Submitted: 13 September 2023
Accepted: 4 March 2024
Published online: 2 July, TAPS 2024, 9(3), 64-66
https://doi.org/10.29060/TAPS.2024-9-3/CS3138

Jayabharathi Krishnan, Sara Kashkouli Rahmanzadeh & S. Thameem Dheen

Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

In preclinical years, histology, which is the study of the microscopic structures of tissue and organs, aids students in understanding the normal morphology of cell and tissue organisation in organs and differentiating their pathological changes (Hussein & Raad, 2015). The study of histology is important as it provides the fundamental basis of anatomical knowledge. Students have adapted to a new learning environment, particularly after the COVID-19 outbreak, by utilising autonomous learning strategies, including online and digital learning, as histology requires visual interpretation that is developed by continuous practice (Yohannan et al., 2019). Given this, we have created a virtual histology platform using our existing tool: the National University of Singapore – Human Anatomy Learning resOurce (NUS-HALO). NUS- HALO is an online platform with digital images and videos and has emerged as a novel tool in transforming anatomy teaching and learning. By integrating cutting-edge, high-definition histology images and relevant learning materials, the histology component of NUS-HALO offers a platform that aids students to excel in histology (Darici et al., 2021).

The NUS-HALO platform aids student learning of histology. Histology resources are organised systematically, along with pertinent teaching resources and explanations, to help students better comprehend each histological slide. Furthermore, during their third year of medical school, when students are introduced to pathology, they must use their earlier understanding of normal histology to identify pathological changes.

II. METHODS

Our team included three technical and five academic staff members. The digitisation of histology sections, selected from our existing collection in the Department, was done using Aperio software, and the digital images were saved on a server to be accessed later for teaching. Overall, images from 160 histology slides comprising 13 organ systems were digitised, each taking about 90 minutes to digitise. These images were clustered with the previously saved images (200 images from seven organ systems) and selected for NUS-HALO’s histology arm. The histology slides were carefully chosen to obtain low- and high-magnification images. The images were labelled to give students a clear understanding of each organ system and its critical features.

III. DISCUSSION

NUS-HALO offers a platform that aids student learning of histology. Histology resources are organised systematically, along with pertinent teaching resources and explanations, to help students better comprehend each histological slide. Furthermore, during their third year of medical school, when students are introduced to pathology, they must use their earlier understanding of normal histology to identify pathological changes.

HALO’s histology resources can be seamlessly integrated with what students learn during their anatomy and physiology classes. The use of this tool allows for a holistic understanding where students are able to correlate the microscopic histological structures with macroscopic anatomical features and physiological functions. Informal feedback that has been obtained from both staff and students has been overwhelmingly positive, highlighting the ease of use and quality of the resources available on the platform. A notable outcome has been the informal feedback received by students, stating that the platform has aided their examination preparation. However, continued and more formal gathering of feedback is essential for the platform’s ongoing improvement.

Future enhancements of the platform include using more diverse slide samples, and more interactive elements such as self-evaluation guides to enhance student’s experience and the effectiveness of NUS-HALO. Self-evaluation guides that are currently being considered include identification exercises, where students name structures on slides, and interpretive questions that can test their understanding of how histological changes might relate to pathological conditions. These tools will reinforce learning and enable students to track their progress.

A. Pedagogical Framework of Digital Histology on NUS-HALO

The resources on the NUS-HALO webpage were organised as follows:

1) Categorisation of Histology Images:

Images were organised based on the organ system they belong to (e.g., respiratory, digestive). Each image was annotated with labels and identification markers highlighting fundamental structures and features.

2) Integration of Teaching Resources:

Short notes describing salient features of the sections were embedded alongside the corresponding histology images to provide students with further explanations. 

3) Navigation and User Interface:

The resources were organised to facilitate easy navigation, with a search function, intuitive m menus, and clear headings.

Figure 1: Showing high-quality images captured and uploaded for student access (leftmost). Image showing information available to students when they select digitised slides.

IV. CONCLUSION

The advent of computer-aided digital media and images has significantly impacted medical education, including image-intensive histology. Digitising histology slides appears cost-effective as it reduces the need for microscope maintenance and preparation of glass slides when damaged and manpower costs. This tool serves as an additional learning resource that students can access in conjuction with their existing histology lectures or practical lessons.

In the future, digital histology can be enhanced by incorporating augmented and virtual reality and artificial intelligence to provide students with an enhanced, immersive, and interactive learning experience.

Note on Contributors

Dr. Jayabharathi Krishnan, Dr. Sara Kashkouli Rahmanzadeh, and Professor S. Thameem Dheen are content experts on the Histology aspect of NUS-HALO. All authors contributed equally to this manuscript.

Acknowledgement

The authors would like to acknowledge the technical staff: Ms . Pan Feng, Ms. Bay SL, Ms. Rebecca Auw, and Mr. Low CP from the Department of Anatomy, Yong Loo Lin School of Medicine, for their technical support. The authors would sincerely like to thank the Department of Pathology for contributing to developing the digitalised images.

Funding

The authors did not receive any funding for this study.

Declaration of Interest

The authors do not have any conflict of interest.

References

Darici, D., Reissner, C., Brockhaus, J., & Missler, M. (2021). Implementation of a fully digital histology course in the anatomical teaching curriculum during covid-19 pandemic. Annals of Anatomy – Anatomischer Anzeiger, 236, Article 151718. https://doi.org/10.1016/j.aanat.2021.151718

Hussein, I. H., & Raad, M. (2015). Once upon a microscopic slide: The story of histology. Journal of Cytology & Histology, 6(6), Article 1000377. https://doi.org/10.4172/2157-7099.1000377

Yohannan, D. G., Oommen, A. M., Umesan, K. G., Raveendran, V. L., Sreedhar, L. S., Anish, T. S., Hortsch, M., & Krishnapillai, R. (2019). Overcoming barriers in a traditional medical education system by the stepwise, evidence-based introduction of a modern learning technology. Medical Science Educator, 29(3), 803–817. https://doi.org/10.1007/s40670-019-00759-5 

*DR K JAYABHARATHI
Department of Anatomy
Yong Loo Lin School of Medicine
MD10, 4 Medical Drive
Singapore 117594
Email: antkj@nus.edu.sg

Submitted: 19 August 2023
Accepted: 21 December 2023
Published online: 2 July, TAPS 2024, 9(3), 41-49
https://doi.org/10.29060/TAPS.2024-9-3/SC3111

Rosy Swee Cheng Tay¹, Debby Regina Wegner², Li Siong Lim³, Joshua Ting⁴ & Shu Ting Ong⁵

¹University of Glasgow Singapore, Singapore; ²Singapore Institute of Technology, Singapore; ³Singapore Institute of Technology, Singapore; ⁴Alexandra Health, Singapore; ⁵Gleaneagles Hospital, Singapore

Abstract

Introduction: The Singapore Institute of Technology-University of Glasgow (SIT-UofG) Nursing Programme has traditionally taken a didactic teaching approach in the delivery of the Evidence-Based Practice (EBP) module.  A hybrid approach was introduced using Game-Based Learning (GBL) to encourage active learning through gameplay. 

Methods: A Randomised Controlled Trial (RCT) was undertaken encompassing a cohort of 100 Nursing students taking the EBP module in their first year at the Singapore Institute of Technology (SIT) in the 2021/22 academic year. The experimental group (n=27) worked through the online GBL intervention and the EBP module, while the control group (n=27) took the EBP module alone. The GBL included five Learning Quests and three case studies.

Results: High levels of satisfaction were reported by both the experimental group (n=22) and the control group (n=15) on the traditional content and delivery of the EBP module. High levels of engagement were reported by the experimental group on the GBL intervention; a one-sample statistics analysis confirming a significant level of engagement (p<0.001). A Mann-Whitney U Test, however, found no significant difference in the Continuous Assessment (CA) scores of the two groups (p=0.507 and 0.461). 

Conclusion: The introduction of GBL designed to deliver educational content directly associated with the learning outcomes increased the nursing student engagement in the EBP module. These findings and discoveries can be utilised to improve the GBL intervention to the EBP module to have a more positive impact the student CA scores and therefore on student learning.

Keywords:           Evidence-Based Teaching, Evidence-Based Practice (EBP), Nursing Education, Game-Based Learning (GBL), Teaching and Learning EBP, Nursing Students, Gamification

I. INTRODUCTION

The Singapore Institute of Technology-University of Glasgow (SIT-UofG) Nursing Programme has traditionally taken a didactic teaching approach in the delivery of the Evidence-Based Practice (EBP) module. Numerous undergraduate nursing programmes have taken a similar approach aimed at preparing students to be informed knowledge generators, rather than the more effective savvy consumers of research, or “evidence users” (Melnyk & Fineout-Overholt, 2019). These undergraduate nursing programmes continue to teach “traditional” nursing research courses that fail to address many of the skills, attitudes, and critical knowledge needed to foster EBP, doing little to promote the development of competencies critical for engaging in EBP in clinical contexts (Davidson & Candy, 2016).

EBP is mandated by the Singapore Nursing Board as a key entry to nursing practice competency (Singapore Nursing Board, n.d.) and yet new graduate nurses still lack the knowledge, skills, and attitudes that nurture EBP. In addition, the COVID-19 pandemic brought about unprecedented challenges when classes moved from face-to-face to online, with one of the side-effects being a marked deterioration in the active engagement of the students in their classes. Active engagement is seen as critically pertinent to the learning development of nursing students in preparing them to be future-ready graduates.

Gamification, or the application of game design elements like levels and badges to non-game activities, has been avidly adopted to support contextual teaching and learning, assignments, and assessments in efforts to strengthen student creativity and retention (Caponetto et.al., 2014). Although, as reported by Tavares (2022), results have been varied, Game-Based Learning (GBL) is being increasingly utilized in nursing education.  The aim of this short communication is to describe the development and evaluation of an innovative teaching strategy to evaluate student satisfaction, perception, level of engagement, and overall achievement of the learning outcomes via the gamification of the EBP module.

II. METHODS

A Randomised Controlled Trial (RCT) was undertaken using the 100 Nursing students taking the EBP module in their first year at the Singapore Institute of Technology (SIT) in Trimester 3 of the 2021/22 academic year. All the students were invited to participate in the study and complete the Informed Consent form. The participants were randomized into either the experimental/ intervention group (n=27) or the control group (n=27).

The control group attended the traditional EBP module made up of lectures, workshops, and seminars. The intervention group completed both the EBP module and the GBL intervention. The web-based, mobile-optimized GBL was composed of five levels or Learning Quests (LQs) and three case studies. The LQs followed six different EBP steps (Melnyk & Fineout-Overholt, 2019), with each LQ calling for increasing levels of knowledge and proficiency to cultivate a spirit of inquiry for the undergraduate nursing students. The intervention group was informed to access the GBL only after the key EBP concepts and teaching were delivered to both groups.

Two surveys were used to evaluate participant satisfaction, perception, level of engagement, and overall achievement of the learning outcomes. At the end of the trimester, a university-wide Module and Teaching Feedback survey (Appendix 1) was used to assess how satisfied both groups were with teaching and learning within the EBP module. The GBL Module Learning Outcomes Feedback survey was to get a sense of how the intervention group evaluated the effectiveness of the four main GBL outcomes (Appendix 2).

III. RESULTS

A total of 54 students out of the 100 (54%) taking the EBP module agreed to participate in this study. A total of 22 (81.5%) participants from the intervention group and 15 (55.6%) from the control group completed the surveys. There was a 44.4% attrition from the control group.

A. Grade Performance

There were two types of Continuous Assessment (CA) used – a group presentation worth 40% of the total grade, and an individual essay worth 60%. For the group presentation the mean score and standard deviation of the intervention group was 79.56 (3.70) and the control group was 78.70 (4.03). For the essay, the mean score and standard deviation of the intervention group was 69.6 (11.93) and for the control group was 67.81 (10.76). The Mann Whitney U Test found that there was no significance difference between the CA scores of the intervention and control groups (p = 0.507 and 0.461).

B. Level of Satisfaction

Overall, there was a high level of satisfaction for the EBP module for both groups (intervention: 95.5%; control: 93.3%) with no significant difference (p=0.658) found between the two groups.

