Submitted: 22 February 2022
Accepted: 3 August 2022
Published online: 3 January, TAPS 2023, 8(1), 47-50
https://doi.org/10.29060/TAPS.2023-8-1/SC2764

Kye Mon Min Swe¹ & Amit Bhardwaj²

¹Department of Population Medicine, University Tunku Abdul Rahman, Malaysia; ²Department of Orthopaedics, Sengkang General Hospital, Singapore

Abstract

Introduction: During the era of COVID-19 pandemic, online learning has become more prevalent as it was the most available option for higher education training which has been a challenging experience for the students and the lecturers especially in the medical and health sciences training.  The study was conducted to determine the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic.

Methods: A cross sectional study was conducted to clinical year medical students at University Tunku Abdul Rahman. The validated Online Learning Environment Survey (OLES) was used as a tool to conduct the study.

Results: Total 84 clinical year students participated in the study. Among four domains of OLES questionnaire, the domain; “Support of online learning” had the highest mean perception scores, 4.15 (0.55), followed by “Usability of online learning tools” 3.89 (0.82), and “Quality of Learning; 3.80 (0.68) and the domain “Enjoyment” was the lowest mean perception scores 3.48 (1.08). Most of the students (52.4%) rated the overall satisfaction of online teaching experiences “Very good” while (13.1) % rated “Excellent”.

Conclusion: In conclusion, the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic were satisfactory although there were challenging online learning experiences during the pandemic. It was recommended to include qualitative method in future studies to provide more useful in-depth information regarding online learning environment.

Keywords:            Online Learning Environment, Perceptions, Medical Students, Malaysia, COVID-19

I. INTRODUCTION

Online learning is defined as learning via web-based technology and students interact with their peers and educators through web-based communication tools (Bonk & Reynolds, 1997). The usability of the web-based learning system is important as are its applications such as interactive video, forums, chat rooms, email, and document sharing systems (Klein et al., 2006).

Online learning is regarded nowadays as a new way of interaction in the educational process and online learning facilities offer various opportunities to get new knowledge and develop students’ skills through engagement and interaction in new learning environments. (Samoylenko et al., 2022)

Due to the novel coronavirus pandemic, all the higher education training has converted to online teaching and assessments including medical programs. To fulfil the student physical learning time requirement, the academic year of MBBS clinical year programmes (Year 3 to Year 5) has been divided into Phase 1; purely online teaching as medical students were not allowed to be posted to hospitals followed by Phase 2; face to face physical clinical training at the hospital. Phase 1 teaching for clinical years include, online task-based learning, online lectures and online case-based discussion, online clinical skill, and procedures. This research study was conducted to evaluate the online learning environment of clinical year students and to find out differences in students’ perceptions between the academic years.

II. METHODS

A cross sectional study was conducted to (total=135) Year 3 to Year 5 clinical year medical students. 43 students were in Year 3, 49 students were in Year 4 and 43 students were in Year 5 at University Tunku Abdul Rahman (UTAR), Selangor, Malaysia. All the clinical year students were invited to participate in the study by sending electronic invitations emails, informed consent was taken. Data was collected via google form and the information was anonymised.

A validated Online Learning Environment Survey (OLES) (Pearson & Trinidad, 2005) was used to evaluate the online learning environment of medical students of UTAR during Phase 1 of purely online teaching. The questionnaire consists of two sessions. Section (I) general demographic information, Section (II) contains 50 items of OLES questionnaires developed by Pearson and Trinidad (2005). The validity of the tool was recorded as Cronbach’s Alpha Coefficient value of 0.79 to 0.90.  The OLES consists of nine scales: Computer Usage (CU); Teacher Support (TS); Student Interaction & Collaboration (SIC); Personal Relevance (PR); Authentic Learning (AL); Student Autonomy (SA); Equity (EQ); Enjoyment (EN); and A-synchronicity (AS) which can further classified into four domains: (1) Support for learning; (2) Quality of learning; (3) Usability of online learning tools; and (4) Enjoyment. Responses were recorded against a five-point scale with the following representations: 1- Never; 2- Seldom; 3- Sometimes; 4- Often; and 5- Almost Always. (Pearson & Trinidad, 2005)

Data were analysed by using SPSS (Statistical Package for Social Science) for Windows, version 26.0. The categorical variables were described by frequency and percentage. Student t-test and Analysis of variance (Anova) test was used to compare means between the groups of different academic years. Ethical approval was acquired from the Scientific Ethical Review Committee of the UTAR.

III. RESULTS

A total of 84 clinical year medical students participated from Year 3 to Year 5. There were 27 out of 43 Year 3 students (62.79%), 26 out of 49 Year 4 students (53.06%), 31 out of 43 Year 5 students (72.09%) who completed the questionnaire. Approximately 82 (97.6%) students were aged between 21 to 25 years and (63.1%) were female students.

The online learning environment survey (OLES) tool consists of four domains to evaluate student online learning environments such as “Support of Online learning”, “Usability of online learning tools”, “Quality of Learning” and “Enjoyment”. Among four domains of OLES tool, the domain; “Support of online learning” had the highest mean perception scores 4.15 (0.55), followed by “Usability of online learning tools” 3.89 (0.82), and “Quality of Learning; 3.80 (0.68) and the domain “Enjoyment” was the lowest mean perception scores 3.48 (1.08).

Domains of perceptions of online learning environment	Subscales of perceptions of online learning environment	Mean (SD)	Mean (SD)
Support for learning	Computer Usage	4.24 (0.64)	4.15 (0.55)
	Teacher Support	4.09 (0.78)
	Student Interaction and Collaboration	4.02 (0.78)
	Equity	4.25 (0.82)
Quality of learning	Personal Relevance	3.60 (0.87)	3.80 (0.68)
	Authentic Learning	3.66 (0.82)
	Student Autonomy	4.16 (0.76)
Usability of online learning tools	A-synchronicity	3.89 (0.81)	3.89 (0.82)
Enjoyment	Enjoyment	3.48 (1.08)	3.48 (1.08)

Table 1: The mean perception scores of domains and subscales of online learning environment

Regarding the relation between academic year and student perception on different domains of the online environment, Year 5 students 3.89 (1.01) enjoyed the online learning as compared to Year 3 3.25(0.95) and Year 4 students 3.22 (1.18) respectively and the difference was statistically significant (P<0.027). Year 4 students perceived more positive on domains support of learning (P=0.658) and quality of learning (P=.396) and Year 5 students perceived online learning tools were useful (P=0.681).

The students were asked to rate their online learning experience via 5 points scale, poor to excellent and (52.4%) of the students found online learning experiences very good followed by (29.4%) good and (13.4%) rated excellent. The data for this research can be accessed at http://doi.org/10.6084/m9.figshare.19322297

IV. DISCUSSION

During COVID-19 pandemic era, medical clinical teaching via online was a challenging experience for both clinical lecturers and clinical year students and this study was to determine the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic.

A. Evaluating Online Learning Environment

In the literature, there were quite several tools which have been developed to specifically evaluate online learning environments such as Constructivist On-Line Learning Environment Survey (COLLES), Web-Based Learning Environment Inventory (WEBLEI), Technology-Rich Outcomes-Focused Learning Environment Inventory (TROFLEI), and Online Learning Environment Survey (OLES). The OLES instruments have been used to evaluate the university’s online learning environment and found to be a useful tool to evaluate online learning environments as the questionnaires were applicable to our local setting of online teaching. The OLES tool consists of four domains to evaluate student online learning environments such as Support of Online learning, Usability of online learning tools, Quality of Learning and Enjoyment. (Chew, 2015) The scores on scales which received specific attention for online educators to monitor the online learning environment provided for students.

1) Support of online learning: This domain includes four sub scales and it is the most important part for the students to be able to cope with the online learning environment. Regarding support for computer usage, the findings indicate the students received good support from the university regarding online learning such as the providing internet package for students, laptops, online learning tools and platforms such as Microsoft team. The support from lecturers and peers were also important in regarding clinical case discussion and group works. But in some cases, the students need to go and use internet at their relative’s house. On the “Lecturer Support Scale” and “Equity scale”, that the students got support and equivalent chances to contribute in class discussion. (Chew, 2015)

2) Usability of online learning tools: This domain includes asynchronicity subscale. Asynchronicity allows students to learn on their own schedule, within a certain timeframe. In this study, there were high mean scores for the “Asynchronicity” scale which indicates that the students found it easier to communicate online. But the result was contrary to a study by Chew (2015), found out that the students found it challenging to communicate online depends on the availability of internet and usage of social media.

3) Quality of learning: This domain includes three subscales: Personal Relevance, Student Autonomy, and Authenticity learning. The findings indicate that the students were able to manage and play significant roles in their learning in the online learning climates.

4) Enjoyment: The Enjoyment scale was used to evaluate the extent of enjoyment of learning in an online learning environment. Among all four domains, the enjoyment was the least mean perception score which indicated that although the students received support from university and lecturers, they enjoyed less with the online classes as the classes were entirely online. The result was similar to a study by Chew (2015), stated that the students had limited enjoyment in online learning environments due to lack of motivation and technical problems.

B. Limitations of the study

The study was conducted in a private medical university and quantitative approach. A mixed methods approach with larger sample was recommended for future investigations. Validation of the survey recommends carrying out for local setting.

C. Implication of the study

The present study evaluates the online learning environment experienced by clinical year medical students which found to be useful by giving them different learning opportunities and this can be used to implicate future clinical teaching as hybrid mode to create an effective and safe learning environment. The information from this study about the students’ perceptions on online learning, provided significant implications in the field such as implementation of hybrid learning, telemedicine in medical curriculum.

V. CONCLUSION

In conclusion, the perceptions of clinical year medical students on online learning environments during the COVID-19 pandemic were satisfactory although there were challenging online learning experience during the pandemic. It was recommended to include qualitative method in future studies to provide more useful in-depth information regarding online learning environment.

Notes on Contributors

Dr Kye is the corresponding author for this paper. She designed the study, analysed the data, prepared the manuscript working together with the co-author.

Dr Amit Bhardwaj made substantial contributions to the design, editing and preparation of the final manuscript.

Ethical Approval

The research study was approved by Universiti Tunku Abdul Rahman Scientific and Ethical Review committee on 20th July 2020 (Approval number: U/SERC/92/2020). 

Data Availability

The data that support the findings of the study are openly available at http://doi.org/10.6084/m9.figshare.19322297

Acknowledgement

We would like to acknowledge the clinical medical students of UTAR (Academic Year 2020/2021) for voluntary participation in this study.

Funding

There was no funding for this research study.

Declaration of Interest

The authors declare that there are no conflicts of interest, including financial, consultant, institutional and other relationships.

References

Bonk, C. J., & Reynolds, T. H. (1997). Learner-centred web instruction for higher order thinking, teamwork, and apprenticeship. In B. H. Khan (Ed.), Web-based instruction (pp.167-178). Englewood Cliffs.

Chew, R. (2015). Perceptions of online learning in an Australian University: Malaysian students’ perspective – Support for Learning. International Journal of Information and Education Technology, 5(8), 587-592. https://doi.org/10.7763/ijiet.2015.v5.573

Klein, H.  J., Noe, R. A., & Wang, C. W. (2006). Motivation to learn and course outcomes: The impact of delivery mode, learning goal orientation, and perceived barriers and enablers. Personnel Psychology, 59(3), 665–702. http://doi.org/10.1111/j.1744-6570.2006.00050.x  

Samoylenko, N., Zharko, L., & Glotova, A. (2022). Designing online learning environment: ICT tools and teaching strategies. Athens Journal of Education, 9(1), 49-62. https://www.athensjournals.gr/education/2022-9-1-4-Samoylenko.pdf

Pearson, J., & Trinidad, S. (2005). OLES: An instrument for refining the design of e-learning environments. Journal of Computer Assisted Learning, 21(6), 396- 404. https://doi.org/10.1111/j.1365-2729.2005.00146.x   

*Kye Mon Min Swe
Jalan Sungai Long, Bandar Sungai Long,
43000 Kajang, Selangor
+601115133799
Email: drkyemonfms@gmail.com

Submitted: 29 May 2022
Accepted: 16 August 2022
Published online: 3 January, TAPS 2023, 8(1), 43-46
https://doi.org/10.29060/TAPS.2023-8-1/SC2807

Kirsty Foster

Academy for Medical Education, Medical School, University of Queensland, Brisbane, Australia

Abstract

Introduction: A series of workshops was held early in our MD curriculum redesign with two aims: gaining stakeholder input to curriculum direction and design; engaging colleagues in the curriculum development process.

Methods: Workshops format included rationale for change and small-group discussions on three questions: (1) Future challenges in healthcare? (2) our current strengths? (3) Future graduate attributes? Small-group discussions were audio-recorded, transcribed and fieldnotes kept and thematically analysed. We conducted a literature review looking at best practice and exemplar medical programs globally.

Results: Forty-seven workshops were held across 17 sites with more than 1000 people participating and 100 written submissions received. Analysis showed alignment between data from workshops, written submissions and the literature review.

The commitment of our medical community to the education of future doctors and to healthcare was universally evident.

Six roles of a well-rounded doctor emerged from the data: (1) Safe and effective clinicians – clinically capable, person-centered with sound clinical judgement; (2) Critical thinkers, scientists and scholars with a thorough understanding of the social and scientific basis of medicine, to support clinical decision making; (3) Kind and compassionate professionals – sensitive, responsive, communicate clearly and act with integrity; (4) Partners and team players who collaborate effectively and show leadership in clinical care, education and research; (5) Dynamic learners and educators – adaptable and committed to lifelong learning; and (6) Advocates for health improvement – able to positively and responsibly impact the health of individuals, communities and populations

Conclusion: Deliberate stakeholder engagement implemented from the start of a major medical curriculum renewal is helpful in facilitating change management.

Keywords:            Medical Education, Medical Curriculum, Stakeholder Engagement, Collaboration

I. INTRODUCTION

The quality of the medical education we provide to future doctors is directly related to the quality of care they will provide to their future patients (Torralba & Katz, 2020). It is the responsibility of those involved and of medical schools to promote the highest standards of medical education and medical student learning. At the University of Queensland, a major reimagining of the MD Program is underway to ensure that our already strong medical program remains informed by best practice in both medicine and in education. This is crucial to enabling our medical graduates to be optimally equipped for their internship, pre-vocational and specialist training. It is our responsibility to enable our graduates to be ready for the future medical needs of the people and communities they serve.

Medical programs are complex and involve many people. As well as University academic and professional staff, medical students are taught, supervised and supported by a wide variety of doctors and other health professionals during the four years of our postgraduate degree. At our university we have approximately 4,500 affiliates who may have a role in teaching, supervising or otherwise influencing one or more medical students at some point during their four-year MD program. Many of these are clinical teachers or supervisors who work for the health services with which UQ has a student placement agreement in place. Cognisant that major curricular review is challenging we implemented a deliberate strategy of engagement with as many of our stakeholders as possible from the start of the MD Design project in 2019. In the first stage we planned a series of engagement workshops with key stakeholders and this is the basis of the study.

The purpose of our study was twofold:

Firstly, to gain input from a wide range of stakeholders early in the process to futureproof our curriculum – that is, to inform the vision on what our graduates need to be able to know, do, and be, to succeed in internship and beyond.

