Bullet Screen in Pre-clinical Undergraduate Pharmacology Education: A Survey Study

doi:10.21203/rs.3.rs-1496533/v1

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Bullet Screen in Pre-clinical Undergraduate Pharmacology Education: A Survey Study

https://doi.org/10.21203/rs.3.rs-1496533/v1

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Background The lack of interaction in pharmacology courses, especially in terms of the Coronavirus Disease 2019 (COVID-19) pandemic, has required a fast shift to remote learning at medical schools, causing students to feel anxious and isolated. As a result, new interactive teaching approaches are required to improve pharmacology learning attention and interaction in traditional classrooms or remoting education.

Methods: We introduced the bullet screen into pharmacology teaching. Then, a survey was distributed to first-, second- and third-year pre-clinical undergraduate medical and nursing students at the Shanghai Jiaotong University School of Medicine from November 2020 to March 2022. We evaluated the essential features, instructional effectiveness, and recreational value of bullet screens. Responses to structured and open-ended questions about strengths and weaknesses of the bullet screen and overall reflections were coded and compared between medical and nursing students.

Results: For the essential features, bullet screen has a high degree of acceptability among students, and this novel instructional style conveniently increased the classroom interaction. For instructional effectiveness, bullet screen might inspire students’ in-depth thinking. Meanwhile, students tended to consider bullet-screen comments as a way to express their support rather than to make additional comments or to express their opposition. For the recreational value, the process of using bullet screen was interesting. The lack of idea might lead to the relative differences between medical and nursing students, indicating that guiding the appropriate use of bullet screen is necessary.

Conclusions: The bullet screen may be popularized as an auxiliary teaching approach to promote interaction between teachers and students in the curriculum as well as remote education. It's interesting and beneficial in pharmacology courses, yet there are several aspects that might be improved for popularization.

Pharmacology teaching counts in variable majors, including clinical medicine, nursing, dentistry, pharmacy, etc. In medical education, a thorough understanding of pharmacology is needed for effective pharmacotherapy and prescribing of medication¹. However, pharmacology is really complex, and contains much theoretical knowledge, including the pharmacological mechanism, pharmacological action, clinical application and adverse reaction. Course content is massive and abstract. Medical students themselves identified pharmacology as requiring more attention in their curriculum^2,3. Also in nursing, the pharmacology training has been claimed to be insufficient^4,5. The Coronavirus Disease 2019 (COVID-19) pandemic has disrupted daily teaching activities. The abrupt transition to online course, which lacks of interaction and communication, has been a challenge. Students are inclined to feel more or less alone and disconnected, and this mental obstacle has made remote learning more difficult⁶. Therefore, pharmacology teaching needs higher demands and optimization. In our study, we attempted to introduce bullet screen into the classroom, in order to break down spatial barrier and improve classroom interaction.

Bullet screen is a technology which allows real-time comments from viewers to fly across the screen like bullets. Liked by the post-90s and post-00s to assist the classroom teaching, bullet screen integrates well with students’ subculture context. Low constraint of speech, high immediacy, interaction and thinking collision in the using procedure makes bullet screen suitable for classroom application⁷. When participating in the comments, students will have the illusion of commenting with other audiences at the same time. With the help of WeChat application, the bullet screen can be realized by scanning the Quick-Response code and sending text. Then the real-time bullet screen comments will appear on the top of slides. The privacy of students could also be protected, thus encouraging students to speak actively. Therefore, as an auxiliary teaching tool, bullet screen is simple and convenient, and can improve interaction, thus alleviating the isolation and anxiety caused by online learning.

We used bullet screen as an interactive platform to put entertaining and enlightening questions to medical students, which may be suitable for the bullet screen in pharmacology education. On one hand, we introduced clinical cases into pharmacology education and let students thinking about patient’s condition and rational drug use. On the other hand, we designed questions on the keynotes and error-prone points, for example, the pharmacological mechanisms and adverse reactions. Besides, we guided students to explore the frontiers of knowledge. We also used multiple-choice question as consolidation exercises. To estimate the acceptance among students, their opinions, and the effect of bullet screen on teaching and classroom interaction, we designed this survey study. According to the investigation results, we also proposed recommendations for improvement of bullet screen in pharmacology education.

Study population

This study was conducted at the Shanghai Jiao tong university, School of Medicine. Eligible participants included medical and nursing students enrolled in their first, second or third year as of November 2020 to March 2022. The Ethics Committee of Shanghai Jiao tong university, School of Medicine approved this protocol. We designed a web-based questionnaire with www.wjx.cn. The questionnaire link was shared in the PowerPoint during the classroom. Each receiver chose whether or not to respond to the questions. In the classroom with bullet screen, 310 medical students and 70 nursing students participated. The questionnaire was completed by 127 students, with the data of 16 students being excluded since no bullet screen was used in these students.

