Submitted: 28 January 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 3-19
https://doi.org/10.29060/TAPS.2024-9-1/OA2947

Thun How Ong¹, Hwee Kuan Ong², Adrian Chan¹, Dujeepa D. Samarasekera³ & Cees Van der Vleuten⁴

¹Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Duke-NUS Medical School, Singapore; ²Department of Physiotherapy, Singapore General Hospital; ³Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ⁴Department of Educational Development and Research, Maastricht University, Maastricht, The Netherlands

Abstract

Introduction: The mini-Clinical Evaluation Exercise (CEX) is meant to provide on the spot feedback to trainees. We hypothesised that an ultra-short assessment tool with just one global entrustment scale (micro-CEX) would encourage faculty to provide better feedback compared to the traditional multiple domain mini-CEX.

Methods: 59 pairs of faculty and trainees from internal medicine completed both the 7-item mini-CEX and a micro-CEX and were surveyed regarding their perceptions of the 2 forms. Wordcount and specificity of the feedback was assessed. Participants were subsequently interviewed to elicit their views on factors affecting the utility of the CEX.

Results: Quantity and quality of feedback increased with the micro-CEX compared to the mini-CEX. Wordcount increased from 9.5 to 17.5 words, and specificity increased from 1.6 to 2.3 on a 4-point scale, p < 0.05 in both cases. Faculty and residents both felt the micro-CEX provided better assessment and feedback. The micro-CEX, but not the mini-CEX, was able to discriminate between residents in different years of training. The mini-CEX showed a strong halo effect between different domains of scoring. In interviews, ease of administration, immediacy of assessment, clarity of purpose, structuring of desired feedback, assessor-trainee pairing and alignment with trainee learning goals were identified as important features to optimize utility of the (mini or micro or both) CEX.

Conclusions: Simplifying the assessment component of the CEX frees faculty to concentrate on feedback and this improves both quantity and quality of feedback. How the form is administered on the ground impacts its practical utility.

Keywords:           Workplace Based Assessment, Mini-CEX, Micro-CEX, Feedback, Assessment

Practice Highlights

• Simplifying the assessment component of the CEX frees faculty to concentrate on feedback.
• A simpler form can result in better and more feedback.
• Making it easy for faculty to use the form is important and increases its utility in providing feedback and assessment.

I. INTRODUCTION

The Mini-CEX is one of the most widely used work-placed based assessment (WBA) tools and is supported by a large body of theoretical and empirical evidence which have shown that when used in the context of repeated sampling, it is both a valid assessment tool and is also an effective education tool in giving feedback to the trainee (Hawkins et al., 2010; Norcini et al., 2003). However, in practice, the educational value of the mini-CEX, as measured chiefly by trainee and faculty perceptions and satisfaction, varied significantly (Lorwald et al., 2018). Factors affecting the educational value have been described by Lorwald et al. and categorised into context of usage, and user, implementation and outcome factors (Lorwald et al., 2018).

Context refers to the situation in which the mini-CEX is executed, and factors which impact its actual usage, such as time needed for conducting the Mini-CEX, or the usability of the tool. Time constraint on the part of both the residents and the assessors is an especially frequent issue across multiple studies (Bindal et al., 2011; Brazil et al., 2012; Castanelli et al., 2016; Lörwald et al., 2018; Morris et al., 2006; Nair et al., 2008; Yanting et al., 2016). The mini-CEX was conceived as a 30-minute exercise of directly observed assessment, and there are 6 or 7 domains which faculty are expected to assess (Norcini et al., 2003). In a busy clinical environment however, what actually occurs is often a brief clinical encounter of 10-15 minutes or even less where only a few of the mini-CEX’s domains were assessed (Berendonk et al., 2018).

User factors refers to trainee and faculty knowledge of the mini-CEX and their perceptions of its use. Studies have found that the mini-CEX is frequently regarded as a check box exercise (Bindal et al., 2011; Sabey & Harris, 2011). Assessor’s and trainee’s training and attitudes, or unfamiliarity with the WBA tools also negatively impact the educational value of the mini-CEX (Lörwald et al., 2018). Reports have shown that educating faculty on the formative intent of mini-CEX can improve feedback provided (Liao et al., 2013).

Implementation factors refer to how the mini-CEX is actually executed on the ground. Some studies have reported that the mini-CEX often occurs without actual direct observation (Lörwald et al., 2018) or feedback provided (Weston & Smith, 2014). Implementation in turn affected outcome, which refers to the trainees appraisal of the feedback received (Lörwald et al., 2018).

One way of improving the educational value of the mini-CEX then might be to improve the context of its usage, by redesigning the mini-CEX to better fit the realities of the clinical workplace. In different clinical encounters, specific domains of performance are more easily and obviously observed and assessed than others (Crossley & Jolly, 2012). Reducing the number of dimensions the assessors are asked to rate was shown to decrease measured cognitive load and improved interobserver reliability (Tavares et al., 2016). It has also been shown that using rating scales that align with the clinician’s cognitive schema perform better, for instance, scales that ask the clinician assessors about the trainees ability to practice safely with decreasing levels of supervision (i.e. entrustability) showed better discrimination and higher reliability (Weller et al., 2014). Compared to multidimension rating scales, global rating scales have greater reliability and validity in assessing candidates in OSCE examinations (Regehr et al., 1998), assessing technical competence in procedures (Walzak et al., 2015) and in simulation-based training (Ilgen et al., 2015).

We proposed therefore to replace the multiple domains with a single rating asking faculty what level of supervision the resident would require in performing a similar task, i.e. a global entrustment scale. The shorter assessment task should refocus the faculty on the feedback component, whilst still retaining the ability to identify trainee progression. One such form has been proposed by Kogan and Holmboe (2018), and we designated this the micro-CEX.

We hypothesised that these changes would improve the usability (“context” as described by Lorwald et al.) and hence improve the educational value of the assessment, measured in this study by the specificity and quality of the feedback given by faculty.

Our study aims to show therefore that the shorter micro-CEX can provide better feedback than the usual mini-CEX. We also sought to find out, from the perspective of the end-users, what other adjustments to the implementation and design of the mini or micro-CEX can be made to improve its acceptability, educational value and validity.

The study focussed on the following questions:

Does the micro-CEX stimulate faculty to provide more specific and actionable feedback compared to the mini-CEX?

Can the micro-CEX provide discriminatory assessment for residents across different years of practice?

What are the perceptions of the faculty and residents regarding the factors affecting utility of the assessment instrument in providing feedback and assessment?

II. METHODS

A. Setting and Subjects

The study was conducted in the division of Internal Medicine in a 1700 bed hospital in Singapore between September and December 2018. All faculty and residents rotating through internal medicine were invited to participate via e-mail, and agreeable faculty and residents paired up. In usual practice, residents must complete at least 2 mini-CEX covering standard inpatient or outpatient encounters during each three-month internal medicine posting, hence both residents and faculty are familiar with the usual mini-CEX.

