response of cohort
1 to these microbiology MCQs was much lower than for other
integrated modules (Figure 3).
Cohort 2 GIS
Data from this cohort included 8 MCQs from the systemsbased
module and 15 MCQs from integrated modules (10 from
parasitology and 5 from microbiology) as well as 7 systemsbased
ARQs and 5 ARQs from different integrated modules (split
between parasitology, microbiology and immunology).
In accordance with data obtained in the CRS module, data
obtained in the gastrointestinal system module also showed a
trend towards a reduction in the numbers of correct responses in
systems-based ARQs compared to ARQs from integrated module,
and increased number of correct responses in systems-based
MCQs compared to MCQs from the integrated modules (Figure 4).
However, these trends were not significantly different (P > 0.05)
when compared to the numbers of correct responses between
ARQs or MCQs in the systems-based module or ARQs and MCQs
in the integrated module, or either type of question between
different modules (systems-based compared to integrated)
Cohort 1 principles of veterinary science
The principles of veterinary science module combine
integrated modules and is designed to pull together all integrated
teaching delivery prior to the students beginning the clinical
curriculum. In this study, three of these modules (microbiology,
parasitology and immunology) were analyzed to determine
whether or not students respond differently in a module which
has no systems-based teaching. The data analyzed consisted of
both MCQs (8 microbiology; 7 parasitology and 8 immunology) as
well as ARQs (5 microbiology; 3 parasitology and 5 immunology).
The data shows that, there were significantly lower numbers of correct responses (P < 0.05) to parasitology ARQs compared to
all other questions. There was no significant difference between
the responses of students to any of the other questions taken
from different modules (Figure 5).
Analysis of the assessment of higher knowledge levels
Knowledge-based essays simply measure the ability of
students to recall facts and to a lesser extent understand and
apply these facts (level 1 to 3 knowledge) and there are no
specific instructions were given regarding content or format.
In contrast, essays based on knowledge integration require
students to recall knowledge but then to place this in context
across the whole of the module and as such measures a deeper
understanding of a subject via the ability of students to apply,
analyse and evaluate knowledge and then to use these to create
(reorganize and represent) knowledge (knowledge levels 3-6).
Students are specifically instructed that knowledge integration
Figure 4: Cohort 2 (gastrointestinal system): Student response to
MCQs and ARQs. No significant difference (P > 0.05) was measured
between the mean responses of student to ARQ or MCQ from systemsbased
versus integrated module questions. Data was analyzed using an
Analysis of Variance (ANOVA) with a one-way classification.
Figure 5: Cohort 1 (principles of veterinary science) MCQ and ARQ.
A significant difference (P < 0.05) was measured between the mean
responses of students to parasitological ARQs and all other MCQs and
ARQs tested within the module. No significant difference was calculated
between other groups. Data was analyzed using an Analysis of variance
(ANOVA) with a one-way classification. * = Significant difference.
essays are designed to assess the ability of students to integrate
material across the module and that students will receive marks
for the selection and integration of appropriate material, as well
as the structure and style of the essay.
Students were placed into cohort 1 or cohort 2 depending on
the year in which they studied the GI modules.
Cohort 1 was asked to write essays on the following questions:
1. Knowledge-based question (Integrated module,
2. Knowledge-based question (Integrated module,
3. Knowledge-based question (Integrated module,
4. Knowledge integration based question (Integrated module,
5. Knowledge integration based question (system-based
6. Knowledge integration based question (system-based
Results from these assessments suggested that students in
cohort 1 generally performed better when asked to integrate
knowledge from sources across the entire module. Students
performance in knowledge integration essays was similar to or
above the overall mean performance and one of these questions
was from an integrated module (microbiology) (Figure 6A).
However, when this cohort were asked to answer knowledgebased
essays only one of the questions scored comparatively
to the overall mean and all three questions were taken from
integrated modules and the equal lowest mean score attained
(30%) in knowledge-based essays was also from microbiology
Cohort 2 was asked to write essays on the following questions:
1. Knowledge-based question (Non-integrated module)
2. Knowledge-based question (Integrated module,
d question (Integrated module,
4. Knowledge integration based question (Non-integrated
5. Knowledge integration based question (Non-integrated
6. Knowledge integration based question (Integrated module,
Results obtained from these assessments indicated that
students in cohort 2 performed similarly in essays which were
knowledge-based or those which required knowledge integration
(Figure 6B). In this analysis mean values of all questions would
have been even closer to the overall mean if one question
Figure 6: Performance of cohorts 1 and 2 in the gastrointestinal
system module assessed by knowledge-based and integrated essays.
The mean percentage marks were recorded for student response
to essay questions which required either knowledge or knowledge integration
in system-based modules (physiology/anatomy of the gastrointestinal
system) or integrated modules (microbiology, biochemistry
and parasitology). (A) = Cohort 1; (B) = Cohort 2. Raw data was analyzed
by an Analysis of Variance (ANOVA) with a one-way classification
and no significant difference (P < 0.05) was found between the marks
obtained for any of the question types or between any of the question
types compared to the overall mean response.
