=Paper=
{{Paper
|id=Vol-2193/paper11
|storemode=property
|title=Local and Global Dimensions of a Clinical Skills E-book Development Project
|pdfUrl=https://ceur-ws.org/Vol-2193/paper11.pdf
|volume=Vol-2193
|authors=Laura Smith, Rebecca O'Rourke, Memory Van Beek, Suzanne Bickerdike, Rania Alkhadragy
|dblpUrl=https://dblp.org/rec/conf/ectel/SmithOBBA18
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==Local and Global Dimensions of a Clinical Skills E-book Development Project==
https://ceur-ws.org/Vol-2193/paper11.pdf
Local and global dimensions of a clinical skills e-book
development project
Laura Smith1, Rebecca O’Rourke1, Memory Van Beek1, Suzanne
Bickerdike1, Rania Alkhadragy2
1 Institute of Medical Education, University of Leeds, Leeds, United
Kingdom
2 Medical Education Department, Suez Canal University, Ismailia,
Egypt
L.E.Smith@leeds.ac.uk
Abstract
This qualitative study develops an account of how, when, where and why Leeds the
undergraduate medical students engage with an online curriculum mapped clinical
skills intended to provide a quality assured resource for placement supervisors to
support teaching and assessment. The research population was medical undergraduates
entering Year 4 . Descriptive statistics and thematic analysis of a short survey
of closed and open questions was compared with usage analytics and documentary
analysis of the development brief. Preliminary analysis shows 96% of students who
completed the questionnaire used the eBook. Students use all features but to varying
extents. The eBook is not used as intended to prepare for and support placement
learning and assessment but predominantly used for assessment and exam preparation.
Keywords: qualitative, clinical skills, clinical placement, e-book,
learner engagement.
1. Introduction
There is growing interest in exploring the use of eLearning (1) and mobile technologies
in undergraduate medical education to support the acquisition and development of
clinical skills (2, 3). This paper reports an initiative in which an open access clinical
skills e-book [CS e-book] was developed by the Clinical Skills Education Team [CSET]
at Leeds Institute of Medical Education to support initial acquisition and subsequent
application and refinement of clinical skills during placement and beyond. The paper
begins with the rationale for developing the CS e-book, including the digital and
pedagogic decisions informing its design and deployment, before presenting interim
findings from a mixed methods research project that explores how, when, where and
why students engage with this resource. Initially designed to explore the extent to
which the developers’ intentions had been met, the study raises questions relevant to
the wider deployment of digital solutions for learning. It also surfaced questions about
how resources developed for use in specific local contexts circulate and are re-used
globally.
2. Context
The acquisition and practice of clinical skills is central to the undergraduate medical
curriculum. Students encounter them in a variety of ways: observation in practice,
simulation-based practice in dedicated practice centres, self-directed learning utilising
written and/or multi-media resources and the application of this knowledge in
supervised practice during placements in. The clinical skills which medical
undergraduates need are organised by body systems and characterised by early and
varied patient contact through clinical placements of increasing length and
responsibility. Consequently, the skills which medical undergraduates develop also
increase in complexity as they progress from their first to fifth year.
This continued involvement in learning and consolidating clinical skills requires
independent learning from the student, prefiguring the lifelong learning they will
engage with as professionals. The CSET supports several initiatives to promote such
learning, often centred on preparation for the Objective Structured Clinical
Examination [OSCE]. These include opportunities for unsupervised practice and peer
learning and assessment. Learning clinical skills is not only knowledge acquisition but
also involves translating this knowledge into practice under the direction of clinical
supervisors during placements. A number of challenges arose from each of these
processes that led, in 2013, to the creation of the CS e-Book.
The first challenge was the frequency with which students’ independent learning
involved consulting unregulated web-based resources, sometimes contrary to national
guidelines, inaccurate or out of date. There was potential for disseminating this
incorrect information during informal and peer learning. .
The second challenge was ensuring clinical supervisors, responsible for teaching and
assessing students in practice, had access to materials clearly setting out the required
procedures and standards students had to achieve. Clinical supervisors cannot access
the university’s virtual learning environment so the e-book was developed as a web-
based open access resource.