B. Design

In order to evaluate for any participant reactivity affecting the CEX data (i.e. a Hawthorne effect) (Paradis & Sutkin, 2017), a baseline sample of 30 of the usual mini-CEX performed in the 3 months prior to the study was randomly selected and deidentified (from June to August 2018) . The quantity and specificity of feedback in these was evaluated as detailed below.

For the study itself, faculty and residents used the usual mini-CEX as the first assessment in the first 2 weeks of the month, followed by a second assessment using the micro-CEX in the next 2 weeks. This sequence was chosen as performing the micro-CEX first might affect how the subsequent mini-CEX was performed. Cases chosen for the mini-CEX and micro-CEX were inpatient or outpatient internal medicine encounters, and faculty were simply instructed to choose cases that represented typical cases of average difficulty with no restrictions on the exact cases to be chosen.

Faculty and residents completed an anonymised survey on their experiences at the end of the study and were invited to participate in a semi-structured group interview to elicit their views regarding which aspects of the mini-CEX exercise influenced feedback and assessment (Appendix 2). Both faculty and residents were informed that the survey and interviews were part of this study and participation in either was taken to be implied consent. The workflow of the study is seen in Figure 1.

Figure 1. Study workflow

Published online: 2 January, TAPS 2024, 9(1), 1-2
https://doi.org/10.29060/TAPS.2024-9-1/EV9N1

The practice of medicine and provision of healthcare is evolving rapidly, driven not just by advancements in new treatment modalities but also by the integration of modern technologies in providing precision care to our patients. It is important to understand and embrace, where appropriate, innovative technologies to respond effectively to the evolving needs of a modern society. What will be seen in this transformative wave is how Artificial Intelligence (AI) has the potential to revolutionise various sectors in medicine and healthcare (Yu et al., 2018).

Focusing on health professions education, AI emerges as a pivotal force in training the future healthcare practitioners and preparing them for the multifaceted challenges of the modern medical landscape (Paranjape et al., 2019). There are 3 distinct uses of AI in education which was reported by Baker et al. (2019): Learner-oriented AI, Instructor-oriented AI and Institution-oriented AI. Let’s focus on some of these areas:

A. Enriched Learning Experiences

One of the most significant advantages of integrating AI into health professions education is the enhancement of learning experiences. AI-powered platforms can provide personalised, adaptive learning modules tailored to individual students’ needs and learning paces (Kong et al., 2021). This personalisation not only accelerates the learning process but also ensures that students grasp complex concepts thoroughly, laying a robust foundation for their future careers. Furthermore, AI provides the opportunity for the students as well as for the trainers to use and adapt the best materials from multiple sources. It also enhances their networking through AI search capabilities and the ability to link up with other experts in the field or learning communities (Luke et al., 2021).

B. Simulation and Practical Training

AI-driven simulations are revolutionising practical training in healthcare education. Medical students can now practice patient safety, surgical procedures, diagnose illnesses, and interact with virtual patients in a risk-free environment. These simulations not only refine their technical skills but also improve their decision-making and inter-professional teamwork abilities. By repeatedly engaging in realistic scenarios, students can hone their expertise, fostering confidence and competence before they enter real-world clinical settings, a critical step to ensure patient safety and ethical practice of medicine.

C. Data-Driven Insights

AI’s ability to analyse large amounts of data quickly and efficiently provide an excellent platform to improve systems and processes (American Medical Association [AMA], 2016). In the context of health professions education, this capability translates into valuable insights. Educational institutions can collect data on students’ performance, identify areas where they struggle, and provide targeted interventions. Educators can adapt their teaching methods based on this data, ensuring that their teaching-learning approaches are appropriate and leading to good outcomes. Moreover, AI can predict trends in learning, enabling institutions to proactively address challenges and optimise their curricula. Funding and resource allocations can also be done where it is needed most or areas of future needs to build capacity and relevance of programs.

D. Fostering Research and Innovation

AI-powered tools are accelerating Scholarship of Teaching and Learning in the areas of research and innovation. AI algorithms help to analyse large amounts of data quickly and identify patterns that researchers could potentially miss. This could help us better understand the complex datasets, find relationships between variables faster, and draw appropriate conclusions and recommendations. AI has also reduced the time required to conduct literature review by analysing large amounts of scientific articles, identifying relevant research, and summarising the content in seconds.

E. Addressing Global Health Disparities

Focusing on medical and health professions education, we believe that this is another area AI could assist and enhance the training of healthcare practitioners in resource poor settings. Unbundling of curricula and connecting with the best training materials as well as experts are key advantages of AI capable training environments could support the resource poor settings.

Another area that AI driven knowledge and skills sharing could be addressing the present shortage of skilled healthcare professionals, leading to significant disparities in healthcare access. AI-based education has the potential to bridge this gap. Online platforms and mobile applications powered by AI can deliver high-quality continuous professional development to remote and underserved communities, reaching out to healthcare professionals irrespective of their geographical location. With this unbundling, the present set programs or training, we believe has the potential to significantly reduce global healthcare disparities.

F. Ethical Considerations and Collaboration

While the potential of AI in health professions education is immense, it is crucial to navigate ethical challenges. In the process of developing AI capable environments, we must ensure that the systems are transparent, unbiased and fair. However, we do not see in any medical school or a healthcare training site developing or having conversations on the use of guidelines/protocols on ethical use of AI in health professional education. Educators, policymakers, and technology developers must collaborate to establish ethical guidelines that ensure the responsible use of AI. This collaboration should prioritise transparency, fairness, and equity, safeguarding the integrity of healthcare education and the welfare of future patients (Chan & Zary, 2019).

Artificial Intelligence provides huge benefits to health professions education in many ways. By embracing AI-powered tools and methodologies, educational institutions can produce a generation of healthcare professionals who are not only adept at leveraging advanced technologies, but also compassionate and skilled in delivering patient-centred care. As we advance and evolve, it is clear that we need to channel our efforts into the investment of AI capabilities, aiming to elevate the learning experiences of our students and residents, propel educational scholarship and research forward, and foster enhanced collaboration. This strategic commitment is essential to maximising the potential advantages of this technology, with a primary objective of ultimately enhancing the health and well-being of patients within both local and global communities. The achievement of success in this pursuit necessitates a united front, where educators, institutions, and policymakers collaborate seamlessly. Only through such concerted efforts can we guarantee that AI not only benefits current learners but also ensures future positive impact on the well-being of the patients they will serve.

