Challenging Pedagogical Styles of Teaching: Amalgamating Blended Learning with Near-peer Teaching for Integrated Structured Clinical Examination (ISCE) Preparation

doi:10.21203/rs.3.rs-2688015/v1

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Research Article

Challenging Pedagogical Styles of Teaching: Amalgamating Blended Learning with Near-peer Teaching for Integrated Structured Clinical Examination (ISCE) Preparation

https://doi.org/10.21203/rs.3.rs-2688015/v1

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Introduction

Near-peer blended learning is a method of combining online virtual teaching with traditional face-to-face lectures delivered by senior students. In this study, we wanted to evaluate the student perceptions of this novel method of education and characterise its overall effectiveness.

Methods

A hybrid Integrated Science and Clinical Examination (ISCE) revision session was hosted simultaneously in-person and online. The session was delivered by fourth-year medical students to over 100 second-year medical students. A survey was sent to students prior to the session to deduce the topics they required most help in. Feedback forms evaluated students’ confidence, satisfaction with the format of the session, and overall student engagement using blended learning with free text responses which recorded individual opinions of students. Tutor perceptions were also obtained using feedback forms that assessed knowledge, confidence, whether they would attend, and teach a hybrid event in the future and their personal preferences on teaching styles.

Results

The results showed that students had a much better understanding of the content after the session and the format was deemed well-suited for delivering ISCE teaching (p = 0.001). Thematic analysis revealed students preferred a hybrid approach for ISCE teaching considering it catered to a wider audience. Live demonstrations that are not well executed in virtual formats are compensated for with in-person teaching. 96% of participants expressed that the material was aimed at their level due to relatability achieved through near-peer teaching. Three of the four tutors preferred a hybrid method of teaching while one preferred a sole online model. An overall increase in tutors’ knowledge and confidence was seen after the session.

Conclusion

Overall positive feedback provides evidence that blended learning using near-peer teaching should be utilised by educational institutions with the potential of revolutionising the delivery of medical education in this post-pandemic.

Near-Peer

Pedagogical

Medical Education

Clinical Assessment

OSCEs

Blended Learning

The COVID-19 pandemic has revolutionised the delivery of medical education. Due to lack of patient exposure, medical schools began integrating blended learning into their curriculum (1). At Cardiff University, the foundation of medical teaching is through case-based learning; a system that amalgamates pre-clinical knowledge with patient scenarios (2). At the end of second year and fourth year of medical school, students are required to sit an Integrated Structured Clinical Examination (ISCE) which tests basic history taking and clinical skills (3). Due to the pandemic, traditional face-to-face ISCE teaching was not available thus learning demands were not being met. Students started supplementing their learning with near-peer, blended teaching alongside lectures (4). This led to the creation of OSCEazy, an online teaching platform that revolves around ISCE teaching created by medical students. Medical education platforms, such as OSCEazy, aim to summarise prior knowledge with a particular focus on concepts that are commonly tested in examinations. This can be delivered either online, face-to-face or through using a hybrid approach that caters to a wider audience. Teaching conducted by these organisations relies on a near-peer tutoring model. The teacher explores recently learnt concepts with their juniors (e.g. a fourth-year medical student teaching a second-year medical student). This has been implemented as it mutually benefits both the teachers and those being taught.

Integrated Structured Clinical Examinations (ISCE)

The ISCE (more widely known as the Objective Structured Clinical Examination (OSCE)) is a summative medical examination that students are expected to sit in their second and fourth year at Cardiff University. According to the Outcomes for Graduates (2018) set by the General Medical Council (GMC), some of the expectations include responsibility, building good rapport with patients, maintaining patient confidentiality and candour, interpreting patient data, and executing clinical skills and physical examinations with confidence (5). During the initial two years, students are allocated to various healthcare settings across Wales to practice history-taking, clinical skills, and physical examinations with an emphasis on the use of models and simulated patients. These skills are further developed during their clinical rotations in their later years of medical school where there is exposure to real patients. At the culmination of second year, students are expected to be confident in their clinical competence in preparation for clinical placements that start in their third year.

