Remote delivery of post-graduate allied health professional prescribing education: A survey of the student experience

doi:10.21203/rs.3.rs-4278186/v1

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Research Article

Remote delivery of post-graduate allied health professional prescribing education: A survey of the student experience

https://doi.org/10.21203/rs.3.rs-4278186/v1

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The COVID-19 pandemic resulted in a rapid transition of many educational courses to an online delivery model which has not been fully investigated in relation to the student experience. The aim of this study was to explore the learning experience of postgraduate allied health professionals enrolled on an online prescribing programme at an institution within Northern Ireland. A mixed methods cross-sectional survey of postgraduate AHP prescribing students who had undertaken online learning and assessment during the COVID-19 pandemic was carried out. The survey was distributed to 120 students with 51 responses received resulting in a response rate of 42.5%.

There was no statistically significant relationship identified between previous student experience of online learning and overall satisfaction with the current postgraduate programme. Thematic analysis revealed that 82% of respondents described their experience as excellent or very good. Flexibility was highlighted as key factor in student satisfaction allowing materials to be rewatched at preferred times. 80% of respondents answered that they preferred the flipped approach versus live synchronous activities and thematic analysis highlighted that this enhanced the student learning experience. However, a strong theme of social isolation emerged as a significant inhibitor in relation to the student experience and needs to be addressed in future online post-graduate programme delivery.

Online Prescribing Education

AHP’s

remote delivery

student experience

In the United Kingdom (UK), non-medical prescribing (NMP) was introduced as part of the National Health Service (NHS) plans which intended to improve and modernise the health care system [1]. This has resulted in the extension of prescribing rights to nurses, pharmacists, and allied health professionals (AHP’s) such as physiotherapists, podiatrists, radiographers, paramedics, and dieticians. Within the UK AHP’s with appropriate training can prescribe via independent prescribing (IP) or supplementary prescribing (SP) mechanisms. Within Northern Ireland (NI) AHP’s can complete a Post Graduate Certificate in Medicines Management to become annotated as IP’s or SP’s dependent upon their profession’s prescribing rights.

In light of the COVID-19 pandemic, many higher education institutions (HEI’s) rapidly adopted Technology Enhanced Learning (TEL) strategies to deliver educational content online with varying success [2]. TEL has also been highlighted as a potential part of staff development and could elicit skills to promote critical thinking with independent decision-making which is particularly pertinent in healthcare education [3]. A key challenge in moving the course online is to maintain the objective of constructive alignment [4] by ensuring the teaching and assessment methods utilised continue to meet the desired learning outcomes of the course. Whilst it is imperative to continue to meet the desired learning outcomes for online courses the student experience should be a key consideration in the transition to an online pedagogy [5].

There is also a potential benefit for students moving from the traditional classroom to online delivery with many similarities to contemporary clinical practice which has embraced remote consultations [6]. Indeed, remote consultations have been of particular importance during the COVID-19 pandemic to minimise face to face interactions and disease transmission. Online delivery aligns with the modernisation of services such as the Transforming Your Care (TYC) reform program with the goal of meeting the growing demand being placed upon services within healthcare. Previous feedback from students on this course has identified work force challenges and the need to have flexibility with regards the course delivery. This fact has also been highlighted at stakeholder events with NHS trust managers who have cited challenges releasing staff for the required number of days during the academic year. This in line with research in the area which identified that releasing staff to attend external continuing professional development events was a challenge for managers [7].

There are key challenges to online delivery with a systematic review by Regmie et al. [8] highlighting the importance of several factors related to e-learning namely considering learner’s motivations and expectations as well as utilising user-friendly technology and putting learners at the centre of pedagogy. There is a need to consider the preferred pedagogical approach from the student perspective with flipped learning representing an ongoing paradigmatic shift to learning-centred instructional strategies [9]. The same authors highlight that whilst the flipped classroom is an exciting development in health professions education there is a need for further evaluation to optimise outcomes. It has also been outlined that along with instructional support, teachers also need to provide technical and pedagogical assistance in TEL environments [10]. This is a particularly important point when considering online assessment of students as there is a need for students to be technologically competent. It might be assumed that students who have completed prior online learning (OL) would have an improved student experience and research has found that students with previous OL experience tended to have more effective learning strategies and higher levels of motivation [11]. Students returning to postgraduate study may have excellent clinical skills but there is often a considerable gap between periods of study [12] and can lack confidence with low expectations of their academic ability [13]. The review by Regmie et al. [8] concluded that there is significant scope for better understanding of the issues related to enablers and facilitators associated with e-learning, and developing appropriate policies and initiatives to establish when, how and where they fit best, creating a broader framework for making e-learning effective.

Study Aims

The aim of this study was to utilise a survey of AHP prescribing students to:

Explore the student experience around the online delivery and assessment of a post-graduate prescribing program and to understand barriers and facilitators to improve the student experience.