Dujeepa D. Samarasekera, Shuh Shing Lee & Han Ting Jillian Yeo
Centre for Medical Education (CenMED), NUS Yong Loo Lin School of Medicine,
National University Health System, Singapore

 

American Medical Association. (2016). Digital Health Study Physicians’ motivations and requirements for adopting digital clinical tools. https://www.ama-assn.org/practice-management/digital

Baker, T., Smith, L., & Anissa, N. (2019). Educ-AI-tion Rebooted? Exploring the future of artificial intelligence in schools and colleges. Nesta. https://www.nesta.org.uk/report/education-rebooted/  

Chan, K. S., & Zary, N. (2019). Applications and challenges of implementing artificial intelligence in medical education: Integrative review. JMIR Medical Education, 5(1), Article e13930. https://doi.org/10.2196/13930

Luke, N., Taneja, R., Ban, K., Samarasekera, D., & Yap, C. T. (2021). Large language models (ChatGPT) in medical education: Embrace or abjure? The Asia Pacific Scholar, 8(4), 50-52. https://doi.org/10.29060/TAPS.2023-8-4/PV3007

Paranjape, K., Schinkel, M., Nannan Panday, R., Car, J., & Nanayakkara, P. (2019). Introducing artificial intelligence training in medical education. JMIR Medical Education, 5(2), Article e16048. https://doi.org/10.2196/16048

Yu, K. H., Beam, A. L., & Kohane, I. S. (2018). Artificial intelligence in healthcare. Nature Biomedical Engineering, 2(10), 719-731. https://doi.org/10.1038/s41551-018-0305-z

Submitted: 11 August 2023
Accepted: 23 August 2023
Published online: 2 January, TAPS 2024, 9(1), 64-65
https://doi.org/10.29060/TAPS.2024-9-1/LE3109

Mildred Lopez

Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico

Notes on Contributors

ML wrote the manuscript and edited it.

Funding

No funding was received for writing this paper.

Declaration of Interest

The author declares that there is no conflict of interest to disclose.

References

Masters, K. (2023). Ethical use of Artificial Intelligence in Health Professions Education: AMEE Guide No. 158, Medical Teacher, 45(6), 574-584. https://doi.org/10.1080/0142159X.2023.2186203

Rospigliosi, P. (2023). Artificial intelligence in teaching and learning: What questions should we ask of ChatGPT? Interactive Learning Environments, 31(1), 1-3. https://doi.org/10.1080/10448 20.2023.2180191

*Mildred Lopez
Ave. Eugenio Garza Sada 2501 Sur. Col Tecnologico,
64710
Monterrey, Mexico
Email: mildredlopez@tec.mx

Submitted: 25 May 2023
Accepted: 27 July 2023
Published online: 2 January, TAPS 2024, 9(1), 61-63
https://doi.org/10.29060/TAPS.2024-9-1/CS3061

Veranja Liyanapathirana

Department of Microbiology, Faculty of Medicine, University of Peradeniya, Sri Lanka

Submitted: 12 June 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 58-60
https://doi.org/10.29060/TAPS.2024-9-1/PV3064

Rintaro Imafuku, Chihiro Kwakami, Kaho Hayakawa & Takuya Saiki

Medical Education Development Center, Gifu University, Japan

I. GLOBALISATION IN EAST ASIA

Globalisation, a complex and multifaceted phenomenon, encompasses not merely an increasing people’s mobility and economical trades, but sometimes, their political and ideological struggles, and cultural identity formation issues, too. While North American and European countries have had a long history of accepting a large number of immigrants, while Asia experienced 74% growth of hosting international migrants from 2000 to 2020, which was most remarkable (McAuliffe & Triandafyllidou, 2021). For example, Japan’s proportion of immigrant population increased from 1.3% in 2000 to 2.2% in 2021, with Chinese migrants constituting the largest group, followed by Vietnamese, Koreans, Filipinos, and Brazilians. Similarly, in 2021, immigrants accounted for 3.4% of Korea’s total population in 2021, compared to 0.5% in 2000. These immigrants came from China, Vietnam, Thailand, Uzbekistan and other countries (McAuliffe & Triandafyllidou, 2021).

These changes in culture and population dynamics have significantly impacted on people’s health and healthcare in East Asia. One of the most challenging issues in such globalised Asian societies is managing intercultural communication between health professionals and migrant patients. Given this context, as languages become a key issue, health professionals are expected to accommodate patients’ communication needs. Moreover, while responding to the rapid internationalisation, health professionals in Asia need to embrace the belief that individuals are members of multiple, diverse, local and non-local networks, thus promoting global citizenship. In fact, the question is: How should Asian health professionals address the intercultural communication situations in healthcare?

II. COMMUNICATION STRATEGIES IN INTERCULTURAL SETTINGS

Many previous linguistic studies have discussed that in Asia, English serves as the lingua franca – a common language adopted among people who do not share a native language. Singaporeans, for instance, use English as an intra-national communication medium, while in East Asian countries, somewhat different contexts would have existed, particularly in relatively ‘monolingual’ speech communities. Given that, most immigrants in East Asia are not native English speakers, in many cases where English does not function as their medium of communication for them. In other words, English is not the sole solution for intercultural communication issues, particularly in East Asian countries. However, some health professionals in Japan viewed English as the panacea for intercultural communication issues, regardless of the patients’ native language, which highlighted the need to consider another communication management strategy in an intercultural setting (Imafuku et al., 2022).

A host country’s plain language, which is defined as clear and concise language accommodation, can be an effective medium of communication (Imafuku et al., 2022). For example, a national survey in Japan demonstrated that many immigrants could understand simple Japanese in daily life, even though their proficiency was limited. Assuming that the speakers tailor their communication to the interlocutors’ language proficiency levels and cultural backgrounds, plain language in spoken communication can be achieved by using short and simple sentences, active voice which emphasises the doer of an action, and personal pronouns which makes it easier for the listeners to picture themselves in the message. Furthermore, speakers must avoid ambiguous expressions and fillers that fill pauses with words, such as “um”, “ah”, “er” and so forth. Visual aids, such as charts, pictures and writing down messages, are also helpful for listeners to process the information in conversations.

Language translation devices, application software, and artificial intelligence (AI) technologies can be useful resources for managing intercultural communication in healthcare. For example, ChatGPT has the potential to assist and enhance health communication in hospitals. In particular, as these AI tools rely on patterns in huge amounts of existing text data, they excel at automating routine tasks, generating document summaries and translating simple texts of factual information. However, the users also need to be aware of the potential drawbacks of these tools, which may lack the ability to interpret patients’ communication signals by patients, such as tone, prosody, and non-verbal cues, potentially resulting in misunderstandings and miscommunications, especially with immigrant patients. This absence of human interaction, including the consideration of patients’ thoughts, emotions, patience, and empathy, emphasises the need for health professionals to critically evaluate and appraise the use of these AI tools for use in intercultural communication (Santandreu-Calonge et al., 2023).

In addition to the linguistic and sociolinguistic aspects, different cultural values and religious beliefs may create barriers in intercultural communication between providers and patients (Zhao, 2023). For example, patients may have diverse perspectives on confidentiality, gender, trust in health professionals and privacy concerns, which greatly impact on interactions in healthcare. Zhao (2023) suggests that patients with certain cultural backgrounds view the family as a collective unit, and would trade off their privacy for family support. However, sharing patients’ information with their family members can pose an issue of confidentiality issues for health professionals. In this case, the patients’ beliefs about family support and ties are closely intertwined with confidentiality in healthcare. In other words, effective intercultural communications will be enhanced by health professionals gaining a better socio-cultural understanding of immigrant patients.

