European Journal of Dental Education ISSN 1396-5883

Cooperative learning in ‘Special Needs in Dentistry’ for

undergraduate students using the Jigsaw approach
M. M. Sua
rez-Cunqueiro, D. Ga

ndara-Lorenzo, R. Marin
~ o-Pe

rez, S. Pin
~ eiro-Abalo, D. Pe

rez-Lo

pez and

s
I. Toma
Oral Sciences Research Group, Special Needs Unit, Department of Stomatology, School of Medicine and Dentistry, Universidade de Santiago de
Compostela, Santiago de Compostela, Spain

keywords Abstract
Aronson’s puzzle; clinical reasoning; cooperative
learning; dental education; Jigsaw approach; Introduction: The goals of this study were to (i) describe the use of the Jigsaw
Special Needs. approach for the resolution of clinical cases by undergraduate students in the subject
‘Special Needs in Dentistry’ and (ii) assess the impact of its implementation on aca-
Correspondence demic performance and the students’ perception.
Inmaculada Tom
as
Oral Sciences Research Group
Materials and methods: The Jigsaw approach was applied to the fifth-year in the
Special Needs Unit
subject ‘Special Needs in Dentistry’, as part of the Dentistry degree curriculum of the
School of Medicine and Dentistry
University of Santiago de Compostela, during the academic years 2012/2013 and 2013/
Universidade de Santiago de Compostela
C./ Entrerrios s/n
2014. A total of 109 dental students were enrolled in the study, and the final marks of
15872 Santiago de Compostela, Spain the Jigsaw (n = 55) and the non-Jigsaw groups (n = 54) were compared. Students’ per-
Tel: +34 981 563100 ext: 12344 ceptions on the Jigsaw technique were assessed using a 13-question questionnaire.
Fax: +34 981 562226
e-mail: inmaculada.tomas@usc.es Results: Academic performance based on the final examination mark for the Jigsaw
and non-Jigsaw groups was 6.45
1.49 and 6.13
1.50, respectively. There were not
Accepted: 1 June 2016
students in the Jigsaw group who failed to attend the mandatory examination (0% vs.
12.96% in the non-Jigsaw group, P = 0.006). The questionnaire’s internal consistency
doi: 10.1111/eje.12221
was 0.90. The mean value for all the questionnaire items was 3.80, with the highest
response score of 4.35 for the statement ‘I have seen the complexity that the resolution
of a clinical case can involve’.

Conclusion: Based on the students’ perceptions, the Jigsaw approach could contribute
to a better understanding of the complexity of solving clinical cases in the subject ‘Spe-
cial Needs in Dentistry’. However, further investigations should be conducted to anal-
yse the influence of this technique on students’ academic performance in the field of
clinical dentistry.

4). From this point of view, one of the teaching methodologies

Introduction
The Bologna process concerned the reform of higher education
systems in 29 countries of the European Union, with the objec-
tive being to create the European Higher Education Area
(EHEA) (1). In the EHEA, the main purpose was to promote
the free movement of students and workers across Europe,
increasing the international appeal of a European education.
The education reforms derived from the European convergence
process were intended to produce an educational philosophy
that was more focused on considering the student to be the
learner, rather than the teacher being a person who teaches (2–
supported by the Bologna plan is Cooperative Learning (Coop-
erative-L), in which individuals seek to obtain results that are
beneficial to both themselves and all other group members (5,
6). This type of learning can also be used with any didactic
material and within any curriculum task.
The methods of Cooperative-L are systematised instructional
strategies that have two main characteristics: (i) the division of
a class into small and heterogeneous groups that are represen-
tative of the general population of the classroom and (ii) the
creation of systems of positive interdependence through area
structures and specific rewards (5, 7–9). The Cooperative-L

ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Jigsaw in Special Needs
technique is a learning system whose principal objectives are
the following: (i) distributing success in order to properly
obtain the required motivation level to activate learning, (ii)
overcoming discriminatory interactions by the supply of similar
experiences to all group members, (iii) promoting the establish-
ment of friendly relationships, acceptance and cooperation,
which are necessary to overcome prejudice and develop a toler-
ant attitude, (iv) encouraging a more active stance on learning,
(v) increasing the sense of responsibility of the learners and
(vi) developing communication skills, as well as intellectual and
professional abilities (5, 10–12).
There are several techniques that can be applied to Coopera-
tive-L, but this study will focus on the best known method, the
so-called Jigsaw approach or Aronson’s puzzle (7). The Jigsaw
approach was introduced in the early 1970s by Elliot Aronson
at the University of Texas, trying to resolve racial conflicts in
the classroom (7–9).
The application of the Jigsaw technique consists in dividing
students into small heterogeneous groups, where each team
member is responsible for a different part of the task. First, stu-
dents from different teams with the same subtheme (same part
of task) make the expert groups and work on a specific ques-
tion. Subsequently, they return to their respective initial groups
for tutoring their peers in the subtheme which they have previ-
ously worked at. The only way for students to learn the other
subthemes that are not theirs is to listen carefully to teammates
and finally express agreement or disagreement. The completion
of the entire work will be determined by mutual cooperation
and responsibility amongst all members of the group (10).
Since 1970, the Jigsaw method has been widely used at ele-
mentary, high school and higher education levels with great
success (7, 13, 14). However, very few studies on the Jigsaw
approach have been undertaken in the field of experimental
and health sciences (15–20). In dentistry, only one study has
applied the Jigsaw approach to the field of dental materials; in
this regard, favourable results were obtained when compared to
the lecture-based method (21). To the best of our knowledge,
Fig. 1. Study design.
2 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Su

arez-Cunqueiro et al.
ours is the first study using the Jigsaw approach to resolve clin-
ical cases in dentistry.
The objectives of this study were to (i) describe the Jigsaw
Cooperative-L technique for the resolution of clinical cases by
undergraduate students in the subject ‘Special Needs in Den-
tistry’ and (ii) assess the impact of its implementation on aca-
demic performance and students’ perception.
Materials and methods
Design and study preparation
This was an educational intervention using the Jigsaw Coopera-
tive-L technique. A total of 109 dental students were enrolled
in the subject ‘Special Needs in Dentistry’ within the Dentistry
degree curriculum of the University of Santiago de Compostela
(Spain) during the academic years 2012/2013 and 2013/2014.
Prior to the educational intervention, students were assigned to
a Jigsaw (experimental group: 55 subjects; 18 males and 37
females) or non-Jigsaw group (control group: 54 subjects; 16
males and 38 females) by way of an Internet-based randomisa-
tion system.
The teaching methodology consisted of theoretical lectures in
which the teacher presented and discussed diagnoses and treat-
ment plans for different clinical cases, as well as clinical train-
ing sessions with patients. Four 3-h seminars were also given
during the first 3 months of both of the academic years consid-
ered. The Jigsaw Cooperative-L technique was applied to the
Jigsaw group sessions, whilst traditional seminars were used for
the non-Jigsaw group (Fig. 1). Traditional seminars consisted
of a series of clinical cases presented by the teacher, who subse-
quently asked directly and individually to students on certain
clinical aspects of the case.
In order to assess the impact of implementing the Jigsaw
approach to learning, the authors evaluated the academic marks
obtained in the June end-of-term examination by comparing
the Jigsaw and non-Jigsaw groups.
Students’ assessment
The maximum score was 10 (100%). The considered categories
were as follows: (i) fail (less than 50%), (ii) pass (from 50% to
70%), (iii) very good (71%—84%), (iv) outstanding (from
85% to 95%) and (v) distinction (>95%).
The complete student evaluation consisted of several parts:
(i) 50% for multiple choice and short-answer examination
questions (part A of the examination), (ii) 25% for the written
resolution of the clinical cases (part B of the examination), and
(iii) 25% for the continuous evaluation of the clinical practice.
The written examination (parts A and B) was mandatory and,
consequently, the repercussions for not attending it implied
that student fails the subject. This assessment had the same fea-
tures in the two groups, reflecting the critical reasoning and
decision-making required within the context of the subject
‘Special Needs in Dentistry’.
Perceptions of the Jigsaw approach were assessed in the 55
Jigsaw-group students using a five-point Likert-type question-
naire. This questionnaire was designed specifically to know the
students’ opinion about this new learning approach, not being
Su

arez-Cunqueiro et al. Jigsaw in Special Needs

Fig. 2. Puzzle group allocation and expert group formation.