C. Level of Perception

Both groups demonstrated similar positive perceptions about the EBP module. 5 themes emerged from the thematic analysis of the open-ended questions (Table 1)

D. Level of Engagement

The GBL was reported by the students to have deepened their learning of EBP. 4 themes emerged from a thematic analysis of the open-ended questions (Table 1).

Table 1. Themes and associated subthemes

Note. This table lists the themes and associated subthemes that were identified from the student responses to the open-ended questions under perception and engagement. Selected student comments are included.

IV. DISCUSSION

There were several key findings from the development of GBL for the EBP module. Although no significant difference was found on the CA grade performance between the groups, both groups expressed a high level of satisfaction upon completing the EBP module.

Despite facing challenges with the usual didactic approach of teaching and learning of EBP, participants expressed appreciation to the faculty for the close stepwise guidance and prompt feedback in facilitating synergistic class teamwork. The systematic flow helped create a positive perception of the module delivery. This well-structured learning scaffold also provided a solid foundation for writing their Honours Thesis.

Gamification using case studies provided good interactivity for applied learning to enhance student engagement and learning. With regards to the interface itself, the navigation of the case studies via the user interface was found to be challenging, so side-by-side scrolling can be considered to improve future user experience.  Standardizing teaching and instructional methods to manage student expectations can also be considered, as there was definite support for moving the EBP module towards game-based learning.

This development of GBL for the EBP module was an innovative hybrid approach to the teaching pedagogy of the educational and healthcare institutions in Singapore. The employment of both didactic and GBL teaching and learning served to enhance the learning experience of the students and helped clarify the future translation of EBP into their respective clinical practice. While the feedback from the intervention group indicated the GBL interface can be improved, the high levels of satisfaction and engagement experienced by this group demonstrated the incorporation of game mechanics in the design of a teaching-learning process can help engage learners in a more productive learning experience.

With no significant difference between the grades of the two groups, it could be argued that the nursing students are already being well guided and supported by Faculty in the teaching and learning of EBP and that the intervention was built upon a firm foundation. Leveraging upon authentic digital learning with a sound pedagogical approach, however, can help to further promote critical thinking, active engagement, and positive learning experiences for the nursing students. Future enhancement to the GBL intervention can consider levelling up the basis of gamifying learning for higher immersive learning experience.  As there was a high attrition from the control group of 44.4%, future studies can consider a larger sample size for better generalizability. As this study only employed the GBL after the key concepts and teaching of EBP was delivered, future studies can consider the teaching and learning pedagogy of GBL along with seminar sessions to evaluate its viability.

V. CONCLUSION

This research project was carried out at the Singapore Institute of Technology to assess the impact of a GBL intervention on teaching and learning in the EBP module for nursing students. Despite no significant differences in grades between the groups, the results show the intervention had a positive impact on the student engagement, satisfaction, and perception of the learning experience, offering an excellent option of combining traditional didactic teaching with the innovative approach of GBL to enhance the EBP teaching and learning of undergraduate nursing students and healthcare professionals in both educational and healthcare institutions.

Notes on Contributors

Assistant Professor Rosy Tay Swee Cheng spearheaded the development of this research project, conducted the survey and data analysis, contributed to the conception, drafted, and critically revised the manuscript.

Ms. Debby Regina Wegener is a Senior Librarian and assisted with the development of a part of this research project, and critically revised the manuscript.

Mr. Lim Li Siong is a Senior Educational Developer in CoLEAD and coordinated the development of the research project and contributed to the critical review of the manuscript.

Mr. Joshua Ting is a Staff Nurse, Alexandra Health and played a key role in the development, conducted the survey and data analysis of this research project, and assisted in the critical review of the manuscript.

Ms. Ong Shu Ting is a Staff Nurse, Gleneagles Hospital and played a key role in the development, conducted the survey and data analysis of this research project, and assisted in the critical review of the manuscript.

All authors gave their final approval and agreed to be accountable for all aspects of the work.

Ethical Approval

Ethical approval approved by Singapore Institute of Technology (SIT) Review Board (IRB Project No. 2021157).

Data Availability

As per institutional policy, research dataset is available on reasonable request to the corresponding author.

Acknowledgement

The authors would like to thank Adjunct Associate Professor Edward Poon, Singapore Institute of Technology (SIT) for his invaluable support to the research project and Tam Yew Chung, Centre for Learning Environment and Assessment Development (CoLEAD), SIT for his advice and invaluable support in navigating the funding process.  

Funding

Funding (WBS Code: P-ALI-A203-0008) was received from Applied Learning and Innovation Grant (ALIGN), CoLEAD, SIT for the development of this web-based EBP game-based learning.  

Declaration of Interest

The authors declare no conflict of interest.

References

Caponetto, I., Earp, J., & Ott, M. (2014). Gamification and education: A literature review. European Conference on Games Based Learning, 1, 50–57.  

Davidson, S. J., & Candy, L. (2016). Teaching EBP using game-based learning: Improving the student experience. Worldviews on Evidence-Based Nursing, 13(4), 285–293. https://doi.org/10.1111/wvn.12152

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4^th ed.). Wolters Kluwer.

Singapore Nursing Board. (n.d.). Guidelines and Standards. https://www.healthprofessionals.gov.sg/snb/guidelines-and-standards  

Tavares, N. (2022). The use and impact of game-based learning on the learning experience and knowledge retention of nursing undergraduate students: A systematic literature review. Nurse Education Today, 117, Article 105484. https://doi.org/10.1016/j.nedt.2022.105484 

*Rosy Tay Swee Cheng
University of Glasgow, Singapore,
10 Dover Drive, Singapore 138683
+65 6592 4521
Email: rosy.tay@glasgow.ac.uk

Submitted: 11 December 2023
Accepted: 18 March 2024
Published online: 2 July, TAPS 2024, 9(3), 67-69
https://doi.org/10.29060/TAPS.2024-9-3/CS3189

Galvin Sim Siang Lin¹, Wen Wu Tan², Yook Shiang Ng¹ & Kelvin I. Afrashtehfar³

¹Department of Restorative Dentistry, Kulliyyah of Dentistry, International Islamic University Malaysia, Malaysia; ²Department of Dental Public Health, Faculty of Dentistry, Asian Institute of Medicine, Science and Technology (AIMST) University, Malaysia; ³Evidence-Based Practice Unit, Clinical Sciences Department, College of Dentistry, Ajman University, United Arab Emirates

I. INTRODUCTION

The landscape of health profession education, particularly dental education, is evolving to equip students with essential contemporary knowledge and skills for competent dental practice. Within this context, dental materials science plays a pivotal role in undergraduate dental programs, providing the foundation for understanding the materials used in clinical dentistry. However, traditional teaching approaches relies on didactic lectures, often rendering this multidisciplinary subject seem dry and challenging (Soni et al., 2021). Students also face difficulties in grasping the practical applications of materials science in clinical dentistry within the confines of passive didactic lectures.

Recognising these limitations, there is a growing need for innovative pedagogical strategies shifting from teacher-centred to student-centred approaches, fostering active learning. Problem-based learning (PBL), case-based learning (CBL), and team-based learning (TBL) emerge as alternatives. While PBL involves open-inquiry scenarios, it can be time-consuming. CBL, a guided inquiry method, recreates clinical settings, with the teacher as a facilitator. Meanwhile, TBL, introduced in the 1970s, is a teacher-centred approach fostering active learning through student engagement (Michaelsen et al., 2004). Despite their efficacy, their application in dental materials science courses remains underrepresented. This gap represents a significant deficiency in dental education, especially given the critical role of dental professionals in selecting and justifying the use of appropriate materials in clinical cases. This study addresses this gap by comparing the academic performance of undergraduate dental students in dental materials science courses, utilising a hybrid TBL-CBL approach against traditional didactic lectures.

II. METHODS

The study received approval from the local institutional ethics committee (approval code AUHEC/FOD/ 2022/28). The preclinical course comprised four modules taught over two semesters (One academic year consists of 2 semesters). A quasi-experimental design involved 74 second-year dental students, comparing continuous assessment scores between didactic lectures (pre-test) and hybrid TBL-CBL (post-test) introduced in the third module. Excluding the first module and final assessment in the fourth module, only scores from modules 2 and 3 were compared. Content validation involved group discussion and consensus among faculty members ensuring question difficulty alignment with learning outcomes. Hybrid TBL-CBL was conducted in seminar rooms with students randomly assigned to groups. Pre-reading materials, including PowerPoint slides from prior lectures were given. The process encompassed a 15-minute introduction, Readiness Assurance Process (iRAT and tRAT), application activities, and a debriefing session. Data collection involved an unbiased faculty member anonymously obtaining consent for module 2 and module 3 assessment scores, evaluated against grading criteria. Descriptive statistics analysed demographic background, while the Wilcoxon test assessed academic performance using IBM SPSS software with a significance level set at 0.05.

III. RESULTS

54 females (73%) and 20 males (27%) consented to assessment score collection. Mean scores increased significantly (p=0.001) from 61.89±15.67 to 67.35±12.57 after hybrid TBL-CBL, with both female and male scores rising. However, male academic improvement was not statistically significant (p=0.130). Following hybrid TBL-CBL, 13 initially failing students in traditional lectures passed (p=0.020). Assessment grades depicted a notable increase in ‘A’ grades (8.1% to 20.3%) and a decrease in ‘D’ and ‘F’ grades (23.0% to 6.7%). These findings underscore the positive impact of hybrid TBL-CBL on academic outcomes and the successful remediation of initially struggling students.

Figure 1. Assessment grades of students before and after the implementation of hybrid TBL-CBL

IV. DISCUSSION

In contrast to traditional didactic lectures, the hybrid TBL-CBL approach requires active student participation in group discussions, case analysis, and feedback sessions. After implementing hybrid TBL-CBL in module 3, significant improvement in students’ comprehension of dental materials science was observed through higher assessment scores. This finding is consistent with other research suggesting that both TBL and CBL improve students’ knowledge retention and learning experiences through active group learning, leading to better academic performance (Ulfa et al., 2021). Students are expected to participate more actively in group discussions and learn better from the prior knowledge they gained through pre-reading materials, which helps them perform well in collaborative learning. Both TBL and CBL involve dividing students into small groups, which provides the opportunity to be more interactive and engage in discussion among each other. Unlike the passive nature of large lecture-based teaching, which often leads to “lecture ennui” among students due to one-way communication.

The current study revealed that both male and female students showed improvement in their mean assessment scores following the implementation of hybrid TBL-CBL approach. However, the improvement was not significant among male students. It is plausible that female students perceived the hybrid TBL-CBL sessions more positively, leading to increased engagement and learning (Das et al., 2019). Conversely, male students frequently attend TBL sessions less prepared and feel that their assessment scores do not accurately represent their level of knowledge. Nevertheless, female students tend to learn in a collaborative, dependent, and participatory manner, whereas male students lean towards independent and competitive ways (Mahamod et al., 2010). Thus, the authors postulated that female students would benefit more from peer learning in hybrid TBL-CBL sessions than male students.

One limitation of the present study is that a comparison of assessment scores among higher-performing and low-performing students were not performed. Although there was no statistically significant increase in the academic performance of male students, it is important to note that this may be because there were fewer male students than female students, which may hinder our ability to detect significant differences. Since the present study utilised a one-group pre- and post-test research design, it is likely that students’ interactions with teachers and learning styles may have an impact on their assessment scores. Moreover, the effectiveness of the present hybrid TBL-CBL would be further supported by randomised control research including a larger sample size in different institutions across the nation.

V. CONCLUSION

The hybrid TBL-CBL enhanced academic performance over traditional lectures, particularly benefiting female students. While promising for dental materials science education, future studies are needed to assess its efficacy across healthcare fields and diverse health professional student populations.

Notes on Contributors

Galvin Sim Siang Lin designed the study, performed data collection, drafted the manuscript and approved the final manuscript.

Wen Wu Tan performed data analysis, drafted and approved the final manuscript.

Yook Shiang Ng drafted, read and approved the final manuscript.

Kelvin I. Afrashtehfar gave critical feedback, read and approved the final manuscript.

Ethical Approval

The present study was approved by the Asian Institute of Medicine, Science and Technology (AIMST) University Human Ethics Committee (AUHEC) with ethical approval code AUHEC/FOD/2022/28.