III. MOVING FORWARD: EDUCATIONAL DEVELOPMENT

Educational development is key to effectively addressing the challenges faced by health professionals in East Asia’s globalisation wave. English has been taught as an ‘international academic language’ in Asian medical schools and serves as the medium of instruction in certain countries and Asian institutions. In other words, English can be a means of facilitating intercultural communication in Asian healthcare, particularly for foreign visitors from Western countries.

Additionally, for more successful language accommodation, plain language should be systematically taught in health communication courses in East Asia’s medical education. A growing body of evidence from Western countries indicates that incorporating plain language training into medical education has positive implications for oral and written communication skills. By using the host country’s plain language for practical training of intercultural communication in the curriculum, medical students in East Asia should be given more opportunities to interact with migrant citizens with different cultural backgrounds.

In addition to the effective use of plain language as an option of communication management strategies, this opportunity will also broaden the students’ worldviews and cultural understanding in the current globalised societies. Specifically, our institution, Gifu University, has incorporated learning opportunities through interactions with migrant citizens from Vietnam, Philippines and Brazil into first year medical education. This can serve as a springboard to cultivate the medical students’ global citizenship by learning diverse cultural values through conversations with the migrants in Japan.

Translation software and AI technologies are increasingly being utilised in the intercultural communication settings. Although these devices and tools are helpful, they can also be a double-edged sword for healthcare professionals as communicators. Health professionals and educators should recognise that human interaction is the foundation of communication. Relying excessively on such tools without critical evaluation may cause serious communication problems with migrant patients and their family members. In Japan, information technology has been newly set as a learning objective in the 2022 revision of the Model Core Curriculum for Medical Education (Medical Education Model Core Curriculum Expert Research Committee, 2022). Further educational development is necessary to train health professionals to fully understand the principles of the information science and technology, and effectively apply them in clinical practice. Specifically, in the field of health communication education, the educators must address the challenges posed by rapid globalisation by developing programs that enable learners to understand the advantages and disadvantages of AI-mediated communications and effectively utilise the information technologies in the intercultural settings.

Finally, from the perspective of medical education research, more internationally published research on intercultural health communication from Asian countries is necessary. The rich descriptions and analysis of the interactions between healthcare providers and migrant patients in the current globalised Asian countries can offer different perspectives on medical education for an international readership. Additionally, for further educational development, it would be worthwhile to explore AI-mediated communication in intercultural situations, as this is a relatively new research area.

Notes on Contributors

Rintaro Imafuku contributed to this manuscript’s conceptualisation, wrote its first draft, and revised its subsequent draft. Chihiro Kawakami, Kaho Hayakawa and Takuya Saiki contributed to the conceptualisation and critically revised the first draft. All the authors discussed and contributed to the final manuscript.

Funding

This study was supported by the JSPS KAKENHI [Grant number: 20K10374].

Declaration of Interest

The authors declare no competing interests.

References

Imafuku, R., Nagatani, Y., & Shoji, M. (2022). Communication management processes of dentists providing healthcare for migrants with limited Japanese proficiency. International Journal of Environmental Research and Public Health, 19(22), Article 22. https://doi.org/10.3390/ijerph192214672

McAuliffe, M., & Triandafyllidou, A. (2021). World migration report 2022. International Organization for Migration (IOM). https://publications.iom.int/books/world-migration-report-2022

Medical Education Model Core Curriculum Expert Research Committee. (2022). Model core curriculum for medical education in Japan 2022. Ministry of Education, Culture, Sports, Science and Technology. https://www.mext.go.jp/content/20230315-mxtigaku -000026049_00003.pdf

Santandreu-Calonge, D., Medina-Aguerrebere, P., Hultberg, P., & Shah, M.A. (2023). Can ChatGPT improve communication in hospitals? Profesional de la información, 32(2), Article e320219. https://doi.org/10.3145/epi.2023.mar.19

Zhao, X. (2023). Challenges and barriers in intercultural communication between patients with immigration backgrounds and health professionals: A systematic literature review. Health Communication, 38(4), 824–833. https://doi.org/10.1080/10410236.2021.1980188

*Rintaro Imafuku
1-1 Yanagido Gifu, Gifu, Japan
+81-58-230-6469
Email: imafuku.rintaro.f9@f.gifu-u.ac.jp

Submitted: 20 April 2023
Accepted: 23 August 2023
Published online: 2 January, TAPS 2024, 9(1), 54-57
https://doi.org/10.29060/TAPS.2024-9-1/SC3048

Atul Kumar¹, Amol Gawande¹, Meghana Bhilare², Vishal Wadajkar², Indrajit Ghoshal³ & Shirish Raibagkar⁴

¹Dr.D.Y. Patil B-School, Pune, India; ²Dr.D.Y. Patil Institute of Management and Research, Pune, India; ³Faculty of Computer Science and Engineering, Poornima University, Jaipur, India; ⁴Savitribai Phule Pune University, Pune, India

Abstract

Introduction: The purpose of this study is to carry out a comparative analysis of the job satisfaction of nurses working in India based on the different types of the hospital they are working with. The study tests the null hypothesis that the job satisfaction of nurses from India across different types of hospitals is the same.

Methods: Four hundred nurses divided into 100 each for four popular types of hospitals – (1) Educational; (2) Government; (3) Charitable Trust; and (4) Private, from all over India were surveyed. Two ANOVA tests were performed. The first one was performed, taking overall job satisfaction as the dependent variable. The second ANOVA was performed by taking the monetary and compensation factors, work environment and management support, and job-related factors as the dependent variables.

Results: The overall mean of job satisfaction was -0.73 (SD 0.60). Overall, 65 percent of the variability of the dependent variable, job satisfaction, is explained by the type of hospital and is statistically significant (p<0.0001).

Conclusion: Monetary and compensation factors, work environment and management support, and job-related factors impact nurses’ job satisfaction. These factors vary with the type of hospital, and hence it can be concluded that due to variation in these factors depending on the type of hospital, the job satisfaction of nurses varies. Implications of our study are for the educational, government, and charitable trust hospitals to improve their work culture, management, and work environment so that nurses will have higher job satisfaction.

Keywords:           Nurses, Job Satisfaction, India, Hospitals, Government, Private, Charitable Trust, Educational 

Type	Total		Monetary		Work Env.		Job related
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Educational	-0.22	0.86	-0.21	0.87	-0.27	0.89	-0.19	0.90
Govt.	-1.55	0.40	-1.53	0.39	-1.60	0.47	-1.54	0.44
Trust	-1.57	0.46	-1.51	0.47	-1.65	0.50	-1.53	0.50
Private	0.42	0.68	0.39	0.74	0.39	0.68	0.48	0.71
Total	-0.73	0.60	-0.71	1.05	-0.78	1.09	-0.70	1.09

Table 1. Descriptive statistics of the sample

The overall job satisfaction mean scores of the hospitals were -0.22 (0.86) for educational hospitals, -1.55 (0.40) for Government hospitals, -1.57 (0.46) for Trust hospitals, and 0.42 (0.68) for private hospitals. For all the 400 respondents taken together, the mean job satisfaction score was -0.73 (SD 0.60).