Survey design and implementation

We designed a total of 16 questions, and only one correct answer was acceptable. 5 points was assigned for “Strongly agree”, 4 points was assigned for “Agree”, 3 points was assigned for “Neutral”, 2 points was assigned for “Disagree” and 1 point was assigned for “Strongly disagree”. To compute the predicted score for each question, we used the average value. Bullet screens were examined based on their fundamental characteristics, teaching efficacy, and recreational appeal. The Supplementary Appendix File contains the questionnaire contents.

Statistical analyses

Descriptive statistics were generated using the mean and standard deviations or counts/frequencies where appropriate, using IBM SPSS Statistics software (version 22.0; IBM Corp., Armonk, NY, USA). To assess internal consistency reliability for structured/closed-ended survey items graded on the same Likert scale, Cronbach’s alpha calculations were also performed using IBM SPSS Statistics software (version 22.0; IBM Corp., Armonk, NY, USA). The statistical tests and percent stacked bar chart were performed with R 4.1.3 (http://www.r-project.org/).

Ethical considerations

We have taken two primary courses of action to assure that students felt free to share feedback honestly without fear of repercussions. On one hand, this survey was completely anonymous, with no connection of student names or identifying information to responses submitted. On the other hand, the survey was voluntary. Data collectors had no way to know who had completed it or who had not. Students were informed at the time of distribution that the survey was both anonymous and optional. We also informed students that their responses would not be linked to their names or course evaluations.

Between November 2020 and March 2022, 111 students participated in this bullet screen classroom. The Cronbach’s alpha for the survey was 0.85 (95% confidence interval 0.81 to 0.89), and the Kaiser-Meyer-Olkin (KMO) value was 0.81 (P<0.001), indicating that this survey had high validity and reliability. There were 25 male participants (22.52%) and 86 female participants (77.48%). Table 1 illustrates general baseline features. 55 (49.55%) of the 111 students majored in clinical medicine, while 56 (50.45%) majored in nursing. There were 4 (3.60%) first-year students, 81 (72.97%) second-year students, and 26 (23.42%) third-year students among those who responded. 88 students (79.28%) were between the ages of 18 and 20, with the remainder between the ages of 21 and 23.

Table 1 Basic characteristics of participants

	No. of Study Participants	Major in Clinical Medicine	Major in Nursing
Overall	111	55 (49.55%)	56 (50.45%)
Sex
Men	25 (22.52%)	22 (19.82%)	3 (2.70%)
Women	86 (77.48%)	33 (29.73%)	53 (47.75%)
Age groups, y
18-20	88 (79.28%)	32 (28.83%)	56 (50.45%)
21-23	23 (20.72%)	23 (20.72%)	0 (0.0%)
Grade
First-year	4 (3.60%)	4 (3.60%)	0 (0.0%)
Second-year	81 (72.97%)	25 (22.52%)	56 (50.45%)
Third-year	26 (23.42%)	26 (23.42%)	0 (0.0%)

The general consensual benefits of bullet screen classroom

According to the findings of the study, the bullet screen classroom has a high degree of acceptability among 111 pre-clinical students, and this novel instructional style might assist increase classroom interaction (Figure 1). Because of the popularity of bullet screen interaction among Chinese college students, almost all of them (96.40%) believed it was not difficult for them to utilize the bullet screen function in class, and this format was convenient for 92 (82.88%) of them. This approach was useful to the majority of students (86.49%). The interactive procedure enabled by the bullet screen was considered highly fascinating by 98 (88.29%) of students. 85.59% agreed that using a bullet screen may assist increase classroom engagement. 75.68% believe bullet-screen remarks are a useful approach to express themselves in class. Furthermore, 74.77% of students agree that the engagement via the bullet screen might inspire their in-depth thinking in class. All of the above seven traits were averaged out to illustrate the favorable aspects, which were all more than 4 points (Table 2). These results showed that bullet screen has a bright prospect of popularization.

Other nine questions among the 111 students revealed a neutral or negative attitude. 13.51 % of students were concerned about the bullet screen's safety. Even if other students used the bullet screen in the classroom, around 30% of students expressed neutral or negative willingness to use it. For around 32% of students, the contents of the bullet screen were not entertaining nor useful for direct textbook education. More than half of the students had a difficulty in writing relevant bullet screen comments.