TABLE 1. Educational topics addressed by the Jigsaw group, detailing the session number, the title of the clinical case and the general objectives pur-
sued in every cooperative seminar

Session Topic Clinical case General objectives

1 Developmental disability
2 Cardiovascular
disease/diabetes
3 Cardiovascular disease/
acquired coagulopathies
4 Head and neck tumours
Dental treatment plan in a patient with
Down’s syndrome
Dental treatment plan in a patient with
type 2 diabetes and hypertension
Dental treatment plan in an anticoagulated
patient with a valve prosthesis
Dental treatment plan in a patient with
head and neck cancer receiving
radiotherapy
To establish a sequenced treatment plan
(first choice and alternatives)
To describe oral pathology-related findings and their treatment
To identify potential complications associated with
both the treatment options and medical conditions; and prevention
To determine the most appropriate anaesthetic technique and time
for treatment, as well as considerations regarding the chair position
To assess the need for drug use (antibiotics,
analgesics, etc.), specifying dose and schedule

adequate for evaluating traditional learning strategies. This con-
sisted of 13 items for a quantitative evaluation, along with an
open section in which the students could freely reflect their
opinions about the technique. Values ranged from 1 (strong
disagreement) to 5 (strong agreement). The items were divided
into four dimensions: (i) motivation, (ii) teamwork, (iii) learn-
ing process and (iv) facilitation. This questionnaire had previ-
ously been used in an earlier research work to analyse students’
perceptions of the Jigsaw approach (22).
Jigsaw Cooperative-L technique
As stated above, the Jigsaw approach was applied to the
experimental group for the resolution of different clinical
cases in the aforementioned subject through the following
steps (Fig. 2):
• Preparation: The teacher explained the new teaching
methodology to the entire Jigsaw group. Thereafter, she pre-
sented the features of a specific clinical case that could be
fit within one or several of the following medical condi-
tions: (i) developmental disability, (ii) cardiovascular disease/
diabetes, (iii) cardiovascular disease/acquired coagulopathies
and, (iv) tumour pathology of the head and neck. She also
provided enough material for a proper assessment of the
case (medical and dental history, radiographic images and
relevant clinical and laboratory data). Table 1 shows the
main educational topics addressed by the Jigsaw group,
detailing the session number, the title of the clinical case
and the general objectives pursued.
• Puzzle group allocation: The teacher randomly created sev-
eral five-member work groups (A, B, C, etc.) in accordance
with the criterion of maximum heterogeneity and based on
the five questions included in each clinical case. These ques-
tions were randomly distributed amongst the members of
each work group. At the same time, a member of each team
was appointed to summarise the group’s final report.
• Expert group formation: Once the work groups were estab-
lished, the expert groups were formed. These were

ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3
Jigsaw in Special Needs Su

arez-Cunqueiro et al.

composed of the students who had been asked to resolve TABLE 2. Jigsaw and non-Jigsaw groups regarding students’ presence at
the same clinical question. the final examination: global and gender-related results
• Cooperative work I: Each expert group designed a work
Number of students (%)
plan aimed at resolving the assigned question. After a speci- Fisher’s
fic period of time, they had to write a short report reflecting Attended Did not attend exact test
the answer to the question. The answers were to be shared Total students (n = 102) (n = 7) (P-value)
by the entire expert group. Subsequently, these groups were
broken up. Jigsaw 55 (100.00%) 0 (0.00%) 0.006