Post-pandemic, educational institutions were challenged as they had to resort to virtual modalities of teaching and assessment. At Cardiff University, face-to-face examinations were still being conducted. One major modification was that authentic patients with elicitable physical findings were no longer being utilised and were substituted with healthy volunteers due to infection risk. Widespread use of personal protection equipment (PPE) was implemented to also reduce the risk of infection. Some institutions adopted a telemedicine approach where the examination was conducted purely online (6). Although this received praise for working smoothly from a logistical standpoint, students were dissatisfied with their scores and believed they would have performed better in a face-to-face examination (6).

For ISCE teaching, due to the pandemic, Cardiff University resorted to a completely online approach while putting an emphasis on self-directed learning. Students were expected to supplement practical aspects of the examination on their own with the support of online resources.

Innovations in medical education: blended learning and near-peer teaching

Blended learning integrates the traditional in person lecture-based approaches with online methodologies (7). The concept is not new; however, it became popularised given the lack of face-to-face teaching amidst the pandemic. Synchronous e-learning is commonly delivered by platforms such as Zoom™. The user-friendly interface and convenience of online learning has led to the emergence of several medical education platforms, including OSCEazy. Platforms such as MedAll™ or Panopto™ allow livestreaming of in-person lectures while simultaneously recording the lecture to allow students to review the content later. This can be used in conjunction with face-to-face teaching. There is a widening evidence base to suggest that blended learning has been beneficial in combining theoretical knowledge with practical skills (8). With blended learning, live demonstrations taught poorly in an online session may be compensated by a more clear and visible demonstration that an in-person setting can offer. This is particularly relevant for examinations such as the ISCE which challenge the application of knowledge to a real-life face-to-face scenario.

Near-peer teaching can be employed to enhance the overall student learning experience. Its benefits stems from having teachers act as an intermediate between lecturers and their juniors (9). Having recently learnt what they teach, the tutors have a better grasp of the concepts and can deliver it in a digestible manner. Tutors deliver teaching on common themes tested in examinations in a summarised format through multiple means including flashcards, webinars, or question banks. Akin to blended learning, near peer teaching has been well-established as an effective teaching method. This is mainly attributed to its interdependent quality: tutors consolidate past knowledge whilst tutees gain a more thorough understanding of what is being taught (10). Near-peer teaching integrates both social and cognitive congruence which are important qualities in providing learner-centred teaching (11). With the teacher having a similar knowledge bank and social role as the student, near-peer teaching has shown a higher attendance rate and satisfaction than traditional teaching (12).

OSCEazy: teaching by medical students for medical students

OSCEazy is a teaching organisation that was founded in March 2021. As universities were still adapting to the circumstances posed by COVID-19, students from various universities were getting little to no support for OSCEs (13). Thus, with the mission of standardising ISCE teaching, OSCEazy was created. In addition to ISCE support, OSCEazy provide pre-clinical and clinical teaching delivered by undergraduate medical students. All branches of the organisation utilise a near-peer teaching style primarily delivered online to reach international audiences. Teaching slides are carefully designed using a themed template to ensure uniformity and are peer-reviewed before being presented to minimise error. A feedback form is sent out at the end of teaching sessions to participants. On completion of the feedback form, participants receive the teaching slides and a recording of the session to review at their own convenience.

Teaching Session Delivered

The aims of this study were to (i) assess the efficiency of near-peer teaching with regards to ISCEs, (ii) compare face-to-face, online, and a blended approach of delivering ISCE teaching and, (iii) gain students’ perspectives on near-peer teaching delivered through a blended approach.

A blended style teaching event on ISCE was run by a group of fourth year medical students who had recently completed their year four ISCEs which are deemed to be more clinically advanced. The target teaching was delivered to second-year students two weeks prior to their summative year two ISCEs. The event was hosted in-person whilst also being livestreamed on MedAll ™ to online viewers.