Secondly, to involve our key stakeholders in the curriculum design process as a component of change management.

II. METHODS

A series of stakeholder workshops was held. The format of each workshop was to start with a brief outline of the drivers and rationale for curricular change, followed by small-group interactive discussions focusing on three questions:

1. What are the major future challenges in relation to healthcare?
2. What are our current strengths as a Medical Program, as a university and as a health community?
3. What are the important attributes for our future graduates to achieve to best prepare them for their careers?

Ethics approval for the study was granted by the University of Queensland Human Research Ethics Committee (Approval number 2019001725). At the start of each workshop attendees were provided with information about the study and given the opportunity to withdraw. Their participation in the workshop was regarded as consent. All small-group discussions were overseen by KF, audio-recorded and transcribed. KF and the administrative team kept field notes capturing any elements additional to the spoken word such as the general atmosphere of the workshop. KF and JH analysed the transcripts thematically identifying key elements in each focus area. In parallel a literature review was conducted looking at best practice medical education and exemplar medical programs across the globe were explored.

III. RESULTS

Over a period 15 months between July 2019 and January 2021 47 workshops were held across 17 sites with more than 1100 people participating. More than 100 written submissions were received and 5814 people and organisations contacted. Analysis demonstrated general agreement that major change was needed and there was good alignment between feedback received from stakeholder workshops, written submissions and the key findings from the current state analysis as outlined above. There were some stakeholders who felt that they needed to see more substantial evidence that the current curriculum needed refreshing. This group felt reluctant to embark on further change in view of modifications already made in recent years. They were also concerned that ‘change fatigue’ may be a challenge especially among our health service colleagues who contribute to the program.

A key finding was that the passion and commitment of our medical community to the education of future medical doctors and to make a positive contribution to healthcare was universally evident.

The resulting vision for our new MD program is:

To nurture and educate future medical graduates who are clinically capable, team players, kind and compassionate, serve responsibly and are dedicated to the continual improvement of the health of people and communities in Queensland, Australia and across the globe.

To enhance the capability of our graduates to meet the needs of their future patients a set of six roles of the all-round high-quality doctor was developed from the data. These roles map to the four domains that the Australian Medical Council require for primary medical degrees (Australian Medical Council (AMC), 2012), and have been adopted as the vertical themes of the new MD program. They are:

1. Critical thinkers, scientists and scholars who have a thorough knowledge and understanding of the social and scientific basis of medicine, and able to apply evidence and research to inform and support clinical decision making.
2. Dynamic learners and educators who continue to adapt, are curious, agile, motivated, self-directed, with the ability to honestly and humbly appraise their own learning needs, and have a commitment to lifelong learning.
3. Advocates for health improvement who stand with people and are able to positively and responsibly impact the health of individuals, communities and populations. Are able to apply an understanding of health inequalities to strive for health equity, and incorporates prevention and advocacy into clinical practice in all settings.
4. Partners and team players who collaborate effectively and show leadership when appropriate in the provision of clinical care and health-related education and research.
5. Kind and compassionate professionals who are sensitive, responsive, communicate clearly and act with integrity. Compassion and professionalism are linked not only to improved patient outcomes but to better practitioner outcomes including job satisfaction and to better institutional outcomes.
6. Safe and effective clinicians who are clinically capable, person-centred and demonstrate sound clinical judgement – and who can see that they cannot be safe and effective unless they are also capable in all other roles.

The new MD program is structured as five fully integrated courses, three year-long and two semester long courses in final year, with assessment focused on growth and development of knowledge skills and attitudes through active engagement in learning. Assessment for learning as well as of learning is fundamental in enabling all students to reach their full potential. The project has progressed through development of staged learning outcomes for each year of the program and now into detailed and appropriately sequenced learning activities.

Figure 1. The six roles of a well-rounded doctor

IV. DISCUSSION

Communication throughout a period of major change is challenging especially where there are many diverse stakeholders across a large and complex organisation like a medical school (Velthuis et al., 2018). Our strategy was a deliberate one to retain connection and involvement during a lengthy process. Our initial engagement work reported here gave us a good start by actively involving as many people as possible from the beginning of the project. As the project has progressed stakeholders have remained engaged and have been particularly keen on seeking the detail needed to assist in implementation of the new curriculum. This has, on occasion, been challenging when tension between some specialist discipline areas protecting their ‘patch’ and the needs of medical students at primary medical degree level emerge. We also found that education is not regarded as a specialist field by some of our experienced clinical teachers. A lack of understanding about the iterative process of outcomes-based curriculum development contributed to colleagues seeking answers about what is to be taught being frustrated at what they saw as a laborious process of careful scaffolding and integration. This contesting of curriculum is recognised within institutions where it can inhibit development of more effective curricula which promote learning and are more than simply identification of content to be taught (Prideaux, 2003). By engaging with stakeholders from the earliest stage of the curriculum development process we feel that we have minimised this effect.

V. CONCLUSION

Our experience demonstrates that a deliberate stakeholder engagement strategy implemented from the start of a major curriculum renewal is helpful in maintaining key stakeholder involvement. We found that facilitating a collective discussion about the direction and underpinning values of an innovative medical curriculum was a helpful strategy although some stakeholders felt that, since their wishes had not been adopted, they had not been involved. Despite this, we found that, in most cases, stakeholder involvement from the start led to ongoing collaboration in the change management of implementing a new medical program.

We must ensure that our graduates are optimally prepared to begin their careers as medical practitioners over the next 30 to 40 years, and are ready to meet the needs of the people of Queensland, Australia and globally. We are confident that our early engagement on MD Design will help to achieve that goal.

Notes on Contributors

KF conceptualised, led the workshops where data were collected, contributed to data analysis and wrote the manuscript.

Ethical Approval

Ethics Approval for the study was obtained from the University of Queensland Human Research Ethics Committee, Application number 2019001725 granted June 2019. Potential participants were provided with study information prior to the workshops and their active participation in the ensuing workshop was taken to indicate consent.

Data Availability

Data is not currently stored in the UQ Data repository because of its nature, as transcripts of meeting discussions where the partipants may be identified would breach the conditions of ethics approval. 

Acknowledgement

The curriculum design project described in this study is an endeavour involving a large number of people. The author would especially like to thank Professor Stuart Carney, Dean of the Medical School for his support in many of the engagement sessions, Dr Jane Hallos for her assistance with data collection, analysis and literature review, Ms Alexandra Longworth for assistance in data collection and all workshop participants for their input.

Funding

The study was funded as part of the MD Design project led by the Faculty of Medicine at the University of Queensland. There was no specific grant funding but the Mayne Bequest supported medical education research expenses.

Declaration of Interest

The author has no conflict of interest to declare.

References

Australian Medical Council (AMC). (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council 2012. Australian Medical Council Ltd.

Prideaux, D. (2003). ABC of teaching and learning in medicine: Curriculum design. BMJ, 326(7381), 268-270. https://doi.org/10.1136/bmj.326.7383.268

Torralba, K. M. D., & Katz, J. D. (2020). Quality of medical care begins with quality of medical education. Clinical Rheumatology, 39, 617-618. https://doi.org/10.1007/s10067-019-04902-w

Velthuis, F., Varpio, L., Helmich, E., Dekker, H., & Jaarsma, A. D. C. (2018). Navigating the complexities of undergraduate medical curriculum change: change leaders’ perspectives. Academic Medicine, 93(10), 1503-1510. https://doi.org/10.1097/ACM.0000000000002165

*Kirsty Foster OAM
Academy for Medical Education, Medical School,
Level 6, Oral Health Centre,
288 Herston Road
Herston QLD 4006 Australia
+61 7 3346 4676
Email: Kirsty.foster@uq.edu.au

 

Submitted: 8 January 2022
Accepted: 26 April 2022
Published online: 5 July, TAPS 2022, 7(3), 51-56
https://doi.org/10.29060/TAPS.2022-7-3/SC2738

Yiwen Koh¹, Chengjie Lee², Mui Teng Chua^1,3, Beatrice Soke Mun Phoon⁴, Nicole Mun Teng Cheung¹ & Gene Wai Han Chan^1,3

¹Emergency Medicine Department, National University Hospital, National University Health System, Singapore; ²Department of Emergency Medicine, Sengkang General Hospital, Singapore; ³Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ⁴Department of Nursing, National University Hospital, National University Health System, Singapore

Abstract

Introduction: During the first wave of the COVID-19 pandemic in Singapore, clinical attachments for medical and nursing students were temporarily suspended and replaced with online learning. It is unclear how the lack of clinical exposure and the switch to online learning has affected them. This study aims to explore their perceptions of online learning and their preparedness to COVID-19 as clinical postings resumed.

Methods: A cross-sectional study was conducted among undergraduate and graduate medical and nursing students from three local universities, using an online self-administered survey evaluating the following: (1) demographics; (2) attitudes towards online learning; (3) anxieties; (4) coping strategies; (5) perceived pandemic preparedness; and (6) knowledge about COVID-19.

Results: A total of 316 responses were analysed. 81% agreed with the transition to online learning, most citing the need to finish academic requirements and the perceived safety of studying at home. More nursing students than medical students (75.2% vs 67.5% p=0.019) perceived they had received sufficient infection control training. Both groups had good knowledge and coping mechanisms towards COVID-19.

Conclusions: This study demonstrated that medical and nursing students were generally receptive to this unprecedented shift to online learning. They appear pandemic ready and can be trained to play an active part in future outbreaks.

Keywords:           Medical Students, Nursing Students, COVID-19, Pandemic, Online Learning, Survey

I. INTRODUCTION

During the first wave of the COVID-19 pandemic in Singapore, the government implemented safe distancing and movement restriction orders in a bid to flatten the epidemiological curve. These measures from 7^th April to 1^st June 2020 were coined the “circuit breaker” period. Clinical attachments for medical and nursing students were suspended to lower the risk of COVID-19 transmission and to focus the hospitals’ efforts towards dealing with the outbreak.

Before the pandemic, students were embedded within clinical teams where they received bedside teachings, practised communications with patients and acquired practical skills. Students perceive online learning during the pandemic to be less effective for acquiring clinical skills due to the absence of patient interaction and real-world practice (Wilcha, 2020). As the pandemic situation stabilised in Singapore, healthcare students gradually returned to the hospitals from May 2020. In one study, students were concerned about returning to the clinical settings as they perceived themselves as untrained and worried about the risks they might introduce to patients (Hernández-Martínez et al., 2021). This may arise from a lack of pandemic preparedness, which is not commonly incorporated into the medical and nursing school curriculum.

To date, there are no studies evaluating the perceptions of both local medical and nursing students towards the disruption of their studies by the pandemic, and whether these perceptions would be similar to those cited in the aforementioned study. Specifically, we aim to describe the perceptions of online learning and pandemic preparedness of medical and nursing students in Singapore during the “circuit breaker” period. Understanding this will help us create more effective learning strategies and reinforce their preparation for future pandemics.

II. METHODS

A. Study Design and Setting

This was a cross-sectional survey involving medical and nursing students from Yong Loo Lin School of Medicine (YLLSOM) and Alice Lee Centre for Nursing Studies (ALCNS), National University of Singapore (NUS); Duke-NUS Medical School (Duke-NUS); and Lee Kong Chian School of Medicine (LKCSOM), Nanyang Technological University (NTU). Students doing clinical attachments in healthcare institutions during the “circuit breaker” period were sent a link to a self-administered, anonymous online questionnaire. Participation was voluntary. Ethics approval for waiver of written informed consent was obtained from NUS Institutional Review Board (Reference number: NUS-IRB-2020-129).

B. Study Instrument

The questionnaire comprised six parts with a total of 74 questions: (1) socio-demographic characteristics; (2) attitudes towards halting clinical attachments and shift to online learning; (3) anxieties towards the pandemic; (4) coping strategies; (5) perceived pandemic preparedness; and (6) specific knowledge about COVID-19. Responses were collected on Likert scales and the questionnaire was adapted from previous studies with permission. Minor modifications were made to standardise the terms used to refer to COVID-19 and online learning and to ensure understandability in Singapore’s context, while preserving the original intent of the source studies. Content validity of the questionnaire was examined by three board-certified emergency physicians involved in undergraduate and postgraduate medical education. 

C. Survey Dissemination

The survey was disseminated to eligible students via email by each school’s administrative staff, who were not part of the study team. Four reminder emails were sent from September to October 2020.

D. Statistical Analysis

Results were analysed using Stata 14 (StataCorp LP, College Station, TX). Categorical variables were reported as proportions in percentages and analysed using χ2 test or Fisher’s exact test, as indicated. A p-value of < 0.05 was considered statistically significant.

III. RESULTS

A total of 316 students were recruited between September and December 2020. 64.2% (203/316) were medical students, most of whom were from YLLSOM (147/203, 72.4%). The majority were between 21 and 29 years of age (250/316, 79.1%).

Table 1 details the respondents’ attitudes towards clinical attachment and their perceived pandemic preparedness. Overall, 57% (180/316) of respondents agreed or strongly agreed with stopping clinical attachments. 81% (256/316) agreed with the shift to online learning. The two main reasons for preferring online learning were the need to finish academic requirements and the perceived safety of studying at home. Of those who disagreed, most preferred learning in the clinical areas and felt there was a lack of personal interaction with tutors and classmates via online learning.

With regards to pandemic preparedness, more nursing students agreed or strongly agreed they had received sufficient infection control training in school or the hospitals they were posted to (75.2% vs 67.5% p=0.019) and had someone to turn to for advice on the use of personal protective equipment if uncertain (p<0.001), compared to the medical students. They were also more likely to have received influenza vaccination (p<0.001) or were recommended to do so (p=0.020).

More than 70% of students used healthy coping strategies such as participating in relaxation activities and interacting with family and friends for support. More than 90% were aware of the basic facts about COVID-19, such as its origin, symptoms, transmission, and prevention methods. Supplementary tables of the complete survey results have been made openly available online at https://doi.org/10.6084/m9.figshare.19646340 .

Table 1. Attitudes towards clinical attachments during Singapore’s circuit breaker period (7 April to 1 June 2020) and their perceived pandemic preparedness

*Fisher’s exact test

Cronbach’s alpha for 9 items of pandemic preparedness = .60

IV. DISCUSSION

A. Paradigm Shift to Online Learning

Our study found that the majority were agreeable with transitioning to online learning during the pandemic. Unsurprisingly, given Singapore’s digital connectivity, students in this study did not lack a reliable internet connection or access to technological devices – reasons why students in other countries found virtual teaching challenging (Wilcha, 2020). Among those who disagreed with the transition to online learning, more than 90% indicated they preferred learning in the clinical areas. They were also concerned about the lack of personal interaction with tutors and classmates. These were similar concerns reflected by medical and nursing students in other studies, who felt that online teaching could not adequately replace clinical teachings and learning of practical clinical skills, in the absence of direct patient contact. Lack of physical interaction with tutors and classmates can also result in reduced student engagement levels which may lead to less effective learning (Wilcha, 2020).