Data Availability

The data supporting the findings of this study are available within the article, but raw data of this study are available from the corresponding author on request. 

Acknowledgement

The authors would like to thank the participants of this study.

Funding

The study received no funding.

Declaration of Interest

All authors have no conflicts of interest.

References

Das, S., Nandi, K., Baruah, P., Sarkar, S. K., Goswami, B., & Koner, B. C. (2019). Is learning outcome after team based learning influenced by gender and academic standing? Biochemistry and Molecular Biology Education, 47(1), 58-66. https://doi.org/10.1002/bmb.21197

Mahamod, Z., Embi, M. A., Yunus, M. M., Lubis, M. A., & Chong, O. S. (2010). Comparative learning styles of Malay language among native and non-native students. Procedia – Social and Behavioral Sciences, 9, 1042-1047. https://doi.org/10.1016/j.sbspro.2010.12.283

Michaelsen, L. K., Knight, A. B., & Fink, L. D. (2004). Team-based Learning: A transformative use of small groups in college teaching. Stylus Pub. https://books.google.com.my/books?id=Hj OdPwAACAAJ

Soni, V., Kotsane, D. F., Moeno, S., & Molepo, J. (2021). Perceptions of students on a stand-alone dental materials course in a revised dental curriculum. European Journal of Dental Education, 25(1), 117-123. https://doi.org/10.1111/eje.12582  

Ulfa, Y., Igarashi, Y., Takahata, K., Shishido, E., & Horiuchi, S. (2021). A comparison of team-based learning and lecture-based learning on clinical reasoning and classroom engagement: A cluster randomized controlled trial. BMC Medical Education, 21(1), 444. https://doi.org/10.1186/s12909-021-02881-8

*Galvin Sim Siang Lin
Department of Restorative Dentistry,
Kulliyyah of Dentistry,
International Islamic University Malaysia,
25200, Kuantan, Pahang, Malaysia
Email: galvin@iium.edu.my

Submitted: 15 September 2023
Accepted: 17 November 2023
Published online: 2 April, TAPS 2024, 9(2),101-104
https://doi.org/10.29060/TAPS.2024-9-2/CS3140

Claudia Ng & Aishah Moore

Medical Education Unit, National School of Medicine (Sydney Campus), University of Notre Dame, Australia

I. INTRODUCTION

Despite agreement on the importance of Interprofessional education (IPE) for health professional education (HPE), best practice in developing and implementing IPE remains ambiguous. Students are important stakeholders and can be allies in IPE, but much of their potential in the development of curricula remains untapped.

In 2022, the University of Notre Dame, Australia (UNDA) partnered with the University of Tasmania (UTAS) to engage students in the co-design, implementation, and delivery of a program to support the development of interprofessional practice for preclinical medical students from the Doctor of Medicine (MD) and final year paramedicine students. The COVID-19 pandemic was a catalyst to re-imagine different ways of learning and teaching in this area. This paper aims to describe the process of and opportunities for involving students as partners (SaP).

II. METHODS

Expressions of interest were invited from student cohorts attending a previous iteration of the program. Four student partners across the professions were recruited.

A collaborative workshop provided an initial opportunity for student and staff partnership. The workshop intended to nurture relationships through dialogue and reflection. Student evaluations from previous programs were reviewed and themes were highlighted for discussion. Opportunities were provided for students and educators from both professions to express individual opinions and perspectives from their own experiences of the program.

The major themes that arose from the student experience were the importance of experiential learning through simulation and the importance of having dedicated time for clinical skills practice. The opportunity to engage in interprofessional education was a consistent theme. Educators and student partners discussed the meaning of “success” in an interprofessional program and whether certain pedagogical models and program design could enhance learner outcomes.

III. OUTCOMES

Engagement of students occurred in various ways (Figure 1) and resulted in co-developed learning outcomes for an updated Rural Trauma week (RTW), focusing on the assessment and management of the patient, understanding the differing roles of each profession, and the impact of communication and teamwork of interprofessional teams on patient outcomes.

Students co-designed and reviewed the sequence of program elements. The program commenced with building the learner’s knowledge base through online delivery of lectures and pre-reading materials.

Student partners were also involved in the development of learning activities, including case-based discussions. The case-based discussions intended to provide opportunities for the application and integration of knowledge from the pre-reading and lecture materials. The content was developed alongside an expert clinician, with academic faculty members providing feedback. Students co-facilitated the case-based discussions with an expert faculty partner.

Specific hands-on skills practice was delivered using an interprofessional, near-peer model for facilitation, with final-year paramedicine students acting as tutors for pre-clinical medical students, under the supervision of expert facilitators.

The week culminated in simulation scenarios, with paramedicine and medical students working alongside each other to better understand the role of each profession and the impact of communication on the patient journey as they managed a range of presentations.

Finally, student partners considered approaches for the evaluation of the program, reviewed the evaluation instrument, and suggested how to optimise response rates. Participating students from both professions rated the interprofessional approach used in RTW highly, with the simulation session being rated Above Average and Excellent by 95% of students. Student partners were similarly positive when reflecting on their experiences.

Figure 1. Opportunities for SaP in IPE

IV. DISCUSSION

There is an emerging impact when cultivating learner agency is prime, and meaningful learning relationships between students and staff develop (Matthews, 2018). Students have potential to be partners in learning and teaching in higher education, becoming more than just passive consumers, acting as change agents to help bring about educational transformation (Healey et al., 2014).

The faculties desired to engage students as partners in the reimagination of RTW. Cook-Sather et al. (2014) described student and staff partnership as “a collaborative, reciprocal process through which all participants have the opportunity to contribute equally but not necessarily in the same ways”. It is a disruptive cultural shift from institutions making decisions to a more collaborative mindset where staff and students are working in partnership as colleagues and collaborators with shared goals (Matthews, 2018). Students may not be content or pedagogical experts, but their expertise lies in their lived experience of being a student. They understand learner needs and how the learning experience can be enriched. In our case study, one of our medical student partners had worked as a paramedic before studying medicine. His paramedic experience provided unique perspectives to the discussions and planning.

“As a former paramedic now studying medicine, I have experienced how each side appears mysterious to the other in what they actually do, or how they contribute to the patient. Our attempts in writing these cases have been to broach this gap, which I felt was received very well.” – Medical Student Partner

Engaging students of both professions in the co-design and delivery of the program also fostered further interprofessional collaboration which is an important step to interprofessional practice. Collaboration between Australian medicine and paramedicine undergraduates is uncommon. Although interprofessional practice is seen to be increasingly important in health care, health systems remain fragmented in the face of increasing complexity. Application of SaP in our example fostered staff-student relationships within a profession, but also between students and staff from other professions leading to an increased sense of interprofessional collaboration.

The use of SaP pedagogy is lacking in inter-institutional and cross-disciplinary initiatives (Mercer-Mapstone et al., 2017). Whilst our case study provides an “outcomes-focused” example of SaP’s application in IPE, translation of theoretical aspects of SaP into an HPE context can benefit from better integration of scholarship from other disciplines where the “process” of SaP has been further developed (Barradell & Bell, 2021).

V. CONCLUSION

Students can have a powerful influence on shaping health professional education through shared success in preparation for interprofessional practice. Engaging students as partners in the co-design of a cross-institutional, interprofessional education activity was a valuable experience for staff and students. Students can be an important ally in interprofessional education. The ideas of “respect, reciprocity, and shared responsibility” in student partnership will provide a foundation for the same values to be shared in interprofessional practice.

Notes on Contributors

Dr Claudia Ng is a lecturer in the MD Program at the University of Notre Dame Australia (UNDA) and is currently completing a Masters in Health Professional Education. Claudia co-authored this manuscript and presented at the Asia Pacific Medical Educators Conference in 2023.

Dr Aishah Moore is Co-Head of Curriculum, MD Program at the University of Notre Dame Australia and a General Practitioner. Aishah co-authored this manuscript.

Acknowledgement

Dr Samuel Bulford is a sessional academic at UNDA and an expert facilitator in the RTW program. Mr David Donato is a lecturer in Paramedicine at UTAS and an expert facilitator in the RTW program. SB and DD contributed to the collaborative workshop. Dr Gisselle Gallego is the Senior Research Fellow at the University of Notre Dame, providing input into research design and analysis of qualitative data arising from the project.

Student Partners, Sidney Flego, Katarina Needham, Matthew Dowsett, and Anthony Salole were involved in the co-design and facilitation of the RTW 2022.

Professor Michael Brydon, UNDA, Associate Professor Andrew Dean, UNDA, and Ms Suzanne Avis oversaw the running of the 2022 RTW program.

The facilitators and staff at Lithgow Clinical School and UTAS Campus were involved in the logistics and running of the program.

Funding

The project was funded by a UNDA Seed Grant for Scholarship of Teaching and Learning in 2022.

Declaration of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References

Barradell, S., & Bell, A. (2021). Is health professional education making the most of the idea of ‘students as partners’? Insights from a qualitative research synthesis. Advances in Health Sciences Education: Theory and Practice, 26(2), 513-580. https://doi.org/10.1007/s10459-020-09998-3

Cook-Sather, A., Bovill, C., & Felten, P. (2014). Engaging students as partners in learning and teaching: A guide for faculty (1st ed.). Wiley.

Healey, M., Flint, A., & Harrington, K. (2014). Engagement through partnership: students as partners in learning and teaching in higher education. York: HEA. https://advance-he.ac.uk/knowledge-hub/engagement-through-partnership-students-partners-learning-and-teaching-higher

Matthews, K. E. (2018). Engaging students as participants and partners: An argument for partnership with students in higher education research on student success. International Journal of Chinese Education, 7(1), 42-64. https://doi.org/10.1163/22125868-12340089 

Mercer-Mapstone, L., Dvorakova, S. L., Matthews, K. E., Abbot, S., Cheng, B., Felten, P., Knorr, K., Marquis, E., Shammas, R., & Swaim, K. (2017). A systematic literature review of students as partners in higher education. International Journal for Students As Partners, 1(1), 15–37. https://doi.org/10.15173/ijsap.v1i1.3119

*Dr Claudia Ng
The University of Notre Dame Australia
School of Medicine
160 Oxford St Darlinghurst
NSW Australia 2010
Email: claudia.ng@nd.edu.au

Submitted: 4 November 2023
Accepted: 20 November 2023
Published online: 2 April, TAPS 2024, 9(2),98-100
https://doi.org/10.29060/TAPS.2024-9-2/PV3165

John Norcini

Department of Psychiatry, SUNY Upstate Medical University, United States of America

I. INTRODUCTION

Over the past 25 years, the Asia Pacific region has seen striking growth in the scholarship of health professions education, and it is poised to continue its development. A window into the past and a glimpse of the future can be found in the meetings of the Asia Pacific Medical Education Conference (APMEC), which recently celebrated its 25th anniversary. To frame my personal observations, a word cloud was created using the titles of the plenaries, keynotes, and symposia of the 2003, 2004, and 2006 conferences and another was created using the titles from 2021, 2022, and 2023. When comparing these two clouds (an exercise akin to interpreting inkblots), three themes emerged: interprofessional education and practice (IPEP), the scholarship of teaching and learning (SoTL), and the growing role of technology.

Interprofessional Education and Practice. In the first three conferences, the most common word was ‘medical’ and in the last three it was ‘education’. This parallels developments in the field, which started with a focus entirely on medical education, expanded to all the health professions, and in its most recent iteration, turned to interprofessional education. The reason for this latest development is research showing that interprofessional practice results in better patient outcomes, improved efficiency of care, and increased satisfaction among providers (Reeves et al., 2017).

One of the biggest barriers to IPEP is social closure, defined by Mackert (2012) as the “process of drawing boundaries, constructing identities, and building communities in order to monopolize scarce resources for one’s own group, thereby excluding others from using them.” (Mackert, 2012). Each profession has an educational model that encompasses as much of practice as possible, and they compete over ownership at the boundaries. This limits interprofessional cooperation and the opportunity for joint training.