To determine if there is a relationship between previous student experience of OL and overall satisfaction with online delivery.

Study Design

The study involved a retrospective cross-sectional online survey exploring student experience around the online delivery and assessment of the PG Cert Medicines Management program at an institution in NI. Students who had completed or were in the process of completing the PG Cert Medicines Management program since its transition to an online delivery format were surveyed.

Sample

Recruitment took place through the dissemination of study information via email to students who had participated on the program during the COVID-19 pandemic. Retrospective analysis of students enrolled on the course program identified a purposive sample of 120 students. A participant information sheet (PIS) and a link to a JISC survey were provided for participants to complete the survey. The survey was open for a 1-month period with an email reminder after 2 weeks to encourage participation and therefore attempt to increase response rates.

Survey Inclusion Criteria

Participants who met the following criteria were emailed the JISC survey:

AHP (dieticians, paramedics, physiotherapists, podiatrists, or radiographers) students who had completed a module within the PG Cert Medicines management during the COVID-19 pandemic.
Students who completed the online teaching and assessment were applicable.

Survey Exclusion Criteria

Students who discontinued the course during the semester and had not completed the online teaching days or modular assessment.

Ethics

Ethical approval was obtained from University Nursing and Health Research Ethics Filter Committee (FCNUR-22-016-A) and was carried out in accordance of the ethical standards laid down in the 1964 Declaration of Helsinki. The principal ethical issues identified were consent and anonymity. Survey consent was requested at the start of the JISC survey, and it was mandatory for participants to provide consent before commencing the survey. All the survey responses provided were anonymous and no personal identifiable information was collected.

Survey Format

Clear and concise research questions informed the development of the survey. There was no survey available that met the needs of the study aims and therefore the questions were designed independently by the chief investigator (CI) and then reviewed by an academic colleague with experience in mixed-methods surveys. The survey was piloted on 5 students to assess its validity and data gathered from the pilot was pooled in the final analysis as no methodological changes were made after completion of the pilot. The survey, consisting of 15 questions, was available in digital format only and was provided via the JISC survey tool. The survey utilised a combination of open and closed questions to gather quantitative and qualitative data regarding the student experience for analysis. The survey also gathered general information such as profession, number of years since achieving primary qualification and highest academic qualification achieved prior to commencing the course.

Data Analysis

Once the 1-month survey period was complete quantitative data was exported from the JISC survey to SPSS Version 25 for analysis. Descriptive statistics were utilised to analyse the responses. Further Thematic analysis [14] of the qualitative responses occurred to understand the student experience and ascertain barriers and facilitators. An independent sample t-test was utilised to compare satisfaction scores with previous experience of OL with p < 0.05 being considered statistically significant. Cross-tabulation was utilised to determine if there was a relationship between student experience and the number of years since achieving primary qualification.

The survey was distributed to 120 students and 51 responses were received with a response rate of 42.5%.

AHP Background

In terms of profession specific responses, 74% of the responses received were from physiotherapists, 20% were from dieticians, 4% were from podiatrists and 2% were from paramedics. Students attending the course must be at least 5 years qualified as a pre-requisite for enrolment and the median number of years qualified was 16.7 years. Regarding experience of OL 63% respondents answered that they had previous experience.

Student Experience

In terms of the utilisation of a remote delivery model for the course 90% of respondents felt that this was suitable and overall student experience was positive (Fig. 1) with 82% respondents describing their experience as excellent or good. Mean overall student experience was calculated at 4.04/5 (SD = 0.72, Variance = 0.52)

AHP student experience of OL during COVID-19 pandemic

Despite the positive findings 10% respondents felt that they would prefer the course to be face to face. Thematic analysis of the student feedback for those respondents that preferred face to face delivery identified a strong theme of social isolation and challenges with more complex areas within the course such as pharmacology and drug calculations.

I think ideally it should be blended allowing attendance virtually and face to face. Exclusive virtual learning missed the opportunity of networking with fellow students and learning from one another.

I felt it made me feel isolated and thought drug calculations would have been easier face to face. A hybrid model of online with occasional face to face delivery would be beneficial in providing peer support.

80% of respondents felt that their learning experience was not negatively affected by the transition to OL and many students highlighted positive experiences particularly around being able to rewatch recorded materials.

I would argue my learning was positively impacted. I was able to accurately review material and understand the course in much greater depth.

As a lot of the information was very detailed, it was great to be able to rewind and play again to gain an understanding and then when it came to exams, it was also very beneficial.

Other positive impacts outlined related to reducing travel times and supporting caring responsibilities.

Living 2 hrs away from university- having online learning meant that I saved 36hrs travel time and avoided the 7am leaving home to make university for 9.30 lectures.

