Constructive Alignment:
An Outcomes-Based Approach
to Teaching Anatomy
John Biggs and Catherine Tang
Outcomes-Based Education
and Outcomes-Based Teaching
and Learning
In order to improve the quality of student
learning, we advocate a form of outcomes-based
education. But first, we need to make an impor-
tant distinction between two kinds of outcomes-
based education.
The first refers to broad institutional out-
comes, such as averaged student performances,
that are used for such purposes as quality assur-
ance, benchmarking, accreditation requirements,
and the requests of external stakeholders like
employers and policymakers [1]. The question
here is for administrators: “How well is the insti-
tution performing in relation to its own mission
statement and performance indicators and in
relation to other institutions?” There is no neces-
sary connection here between these externally
driven managerial concerns and the quality of
the teaching that supposedly produced those
outcomes.
The second kind of outcomes-based education
is intended directly to improve student learning,
so we refer to it as “outcomes-based teaching and
learning,” which addresses the learning outcomes
John Biggs, PhD (*) • Catherine Tang, PhD
Tasmanian Institute of Learning and Teaching,
University of Tasmanian, Hobart, TAS, Australia
e-mail: jbiggs@bigpond.com
L.K. Chan and W. Pawlina (eds.), Teaching Anatomy: A Practical Guide,
DOI 10.1007/978-3-319-08930-0_4, © Springer International Publishing Switzerland 2015
4
that students are expected to achieve at both
program and especially course levels. The ques-
tion here is for teachers: “What do I want my stu-
dents to be able to do as a result of their having
learned specified topics?” The intended outcomes
not only nominate the topic content but addition-
ally what the student is intended to do with that
content. The intended outcomes for any given
course may be determined by the individual
teacher or the teaching team, together with any
relevant external input.
Once the outcomes have been defined, teach-
ing should be designed to engage students in
learning activities that are likely to achieve those
outcomes. Assessment then addresses how well
those outcomes have been achieved by students
and is therefore criterion referenced. Such assess-
ment is best achieved by rubrics or statements
that specify the standards for different levels of
student performance. Assessment tasks should
also allow for any unexpected or unintended but
desirable outcomes. While unintended but desir-
able outcomes cannot be specified in advance,
they can be allowed for by asking students to
place any evidence they think appropriate for
their achieving unintended outcomes in a portfo-
lio that is submitted for assessment. In outcomes-
based teaching and learning, students should not
be assessed according to how their performances
compare with each other and then graded accord-
ing to a predetermined distribution such as the
bell curve.
These issues of linking teaching and assess-
ment to achieving the intended learning outcomes
31
32
(ILOs) are specifically addressed in the version
of outcomes-based teaching and learning known
as constructive alignment, as discussed below.
Constructive Alignment
Some years ago, Thomas Shuell summarized the
implications for teaching and learning of cogni-
tive psychology thus [2]:
If students are to learn desired outcomes in a rea-
sonably effective manner, then the teacher’s funda-
mental task is to get students to engage in learning
activities that are likely to result in their achieving
those outcomes.… It is helpful to remember that
what the student does is actually more important in
determining what is learned than what the teacher
does.
Embedded in this seemingly obvious statement
is a powerful design for teaching that draws on
two important principles:
• Knowledge is not transmitted by a teacher but
is constructed by students through their own
learning activities.
• The intended outcomes of teaching need to be
stated upfront, and teaching methods and
assessments need to be aligned to what those
outcomes require if they are to be met.
These principles are the basis for constructive
alignment [3, 4]. Constructive alignment is a
form of outcomes-based teaching and learning in
which both teaching and assessment are aligned
to the ILOs, which specify what the student is
expected to do with the content taught. The tradi-
tional topic-based curriculum only specifies what
content the teacher is to address.