Social closure has been institutionalised through the regulatory processes (i.e., accreditation and licensure/registration) used in many countries. These fix the boundaries of the professions and the nature of training and practice. Regulation ensures initial competence but makes it challenging to develop shared competencies across the professions. Moreover, there are few regulatory requirements for keeping up with changing practice and even fewer ways to acknowledge the acquisition of additional competencies after formal training.

Digital badges or micro-credentials are one way to approach the issue of social closure.  They are circumscribed credentials based on shorter educational experiences followed by assessment. They can be part of existing broad educational and regulatory processes, complement them, or replace them in part. These credentials can be applied across professions and throughout careers.

Micro-credentials can support the development of IPEP by increasing access and shifting the focus from what the professions can do, to what patients and healthcare systems need. The fact that different professions experience the same educational process leads to comparability across providers regardless of discipline, less siloed regulation, and increased interprofessional collaboration. Furthermore, it offers a pathway for practitioners who seek to upgrade their skills or acquire new competencies.

The scholarship of teaching and learning. The second theme that emerged from a comparison of the word clouds was the scholarship of teaching and learning (SoTL). ‘Curriculum’ and ‘assessment’ were prominent in the first APMEC conferences, but they vanished recently, with ‘learning’, ‘scholarship’, and ‘educator’ being more prominent. In my view, this shift signifies the growing role of SoTL.

The goal of SOTL is to improve student learning by identifying effective teaching practices and disseminating those practices. It is a relatively new field of scholarship that has nine attributes: “committed engagement in action, critique-based, disciplinary, context-oriented, critical enquiry process, continuous deep reflection, dynamic process, shared publicly, and learning focused.” (Mirhosseini et al., 2018).

A recent edition of the Asia Pacific Scholar exemplifies this work (Lee & Norcini, 2023). It included studies that addressed topics such as community based interprofessional education, cultural awareness training in the emergency room, approaches to vaccine hesitancy, innovative oral exams for occupational therapy students, and coaching programs for faculty members.

Technology. The third theme that emerged from the comparison of the word clouds was technology.  ‘eLearning’, prevalent in the early days of the conference, has disappeared to be replaced by ‘technology’. In my view, this signifies its growing role in health professions education and assessment. To pursue this further, Bard (Google’s AI chatbot) was asked, “What effect will technology have on education in the health professions?” Below is Bard’s response, edited for British spelling and for length by removing examples.

“Technology is already having a significant impact on education in the health professions, and this trend is only going to accelerate in the coming years. Here are some of the key ways in which technology is transforming health professions education

• Increased use of e-learning and simulation provides students access to high-quality educational resources and experiences, regardless of location or time constraints.
• Technology can be used to create personalised learning experiences for each student.
• Technology can be used to facilitate interprofessional collaboration between students and healthcare professionals from different disciplines.
• Technology can be used to collect and analyse data on student learning and performance.

Overall, technology is making health professions education more accessible, personalised, and effective.

Here are some of the potential benefits of using technology in health professions education:

• Improved access to education: Technology can help to break down barriers to access to education, such as distance, time constraints, and financial resources.
• Increased student engagement: Technology can be used to create more engaging and interactive learning experiences.
• Improved learning outcomes: Technology can be used to personalise learning, provide feedback, and track student progress.
• Better preparation for practice: Technology can be used to simulate real-world clinical scenarios and help students to develop the skills they need to be successful practitioners.

However, there are also some potential challenges associated with the use of technology in health professions education, such as:

• Cost: Technology can be expensive to purchase and maintain
• Digital divide: Not all students have equal access to technology resources
• Technical challenges: Technology can be complex and difficult to use
• Quality control: It is important to ensure that technology-enhanced learning resources are high-quality and effective

Overall, the benefits of using technology in health professions education outweigh the challenges. However, it is important to use technology thoughtfully and strategically to ensure that it is used to enhance learning, not replace it.” (Bard, 10/30/2023)

This is an impressive performance by Bard, and it offers a small preview of what technology may do. The ideas are not novel, but a wide range of thinking was summarised in a systematic fashion within seconds. This is just the beginning for generative artificial intelligence but it is clear that technology will reshape educational practice and scholarship. It also raises important questions about how we interact with it going forward.

II. SUMMARY

APMEC’s history provides a means of describing the dramatic growth in health professions education in the Asia Pacific region. The past 25 years have seen the focus of research expand from its start in medical education through all the health professions to IPEP. To drive this growth, new forms of scholarship have taken root. With its strong emphasis on context, SoTL enhances the relevance of this research to the cultures and practices of the region. Finally, technology, and our relationship with it, will have profound effects going forward. Taken together, these trends lay the groundwork for future work that will serve the needs of the region and have sizeable influences beyond it.

Note on Contributor

John Norcini wrote the paper.

Funding

No funding was involved.

Declaration of Interest

There are no conflicts to declare.

References

Lee, S. S., & Norcini, J. (2023). Celebrating excellence in the scholarship of teaching and learning. The Asia Pacific Scholar, 8(2), 1-3. https://doi.org/10.29060/TAPS.2023-8-2/EV8N2

Mackert, J. (2012). Social Closure. Oxford University Press.

Mirhosseini, F., Mehrdad, N., Bigdeli, S., Peyravi, H., Khoddam, H. (2018). Exploring the concept of scholarship of teaching and learning (SoTL): Concept analysis. Medical Journal of The Islamic Republic of Iran, 32(1), 553-560. https://doi.org/10.14196/mjiri. 32.96

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 6. https://doi.org/10.1002/14651858.CD0000 72.pub3

*John Norcini
Upstate University Hospital
750 East Adams Street
Syracuse, NY 13210
Email: John.norcini@gmail.com

Submitted: 30 June 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 95-97
https://doi.org/10.29060/TAPS.2024-9-2/PV3075

Gabriel Tse Feng Chong^1,2

¹Singapore Armed Forces HQ Medical Corps, Singapore; ²Dental Specialist Accreditation Committee (Dental Public Health), Singapore

There is growing awareness of the need to include humanities in educating dental students at the undergraduate/pre-doctoral level (Marti et al., 2019). However, there appears to be no literature discussing or advocating the inclusion of humanities for the training of dental specialists. Dental Public Health (DPH) is one such dental specialty where its trainees and practitioners would benefit from an inclusion of humanities in its pedagogy.

This author opines that exposure to humanities (which includes, but is not limited to, literature – both fiction and non-fiction, art, history, narrative dentistry/medicine, philosophy, ethics, and medical anthropology) that touch on dental themes can make a DPH trainee/practitioner more rounded; able to empathise better with the individuals that his/her policies and programs would affect; become even more persuasive in health promotion efforts; and more articulate in their advocacy efforts with stakeholders and policy makers.

Unfortunately, the curriculum of most DPH training programs (in English speaking jurisdictions) do not include humanities apart from the inclusion of ethics in North American programs. Perhaps the roots of this problem can be traced back to the dental undergraduate/pre-doctoral level where the typical training is predominately focused on biomedical subjects. The result is “few dental schools have implemented humanities in their dental education” and where humanities are taught, ethics tend to form the bulk (Marti et al., 2019). At the postgraduate specialty-training level, this traditional segregation between what are considered ‘sciences’ on one hand, and ‘humanities’ on the other hand, are already ingrained for most dental specialties. However, the DPH curriculum is different from the sister dental specialties because the trainee is required to understand for instance: sociology, health-related behaviors, the interactions of social, cultural and political variables (including age, gender, socioeconomic status, culture, religion, ethnicity and globalisation) on public health, health inequities, and the provision of health services. In essence, the DPH curriculum aims to re-orientate the trainee from a biomedical model of care to a biopsychosocial model of care. As such, the DPH curriculum is a natural starting point for the inclusion of humanities in the training of dental specialists.

There are some foreseeable barriers to implement humanities in the DPH training curriculum – (i) the possible lack of DPH educators and practitioners who are well-versed or at least comfortable with humanities and this itself may be a barrier to even commencing the addition of humanities into the pedagogy, and (ii) finding the time and space to include humanities into the voluminous curriculum that the DPH trainee is expected to cover in a relatively short amount of time. One suggestion to resolve the former barrier is cross-disciplinary training, where dental and/or public health schools can reach across to educators and researchers in the humanities departments to co-develop the DPH-humanities curriculum and training materials. The latter barrier can perhaps be tackled by infusing readings and discussions on humanities into the DPH curriculum that already require the trainee to adopt a biopsychosocial approach to healthcare and where humanities would be natural additional skillsets for inclusion in the DPH trainees’/practitioners’ toolbox.

Oral health inequities exist in most, if not all, societies. The burden and resultant impact of dental caries is largely borne by those who are disadvantaged and underserved. This is true even of an affluent country in Asia-Pacific like Singapore with a highly educated populace with very good healthcare system, infrastructure, and policies. Singapore enjoys (i) an universal community water fluoridation program covering 100% of Singapore’s population, (ii) public health education to increase awareness and health literacy by actors, such as, the Ministry of Health (MOH) and Health Promotion Board (HPB), (iii) free dental care to school children up to 18 years of age, and (iv) an extensive network of dental clinics in the private and public sector (Chong & Tseng, 2011). Despite all these benefits, the burden of poor oral health is mainly carried by members of lower socioeconomic groups and certain racial groups (Chong & Tseng, 2011).

Humanities can also challenge the lens through which a DPH trainee/practitioner views oral health problems. For instance, even the current epidemiological trends of dental caries was not always the case. For example, if we were to go back in time to about the late 18th century, dental caries in Europe was largely a disease of the affluent. This is even mentioned in a gastronomical literature text ‘The Physiology of Taste’, written by Brillat-Savarin (published in 1825), in which the author describes the poor oral health of his fellow diners. He writes “what then if the mouth is neither fresh nor pretty? And what shall be said of those monstrous chasms which open up to reveal pits that would seem bottomless, if it were not for the sight of shapeless, time-corroded stumps?” (Chong, 2012).

What caused the epidemiological shift such that dental caries was no longer a disease of the affluent but became one of the poor? This is because until about the late 18^th century, sugar was not yet widely available to the masses for consumption frequently and/or in large quantities so as to cause widespread decay. For example, in England, the annual consumption of sugar per capita increased from almost zero in the 17^th century to 1.8kg in 1704 to 8.2kg in 1800, and finally to 40.8kg by the mid-19^th century (Chong, 2012). Several factors have been identified as the causes of increased consumption of sugar during this period: increased disposable income due to the industrial revolution; the availability of processed foods and beverages; and the change in dietary habits to add sugar as a sweetener to tea and coffee (Chong, 2012). 

This historical trend is important for the modern DPH trainee/practitioner because it approximates ecological studies and supports our modern understanding that the intake of dietary sugars is the most important risk factor for developing dental caries. This should focus DPH trainees’/practitioners’ efforts to tackle the Social Determinants of Health (including the commercial determinants, such as the health risks posed by the sugar and fast-food industries). Furthermore, the 180-degree shift in the epidemiology of dental caries should serve as a reminder that what is the norm of today can be changed drastically in the future, and therefore improvements at a societal-level are possible.

Despite being the most prevalent chronic disease condition globally, dental caries is seldom reported in the news save for the rare occasions where it is extremely headlines worthy, such as the case where a 12-year old American boy (Deamonte Driver) passed away because of an untreated tooth abscess arising from dental caries (Otto, 2017). In this regard, DPH trainees and practitioners can utilise the humanities (in the form of literature, narrative dentistry, and art) as useful media to showcase the plight of the poor and the injustice of oral health inequities. This is needful because sometimes key stakeholders and policy makers (who usually do not have healthcare backgrounds) may not quite comprehend or relate to quantitative data, whereas the narrative aspects such as the description of the individuals’ experience can be very emotive to nudge those stakeholders and policy makers towards the right direction. Editors and reporters of traditional media channels are more likely to publish articles and editorial pieces that are deemed ‘headlines worthy’ with a compelling story to tell.

To highlight the potential power of humanities in telling a story, the author would like to quote a passage from the novel ‘Les Miserables’ by Victor Hugo (originally published in 1862), that depicts the emotional and physical pain of those who were forced to sell their teeth out of dire economic circumstances; which was a fairly common practice in European society of that time.

Excerpt from Les Miserables (Hugo, 1982, p. 177 – 178):

He was an itinerant dentist selling sets of false teeth, opiates, powders, and elixirs… seeing Fantine laugh, the dentist cried:

‘You’ve got a fine set of teeth, my lass. If you’d care to sell me your two incisors I’ll pay you a gold napoleon for each.’

