With the transition from traditional lecture-based instruction to active learning, many educators have explored ways to motivate students and maximize student-instructor or student-student interaction. When balanced with clear learning outcomes and the appropriate level of organization, active learning motivates and engages all students, stimulates in-depth discussion and fosters collaborative learning. The digital age has revolutionized the ways people receive and learn new information and skills, which presented challenges and opportunities. Superior to the conventional in-person instruction, web-based teaching can be asynchronous, multi-modal and more accessible and sharable . With the development of new information technology and increasingly open access to the internet, we have more digital tools to explore creative ways to replicate the face-to-face active learning environment . With the increasing popularity of online teaching, such pedagogical innovations are necessary in hospitals with resident training programs. Previous studies proposed that the keys to improving web-based instruction quality and enhancing student learning are student motivation and timely feedback [15, 16]. Simulation modules have been developed and widely used in clinical skill trainings in medical schools, including for patient communication, emergency airway management and basic life support [8,17~23]. In our model, we explored ways to incorporate these evidence-based pedagogical principles and practices into our remote instruction and yielded satisfactory results in the acquisition of key skills in the donning and doffing of PPE.
The unexpected outbreak of novel coronavirus pneumonia led to social distancing and quarantine practices and posed unprecedented challenges, which we resolved by web-based pedagogical advancement. To begin with, we adopted a multimodal approach to accommodate different preferences for learning modality, which include visual (instructional video), auditory (audio explanation), read (protocol in text) and kinetics (simulation teaching). Following the live-streaming demonstration of simulated donning and doffing of PPE techniques, our department designed an intervention phase where students recorded videos of themselves practicing the procedure and uploaded them to the WeChat platform for feedback [24, 25]. The WeChat platform is the most widely used social media in China with multiple functions such as hosting meetings, broadcasting and file sharing. Therefore, it serves as the best accessible digital option. In countries outside China, similar softwares such as Microsoft Team and OneNote can serve as an alternative platform. Compared to the independent study group, residents who participated in the video feedback demonstrated significantly higher competency in proper handling of PPE. We attribute this success to several competency based active learning practices. 1. In the effort to record a successful video, the trainees had to practice repeatedly, which in effect resulted in the meaningful connection between the theoretical knowledge and the practical operation and eventually increased proficiency among trainees . 2. We evaluated their newly acquired skills in details and then reinforced through instructor and peer feedback in a collaborative environment, which eventually led to mastery of those techniques. 3. The repeated asynchronous video feedback mechanism mimics the real-time intervention and guidance students receive in face-to-face training sessions where instructors closely monitor student progress and provide targeted feedback. 4. The independent learning group may have not done the necessary practices as instructed due to the lack of a supervision mechanism. Coincidently, the IL group had higher prevalence of common mistakes compared to the VF group. It is possible that our student were not accustomed to web-based teaching modules and needed more practice in self-directed learning (SDL), which is a learned skill and depends on past learning experiences . Some of best practices in current SDL models employed directed studies, followed by a debriefing phase where students receive feedback and targeted instruction . While we could not rule out the possibility that the VF group may have had higher SDL skills because they made fewer mistakes in the learning phase (Table 3), they still showed further improvement during the final skill assessment, validating the benefits of the video feedback intervention.
Taken together, these active learning strategies led to specific improvement in practical skills but made no difference in gains in conceptual knowledge. For trainees who did not participate in the video feedback intervention, they missed the benefits of applying key concepts to practices and custom feedback to correct mistakes. Therefore, a live streaming demonstration of practical skills followed by self-practices subject to asynchronous but frequent instructor and peer feedbacks serves as a good model to improve students' mastery of clinical skills in online learning. In the meanwhile, we did not observe any difference in the theory and operational scores among the residents across three years, suggesting that prior experience or knowledge provided no advantage. It is likely that handling of PPE is a new skill and therefore its acquisition does not depend on prior clinical skills.
In our questionnaire, we found that most residents who participated in the video feedback intervention felt that the teaching format was friendly and pleasant with enough flexibility. This contrasts with the initial resistance to participate in the video feedback intervention from all participants, suggesting a shift in student’s attitude toward web-based learning as the additional positive outcome from the study. It is also possible that in the initial recruiting process, we did not explicit expectations from participants, which led to confusion or anxiety among them. For instance, we were surprised to learn that the top reason for not participating was the lack of props at home. In retrospect, we should have provided more explanation on how to choose props from household items. Due to the lack of volunteers, we switched to a lottery system while giving participants options to opt-out when their names were drawn. Two first-year residents won the lottery but later refused to participate in the video feedback intervention for fear of performance. Another 11 students were disappointed for not being selected to participate in the video feedback teaching. We feel that the lottery system may have served as a better way to ensure the same baseline of motivation between the two groups because students did not self-select themselves for the experimental group. In order to probe further into student’s experience, we collected written comments from the video feedback groups from whom we received 41 valid suggestions as summarized in the following points.
- The preparation time of recording video is long, which is only suitable for the current severe epidemic period when workload is relatively light.
- The whole process is too long with delayed feedback. Instructors should watch all videos and prepare comments in advance to avoid delaying the training time by typing and sending comments.
- Even though using household items was a creative training method, it does not substitute working with real PPE.
We conclude that in order to achieve desired learning outcomes and ensure quality online learning, especially in mastering clinical skills, the training plan must incorporate practices that simulate the interactive and collaborative learning environment in the face-to-face setting. To do so, we have to implement a mechanism where students take initiatives in their own learning and have the opportunities to practice while receiving immediate feedbacks to guide their learning process. It is also necessary that students reflect on their own learning and provide feedback to instructors, which can be challenging to achieve in the common one-way online teaching methods. However, this pedagogical approach might not benefit students who are uncomfortable for sharing videos of themselves on social media. Lastly, occasional distortions in video recording and web-based demonstration also affect the quality of instruction .