Table 2 The overall scores for each question, ranked by scores

Questionnaire	Score (Mean±s.d.)
Not difficult to use	4.63±0.64
Interesting interaction process	4.34±0.68
Improvement in classroom interaction	4.16±0.71
Beneficial to use in class	4.10±0.59
Convenient to participate	4.08±0.79
Way to express one’s opinions	4.08±0.84
Helpful in stimulating one’s thinking	3.98±0.82
Safe to use	3.83±0.99
Willingness to use	3.84±0.93
Trend to follow suit	3.79±1.12
Interesting bullet-screen comments	3.87±0.91
Helpful in acquiring a better understanding	3.91±0.86
Way to express one’s support	3.52±1.01
Needs further improvement	3.3±0.82
Enough ideas to participate	3.28±0.95
Way to express one’s opposition	2.92±1.04
Way to make additional remarks	2.87±1.05

5 points was assigned for “Strongly agree”, 4 points was assigned for “Agree”, 3 points was assigned for “Neutral”, 2 points was assigned for “Disagree” and 1 points was assigned for “Strongly disagree”. We considered the average value to calculate the expected score for each question.

Perspectives on the basic properties of bullet-screen interaction in medical or nursing students.

Our study found that the students majoring in nursing were more reluctant to write bullet-screen comments than those majoring in clinical medicine (3.70±0.89 Vs. 4.09±0.87, P=0.02). In addition, the classroom environment is less active in the nursing specialty. When they notice that other students have written bullet screen comments, less nursing students want to do the same (3.57±1.19 Vs. 4.09±0.91, P=0.01). Although students appreciated using the message board to express themselves, we discovered that students majoring in both nursing and clinical medicine did not have enough ideas to contribute to the bullet screen in class, and students majoring in nursing were even less insightful (Nursing 2.98±0.94 Vs. Clinical medicine 3.51±0.88, P=0.003). According to the results, many students had concerns about the safety issue of the bullet screen (Table 3). This may be attributed to the limited condition of the current bullet screen software, which could not conceal profile pictures.

Table 3 Perspectives on the basic properties of bullet-screen interaction in medical or nursing students.

	Major	Number	Mean ± s.d.	P value
Not difficult to use	Clinical medicine	55	4.76±0.47	0.13
	Nursing	56	4.61±0.59
Convenient to participate	Clinical medicine	55	4.18±0.70	0.12
	Nursing	56	3.95±0.86
Beneficial to use in class	Clinical medicine	55	4.16±0.57	0.20
	Nursing	56	4.02±0.62
Way to express one’s opinions	Clinical medicine	55	4.13±0.88	0.82
	Nursing	56	4.09±0.84
Willingness to use	Clinical medicine	55	4.09±0.87	0.02
	Nursing	56	3.70±0.89
Trend to follow suit	Clinical medicine	55	4.09±0.91	0.01
	Nursing	56	3.57±1.19
Safe to use	Clinical medicine	55	3.84±0.98	0.86
	Nursing	56	3.80±1.00
Enough ideas to participate	Clinical medicine	55	3.51±0.88	0.003
	Nursing	56	2.98±0.94

Perspectives on the education properties of bullet-screen interaction in medical or nursing students.

We then evaluated the value of bullet screen to classroom effect. Almost three fourths (83/111 74.77%) of the students approved that the interaction through the bullet screen could stimulate their in-depth thinking in class. However, among students majored in nursing, the thought-provoking effect was poorer (Nursing 3.80±0.86 Vs. Clinical medicine 4.18±0.70, P=0.01). For general, around 32% of students, the contents of the bullet screen were not useful for direct textbook education (Table 4). Pre-clinical students tended to consider bullet-screen comments as expression of support rather than as a method to make additional comments or to express their opposition.

Table 4 Perspectives on the education properties of bullet-screen interaction in medical or nursing students.

	Major	Number	Mean±s.d.	P value
Helpful in stimulating one’s thinking	Clinical medicine	55	4.18±0.70	0.01
	Nursing	56	3.80±0.86
Helpful in acquiring a better understanding	Clinical medicine	55	4.09±0.82	0.12
	Nursing	56	3.84±0.87
Way to express one’s support	Clinical medicine	55	3.44±1.00	0.61
	Nursing	56	3.54±1.03
Way to make additional remarks	Clinical medicine	55	2.93±1.10	0.54
	Nursing	56	2.80±1.03
Way to express one’s opposition	Clinical medicine	55	2.87±1.02	0.48
	Nursing	56	3.02±1.14

Perspectives on the interactive or entertaining properties of bullet-screen interaction in medical or nursing students.