‘What are my incisors?’

‘Your two top front teeth.’

‘How horrible!’ exclaimed Fantine.

‘Two napoleons,’ grumbled a toothless old woman standing near. ‘She’s in luck!’

Fantine fled, covering her ears to shut out the man’s hoarse voice as he shouted after her:

‘Think it over, my girl. Two napoleons are worth having. If you change your mind you’ll find me this evening at the Tillac d’argent.’…

When Marguerite entered Fantine’s room next morning… she found her seated cold and shivering on her bed… and it seemed that she had aged ten years overnight.

‘Lord preserve us!’ cried Marguerite, ‘What’s the matter with you?’

‘Nothing is the matter with me,’ said Fantine, ‘I’m happy. My baby isn’t going to die of that dreadful disease for lack of medicine.’

She pointed to two napoleons that lay gleaming on the table.

‘A fortune,’ murmured Marguerite. ‘A fortune! Where did you get them?’

‘I earned them,’ said Fantine.

She smiled as she said it, and the candle lighted her face. It was a bloodstained smile. There were flecks of blood at the corners of her mouth and a wide gap beneath her upper lip.  

Notes on Contributors

The author conceived the ideas stated in this personal review article and wrote the manuscript.

Funding

The author declares that no financial support was received for this personal view article.

Declaration of Interest

The author declares that there is no potential conflict of interest.   

References

Chong, G. T. F. (2012). Jean-Anthelme Brillat-Savarin’s 1825 treatise on the mouth and ingestion. Singapore Dental Journal, 33(1), 31-36. https://doi.org/10.1016/j.sdj.2012.10.002

Chong, G. T. F., & Tseng, P. (2011). A review of the uses of fluoride and outcomes of dental caries control in Singapore. Singapore Dental Journal, 32(1), 14-18. https://doi.org/10.1016/ S0377-5291(12)70011-1

Hugo, V. (1982). Les Miserables. Penguin Classics.

Marti, K. C., Mylonas, A. I., MacEacher, M., & Gruppen, L. (2019). Humanities in predoctoral dental education: A scoping review. Journal of Dental Education, 83(10), 1174-1198. https://doi.org/10.21815/JDE.019.126

Otto, M. (2017, June 13). How can a child die of toothache in the US? The Guardian. https://www.theguardian.com/inequality/2017 /jun/13/healthcare-gap-how-can-a-child-die-of-toothache-in-the-us

*Gabriel Chong
Singapore Armed Forces HQ Medical Corps,
701 Transit Rd,
Singapore 778910
Email: g.chong@mail.com

Submitted: 6 May 2023
Accepted: 12 September 2023
Published online: 2 April, TAPS 2024, 9(2), 92-94
https://doi.org/10.29060/TAPS.2024-9-2/PV3054

Bhuvan KC¹ & Pathiyil Ravi Shankar²

¹School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Australia; ²IMU Centre for Education, International Medical University, Malaysia

I. INTRODUCTION

Learning spaces can be physical, virtual, or hybrid spaces where students engage with the learning material and interact with peers and facilitators. Traditionally, learning spaces used to be classrooms, lecture halls, laboratories, and libraries and would include a teacher and students working inside a fixed space using a blackboard/whiteboard, PowerPoint projector, boards, and flexible/fixed seating arrangements.  With the advancement in educational methodologies and incorporation of technology and newer applications, learning spaces now include simulated laboratories, online learning platforms, and virtual and augmented reality-based platforms. Using virtual spaces students can interact and learn from wherever they are living/staying.

The healthcare sector has a demand for personalised and precision medicine, teleconsultation, artificial intelligence (AI)-assisted devices and programs, health/clinical applications, health informatics, and robotics along with the need for healthcare and clinical services and medicines. However, there has not been enough research and discussion around the built-in environment i.e., learning spaces in health sciences education and the activities of teaching and learning (Temple, 2007). Against this backdrop, we need to examine how students use learning spaces to interact and engage with the learning material in our current environment and think about how we can optimise the learning spaces for active learning and make them more impactful and future-ready.

II. LEARNING SPACES

Learning spaces in health sciences must consider the unique needs of these subjects in terms of teaching and learning activities, student engagement, and hands-on sessions. Learning spaces design are domain specific and must cater to the teaching and learning needs of the discipline. Designing learning spaces for health sciences is challenging. Learning space can have a significant impact on teaching and learning experiences. A well-designed learning space can help students in many ways:

• It can promote student engagement, is always inviting and comfortable, and stimulating for students. They can sit together and discuss a case or work on a project (Wilson & Randall, 2012).

• A nice and comfortable multi-purpose space can help students engage in project work. They can move the seating to suit their group’s needs, write on the table surface, and whiteboards and discuss, charge their laptops, and use the internet to interact in virtual spaces. Interactive classrooms could make instruction more efficient and effective. More research is needed on the effect of learning space design on students’ engagement and the outcomes of teaching and learning. Health sciences students engage in formal and informal learning, peer support and discussion, clinical case practice and use different diagnostic equipment.

• A well-designed and well-equipped classroom can allow teachers to design workshops and activities that engage students in groups. A flexible learning space can help teachers be more creative and innovative in their approach. Flexible learning spaces provide pedagogical opportunities and support innovative practices that are not easily provided by traditional learning spaces (Benade, 2019). Health Sciences schools must think of ways to design and use learning spaces to promote active learning and help students learn clinical decision-making, required skills, therapeutic reasoning, clinical examinations, and other important practical skills.

• A well-designed learning space can promote collaboration and enhance creativity among the students. A learning space where students can interact face to face, bring their devices, and use tables, boards, and other tools will promote better collaboration and learning. However, one significant challenge is to have enough collaborative learning rooms to accommodate students; multipurpose tables, boards, and other teaching aids and devices are important given that space is at a premium, especially in urban centres (Jamieson, 2003; Van Joolingen et al., 2005). Hybrid learning spaces may partly address this problem.

III. DESIGNING A COLLABORATIVE LEARNING SPACE

To design a collaborative learning space for health sciences we must examine how learning occurs. Active learning plays an important role. There is extensive use of technology in learning. We use interactive whiteboards, create personalised learning environments, wireless networks and the internet, interactive software such as PollEverywhere, Slido and MyDispense, games, applications, etc. to engage with learners in a physical, virtual, or hybrid environment. So, our first consideration is to have a learning space that is flexible, accommodative, supports technologies used for teaching and learning, and is sustainable. Some steps that we can include in our planning and design of learning space can be:

1) Define the learning objectives: The first key consideration while designing a learning space is to look at the programme learning objective. We need to evaluate what students want to achieve in terms of learning outcomes and what skills do they need to acquire for that programme/subject. For campuses running multiple programmes collaboration across the discipline is needed during the planning stage to look at learning spaces that can work for multiple disciplines. Health sciences students gain specialised skills for patient care, including clinical competence, interdisciplinary collaboration, ethics, cultural sensitivity, and patient communication.

2) Consider the size and layout: The learning space must have adequate room to fit all the pupils in the group, necessary furnishings, and equipment. Consider the programme’s enrolment and the activities that the learners will take part in. The layout should encourage student collaboration and active learning.

3) Utilise technology: Technology plays a significant role in modern-day learning. Our subjects/programmes are managed via online platforms like Moodle, CANVAS, Blackboard, etc. Post-COVID Universities/ Schools are running their programmes in a hybrid fashion. Integrating the latest technology, especially the information and communication technology (ICT) based applications and built-in system seems to be vital when we deliver our programmes through online platforms. Tests are run via online quizzes and electronic assessment platforms.

4) Flexibility in learning spaces: Flexibility is the key consideration when designing a learning space in modern classrooms. These learning spaces must be customisable to accommodate the various learning requirements of the students in a flexible learning environment.

5) Optimise lighting and acoustics: Lighting and acoustics are critical factors that can impact learning. It is important when we want to use a virtual environment for immersive learning or play a video to demonstrate 3D- anatomical illustrations. Ensure the learning space has adequate lighting, and acoustics are optimised to minimise noise levels and distractions.

6) Emphasise sustainability: When designing the learning space, sustainability should be a top priority. To lessen the environmental impact and foster a healthy learning environment, incorporate sustainable materials and designs.

7) Encourage collaboration: Active learning requires collaboration, which is a crucial component. Think about including group tables, breakout rooms, and collaborative learning spaces.

8) Customisation of learning spaces: Learning spaces (formal or informal) must be accommodative. For example, a learning space must fit multiple activities like workshops, lectures, problem-based learning, small group discussions, simulation activities, etc. Thus, having flexible elements like collapsible walls, movable desks and chairs, computers on wheels, and foldable furniture and equipment will be ideal from a customisation perspective.

IV. CHALLENGES IN DESIGNING LEARNING SPACES

Learning space design is challenging especially for health and medical sciences programmes because of the specialisation and the complexities of the curriculum and its requirements. It is even more challenging for resource limited settings where universities and schools are struggling to deliver high quality teaching and learning even in traditional environments. These challenges are manifold:

1) Health sciences curricula are content-rich but traditionally taught didactically. Designing learning spaces, crucial for activities like problem-based learning, clinical skill practice, and immersive anatomy learning, presents challenges due to their specialised requirements. Altering spaces to these needs is complex.

2) Keeping the learning spaces human centred is another challenge given the rapidly changing teaching and learning delivery methods brought about by information technology. The pedagogy must be the priority and technology must support it and make it more efficient.

3) Designing learning spaces involves multiple priorities. There are elements like curriculum/content requirement, disability access, collaborative learning, and use of technology. Creating a learning space balancing these elements is a challenge, especially for educational institutions in low resource settings.

4) Designing adaptable learning environments that embrace evolving technologies and teaching methods is complex. A versatile collaborative space, equipped with tables, chairs, digital tools, and virtual platforms, must serve diverse students and activities. This challenge is intensified in resource-limited settings, where maintaining physical and virtual elements, costly online resources, and internet quality pose additional hurdles.

V. CONCLUSION

Learning spaces need proper focus. Health science programs are undergoing major structural transformations. Thus, our learning space must be coordinated with active learning pedagogy and philosophy. While designing learning spaces we must consider flexibility, comfort, technology, collaboration, and safety to build a collaborative and futuristic learning space that allows students to engage with their learning content and achieve the required learning outcomes.

Notes on Contributors

BKC contributed to the conceptualisation of the manuscript, wrote the first draft, revised the subsequent draft, and contributed to the final draft. PRS contributed to the conceptualisation of the manuscript and critically revised the first draft. He contributed to the subsequent revision and finalisation of the manuscript.

Funding

The authors did not receive any funding for this article.

Declaration of Interest

The authors would like to declare that they do not have any conflict of interest.

References

Benade, L. (2019). Flexible learning spaces: Designed for inclusion? New Zealand Journal of Education Studies, 54(1), 53-68.

Jamieson, P. (2003). Designing more effective on‐campus teaching and learning spaces: a  role for academic developers. International Journal for Academic Development, 8(1-2), 119-133. https://doi.org/10.1080/1360144042000277991

Temple, P. (2007). Learning spaces for the 21st century: A review of the literature. Retrieved from https://www.advance-he.ac.uk/knowledge-hub/learning-spaces-21st-century

Van Joolingen, W. R., de Jong, T., Lazonder, A. W., Savelsbergh, E. R., & Manlove, S. (2005). Co-Lab: Research and development of an online learning environment for collaborative scientific discovery learning. Computers in Human Behavior, 21(4), 671-688. https://doi.org/10.1016/j.chb.2004.10.039

Wilson, G., & Randall, M. (2012). The implementation and evaluation of a new learning space: a pilot study. Research in Learning Technology, 20(2), 14431. https://doi.org/10.3402/rlt.v20i0.14431

*Bhuvan KC
Discipline of Pharmacy, School of Clinical Sciences,
Queensland University of Technology,
2 George Street, Brisbane, Qld, Australia
Email: kc.bhuvan@qut.edu.au

Submitted: 17 August 2023
Accepted: 21 December 2023
Published online: 2 April, TAPS 2024, 9(2), 87-91
https://doi.org/10.29060/TAPS.2024-9-2/SC3114

Isharyah Sunarno^1,2, Budu Mannyu^2,3, Suryani As’ad^2,4, Sri Asriyani^2,5, Irawan Yusuf ^2,6, Rina Masadah^2,7 & Agussalim Bukhari^2,4

¹Department of Obstetrics and Gynecology, Faculty of Medicine, Hasanuddin University, Indonesia; ²Department of Medical Education, Faculty of Medicine, Hasanuddin University, Indonesia; ³Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁴Department of Clinical Nutrition, Faculty of Medicine, Hasanuddin University, Indonesia; ⁵Department of Radiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁶Department of Physiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁷Department of Pathological Anatomy, Faculty of Medicine, Hasanuddin University, Indonesia

Abstract

Introduction: The study aimed to ascertain how the faculty at the Faculty of Medicine, Hasanuddin University perceived their role as a tutor during a problem-based learning activity during the academic phase of medical education, based on the length of time they acted as a tutor.