(question 5) was removed from the data set, since students
scored very highly in this questions and this elevated the overall
Another interesting observation when comparing cohort 1
and 2 data was that when one, almost identical, question which
was taken from an integrated module (parasitology) required a
knowledge-based answer (cohort 1, question 1) or knowledge
integration (cohort 2, question 6) the mean result was almost
identical with mean values of 53% and 50% respectively (Figure
6A,6B). Another question which was almost identical (cohort 1
question 2 and cohort 2 questions3) in both years was knowledgebased
but results regarding student performance showed that
the performance of cohort 2 was almost twice as high as those for
cohort 1 when answering the question.
For the OFG, the recruitment target was set at eight students
in accordance with studies by Chapple and Murphy,  who
reported that this number was enough to provide meaningful
data. However, Krueger and Casey,  reported that a 20% over-recruitment target should be aimed for to take into account
the average drop out, or initial non-compliance, rates from these
studies. Therefore, we randomly selected twelve students (25%
more than required) from second and fourth year undergraduate
lists. Ten, second year students and eight, fourth year students
responded to the questions. This in itself was an interesting
result since it represented a major increase in student response
compared with our previous study which had used a conventional
(rather than OFG) technique . The views of students regarding
module integration were surprisingly consistent in the different
year groups with all students perceiving integrated modules as
being a component part of the more dominant systems-based
module rather than a 'stand alone' module within a systemsbased
module. However, there tended to be a more conscious
recognition of module integration by fourth year undergraduates
compared to second year students. The view of our cohorts
mirrors that reported in a previous study with a biomedical
student who appreciated the applied nature of the course
and the benefits of contextualization within the course .
This contextualization has a pedagogical value similar to that
described for medical courses by Regehr and Norman, . Our
study shows that, students in both non-clinical and clinical years
have an appreciation of whole body systems and this may have
great importance once these students qualify. Veterinarians focus
on the affected body systems and then consider which agents
and factors lead to resultant pathology. Contextualization of
the relevant knowledge to specific body systems may, therefore,
aid the practitioners recall as it is already linked to cases rather
than having to pick specific knowledge from stand alone block
modules. Thus, integration may facilitate student development
towards a more holistic approach to clinical cases which is
required in practice. As such, the cognitive depth may also be
increased since a broad knowledge of a body system (including
the relevant micro-organisms that may infect it and the likely
immunology and pathology which may be highly specific to that
body system) may be in easier 'cognitive reach', similar to the
coherence principle discussed by Mayer, et al. .
One question we wanted to answer here was whether the
depth of knowledge was affected by the integration of subjects
compared to the depth of knowledge attained within the main
module. We carried out a quantitative analysis of student
performance in different cognitive level assessments. MCQs are
generally favoured greater than open-ended questions such as
essays  but are usually used to assess knowledge retention
 which is the lowest level of knowledge (level 1) according
to Anderson and Krathwohl, , while ARQs and essays may
assess higher levels of knowledge [16,29,30]. In some cases, the
lower proportion of ARQ questions included in final examinations
made a comparison of student performance, with ARQs and other
formats, impossible to measure. Overall our study shows that
students did not perform differently when answering different
question types (which assessed different knowledge levels) when
comparing questions requiring knowledge of integrated modules
or systems-based modules. However, we have previously
reported that students are less successful when answering ARQs
compared to other short answer question formats but this is a general phenomenon and is not associated with integrated
versus non-integrated content . Thus, students do not learn
systems-based areas of a module to the detriment of integrated
modules contained within these systems-based modules, which
has been a concern of integrated module convenors. This may
be explained by the student perception of integrated modules
(as discussed earlier) which indicated a focus towards systemsbased
modules as a whole unit, and a perception that any teaching
within these modules (independent scientific disciplines which
form integrated modules) were not considered to be separate
'tag-on' subjects. This may benefit students once they graduate
because it suggests that they are learning integrated subjects in
the context of the body systems to which they apply. Integration
also allows a re-visitation (and re-evaluation) of knowledge since
certain facets of a particular integrated discipline may appear
in more than one body system. For example, specific immune
cell types are activated in response to specific pathogens in all
body systems and this allows the teaching of the biology of these
immune cells to be repeated and expanded when appropriate,
which probably has a positive effect on knowledge retention
(by a certain degree of repetition) while building on more basic
levels of knowledge as the integrated module develops. This
spiral curriculum, previously proposed by Bruner,  is further
reinforced by some of the same first and second year modules
being taught, at a higher cognitive level, in the fourth year, and
is therefore also in accordance with the concept of cognitive
hierarchies [12,13]. Therefore, module integration may promote
a smoother cognitive connection between different disciplines,
rather than an assembly of disconnected disciplines into a rational
order, prior to solving a scientific/clinical problem. However, this
cannot be confidently proposed unless we compare the response
of students from non-integrated (traditional) veterinary courses
to the same questions, particularly those which specifically
require integrated knowledge (such as year two GIS essays).
Nevertheless our study at least suggests that students almost
subconsciously learn disciplines which are integrated within
In conclusion, our study provides some pedagogical evidence
to suggest that module integration may have a beneficial effect on
undergraduate education in veterinary science and medicine.
All datasets were analyzed with the approval of both
Nottingham school of Veterinary Medicine and the University of
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