3. Digital Solution
The CS e-book is a self-directed learning tool that can be accessed on a mobile phone,
tablet or PC. The resource was developed by staff from the CSET working with clinical
placement providers and educational technologists. Pedagogy rather than technology
led the initiative. The technology input is deceptively simple: embedded videos,
interactive diagrams and text within a swipe left / swipe right format and hyperlinks
from chapter headings and sub-heading and to launch videos and images. The emphasis
is on content and demonstration. Interactivity is carefully designed to keep page
lengths manageable on mobiles and tablets. Collaboration with placement providers
was an important aspect of ensuring the CS e-book was fit for purpose and it was hoped
involvement in developing the resource would encourage its adoption in the clinical
supervision relationship.
4. Practical deployment
The resource is mapped to the undergraduate medical curriculum, divided into chapters
for Year 1, 2, and 3 with each broken down into the 7 or 9 key clinical skills
respectively, plus chapters on clinical examination, history taking and the crash trolley
(adult). Each chapter follows a similar structure: video in which each skill is
demonstrated; full written description of the skill; checklist outlining the kit along with
photographs of the equipment needed. Content is regularly updated and new chapters
added.
5. Methodology
The CS e-Book has been available for five years and collection of usage data is built in
to the site. However, this data raises as many questions as it answers and so it was
agreed to run a mixed-method evaluation to explore how undergraduates actually
engaged with the resource and the extent to which the designers’ aims had been
realised.. The research population was medical undergraduates entering Year 4 of
Leeds university’s MBChB who completed a short survey of closed and open
questions. Descriptive statistics and thematic analysis of their responses were compared
with usage analytics and a documentary analysis of the development brief. A second
phase of the study will interview students about the ways in which they use the e-book
to embed learning. One aim for the evaluation project is to create baseline data for
future analysis of the CS e-Book.
The project received ethical approval from the University of Leeds School of Medicine
Research Ethics Committee in 2017.
6. Findings
There was a 57% return rate ; of these, 96% had used the CS e-book.
6.1 Frequency of Use
Google analytic data from the web pages show the usage patterns from all users
worldwide. They show spikes in usage during the university’s revision and
examination periods and on skills assessment days. However, this data is not trackable
to individuals. The survey responses, and follow-up interviews, make it possible to
drill down into the detail of these broad patterns. They show the resource is used by
the majority of registered medical undergraduates but with variation in frequency.
About a third of the respondents gave a figure of 10 or lower; about half a figure of up
to 100. The remainder reported using the resource “Many times a week”, “Very often
before OSCEs” and, in one case, “Several times a day during revision”.
It was expected revision and the exam period would figure highly and they did . Other periods of more frequent use, e.g. to prepare for the start
of the year, the teaching of new skills or starting a placement were significantly lower
(in single figures). This highlights the need for further work to achieve the full range
of use envisaged, particularly refreshing knowledge prior to performing a clinical skill
, practicing clinical skills and during placements .
6.2 Where participants access the CS e-Book
The designers had intended the CS e-Book to be accessible, and used, in a variety of
settings especially clinical placements. Although students did access the CS e-book in
clinical practice this option received the lowest score and they were most likely
to use it at home or the university . These options were not mutually
exclusive – participants were invited to record all that applied. A supplementary
question asked where participants most often used the CS e-Book. Home was by far
the most popular location , with the Clinical Practice Centre and
Placements reported as 2nd and 3rd choices.
For students who did consult the CS e-Book during placements in clinical practice a
supplementary question ascertained who they were with when they did so. This showed
an overwhelming preference for using the CS e-Book privately and with
colleagues . A minority used it with patients suggesting issues around
perception of confidence and expertise are in play. However, the equally low number
using it with their supervisors highlights the need for further work to realise this
intended purpose.
