Factors That Enhance and Hinder the Retention and Transfer of Online Pre-Clinical Skills Training to Facilitate Blended Learning

Figures & data

Figure 1 A conceptual framework for educational design at a modular level to promote the transfer of learning - adapted from Botma et al (2015).²¹

Table 1 Excerpts from student and tutor responses regarding asynchronous online learning

Pre-reading	“Recorded lectures are always accessible if I forget something and need a reminder” – [S23] “Attempting the online skills quizzes before the skills live zoom session prepared me for the session and to have a good understanding of the work” – [S44] “Students should pre-read the course material before the small group zoom sessions.” – [T4]
Self-motivated, self-directed	“I am self-motivated. That helped me keep up with the work and take online learning seriously” – [S17] “My lazy, non-productive side grew by a greater margin” – [S85] “It is important that students take responsibility for their learning.” – [T6]
Quality of lecture delivery	“Pre-recorded lectures on Learn21 [LMS] allows one to go through the material as many times as needed” – [S92] “Lecturers reading off their slides doesn’t assist us in understanding and processing all the new information” – [S75] “I don’t think that our online learning is very effective for medical students in departments other than the clinical skills department” – [S32]
Environmental factors	“The learning environment was not conducive at home and at res as we are sharing rooms” – [S51]
Device fatigue	“Sitting through hours of lectures is very draining” – [S79]

Table 2 Excerpts from student and tutor responses regarding synchronous online learning

Interactive student engagement	“The skills lecturers went out of their way to ensure we understood the skills, and I feel like my theoretical knowledge is solid and sufficient” – [S76] “The online Zoom sessions feel more interactive than [traditional] class sessions” – [S13]
Foundational concepts through innovative teaching design	“They learned an approach to a patient and formulating a differential diagnosis, better than when they attended the skills training in person” – [T4] “There should always be breakout rooms, just as it is in the clinical skills lab” – [S94] “[The home-made simulation] was the closest I’ve gotten to having the experience as if we were taught the skill in person” – [S102] “I enjoyed the history taking online, which was very similar to history taking in real life” – [S76].
Spaced learning and consolidation of knowledge through constructive instructional design	“We studied the material well before the zoom practical as we knew we would be questioned on it during the session. It also helped us consolidate & identify gaps in our knowledge” – [S102]. “Students were given course material in advance as pre-reading and attended lectures prior to having small group zoom [practical] sessions, where information was repeated. The idea was for students to interactively apply that knowledge, which would re-enforce the information” – [T4]. “Repetition helps a lot, and there’s a big difference in the way I understand the 3rd year syllabus compared to 2nd year. I also really like the quizzes because it tests how much I understand from the theory” – [S23]. “I couldn’t really gauge body language and facial expressions from the patient, and this made empathizing with the simulated patient difficult” – [S11].
Immediate feedback and remediation	“The tutor guided us through the process and helped us with our mistakes” – [S30]. “We observed the interaction and were offered real-time comments by the tutor” – [S44]. “Positive criticism from the tutor and classmates did help motivate me to go back and practice more” – [S57].
Preparedness for demonstration of clinical skills	“I know the theory very well, but I have had no practice applying it”, – [S76] “The active learning, continuous revision and tutor engagement were key factors contributing to my preparedness; however, no amount of online learning would allow you to feel totally confident in performing these skills for the first time in real-life on a simulated patient.” – [S44]

Table 3 Excerpts from student and tutor responses regarding synchronous onsite learning

Appreciation for hands-on practice	“It was great getting an opportunity to finally hold the equipment that we use for certain procedure skills, such as a speculum for a pap smear. I also enjoyed the hands-on experience of palpating a pregnant abdomen” – [S52] “The RP was useful in bridging the gap and exposing us to ‘real’ scenarios” – [S44].
Effectual transfer of skills	“I learned a lot in just 2 hours, and I will remember the skill better with the practice I received” – [S62]. “It boosted my confidence” – [S9]. “I was able to see how much I had truly learned through online lessons” – [S32] “The students were able to translate the skill from online to the mannequin with ease and competence. I think the training was highly beneficial to the students” – [T3]. “The one-on-one interaction with facilitators was extremely helpful in identifying specific gaps in our practical approach to these skills” – [S60].
Personalized interaction, feedback, and remediation	“Not only were my own skills tested and corrected but I was also given tips and guidance on how to improve my techniques” – [S11]. “I felt the session to be very useful in preparing me for the wards” – [S23]