Methods: This was prospective observational research with an explanatory sequential mixed-method design, which was performed at the Undergraduate Medical Study Program, Faculty of Medicine, Hasanuddin University, from January 2023 until May 2023. Research subjects were divided into two groups: a) the Novice group and b) the Expert group. Quantitative data were collected by giving a questionnaire containing six categories with 35 questions and distributed by Google form. An independent t-test was used to compare the faculty’s perception, with a p-value <.05 significant. Followed by Focus Group Discussion (FGD) for qualitative data, which then were analysed by thematic analysis. The last stage is integrating quantitative and qualitative data.

Results: There were statistically significant differences in seven issues between the two groups. Most of the tutors in both groups had favorable opinions, except for the expert group’s disagreement with the passive role of the tutor in the tutorial group. Eight positive and twelve negative perceptions were found in the FGD.

Conclusion: Most tutors positively perceived their role in PBL, with the expert group having more dependable opinions and well-reasoned suggestions.

Keywords:           Problem-Based Learning, Undergraduate Medical Education, Focus Group Discussion

I. INTRODUCTION

The transition from teacher-centered to student-centered learning occurs with the introduction of active learning based on the needs of the students. The majority of effective active learning activities in the classroom were created in small groups using the Problem-Based Learning (PBL) approach. PBL has no worse outcomes in terms of academic performance and is more effective than conventional methods at enhancing social and communication skills, problem-solving abilities, and self-learning abilities, and allows the students to collaborate while integrating science, theory, and practice (Trullàs et al., 2022; Wiggins et al., 2017). A tutor or a facilitator is a pertinent element for the success of tutorial activities in PBL, thus evaluating periodically their perception and understanding about PBL activities, will help determine the need for resource development at the faculty level. Based on the aforementioned background, the author is intrigued to understand how the faculty at the Undergraduate Faculty of Medicine at Hasanuddin University perceived their role as a tutor during a PBL activity based on the duration they acted as a tutor.

II. METHODS

Short-case PBL tutorial is the model being implemented in our institution. An explanatory sequential mixed-methods observational prospective design study was carried out from January 2023 to May 2023. Informed consent was obtained from all the participants (ethics approval recommendation number: 99/UN4.6.4.5.31/PP36/2022). The study was conducted in three stages (Figure 1):

A. Stage 1

Gathering quantitative data via a survey disseminated using Google form, after which the information was analysed using SPSS version 25. The Likert scale, which ranged from 1 (extremely disagree) to 5 (extremely agree), was used to evaluate the 35 items in the questionnaire that served as the study’s primary data collection tool (Table 1 which is openly available on Figshare). The validity and reliability test for the study’s questionnaire was carried out as the first step and the Pearson Correlation was used to examine the outcome; all questions were valid with Cronbach’s α .951. The next step was to collect data through convenience sampling. Inclusion criteria were lecturers who: have attended training to become PBL tutors, are actively involved in PBL activities, and are willing to participate in the research projects to completion. Exclusion criteria were lecturers who were not familiar with the Google form application. Subjects with other commitments that prevented them from finishing the research activities and with a conflict of interest in continuing the study were considered dropouts. The research participants were split into two groups: the novice group (participants who served as tutors for less than five years) and the expert group (participants who served as tutors for five years or more). The Slovin formula was used to determine the minimum sample size, and the result was 32 people for each group. Characteristics of the study subjects were presented descriptively. An independent t-test was used to compare the faculty’s perception of their role as a tutor during a problem-based learning activity, with a p-value <.05 significant.

B. Stage 2

Focus Group Discussions (FGD) were held to collect qualitative data. The participants in the FGD were divided into two groups using the identical criteria utilised for the quantitative group categorisation, and each group consisted of six subjects. Each participant received a set of open-ended questions to be discussed during the FGD. All events and discussions were recorded, and then all conversations were transcribed using the VERBATIM app. MAXQDA 2020 was then used to tag and categorise the data. Thematic analysis was used to assess qualitative data. We used an audit trail and triangulation during data collection and conducted a peer review during data analysis to ensure the validity of the qualitative data.

C. Stage 3

Integrating quantitative and qualitative data was performed by linking data, followed by integration at the interpretation and reporting level which was conducted by integration through a narrative with a weaving approach.

III. RESULTS

A. Characteristics of the Subjects

The subjects in the novice groups were all under 45 years old, but the expert group was predominately made up of older faculty members. Both groups were predominately female. At the time of the research, medical doctors dominated the novice group, but the expert group included people with a range of educational backgrounds. Characteristics of the study subjects are openly available in Table 2 on Figshare.

B. Quantitative Data

Seven question items from four categories significantly differed between the novice and expert groups as shown in Table 3 which is openly available on Figshare.

C. Qualitative Data

Thematic analysis from the FGD revealed that the expert group only has negative perceptions, whereas the novice group has both negative and positive perceptions. The data are openly available in Table 4 on Figshare.

D. Integration of Quantitative and Qualitative Data

Faculty staff has the same perception about almost all concepts about the role of a PBL tutor, except for seven concepts that were statistically significantly different (Figure 1): 

1) PBL as Pedagogical Method: Q5 (group tutorials help students share experiences) and Q9 (PBL is a great tool for student learning) were significantly different, with the majority of the novice group agreeing with it while the majority of the expert group were extremely agreeable. Nevertheless, while the novice had a positive perspective shown in the discussion, the expert expressly stated that “(PBL) increased the (student’s) ability to discuss but not the depth of knowledge.”

2) Supervising Problem Processing in Tutorial Groups: Q12 (I function as a resource person in the group) and Q13 (I participate in creating a positive work environment for the group) were significantly different, with most of the novice group agreeing to the concept while the majority of the expert group were extremely agreeable. The novice group stated in the FGD that “PBL is very effective for building students’ analytical skills because the students can interact with each other to express their opinions and find key problem-solving strategies.” Both groups had the same perception that some tutors attended the PBL activities “just as a formality.” Q17 (I am sensitive to the wishes of the students regarding their need for support) was also significantly different, with most participants in both groups agreeing that tutors are sensitive to the student’s need for support, but 5.71% of the novices extremely disagreed. In contrast, none of the experts in the expert group disagreed with the concept. From the FGD results, the expert group suggested that the “tutor should give feedback and guidance to the students”.

3) Potential Barriers to Student Learning in PBL: the majority of both groups agreed that the group size is just right from a tutorial point of view (Q24), but the novice group had a wide range of responses (from extremely disagree to extremely agree), while 77.14% of the expert group agreed. “Six to eight students in one PBL group” is an elaborate suggestion made by the expert group as a result of the FGD.

4) There was a statistically significant difference between the two groups regarding the role of the tutor, which is usually passive in the tutorial group (Q29), with the expert group’s consensus on the matter being unfavorable, whereas the novice group’s responses were evenly split between neutral and disagree. The FGD’s results revealed that the novice merely stated, “If the students had a misleading concept, the tutor could not be kept silent,” whereas the expert suggested, “The tutor should be the chairman of the group discussion,” and “Questions and keywords must be made by the tutor.”

Figure 1. Integration of Quantitative and Qualitative Data

IV. DISCUSSION

PBL can be regarded as a multidisciplinary method that allows the learners to resolve real-life problems and situations in every aspect, learn how to construct new information meaningfully, put away the understanding of ready-to-use knowledge, and acquire critical thinking skills. Problem processing or facilitation is a challenging task (Aydogmus & Mutlu, 2019). Since PBL can be used in specific topics and can break up the monotony of traditional didactic teaching, it has become a popular alternative teaching strategy for undergraduate medical students. It can also be used as a method of integrated teaching. Overall, it is a great tool for students learning (Gadicherla et al., 2022).

The group size is one of the possible obstacles to students’ learning in PBL. All students will not be able to participate in a team that is too big. A team that is too small could not have enough members to address the learning objectives or enough diverse opinions to guarantee a robust discussion. The tutor should be aware of how the participants play their roles, noting those who do not contribute to debates or who are silent. Therefore, they must pay close attention to what is happening in the group process to intervene and provide feedback, promoting the participants’ individual and group progress. The tutor can assist the student in identifying their requirements through motivated evaluations and simple feedback, fostering the growth of self-confidence, autonomy, and, ultimately, integration into group dynamics. PBL teams ideally consist of 6–10 students (Dent et al., 2017).

V. CONCLUSION

Aside from seven concepts, both groups mostly had positive perceptions about their role as tutors, with the expert group having more dependable opinions and well-reasoned suggestions.

Notes on Contributors

Isharyah Sunarno made the following contributions to the study: conceptualised, created the initial draft and study design, investigated and collected data, conducted formal analysis, looked for research references, performed critical revision of the article, reviewed and edited the article, and approved the study’s final published version.

The following are the contributions Budu Mannyu made to the study: provided insights into the methodology, suggested research references, served as a peer reviewer of the study’s findings, performed critical revision of the article, and gave his approval of the final draft to be published.

Suryani As’ad contributed the following to the study: she offered insights into the methodology, proposed research references, served as a peer reviewer of the study’s findings, revised the article critically, and approved the final draft of the manuscript to be published.

The study benefited from Sri Asriyani’s efforts, which included: suggestion for research references, peer review of the study’s findings, and performed critical revision of the article.

The following contributions were made to the study by Irawan Yusuf: peer reviewing of the result, supervising the research activities, and critical editing of the publication.

The following are the contributions Rina Masadah contributed to the study: provided ideas into the original draft, supervised the research activities, and edited the publication critically.

Agussalim Bukhari made the following contributions to the study: offered insights into the methodology, oversaw the research activities, critically revised the final version of the article.

Ethical Approval

The study was approved by the Research Ethical Committee Faculty of Medicine Hasanuddin University with recommendation number: 99/UN4.6.4.5.31/PP36/ 2022.

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article and its Supplementary material for research instrument in https://doi.org/10.6084/m9.figshare.23646918

Acknowledgement

Authors would like to express our sincere gratitude to all the tutors who participated in this study. A special appreciation is given to Ichlas Nanang Affandi and A. Tenri Rustam from the Psychology Study Program, Faculty of Medicine, Hasanuddin University for their valuable support throughout the research process, including their role as the facilitator of the FGD. We also would like to thank Andriany Qanitha and the CRP team from Faculty of Medicine, Hasanuddin University for their support in developing the manuscript. We are also grateful to the Department of Medical Education, Faculty of Medicine, Hasanuddin University for providing us with the resources and support we needed to complete this study.

Funding

This research received no external funding.

Declaration of Interest

The authors declare no conflict of interest.

References

Aydogmus, M., & Mutlu, A. (2019). Problem-based learning studies: A content analysis. Turkish Studies-Educational Sciences, 14(4), 1615–1630. https://doi.org/10.29228/turkishstudies.23012

Dent, J. A., Harden, R. M., & Hunt, D. (2017). A practical guide for medical teachers (5th ed.). Elsevier.

Gadicherla, S., Kulkarni, A., Rao, C., & Rao, M. Y. (2022). Perception and acceptance of problem-based learning as a teaching-learning method among undergraduate medical students and faculty. Azerbaijan Medical Journal, 62(03), 975–982.