To address the perceived weaknesses of online learning, educators worldwide have increasingly adopted novel teaching methods. These include virtual simulations and ward rounds where students can interact with real patients, and simulated set-ups at home for clinical skills practice. In several studies, positive feedback was cited in terms of an increase in medical knowledge, clinical reasoning, and communication skills with these teaching methods (Wilcha, 2020). Our study focused on their perceptions of online learning in the initial phase of the pandemic. As the pandemic persists and with more experience in these innovative ways of online engagement, it is unclear whether the students may view online learning differently now.

It is also uncertain whether online learning is less effective in acquiring knowledge compared to clinical placements. Weston and Zauche (2021) found no difference in standardised assessment scores between nursing students who completed an in-person paediatric clinical practice versus those who used high-fidelity virtual simulation software with pre-briefing and debriefing components. More research is needed to evaluate the effectiveness of technology-assisted education in imparting clinical competency compared with traditional bedside teaching.

B. Pandemic Preparedness

In this study, we found most of the medical and nursing students felt they were prepared for the pandemic. However, a greater proportion of nursing students perceived they had received sufficient infection control training or had someone to seek advice on the use of personal protective equipment. More had also received the influenza vaccination or were recommended to do so. A previous study found that nursing students were superior to medical students in hand hygiene performance (Cambil-Martin et al., 2020). This was attributed to curriculum differences and less practical training in the healthcare setting for medical students. Our results may reflect similar curriculum disparities, suggesting a need to narrow this gap in pandemic preparation education.

A systematic review by Martin et al. (2020) found that medical students were keen to assist in responses to pandemics and other global health emergencies, in both clinical and non-clinical roles, citing social responsibility and an obligation to help. Having adequate training and knowledge were some factors encouraging their participation. In this study, we did not directly examine if students were willing to serve in the pandemic should the need arise. They however did demonstrate satisfactory basic knowledge about COVID-19 and had healthy coping strategies. This suggests they may be pandemic-ready and may be recruited to play a more active part in future outbreaks.

C. Limitations

Our study has its limitations. First, the voluntary survey results are subjected to non-response bias. However, the demographics of responders were similar to the entire student body and should be representative of the cohort. Second, a cross-sectional survey does not allow the tracking of changes in responses over time. Third, the results may not be generalisable to other countries at varying stages of socio-economic development. Lastly, the results cannot capture responses outside the pre-set questionnaire. For this, qualitative studies would be required to further explore the impact of COVID-19 on the students’ perceptions towards online learning and pandemic preparedness.

V. CONCLUSION

The COVID-19 pandemic has disrupted the education of medical and nursing students in Singapore, causing an unprecedented shift from classroom teaching and bedside clinical attachments to online learning. Although this study demonstrated that medical and nursing students were generally receptive towards this paradigm shift, there is a need to continue implementing and refining online learning methods, especially in teaching clinical skills that are traditionally acquired at the bedside. Additionally, our study found that local medical and nursing students may be pandemic ready and can be trained to take an active part in future outbreaks.

Notes on Contributors

Yiwen Koh reviewed the literature, designed the study, analysed the data and wrote the manuscript. Chengjie Lee performed data collection, analysed the data and critically revised the manuscript. Mui Teng Chua advised on statistical analysis methods, analysed the data and critically revised the manuscript. Beatrice Soke Mun Phoon performed data collection and critically revised the manuscript. Nicole Mun Teng Cheung designed the study instrument and critically revised the manuscript. Gene Wai Han Chan reviewed the literature, conceptualised the overall design of the study and critically revised the manuscript. All authors have read and approved the final manuscript.

Ethical Approval

Ethics approval for waiver of written informed consent was obtained from the NUS Institutional Review Board (Reference number: NUS-IRB-2020-129).

Data Availability

The ethical approval by NUS Institutional Review Board was based on the conditions that only study team members will have access to the raw data that will be stored in a password-protected file. A copy of the survey questions and the additional tables of survey results are openly available at https://doi.org/10.6084/m9.figshare.19646340  

Acknowledgement

The authors would like to thank the administrative staff of the Yong Loo Lin School of Medicine, Duke-NUS Medical School, Lee Kong Chian School of Medicine and Alice Lee Centre for Nursing Studies for their kind assistance with this study.

Funding

No funding sources were used for this research study.

Declaration of Interest

The authors have no conflicts of interest to declare.

References

Cambil-Martin, J., Fernandez-Prada, M., Gonzalez-Cabrera, J., Rodriguez-Lopez, C., Almaraz-Gomez, A., Lana-Perez, A., & Bueno-Cavanillas, A. (2020). Comparison of knowledge, attitudes and hand hygiene behavioral intention in medical and nursing students. Journal of Preventive Medicine and Hygiene, 61(1), E9–E14. https://doi.org/10.15167/2421-4248/jpmh2020.61.1.741

Hernández-Martínez, A., Rodríguez-Almagro, J., Martínez-Arce, A., Romero-Blanco, C., García-Iglesias, J. J., & Gómez-Salgado, J. (2021). Nursing students’ experience and training in healthcare aid during the COVID-19 pandemic in Spain. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.15706

Martin, A., Blom, I. M., Whyatt, G., Shaunak, R., Viva, M., & Banerjee, L. (2020). A rapid systematic review exploring the involvement of medical students in pandemics and other global health emergencies. Disaster Medicine and Public Health Preparedness, 1–13.  https://doi.org/10.1017/dmp.2020.315

Weston, J., & Zauche, L. H. (2021). Comparison of virtual simulation to clinical practice for prelicensure nursing students in pediatrics. Nurse Educator, 46(5), E95–E98. https://doi.org/10.1097/NNE.0000000000000946

Wilcha, R. J. (2020). Effectiveness of virtual medical teaching during the COVID-19 crisis: systematic review. JMIR Medical Education, 6(2), e20963. https://doi.org/10.2196/20963

*Chengjie Lee
110 Sengkang East Way,
Singapore 544886
Email: lee.chengjie@singhealth.com.sg

Submitted: 7 June 2021
Accepted: 20 January 2022
Published online: 5 July, TAPS 2022, 7(3), 46-50
https://doi.org/10.29060/TAPS.2022-7-3/SC2715

Pilane Liyanage Ariyananda, Chin Jia Hui, Reyhan Karthikeyan Raman, Aishath Lyn Athif, Tan Yuan Yong, Muhammad Hafiz

International Medical University, Malaysia

Abstract

Introduction: We aimed to find out how medical students coped with online learning at home during the COVID 19 pandemic ‘lockdown’.

Methods: A cross-sectional study was carried out from July to December 2020, using an online SurveyMonkey Questionnaire®, with four sections: biodata; learning environment; study habits; open comments; sent to 1359 students of the International Medical University, Malaysia. Responses of strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree and strongly agree for the closed-ended questions on the learning environment and study habits, were scored on a 5-point Likert scale. Percentages of responses were obtained for the closed ended questions.

Results: There were 323 (23.8%) responses. This included 207 (64%) students from the preclinical semesters 1 – 5 and 116 (36%) students from clinical semesters 6 – 10. Of the respondents, more than 90% had the necessary equipment, 75% had their own personal rooms to study, and 60% had satisfactory internet connections. Several demotivating factors (especially, monotony in studying) and factors that disturbed their studies (especially, tendency to watch television) were also reported.

Conclusion: Although more than 90% of those who responded had the necessary equipment for online learning, about 40% had inadequate facilities for online learning at home and only 75% had personal rooms to study. In addition, there were factors that disturbed and demotivated their online studies.

Keywords:            Online Learning, Self-directed Learning, Self-regulated Learning, Learning Environment, Malaysian Medical Students

I. INTRODUCTION

In response to the COVID 19 pandemic, the government of Malaysia imposed a movement control order which is referred to as a lockdown, on 18, March 2020. The International Medical University (IMU), which is a private medical university in Malaysia has been relatively resourceful with respect to e-learning even before the occurrence of the lockdown as it had Moodle®, an online Learning Management System (LMS) platform, in its e-learning portal. Like most educational institutions, the IMU, within a short period of time, had to shift the teaching and learning process from a face-to-face mode to an online mode using Microsoft Teams® most of the time during the lockdown.

The objectives or our study were: to describe the learning environment and the study habits of undergraduate medical students while attending online learning sessions during the lockdown; to determine whether undergraduate medical students used the online resources to practice clinical skills (such as communication skills, physical examination skills) and to develop clinical reasoning.

II. METHODS

A literature search was done in PubMed and Google Scholar using search words: online learning, self-directed learning, self-regulated learning, and learning environment. Study setting and sample selection: Our study population was undergraduate medical students of the IMU. Sample size was calculated to be 293, using the formula provided by Fluid Surveys (2020), for a population size of 1359, with a confidence level of 95% and a margin of error of 5%. A cross-sectional study was carried out using an online SurveyMonkey Questionnaire®, from July to December 2020. As online surveys are well known to have high non-response rates, the questionnaire was sent to all the undergraduate medical students in the IMU, during the lockdown. Data collection and analysis: Informed written consent was obtained from all participants. The questionnaire had four sections: biodata; learning environment; study habits and open comments. There was a total of 12 questions with questions 4, 10 and 11 being closed-ended and having 4, 5 and 14 subsidiary questions, respectively within them. Responses to the closed-ended questions were scored on a 5-point Likert scale: strongly disagree; somewhat disagree; neither agree nor disagree; somewhat agree; strongly agree. Percentages of responses were calculated for the closed-ended questions. Data were analysed using software SPSS version 26.0 (IBM Corporation), and summarised, and descriptive statistics are presented.

III. RESULTS

Data that support the study are openly available in Figshare at http://doi.org/10.6084/m9.figshare. 16909384 (Ariyananda et al., 2021). 323 students (23.7%) responded. This included 207 (64%) students from the preclinical semesters 1 – 5 and 116 (36%) students from clinical semesters 6 – 10. 75% were in their homes and the remainder were in rented accommodation close to the university. Data mentioned below are summarised in Table 1. More than 98% had either a laptop or a tablet and a smart phone. 93% had Internet and WiFi connections, but the internet connection was stable only for 59.4% and only 64.7% had uninterrupted power supply. The locations of their study areas were as follows: personal room 75%; common ‘living room’15.8%; twin shared room 6.5%; varying locations 2.7%. The following demotivating factors were reported: monotony in studying (70.6%); lack of access to real patients (56.3%); lack of support from peers and mentors (50.5%); inadequacy of e-learning resources (25.7%). In addition, 85.7% reported a variety of other causes as demotivating factors. Factors that distracted were watching television (83.6%); sleeping (55.4%); distractions from other members of the family (40.2%) and house chores (40.2%). For demotivating factors and distractions students were invited to offer one or more responses. Ability to obtain feedback, learn clinical skills, learn clinical reasoning and to prepare for assessments were rated as insufficient (scored as strongly disagree, somewhat disagree or neither agree or disagree) as 55.1, 80.5, 57.2 and 56.6 percent, respectively. Those who strongly agreed or somewhat agreed or neither agreed or disagreed that following issues impair their study performances were: inability to access educational resources physically (62.8%) and deterioration of self-discipline (74.3%).

To determine which online resources were statistically significant with respect to their perception of adequacy to learn and practice clinical skills, an independent sample t test was used to compare the mean score on perception of adequacy of different online resources for 63 (19.5%) students who answered ‘yes’ (strongly agree & somewhat agree) against 260 (80.5%) who answered ‘no’ (strongly disagree, somewhat disagree & neither agree nor disagree). A similar statistical comparison was done regarding learning clinical reasoning during online learning to 138 (42.7%) students who answered ‘yes’, with 185 (57.3%) who answered ‘no’ with respect to perception regarding adequacy of resources. Both comparisons yielded highly significant p values.

Statement	Strongly Disagree n (%)	Somewhat Disagree n (%)	Neither Agree nor Disagree n (%)	Somewhat Agree n (%)	Strongly Agree n (%)
There was adequate lighting for me to study	5 (1.5)	15 (4.6)	9 (2.8)	81 (25.1)	213 (65.9)
I had adequate workspace study	8 (2.5)	22 (6.8)	10 (3.1)	86 (26.6)	197 (61)
There were no external distractions around my study	48 (14.9)	95 (29.4)	53 (16.4)	66 (20.4)	61 (18.9)
Comfort factor (prepared meals and clean laundry) helped to make a more productive studying environment	22 (6.8)	19 (5.9)	37 (11.5)	77 (23.8)	168 (52)
The inability to access resources (textbooks, quiet study environment etc.) from a physical library affected the quality of my studies.	59 (18.3)	61 (18.9)	70 (21.7)	88 (27.2)	45 (13.9)
I required supervision from lecturers to effectively study.	84 (26)	86 (26.6)	77 (23.8)	49 (15.2)	27 (8.4%
I struggled with self-discipline to concentrate fully on my studies while at home.	33 (10.2)	50 (15.5)	39 (12.1)	97 (30)	104 (32.2)
I prefer studying in groups rather than in isolation.	68 (21.1)	81 (25.1)	75 (23.2)	49 (15.2)	50 (15.5)
I was able to manage my time better during the lockdown for my studies.	54 (16.7)	64 (19.8)	75 (23.2)	93 (28.8)	37 (11.5)
I am confident to use online resources for my studies.	0 (0.0%)	19 (5.9%)	51 (15.8%)	133 (40.9%)	120 (37.2%)
IMU e-learning resources were adequate to facilitate my studies.	17 (5.3)	37 (11.5)	88 (27.2)	131 (40.6)	50 (15.5)
I was able to navigate my way through IMU e-learning to get the materials required for my studies.	6 (1.9)	29 (9)	60 (18.6)	143 (44.3)	85 (26.3)
I found online teaching sessions helpful to me to achieve the learning outcomes.	20 (6.2)	44 (13.7)	89 (27.6)	109 (33.7)	61 (18.6)
Scheduled online sessions helped me organize my time for my studies.	27 (8.4)	43 (13.3)	67 (20.7)	108 (33.7)	78 (23.8)
Scheduled online sessions helped me motivate myself to do my own self-study.	32 (9.9)	48 (14.9)	75 (23.2)	99 (30.7)	69 (21.4)
I was able to participate in online discussions with ease.	19 (5.9)	43 (13.3)	76 (23.5)	123 (38.1)	62 (19.2)
I was able to receive relevant feedback from my mentors on my performance through online sessions.	25 (7.7)	63 (19.5)	90 (27.9)	84 (26)	61 (18.9)
I was able to learn clinical skills (previously through CSSC sessions / Clinical Postings) through online sessions.	122 (37.8)	93 (28.8)	45 (13.9)	48 (14.9)	15 (4.6)
I was able to apply clinical reasoning in cases discussed through online sessions.	32 (9.9)	58 (17.6)	94 (29.7)	110 (34.1)	29 (8.7)
I was able to prepare well for assessments through online sessions.	31 (9.6)	66 (20.4)	86 (26.6)	101 (31.3)	39 (12.1)
I had stable Internet connection for online sessions.	30 (9.3)	44 (13.6)	57 (17.6)	108 (33.4)	84 (26)
I did not experience any power outages which interrupted online sessions.	19 (5.9)	61 (18.9)	34 (10.5)	81 (25.1)	128 (39.6)

Table 1. Information about the online resources and learning environments.