In the case of educational hospitals, all three factors of job satisfaction were negative – monetary and compensation factors (M= -0.21, SD 0.87), work environment and management support (M= -0.27, SD 0.89), and Job-related factors (M= -0.19, SD 0.90). The same was the case with government hospitals which reported negative job satisfaction for all three factors – monetary and compensation factors (M= -1.53, SD 0.39), work environment and management support (M= -1.60, SD 0.47), and Job-related factors (M= -1.54, SD 0.44).

Further, charitable trust hospitals too reported negative job satisfaction for all three factors – monetary and compensation factors (M= -1.51, SD 0.47), work environment and management support (M= -1.65, SD 0.50), and job-related factors (M= -1.53, SD 0.50). However, private hospitals were the only type of hospitals that reported positive job satisfaction for all three factors – monetary and compensation factors (M= 0.39, SD 0.74), Work environment and management support (M= 0.39, SD 0.68), and job-related factors (M= 0.48, SD 0.71).

B. Testing of the Hypotheses

Two ANOVA tests were performed. The first one was performed, taking overall job satisfaction as the dependent variable (R² 0.65, p<0.0001). The second ANOVA was performed by taking the monetary and compensation factors (R² 0.62, p<0.0001), work environment and management support (R² 0.64, p<0.0001), and job-related factors (R² 0.64, p<0.0001) as the dependent variables.

IV. DISCUSSION

The overall job satisfaction score of the entire sample size of 400 respondents is -0.73 (SD 0.60), which is close to -1, indicating somewhat dissatisfied. Thus, on an overall basis, Indian nurses have reported job dissatisfaction. An important reason for this is the mismatch between the guidelines of the Nursing Council about the working conditions and the actual working conditions at the various hospitals. The analysis shows that for all the three factors, namely, the Monetary and compensation factors, the work environment and management support factors, and job-related factors the scores are range-bound. This indicates a close relationship between these three factors.

However, when we look at the analysis by the type of hospitals, major variations are seen. Three out of the four types: educational hospitals, government hospitals, and charitable trust hospitals, show negative job satisfaction, whereas only one type, the private owned hospitals, show positive job satisfaction. This is because private hospitals offer a much better and more professional work culture leading to higher job satisfaction among the nurses (Srimulyani & Hermanto, 2022). Interestingly, there is not much difference between the job satisfaction scores of government hospitals and charitable trust hospitals. The standard deviations associated with these two high negative scores are also similar. Scores of government hospitals and charitable trust hospitals can be taken as lying between somewhat dissatisfied and strongly dissatisfied ratings, pointing out a big gap between the prescribed norms of working conditions and the actual working conditions. The score of -0.22 indicates relatively much lesser job dissatisfaction in the case of educational hospitals (as compared to government and charitable trusts). It indicates that the control over educational hospitals is better as compared to the other two types of hospitals. The positive score of 0.42 in the case of private hospitals lies between neutral and somewhat satisfactory pointing a positive and professional work culture.

An important observation that emerges from the analysis is that for each of the four types of hospitals, there is little variation in the three factors of job satisfaction or dissatisfaction. This is because the three factors are closely related to each other.

V. CONCLUSION

Indian nurses, on an overall basis, are somewhat dissatisfied with their jobs. However, when we look into different types of hospitals, it is concluded that nurses working in private hospitals are moderately satisfied, those working in educational hospitals are moderately dissatisfied, and those working in government and charitable trust hospitals are highly dissatisfied. monetary and compensation factors, work environment and management support, and job-related factors impact nurses’ job satisfaction. These factors vary with the type of hospital, and hence it can be concluded that due to variation in these factors depending on the type of hospital, the job satisfaction of nurses varies. This impact is strong on an overall basis, as well as for the three factors (monetary and compensation Factors, work environment and management support, and job-related factors) separately. Interestingly there is a strong correlation among the three factors that we have used for measuring the job satisfaction of nurses. We conclude that positive and relatively higher job satisfaction among nurses working in private hospitals (Srimulyani & Hermanto, 2022) can be attributed to professional working culture, better monetary and compensation factors, better co-worker relationships, and other factors.

Notes on Contributors

Dr. Atul Kumar contributed to the conceptualization of the entire study. Dr. Amol Gawande contributed in designing methods for the study. Dr. Meghana Bhilare contributed to data collection. Dr. Vishal Wadajkar contributed to data analysis. Dr. lndrajit Ghoshal contributed in deducing findings and writing the discussion. Dr. S S Raibagkar contributed in writing the full paper including the conclusion. All the authors have read and approved the final manuscript.

Ethical Approval

The study got ethics committee approval number DYP202301, from the Institutional Review Boards of Dr.D Y Patil (Deemed to be) University, Pune, India, and Dr.Ajeenkya D Y Patil University, Pune, India.

Data Availability

All 400 responses were collated in a data set that has been deposited in a repository and can be accessed at https://www.openicpsr.org/openicpsr/project/190042/version/V1/view

Funding

No external funding was used for the study.

Declaration of Interest

We declare that there is no conflict of interest or competing interest of any sort with any individual or organization.

References

Bhilare, M. (2023). Data set Nurses Job Satisfaction (ICPSR 190042; Version V1) [Data set]. ICPSR. https://www.openicpsr.org/openicpsr/project/190042/version/V1/view

Business Standard. (2021, September 2). India in need of 4.3 mn more nurses by 2024 to meet who norms: Nurse org. Retrieved March 29, 2023, from https://www.business-standard.com/article/ current-affairs/india-in-need-of-4-3-mn-more-nurses-by-2024-to-meet-who-norms-nurse-org-121090201448_1.html

Chang, E., Cohen, J., Koethe, B., Smith, K., & Bir, A. (2017). Measuring job satisfaction among healthcare staff in the United States: a confirmatory factor analysis of the Satisfaction of Employees in Health Care (SEHC) survey. International Journal for Quality in Health Care, 29(2), 262-268. https://doi.org/10.1093/intqhc/mzx012

Rahnavard, F., Sadati, A. K., Hemmati, S., Ebrahimzade, N., Sarikhani, Y., Heydari, S. T., & Lankarani, K. B. (2018). The impact of environmental and demographic factors on nursing job satisfaction. Electronic Physician, 10(4), 6712. https://doi.org/10.19082%2F6712

Srimulyani, V. A., & Hermanto, Y. B. (2022). Organizational culture as a mediator of credible leadership influence on work engagement: empirical studies in private hospitals in East Java, Indonesia. Humanities and Social Sciences Communications, 9(1), Article 274. https://doi.org/10.1057/s41599-022-01289-z

*Shirish S Raibagkar
Savitribai Phule Pune University,
Ganeshkhind, Pune, India
Email: ssrssr696@gmail.com

Submitted: 5 March 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 49-53
https://doi.org/10.29060/TAPS.2024-9-1/SC3016

Thamudi D Sundarapperuma^1, Eranthi Weeratunga¹, Prabhavi Wijesiriwardhana², Eranga Silva², Shanika Karunanayaka³, & Kithmini Yasarathne³

¹Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka; ²Department of Medical Laboratory Science, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka; ³Department of Pharmacy, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

Abstract

Introduction: Several nations around the world had to close schools, colleges, universities, and other educational institutions as they were badly affected by the spread of COVID-19. The purpose of this study was to measure the effectiveness of online vs physical teaching during the COVID-19 pandemic, at the Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR) Sri Lanka.