I was lucky to still be able to do my second week of lectures as I had covid and was isolating but could still partake at home.

Had to do school pickups and online delivery allowed flexibility and me to watch lectures at a later time if required.

20% of respondents outlined negative impacts upon their learning. This was reflected in the emerging themes of social isolation and a lack of networking as having an impact on the learning experience.

Networking and peer support aspect was negatively impacted.

I felt it made me feel isolated and unsupported by being delivered online however I feel a hybrid model with occasional face to face delivery would be beneficial in providing peer support.

Student experience and previous online experience

Within the survey 63% of respondents answered that they had experience with OL and had a mean satisfaction of 3.97/5 (+- 0.73). 27% of respondents stated they had no experience of OL and had a mean satisfaction of 4.2/5 (+- 0.6). An independent sample t-test was utilised to compare satisfaction scores with previous experience of OL and there was no significant difference between the mean satisfaction scores (t = 1.5099 and < critical value of 1.677)

Cross tabulation was utilised to determine if there was any relationship between years since receiving primary qualification and average satisfaction. Students who had qualified 5–10 years had the highest mean satisfaction at 4.42/ 5 (+- 0.79) and students who had qualified greater than 20 years had the lowest mean satisfaction at 3.82/ 5 (+- 0.83) indicating a trend towards lower mean satisfaction in respondents who had qualified longer. Despite this the difference in mean satisfaction scores was deemed not to reach statistical significance (p = 0.47), Chi-square = 8.901.

Synchronous learning activities versus flipped learning

80% of respondents answered that they preferred the flipped approach versus live synchronous activities. Thematic analysis of responses identified a common theme that flipped learning was the favoured approach and enhanced the learning experience.

The most useful method employed was watching a pre-recorded lecture and meeting with the tutor at periods throughout the session to discuss e.g. complete section and return to the virtual classroom to discuss. This meant I was able to rewind and pause parts that i was unsure of and able to ask 'live' questions in real time.

“Due to the nature of the pandemic and having fewer childcare options, it was helpful to have recorded lectures if you missed anything.

Online Assessment

Participants were questioned whether they felt summative online assessment for the program was appropriate and 41 (80%) responded that they felt this was the case. A student theme of online assessments being less stressful was identified.

Found online assessment less stressful than attending exam in person.

I thought it worked well and felt a little less stressful than in person exams.

I think this method of assessment achieved the goals of the course better than previous methods. When speaking with colleagues who completed the course prior to Covid we felt this method was better for understanding and synthesising literature than other forms of learning that are easily forgotten.

Despite this 4% of respondents felt that summative online assessment was not appropriate, and 16% of respondents were unsure regarding its suitability.

I found the technology aspect and the fact the exam was done at home added an additional level of stress, however it was stressful to complete exams after such a long gap since my undergraduate degree also.

Was very anxious and nervous that the technology would work. Initially we had some teething problems with Trust computers and blackboard collaborate access.

Facilitators

Students were asked how their online experience could have been improved and asked to rank factors in order of most to least important. The factors identified as most important are outlined in Fig. 2.

Most Important factor to improve student experience

Thematic analysis of the responses in the “other” category highlighted a desire for at least 1 face to face induction session as well as more specific professional support groups.

Within this survey student experience of OL and assessment was broadly positive with added flexibility and rewatching pertinent materials as a key factor for students. This is consistent with a study by Dost et al.[15] which highlighted added flexibility as a benefit for students to digest information in their own time but also allows the students to then discuss this constructively with their peers. Less travel time was also a theme highlighted within the thematic analysis and a systematic review by Elshami et al. 16] concluded that the use of electronic learning in health science education can improve learner’s level of knowledge and performance by making learning resources accessible regardless of geographical location. An added advantage of OL is that this can make a valuable contribution regarding education for sustainable development and sustainable lifestyles which is one of the most important goals and targets of the United Nations Sustainable Development goals for 2030 [17]. This is a key consideration for many HEI’s and in the context of NI many health professionals would be considered rurally based, making attendance at courses less viable, the use of OL may enhance access and as highlighted by some respondents this was a clear advantage.

Despite the benefits described, consistent with research in the area OL can be viewed by some students as isolating when compared with traditional learning methods due to feelings of a lack of social connections [18]. Social isolation was consistently highlighted within the thematic analysis of survey responses and regarding improving the student experience with 37% of students identifying improved networking as the most important factor. A number of responses indicated that students would prefer a hybrid option to improve social integration and improve their learning experience. A systematic review by Jamaludin and Osman [19] concluded that blended learning demonstrated consistently better effects on knowledge outcomes when compared with traditional learning in health education though further research is required to confirm these results and to explore the utility of different design variants of blended learning. In the context of post-graduate healthcare education this would be an area where further research is warranted with consideration of courses teaching manual techniques.