Accordingly, the ILOs need to state not only
what the student is intended to learn but how, to
what level, and in what context. Thus, if the topic
in question is the anatomy of the upper and lower
limbs, the learning outcome focuses on what the
student is supposed to be able to do with that ana-
tomical knowledge, for example, to list the mus-
cles, bones, joints, nerves, and blood supply to
the limbs or at a higher level to explain how
the different anatomical components work and
coordinate to produce movement or higher still
J. Biggs and C. Tang
to predict what functional disability will result
from a specified injury to a certain part of the
anatomy and to design a management program or
a treatment protocol for such an injury. Thus, the
student will not only know about the anatomy of
the upper and lower limbs but be able to act prop-
erly on the basis of that knowledge—which is
after all the purpose of professional education.
Good teachers have always taught with a view
to what students should be able to do after being
taught and how well they should do it—that is
one reason why they are good teachers. In con-
structively aligned teaching, we simply make this
explicit.
These verbs in the ILOs are used to prescribe
the teaching/learning activity (TLA) the students
need to engage in order to optimally achieve
the outcome. If the ILO refers to explain the
functioning of the musculoskeletal system, the
TLA would require the students themselves to
explain how the system functions, say to another
student or in a presentation, not just to listen and
take notes from a teacher who is doing the
explaining.
The assessment task in turn addresses that
verb in the ILO; if the verb is explain, the assess-
ment is in terms of how well the explanation is
carried out. Often, the most appropriate assess-
ment task is the TLA itself, making alignment
perfect. This is the case in problem-based learn-
ing (PBL), in which the ILO is solving a particu-
lar professional problem, the teaching/learning
activity is solving the problem, and the assess-
ment is how well the problem is solved.
High-level verbs in the ILO, such as hypothe-
size, reflect, solve unseen problem, or create,
leave the outcome quite open. In that case, the
assessment task needs to allow for the unex-
pected, as does an assessment portfolio.
Several writers have mentioned the utility of
constructive alignment in teaching different
subjects: computing science [5], earth sciences
[6], designing e-learning [7], engineering edu-
cation [8], health sciences [9], plant physiology
[10], physiology [11], social work [12], statis-
tics [13], teacher education [14], and veterinary
sciences [15]. Typical advantages of using
4 Constructive Alignment: An Outcomes-Based Approach to Teaching Anatomy
constructive alignment referred to in these stud-
ies include:
• Students being able to focus more effectively
on the key learning goals
• Fairer and more reliable assessment
• Improved learning outcomes, including criti-
cal thinking and depth of student work
• Greater transparency leading to easier and
more accurate interuniversity and interna-
tional comparisons
• Greater coherence in programs and more
effective evaluation of modules and courses
The major disadvantages refer to staff and stu-
dent workloads. The major staff workload is in
the initial transition from traditional to construc-
tively aligned teaching, while that for students is
often self-inflicted—they work harder in con-
structively aligned courses.
The principles of constructive alignment are
used as frameworks for quality assurance agen-
cies in the UK and Hong Kong [16]. Edström
[17] writes: “course evaluation should be
regarded as a component of constructive align-
ment, together with the ILOs, learning activities
and assessment.” Constructive alignment is
widely regarded as a key idea on postgraduate
certificates in higher education [18].
There are three main stages involved in apply-
ing constructive alignment to the teaching of
anatomy: designing the ILOs, designing the
teaching/learning activities (TLAs), designing
and aligning assessment tasks (ATs), and obtain-
ing a final grade.
Designing the Intended Learning
Outcomes (ILOs)
ILOs contain a content topic or topics, action
verbs that help specify the level of performance
the students are expected to achieve, and a con-
text for the learning to take place. Verbs such as
identify, name, describe, explain, predict, plan,
design, hypothesize, generate, and create are
examples of increasing levels of understanding.
Thus, to use the verb understand itself in an ILO
is inadequate because it does not identify the kind
or level of understanding required. The ILO verbs
33
give students a clear signpost as to what and how
they are to learn and on which they will be
assessed. Ideally, there should be no more than
five or six ILOs for a one semester course.