The session was publicised via the OSCEazy social media platforms and was attended by over 100 students. The teaching was delivered by four fourth-year medical students (RB, SM, MG, VN) from Cardiff University, and lasted approximately 3 hours. The session comprised of history taking demonstrations, data interpretation activities and summaries of common clinical conditions including their investigation and management. A pre-session questionnaire was sent out to the second-year medical students prior to the session to gauge what topics they struggled most with. The areas most commonly reported as difficult were psychiatry, neurology, musculoskeletal and sexual health.

Questionnaire Design and Dissemination

The feedback form was designed on the MedAll™ platform and a link to complete it was distributed to all attendees using a quick response (QR) code. The slides and recording of the session were accessible to the students upon completion of the feedback form. It contained a mix of 5-point Likert Scales and free text boxes at the end of the questionnaire to allow the respondents to express any further opinions. Questions assessed levels of confidence, satisfaction with the session format, personal engagement, and the overall perceived usefulness of the content.

Simultaneously, questions on a Google Form™ were sent across to the four tutors to obtain their perception on the teaching session. Questions assessed their knowledge, confidence before and after teaching the session, whether they would attend and teach at a near-peer session in the future, their preference in teaching an online, in-person or a hybrid method and other opinions on the event. The questionnaires contained 5-point Likert scales and free text response answers.

Statistical Analysis

All data was analysed using Microsoft Excel and SPSS. A related samples Wilcoxon Signed Rank test was used to identify the differences in participants’ confidence before and after the teaching session. A p-value threshold of < 0.05 was considered significant.

Tutee perceptions

A total of 80 responses were received for this survey. The results indicate that the students found the teaching engaging (median: 5, IQR: 4–5) and found the content to be helpful for their revision (median: 5, IQR: 4–5). In addition, the students found the format of the teaching session quite interesting (median: 5, IQR: 4–5). Furthermore, there was a significant difference in the confidence levels in the topic covered before and after the session (median: 3 IQR: 3–3 vs median:4 IQR: 4–5, p = 0.001) at a 95% confidence interval.

73% of the students preferred an in-person style of ISCE teaching, while 27% preferred online teaching. Thematic analysis of the free text box revealed many enjoyed the method of teaching employed, however, some found that certain parts of the teaching were above their level of training (Fig. 1).

Most of the feedback in the free text box are positive excluding the 36.25% respondents with no other feedback. There were 48.75% respondents in total expressing positive feedback and

enjoying different aspects of the lecture which includes enjoying the live demonstration format, enjoying the ease of accessibility and convenience of online teaching, finding the

content useful, enjoying the method of teaching with 10% of respondents expressing their gratitude for the organisation of the session. The word cloud generated highlights some of the common phrases used in the feedback including ‘great’ and ‘great session’ (Fig. 2). Feedback collated on individual speaker’s knowledge and presentation showed that near-peer teaching was well received and highly regarded by students. All the presenters received a median of 5 for both presentations (IQR: 5–5) and individual knowledge (IQR: 5–5).

Tutor perceptions

Three of the four tutors preferred a hybrid method of teaching while one preferred a sole online model. Prior to the session, tutors demonstrated a higher confidence in teaching online (median: 5) compared to teaching in-person (median: 4). An overall increase in knowledge (median: 3.5 to 5) and confidence (median: 3.5 to 5) was seen after the session. All tutors were highly likely to participate in a near-peer teaching session both as a tutor (median:5) and as a student (median: 5). The most common themes seen among tutors regarding online teaching was the ease in connectivity for students across the world, logistical convenience, and use of online features to increase student engagement (Fig. 3). Themes of perceptions seen among tutors with respect to in-person teaching showed the ability to see audience reactions to content and better interactivity (Fig. 3).

This is the first near-peer, blended learning study conducted in Cardiff currently. Most of the responses being positive has suggested that the blended style of learning and near-peer teaching is a suitable and effective method of delivering ISCE teaching to students.

The feedback from the session displayed that several participants enjoyed this method of teaching and that they had a better understanding of the content. This is in line with Bornkamm et al. which found that students were not only more satisfied with a blended approach of learning but it also improved their overall OSCE performance (14).