Method: A cross-sectional study was conducted among 200 undergraduates. The data were collected through displayed/approved results sheets of the students of selected batches in the Department of Nursing, Department of Pharmacy, and Medical Laboratory Science (MLS). Paired sample T-test was used to compare the results of undergraduates.

Results: The examination results of 47-54 undergraduates in nursing, 28 in pharmacy, and 22 in MLS were analysed. Significant differences in Psychiatry in Nursing and Nursing Clinical Attachment were identified in the Department of Nursing (p=0.001). In the Department of Pharmacy, only Pharmaceutical Chemistry I (p=0.012) reported a significant difference. The undergraduates of MLS who underwent online theory sessions had scored more in Microbiology and Immunology (p=0.022) and Basic Genetics and Molecular Biology (p=0.000) whereas in Research Methodology and Epidemiology, the undergraduates who participated in physical lectures had scored more marks (p=0.001).

Conclusion: Practical/interactive session-based course units and clinical appointments had a higher impact on the mode of teaching than many theoretical course units. The results might serve as a primer for the creation of an action plan to support the academics and clinical/practical components of undergraduates.

Keywords:           Undergraduates, Online Teaching, Physical Teaching, Examination Results, COVID-19

I. INTRODUCTION

The provisional closure of educational institutions during the coronavirus disease-19 (COVID-19) pandemic has unexpectedly transformed the Sri Lankan education landscape in favour of distance learning or online learning. As a result of this, drastic changes in digital platforms and applications i.e., digital learning management systems became common among universities (Ariyananda et al., 2022). These universities used existing modular object-oriented dynamic learning environment-based learning management systems (Moodle) and the Lanka Education and Research Network (LEARN) was connected to university web servers and used for online education to mitigate the effects of disrupted learning (Hayashi et al., 2020).

Online teaching was a novel experience for university lecturers and undergraduates, and it was a huge challenge for both parties. In the beginning, both parties had to face several issues due to the unfamiliarity of these novel methods, the unavailability of basic facilities, and insufficient network coverage in Sri Lanka. Though it would be an effective alternative to conduct Zoom lectures again as physical lectures once the university reopened, we were unable to conduct lectures due to limited time during the semester. Therefore, the need emerged to identify a more effective mode to deliver lectures to undergraduates. This study aims to address the effectiveness of online vs. physical teaching during the COVID-19 pandemic, by analysing the examination results at the Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR).

II. METHODS

A cross-sectional study was conducted to measure the effectiveness of online teaching vs. traditional/physical teaching and its impact on the performance of undergraduates. The data were collected through displayed/approved results sheets of the students of selected batches in the Department of Nursing, Pharmacy, MLS, FAHS, UoR. Nursing, though considered as a separate discipline from other para-medical disciplines in other countries, is considered under the Faculties of Allied Health Science in Sri Lanka.  The examination results of two batches of undergraduates in a similar semester but who had learned in a different mode (in this group one batch has completely learned online while another batch has learned physically) were purposefully selected from each department. All lectures done via Zoom were recorded and distributed among students. Both groups underwent the same types of examination, mainly multiple-choice questions (MCQs) and short structured questions (SEQ) for theoretical knowledge. Practical and clinical skills were assessed using practical-based examination and patient-based clinical examination respectively. These examinations had been conducted in 2021 and 2022 and results were released in 2022. The analysis of results was conducted in January and February 2023.

Data from approximately 208 proper undergraduates (who sat for the first time) were analysed. The population was composed of nursing (n=108), pharmacy (n=56), and MLS (n=44) students. However, the results of repeat undergraduates were excluded. Six subjects were considered under the Department of Nursing. The number of candidates for the subjects was not equal. To analyse the effectiveness, a comparative analysis of the results of the end-semester examinations was performed by three departments separately. Mainly, in the Department of Nursing and Pharmacy the end semester examination results (two examinations/academic year) were evaluated while in the Department of MLS, the final term results were evaluated (three examinations /academic year).

Statistical Package for Social Science (SPSS) 26 software was used to analyse data. The mean and standard deviation (SD) values of the results sheets were analysed using descriptive statistics. After considering the distribution of the data set, paired sample T-test was used to compare the means of two batches. All results were regarded as statically significant at p < 0.05.

Ethical approval was obtained to analyse the published data from the Ethics Review Committee, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka (Ref. no. 200.01.2023). Consent was obtained from all relevant authorities before taking results from the notice board.

III. RESULTS

Two batches were selected in the nursing department and each batch consisted of 54 undergraduates.  An equal number of candidates had not participated in every subject and therefore results were analysed based on students’ attendance for the different subjects.  Under the nursing department, there were six subjects for students. Four subjects out of these six subjects consisted only of theory components. One subject had both theory and clinical components and the other subject had only clinical-based examination.

All the subjects had only a theory component in the selected semester in the pharmacy department. Under the department of MLS, all subjects consisted of theory and practical components.

Submitted: 24 January 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 42-48
https://doi.org/10.29060/TAPS.2024-9-1/SC2997

Rahizan Zainuldin¹ & Heidi Siew Khoon Tan^1,2

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Pre-Professional Education Office, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: Singapore Institute of Technology’s undergraduate (UG) occupational therapy (OT) and physiotherapy (PT) programs are one of the first implementors of Entrustable Professional Activities (EPAs) in the respective allied health professions training. The aim of the paper is to report the outcomes of the first year of EPAs implementation in clinical practice education (CPE) and share next steps refining implementation.

Methods: A quality improvement (QI) study using the Plan-Do-Check-Act (PDCA) cycle was conducted. UG OT Year 2 and Year 3 students, UG PT Year 3 students and their clinical educators (CEs) who experienced the use of EPAs for the first time were surveyed at the end of the clinical block.

Results: There was generally high agreement (>70% agreed or strongly agreed) among all groups in using EPAs to better understand the learning objectives of CPE and practice expectations as future entry-level practitioners at conditional-registration. More than 70% of OT respondents but less than 50% PT respondents found the EPA assessment forms easy to use. Less than 60% of both program CEs did not include colleagues for EPA assessments. 55% of both OT and PT CEs found the EPA training and resources adequate. Overall, PT respondents showed lower agreement than OT respondents in five survey items.

Conclusion: The first implementation cycle of EPA in the undergraduate OT and PT CPE had mixed acceptability to the EPA assessment tools. Three strategic changes were made for the second implementation cycle., i.e., redesign of EPA-based assessment forms, training focus and ‘just-in-time’ training with streamlined resources.