The SOLO taxonomy [4] provides a useful
guide in deciding the levels of understanding or
performance. The first two levels, unistructural
and multistructural, see understanding as a quan-
titative matter of knowing more. The next two
levels focus on qualitative changes as under-
standing deepens. At the relational level, students
are able to put things together by interrelating the
multiple aspects to create a structure, while at the
extended abstract level, students are able to go
beyond the given and take the argument or appli-
cation of a principle to a new dimension. When
writing ILOs, teachers need to decide what levels
of understanding or performance students are
expected to achieve and clearly indicate those
levels by the ILO verbs. Other taxonomies such
as the Bloom taxonomy may also used as a
source of verbs, but we have found SOLO more
useful as it provides a hierarchy of levels of
understanding.
Let us take the example when students are
learning the anatomy of the upper and lower
limbs. Some of the relevant ILOs could be for the
students to be able to:
1. Identify and name all the muscles, bones, liga-
ments, joints, nerves, and blood supply to the
upper and lower limbs.
2. Describe the origin, course, and insertion of
the muscles in the upper and lower limbs.
3. Describe the courses of the nerves and blood
vessels in the upper and lower limbs.
4. Explain how movements are produced in the
upper and lower limbs.
5. Compare and contrast the mobility and stabil-
ity of a ball and socket joint and a hinge joint
in relation to their anatomy, using the shoul-
der joint and the knee joint as examples,
respectively.
6. Predict what functional disability will result
from injuries to a particular anatomical struc-
ture of the upper and lower limb.
These ILOs are generic and only meant here
to serve as examples: readers will need to design
their own (see To Do below).
34
To Do
• Consider a topic in anatomy that you are
going to teach. Design up to 5 ILOs that
you intend your students to achieve.
• We will return to these ILOs in later
exercises.
When designing ILOs, teachers need to con-
sider the context within which the course is being
taught, the aims of the course, the level of the
course, the target students, the reasons for which
they are taking the course, and the needs of the
profession which the students will be engaged in
after graduation. Where clinical applications are
desirable, ILOs might contain verbs such as assess,
diagnose, plan (management/treatment program),
implement, make a prognosis, and evaluate.
Apart from the ILOs that are specified in the
curriculum, there may well be outcomes that are
a positive outcome of teaching but that weren’t
intended by the teacher. Teachers need to allow
for such unintended but desirable outcomes
with open-ended assessment tasks so that the
students themselves may provide evidence of
such outcomes.
Designing the Teaching/Learning
Activities (TLAs)
Teachers need to design activities that will engage
students in activating the ILO verbs. The tradi-
tional lecture usually provides a one-way trans-
mission and teacher-centered mode of teaching,
with little opportunity for student engagement. If
students are expected to explain how movements
are produced in the upper and lower limbs, it is
insufficient for the teacher to explain this in a lec-
ture for here the students are not engaged in
explaining but in listening, taking notes, and
perhaps asking a question. For the students to
achieve the ILO explain, they need to do the
explaining themselves if that is what it is intended
that they should be able to do.
Take the example in the previous section when
students are learning the anatomy of the upper
J. Biggs and C. Tang
and lower limbs; to be able to explain, students
can acquire the background information from
books or other sources, doing dissection in anat-
omy lab, and then engage in explaining to fellow
students—in pairs or in a group in class—on how
movements are produced, say by using a model
skeleton, by pulling on the muscles on a dissected
cadaver in the anatomy lab, or by drawing a con-
cept map to explain how the various anatomical
components work in producing movements. An
assignment would allow the students to explain
in written form. These are some aligned TLAs for
the ILO explain, and teachers can decide on the
appropriate ones that would suit the particular
teaching sessions.
A higher-level ILO might require students to
predict what functional disability would result
from injuries to a particular anatomical structure
of the upper and lower limb. Again, students need
to do the predicting themselves. Students doing
background reading on relevant information,
discussing with fellow students, role-playing the
resulting disability, or working on a case study
are aligned teaching and learning activities for
the achievement of the ILO to predict.
Aligned TLAs can be conducted in large or
small class situations and can also be either man-
aged by the teacher or students or as self-learning
activities, consistent with available resources.
There are many suitable TLAs other than lectures
and tutorials.