Interestingly, the free text element of the questionnaire revealed a dichotomy between satisfaction with live demonstrations and preference of online teaching due to perceived convenience. Although the aim was to integrate these elements with our hybrid approach, there remained certain participants who preferred the session to be delivered completely online. This brings into question whether a blended approach is more beneficial than online teaching in the context of practical demonstrations such as ISCE teaching. Grover et al states that the advantages of online OSCE teaching sessions include increased accessibility and feasibility due to reduced travelling time (15). However, the drawbacks of virtual sessions were that practical demonstrations had to be verbally explained which could lead to information being interpreted incorrectly (15). Furthermore, a well-established limitation with virtual formats of teaching is unreliable internet connection (16). With the blended approach, both these problems are rectified as the face-to-face component ensures clinical skills and practical examinations are taught thoroughly. Moreover, accessible recordings of the live session allow participants to review the taught content even if they were unable to attend the live session.

Although our study focussed on ISCE teaching, we also pondered over the use of a blended near-peer approach for conducting a formative ISCE examination. The term ‘VOSCEs’ (abbreviation for virtual OSCEs) and ‘e-OSCEs’ started to become popular during the pandemic. One study conducted a peer-led e-OSCE examination on Zoom™ and found that if an online participants’ internet connection was not at an optimum speed, this had a downstream negative effect on candidates that followed (17). Thus, with larger sample sizes, a small delay in internet connection can cause larger subsequent problems. On the contrary, Shorbagi et al., found that an online OSCE was more accessible and feasible but suggested it was only effective for the history-taking aspect of the examination (18). Thus, the notion of a virtual ISCE/OSCE still needs several adjustments before its utility can be validated for widespread use.

Peer assessors for ISCE examinations have also been a point of interest. One study conducted in the University of Heidelberg trialled near-peer examiners for formative OSCEs and received an overwhelmingly positive response (19). In addition to students feeling they received more useful and in-depth feedback; they also felt more confident performing the examination which enhanced their learning experience. The major drawback of implementing this system for a summative ISCE was the inter-rater reliability.

With the advancements in medical education post-pandemic, it is interesting to compare hybrid forms of learning with traditional face-to-face teaching practices. Cost-effectiveness is a notable benefit of a hybrid approach because if fewer students are present in person, fewer resources will be used (20). This reduces the burden on educational institutions in terms of the financial and logistical implications of for using lecture theatres (20). Furthermore, online attendees do not pose an additional cost for the university as they only require their personal devices and a stable internet connection to access teaching. A hybrid approach also increases accessibility to sessions thus widening participation (21). However, a significant drawback with hybrid teaching is the risk of reduced face-to-face participation. Not only does this negatively impact the social factor of face-to-face teaching, but this can reduce the motivation of the lecturer to teach due to reduced audiences and interaction (22). One potential solution is disseminating attendance forms prior to the session to gauge the likely ratio of live to online attendees. If there is concern of reduced student engagement due to a majority of participants attending the session online, delivering teaching in smaller groups may also increase interaction (23).

Most participants in our study felt that the teaching was catered to their level, and this could be attributed to the near-peer teaching approach. This teaching model has a number of benefits including improving teaching skills, confidence in public speaking and developing a rapport between tutor and tutees that aids in the process of understanding the topics being taught (9). With the expectation of medical students to become educators at some point during their careers; be it bedside teaching or clinical lecturers, near-peer teaching allows students to get an early insight into the important skills required for effective teaching (24). Furthermore, learning how to teach is a skill not often taught to medical students thus in some cases, near-peer teaching may be their only exposure to developing as an educator (25). Relatability is another positive aspect that near-peer teaching offers as it allows senior students who have sat the examination themselves to give a better idea of what to expect. This may not be the case with senior lecturers as the content they deliver may be more informative rather than ‘exam-focussed’ (26).

Although there is clearly much to praise about near-peer teaching, potential systematic errors are one of its biggest flaws. This is the transfer of preconceived misconceptions that the student teacher may have about the topic that they teach to their peers. One can argue that senior lecturers are also at the stake of making mistakes however, these are usually random errors and are uncommon compared to systematic errors (26). At OSCEazy, slides are peer-reviewed to decrease the rate of systematic errors. Moreover, presentations are often shared and edited by senior members of staff beforehand.