IV. DISCUSSION

Although more than 90% of those who responded had the necessary equipment, about 40 % had inadequate facilities for online learning at home and only 75% had personal rooms to study. This is a substantial minority of students who are not equipped to carry out online learning effectively and it is a matter of concern. Areas that need urgent attention to improve online learning which would cater to 40% that lack facilities are: providing reliable power supply and fortification of web-based infrastructure and services (expansion of internet bandwidth and expansion of WiFi facilities, subsidized access to internet) and subsidizing hardware. It is known that use of the internet by medical students has not translated into improved online learning behaviour (Venkatesh et al., 2017). Previous studies suggest that self-study can be both efficient and inefficient depending on how the learners behave (Evans et al., 2020).

Majority of students strongly agreed and somewhat agreed with regards to adequacy of environmental factors/comforts such as illumination (91%), workspace (96.6%); and prepared meals and clean laundry (75.8%). Studies have shown that temperature, lighting, and noise have significant direct effects on university students’ academic performance (Realyvásquez-Vargas et al., 2020).

Furthermore, there were factors that disturbed and demotivated their online studies such as monotony in studying; lack of access to real patients; lack of support from peers and mentors and inadequacy of e-learning resources. Monotony when studying alone may be overcome by getting students to interact through peer online discussion groups and by providing gamified/interactive learning material online. Gaps due to lack of access to real patients may be reduced by use of photos (especially in dermatology and ophthalmology), images (such as radiographs, CT and MRI scans), video clips (in neurology to demonstrate involuntary movements and seizures), audio clips (to listen to abnormal heart sounds and murmurs) and by studying case scenarios. Examining parents and siblings at home may help to practice clinical examination techniques of different body systems. Role play by teachers and peers on predetermined scripts will help to develop clinical reasoning and communication skills. As non-verbal cues contribute to a great extent in data gathering during history taking, there is a high chance of students missing this aspect, as online learning is two-dimensional compared to three-dimensional experience they would get in real life. Our observations with regards to perceptions on learning clinical reasoning online is better than for learning clinical skills, as many as 42.7% perceive those resources at their disposal as adequate to learn clinical reasoning. This finding may be supported by the understanding that clinical reasoning can be learned without actual physical contact with patients.

However, these methods will not be able to substitute the kinaesthetic experiences of palpating abdominal lumps and uterus (at different stages of foetal development) as well as vaginal examination in normal and diseased states as done in clinical settings. As for learning clinical procedures, although theoretical aspects can be learned remotely, procedural skills cannot be properly acquired without performing in clinical settings. Simulations closely matching clinical settings using artificial intelligence, AR and VR technologies are available and would be further developed in the future.

Limitations: The main limitation of this study is the low response rate of 23.7% despite an email reminder and persuasion by the leader of each cohort. Although the sample exceeded the minimum sample size of 293, the findings may not be generalizable to the rest of the students at the IMU. The study does not address findings specific to different cohorts as subgroup analysis has not been done as sample sizes of cohorts were too small to arrive at valid conclusions. Since majority (64%) of students who responded are from the pre-clinical phase (whose clinical training is much less compared to clinical phase), pooled data regarding ability to learn clinical skills and clinical reasoning online would not be generalizable across all semesters.

V. CONCLUSION

It is concerning to find that 40% did not have stable internet and one-fourth did not have personal study rooms despite 90% possessing hardware. Furthermore, there were factors that disturbed and demotivated online studies. These should be remedied by providing reliable power supply and fortification of web-based infrastructure and services and by providing subsidised hardware.

Although acquisition of clinical reasoning and clinical skills were perceived to be possible, through online teaching/learning sessions, by one in five and two in five students respectively; every possible effort should be made to remedy shortcomings of the remaining students.

As the pandemic is likely to prevail for some time, we recommend further studies, especially to obtain perceptions of medical students studying in other medical schools in Malaysia and in poorly resourced countries and in the subset of clinical students.

Notes on Contributors

Pilane Liyanage Ariyananda contributed to the conception, design of the study, interpretation of data, and preparation of the paper. Chin Jia Hui, Reyhan Karthikeyan Raman, Aishath Lyn Athif, Tan Yuan Yong, Muhammad Hafiz contributed to conception, acquisition and analysis of data.

Ethical Approval

Permission was obtained from the Institutional Review Board (Project ID No.: IMU: CSc/Sem6 (34) 2020) of the IMU to collect and analyse the data.

Data Availability

A copy of the informed consent form, survey questionnaire and anonymized database are available at https://doi.org/10.6084/m9.figshare.16909384%20 under CC0 license.

Acknowledgement

We are grateful to IMU of Malaysia for permitting us to acquire and analyse data and to Professor IMR Goonewardene for his insightful comments on the manuscript. We thank students who participated in the study.  

Funding

This work was supported by the International Medical University of Malaysia (Project ID No.: IMU: CSc/Sem6 (34) 2020).

Declaration of Interest

The authors have no competing interests. 

References

Ariyananda, P. L., Hui, C. J., Raman, R. K., Athif, A. L., Yong, T. Y., & Hafiz, M. (2021). Online learning during the COVID pandemic lockdown: A cross sectional study among medical students [Data set]. Figshare. https://doi.org/10.6084/m9.figshare. 16909384

Evans, D. J. R., Bay, B. H., Wilson, T. D., Smith, C. F., Lachman, N., & Pawlina, W. (2020). Going virtual to support anatomy education: A STOPGAP in the midst of the COVID-19 pandemic. Anatomical Sciences Education. 13,279-283. http://doi:10.1002/ASE.1963

Fluid Surveys. (2020). http://fluidsurveys.com/university/survey-sample-size-calculator

Realyvásquez-Vargas, A., Maldonado-Macías, A. A., Arredondo-Soto, K. C., Baez-Lopez, Y., Carrillo-Gutiérrez, T., & Hernández-Escobedo, G. (2020). The impact of environmental factors on academic performance of university students taking online classes during the COVID-19 pandemic in Mexico. Sustainability, 12(21), 9194. https://doi.org/10.3390/su12219194

Venkatesh, S., Chandrasekaran, V., Dhandapany, G., Palanisamy, S., & Sadagopan, S. (2017). A survey on internet usage and online learning behaviour among medical undergraduates. Postgraduate Medical Journal, 93, 275–279. https://doi.org/10.1136/postgradmedj-2016-134164

*Pilane Liyanage Ariyananda
Clinical Campus,
International Medical University,
Jalan Rasah, Seremban 70300
Negeri Sembilan, Malaysia
Email: ariyananda@imu.edu.my

Submitted: 26 February 2022
Accepted: 22 April 2022
Published online: 5 July, TAPS 2022, 7(3), 42-45
https://doi.org/10.29060/TAPS.2022-7-3/SC2766

Gabriel Lee Keng Yan, Lee Yun Hui, Wong Mun Loke, & Charlene Goh Enhui

Faculty of Dentistry, National University of Singapore, Singapore

Abstract

Introduction: Nurturing preventive-minded dental students has been a fundamental goal of dental education. However, students still struggle to regularly implement preventive concepts such as caries risk assessment into their clinical practice. The objective of this study was to identify areas in the cariology curriculum that could be revised to help address this.

Methods: A total of 10 individuals participated and were divided into two focus group discussions. Thematic analysis was conducted, and key themes were identified based on their frequency of being cited before the final report was produced.

Results: Three major themes emerged: (1) Greater need for integration between the pre-clinical and clinical components of cariology; (2) Limited time and low priority that the clinical phase allows for practising caries prevention; and (3) Differing personal beliefs about the value and effectiveness of caries risk assessment and prevention. Participants cited that while didactics were helpful in providing a foundation, they found it difficult to link the concepts taught to their clinical practice. Furthermore, participants felt that they lacked support from their clinical supervisors, and patients were not always interested in taking action to prevent caries. There was also heterogeneity amongst students with regards to their overall opinion of the effectiveness of preventive concepts.

Conclusion: Nurturing preventive-mindedness amongst dental students may be limited by the current curriculum schedule, the prioritisation of procedural competencies, the lack of buy-in from clinical supervisors, and a perceived lack of relevance of the caries risk assessment protocol and should be addressed through curriculum reviews.

Keywords:           Dental Education, Caries Risk Assessment, Cariology, Preventive Dentistry, Qualitative Study, Clinical Teaching, Cariogram

I. INTRODUCTION

According to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, dental caries in permanent teeth affects an estimated 2 billion people globally yet it is largely preventable. Thus, nurturing preventive-minded dental students has been a fundamental goal of dental education, and a recurring topic of discussion among dental educators (Pitts et al., 2018).  Apart from the operative management of dental caries with fillings, dental students are taught to conduct caries risk assessments for their patients.  This enables students to construct a tailored caries prevention plan leveraging the use of fluoride varnishes or dietary advice to prevent the onset or progression of carious lesions. However, studies have reported that while students are taught to assess patients’ risk for dental caries and customising preventive plans as part of the Cariology curriculum, they struggle to regularly incorporate prevention into their clinical practice (Calderon et al., 2007; Le Clerc et al., 2021).

The objective of this study was to identify areas in the Cariology curriculum that could be enhanced to help dental students become more prevention orientated in their clinical practice.

 II. METHODS

A. Cariology Curriculum at NUS

The Faculty of Dentistry, National University of Singapore offers a four-year Bachelor of Dental Surgery (BDS) programme, mainly divided into pre-clinical and clinical phases. The Cariology curriculum begins in Year 1, where pre-clinical students are equipped with an understanding of the aetiology and pathogenesis of dental caries, along with its preventive and operative management. In Year 2, behavioural science and oral health education and promotion strategies are introduced.  Commencing the clinical phase, Year 3 students are taught to utilise the Cariogram electronic assessment tool (D Bratthall, Computer software, Malmö, Sweden), to systematically assess a patient’s caries risk by using self-reported information on plaque control, dietary habits, fluoride exposure, and other caries-related risk factors. From the Cariogram results, a patient’s caries risk profile is generated to guide the development of a targeted caries prevention plan for the patient and aid in the delivery of patient education. A summative assessment is held during the final term of Year 4 where students are required to submit three patient case logs with caries risk assessments and prevention plans documented for one-to-one discussion with faculty members involved in the Cariology curriculum.

B. Study Design

An e-mail invitation was sent to the cohort of 2020 (N=55) within a month after the final examination results were released. Ten individuals responded, willing to participate and giving consent. Participants were divided into two groups where focus group discussions (FGDs) were conducted, held on a teleconferencing platform (Zoom Video Communications), facilitated by one study team member using a discussion guide. Audio recordings of the FGDs were transcribed by the facilitator and two other study team members. All the study team members conducted the thematic analysis. Key themes were identified based on their frequency of being cited.

III. RESULTS

Three major themes emerged from the FGDs.

A. Greater Need for Integration between the Pre-clinical and Clinical Components of Cariology 

Participants felt that the pre-clinical lectures provided a foundational understanding of dental caries that they could draw from during their clinical phase of training. However, they suggested that the clinical application of Cariology, such as the use of the caries risk assessment (CRA), can be further emphasised at the beginning of the clinical phase of the BDS programme to reinforce its relevance and significance in the context of overall patient care.

“…not really on our mind when we enter clinics. Maybe the staff can run through the CRA assessment forms before entering clinics.”

[P6]

Participants also highlighted that the three cases due in Year 4 could be submitted and discussed with faculty staff earlier in the clinical phase of the course to concretise concepts and allow an opportunity to implement suggested modifications to their patients’ preventive plans. 

“But CRA presentation could have been done earlier like in Year 3. Only after the discussion did it really stick in.”

[P10] 

“By the time it made sense, clinic was over.”

[P6]

B. Limited Time and Low Priority to Practice Dental Caries Prevention in the Clinical Phase of Training

Participants shared that the main emphasis of a dental student’s limited clinical time was on operative procedures, as it would mean fulfilling clinical competency requirements essential for graduation.

 

“As students, we’re slow, so we want to maximise time for treatment rather than talking about prevention.”

[P2]

“…there are other more important requirements.”

[P9]

The low priority dental students accorded to dental caries prevention was also influenced by their clinical supervisors. Some participants noted that their clinical supervisors did not appear keen to discuss caries risk assessment findings during the clinical sessions and did not provide guidance on developing caries prevention plans.

“It is just a two-way thing between patients and students, and not with assessors”.

[P3]

“In the clinics no one really checks our caries risk assessments.”

[P1]

Participants also perceived a lack of interest among patients regarding prevention which discouraged them from providing advice.

“Out of the 30 (patients) I saw, only one was interested in oral hygiene instructions and good oral practices.”

[P2]

C. Differing Personal Beliefs about the Value and Effectiveness of Caries Risk Assessment and Prevention

There was a diverse spread of beliefs among participants about the value and effectiveness of caries risk assessment and caries risk management in clinical practice. Several participants saw the value of caries risk assessments and preventive management as necessary tools to help patients prevent the onset and progression of dental caries.

“Caries risk and prevention is what dentistry is about. It would shape preventive strategies and conversations.”

 [P10]

“Knowing how to assess risk for the individual is meaningful as it helps employ more time-effective approaches to managing the patient.”

[P5]

Contrastingly, some participants felt that performing caries risk assessments had little added benefit in guiding their preventive advice as,

“…in the end the advice given is the same regardless…”

[P1]

“I didn’t really have to go through the caries risk assessment to tell them what good habits to have.”

[P7]

IV. DISCUSSION

The findings present several perceived barriers that students face from having a more prevention oriented clinical practice. As dental schools focus heavily on procedural competencies, students will place a larger emphasis on fulfilling these requirements and less on assisting their patients with preventive regimes. Furthermore, the duration of the clinical phase of dental training is insufficient to see the results of the preventive advice given, such as a reduction in incidence of new carious lesions, resulting in students finding its impact less meaningful or tangible as compared to placing a filling or extracting a tooth. One solution is to implement formative grading systems in place of the current summative assessments where students would actively identify patients at risk of caries and conduct one-to-one case discussions with their supervisors throughout the clinical phase and be graded accordingly. This system allows for opportunities to reinforce caries prevention concepts and patient management skills throughout the duration of the clinical training instead of only at the end. To address the scepticism some of the students may have with regard to caries risk assessment, steps to address misconceptions may need to be established (Maupome & Isyutina, 2013). A clearer delivery of concepts at the lecture sessions and opportunities during one-to-one case discussions could be implemented in the revised curriculum.

A frequent theme that emerged was the lack of buy-in from the clinical supervisors about carrying out caries risk assessments and preventive management in the student clinics. This may not be surprising as similar sentiments were reported in a recent qualitative study among practising dentists (Leggett et al., 2021). Majority of clinical supervisors are not involved in teaching Cariology and hence it may be necessary to align them with the teaching of caries management paradigms and their roles in informing preventive treatment plans.  This can enable them to reinforce such concepts when they supervise the students in the clinics. 

The lack of interest in preventive advice among the participants’ patients is similarly observed in other countries – patients know about prevention but are not interested to change (Leggett et al., 2021). Clinical supervisors can encourage dental students to consider different methods of patient engagement through techniques such as Motivational Interviewing, or even take the opportunity to exploit behavioural change models to effect a more pro-prevention lifestyle.  In so doing, patients may appreciate better the importance of prevention from various perspectives including the associated cost savings with a reduction in the operative management of dental caries.