To Do
• Select one ILO from the list you have
written in the previous section. Design
some TLAs that would engage your stu-
dent in achieving the outcome.
• When designing these TLAs, you may
consider what you need to do as a
teacher, but it is more important to con-
sider what your students will be required
to do themselves.
• You will also need to consider any
required and available resources to
implement those TLAs.
4 Constructive Alignment: An Outcomes-Based Approach to Teaching Anatomy 35

into consideration the workload for the teacher

To Do
• Using the same ILO that you have
designed TLAs for in the previous exer-
cise, design ATs that would be appropri-
ate to assess the student’s achievement
of that ILO.
• When designing these ATs, you may con-
sider first whether the TLAs used would
be appropriate for perfect alignment.
• Also consider any required and available
resources for implementing these ATs.
Designing and Aligning Assessment
Tasks (ATs)
Assessment tasks (ATs) for a given ILO or set of
ILOs are aligned to the target ILO(s) by present-
ing the student with tasks that require them to
enact the verbs in the ILOs—or closely related
ones—and provide evidence of the level of per-
formance that they have achieved. The best form
of alignment is where the TLA is itself the assess-
ment, as in problem-based learning. There are
two steps in designing a suitable assessment task:
1. Selecting a practicable task that embodies the
target verb
2. Judging how well that task has been performed
In designing ATs, we need to select practicable
tasks that embody the target ILO verb(s), taking
and students and the available resources in imple-
menting the tasks. The invigilated examination
provides a very restrictive assessment environ-
ment that will very likely not be able to address
many ILOs, especially the higher-level ones.
Take the two ILOs that we have been using:
“Explain how movements are produced in the
upper and lower limbs,” and “predict what func-
tional disability will result from injuries to a par-
ticular anatomical structure of the upper and
lower limb.” A written assignment, an oral pre-
sentation, a concept map, and a case study are all
possible and aligned ATs. Where the TLAs are
the assessment tasks, alignment is perfect.
In outcomes-based teaching and learning,
assessment is criterion referenced. Student perfor-
mances can be assessed by judging them against
established grading criteria or rubrics, instead of
the more usual practice of marking quantitatively
by accruing marks bottom-up. In constructive
alignment, the logic of assessment is holistic, not
analytic. The sample rubrics in Tables 4.1 and 4.2
enable the whole to be assessed and awarded a
qualitative assessment category, such as A, B, C,
or D. However, for logistic purposes such as
obtaining a final grade, a quantitative scale can be
allotted to each category or subcategory (see sec-
tion “Obtaining a Final Grade”).
These criteria are made clear prior to the
assessment process to all parties involved in
assessment, students, teacher, and any other par-
ties such as the assessment panel or external

Table 4.1 Example of rubrics for explain (this is only a generic example. Rubrics for “explain” in a particular content
need to be developed in context)
Subgrades
(scale score) Evidence
A A- A A+ As in “B” but also provides views on possible alternative causes and/or results depending on
3.7 4.0 4.3 changes of conditions
Able to link current reasoning to situations in real-life and/or professional contexts
B B- B B+ Able to identify a full range of relevant points with details. Support by relevant literature
2.7 3.0 3.3 Points are organized to provide a comprehensive and cohesive reasoning or causality
C C- C C+ Able to identify a number of relevant points with some details
1.7 2.0 2.3 Use these points to provide a fair reasoning of causality, but little or no evidence of a
comprehensive overview of reasoning or causality
D 1.0 Able to identify and briefly write about limited points
Very little evidence of using these points to provide reasoning to why they are interrelated
F 0.0 The information is sparse and is mainly inaccurate
Explanation lacks relevant reasoning or is based on irrelevant information
36 J. Biggs and C. Tang

Table 4.2 Example of rubrics for predict (This is only a generic example. Rubrics for “predict” in a particular content
need to be developed in context)
Subgrades
Grade (scale score) Evidence
A A- A A+ As in “B” but also provides a comprehensive and holistic view on how and why the
3.7 4.0 4.3 prediction has been made
Able to provide possible implications of prediction to situations in real-life contexts
Evidence of attempting to provide suggestions for intervention to amend or counteract any