Tutor perceptions

Tutors reported that their confidence and knowledge in topics increased through the process of creating and delivering the teaching session and mention that they are highly likely to attend future near-peer teaching sessions both as tutors and as tutees. Studies by Sawyer et al., Gottlieb et al., and Sader et al. show similar tutor perceptions as identified in our study (27) (28) (29). Wheiss et al. suggest that “to teach is to learn twice” suggesting that tutors tend to have an academic edge in performing better in examinations (30).

Limitations

Although the study had a large sample size, attendance for the session was voluntary hence the data was affected by self-selection biases. Additionally, the sample only included second year medical students hence the data from this study may not be representative of the general population of medical students. To prevent this, a blended near-peer ISCE teaching session can be held again for medical students from any year group and this session should be incorporated into the teaching timetable so that it forms part of their curriculum.

Another limitation was that this study only focussed on exploring blended near-peer teaching for ISCE preparation. As ISCE teaching intertwines live demonstrations and lecture-based aspects, it worked efficiently. Further improvements would be to try this teaching style for other topics (e.g.: anatomy teaching) or even beyond the scope of medicine. This can allow us to see whether the success of this teaching style is restricted to ISCE teaching.

To make more accurate comparisons, a control group could have been incorporated. If this study was conducted once again, students can be split into groups receiving different styles of teaching: online, in-person and a hybrid approach.

In conclusion, the preliminary findings provide us with confidence that a blended, near-peer teaching system is an efficient tool for ISCE preparation. The observations made from this study gives us insight on how unprecedented situations in the future can be resolved to continue the delivery of medical education without compromising on quality. With reduced burden on educational institutions and a means of widening participation, blended learning seems like a step in the right direction. In addition, with overwhelmingly positive feedback on near-peer teaching, it would be prudent to further explore its value and evaluate the use of peer assessors in formative exams as there is a paucity of research in this area. Although this study has shown the benefits of blended near-peer teaching for ISCE preparation, more studies are needed to be done to assess the long-term risks and benefits of near peer teaching.

Ethics approval and consent to participate

Cardiff University School of Medicine Research Ethics Committee confirmed that formal ethical approval was not required.

All data was collected and stored according to General Data Protection Regulation (GDPR) guidelines. All methods were carried out in accordance with the relevant guidelines and regulations. All participants were made aware and informed of the study. All participants provided informed consent.

Consent for publication

Not applicable

Availability of data and material

All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests

The authors report no competing or conflicting interests

Funding

The Authors report no sources of funding

Authors contributions

S.S and R.B. (Ravanth Baskaran) conceptualised, administered surveys, did data analysis and wrote the main manuscript as Co-First authors, S.M. (Srinjay Mukhopadhyay) and M.P.G. Delivered teaching sessions, conceptualised and drafted the manuscript, N.D. and V.N. reviewed and edited the manuscript, A.d.A and A.H. conceptualised, reviewed, resolved conflicts, edited and oversaw the whole project. All authors reviewed the manuscript and have agreed upon submission.

Acknowledgements

We would like to thank the OSCEazy team and the OSCEazy Research Collaborative for their support through this. We would also like to thank the Centre for Medical Education (C4ME) at Cardiff University School of Medicine for their support through this.

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No competing interests reported.

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Challenging Pedagogical Styles of Teaching: Amalgamating Blended Learning with Near-peer Teaching for Integrated Structured Clinical Examination (ISCE) Preparation

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Version 1

Abstract

Introduction

Methods

Results

Conclusion

Figures

Introduction

Integrated Structured Clinical Examinations (ISCE)

Innovations in medical education: blended learning and near-peer teaching

OSCEazy: teaching by medical students for medical students

Methods

Teaching Session Delivered

Questionnaire Design and Dissemination

Statistical Analysis

Results

Tutee perceptions

Tutor perceptions

Discussion

Tutor perceptions

Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1