The issues highlighted through the FGDs are summarised in Table 1 together with possible modifications.

Table1. Issues identified in the FGDs and possible mitigating modifications to the current cariology curriculum

V. CONCLUSION

Nurturing preventive-mindedness among dental students may be limited by the current curriculum content and delivery, the prioritisation of procedural competencies, the lack of buy-in from clinical supervisors, and a perceived lack of relevance of the caries risk assessment protocol.  Nevertheless, prevention remains the best cure for dental caries and the issues raised through the FGDs can be addressed through curricular modifications discussed earlier.  This will, in turn, enhance the preventive-mindedness of the dental students.

Notes on Contributors

GLKY conceptualised the study, participated in data collection, analysis, and interpretation, drafted the manuscript, and approved the final version to be published.

LYH conceptualised the study, participated in data collection, analysis, and interpretation, critically revised the manuscript, and approved the final version to be published.

WML conceptualised the study, critically revised and approved the final version of the manuscript

CGE designed the methodology, participated in data collection, analysis, and interpretation, and critically revised and approved the final version of the manuscript.

Ethical Approval

This study was approved by the NUS Institutional Review Board (IRB No: S-20-141E).

Data Availability

The transcripts/data of this qualitative study are not publicly available due to confidentiality agreements with the participants.

Acknowledgement

The authors would like to thank the participants for their invaluable input and feedback.

Funding

There was no funding for this study.

Declaration of Interest

The authors have no conflicts of interest to declare.

References

Calderon, S. H., Gilbert, P., Zeff, R. N., Gansky, S. A., Featherstone, J. D., Weintraub, J. A., & Gerbert, B. (2007). Dental students’ knowledge, attitudes, and intended behaviors regarding caries risk assessment: impact of years of education and patient age. Journal of Dental Education, 71(11), 1420-1427. https://doi.org/10.1002/j.0022-0337.2007.71.11.tb04412.x

Le Clerc, J., Gasqui, M.-A., Laforest, L., Beaurain, M., Ceinos, R., Chemla, F., Chevalier, V., Colon, P., Fioretti, F., Gevrey, A., Kérourédan, O., Maret, D., Mocquot, C., Özcan, C., Pelissier, B., Pérez, F., Terrer, E., Turpin, Y.-L., Arbab-Chirani, R., . . . Doméjean, S. (2021). Knowledge and opinions of French dental students related to caries risk assessment and dental sealants (preventive and therapeutic). Odontology, 109(1), 41-52. https://doi.org/10.1007/s10266-020-00527-7

Leggett, H., Csikar, J., Vinall-Collier, K., & Douglas, G. (2021). Whose responsibility is it anyway? Exploring barriers to prevention of oral diseases across Europe. JDR Clinical & Translational Research, 6(1), 96-108. https://doi.org/10.1177/2380084420926972

Maupome, G., & Isyutina, O. (2013). Dental students’ and faculty members’ concepts and emotions associated with a caries risk assessment program. Journal of Dental Education, 77(11), 1477-1487. https://doi.org/10.1002/j.0022-0337.2013.77.11.tb05624.x

Pitts, N. B., Mazevet, M. E., Mayne, C., & Shaping the Future of Dental Education Cariology Group (2018). Shaping the future of dental education: Caries as a case-study. European Journal of Dental Education, 22 Suppl 1, 30–37. https://doi.org/10.1111/eje.12345

*Gabriel Lee Keng Yan
9 Lower Kent Ridge Rd, Level 10,
Singapore 119085
Email: dengabriellee@nus.edu.sg

Submitted: 23 August 2021
Accepted: 28 October 2021
Published online: 5 April, TAPS 2022, 7(2), 56-60
https://doi.org/10.29060/TAPS.2022-7-2/SC2686

Mae Yue Tan, Nicholas Beng Hui Ng, Marion Margaret Aw & Jeremy Bingyuan Lin

Khoo Teck Puat -National University Children’s Medical Institute, National University Health System, Singapore

Abstract

Introduction: The transition from medical student to houseman is well recognised as a stressful period for newly qualified doctors. This stress is likely to be heightened when the transition occurs during a pandemic. We aimed to evaluate the perceived stress levels of housemen as they begin housemanship and explore their sentiments and preparedness in starting work amidst the coronavirus disease 2019 (COVID-19) pandemic.

Methods: Housemen starting work at a tertiary institution in Singapore in May 2020 completed the following: (1) Perceived Stress Scale, (2) open-ended questions on perceived challenges and concerns and (3) questionnaire on preparedness and confidence in starting work. Descriptive statistics were used to analyse quantitative data and modified thematic analysis performed for qualitative data.

Results: Sixty-one housemen participated. Thirty-five (57.4%) reported high perceived stress. The themes for perceived challenges in this transition included coping with constant change, lack of reliable information from authorities, dealing with disappointment, physical fatigue, and loss of autonomy. The themes for concerns in beginning housemanship elicited relate to clinical competence, transitioning into new responsibilities, risk of infection with COVID-19, senior expectations, physical fatigue and training-related concerns. Despite these challenges and concerns, housemen were prepared to begin work during this pandemic.

Conclusion: Housemen transitioning during this pandemic experienced additional stressors and unique challenges pertaining to working in a pandemic. Encouragingly, they remain prepared to start work. Institutions and departments should be mindful of the specific concerns and challenges so that appropriate support can be put in place to support these junior doctors.

Keywords:            COVID-19, Junior Doctor, Intern, Pandemic, Challenges, Preparedness

Figure 1. Perceived challenges in the transition period, and perceived concerns of new housemen just before starting their housemanship.  The size of the boxes corresponds to the frequencies of the themes with examples of verbatim responses transcribed.

IV. DISCUSSION

Our results show that a significant proportion of housemen starting work in the current pandemic have high perceived stress; this appeared to be higher than what is reported in literature for medical students and house officers in non-pandemic settings (Drachev et al., 2020), and higher than healthcare workers during this pandemic (Chen et al., 2020). As such, we believe that this is a significant finding warranting attention.

The challenges of transitioning from medical school to housemanship is well established: not only do housemen have to cope with the responsibility of being a full-fledged doctor, there is also increased physical fatigue and professional expectations that need to be met. Some of these challenges specific to transitioning have also been raised by our housemen.

The sentiments of housemen transitioning during a pandemic are not unique to this group alone: dealing with frequent and constant change and the lack of reliable and timely information are challenges that have also been reported among other healthcare workers. However, there were specific points unique to this group of junior doctors we had studied, particularly the perceived insecurity over their qualifications due to disrupted student clinical training and modified final examinations. This we feel is an important point that medical schools should be aware of; in the event of disruptions or sudden changes to the process of assessment or accreditation, it is important that these be conveyed clearly to the student body, with appropriate engagement, opportunities for clarification and reassurance on any insecurities which they may result from these changes.

Significant pandemic-specific concerns included fears of contracting the COVID-19 infection and transmitting this to others. This fear is not uncommon among healthcare workers and has been reported in recent literature. There was also the additional concern of postgraduate training disruption, which was not unexpected given the disruptions to teaching, deployment to pandemic areas and the lack of choices in the selection of their postings.

We were encouraged to find that despite the higher perceived stress, reported challenges and concerns shared, the majority had felt that their medical schools had prepared them adequately to be a junior doctor, and to deal with pandemic related demands. Additionally, despite the concerns about starting work earlier, majority still reported being ready to start work and felt confident to work effectively – their response to readiness meant that they were not shying away from the call of duty during this pandemic. 

Our study is not without limitations. Open-ended questions instead of interviews that were done in line with social distancing restrictions limited the depth of the qualitative data. That said, the 100% response rate provided us which rich data that could be analysed. Additionally, the use the modified questionnaire on preparedness not only lacked external validation; we are also aware that self-reported preparedness may not correlate with actual readiness.

We believe that the key sentiments we have reported on housemen starting work in a pandemic are likely to be universal and not unique to our institution alone. These data would be informative for institutions to provide targeted support for new housemen amidst the pandemic. These include:

1. Providing clear and effective information transfer particularly on rapidly changing protocols.
2. Emphasis on training on personal protection and infection prevention throughout their postings.
3. If manpower resources permit, institutions may consider first deploying housemen to non-pandemic services with initial job-shadowing before sending them to pandemic areas.
4. Close clinical supervision from immediate seniors.
5. Specific teaching program catering to the learning needs of housemen during the pandemic.
6. Enforcing strict work-rest cycles to ensure adequate rest.
7. Dedicated mentors for housemen to share concerns and grievances. These mentors have the responsibility of identifying housemen who are struggling such that early support can be rendered.
8. Appropriate resources for housemen who require additional support.

V. CONCLUSION

Newly qualified doctors beginning their housemanship during the COVID-19 pandemic have high perceived stress with specific pandemic-related concerns and challenges on top of the usual stressors in transitioning. That said, there is encouraging data on housemen preparedness in starting work during this time. Institutions should ensure that support systems are in place to support junior doctors in these likely protracted extraordinary times. A successful transition from medical school to workplace is the cornerstone that allows these junior doctors to integrate effectively to contribute to the workforce in the pandemic, and the long journey beyond.

Notes on Contributors

Mae Yue Tan contributed to analysis and interpretation of data, drafting and critical revising of the article.

Nicholas BH Ng contributed to analysis and interpretation of data, drafting and critical revising of the article.

Marion M Aw contributed to interpretation of data, drafting and critical revising of the article.

Jeremy BY Lin contributed to conception and design, interpretation of data, drafting and critical revising of the article.

All authors gave final approval of the version to be published.

Ethical Approval

Ethics approval was obtained from from the NHG Domain Specific Review Board (DSRB), with NHG DSRB reference number of 2020/00392.

Data Availability

The data for this study can be found at https://doi.org/10.6084/m9.figshare.16399107 and https://doi.org/10.6084/m9.figshare.16399419. The access to these datasets are available for use subject to approval of the authors of this article.

Acknowledgement

The authors would like to thank the housemen who participated in this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Interest

All authors have no conflict of interest to declare.

References

Chen, B., Li, Q. X., Zhang, H., Zhu, J. Y., Yang, X., Wu, Y. H., Xiong, J., Li, F., Wang, H., & Chen, Z. T. (2020). The psychological impact of COVID-19 outbreak on medical staff and the general public. Current Psychology, 1–9. https://doi.org/10.1007/s12144-020-01109-0

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behaviour, 24(4), 385-396.

Drachev, S. N., Stangvaltaite-Mouhat, L., Bolstad, N. L., Johnsen, J. K., Yushmanova, T. N., & Trovik, T. A. (2020). Perceived stress and associated factors in Russian medical and dental students: A cross-sectional study in North-West Russia. International Journal of Environmental Research and Public Health, 17(15), 5390. https://doi.org/10.3390/ijerph17155390

Sturman, N., Tan, Z., & Turner, J. (2017). “A steep learning curve”: Junior doctor perspectives on the transition from medical student to the health-care workplace. BMC Medical Education, 17(1), Article 92. https://doi.org/10.1186/s12909-017-0931-2

Zagelbaum, N. K., Heslin, K. C., Stein, J. A., Ruzek, J., Smith, R. E., Nyugen, T., & Dobalian, A. (2014). Factors influencing readiness to deploy in disaster response: Findings from a cross-sectional survey of the department of veterans affairs disaster emergency medical personnel system. BMC Emergency Medicine, 14, Article 16. https://doi.org/10.1186/1471-227X-14-16

*Tan Mae Yue
1E Kent Ridge Road,
NUHS Tower Block Level 12,
Singapore 119228
Tel: +65 6772 5555
Email: mae_yue_tan@nuhs.edu.sg

Submitted: 11 November 2021
Accepted: 27 January 2022
Published online: 5 April, TAPS 2022, 7(2), 51-55
https://doi.org/10.29060/TAPS.2022-7-2/SC2710

Rintaro Imafuku, Kaho Hayakawa & Takuya Saiki

Medical Education Development Center, Gifu University, Japan

Abstract

Introduction: Personal statements are important documents in the admission and programme application processes, including international elective programmes, in medical education. However, writing these is challenging for international applicants not only because of their unfamiliarity with this genre but also their English academic writing skills. This study aims to explore the organisation and elaboration of text in personal statements written by Japanese medical students for international elective programme application.

Methods: Drawing on genre analysis, the first draft of personal statements written by eight fifth-year medical students at a Japanese university were analysed. The text data were deductively classified into moves and steps, using Chiu’s framework of the personal statement genre.

Results: In the introduction, Japanese medical students commonly described the context and issues of healthcare in Japan and the future goals for physicians. In the move of the relevant background, it was notable that six out of eight personal statements showed personality. Although a range of moves was covered when writing about the reasons for applying, only two students described their understanding of programmes and institutional attributes. In the move of conclusion, they focused more on writing their goals of future success and contribution to the course. Furthermore, no applicant expressed self-promotion and praise for academics, programmes, and institutions.

Conclusion: The findings of this study can provide a springboard for the development of support for Japanese students’ academic writing in English in medical education across cultures.

Keywords:           Medical Education, International Electives, Personal Statement, Genre Analysis, Discourse, Rhetorical Patterns, Written Communication

I. INTRODUCTION

The personal statement, as a promotional academic genre, is an important document in the admission process for higher education. However, numerous applicants face difficulties while preparing application materials because of their unfamiliarity with the genre of discourse and audience expectations (Ding, 2007). In medical education, particularly institutions in Western countries, several instances require the submission of personal statements for application to, for instance, medical schools, international electives, residency programmes, and research programmes.

Globalisation in medical education has promoted worldwide student mobility. Currently, many Asian medical students, including Japanese students, participate in international electives in Western countries. International electives provide several benefits to medical students, including cultural competence, communication skills, and clinical reasoning (Imafuku et al., 2021). However, because some institutions require the submission of personal statements for application to the international elective programme, it can be challenging for international applicants not only because of their unfamiliarity with the genre of discourse but also their English academic writing skills.

As the preparation of application materials, including personal statements, can be challenging for Asian medical students, educators must facilitate a more comprehensive pre-departure course, along with providing support for composing such documents. Specifically, a better understanding of the linguistic features of their personal statements is fundamental for developing academic writing support for their application documents. Therefore, this study used the genre analysis framework (Swales, 1990) to explore the organisation and elaboration of text in personal statements written by Japanese medical students for the international elective programme application. Specifically, the following research question was developed: What are the rhetorical characteristics of Japanese medical students’ personal statements written in English?

II. METHODS

A. Setting

International electives, which allow the students at the Gifu University School of Medicine to study overseas, are optional modules of either four or eight weeks in the final year of the clinical clerkship programme with the goals of observation, understanding and experiencing clinical practices in different cultural contexts. Through this programme, every year, 10–15 medical students study clinical medicine in a foreign country and gain cross-cultural experience in a clinical setting. As some highly competitive overseas institutions require the submission of personal statements, letters of recommendation, and curriculum vitae during the application, faculty members of the medical education division provide some support for their preparation, if required by the students. Although the guidebook for international electives briefly explains the definition and role of personal statements, the students are not officially given any sample or format of English personal statements.