possible adverse effects as a result of the prediction. In the case of medical and allied health
students, this may be suggestion of any possible management or treatment programs (the
merits of which need to be considered in relation to the level of study of the students)
B B- B B+ Prediction is accurate and realistic
2.7 3.0 3.3 Able to identify a full range of relevant points to support the prediction
Evidence of integrating the details in a cohesive manner with some evidence of a
comprehensive overview of various factors or reasons leading to the prediction
C C- C C+ Prediction is largely accurate
1.7 2.0 2.3 Able to provide some details of relevant information to support the prediction
Evidence of providing a fair reasoning to support the prediction but little or no evidence of
a comprehensive overview of various factors or reasons leading to the prediction
D 1.0 Prediction is incomplete
Able to provide limited information
Very little evidence of using the information to support the prediction
F 0.0 Information is sparse and mainly inaccurate
Prediction is inaccurate and irrelevant to the context given

assessor. Examples of rubrics for assessing the
two ILOs for explain and predict are provided in
Tables 4.1 and 4.2, noting these are generic
examples and such criteria need to be developed
in the context of the content area and the disci-
pline concerned.
Traditionally, the teacher has been the sole
party responsible for assessing and grading the
student performance. Research has shown that
students could be involved in the assessment
process [19, 20]. Students assessing their own
work (self-assessment) or assessing their peers’
work (peer assessment) can be used as a TLA or
an AT. To be able to assess either their own or
their peers’ work, students need to be very clear
beforehand about the ILO(s) that the ATs address
and the criteria with which the performance is to
be assessed, thus reinforcing their own under-
standing and enabling them to better achieve the
ILOs. Making a judgment about whether a
performance meets the given criteria is vital for
reflective professional practice, when profes-
sionals need to judge their own and their peers’
performance and to identify how their perfor-
mance can be improved. These are important
lifelong learning skills that many professionals
say are most lacking in their undergraduate
education [21].
Obtaining a Final Grade
Individual assessments of a student’s different
performances need to be combined to form a final
grade for the course. Qualitative assessments can
be converted into a number scale that can then be
dealt with arithmetically to yield a final grade.
Thus, in Tables 4.1 and 4.2, a quantitative num-
ber may be allocated to each category and subcat-
egory: thus, A+ is given 4.3, A 4.0, and A− 3.7.
There is a larger gap across categories than within
categories: B+ is 3.3, that is, 0.4 difference from
A− rather than 0.3 as within categories (these fig-
ures are taken from the policy of one university).
The final grade can thus be determined by aver-
aging these figures, and when the average has
been computed, it can be converted back to the
nearest letter grade.
4 Constructive Alignment: An Outcomes-Based Approach to Teaching Anatomy
To Do
• Now try to develop rubrics for the ILO
that you have selected and used in the
previous exercises.
• If you have selected the same ILO that
we have used in this chapter (explain/
predict), you will need to consider how
the sample rubrics need to be modified
to suit the content and context of your
teaching.
• You will also need to consider any
required and available resources to
implement them.
Alternatively, it is possible to derive an a priori
system by which the final grade is awarded
according to a predetermined pattern of letter
grades. For example, the final grade of A is
awarded if most other performances are A grade
with none lower than B; a similar procedure is
sometimes used to award the class of honors in an
undergraduate program.
If a pass/fail system is used, then the teacher
needs to decide what minimal levels of outcome
are needed to meet the particular professional
requirements.
Conclusions
We have outlined here a design for teaching that
is eminently suited to teaching anatomy. Clearly,
the statements of ILOs will be specific to a par-
ticular course and the purposes for which it is
being taught. We have given examples of TLAs
and ATs for two different ILOs, explain and pre-
dict, in the hope that readers will be able to con-
struct their own ILOs and align suitable TLAs
and ATs to them. Further details about the the-
ory, and examples of implementation of con-
structive alignment from several disciplines, are
available [4].
37
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