Trullàs, J. C., Blay, C., Sarri, E., & Pujol, R. (2022). Effectiveness of problem-based learning methodology in undergraduate medical education: A scoping review. BMC Medical Education, 22(1), 1–12. https://doi.org/10.1186/s12909-022-03154-8

Wiggins, B. L., Eddy, S. L., Wener-Fligner, L., Freisem, K., Grunspan, D. Z., Theobald, E. J., Timbrook, J., & Crowe, A. J. (2017). ASPECT: A survey to assess student perspective of engagement in an active-learning classroom. CBE Life Sciences Education, 16(2), 1–13. https://doi.org/10.1187/cbe.16-08-0244

*Isharyah Sunarno
Jl. Perintis Kemerdekaan Km. 11,
Faculty of Medicine, Hasanuddin University
+62411-585859
Email: isharyahsunarno@gmail.com

Submitted: 20 April 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 70-80
https://doi.org/10.29060/TAPS.2024-9-2/OA3044

Xiang Ren Tan^1,2, Anthony J Goff¹ & Li Whye Cindy Ng^1,3

¹Health and Social Sciences, Singapore Institute of Technology, Singapore; ²Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Physiotherapy, Singapore General Hospital, Singapore

Abstract

Introduction: Objective structured clinical examinations have traditionally been used to assess clinical skills. However, these face-to-face clinical assessments were hindered by physical and social restrictions imposed during COVID-19. This created a need to develop novel approaches for reliable assessment of clinical skills. We explored and evaluated a virtual exercise teleconsultation assessment (VETA) to replicate a teleconsultation setting where physiotherapy students were assessed on exercise prescription and coaching skills.

Methods: We conducted a cross-sectional mixed-methods study using convenience sampling. A VETA was implemented for 172 physiotherapy students via Zoom to allow synchronous interaction with standardised patients (SPs). 67 students and 9 SPs completed two separate post evaluation surveys on themes relating to administration, support, authenticity, effectiveness, and value of the VETA. Likert-type responses were categorised as positive, neutral, or negative while coded qualitative responses were consolidated into themes by inductive content analysis.

Results: 76% of students agreed that the assessment was authentic while 93% felt that the SPs were realistic and believable. Responders also highlighted important challenges including the limited camera viewing angle, time and space constraint, adequacy of equipment and reliability of connectivity. Exploratory factor analysis of responses revealed three latent constructs: (1) clarity of assessment, (2) clinical relevance, and (3) value of assessment.

Conclusion: Despite the technical challenges, VETA demonstrated clarity and value as an alternative assessment and showed relevance to future telehealth practice, which is increasingly pervasive in clinical settings. This paper demonstrates a feasible approach for the virtual assessment of clinical competencies.

Keywords:           Health Sciences Education, Virtual Assessment, Clinical Skills, OSCE, Physiotherapy, Exercise Prescription

Practice Highlights

• The ability to assess students non-obtrusively allows for fair assessment with reduced anxiety.
• Despite several technical challenges, VETA demonstrated value as an alternative assessment.
• An appropriate context of use, content validity and authenticity of virtual assessment are crucial.
• VETA format may be used for distant learning and remote assessment of clinical competency.
• Virtual care delivery should be included as part of healthcare professionals’ formal training.

Table 1. Response frequency for Likert-type questions

IV. DISCUSSION

A. Keeping Pace with the Digital World

With the advent of technology and increasing prevalence of virtual care (Stamenova et al., 2022), there is a need to rethink conventional assessments of clinical competencies in medical and allied health education. Formal exposure, training, and assessment of clinical care delivery over virtual platforms will be important to prepare students for the digital world, beyond traditional face-to-face environments (Fickenscher & Pagliaro, 2021). Many digitally empowered patients have turned to web-based platform for telerehabilitation services (Brennan et al., 2009). This underscores the need for future healthcare professionals to demonstrate clinical competencies that complement the virtual mode of care delivery.

In our study, VETA was designed as an alternative to traditional OSCEs for the reliable assessment of exercise prescription and coaching skills of physiotherapy students within a simulated teleconsultation setting. Standardised patients were involved to enhance the realism of the consultation session where it allows students to practice patient-centred care and professionalism in patient handling. VETA has garnered largely positive experience from both students and SPs. The qualitative responses from the surveys were supportive of the validity, authenticity, and value of VETA; however, important limitations have been highlighted to consider for improvements in the future. This represents a real-world use case of online synchronous assessment that can be implemented to evaluate clinical skills and competencies in medical or allied health education.

B. Assessment Authenticity and Relevance

In this study, VETA provided a unique opportunity for students to conduct and experience a simulated teleconsultation and it has been largely perceived as a valid and authentic assessment. The content validity of VETA can be assessed from the realistic clinical tasks perceived by students, the test content which represents what the curriculum needs to assess (exercise prescription and coaching skills), and the right domains being tested such as communication and patient-care skills and the safe conduct of exercise (American Educational Research Association, 2014). The authenticity and value of VETA were echoed by both the quantitative and qualitative responses in this study where students felt that it was a good way to equip them with skills necessary for telehealth practice. It is paramount to note that the challenge in conducting physical assessments under COVID-19 climate is not uniquely experienced by students but also, by health practitioners (Chen et al., 2020). Telerehabilitation has been advocated and practiced during the pandemic (Turolla et al., 2020; Werneke et al., 2021) to improve accessibility to care despite the movement restrictions.

The current pandemic may bring forth a new era where telehealth becomes more significant and forms a vital service delivery platform for allied health professionals in the future (Negrini et al., 2020). Hence, this supports the relevance of a teleconsultation setting with standardised patients in our virtual assessment. The lack of exercise equipment provided during examination, albeit perceived as a limitation by students, could present a learning opportunity for students to react and cope in low-resource settings which is valuable to their future professional practice. In addition, the ability to assess students’ performance non-obtrusively allows a fair assessment with introducing unnecessary anxiety with the presence of assessor, which might be unavoidable in conventional OSCE stations (Ferreira et al., 2020). Therefore, VETA serves as a viable alternative that allows remote assessment of clinical competency in physiotherapy students.

C. Challenges with Implementation

VETA was conducted synchronously through Zoom platform within campus with students and SPs residing in different locations. Consequently, a reliable IT support structure and network connectivity was crucial to the success of the online assessment (Hopwood et al., 2021). Indeed, the connectivity issue has been reflected in this study where it has led to the loss of precious time for students to perform their teleconsultation. In this scenario, the examiner had to make a precise judgement to either (1) extend the timing and risk delays to the examination process, or (2) determine if there was enough “interaction content” to assess with and proceed with original scheduled time. Therefore, this underscores the need to include buffer time for similar situations when planning for virtual assessment.

Furthermore, the wearing of masks has resulted in the muffling of voices which prevented effective communication between students and SPs on the teleconferencing platform. Facial gestures and expression are known to play an important role in interpersonal communication, comprehension, and the delivery of intended messages and this can be affected by mask-wearing (Mheidly et al., 2020). To ensure that the SP is able to understand the prescription adequately, transparent face-masks could be worn to facilitate communication. Nonetheless, we advocate that allied health students should learn and master non-verbal communication skills as transparent face-masks may not be commonly used in clinical settings.

Time and space allocation have also been perceived to be inadequate. Based on students’ qualitative feedback, the perceived lack of time was pertaining to the interaction with the SP during exercise prescription, and not the duration for reading and planning. Pacing of speech, ensuring clarity and prioritising of information to convey are instrumental in time-effective clinical communication which students need to master (Laidlaw et al., 2014). Therefore, the timing of teleconsultation has to be optimised, not solely based on students’ expectations, but also on the assessment criteria and desired difficulty level. Furthermore, the time allocated should reflect the duration of an actual teleconsultation session where it has been reported in vascular telemedicine setting to be approximately 10 minutes (Baldwin et al., 2003), similar to the VETA format. Secondly, to ensure that SPs can perform exercise freely and safely, future runs of the assessment should cater for 20 to 50 square feet of space in the rooms, as recommended by American Council on Exercise (American Council on Exercise, 2009).

D. Study Limitations

In our study, only 39% of the total student cohort who undertook the VETA completed the survey. Hence, this may inadvertently create responders’ bias in the survey findings (e.g., those who had a positive experience may feel more motivated to participate). In our study, the evaluation survey was disseminated to students only a day after the conduct of VETA. Future studies may explore administering the survey immediately after the completion of the virtual assessment, via accessible QR codes or weblinks, to encourage greater participation rate.

Additionally, the assessment scope of VETA was limited to only a single domain of skill competency (safe exercise coaching and prescription) of the physiotherapy program and may not represent the relevance of such format for evaluating other competencies. As VETA has only been evaluated in one school setting, it remains to be ascertained if a similar format can be successfully adopted by other universities or a different structured health sciences program. Future studies may explore VETA’s implementation in other settings (i.e., evaluating other clinical competencies or conducted in other programs) and identify the potential facilitators and barriers to its adoption.

Despite the use of self-reported questionnaires to evaluate predetermined themes, the exploratory factor analysis has showed that the “effectiveness” component may not be reliably assessed by the items that were designated. To be an effective assessment, it also implies that the assessment has to mimic actual clinical settings and test skills relevant to a physiotherapist. Therefore, the same items have been correlated to the identified constructs such as clinical relevance (directly linked to assessment authenticity) and the value of assessment. Nonetheless, the distilled 13-item subset survey with good internal consistency can be employed to evaluate other novel assessments related to clinical competency.

E. Implications of a Virtual Approach

Virtual OSCE, while shown to be a useful examination format, cannot entirely replace the traditional OSCE in the assessment of physical skills which is required for allied health professional practice. For instance, hands-on skills such as manual therapy involving the massage, manipulation and mobilisation of muscles and joints, are critical to restore the patient’s functional capabilities and promote their self-efficacy (Bronfort et al., 2010). It is challenging to assess such components using virtual assessments. Specific to therapeutic exercises, it is vital to assess physical facilitation (provision of support and tactile cues) during coaching of exercise to frail individuals or patients with mobility limitations. This cannot be properly assessed without allowing physical close contact with the SPs.

Nonetheless, the success of VETA in this study highlights the feasibility of assessing specific clinical skills reliably using an online synchronous approach. When utilised in an appropriate context (e.g., for assessing online exercise prescription skills), the virtual assessment can help students gain literacy and confidence in online care delivery. At the same time, it allows them to appreciate and navigate the challenges in virtual care settings such as the lack of space or limited camera viewing angle identified in this study. With the COVID-19 pandemic, the demonstration of clinical competency over an online platform may prove to be as, if not more, relevant than traditional face-to-face assessments.

F. Looking Ahead: The Application and Value of Virtual Assessments

To understand how virtual assessments can play a bigger role in medical or allied health education, it is first important to identify which clinical skillsets and competencies are applicable or commonly used in telehealth settings. This can help in the selection of appropriate assessment to be used. Digital literacy and proficiency in the use of telehealth technologies should form a key component of undergraduate clinical education. The use of web-based or teleconferencing platforms for care delivery should also be included as part of their formal training as a healthcare professional. This will help equip the students with the relevant skills for the evolving digital world. There is also a need for a paradigm shift to not just rely on traditional OSCEs for clinical assessments, but to incorporate elements of technology and virtual care delivery relevant to telehealth practice wherever applicable.

V. CONCLUSION

While there are still technical difficulties to consider, our current model and examination setup provides an initial framework for others to adopt as an online synchronous method to assess clinical skills, especially during lockdowns or restricted periods. Furthermore, this VETA format may be used for distant learning and remote assessment of clinical competency for healthcare workers residing in rural areas (Palmer et al., 2015) or students on placement in medically underserved areas. As the use of virtual assessments removes geographical barriers, this allows other experienced teachers and faculty from external institutions to join as assessors or observers to calibrate and align assessment outcomes, thereby enhancing the overall quality of medical education across institutions. Taken together, the use of virtual clinical skills assessment is promising and should be carefully considered for integration into the current medical or allied health education system.

Notes on Contributors

TXR contributed to the study design, conceptualised VETA, conducted data collection and analysis, and drafted the manuscript. AG contributed to assessment design and results interpretation. CN devised the study, innovated the VETA format, conducted data collection and contributed to results interpretation. All authors have read and approved the final manuscript.