• Cooperative work II: The initial work groups were reconsti-
tuted. At this point, each ‘expert member’ explained and
discussed the solution to his/her question with the rest of
the team. Finally, each work group developed a dossier with
a complete solution to the clinical case.
• Presentation and exhibition: Once the four sessions were
finished, each work group prepared and presented one of
the clinical cases that had been previously addressed. In
addition, the teacher discussed and clarified the doubts that
were unresolved.
Data analysis
The data analysis was performed using the statistical program
PASW 21 for Windows (SPSS Inc. Chicago, IL, USA) and R
program. The values of the analysed quantitative variables
showed a non-normal distribution, which was determined by
the Shapiro–Wilk test. The Mann–Whitney U-test was used to
compare the average scores between the two groups (Jigsaw
and non-Jigsaw groups), which were additionally differentiated
by gender. Likewise, the Fisher’s exact test was used to compare
the percentage of students who ‘attended’ and ‘did not attend’
the final examination between both groups. The Fisher’s exact
test was also used to compare the final qualitative scores (fail,
pass, very good, outstanding and distinction) between both
groups and according to gender.
The internal consistency of the questionnaire items was eval-
uated using a reliability analysis (Cronbach’s alpha). A value of
P < 0.05 was considered to be statistically significant.
Results
Academic performance: Clinical reasoning and
decision-making
In terms of academic performance, the average score of the Jig-
saw group was 6.45
1.49 (6.11
1.50 for males and
6.61
1.47 for females), whilst that of the non-Jigsaw group
was 6.13
1.50 (6.00
1.56 for males and 6.19
1.49 for
females). With respect to gender, there was a higher average
score amongst females in the Jigsaw group than in the non-Jig-
saw group, but this result was not statistically significant.
In relation to the percentage of students who failed to attend
the final examination, there was a significant difference for stu-
dents in the Jigsaw group in comparison with those in the
non-Jigsaw group (0% vs. 12.96%, respectively; P = 0.006)
(Table 2). With reference to gender, the percentage of both
male and female students in the Jigsaw group who did not
attend the examination was much lower than in the non-Jigsaw
group. Significantly, this difference was more pronounced in
females (0% vs. 15.79%, respectively; P = 0.025).
Non-Jigsaw 47 (87.04%) 7 (12.96%)
Attended Did not
Male students (n = 33) attend (n = 1)
Jigsaw 18 (100.00%) 0 (0.00%) 0.471
Non-Jigsaw 15 (93.75%) 1 (6.25%)
Attended Did not
Female students (n = 69) attend (n = 6)
Jigsaw 37 (100.00%) 0 (0.00%) 0.025
Non-Jigsaw 32 (84.21%) 6 (15.79%)
In terms of the final qualitative scores, the increase in the ‘very
good’ (45.45% vs. 42.55%) and ‘outstanding’ (5.46% vs. 2.13%)
marks in the Jigsaw group was notable compared with those
achieved by the non-Jigsaw group. A decline in ‘fail’ marks was
also found in the former group (20.00% vs. 25.53%). In terms of
gender, both males and females in the Jigsaw group had an
increase in the number of ‘very good’ marks. Females in the Jig-
saw group had fewer ‘fail’ qualifications (16.22% vs. 25.00%) and
a 4.97% increase in ‘outstanding’ marks compared with the
females in the non-Jigsaw group (Table 3), although these results
were not statistically significant.
Students’ perception
A total of 55 students in the Jigsaw group completed the ques-
tionnaire (response rate = 94.55%). The internal consistency
(Cronbach’s alpha) for the full 13-item questionnaire was 0.90.
Table 4 shows the students’ answers to each question. The
average value for the whole group was 3.79
0.80. The
response with the highest score (4.35) was ‘I have seen the
complexity that the resolution of a clinical case can involve’,
followed by ‘I have learnt from my colleagues’ (4.12), along
with ‘This activity is appropriate for the course content’ and
‘The teacher0 s explanations about the process have been clear’
(4.02). The vast majority of the answers collected in the ques-
tionnaire to the open question ‘Why would I say that I was sat-
isfied with this type of cooperative learning’ were mostly based
on positive connotations. However, some negative comments
were also documented. Some of the statements in favour of the
Jigsaw learning were as follows: ‘It solves doubts that I would
have never noticed’, ‘There is a shared understanding that helps
resolve the clinical case’, ‘Knowledge is shared and concepts
can be related’, ‘Better use of the time’, ‘Working as a group
helps to assess aspects that would not be taken into account in
any other way’, ‘It encourages me to solve the clinical case
instead of the teacher’, and ‘It forces you to revise the topic’.
Some of the comments against the Jigsaw approach and