B. Data Collection and Analysis

This study collected personal statements written in English by fifth-year medical students (n=8; Student A-H) at a Japanese university, from 2013 to 2017, as part of the application documents for international electives in institutions in the United Kingdom (UK) or the United States (US). Their TOEFL (Test of English as a Foreign Language) (iBT) score ranges from 90 to 101. Written informed consent to participate was obtained from them. Their first drafts were analysed through the lens of move analysis as an element of genre analysis (Swales, 1990) to reveal rhetorical patterns from a cultural perspective. The first draft, which has not been revised using feedback from others, directly reflects their cultural and linguistical influences regarding the rhetorical patterns. Text data were analysed by the first author, who has a background in applied linguistics and medical education. Subsequently, the preliminary findings of the text analysis were discussed by all the research team members to establish the credibility and dependability of the data analysis.

Genre analysis aims to describe the organisational patterns of text in a specific context, and genres are viewed as staged goal-oriented social processes of the written or spoken practice. For example, in written communication, reader expectations, document structure, and rhetoric development vary depending on the genre, such as research articles, invitation letters, and reminder emails. A move is an analytical unit defined as a rhetorical component shifting from one part of a text to another that performs a specific communicative function (Swales, 1990, p.140). Each move is subcategorised into one or more functional units called steps.

Specifically, this study applied Chiu’s (2016) framework of moves and steps in the context of personal statements for graduate school application to medical education. Drawing on this analytical framework that comprises five moves: introduction, relevant background, reasons for applying, extra-curricular information, and conclusion, the text data were deductively classified into moves and steps.

Ethical approval was obtained from the Gifu University Ethics Committee (No. 25–367). Students were assured of the confidentiality of the contents.

III. RESULTS

The average length of the personal statements was 535.5 words (range: 314–873 words). The deidentified data of personal statements by some participants who gave their consent to share the whole text that support the findings of this study are available in Figshare at http://doi.org/10.6084/m9.figshare.17030705. All the data set can be available from the corresponding author on reasonable request. Table 1 indicates the total number of personal statements that consists of any step of each move and shows the representative text in each move.

Table 1. Moves and steps of the personal statements for international electives written in English by Japanese medical students

 

As can be seen from Table 1, in the introduction, Japanese medical students commonly described the context and issues of healthcare in Japan (1-B) and future goals for physicians (1-D). Expressions of their research and clinical interests (1-C) were made the least in the introduction move. In the relevant background move, it is notable that six out of eight personal statements in this study showed personality (2-G), which is much higher than the rest of the other steps. In the reasons for applying move, six Japanese medical students made the rhetorical step of personal development and ambition, whereas only two students described their understanding of programmes and institutional attributes (3-C) and disciplinary and research reasons (3-E). Extra-curricular information (Move 4) was not provided by the applicants in this study. In the move of conclusion, Japanese medical students focused only on their future success goals (5-A) and contribution to the course (5-E). Furthermore, no applicant expressed self-promotion (5-B) and praise for academics, programmes, and institutions (5-D) in this study.

IV. DISCUSSION

Drawing on genre analysis (Swales, 1990), this study revealed the rhetorical patterns of personal statements written by Japanese medical students. Although the participants had high or adequate English proficiency, they seemed to struggle with personal statement writing due to the unfamiliar genre of discourse. Imafuku et al. (2021) found that the participants faced several difficulties related to linguistic, sociolinguistic, and sociocultural aspects during the international electives, whereas this study showed that the applicants had already experienced difficulties of cross-cultural communication at the pre-departure stage.

Genre analysis offers a useful theoretical framework and an analytical perspective of people’s communicative practices in a cultural context, especially allowing educators or researchers to examine how language is used in specific contexts for particular purposes, thus contributing to the knowledge of specific writing instructions (Ding, 2007). Writing a personal statement is a common issue not only in medical education but also in higher education. Personal statements are a type of promotional academic genre in admissions to higher education institutions or programmes that expects textual self-aggrandisement by applicants. Chiu (2016), who examined personal statements in the areas of educational policy, language and literacy, and higher education, demonstrated that self-promotion or evaluation is an important step in the conclusion move for graduate school applications in the UK and the US. As a response to Chiu’s (2016) study, the finding of this study that self-promotion or evaluation is not indicated in the move of conclusion by Japanese medical students suggests their need to learn not only the rhetorical structure and reader expectations but also ways of logically and effectively expressing their own strengths. The results of this study can be a useful learning resource to understand what rhetorically characterises a personal statement.

Reflecting on the rhetorical patterns of the students in a given genre is pivotal to communicative achievement in intercultural settings. In this sense, contrastive rhetoric studies have provided useful implications for a better understanding of writing patterns from a cross-cultural viewpoint. For example, contrastive rhetoric studies of Japanese and English to date have shown different discourse organisations of and approaches to writing in a variety of genres, such as newspaper columns, doctoral dissertations, and narrative essays (Connor, 1996). In the previous studies reviewed by Connor (1996), Japanese writing was characterised by a reader-responsible language and a deductive rhetorical pattern. Furthermore, the Japanese are oriented to share values of indirectness, and the reader is expected to interpret what the writer intended to convey. This study suggests that understanding the rhetorical features in the writer’s own cultural context is essential to writing in the target genre of discourse in different cultural contexts.

Although this study illuminates written communication across cultures through the text analysis of personal statements, investigation should be undertaken continuously for further data collection, as the sample size of text data from eight students is limited to a particular institution. Furthermore, follow-up interviews are worthwhile to explore students’ writer identity and cognitive process during writing.

V. CONCLUSION

There are increased opportunities for cross-cultural communication, including both spoken and written formats, in globalised contexts, such as medicine. For written communication, in the genre of personal statements in medical education, this study found that Japanese students shared limited information about the relevant background (Move 2) and did not express adequate self-promotion (Move 5). The findings can act as a springboard for the development of support for Japanese students’ academic writing in English in medical education across cultures.

Notes on Contributors

Rintaro Imafuku reviewed the literature, designed the study, conducted text analysis, and wrote the manuscript.

Kaho Hayakawa was involved in data collection and analysis of the text.

Takuya Saiki was involved in data collection and analysis of the text.

All the authors have read and approved the final manuscript.

Ethical Approval

This study was approved by the Gifu University Ethics Committees (No. 25–367). Consent was obtained from all participants for the research study. Confidentiality was assured for the contents of students’ writing. All participants have given written consent for their data to be used in the research and for publication.

Data Availability

Deidentified data of personal statements by the participants who gave their consent to share the whole text are openly available at http://doi.org/10.6084 /m9.figshare.17030705. The data are available from the corresponding author on reasonable request.

Funding

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

Declaration of Interest

The authors report no conflicts of interest.

References

Chiu, Y.-L. T. (2016). ‘Singing your tune’: Genre structure and writer identity in personal statements for doctoral applications. Journal of English for Academic Purposes, 21, 48-59. https://doi.org/10.1016/j.jeap.2015.11.001

Connor, U. (1996). Contrastive rhetoric: Cross-cultural aspects of second language writing. Cambridge University Press.

Ding, H. (2007). Genre analysis of personal statements: Analysis of moves in application essays to medical and dental schools. English for Specific Purposes, 26(3), 368-392. https://doi.org/10.1016/j.esp.2006.09.004

Imafuku, R., Saiki, T., Hayakawa, K., Sakashita, K., & Suzuki, Y. (2021). Rewarding journeys: Exploring medical students’ learning experiences in international electives. Medical Education Online, 26(1), 1913784. https://doi.org/10.1080/10872981.2021.1913784

Swales, J. (1990). Genre analysis: English in academic and research settings. Cambridge University Press.

*Rintaro Imafuku
1-1 Yanagido, Gifu, Gifu, 501-1194
Email: rimafuku@gifu-u.ac.jp

Submitted: 30 July 2021
Accepted: 17 January 2022
Published online: 5 April, TAPS 2022, 7(2), 46-50
https://doi.org/10.29060/TAPS.2022-7-2/SC2662

Kheng Tian Lim¹ & Bao Yun Koh²

¹Department of General Surgery, Khoo Teck Puat Hospital, Singapore; ²Education Development Office, Khoo Teck Puat Hospital, Singapore

Abstract

Introduction: Medical students (MS) may lack the knowledge and experience in performing basic surgical skills (BSS) when they first commence their postgraduate surgical training. We conducted a pilot BSS workshop with specific learning outcomes for MS.

Methods: Our BSS workshop program consisted of reading the pre-workshop online modules, watching the instructional videos of skills demonstration, and completing the pre-workshop multiple-choice questions (MCQ). MS attended the onsite workshop a week later, which consisted of a basic surgical theory lecture, live demonstration of the skills by the teaching faculty and, supervised skills training coupled with feedback. Surgical skills taught were knot tying, suturing techniques, laparoscopic peg transfer, precision cutting, application of endoloop ties. A standardised surgical skills rubric was used to assess the competency and safety of BSS. A post-workshop MCQ was administered to assess the knowledge learned. The criteria for successful completion of BSS were a satisfactory grade in the surgical skills assessment and a pass score in the MCQ.

Results: All the participating MS achieved a satisfactory grade in the surgical skills assessment and passed the MCQ. Several pedagogical methods were used to enhance knowledge learning and practical skills competency including a flipped classroom in blended learning, technology-enhanced learning, kinesthetic learning, and providing effective feedback.

Conclusion: MS taught in BSS workshop can achieve competency in knowledge, skills, safe attitude and prepare them for future postgraduate surgical training. In the current COVID-19 pandemic, our challenge is to develop similar BSS in a safe environment using technology-enhanced tools such as online instructional videos and online feedback.

Keywords:           Assessment, Basic Surgical Skills, Competency, Feedback, Medical Students, Outcome-based Education

I. INTRODUCTION

Medical students (MS) may lack the knowledge and experience in performing certain basic surgical skills (BSS) when they first commence their postgraduate surgical training in hospitals. Traditionally, BSS are usually not taught formally in the undergraduate medical curriculum until much later in the postgraduate level. The opportunity for teachers to teach BSS and for MS to learn is much dependent on the situation in operating rooms during assigned core surgical postings or student selective postings.

In Singapore, Yong Loo Lin School of Medicine, National University of Singapore (NUS) provides basic and advanced clinical procedural simulation training to undergraduate MS. Skills taught include gowning, scrubbing techniques, suturing, and knot-tying. Lee Kong Chian School of Medicine, Nanyang Technological University (NTU) teaches suturing and knot-tying skills in dry laboratory to undergraduate MS. All these stimulated practical skills and experience acquired by MS are transferrable to real patients’ environments. In addition, SingHealth Academy, an educational arm of SingHealth, provides BSS workshop training at the postgraduate level for interested learners. In the United Kingdom and Ireland, the BSS course is a curriculum-mandated course for postgraduate Core Surgical Training programmes.

Healthcare institution partners such as Khoo Teck Puat Hospital (KTPH), provide clinical training for MS of NUS and NTU. Our Department of General Surgery (GS) identifies the need in the learning outcomes for the graduating MS, to equip them with the competent foundation of BSS for postgraduate surgical training, although not a graduating competency requirement set by Singapore Medical Council. We conducted a small pilot workshop at our institution, aiming at educational quality improvement for our MS in three learning domains, namely surgical knowledge, practical surgical skills, and attitudes in safety that are common to all forms of surgery.

II. METHODS

A. Workshop organization, MS and Teaching Faculty, Teaching Materials

The Department of GS and Education Development Office (EDO), KTPH organised a 1-day BSS workshop for MS with the request from MS and was scheduled on 20^th December 2019. Planning over three months was required to prepare the learning objectives and outcomes, workshop programme schedule, venue, teaching materials, surgical scrubs, sustenance, and coordination by the workshop director and EDO. Both the local and overseas MS were invited and recruited for training. Experienced local teaching faculty members were invited and briefed on the teaching methodology, feedback provision, and assessment criteria.

MS who agreed to participate were given instructions to read the pre-workshop fundamentals of the BSS document, watch the instructional video clips of the BSS demonstration and, complete pre-workshop multiple-choice questions (MCQ), all of which were provided online 1 week before the workshop. These pre-workshop activities may help to motivate the MS and provide an opportunity for self-assessment of their understanding of the BSS topics. MS were allowed to post questions to the workshop director for guidance. The course content and MCQ were prepared by the course director to be appropriate to the MS level.

The workshop was divided into morning and afternoon sessions to cater to a larger group of interested MS coming from overseas. The onsite workshop consisted of a short basic theory lecture, a live demonstration of the practical BSS, MS performing the practical BSS with direct supervision and corrective feedback. BSS taught were knot tying using one-hand, two-hand, and instrumental techniques. Suturing techniques taught included simple, mattress, interrupted, continuous suture. More advanced laparoscopic skills such as laparoscopic peg transfer, precision cutting, and application of endoloop ties were taught. A post-workshop MCQ was administered.

B. Assessment in Knowledge, Skills, and Attitudes

The surgical knowledge was assessed using the pre-and post-workshop MCQ, based on the course content prepared for MS.

The surgical skills assessment was carried out by direct observation of procedural skills (DOPS) using a standardised surgical skills rubric. Open surgery skills assessment included instrument selection and handling, knotting techniques, tissue handling, and suturing techniques. Laparoscopic surgery skills assessment included instrument selection and handling, peg transfer, precision cutting, and ligating loop. The overall summative assessment of global grading in the surgical skills domain by the teaching faculty was either satisfactory or unsatisfactory.

MS were assigned to work in pairs with the ratio of MS: teaching faculty as 2:1. Assessment in the attitude and behavior domain was based on direct observation in the safe handling of sharps and needles, general assisting, and laparoscopic camera assisting skills.

C. Feedback and Competency

The teaching faculty used DOPS to provide feedback on the practical BSS performed by the MS which allowed the MS to improve and progress from a novice to a competent learner level in the skills and attitude domains. The specific, timely, and purposeful feedback served as a channel for MS to improve and reflect on their learning outcomes in these domains.

The competency criteria for successful completion of the BSS workshop were set as a pass mark of 60% in the summative MCQ test and a satisfactory grade in the summative skills assessment by the teaching faculty. A Certificate of Attendance would be awarded to MS who have acquired the competency criteria.

III. RESULTS

Assessment and evaluation data gathered for this workshop and pre-workshop MCQ questions were uploaded to an online repository for archiving and validation purposes. It may be assessed through the following Digital Object Identifier (DOI): https://doi.org/10.6084/m9.figshare.16884877.v2 (Lim & Koh, 2021).

A total of 38 MS signed up for the BSS workshop with 1 dropout. Thirty-seven MS attended the workshop of which 25 were from overseas medical schools. Thirty-six MS attempted the pre-workshop MCQ (10 questions). Thirty-seven MS passed the post-workshop MCQ (15 questions). All MS achieved satisfactory grades in practical skills. There was no needle stick injury reported.

The BSS workshop program evaluation form was administered and completed anonymously for the quality improvement process after verbal consent was taken from the participants. (Table 1).

Table 1. BSS Workshop for MS Program Evaluation

IV. DISCUSSION

Bloom’s Taxonomy comprises three learning domains known as cognitive (knowledge), affective (attitude), and psychomotor (skills). Each domain has a hierarchy that corresponds to distinct levels of learning which is important for students to develop holistically. The learning objectives of the BSS workshop for MS are thus designed to fulfil these three domains, specifically to: 1) acquire the fundamental knowledge of BSS (knowledge), 2) demonstrate a variety of surgical knots and suturing skills effectively (skills) and, 3) handle and use of surgical instruments and tissue safely (attitude).