Keywords:           Clinical Training, Entrustable Professional Activities, Occupational Therapy, Physiotherapy, Undergraduate, Workplace-based Assessment

I. INTRODUCTION

In 2021, the occupational therapy (OT) and physiotherapy (PT) undergraduate programs at Singapore Institute of Technology (SIT) added a novel assessment, Entrustable Professional Activities (EPAs), to the extant competency-based assessment tools in clinical practice education (CPE). EPAs are units of professional activities entrusted to a learner determined by five levels of supervision, once the learner has demonstrated the required competence (ten Cate & Taylor, 2020). OT EPAs and PT EPAs (Zainuldin & Tan, 2021) were developed and introduced to SIT CPE as part of the Ministry of Health’s review of healthcare professions’ training standards. EPA-based assessments are relevant in CPE where students perform professional activities at workplace, supervised by onsite clinical educators (CEs). Previous CPEs assessed only OT and PT student competencies using the validated Student Practice Evaluation Form-Revised Edition (SPEF-R) (Turpin et al., 2011) and the Clinical Competency and Reasoning Assessment (CCRA), respectively. Conceptually, the pairing of EPAs with SPEF-R or CCRA potentially offer CEs an opportunity to empower students through graduated levels of entrustment supported by appropriate proficiency levels. Operationally, EPA assessment does not add new activities. OT and PT CEs can utilise routine observations of students’ tasks, case discussions and case-notes documentation as sources to inform entrustment levels in EPAs.

No EPA implementation in any OT and PT curricula has been documented. At SIT, EPA implementation in CPE needs evaluation. Recognising that implementing process changes requires an iterative approach, SIT embarked on a quality improvement study using the Plan-Do-Check-Act (PDCA) cycle. This paper reports the results of operationalising EPAs for the first time in OT and PT CPE, including the use of EPA-based assessment forms. The Methods section describes the Plan and Do, followed by the Results section reporting outcomes of the Check and the Discussion section highlighting the Act to improve implementation.

II. METHODS

A. CPE Structure

OT CPE consists of four blocks of seven weeks each and interspersed between academic modules in Years 2, 3 and 4. PT CPE consists of five consequent blocks (four core and one elective) of six weeks each, begins only after all academic modules are completed in Year 3 and continues to Year 4. OT and PT students complete different clinical settings for each CPE block.

B. Participants and Study Design

OT Year 2 and Year 3 students, PT Year 3 students and their CEs who experienced EPA use for the first time were surveyed at the end of a clinical block. An online EPA survey is incorporated with routine post placement feedback for both students and CEs, therefore no consent was required. The QI study was exempt from ethics review (SIT Institutional Review Board, No. 2022122). Survey results were extracted from February to December 2021.

C. PDCA Cycle: Plan-Do

OT and PT have five core EPAs each. EPA-based assessment activities are short practice observations, entrustment-based discussions and case-notes evaluations. These activities serve as sources of information (SOIs), or workplace-based assessments (WBAs) in OT CPE, to inform entrustment decision-making. OT CE assesses EPAs by documenting in a single patient case form with all three WBAs per EPA. PT CE assesses EPAs for every patient case anchored by three different SOI forms with written justifications. OT and PT CEs and students were trained on nuts and bolts of EPAs and on using WBA/SOI forms in CE training workshops and student pre-CPE briefing, respectively.

Each OT EPA requires a total of six patient cases entrusted to students at Level 3 entrustment (indirect supervision) across four CPE blocks. Each PT EPA requires six cases at Level 3 entrustment at each core clinical block, which totals 24 cases by end of the program. Appendix 1 and 2 provides visualisation of EPA implementation across multiple CPE blocks.

The EPA survey has ten items. The first eight items are scored on a 4-point Likert-scale (strongly disagree-strongly agree). The final two questions seek qualitative feedback on benefits and challenges and suggestions for improvements. Unless indicated, items are phrased in the same manner in both student and CE surveys.

D. Data Collection and Analysis

Data were counted as proportions of respondents who agreed (pooled response from ‘agree’ and ‘strongly agree’) and proportions disagreed (pooled from ‘disagree’ and ‘strongly disagree’). The authors grouped the qualitative narrative into benefits and challenges.

III. RESULTS

A. PDCA Cycle: Check

There were 99.0% response rate from OT Year 2 students (105/106), 97.7% from Year 3 OT students (85/87), 93.2% from PT Year 3 students (137/147), 98.5% from OT CEs (199/202) and 92.5% from PT CEs (247/267). Proportion of respondents who agreed with each item statement is shown in Table 1. Data on item scores for each student and CE are available at online repository, http://doi.org/10.6084/m9.figshare.21941288

Submitted: 5 April 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 28-35
https://doi.org/10.29060/TAPS.2024-9-1/OA3035

Aminda Faizura Omar, Tun Yasmin Iffah Mohd Suria Affandi, Mohd Isyrafuddin Ismail, Mas Suryalis Ahmad & Ilham Wan Mokhtar

Comprehensive Care Centre of Studies, Faculty of Dentistry, Universiti Teknologi MARA, Malaysia

Abstract

Introduction: This study was undertaken to investigate students’ perceptions of innovation-integrated learning, adopted as an alternative approach for special care dentistry (SCD) training.

Methods: Ninety final-year dental students from the 2021 cohort were divided into eight groups to complete an innovation project dedicated to eight categories of patients with special health care needs. Discussion and final presentations, involving related experts were conducted remotely via an online platform. Then, students were invited to answer a validated online feedback survey on their perceptions of the learning approach.

Results: The response rate for the feedback survey was 91.1% (n=82). Most students agreed that the activity was interesting, improved their knowledge and understanding of SCD, allowed engagement between peers, supported sharing of ideas and experiences, encouraged student–lecturer interactions, and enhanced knowledge integration and application. Students also expressed that the activity enhanced creativity and innovation, instilled an interest and positive attitude toward learning SCD, and encouraged teamwork. However, a few students noted facing some limitations in completing their projects (i.e., technological challenges and reduced physical access to purchase materials). Around half felt neutral about having an increased workload from this activity. Moreover, perceptions differed regarding time and financial commitments, as well as supervisors’ and patients’ involvement during the project development process.

Conclusion: Students perceived that the innovation-oriented learning activity, was beneficial in multiple aspects of SCD training.

Keywords:           Innovation, Learning, Dental Students, Perception

Practice Highlights

• We have developed a new integrated teaching method via the utilisation of innovation development for special needs groups.
• Students’ perceptions of this learning method were explored using both quantitative and qualitative methods via an online feedback questionnaire.
• Overall, students positively responded to the teaching method when it came to improving their knowledge and understanding of SCD, engagement between peers, sharing of ideas and experiences, student–lecturer interactions, and knowledge integration and application.
• This novel teaching method achieves the highest level of Bloom’s Taxonomy which is to create something new.

I. INTRODUCTION

Special care dentistry (SCD) involves managing patients with special health care needs, such as those with physical, intellectual, psychological impairments as well as complex medical conditions (Royal Australasian College of Dental Surgeons, 2021). At the undergraduate level, many teaching and learning activities have been conducted to provide students with learning experience in this area of patient care. These activities include lectures, community-based learning, simulation exercises and clinical training (Ahmad, Mokhtar, et al., 2020; Mohamed Rohani & Mohd Nor, 2021). Students who received training in SCD were found to have demonstrated better comfort and attitudes in managing patients with special health care needs (Mohamed Rohani et al., 2021).