4 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Su

arez-Cunqueiro et al. Jigsaw in Special Needs

TABLE 3. Qualitative marks obtained by the Jigsaw and non-Jigsaw TABLE 4. Percentage and mean scores of students’ five-point responses
groups, excluding those who did not attend the examination: global and (strong disagreement–strong agreement) to the questionnaire items
gender-related results
Percentage of response
Number of students (%)
Qualitative marks Fisher’s Mean
Jigsaw Non-Jigsaw test Items 1 2 3 4 5 score
Total students (n = 55) (n = 47) (P -value)
Cooperative work
Fail 11 (20.00%) 12 (25.53%) 0.944 Cooperative learning 7.70 7.70 26.90 42.30 15.40 3.50
Pass 16 (29.09%) 13 (27.66%) requires more effort
Very good 25 (45.45%) 20 (42.55%) than lectures
Outstanding 3 (5.46%) 1 (2.13%) It improved 3.80 9.60 46.20 23.10 17.30 3.40
With distinction 0 (0.00%) 1 (2.13%) cooperation,
knowledge and
Jigsaw Non-Jigsaw communication
Male students (n = 18) (n = 15) with different partners
I have learnt from 0.00 0.00 21.20 46.20 32.70 4.12
Fail 5 (27.78%) 4 (26.67%) 1.000 my colleagues
Pass 5 (27.78%) 5 (33.33%) Facilitation
Very good 8 (44.44%) 6 (40.00%) This activity is 3.80 3.80 23.10 25.00 44.20 4.02
Outstanding 0 (0.00%) 0 (0.00%) appropriate for the
With distinction 0 (0.00%) 0 (0.00%) course content
The teacher’s 0.00 3.80 25.00 36.50 34.60 4.02
Jigsaw Non-Jigsaw explanations about
Female students (n = 37) (n = 32) the process have been
clear
Fail 6 (16.22%) 8 (25.00%) 0.845
I was satisfied with 1.90 15.40 15.40 42.30 25.00 3.73
Pass 11 (29.73%) 8 (25.00%)
this Jigsaw approach
Very good 17 (45.95%) 14 (43.74%)
Motivation
Outstanding 3 (8.10%) 1 (3.13%)
I would extend this 5.80 5.80 30.80 36.50 21.20 3.62
With distinction 0 (0.00%) 1 (3.13%)
experience to other
subjects
This approach will 0.00 9.60 26.90 44.20 19.20 3.73
favouring traditional seminars were as follows: ‘I think the
help me prepare the
cases should be answered exclusively in class by the teacher’, ‘I
course better
think we don’t have enough knowledge to address the cases’,
The Jigsaw approach 0.00 5.80 28.80 46.20 19.20 3.79
‘Too much time is lost splitting groups’, and ‘Too much time
had a positive impact
is lost with the change of group’.
on my learning
Learning process
Discussion I have seen the 0.00 0.00 9.60 46.20 44.20 4.35
complexity that the
To our knowledge, this is the first study to evaluate the appli- resolution of a
cation of the Jigsaw Cooperative-L technique in the training of clinical case
undergraduate students in the subject ‘Special Needs in Den- can involve
tistry’. Nevertheless, this learning method has been applied to It has allowed me to 0.00 17.30 36.50 30.80 15.40 3.44
other health professions such as medicine and nursing (15, 18, delve deeper into the
23). These studies (15, 18, 23) demonstrated that Cooperative- resolution of a clinical
L improves clinical competence on issues related to the plan- case
ning and implementation of treatments, communication with I like to alternate the 0.00 5.80 21.20 42.30 30.80 3.98
patients and family, and professional behaviour, which are very traditional
important skills for professional dentistry. The technique’s methodology with
main goals are to promote social–emotional development, this type of learning
make the acceptance of diverse opinions easier and improve It has allowed me 0.00 5.80 44.20 42.30 7.70 3.52
the integration of students. This requires users to develop their to understand the
subject better
active involvement and form partnerships, as well as to
improve their basic skills, critical thinking and motivation. It
also reduces anxiety and enhances self-esteem (24). Likewise, empathy and a sense of responsibility (25). This means know-
the technique prepares participants for sharing leadership, ing how to communicate and how to work in teams, which are
working in a group and improving their academic performance. fundamental in health sciences. During the Jigsaw seminars, the
In the same way, it promotes the core values of professionalism participants were encouraged to discuss the clinical case before
such as ethical commitment, common respect for others, reaching a consensus. They were also asked to search medical

ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5
Jigsaw in Special Needs
databases to find the best scientific evidence related to the case
in order to answer the different questions. As a consequence,
the work of each student was essential for the completion and
full understanding of the case, as each of them was responsible
for solving one of the questions proposed, meaning that they
were valued by others in the group (26).
When the two learning strategies were compared regarding
to the fact of attending the final examination, the attendance
was significantly higher in the Jigsaw than in the non-Jigsaw
group. Indeed, in the former, all the students attended the test,
whilst in the latter only 87% did. In this regard, the scientific
literature has usually indicated that Cooperative-L methods,
including the Jigsaw technique, promote greater motivation
and commitment (27). Moreover, when gender was considered,
it was noted that most of the students who did not attend the
examination were females, reaching a value of 86% (6 of 7 stu-
dents). According to some studies (28, 29), females tend to
have a more positive attitude to teamwork than males and are
also more willing and more motivated to participate.
With respect to the academic performance, it was observed
that the subjects who belonged to the Jigsaw group obtained
higher academic scores, especially the females, although these
results were not statistically significant. However, it has been
reported that significantly higher final scores are achieved by
students who participate in dynamic cooperative work groups
than by those who do not (30).
In terms of students’ perception of the new learning approach,
the Jigsaw technique was generally assessed positively. Most of
the participants responded that this technique had allowed them
to understand the complexity of searching for a complete solu-
tion to a clinical case in the field of ‘Special Needs in Dentistry’.
On the one hand, they understood that in order to answer the
different questions in groups, they had to use dialogue and inte-
grate different points of view. This is obviously good for stu-
dents, because it forces them to use subject-related vocabulary,
improving their ability to manage dental and medical terms. On
the other hand, they also developed a deeper learning strategy for
the subject, and consolidated new knowledge more efficiently.
This technique also improved their communication skills, which
are essential for health professionals. In this context, it has been
stated that negotiation between equals and the promotion of
self-assessment is of essential importance when it comes to inter-
actions with other colleagues (26). Of special interest was the
study performed by Persky et al. (17), in which the authors
developed a hybrid Jigsaw technique that encouraged students to
work with their expert groups outside the classroom before the
intervention day. It was found that the subjects who had an unfa-
vourable relationship with the group reported difficulties in
working together (17). In our view, to avoid this problem, the
technique should be carried out in the classroom, where the tea-
cher can supervise the activity and observe the participation of
each group member.
From the point of view of students, although the technique
required more effort than traditional teaching, they believed
that it should be applied to other subjects. Some of these com-
ments were as follows: ‘It’s a different and practical way of
reviewing the subject’, ‘Teamwork helps to assess aspects you
would not value on your own’, and ‘It solves doubts that I
would have never noticed’. There was similar positive feedback
6 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Su

arez-Cunqueiro et al.
from students in other studies in which a modified Aronson’s
puzzle technique was applied: ‘Good review of study design’, ‘It
helps the understanding of the subject’ or ‘Good way to prac-
tice reading’ (19). In the present study, there were very few
negative comments: in summary, some participants considered
that the clinical cases solved by means of the new learning tech-
nique should be explained by the teacher in another session
and in a traditional way so they would know whether the clini-
cal solution they had proposed was correct. However, we
believe that this attitude reveals a lack of perspective and con-
tradicts the philosophy of this technique, in which cases are
solved through a presentation by students with the support and
advice of the teacher. In this regard, the literature has con-
firmed the difficulty that students have in adapting to these
dynamic methodologies, which require a continuous effort in
learning, unlike what happens in the traditional curriculum in
which they act as ‘mere receivers of information’ (31). In the
same way, some students also reported having spent much time
organising the activity and in the change from the expert
groups to the initial work groups, as the classrooms were not
equipped for the Cooperative-L technique. Consequently, we
believe that medical and dental schools should have classes or
laboratories designed specifically for this type of learning; for
instance, classrooms with round tables would be of benefit to
the face-to-face discussions required with this method.
Using the Cooperative-L technique to resolve clinical cases,
students must first set out a list of problems. They then have
to formulate hypotheses for the case in question, gather infor-
mation to discuss within the team and finally reach a consensus
solution which usually consists of various preventive and thera-
peutic options. In this way, students need to apply critical
thinking, although they realise that solving a case in the most
appropriate manner may be challenging and extremely time-
consuming (32). Likewise, it is important to note that students
are able to work together and gather evidence, which is
achieved when they are encouraged to be active and indepen-
dent learners and problem solvers. It has been stated that the
active processing of information leads to learning success (33).
Although learning through understanding takes time (34, 35),
students have a better grasp and retention of knowledge when
they are taught actively than is the case for passive methods.
In order to implement this Cooperative-L technique in a
classroom, it is essential that the teacher possesses appropriate
social skills, as he/she is the person who knows the objectives
of the method, assigns the groups, explains the task and evalu-
ates the effectiveness of learning groups and individual achieve-
ments. Once trained, the teacher begins to reduce the use of
passive classes and applies more effort to help students to
become responsible for their own learning. As stated by some
authors: ‘There is a difference between the concepts of teaching
and learning, there is too much teaching and learning is not
enough’ (36, 37).
Cooperative-L has often been used as part of the PBL meth-
ods. Although Turan et al. (38) did not find any differences
between using PBL alone or learning associated with Coopera-
tive-L for the topic of acute abdominal pain, the study con-
firmed that when using the latter, a relationship existed
between the allocated study time and achievement, and student
satisfaction. Similarly, Willet et al. (19) combined the journal
Su