Ethical Approval

The study was exempted from ethical review with the use of anonymous surveys with no recording of any identifiable information. In line with the Declaration of Helsinki and the institutional IRB exemption criteria, the study presents minimal risk to participants, does not touch on sensitive topics, does not involve vulnerable population, and does not involve deception or withholding of study’s stated aims and objectives from participants.

Data Availability

Datasets generated and/or analysed during the current study are available from the following DOIs: https://doi.org/10.6084/m9.figshare.22641013

https://doi.org/10.6084/m9.figshare.22641115

https://doi.org/10.6084/m9.figshare.22640998

Acknowledgement

We would like to thank all the students and standardised patients who participated in this study.

Funding

The authors received no specific funding for this study.

Declaration of Interest

The authors report no conflicts of interest.

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*Tan Xiang Ren
SIT Dover Campus,
10 Dover Drive,
Singapore 138683
Email: XiangRen.Tan@singaporetech.edu.sg

Submitted: 12 June 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 81-86
https://doi.org/10.29060/TAPS.2024-9-2/SC3066

Lean Heong Foo¹, Nurul Haziqah Binte Suhaimi², Saudha Binte Sadimin², Marianne Meng Ann Ong¹

¹Department of Restorative Dentistry, National Dental Centre, Singapore; ²Dental Assisting, National Dental Centre, Singapore

Abstract

Introduction: An online survey was conducted on 16 National Institute of Technical Education Certificate (NITEC) Dental Surgery Assistant (DSA) trainees in National Dental Centre Singapore to find out their perceptions and understanding of mental well-being.

Methods: The 43-item survey included (i) Psychological General Well-being Index (PGWB) with 22 items based on 6 domains (anxiety, depression, positive well-being, self-control, general health, and vitality); (ii) 5 items on mental health knowledge; (iii) 4 items on lifestyle; and (iv) 12 items on perceptions of mental well-being and working in the dental clinic. Responses were collated for descriptive analysis and Cronbach’s alpha analysis was done for internal consistency for Likert scale items.

Results: The average PGWB score was 61.5 (range 18-89). Fourteen trainees (75%) indicated they were feeling depressed and 31.2% of trainees felt under stress in the past month. The majority (81.3%) of trainees recognised the role of exercise in maintaining mental health and 75% of trainees were able to differentiate between sadness and depression. However, 56.3% and 87.5% of the trainees incorrectly answered that mental and psychological disorders are not preventable conditions and mental disorders are caused by a wrong way of thinking respectively. The Cronbach’s alpha on PGWB (a = 0.87) and trainees’ perception of working in the clinic (a = 0.76) revealed good internal consistency.

Conclusion: The PGWB scores and survey analysis indicate there is a knowledge gap about mental health and the need to improve mental well-being in this cohort of NITEC DSA trainees.

Keywords:            Mental Well-being, Dental Surgery Assistant Trainee, Psychological General Well-being Index

I. INTRODUCTION

In National Dental Centre Singapore (NDCS), Dental Surgery Assistant (DSA) trainees are required to complete a 1-year National Institute of Technical Education Certificate (NITEC) DSA programme to be qualified as a DSA. Similar to the training of dental students, DSA trainees undergo a significant transition from learning in a classroom setting (4 weeks pre-clinical didactic and observation) to a high-stress dental clinic work environment (clinical) when they start on-the-job training 1 month after commencing their programme. During this transition period, they need to multi-task and adapt to new clinical responsibilities related to infection control, patient management, and assisting clinicians. It has been reported that 80% of 299 Israeli DSAs suffered from a high level of burnout where the most stressful work-related factors were low income, high workload, and work hazards (Uziel et al., 2019). A survey was thus conducted to gain insights into the perceptions of mental well-being and working in the dental clinic among NDCS’s NITEC DSA trainees. This was a needs analysis survey done in June 2022 for a mental wellness module that aimed to provide support to DSA trainees enrolled in the 1-year NITEC DSA programme.

II. METHODS

An online anonymous survey with written consent was disseminated via Form.SG to the 2022 cohort of DSA trainees to complete three months after starting their 1-year programme.  The 43-item survey included (i) Psychological General Well-being Index (PGWB) with 22 items based on 6 domains (anxiety, depressed mood, positive well-being, self-control, general health and vitality) (Dupuy, 1984); (ii) 5 items on knowledge about mental health; (iii) 4 items on lifestyle; and (iv) 2 items on perception of mental well-being (adapted from Puspitasari et al., 2020) and 10 items on working in a dental clinic (crafted based on NDCS context). DSA trainees rated their level of agreement based on a 6-point Likert scale for PGWB (5 -most favourable response to 0 – unfavourable response) and a 5-point Likert scale for the perception of mental health and working in a dental clinic (5 – strongly agree to 1 – strongly disagree). The PGWB score ranges from 0 to 110, effectively representing an individual’s comprehensive subjective well-being. Additionally, the six dimensions of the PGWB index provide valuable insights into the subjective well-being associated with each specific dimension. The survey responses were collated for descriptive analysis and Cronbach’s alpha analysis was done for internal consistency for Likert scale items.

III. RESULTS

The entire cohort of sixteen DSA trainees {all female; age 17-50, mean 28.19 (23.39-32.99)} completed the online survey (100% response rate). The data of this study are openly available in the Figshare repository at http://doi.org/10.6084/m9.figshare.23501136.

Only 25% of trainees (4/16) had more than 1 year of prior working experience in a dental clinic. Their collated responses based on their second-month experience of the 1-year programme are as follows:

A. Psychological General Well-being Index (PGWB)

The average PGWB score for this cohort was 61.5 (range 18-89, 95% CI 52.80 – 70.20), indicating lower than average general well-being in this cohort {normal range 68-83 (Dupuy, 1984)}. No significant correlation was found between age and dental clinic experience on PGWB (r=-0.03; -0.06). The Cronbach’s alpha in PGWB (a = 0.93) indicated good internal reliability with a good individual domain analysis of 0.85 for all the domains (Appendix A: Table 1, Figures 2 and 3).

1) General health: The trainees achieved a mean score of 8.94 (Range 0-15) in general health. The majority (68.75%, 11/16) of trainees agreed they felt healthy enough to function.

2) Positive well-being: The trainees experienced a lower than moderate level of positive emotion and life satisfaction with a mean score of 9.94 (Range 0-20). Only 5 out of 16 trainees (31.25%) were happy with their personal life most of the time.

3) Self-control: The trainees possessed a moderate to higher level of self-control in regulating their behavior and emotions (mean 56, Range 0-15). However, about half of the cohort (56.25%, 9/16) admitted they felt a lack of control over their action in the past month.

4) Vitality: The trainees exhibited a moderate level of energy and vitality (mean 10.31, Range 0-20). However, 7 trainees (43.75%) admitted they felt worn out and exhausted most of the time in the past month.

5) Depressed mood: The trainees, on average, experienced a relatively moderate level of depressive symptoms in the past month (mean:88, Range 0-15). Fourteen trainees (75%) admitted they were feeling depressed and 31.2% of trainees (5/16) had felt under stress in the past month.

6) Anxiety: The trainees exhibited a moderate level of anxiety (mean 12.88, Range 0-25). Majority (81.25%, 13/16) of trainees admitted they felt high-strung quite a good bit of time in the past month.

B. Knowledge about Mental Health

Majority of DSA trainees (81.3%, 13/16) recognised the role of exercise in maintaining mental health and 75% (12/16) of trainees were able to differentiate between sadness and depression. However, 56.3% (9/16) of the trainees incorrectly answered that mental and psychological disorders are not preventable conditions, and a majority (87.5%, 14/16) incorrectly answered that mental disorders are caused by a wrong way of thinking (Appendix B).

C. Lifestyle

Half of the cohort exercised at least once a week. Only 50% of the cohort had self-care activities for themselves. Majority of the trainees (15/16) did not meditate and 50% of the trainees sought help from their friends and family when necessary (Appendix B).

D. Perception of Mental Well-being and Working in a Dental Clinic

Majority of the trainees also gave a neutral response (75%, 12/16) to the statement related to stress from working in the dental clinic. Majority agreed that mental health is important for their general health (87.5%, 14/16). Only half of the cohort indicated they were comfortable to work in the dental clinic (56.3%, 9/16) (Figure 1). About ¾ of the cohort believed they could complete the training programme and were confident to perform the on-the-job training (75%, 12/16). Majority (81.3%, 13/16) were willing to seek help if they encountered problems working in the dental clinic (Figure 1). The Cronbach’s alpha of trainees’ perceptions of working in the clinic (a = 0.76) revealed good internal consistency.

Figure 1. Perceptions of DSA trainees of mental well-being and working in the dental clinic in the second month of their 1-year programme

IV. DISCUSSION

Mental well-being is associated with one’s ability to cope with normal stresses of life and work productivity. This is particularly important in health professionals, including DSAs, to ensure the quality of patient care and professional satisfaction. To our knowledge, this is the first local survey to investigate DSA trainees’ perceptions of mental well-being and working in the dental clinic. The PGWB analysis revealed this cohort of DSA trainees had a lower-than-normal score that was even lower than a group of 320 Japanese dental students (61.5 versus 68.63) (Sugiura et al., 2005). Additionally, the trainees also demonstrated moderate levels of depression and anxiety, with a detailed analysis indicating a significant number experiencing stress.  This observation highlighted the transition from pre-clinical to clinical training phase can be challenging and stressful with increased workload and responsibility, as evident among DSAs who demonstrated a moderate level of professional burnout (Uziel et al., 2019). A similar trend was observed in this transition phase for dental students, where stress was associated with increased responsibility and demands associated with caring for real patients (de Souza Ferreira et al., 2023). Despite the difference in curriculum and a larger student cohort, the Japanese dental students (Sugiura et al., 2005) appeared to cope with their training better as their PGWB revealed they were more relaxed (Anxiety 16.43 versus 12.88) and cheerful (Depression 11.24 versus 9.88) compared with our DSA trainees. This finding reflects the need for providing mental well-being support for our DSA trainees in their programme.

The misconceptions about mental health and infrequent self-care practices among trainees suggest a lack of awareness of mental wellness.  Implementing a mental wellness module focusing on positive psychology, coping techniques like breathing exercises and meditation, and resource awareness can help address these issues. The Trainees’ willingness to seek help and recognise exercise’s role in mental health shows openness to support and intervention. Our pilot data is constrained by a small sample size and the absence of a control group for comparison, making it insufficient for general population inferences. The limitation of PGWBI includes only 6 dimensions and the potential of bias due to self-reported data.  Future recommendations involve re-evaluating the impact of the mental wellness module at the end of the 1-year program, inclusion of qualitative data, and establishing a supportive work environment with accessible mental health resources and mentorship to enhance the well-being and job satisfaction of DSAs.

V. CONCLUSION

In conclusion, the survey findings from this small cohort of DSA trainees underscore the importance of addressing mental health and well-being in this group of learners. The high prevalence of depressive symptoms and reported stress among the trainees highlights the need for targeted interventions and support systems to promote mental well-being. Hence, a mental wellness module will be introduced to this cohort of DSA trainees and this survey will be repeated 3 months after the module completion to assess any changes in this cohort’s perception of mental well-being and working in the dental clinic. 

Notes on Contributors

FLH reviewed the literature, contributed to the study conception, data acquisition, and data analysis, drafted, and critically revised the manuscript.

NHS contributed to the data acquisition, data analysis, and critically revised the manuscript.

SS contributed to the data acquisition, data analysis, and critically revised the manuscript.

MO contributed to the study conception, data acquisition and critically revised the manuscript. All authors gave their final approval and agreed to be accountable for all aspects of the work.

Ethical Approval

This study was exempted from the formal Centralised Institutional Review Broad review by SingHealth Institutional Review Board (CIRB Ref: 2022/2122).

Data Availability 

The data that support the findings of this study are openly available in the Figshare repository http://doi.org/10.6084/m9.figshare.23501136.

Acknowledgement

We would like to thank Ms Liu Yanting for her help in data preparation and collection.

Funding

There was no funding involved in the preparation of the manuscript.

Declaration of Interest

The authors declare no conflict of interest.

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*Foo Lean Heong
National Dental Centre Singapore
5, Second Hospital Avenue
168938 Singapore
Email: foo.lean.heong@singhealth.com.sg