We also analyzed the entertaining and interactive effects of bullet screen. 98 (88.92%) students found the using process of bullet screen was interesting. However, only 76 (68.47%) students enjoyed the content of the bullet-screen comments. This may be due to the relatively serious classroom atmosphere. Also, students’ lack of idea about course content could also lead to the monotonous bullet-screen content. The effect to improve classroom interaction was better among students majored in clinical medicine (4.33±0.67) than those majored in nursing (3.93±0.71) (P=0.003) (Table 5).

Table 5 Perspectives on the interactive or entertaining properties of bullet-screen interaction in medical or nursing students.

	Major	Number	Mean±s.d.	P value
Interesting interaction process	Clinical medicine	55	4.36±0.75	0.96
	Nursing	56	4.36±0.62
Improvement in classroom interaction	Clinical medicine	55	4.33±0.67	0.003
	Nursing	56	3.93±0.71
Interesting bullet-screen comments	Clinical medicine	55	3.95±0.99	0.37
	Nursing	56	3.79±0.89

Students in pharmaceutical education have accustomed to passive knowledge transfer, making it difficult to arouse the motivation for issue analysis and real-time participation. Furthermore, the COVID-19 outbreak presents additional challenges for educators⁸. In the case of students, a lack of sufficient planning, monitoring, and communication may lead to a reduction in motivation to learn at home⁹. The involving of active teaching styles with collaborative learning can carry out the excitement of idea collision and be capable of integrating students' cultural settings¹⁰. At the same time, the great majority of Chinese college students prefer watching films with bullet-screen remarks because of their subculture context, minimal limitation, high immediacy, and, most importantly, "social viewing" characteristic¹¹. Young people feel that the bullet screen will assist them in achieving self-expression and self-identification. These characteristics of bullet screen correspond well to the needs of educational reform, but it has seldom been applied to the educational field. Therefore, we supposed that, by using the bullet screen pursued by the post-90s and post-00s to assist the classroom teaching, students could be better liberated from the serious and restrained traditional classroom atmosphere, and the classroom interaction could be greatly improved.

In this study, 111 pre-clinical students used the bullet screen classroom. 55 of them majored in clinical medicine, while the remaining 56 majored in nursing. In medical education, we evaluated the essential features, instructional effectiveness, and recreational value of bullet screens. We also investigated how specialties influenced the variable characteristics. Our investigation results preliminarily verified the role of bullet screen in medical education. In accord with the Chinese social investigation, students found the interactive process realized by the bullet screen really interesting (4.34±0.68). They can immediately express their opinions of theoretical learning through this interaction (4.08±0.84). Thus, the bullet screen could indeed improve classroom interaction (4.16±0.71) and stimulate students’ in-depth thinking (3.91±0.86). However, the interaction was far from enough. Students still had not enough idea to participate and their critical thinking ability needs further exercise. Besides, students majored in nursing have even less subjective initiative. These phenomena informed teachers that, more elaborate course design is needed to further arouse students’ enthusiasm and thinking. Overall, we determined that the bullet screen classroom was well-liked by students and had a positive impact on improving classroom engagement and encouraging students' self-expression. In view of all these benefits and high acceptance, we considered that the bullet screen could be popularized to a wider range of occasions. We've also identified possible improvement paths for better integrating this technology into classroom teaching.

The specific application of bullet screen in pharmacology education

Learning requires chances for practice and discovery, as well as time to reflect "in your brain" and communicate with others¹². A series of appropriate interaction questions may lead to students being involved with the issue, giving them enough time to think and communicate, which has a direct impact on the quality of the outcomes. Turning theory into practice, we have explored several interactive modes and cases, which may be suitable for the bullet screen in pharmacology education. First, to introduce the topic and arouse students' attention, teachers might ask some pre-planned short yes or no questions at the start of class. For example, to keep on a diet or to develop diabetes (hypoglycemic drugs), to enforce healthy routine or to suffer heart failure (anti-heart failure drugs), to keep slim or to save live (glucocorticoids). The open discussion can immediately catch students’ eyes and stimulate their enthusiasm to participate in the classroom. Second, during the class, clinical cases could be used, and teachers can ask some questions on this case, for example, whether the patient is seriously ill, whether he/she needs certain medication, whether the medication is rational according to the condition. Under the circumstances, bullet screen can allow student to think independently and each air his own views without worrying about others’ judgement. Third, after explaining the keynote and difficulty of variable mechanisms and adverse reaction, for example, the medication time of glucocorticoid, the effect of digoxin on the myocardium oxygen consumption, teachers can use bullet screen to checkout students’ mastery degree. Teachers can better recognize students' thinking modes and misunderstandings of specific problems by viewing real-time bullet screen replies, allowing them to change their interpretation to help students acquire the knowledge. Finally, at the end of the class, teachers can post enlightening questions, so that students could further approach the topic. For example, how to improve the application of insulin, whether the application of angiotensin-converting enzyme inhibitors would influence the prognosis of COVID-19 infection, whether heart transplantation of pig could solve the problem of end-stage heart failure. Bullet screen is beneficial for this brainstorm, through which students’ divergent thinking capacity could be trained. Besides, bullet screen allows students to wake up their cognition and cause resonance. Also, some conventional multiple-choice question can be posted to review the course content.