arez-Cunqueiro et al.
club with the Jigsaw approach and noted that medical students
were much more engaged when using the Cooperative-L tech-
nique than in typical one-presenter journal club exercises. Fur-
thermore, the Jigsaw approach has also been used in science
courses, with the goal being to make primary research papers
more accessible, as well as helping students write scientific
manuscripts (39). In addition, Sim et al. (20) considered the
Prescribing Initiative for Life-long Learning Skills (PILLS) team
in their institution and applied the Jigsaw learning technique to
final-year medical students.
In the present study, based on the Dentistry degree curricu-
lum of the University of Santiago de Compostela and the par-
ticularities of the subject ‘Special Needs in Dentistry’, we
believe that students can take better advantage of both tradi-
tional and cooperative seminars if theoretical lectures are given
first. However, in other subjects, the application of PBL meth-
ods associated with Cooperative-L could be contemplated. In
this sense, Sagsoz et al. (21) did not give lectures to the experi-
mental group; instead, the students were asked to prepare the
theory during the first week. These authors also organised the
Jigsaw sessions over 3 weeks, whilst just 1 day was used in our
study for each cooperative seminar. This means that students
have to solve the clinical case in the same session. For this rea-
son, we affirm that it is very important to teach some minimal
theoretical concepts to the entire class in advance.
One of the strengths of this study was the existence of a con-
trol group from the same classroom that was not subjected to
the Jigsaw technique. However, one of its limitations was the
relatively short period during which the Jigsaw method was
applied. In our study, this technique represented around 20%
of the complete programme. In this regard, we consider that
Cooperative-L should be promoted. However, as it is the first
time such a technique has been applied to the dental field, and
whilst its final results still remain unclear, we suggest that this
method should be implemented progressively in order to anal-
yse its efficacy in the learning process.
Conclusion
Although the results of the present study do not clarify the
impact of the Jigsaw approach on the academic performance of
dental students in the field of ‘Special Needs in Dentistry’, stu-
dents’ perceptions of the Cooperative-L technique are more
positive than negative. The students believe that this methodol-
ogy requires more effort than traditional learning systems,
allows them to be aware of the degree of complexity of a clini-
cal case and favours ‘group learning’ in the subject considered
in this study. They also support its implementation in the Den-
tistry curriculum.
The Jigsaw Cooperative-L technique could contribute to the
improvement of the understanding of processes of clinical rea-
soning and decision-making, as well as the resolution of prob-
lems in different clinical subjects, including ‘Special Needs in
Dentistry’.
Acknowledgements
The authors declare no conflict of interest or funding source.
ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Jigsaw in Special Needs
References
1 Oliver R, Sanz M. The Bologna Process and health science
education: times are changing. Med Educ 2007: 41: 309–317.
2 Rich SK, Keim RG, Shuler CF. Problem-based learning versus a
traditional educational methodology: a comparison of preclinical
and clinical periodontics performance. J Dent Educ 2005: 69: 649–
662.
3 Shanley DB. Dental education and dentistry in Europe. J Am Coll
Dent 2007: 74: 4–8.
4 Plasschaert AJ, Manogue M, Lindh C, et al. Curriculum content,
structure and ECTS for European dental schools. Part II: methods
of learning and teaching, assessment procedures and performance
criteria. Eur J Dent Educ 2007: 11: 125–136.
5 Slavin R. Cooperative learning: theory, research and practice. 2nd
edn. Boston: Pearson Allyn & Bacon, 1995.
6 Pratten MK, Merrick D, Burr SA. Group in-course assessment
promotes cooperative learning and increases performance. Anat Sci
Educ 2014: 7: 224–233.
7 Aronson E, Bridgeman D, Geffner R. Interdependent interactions
and prosocial behavior. J Res Dev Educ 1978: 12: 16–27.
8 Aronson E. Nobody left to hate: teaching compassion after
Columbine. New York: W. H. Freeman & Company, 2000.
9 Aronson E. The Jigsaw classroom. Available at: https://
www.jigsaw.org/ (accessed 26 October 2015).