As highlighted within the results 80% of respondents preferred the flipped classroom. The flipped classroom can enhance student engagement by promoting active learning during activities [19] whilst some of the control is shifted from the teacher to the learner and as such encompasses modes of collaborative learning, cooperative learning, and problem-based learning [20]. This is further highlighted by other research which states that today’s health professions educators should develop learners’ skills at the higher levels of Bloom’s solo taxonomy that require demonstration of deeper cognitive processing such as critical thinking and evaluative judgments, therefore ensuring effective and safe prescribing [21]. A study by Khalil et al. [22] discussed the failure of the OL environment to address the needs of courses that require hands-on practice. However, the nature of the postgraduate prescribing course negates this need as students achieve practical experience with medical practitioners in clinical practice. In other healthcare related courses this delivery model may not be applicable therefore making extrapolation of the results difficult and as discussed earlier further research is warranted in this area.

Consistent with previous research by Elshami et al. [16] within the study there was no relationship between previous experience of OL and reported student experience. Interestingly the mean satisfaction score was higher for students who had no experience of OL however this did not reach statistical significance and it is also important to note that the previous level of experience of OL was not ascertained. Further thematic analysis of the study data also indicated that there was no link between perceived competency with technology and overall satisfaction with OL and assessment. This is inconsistent with research by Vermisli et al. [23] which found that student satisfaction was high amongst students who had increased digital literacy though it is important to note this can be difficult to measure and various tools have been proposed. The lack of link between perceived competency with technology and overall satisfaction slightly contradicts the fact that in terms of facilitating an improved student experience of OL there was a theme relating to technology understanding, improved wi-fi and improved information technology (IT) skills. A study by Kumpikaitė-Valiūnienė et al. [24] support the importance of digital competence on perceived stress, burnout and well-being among students studying online during the COVID-19 lockdown. Whilst this survey did not gather respondent age there was a trend towards lower mean satisfaction scores in healthcare students who had received their primary qualification longer. A study by Sandars et al. [25] that surveyed 100 doctors about choice and approach to learning found younger doctors who were high users of technology and more recently graduated appeared to have a deeper approach to learning with web-based approaches. An important consideration regarding technological competency relates to online assessment. Thematic analysis of student responses who felt online assessment was not appropriate identified technological concerns as a key issue. There is therefore a need to ensure digital literacy, ensure students understand the institutional technology utilised and provide additional IT support as required to maximise the student OL experience.

Strengths and Limitations

Whilst the results are positive with regards the post-graduate prescribing learning experience for AHP’s it may be difficult to generalise the results to other student groups both inside and outside NI as the study only ascertains the experience of students on one course at one university. Survey response rates are highly variable within the literature and whether a survey response rate of 42.5% minimises non-response bias is debatable. The small sample size of 51 respondents is also a limiting factor. Given the fact that the CI is also part of the lecturing staff delivering on the program and that not all students had completed the program there is also a risk of response bias. Whilst no statistically significant relationship was found between experience of OL learning and student satisfaction it is important to note that the level of experience of participants was not ascertained. Given the study was retrospective in nature there is also a risk of recall bias. The study findings however are consistent with other research in the area and does add knowledge in terms of the post graduate AHP student experience.

The utilisation of OL and assessment was suitable in the context of delivery of this postgraduate prescribing course with 82% of students describing their experience as excellent or very good. In terms of delivery, students preferred the flipped classroom with 80% of respondents highlighting preference for this approach. Students enjoyed the benefits of being able to re-watch complex materials and appreciated the benefits of added flexibility and reduced travel time. Despite the benefits, social isolation was identified as a key barrier and analysis highlighted a trend of desire for hybrid learning with improved socialisation being the most important factor identified by students in improving experience. There was no significant difference between students with prior OL learning and those who did not in terms of satisfaction with the course. bias. Further larger scale studies relating to post-graduate healthcare education and OL would be beneficial to further enhance the student learning experience.

Ethical Approval: Ulster University Research Governance Filter Committee, category A research [23/3/2022] Reference: FCNUR-22-016-A

Declaration of conflicting interest: The author(s) can confirm that there are no conflicts of interest.

Funding: The research received no grant from any funding agency in the public, commercial or not-for-profit sectors.

Data Availability: The data that support the findings of the study are available within the article and are also held in a JISC repository.

Code Availability: Not applicable

Author Contributions: Not applicable

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No competing interests reported.

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Remote delivery of post-graduate allied health professional prescribing education: A survey of the student experience

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Abstract

Figures

Background

Study Aims

Materials and Methods

Study Design

Sample

Survey Format

Data Analysis

Results

AHP Background

Student Experience

Student experience and previous online experience

Synchronous learning activities versus flipped learning

Online Assessment

Facilitators

Discussion

Strengths and Limitations

Conclusion

Declarations

References

Additional Declarations

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