With the help of bullet screen, students can get rid of the constraint of traditional speech pattern, and teachers can give feedback in time. Thus, teaching and learning can come into a virtuous cycle of interaction.

Current problems and room for improvement of bullet-screen classroom

Firstly, although introducing the bullet screen into classroom could improve classroom interaction, we found that the interaction was still insufficient. Students’ in-depth thinking could be stimulated by using bullet screen, but it needs teachers’ excellent guidance and question-and-answer design. Therefore, teachers should not only expand the scope of knowledge reserve, but also adjust to changing circumstances. At the other extreme, if teachers let students release their own ideas with abandon, the teaching rhythm will be seriously disturbed and the teaching objectives could not be achieved. Hence, teachers should also properly grasp the use limit of bullet screen. In a word, the bullet-screen classroom will demand more from teachers, but the following great influences deserve it.

Secondly, this classroom mode has its scope of application. It is not suitable for the course containing numerous theoretical knowledge, which needs elaborate explanation and leaves little divergent thinking. But in flipped classroom or a massive open online course (MOOC), the bullet screen may play a more important role. Students could explore, supplement, criticize, etc. by themselves¹³. Also, we found that, in the courses containing more plot, unknown and exploration, for example, those concerning drug design and development, the bullet screen could inspire students’ creativity to the maximum and thus help them to explore the unknown. It remains to be seen if the bullet screen will be better appropriate for these new classroom formats in pharmaceutical education.

Besides, the bullet-screen software should make some adjustments. Young people enjoy the anonymity feature of traditional bullet screens, so that they carry few consequences, and people feel free to express themselves without having to worry about judgment. But the current bullet screen software used in classroom could not hide the profile picture when showing comments. This point has troubled many students, as they have social phobia to be recognized when making comments. In addition, the operation procedure should be optimized to be more convenient.

Limitations

There are some limitations to consider when interpreting these results. First, this study is a single-center analysis, which will limit broader generalizability to other institutions. Since Shanghai Jiao tong University School of Medicine is one of the best medical college in China, whether the bullet screen could also work well in an inferior college remains to be discussed. Second, the sample size was not large enough and therefore we could not analyze students’ perception by age, gender, grade, etc. We only analyzed the differences based on their specialty. This limits our ability to understand the potential effects in different student population. Finally, we focused solely on students’ experience, but paid little attention to teachers’ opinion. Bullet screen is popular among young people, whether older teachers could accept and adapt to this mode needs further research. Teachers are the orienteer of the classroom. It needs further investigation of teachers’ evaluation to better improve this model of teaching.

We applied the bullet screen technology to the pharmacology education and evaluated its influence in several aspects. Bullet screen was well received by students, and could conveniently increase the classroom interaction. For instructional effectiveness, bullet screen might inspire students’ in-depth thinking. For the recreational value, the process of using bullet screen was interesting. The lack of idea might lead to the relative differences between medical and nursing students, which reminded us of better classroom guidance and the appropriate use of bullet screen. Thus, the bullet screen may be popularized as an auxiliary teaching approach to promote interaction in the curriculum as well as in remote education.

Acknowledgements

The authors are grateful to the participants and the fundings that supported this study.

Authors’ contributions

G.J contributed to the study design; Y.X.C contributed to the analysis of the data; G.J. and Y.X.C. wrote the paper. Q.H., Y.Q. and J.L. contributed to the data collection; L.Z., W.H. and X.L.G. provided help for the study. All authors read and approved the final manuscript.

Funding

This work was supported by the National Natural Science Foundation of China (grant numbers

82171358, 81973272, 92068111), Shanghai Science and Technology Committee (19410710100, 21XD1422200)

Availability of Data and Materials

The datasets used and analyzed during this study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines. The Ethics Committee of Shanghai Jiao tong university, School of Medicine approved this protocol. Documentation of informed consent was secured at the beginning of the survey. Students were informed the survey was both anonymous and optional.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Bullet Screen in Pre-clinical Undergraduate Pharmacology Education: A Survey Study

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