10 Aronson E, Patnoe S. Cooperation in the classroom: the Jigsaw
method. 3rd edn. London: Pinter & Martin Ltd, 2011.
11 Johnson D, Maruyama G, Johnson R, Nelson D. Effects of
cooperative, competitive, and individualistic goal structures on
achievement: a meta-analysis. Psychol Bull 1981: 89: 47–62.
12 Johnson P. Problem-based, cooperative learning in the engineering
classroom. J Prof Issues Eng Educ Pract 1999: 125: 8–11.
13 Perkins D, Saris R. A “jigsaw classroom” technique for
undergraduate statistics courses. Teach Psychol 2001: 28: 111–113.
14 Souvignier E, Kronenberger J. Cooperative learning in third graders’
jigsaw groups for mathematics and science with and without
questioning training. Br J Educ Psychol 2007: 77: 755–771.
15 Charania NA, Kausar F, Cassum S. Playing jigsaw: a cooperative
learning experience. J Nurs Educ 2001: 40: 420–421.
16 Doymus K. Teaching chemical equilibrium with the Jigsaw
technique. Res Sci Educ 2008: 38: 249–260.
17 Persky AM, Pollack GM. A hybrid Jigsaw approach to teaching
renal clearance concepts. Am J Pharm Educ 2009: 73: 49.
18 Earl GL. Using cooperative learning for a drug information
assignment. Am J Pharm Educ 2009: 73: 132.
19 Willett LR, Kim S, Gochfeld M. Enlivening journal clubs using a
modified ‘jigsaw’ method. Med Educ 2013: 47: 1127–1128.
20 Sim SM, Foong CC, Tan CH, Lai PS, Chua SS, Mohazmi M. The
use of jigsaw learning technique in teaching medical students
prescribing skills. Med Teach 2014: 36: 182.
21 Sagsoz O, Karatas O, Turel V, Yildiz M, Kaya E. Effectiveness of
Jigsaw learning compared to lecture-based learning in dental
education. Eur J Dent Educ 2015. doi: 10.1111/eje.12174.
22 Maceiras-Pombo L. Cooperative-learning for the resolution of
clinical cases in dentistry. Bachelor’s thesis, Santiago de Compostela
University, 2013.
23 Buhr GT, Heflin MT, White HK, Pinheiro SO. Using the jigsaw
cooperative learning method to teach medical students about long-
term and postacute care. J Am Med Dir Assoc 2014: 15: 429–434.
24 Matchett N. Cooperative learning, critical thinking, and character.
Public Integr 2009: 12: 25–38.
25 Johnson D, Johnson R, Smith K. The state of cooperative learning
in postsecondary and professional settings. Educ Psychol Rev 2007:
19: 15–29.
7
Jigsaw in Special Needs
26 Phillips J, Fusco J. Using the Jigsaw technique to teach clinical
controversy in a clinical skills course. Am J Pharm Educ 2015: 79:
90.
27 Yoshida M, Tanaka M, Mizuno K, et al. Factors influencing the
academic motivation of individual college students. Int J Neurosci
2008: 118: 1400–1411.
28 Wilhelmsson M, Ponzer S, Dahlgren LO, Timpka T, Faresj€ o T. Are
female students in general and nursing students more ready for
teamwork and interprofessional collaboration in healthcare? BMC
Med Educ 2011: 21: 15.
29 Hansson A, Foldevi M, Mattsson B. Medical students’ attitudes
toward collaboration between doctors and nurses - a comparison
between two Swedish universities. J Interprof Care 2010: 24: 242–
250.
30 Okubo Y, Ishiguro N, Suganuma T, et al. Team-based learning, a
learning strategy for clinical reasoning, in students with problem-
based learning tutorial experiences. Tohoku J Exp Med 2012: 227:
23–29.
31 Lujan HL, DiCarlo SE. Too much teaching, not enough learning:
what is the solution? Adv Physiol Educ 2006: 30: 17–22.
8 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Su

arez-Cunqueiro et al.
32 Bolles E. Remembering and forgetting: an inquiry into the nature of
memory. 1st edn. New York: Walker & Co, 1988.
33 Miller GE. An inquiry into medical teaching. J Med Educ 1962: 37:
185–191.
34 McDermott L. How we teach and how students learn - a mismatch?
Am J Phys 1993: 61: 295–298.
35 Rao SP, DiCarlo SE. Active learning of respiratory physiology
improves performance on respiratory physiology examinations. Adv
Physiol Educ 2001: 25: 127–133.
36 Vander AJ. The Claude Bernard Distinguished Lecture. The
excitement and challenge of teaching physiology: shaping ourselves
and the future. Am J Physiol 1994: 267: S3–S16.
37 Haramati A. Teaching physiology: filling a bucket or lighting a fire?
Physiologist 2000: 43: 117–121.
38 Turan S, Konan A, Kilic YA, Ozvaris SB, Sayek I. The effect of
problem-based learning with cooperative-learning strategies in
surgery clerkships. J Surg Educ 2012: 69: 226–230.
39 Lom B. Classroom activities: simple strategies to incorporate
student-centered activities within undergraduate science lectures. J
Undergrad Neurosci Educ 2012: 11: A64–A71.