Aim of the study
The overall aim of the study was to evaluate the effectiveness of EthAKUL and determine the feasibility for curriculum-wide adoption. Specifically, the study focused on determining changes in learners’ knowledge of bioethics and attitudes towards m-Learning at the end of the intervention and exploring participants’ experiences of using EthAKUL focusing on the benefits and challenges of using m-JiTL approach for teaching bioethics.
Design
The study used intervention mixed methods design [19, 20] where qualitative data were collected through focus group discussions, discussion logs, responses to open-ended questions about experiences, and quantitative data were collected through pre-and post-questionnaire and knowledge tests. All three authors were participant-researchers in the intervention with KG also serving as a facilitator. Mixed methods design was used to combine the quantitative data and qualitative in-depth analysis to establish a comprehensive understanding through data triangulation. Integration of methods occurred at the design (i.e., intervention mixed methods), method (i.e., embedding) and at the interpretation and reporting (i.e., narrative) levels.
Intervention
Bioethics teaching is an integral part of the medical and nursing education at the private university in Pakistan where the m-JiTL intervention for teaching bioethics was implemented. The details of the design phase are reported elsewhere. [18] During the intervention phase, the m-JiTL environment, called EthAKUL, was used with medical and nursing students and trainees to engage learners in exploring real-life ethical dilemmas as a part of m-JiTL approach. The pedagogical approach was asynchronous discussions allowing learners to access the content and participate in discussions in their own time, which is especially important for healthcare professionals with demanding or inflexible schedules.
EthAKUL is password-protected, available for iOS and Android operating systems with the following features (Fig. 1):
After the recruitment of participants, four workshops of 1.5 hours each were organised to introduce EthAKUL and to collect pre-intervention data. Depending on their availability, learners attended one of four workshops in which they were introduced to the project’s aim and duration. Informed consent was taken; consenting learners downloaded EthAKUL and completed the pre-intervention data collection tools.
One orientation workshop was organised for the facilitators, where they were introduced to the research study, their role as facilitators, and the theory and practice of m-JiTL. Informed consent was obtained. An on-call schedule was devised to facilitate discussions. Each facilitator was randomly partnered with another, resulting in 8 pairs of facilitators responsible for facilitating asynchronous discussions.
At the outset of the intervention, an introduction email was sent to all learners, encouraging them to submit their ethical dilemmas on the "Let's Talk" forum. At the end of each week, an email was sent to all learners outlining the issues that had been discussed and a reminder to post further ethical dilemmas. A facilitators’ WhatsApp group was formed to assist administrative and IT-related concerns. The discussions took place in English, which is the medium of instruction at the university. During November 2018- February 2019, the learners posted ethical issues/dilemmas on the “Let’s Talk” forum and the faculty members facilitated the discussion.
Participants and setting
Undergraduate and postgraduate medical and nursing students, residents, and practising nurses were invited to join the study. The inclusion criteria included participants who: 1) owned a smartphone, 2) could converse in English, and 3) were willing to join the study voluntarily. The study enrolled 67 learners from diverse specialities who matched the inclusion criteria. A total of 26 faculty members were invited based on their interest in teaching bioethics in their departments. Sixteen, including the research team, agreed to join as facilitators. They were from various specialties, such as internal medicine (n = 3), basic sciences (n = 1), psychiatry (n = 1), surgery (n = 3), emergency medicine (n = 1), community health sciences (n = 2), paediatrics (n = 1), oncology (n = 1), nursing (n = 2), and obstetrics and gynaecology (n = 1). Students have been referred to as learners throughout this paper, and faculty members have been referred to as facilitators.
Data collection
The data were collected during three stages, i.e., pre-intervention, during-intervention, and post-intervention (Fig. 2).
Questionnaire
For the pre-and post-intervention, a questionnaire was administered using Google forms to collect data on learners' experiences with and attitudes about m-learning. The questionnaire had two sections. Section A featured eight questions concerning socio-demographics (name, gender, English language fluency), and learners’ year and programme of study. Section B included eight questions on past experiences with utilising mobile devices for study purposes, smartphone ownership, and perceptions about the reliability of information obtained via mobile devices adapted from [21] and a 19-item attitudinal scale to assess learners' views about m-learning based on [22]. The two instruments were selected because of their relevance to the present study’s context. 04 items were included in the post-intervention questionnaire to assess learners' experiences during the intervention. Cronbach alpha scores for pre-intervention (0.935) and post-intervention (0.909) for the attitude scale (19 items) suggest that the scale's internal consistency was high [23]. The learners completed the pre-intervention questionnaire during the orientation workshops. The link to the post-intervention survey was emailed to all learners one week after the intervention ended, so they may complete it at their leisure.
Knowledge Tests
A knowledge test was designed and administered before and after the intervention to assess changes in learners’ knowledge of bioethics. EthAKUL contained modules on seven topics: medical error, conflict of interest, confidentiality, consent taking, resource allocation, harassment, and effective communication skills. The test included 21 items with three questions on each topic. The learners completed the pre-test during the orientation workshops, whereas the post-test link was emailed one week after the intervention had ended.
Discussion logs
After the end of the intervention, the research team met and discussed the logs of the discussions in the “Let’s Talk” forum. Discussion posts were saved on the server from where they were copied and pasted on a word file for analysis purposes.
Focus Group Discussions (FGDs)
In the 10th week of the intervention, 15 learners participated in an hour-long FGD geared towards understanding the learners’ experiences of using EthAKUL. At the end of the intervention, two ~ 50 minutes FGDs were organised with the facilitators to obtain their views on the intervention. The FGDs were attended by 10 facilitators and were audio-recorded with permission.
Document review
Five research team meetings were held during the intervention, and the meeting notes were analysed as a part of the document review to explore how EthAKUL can be used in the future.
Data analysis and statistical methods
All the numerical data were analysed using SPSS version 19. The descriptive analysis was done by calculating frequencies and means, and a paired sample T-test was used to determine the difference between pre and post-tests and survey results. The qualitative data were reviewed, and a coding scheme was generated by two team members independently, followed by a discussion to agree on common themes. Data were anonymised and learners’ qualitative responses are represented as roles followed by gender (e.g., practising_nurse, female). The facilitators’ qualitative responses are represented as “F” followed by number and gender (e.g., F0, male). The convergence of qualitative and quantitative data strengthened the analysis and study conclusions. The quantitative analysis provided data driven insights into pre-and-post experiences, while qualitative data provided deeper insights into the experiences during the intervention.
Ethical considerations
Ethical approval was granted by the Aga Khan University’s Ethics Review Committee. All participants were given written information about the study, and they gave written informed consent before joining the study. All methods were performed in accordance with the relevant guidelines and regulations. Data were anonymized and stored in secure location.