6.3 Devices used to access the CS e-Book
Participants were asked about all the devices they used to access the CS e-Book and
to identify the one they used most frequently. Responses confirmed findings that
medical undergraduates predominantly saw the CS e-Book as being for private use,
linked to revision, rather than a resource to support placements and supervision in
clinical practice. When asked about all the devices they used, the most popular were:
personal laptop or pc , personal mobile phone and personal tablet . When asked which device they used most frequently the personal laptop or pc was significantly more popular than other devices. Personal mobile phone was the
second most frequently used device with personal tablets or iPads
significantly higher than public devices: the practice centre iPad and hospital pc
. Students using mobile phones were most likely to access the e-book in clinical
practice.
6.4 How has the CS e-Book been used?
Questions established not only what content had been accessed but how participants
had accessed that content. Offering a combination of media was designed to support
its use at different stages of development: acquiring skills and preparing to acquire
them, preparing for clinical placement, applying knowledge in practice and revising for
assessment. The different mediums support these different purposes, e.g. checklists for
refreshing knowledge prior to application, videos provide an overview and introduction
to the skill. These choices also acknowledged preferences in learning, offering visual
alternatives to the written word.
The data shows students use all features built into the eBook Data analytics show
technical/procedural skills are more commonly viewed than examination skills (which
could reflect examination skills having been added recently). Individuals reported an
overwhelming preference for the combination of all three modes suggesting a more
dialogic approach is needed to understand how exactly medical undergraduates use the
CS e-Book to develop, reinforce and apply their learning about clinical skills. This will
be explored in interviews during phase 2.
6.5 Why participants use the Clinical Skills e-Book
Participants could choose from a list of statements to report all their reasons for using
the CS e-Book– see figure 1. Revision and exam preparation top the list and
confirm the power of assessment to both drive and define the learning experience of
medical undergraduates. However, the broader purposes envisaged - consolidating
skills , preparation for placement and clarification - are recognised
and valued, albeit marginally
Why do students use the clinical skills ebook?
Curious after hearing friends discuss it 10
Look ahead to see what I will be learning in the… 18
Clarify something I encountered on placement 46
Preparation for placement 58
Videos help as I am a visual learner 76
Practice Skills I Struggle with 78
Prepare for upcoming Clinical Skills Session 78
Prepare for Formative OSCE 80
Consolidate Taught Skills 93
Prepare for Summative OSCE 104
0 20 40 60 80 100 120
Figure 1 Reasons medical undergraduates use the CS e-book
7. Open Challenges
The study found that the resource was not used as intended. Leeds students use the
eBook in a legitimate way- predictably driven by assessment and exam preparation –
but one which counters the primary aim of the designers to develop a resource
supporting placement and placement supervision. The eBook usage demonstrates a
need is met but only by speaking to students will we know if this is active and
developmental, providing a foundation for lifelong self-directed learning, or the high
achieving student seeking reassurance. A further challenge surfaced by the evaluation
is the need for further work to promote the CS e-Book to clinical supervisors and
provide guidance as to how best they can draw on its resources during placements.
Whilst we continue to investigate local users is it also timely to reflect whether we
should also be exploring, and perhaps guiding, how this resource is used on a global
scale. Data analytics from 2015 to date show the Clinical Skills eBook has been viewed
across 88 countries. There are limited channels for feedback which would enable the
designers to understand how it is being used in these very different contexts. This
challenge has technical and pedagogical dimensions. Technically, the question is
whether it is possible, or desirable, to build some form of evaluation into the resource
– perhaps a social media based network to gather and exchange information about how
the resource is being used.
Pedagogically, the challenge is greater. Martimianakis and Hafferty (5) identify
three distinct discourses of medical education in a globalized world: the universal
global physician, the culturally versed global physician and the global physician
advocate. These are distinguished by the extent to which they believe it possible or
desirable to achieve universal standards of medical competency and training. The
discourse of the universal global physician assumes someone can be trained anywhere
in the world using a set of universally applicable standards of competency. It contrasts
with the discourse of the culturally versed global physician, which assumes the
acquisition of culturally specific knowledge and training through exposure and
experience, and discourse of the global physician advocate, whose bio-medical
knowledge is complemented by knowledge of the economic, cultural and political
determinants of health and who advocates for social change in the medical context.
The CS e-book, within the specific medical undergraduate population it was
designed for and the global contexts within which it circulates, is both produced by
these discourses and contributes to their reproduction.
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