4.1 Preference for blended learning
While studies have explored health education adaptations during the COVID pandemic (15, 20), the present study delves into the specific impact of teaching disruptions on clinical skills educators and their individual experiences during this period. Specifically, it addresses the respondents’ perceptions of the effectiveness and impact of educational interventions implemented in response to the pandemic (20).
A significant finding of this study is the preference for a blended teaching approach over exclusive F2F or online methods. A substantial majority (89%) of educators expressed a desire to integrate elements of online teaching into future clinical skills instruction. This aligns with existing evidence indicating a significant preference for blended learning models for clinical skills acquisition (21, 22), which other studies have demonstrated greater knowledge gained compared to either F2F or online modalities alone (23, 24).
One study conducted at University College London Medical School utilised a diverse, blended approach (25). They distributed procedural skills equipment kits to students' homes and conducted synchronous teaching sessions, which were praised for their interactive and creative nature (26–28). Findings from Kimmons et al may explain this such that leveraging students' creativity fosters greater creative problem-solving and deeper, contextualized learning, potentially surpassing both passive and interactive learning methods (29). These findings contrast with those of Kan et al., who employed a similar but asynchronous approach to facilitate hands-on practice for medical documentation (5). Students were given a pre-workshop assignment, e.g., to write a sample discharge summary which was then reviewed F2F. Asynchronous learning, while offering flexibility, is susceptible to distractions, delayed learning, and learner disengagement due to the absence of immediate feedback and social interaction(30). Furthermore, when asynchronous learning is optional and supplementary to face-to-face or synchronous methods, it may be perceived as less essential. Therefore, students in this study may have concentrated less in the activities and failed to achieve adequate competency.
There are, however, several benefits to asynchronous teaching. In our study, educators reported incorporating asynchronous learning by delivering theoretical aspects of clinical skills and preparatory lessons prior to F2F practical sessions. This approach highlighted the flexible, accessible and personalized approach to education, allowing students to study at their own pace thus improving productivity(31, 32).
Some of our respondents have also used the asynchronous approach through video resources and pre-session reading to optimize the efficiency of skills acquisition, such that providing the contextual and theoretical knowledge in advance will allow more time for hands-on practice during F2F sessions. It is important to note that the increased freedom and lack of immediate feedback for students needs to be carefully mediated and supported to mitigate any potential disinterest and disengagement among learners. One way this has been done in the literature is through online discussion forums (33). Discussion forums are often used in asynchronous online teaching to allow educators to monitor student engagement by reviewing their posts and responses on the discussion board (33, 34). Educators can also initiate discussions by posting thought-provoking and relevant prompts (33).
Regardless, studies have found asynchronous learning to be more suitable for mature and self-directed students, although they did not specify if this also applies to practically taught clinical skills content (12, 35). It is important to note when discussing the benefits and drawbacks of both synchronous and asynchronous teaching, that whilst findings have been observed across various educational contexts including the present study, their specific application within clinical skills teaching in the wider evidence base remains unexplored, indicating a gap in the current research.
4.2 Advantages for communication skills
The efficacy of online teaching for communication skills, particularly history taking and consultation skills has been highlighted by this study. Some respondents utilised online simulation to replicate F2F consultations, where the student undertook a history taking or counselling scenario over live video. One respondent reflected on the increasing prevalence of online consultations in general practice due to social distancing measures. As the use of online consultations continues to grow, teaching to simulate these interactions become increasingly relevant to the healthcare landscape (36, 37).
Online medical simulation, employing digital technologies to replicate clinical scenarios, offers a safe environment for learners to practice patient care without impacting on patient safety(38). Studies have shown that both synchronous and asynchronous simulations with virtual patients and environments enhance clinical skills and decision-making (39, 40). The flexibility, instant feedback, and standardisation of training prepares learners for online consultations akin to face-to-face placements for clinical competency. Furthermore, akin to blended learning, combining online simulation with F2F teaching improves outcomes by offering standardized training in psychologically safe environments for learners prior to face-to-face activities (23, 24).
4.3 Barriers to online clinical skills teaching
While some respondents showed faith in the blended approach for its flexibility and adaptability in enhancing clinical skills teaching, many remain sceptical about online teaching as a replacement for F2F teaching. Research by Kan et al. on online clinical skills workshops for final-year medical students highlighted the limitations of online platforms in teaching hands-on procedures (5). They found that such skill could not be taught comprehensively via an online platform, suggesting that while online lessons can elucidate the cognitive reasoning behind clinical skills, they do little to address practical application. Similarly, Önöral and Kurtulmus-Yilmaz's recent study (21) in a related field concluded that online learning complements does not replace F2F teaching, echoing sentiments from participants in our study. These findings highlight significant drawbacks of online teaching that prevent educators from viewing it as a viable replacement. Many educators valued “hands-on” teaching and believe it to be the gold standard of skills education. In accordance to Bloom’s taxonomy (41, 42), it is the physical practice that allows students to traverse the cognitive domain into the psychomotor domain and thereby consolidate skill (32). For instance, online learning fails to facilitate the development of muscular and neuronal pathways essential for fine motor control, which require extensive physical repetition and immediate error correction, all of which prove challenging to replicate virtually (43, 44).
Figure 6 is a flow chart demonstrating how Bloom’s Taxonomy could be in utilised in blended teaching for clinical skills practice. Educators can use each online, blended and F2F modalities to help guide learners across each domain.
Another crucial consideration is the ramifications of inadequately taught clinical skills and skills incompetence, particularly given the intricate nature of many procedures and their impact on patient safety if performed incorrectly. This concern is echoed in the findings of Shih et al., who utilized Zoom for teaching ophthalmic clinical skills to second-year medical students (4). Educators from this study emphasized the risks that certain procedures posed if performed incorrectly, underscoring the necessity for thorough instruction that is best facilitated through F2F teaching, to ensure the safety of both the practitioner and the patient. It is essential to recognize that this primarily pertains to procedural clinical skills involving a physical component, and as stated previously, many educators believe online teaching can still effectively develop full competency in communication and online consultation skills.
Lastly, this study highlights the persistent challenge of navigating technological barriers in online teaching, as reported by both educators and students. This finding aligns with previous research where educators expressed their concerns regarding widespread difficulties in achieving digital fluency (21)((22, 25, 45). These challenges stem from various factors, including insufficient faculty development, technological issues with hardware and software, limited internet accessibility, and inadequate orientation to digital tools (46, 47).
When assessing how educators integrate technology within their teaching, we consider the 'Replacement, Amplification, Transformation (RAT)' axis of the PICRAT matrix (29). The objective being that technology should serve as a means to an end, not as an end itself (29). During the earliest stages of the pandemic, many educators quickly adopted online platforms as a direct substitute for F2F instruction, often without adapting their pedagogical methods. This approach, exemplified by delivering synchronous lectures via live conferencing software, where the lesson remained unchanged from its face-to-face variant in both content and delivery, underscored the unpreparedness of most health professions schools and institutions for the rapid transition to online learning. Consequently, both educators and learners encountered negative experiences, leading to perceptions that online education has inherent limitations, particularly regarding its ability to facilitate communication and connection and so should only be used in emergencies(12, 46). Nevertheless, with increased familiarity and skills, this study has demonstrated that technology has the potential to enhance or even transform pedagogical approaches. For instance, the distribution of procedural skills equipment kits to students' homes, which exemplifies a shift in both teaching methodology and modality to accommodate the online learning environment.