Harden et al. (1999) described an outcome-based education framework that comprises six levels of training to achieve the outcomes. These six levels of training are: 1) awareness of the procedure, 2) full theoretical understanding of the procedure, 3) observation of the procedure, 4) carrying out part of the procedure, 5) undertaking the procedure under the supervision and, 6) undertaking the procedure unsupervised. Similarly, the programme activities of the BSS workshop for MS were developed to cover these six levels of training. The learning outcomes of this workshop are to equip the MS with the competency of BSS for postgraduate surgical training. The teaching faculty members share their knowledge, demonstrate their expertise, advise MS, and provide feedback to improve technical skills and promote learning.

Effective feedback is necessary to enhance learning. Pendleton et al. (2003) described a four-step process for carrying out a feedback session. Ramani and Krackov (2012) described twelve tips for clinical teachers to provide effective feedback to undergraduate and graduate medical trainees. Our teaching faculty members were able to provide effective feedback to MS using these frameworks to establish a respectful learning environment, feedback on direct observation, make feedback timely, reinforce and correct observed behaviors, use specific language to focus on performance, confirm the learner’s understanding and conclude with an action plan.

The assessment for learning in the BSS workshop for MS was designed to align with the three learning domains using: 1) pre-and post-workshop MCQ to test surgical knowledge, 2) DOPS by the teaching faculty to test surgical skills and, 3) DOPS in the safe handling of sharps and needles, general assisting and laparoscopic camera assisting skills to test the attitude and behavior. A standardised surgical skills rubric was used for DOPS.

Technology-enhanced learning (TEL) intervention and enhancement can be characterised by 1) replicating existing teaching practices, 2) supplementing existing teaching or, 3) transforming teaching, learning processes, and outcomes (Kirkwood & Price, 2014). Several pedagogical methods were used in this BSS workshop to enhance knowledge learning and skills acquisition such as flipped classroom in blended learning, a mixture of the three characteristics of TEL, kinesthetic learning, and providing effective feedback. In the current COVID-19 pandemic, there are challenges to conducting such a practical workshop. TEL tools that combine online educational materials, instructional videos, feedback, and face-to-face online interaction such as Zoom, and Microsoft Teams are the new norm.

The limitation of this workshop includes the lack of MCQ standardisation process and the quality of the video clips which we intend to improve in the next workshop.

V. CONCLUSION

Conducting a BSS workshop for MS with specific learning outcomes is feasible where the MS can achieve competency in knowledge, skills, safe attitude and prepare them for postgraduate surgical training. In the current COVID-19 pandemic, our challenge is to develop similar BSS in a safe environment using TEL tools.

Notes on Contributors

Dr. Lim Kheng Tian designed the work, reviewed the literature, drafted the work, revised the content critically, and wrote the manuscript. Ms. Koh Bao Yun contributed to the design and administration of the work, gave critical feedback to the content, and revised the manuscript. All authors have read and approved the final manuscript.

Ethical Approval

This 1-day workshop program was conducted for educational quality improvement (QI) with approval from the Department of GS and EDO, KTPH. This article was submitted with Institutional Review Board/Ethical approval for exemption from full review. We have attached the local IRB waiver document NHG DSRB Ref: 2021/00888.

Data Availability

 

Inline to make research available to the scientific community for data replication and scientific progress, the dataset of this workshop may be found for free through the Figshare website: https://doi.org/10.6084/m9. figshare.16884877.v2

Acknowledgement

The authors want to thank all the MS and teaching faculty who participated in the workshop. We would like to acknowledge Dr. Lee Yao Zong, Associate Consultant of the Department of GS, KTPH for providing help in the laparoscopic educational content. We would like to acknowledge the technical help of Mr. Mohamad Sean Abdullah, former Experimental Surgical Services Development Executive of the Department of GS, KTPH. We would like to acknowledge equipment support from KARL STORZ Endoscopy Singapore Sales Pte Ltd for providing the reusable laparoscopic trainer and laparoscopic instruments. We also like to acknowledge NHG Education for linking up EDO, KTPH with the Singapore Medical Society of Australia and New Zealand (SMSANZ).

Funding

There is no funding for this paper. The suturing materials used in the workshop were funded by the Pre-Employment Clinical Training (PECT) Funds received by KTPH for local MS whilst overseas MS were self-funded. The funder was not involved in the design, delivery of the workshop, or submission of the paper.

Declaration of Interest

All authors declare no conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest. 

References

Harden, R. M., Crosby, J. R., Davis, M. H., & Friedman, M. (1999). AMEE Guide No. 14: Outcome-based education: Part 5-From competency to meta-competency: A model for the specification of learning outcomes. Medical Teacher, 21(6), 546–552.  https://doi.org/10.1080/01421599978951

Kirkwood, A., & Price, L. (2014). Technology-enhanced learning and teaching in higher education: What is ‘enhanced’ and how do we know? A critical literature review. Learning, Media and Technology, 39(1), 6–36. https://doi.org/10.1080/17439884.2013.770404

Lim, K. T., & Koh, B. Y. (2021). Start small and aim big in conducting a basic surgical skills workshop for medical students—Repository data (p. 11710 Bytes) [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.16884877.v2

Pendleton, D., Schofield, T., Tate, P., & Havelock, P. (2003). The New Consultation. Oxford University Press.

Ramani, S., & Krackov, S. K. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 34(10), 787–791. https://doi.org/10.3109/0142159X.2012.684916

*Lim Kheng Tian
Department of General Surgery,
Khoo Teck Puat Hospital,
90 Yishun Central,
Singapore 768828.
Tel: +65 65558000
Email: lim.kheng.tian@ktph.com.sg

Submitted: 22 August 2021
Accepted: 28 December 2021
Published online: 5 April, TAPS 2022, 7(2), 42-45
https://doi.org/10.29060/TAPS.2022-7-2/SC2682

Lee Man Xin^1*, Zhang Yuan Helen^2* & Fatimah Lateef^2,3

¹Changi General Hospital Emergency Department, Singapore; ²Singapore General Hospital Emergency Department, Singapore; ³Singhealth Duke-NUS Institute of Medical Simulation (SIMS) Education Office, Singapore

*Joint first authors

Abstract

Introduction: Advanced Cardiac Life Support (ACLS) course is one of the mandatory certifications for the majority of medical as well as some nursing professionals. There are, however, multiple variations in its instruction model worldwide.  We aim to evaluate the efficacy of traditional ACLS course versus a hybrid ACLS course utilised during the COVID-19 pandemic.

Methods: This retrospective study was carried out at SingHealth Duke-NUS Institute of Medical Simulation using course results of participants in the centre’s ACLS course between May to October 2019 for the traditional course were compared with participants attending the hybrid course from February to June 2021.

Results: A total of 925 participants were recruited during the study period. Of these, 626 participants were from the traditional group and 299 participants were from the hybrid learning group. There is no statistically significant difference between the two group (χ²=1.02 p = 0.313) in terms of first pass attempts; first pass attempt at MCQ (p=0.805) and first pass attempt at practical stations (p=0.408). However, there was statistically significant difference between the mean difference in results of traditional vs hybrid MCQ score, -0.29 (95% CI: -0.57 to -0.01, p=0.0409). Finally, senior doctors were also found to perform better than junior doctors in both traditional (p=0.0235) and hybrid courses (p=0.0309) at the first pass attempt of ACLS certification.

Conclusion: Participants in the hybrid ACLS course demonstrated at least equal overall proficiency in certification of ACLS as compared to the traditional instruction.

Keywords:           Advanced Cardiac Life Support, Teaching Model, COVID-19, Hybrid Learning

I. INTRODUCTION

Cardiopulmonary resuscitation (CPR) represents an emergency lifesaving procedure for cardiac arrest patients. It is a core skillset for every licensed physician, graduating medical students and paramedics. It provides evidence-based algorithms to be executed to optimise the likelihood of survival in cardiac arrest patients. Cardiac arrest poses a major public health challenge. Worldwide, sudden and unexpected cardiac death is one of the most common causes of death. Given such a substantial disease burden, structured and continued training of physicians and first responders on advanced cardiac life support (ACLS) is extremely crucial. In Singapore, about 3000 people have a sudden cardiac arrest every year (Ong, 2020).  

The first Advanced Cardiac Life Support (ACLS) course in Singapore, was started in late 1985 and traditionally it has been conducted over two days. It comprises of pre-reading from a manual outlining the procedure algorithms, a combination of face-to-face didactics and hands-on skills stations conducted by licensed providers and instructors, followed by multiple-choice theory and practical certification tests. It mainly focuses on technical knowledge and skills which needs to be recertified every two years (Anantharaman, 2017). Since the implementation of social distancing measures under DORSCON Orange in Singapore in response to the COVID-19 disease outbreak on 7^th February 2020, ACLS teaching model has since been modified to multimedia lectures followed by small-group (maximum 5 people) practical lessons, which was further adjusted to include an online self-administered pre-lecture quiz from 18^th February 2021 onwards. Limited evidence has shown that written evaluation is not a predictor for skills performance in an ACLS course and there is now, a growing body of advocates for high-fidelity mannequin-based simulation supplementing ACLS curricula. Multiple research studies have focused on the efficacy of various educational and instructional methods for ACLS teaching in terms of improvement to the resuscitation knowledge and clinical skills (Thorne et al., 2017).

We aim to retrospectively evaluate the efficacy of our new hybrid ACLS teaching model based on participants passing rate of both theory and practical tests as compared to the traditional ACLS instruction model. The primary goal is to provide enhanced insights into the way ACLS training should be conducted and further refine our courses as we evolve in the new norm of living with the COVID-19 pandemic. Institutional Review Board waiver has been obtained through Singapore Health Service (CIRB: 2021/2499).

II. METHODS

A. Study design and participants

This retrospective study was carried out at SingHealth Duke-NUS Institute of Medical Simulation (SIMS) using the course results of participants in the centre’s Advanced Cardiac Life Support (ACLS) course. A waiver of consent was approved by the institute’s CRIB committee as the results were anonymised.

The ACLS course traditionally comprises face-to-face didactic lecture components and practical skills stations culminating in MCQ and practical assessment. Successful completion of both MCQ and practical assessment results in certification or recertification for the participants.

In the hybrid ACLS learning model, the didactic lecture component has been replaced with an interactive online learning platform while maintaining the same practical skills stations with reduced instructor to student ratio because of safe distancing measures. To facilitate learning, a pre- and post-lesson quiz, with 25 MCQ questions, was administered on the online learning platform.

Course results of participants attending the traditional course from May to October 2019 were compared with participants attending the hybrid course from February to June 2021. No participants were found to have attended both the traditional and hybrid ACLS courses, to date. We did not differentiate between recertification and certification courses since there are no differences in assessments.

B. Outcome measures

Our primary outcome measure was the proportion of participants with successful first pass attempt at course certification between traditional and hybrid ACLS courses.

For secondary outcomes, we analysed the mean difference in MCQ scores and first pass attempts at practical stations between traditional and hybrid ACLS instructions. We also compared differences between pre- and post-lesson quiz scores administered during the hybrid learning to assess retention of theoretical knowledge. Lastly, we conducted a sub-group analysis comparing the proportion of senior doctors and junior doctors who pass the course at the first attempt, in both the traditional and hybrid learning groups. Here, senior doctors refer to individuals with specialist registration while junior doctors refer to all other registered medical practitioners.

C. Statistical analysis

A priori sample size estimation was carried out with the assumption that 90% of participants will pass with the first attempt in both traditional and hybrid ACLS teaching models. We used a non-inferiority margin of 10%. Taking α = 0.05 and a statistical power of 80%, we determined that would require at least 155 participants per group.

Statistical analysis was performed using Microsoft Excel 2019. T-test was used when comparing means, Chi-square test was used when comparing categorical variables.

III. RESULTS

A total of 925 participants were recruited during the study period. Of these, 626 participants were from the traditional group and 299 participants, from the hybrid learning group. No participants were excluded from the study. Table 1 shows the characteristics of both groups. The data supporting this study are openly available at https://doi.org/10.6084/m9.figshare.15131664.v1 (Lee et al., 2021).

For the traditional group, 87.7% (549 of 626) passed at the first attempt, whilst for the hybrid group, 90.0% (269 of 299) passed at first attempt (See Table 1). There was no statistically significant difference between the two groups (p = 0.313).

Table 1. Baseline Demographics of Participants for the ACLS Courses and comparison of primary and secondary outcome measures between the Hybrid and Traditional ACLS courses participants

¹ Senior doctors are registered specialists under Singapore Medical Council. Junior doctors are all other registered medical practitioners under Singapore Medical Council.

There were no statistically significant differences between the two groups in terms of proportion of first pass attempt at MCQ (p=0.805) and first pass attempt at practical stations (p=0.408). There was however, a statistically significant difference, but with a very small effect size, between the mean difference in results of traditional vs hybrid MCQ score, -0.29 (95% CI: -0.57 to -0.01, p=0.0409).

We also compared the pre- and post-lesson quiz scores in the hybrid learning group. 21 participants were excluded from the analysis due to incomplete pre- or post- test results. We found a mean score difference of 2.32 (95% CI: 1.84 to 2.80, p < 0.001), out of a maximum score of 25, which was higher in post-test group.

Lastly, we compared the proportion of first pass test attempts between senior and junior doctors in both traditional and hybrid learning groups. Senior doctors consistently performed better than junior doctors in both traditional (96.3% vs 87.8% p=0.0235) and hybrid settings (100% vs 89.4% p=0.0309).

IV. DISCUSSION

ACLS is one of the most basic yet crucial skills of medical practitioners worldwide receiving special attention in the framework of various international and national resuscitation councils and societies (Thorne et al., 2017). Clinical educators must explore modalities and evolving technologies that can overcome the barriers of cost, access, and frequency of exposure, while balancing flexibility and applicability that follow deliverable sequelae. Thus far, participants of blended e-learning ACLS courses are known to demonstrate similar scores on the knowledge test, skills test and their final passing rate. The e-learning ACLS course also demonstrates equivalence to traditional face-to-face learning in equipping participants with ACLS skills when compared to the traditional course. This was demonstrated in our results as well. This is a value-added benefit, especially when considering factors such as increased autonomy, cost-effectiveness, decreased instructor burden and improved standardisation of course material (Thorne et al., 2017).

As we shift more towards andragogy among adult professionals, the principles for ACLS instruction should also focus more on self-directed, self-motivated and experiential instruction. Evidence does support that the form and content of these highly structured/model courses are important to transfer the clinical competence that is needed, especially in unstructured, emergencies (Rasmussen et al., 2013). Hence, exploring a sustainable model of ACLS knowledge translation is another important point since further research is needed to develop the optimal evaluation system for the ACLS training program which includes evaluation of the participants, the instructors, and the overall program. The goal should be to assess the degree to which the ACLS program is meeting its objective: to educate medical practitioners, first responders and rescuers.