However, these learning activities may be compromised by situations that limit face-to-face interactions, either among students, between teacher and learners, as well as with the patients. Such situations may happen due to disease (such as the recent COVID-19 pandemic), geographical barriers and accessibility issues (Amir et al., 2020). It was found that limitations of dental training that requires physical contact may compromise students’ learning experience, thus affecting their competency, knowledge and confidence in patient care (Chang et al., 2021).

Meanwhile, it has become incumbent on dental education providers to prepare future graduates with essential skills that are deemed beneficial for practicing health care professionals. These skills include innovation, leadership, critical thinking and enterpreneurial abilities (Malaysian Dental Council, 2021). Acquisition of these abilities have been associated with many aspects of personal and professional development including emotional intelligence and practice management (Saleem et al., 2019; Wang et al., 2020).

In view of the various challenges and demands of the current (and future) educational environment and healthcare needs, an innovation-integrated educational approach was developed and adopted as an alternative teaching and learning method to teach SCD. This approach, undertaken mostly remotely using an online learning platform, involved the integration of students’ cognitive function, psychomotor ability, and affective skills through the development of innovative products to address oral health issues experienced by the different categories of patients with special health care needs. As a novel educational approach, assessment of its effectiveness is therefore essential. This study was undertaken to investigate students’ perceptions of the innovation-integrated learning, conducted remotely via an online platform, developed during the COVID-19 pandemic, as an alternative approach for SCD training.

II. METHODS

A. Study design

This was a descriptive, cross-sectional, quantitative and qualitative study, using a validated online feedback questionnaire involving the final-year undergraduate students of the Bachelor of Dental Surgery program of the Faculty of Dentistry, Universiti Teknologi MARA.

B. Study Population

Because this module is a compulsory component of the final-year undergraduate dental curriculum (Faculty of Dentistry, 2022), all students were required to be involved with the group innovation project. However, participation in the online feedback survey was voluntary. At the beginning of the semester, the students were made aware of the study and that their participation in the innovation program and the research were treated separately.

All students who agreed to participate in the online feedback survey provided informed consent, attached to the information sheet supplied to all potential participants via their official university email. To avoid coercion, students were provided with an explanation in the information sheet that their participation was entirely voluntary and anonymous. Those who wished not to participate in the online feedback survey would not be penalised, and they could withdraw their participation at any point without having to provide a justification.

C. Study Instrument

The questionnaire used for the online feedback survey was adopted from the study by Rowe and Wood (2008). It was content-validated by a panel of 2 experts in dental education before its use in the main survey. From the item-level content validatiy index (I-CVI) for each item as well as a summation of the I-CVI divided by the number of average (S-CVI/Ave), a  score of 1 was obtained for both indices as the  panelists rated all items with a score of 3 or 4. The questionnaire consisted of nine items about the perception of students towards this teaching method, measured using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). Open-ended questions were included at the end of the questionnaire to further explore students’ perceptions of the learning activities.

D. Study Conduct

For the group innovation project, all final-year students (n=90) were divided into eight groups, based on their assigned clinical groupings. Each group was assigned to an academic or clinical specialist in SCD, who acted as a supervisor. Eight categories of patients with special health care needs were identified and randomly allocated to the different groups. The categories of patients were 1) hearing disability, 2) speech disability, 3) visual disability, 4) geriatric, 5) Down syndrome, 6) autism, 7) cerebral palsy, and 8) dementia.

Students were given three months to develop innovative products. They were expected to engage with their supervisors during the whole development process, which involved 1) identification of health complications related to the condition and its impact on oral health, 2) understanding of issues related to patients’ oral health care; 3) creation of a prototype to address the related oral health–related complications. Because all students were at the time subjected to restrictions in having physical classes due to COVID-19 (Samat et al., 2020), large-group discussions and final presentations were undertaken remotely online.

At the end of this group activity, an online presentation, judged by experts in related fields, was conducted as a form of assessment, as well as constructive feedback on improvements and the marketability of the product. Students were then invited to participate in the online feedback questionnaire, which was distributed via their official university email. An English language questionnaire was used as the respondents were undergraduate dental students with a good command and understanding of the language. A reminder email was sent a week later, with another reminder sent the following week.

E. Data Analysis

To maximise the outcome, quantitative data were simplified into a 3-point Likert scale (agree, neutral, and disagree). Using SPSS version 27, the frequency of the data was analysed to compare students’ responses for each item. For analysis of the benefits, the nine items of the questionnaire were further categorised into different themes: Theme 1—Acceptance of the teaching method concept (Item 1), Theme 2—Effectiveness of teaching method (Items 2, 3, 6, and 7), Theme 3—Important role of supervisors (Items 4, 5, and 8), and Theme 4—Impact on students’ workload (Item 9).

For the qualitative component, data were analysed via thematic analysis involving open and closed coding. Emerging themes were then identified based on these codes, which were then validated through comparisons amongst researchers.

F. Ethical Approval

Ethics approval was obtained from the Research Ethics Committee (REC) Universiti Teknologi MARA, Malaysia, in accordance with the Declaration of Helsinki (REC12/2021 [MR 1004]).

III. RESULTS

A total of 82 out of 90 students returned the questionnaire, giving a response rate of 91.1%. The frequency of responses for each question or item, categorised into the different themes, is shown in Table 1.

Submitted: 30 January 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 20-27
https://doi.org/10.29060/TAPS.2024-9-1/OA2999

Mitsumi Masuda, Naomi Kimura & Akemi Nakagaki

Graduate School of Nursing, Nagoya City University, Japan

Abstract

Introduction: The level of BLS achievement at the end of basic education is not clear, so to develop a BLS training program using QCPR Learner^Ⓡ and to verify its effectiveness.

Methods: A quantitative descriptive study design was used. The developed BLS program was implemented for 81 fourth-year students at the school of nursing. The program consisted of 2 minutes of training per student and real-time feedback by QCPR Learner^Ⓡ as well as feedback among students and from faculty members and was conducted twice for each student. Evaluation was conducted from three aspects: learner response and program evaluation both using questionnaires, learning achievement of QCPR score.

Results: The mean values of learners’ responses before and after the program were: attention, 4.32 before and 4.59 after; relevance, 4.48 before and 4.75 after; confidence, 2.32 before and 3.78 after; and satisfaction, 2.12 before and 3.41 after, which increased significantly after the program. The QCPR Learner^Ⓡ scores increased significantly from 74.08 for the first time to 86.76 for the second time. In the free response, some respondents stated that “visualisation of the procedure by the application improved my skills.”

Conclusion: The results of the evaluation from three aspects showed that this program was effective in improving students’ motivation to learn and skills.

Keywords:           Basic Life Support, Real-Time Feedback, Basic Nursing Education, Simulation Training, QCPR Learner

Practice Highlights

• Real-time feedback application was effective in increasing motivation to learn and BLS skills.
• QCPR Learner^Ⓡ can be easily installed on the learner’s device, making it suitable for self-learning.

I. INTRODUCTION