The COVID-19 pandemic has affected simulation centres where ACLS courses are routinely held. Alternative education modalities have been employed, which include computer-based simulation where technology is used to enhance, augment or even at times, replace real-life simulation. It not only offers the professionals convenience but, complies with safe-distancing or ‘work-from-home’ restrictions put forth by regulatory bodies in many countries. Online modules of virtual reality have also been explored as these can be accessed anywhere electronically and can reduce the amount of face-to-face time that routine training normally requires.

V. CONCLUSION

Hybrid instruction of ACLS training for certification should be recommended as one of the main formats of course delivery as it is as effective compared to the traditional face-to-face training program. From our results it has performed well enough to allow for the safe transition and application of ACLS training in this new era.

Notes on Contributors

Lee Man Xin is involved in conceptualising the study, analysing and interpreting the data, drafting the above manuscript and approving the version to be published. He agrees to be accountable for all aspects of the work.

Zhang Yuan Helen is involved in conceptualising the study, interpreting the data, drafting the above manuscript and approving the version to be published. She agrees to be accountable for all aspects of the work.

Lateef Fatimah is involved in finalising the study conceptualisation and determining key elements for analysis. She is involved in the revision and final approval of the version to be published. She agrees to be accountable for all aspects of the work.

Ethical Approval

Institutional Review Board waiver has been obtained through Singapore Health Service (CIRB: 2021/2499).

Data Availability

The data supporting this study are openly available at figshare repository: https://doi.org/10.6084/m9.figshare.15131664.v1

Acknowledgement

The authors would like to thank Mr Billy Tee, Ms Suppiah Madhavi and Ms Angeline Ng from Singhealth Duke-NUS Institute of Medical Simulation (SIMS) Singapore for providing the data sets.

Funding

This paper receives no funding from outside sources.

Declaration of Interest

Authors have nothing to declare, nor any conflict of interests.

References

Anantharaman, V. (2017). The National Resuscitation Council, Singapore, and 34 years of resuscitation training: 1983 to 2017. Singapore Medical Journal, 58(7), 418–423. https://doi.org/10.11622/smedj.2017069

Lee, M. X., Lateef, F., & Zhang, H. Y. (2021). Hybrid ACLS model (version 1). [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.15131664.v1

Ong, M. E. (2020, October 2). Improving outcomes for Out-of-Hospital cardiac arrest victims. The Straits Times. https://www.singhealth.com.sg/rhs/news/research/improving-outcomes-for-out-of-hospital-cardiac-arrest-victims

Rasmussen, M. B., Dieckmann, P., Barry Issenberg, S., Østergaard, D., Søreide, E., & Ringsted, C. V. (2013). Long-term intended and unintended experiences after Advanced Life Support training. Resuscitation, 84(3), 373–377. https://doi.org/10.1016/j.resuscitation.2012.07.030

Thorne, C. J., Lockey, A. S., Kimani, P. K., Bullock, I., Hampshire, S., Begum-Ali, S., & Perkins, G. D. (2017). e-Learning in Advanced Life Support-What factors influence assessment outcome? Resuscitation, 114, 83–91. https://doi.org/10.1016/j.resuscitation.2017.02.014

*Lee Man Xin
Changi General Hospital Emergency Department
2 Simei Street 3, Singapore 529889
Email: Lee.Man.Xin@singhealth.com.sg

Submitted: 10 August 2021
Accepted: 28 October 2022
Published online: 5 April, TAPS 2022, 7(2), 37-41
https://doi.org/10.29060/TAPS.2022-7-2/SC2670

Qianhui Cheng¹, Joanna Pearly Ti^1,2, Wai Yung Yu^1,2, Hui Ping Oh¹, Yih Yian Sitoh^1,2

¹Department of Neuroradiology, National Neuroscience Institute, Singapore; ²Duke NUS Graduate Medical School, Singapore

Abstract

Introduction: Magnetic Resonance (MR) safety is critically important in any Radiology Department, and MR-related accidents are preventable. Serious games provide opportunities for learners to build MR safety awareness through play in an immersive learning environment by using simulated scenarios such as screening virtual patients and managing an MR-related accident.

Methods: We developed a serious game, in partnership with a game developer, introducing MR safety concepts to learners as they navigate through a virtual 3D Radiology department. Drag-and-drop minigames are incorporated to aid the learner to identify hazards in and around the MR environment. Virtual patients are placed in waiting areas to provide realism, and learners are tasked to screen them as part of MR Safety Screening checks. A simulation of an MR-related accident prompts learners to make decisions or take actions to ensure safety and mitigate further risks during the accident. The learner also role-plays as a Risk Officer to identify the multiple key incidents that led to the accident. These formative assessments, with instantaneous feedback, assesses the learners’ knowledge of MR safety.

Results: Pilot feedback of this serious game revealed that it is realistic, engaging and relatable. The instructions within the game were clear and aided learning. The game has also been scaled up and customised for the radiology departments of 3 other healthcare institutions.

Conclusion: Serious games provide a training solution to raise MR safety awareness by simulating real-life scenarios in an immersive learning environment. It supplements face-to-face training and is scalable to other healthcare institutions.

Keywords:           Medical Education, Technology-Enhanced Learning, Gamification, MR Safety, Workplace Safety, Simulation

I. INTRODUCTION

Magnetic Resonance (MR) safety plays a critical role in any Radiology Department to ensure the safety of patients and healthcare workers. MR is an imaging tool that uses a magnetic field to acquire detailed images of the body for the investigation of diseases.

MR-related incidents are prevalent; for instance, the US Food and Drug Administration (US FDA) received 1568 adverse events reports for MR-related incidents over 10 years between 2008 and 2017 (Delfino et al., 2019). These reported adverse events included mechanical events (eg. crushed injuries) and projectiles that are caused by objects pulled in by the magnetic field.

Hence, caution must be taken as the MR scanner’s magnetic field is always on and poses safety risks when MR safety protocols are not adhered to. Ferromagnetic objects can become projectiles within or near the magnetic field and pose a danger to patients and staff members present within it. MR-related accidents are preventable and are caused by MR safety lapses, occasionally resulting in deadly outcomes. Hence, building MR safety awareness for all levels of healthcare staff, from ward staff to those who work in the radiology department, is crucial.

Today’s generation of learners, coined as ‘digital natives’ are accustomed and receptive to the digital world and game-based learning (Girard et al., 2013). Serious games refer to digital games with the specific purpose of training learners to meet an educational objective (Girard et al., 2013). It has been used as an educational tool to realistically simulate incidents for disaster risk management (DRM) and to raise awareness (Solinska-Nowak et al., 2018). Similarly, it has also been used as training tools in health professional education for patient safety (Ricciardi & De Paolis, 2014).

Serious games can virtually replicate the MR environment and simulate MR incidents that are too dangerous to re-enact in the real world, thus preparing the healthcare professionals for such scenarios. The serious game is an ideal training solution to complement face-to-face training of healthcare professionals on MR safety and can be incorporated into the standardised curriculum design. The intended learning outcomes can be achieved through the constructive alignment of learning activities (within the game and on-the-job) and coupled with assessment and in-game feedback.

Using a learner-centric approach, serious games provide learners with risk-free decision-making opportunities, enhancing MR safety competency through play within an immersive, yet safe, virtual learning environment. These allow learners to exercise the safety behaviours and actions required at the workplace to handle situations that they may encounter.

This short communication aims to describe how this serious game was developed and how the game was evaluated at the pilot stage.

II. METHODS

The team was awarded the Learning Technology Adoption Grant in January 2020 offered by SkillsFuture Singapore (SSG). It is a grant to fund medical education serious games in SingHealth. SingHealth Academy partnered the team with game developers, including instructional designers who helped with the game development.

MR safety lapses can be deadly, and the learning outcomes of the game are to gain knowledge of MR safety and accident risk management, and to be able to demonstrate understanding of these concepts by application of knowledge in the application scenarios within the game and at the workplace.

The target audience for this game includes radiology staff, healthcare staff or ancillary staff, such as housekeeping personnel, who may enter the MR environment and thus, are required to ensure MR safety in their line of work.

The game sets out in a virtual radiology department, modelled after the Neuroradiology department at the National Neuroscience Institute. The virtual world includes virtual patients, staff as player and non-player characters in institutional uniforms, and medical devices that mirror real-life equipment in the radiology department.

Two games were created in the MR safety series. In the first game, learners navigate as an avatar to interact with objects in the MR environment, such as medical devices and virtual patients. The learning outcome of the first game is to understand the key MR safety concepts which follow the American College of Radiology (ACR) guidelines (American College of Radiology, 2020).

The second game was modelled on an MR-related accident. Learners assess the accident scenario (Fig 1a) and consider strategies for risk management, evaluating their options within the game. Critical wrong decisions or actions made during the gameplay may trigger an abrupt end to the game. This emphasises the urgency of actions required in an MR-related accident when a life is in danger and the immediate steps required to be taken to reduce the risk for further injuries. Beyond the virtual accident, the learner role-plays as a Risk Officer to assess and identify several key incidents that led to the accident as part of a root cause analysis investigation.

Figure 1a (left): MR accident scenario within the serious game

Figure 1b (right): Application of MR safety labelling near the MR scanner

Minigames are used as formative assessments, and learners receive instantaneous in-game feedback from their attempts. By screening virtual patients and placement of medical devices in their appropriate location, as part of the MR safety screening checks, the game assesses learners’ ability to identify hazards in and around the MR environment (Fig 1b), with correct placement demonstrating their learning.

For the purpose of game development, beta testers from the Neuroradiology department were included to gather preliminary feedback about the game through implied consent. A survey was administered, and responses ranged on a Likert scale (1=Strongly disagree to 5= Strongly agree).

III. RESULTS

In the initial phase of game development, beta testing of the game was conducted on 11 staff, including radiographers, radiologists, radiography assistants, radiology nurses and administrative staff with differing years of MR work experience. Beta-testers were also selected for their experiences in playing games, ranging from none to some experience. Data reported below as ‘agreed’ is aggregated to reflect ‘agreed’ and ‘strongly agree’ responses (Cheng et al., 2021).

In terms of the learning instructions, all respondents (100%) were aware of the learning outcomes. 81.82% found the instructions clear, and they knew what to do at every stage.

In terms of the virtual game environment, respondents generally felt the game has realistic engagement regarding the design. All respondents (100%) agreed that the game environment was realistic; the avatars (player characters) and objects in the game resembled those at the workplace (100%), and the background sound aided the engagement with the game (81.82%). 90.91% of respondents could also relate to the main player character within the game.

On the contrary, some respondents had trouble operationalising the game mechanics; 27.27% had trouble using the controls, and 36.36% found it difficult navigating within the game.

Overall, 90.91% found the game was fun, and engaging (100%). 81.82% agreed that their past experience helped them to overcome some of the obstacles in the game. Furthermore, 81.82% agreed that the results are a fair reflection of their skill and competency in MR safety.

Arising from the positive preliminary feedback of this serious game, the game has been shared and further adopted by radiology departments from three other healthcare institutions [Singapore General Hospital (SGH), KK Women’s and Children’s Hospital (KKH) and Sengkang General Hospital (SKH)]. The respective teams are working with the game developers to customise and adapt the environment to the local site, including medical devices and safety labels in their local settings for MR safety education.

IV. DISCUSSION

The MR safety game is an educational tool to assess and align MR safety competency for healthcare staff. Furthermore, the game can be incorporated into the orientation curriculum of radiographers as part of a competency checklist onboarding package, supplementing face-to-face training.

Being accustomed to the digital games, ‘digital natives’ as the target generation of learners would find this mode of delivery more relatable, engaging and realistic (Girard et al., 2013). At the same time, it also incorporates a structured learning design, constructively aligned with clear learning outcomes, learning activities and assessment coupled with instantaneous in-game feedback.

However, we acknowledge that some learners may experience difficulties with navigation in a virtual world.  Hence, clear instructions by the facilitator on gaming instructions need to be incorporated in the pre-briefing to learners for more effective engagement and outcomes.

As learners navigate the virtual environment, they pick up MR safety knowledge and apply them to game scenarios as part of active learning. Role-playing as a Risk Officer also makes them more aware of the possible safety lapses that may occur and lead to an MR-related accident. Post-game play feedback should also be incorporated for learners to align the behaviours expected of learners at the workplace.

Beyond the institution, it is scalable to staff from other radiology departments and hospital ward staff, such as nurses and doctors who have no prior knowledge of MR safety but would have adhoc opportunity to be in the MR environment, for example, accompanying a patient to the radiology department for an MR scan.

Finally, through experiential learning, the game emphasises that everyone plays a critical role in MR safety and that safety lapses can lead to accidents.

V. CONCLUSION

Purpose-built simulation serious games that mimic a virtual radiology department provide an ideal training solution for MR safety education. Serious games provide an immersive learning environment where simulated scenarios such as safety screening of virtual patients and MR-related accidents is made possible. Simulation of dangerous scenarios that are impossible to recreate in the real world provides opportunities to raise MR safety awareness and is also scalable to the wider healthcare community.

Notes on Contributors

Cheng Qianhui contributed to the conceptualisation and design of this serious game, drafting the manuscript and approved the final version to be published.

Joanna Pearly Ti contributed to the conceptualisation and design of this serious game, revised the manuscript for intellectual content and approved the final version to be published.

Yu Wai-Yung is a mentor to the team, revised the manuscript for intellectual content and approved the final version to be published.

Oh Hui Ping contributed to the conceptualisation and design of this serious game, revised the manuscript for intellectual content and approved the final version to be published.

Sitoh Yih Yian is a mentor to the team, revised the manuscript for intellectual content and approved the final version to be published.

Ethical Approval

Review not required as stipulated by CIRB (CIRB Reference No.: 2021/2397).

Data Availability

The beta testing evaluation data presented in this manuscript is available in the Figshare data repository: https://doi.org/10.6084/m9.figshare.14473074.v1

Acknowledgement

We would like to thank SingHealth Academy and Playware Studios for their tremendous contribution for the creation of this serious game. We are also thankful to NNI neuroradiology staff for their help with the pre-testing of the game, contributing to the game development through honest feedback. We are thankful to Serious Games Asia and Singapore University of Technology and Design (SUTD) for co-developing the survey evaluation. We sincerely thank our scale-up teams, the radiology departments from Singapore General Hospital (SGH), Sengkang General Hospital (SKH) and KK Women’s and Children’s Hospital (KKH) so that more staff across SingHealth can benefit from MR safety training through this serious game.

This project has been presented as Free Communication at the Asia Pacific Medical Education Conference 2021, and the author was awarded the Young Scholar Award Runner-up.

Funding

The game development and scale-up is funded by Learning Technology Adoption Grant (LTAG) offered under SkillsFuture Singapore (SSG), which SingHealth Academy has applied to jumpstart medical education serious games in SingHealth institutions. SingHealth Academy is the education arm in SingHealth to coordinate the application with SSG.

Declaration of Interest

The authors declare no conflict of interest.

References

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Cheng, Q., Ti, J. P., Yu, W.-Y., Oh, H. P., & Sitoh, Y. Y. (2021). MR safety beta testing data [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.14473074.v1

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*Cheng Qianhui
National Neuroscience Institution
11 Jalan Tan Tock Seng,
Singapore 308433
Singapore 117593
Email: qianhui_cheng@nni.com.sg