Table 4 Excerpts from student responses regarding asynchronous onsite learning

Self-directed and peer practice promotes retention and competence

“We practice the skills on each other and give each other feedback and correction” – [S17]. “I have had several opportunities to go through the theory part and to practice with my peers” – [S67] “I wanted to practice the skill in person to highlight any gaps in my knowledge and ensure I am able to carry out the procedures on an actual patient in the future.” – [S11]

Table 5 Excerpts from student and tutor responses regarding the evaluation of the program

Continuous Assessments benefits students	“The active learning, continuous revision, and tutor engagement were key factors contributing to my preparedness” – [S44]. “Keep quizzes and practice tests online as a [DP] measure of the student’s progress during the module” – [T3] “I would have really enjoyed doing these Clinical Skills [mock] OSCE revision sessions throughout the year” – [S33]
Summative Assessments Identify knowledge and teaching gaps	“We did not have an OSCE in second-year, so it is hard to trust what we learnt.” – [S26] “I could answer theory questions, but when it came to the actual [ONSITE FORMATIVE] exam, I had some shortcomings.” – [S11] “The OSCEs prepared me well. I was forced to study and know those skills so it would be easier for me to perform them” – [S41]
Strengths: Blended approach Tutor support	“I think a blended approach can be quite helpful - to have lectures and tutorials online and then one-on-one skills with the tutors. This way can allow us to be competent in the theory and practical component” – [S1]. “Blended learning including online followed by onsite learning is essential to consolidate and re-enforce what the student has learned” – [T4]. “The tutors seem like they love what they are doing, and therefore it makes it easier to be attentive. Some days I attend even though I don’t want to, just to respect them and the amount of work they exert into our Practical sessions” – [S29].
Opportunities: Technical upskilling Collaboration Blended approached	“I was not prepared for the transition, it was a steep learning curve, but I was able to overcome the technical and time challenges brought about by the transition. I now feel confident using the online platform to teach clinical skills” – [T3]. “There also needs to be interdepartmental co-operation when curricula are established.” – [T4] “Curriculum needs to be correctly structured so that priority is given to ‘must know’ content. There also needs to be interdepartmental co-operation when curricula are established.” – [T4] “I think teaching skills online should continue to be implemented even post-pandemic, especially the zoom sessions. I think it was much more beneficial than having a lecture at campus just before we practiced the skill” – [S102].
Weaknesses: Workload for tutors and students Connectivity	“The number of sessions scheduled in a day needs to be evaluated properly when the timetable is being structured because it does not seem right to subject students to multiple sessions a day and expect them to be prepared, present, and attentive to all” – [S92] “It was harder to concentrate as there was no allocated break.” – [S50] “Sometimes network issues mess up the session, and you may miss what your colleague was saying. Students not being able to switch their videos on or not willing to participate as they should, made it more difficult” – [S62].
Threats Connectivity Technical support Load shedding	“The technical difficulties have challenged us and taken away vital parts of the learning experience” – [S6]. “Connectivity and data made it difficult to learn online as often I had to buy data or borrow devices” – [S61] “If you have a [connectivity] problem, you get left out. It would be nice if assistance is provided in these cases” – [S35]. “Timetables must take into consideration loadshedding and therefore schedule sessions to accommodate such to improve accessibility” – [S9]

Figure 2 Mean level of agreement of students and tutors with statements related to factors impacting asynchronous online learning.

Figure 3 Mean level of agreement of students and tutors with statements related to factors impacting synchronous online learning.

Figure 4 Mean level of agreement of students and tutors with statements related to factors impacting synchronous onsite learning.

Figure 5 Mean level of agreement of students and tutors with statements related to factors impacting asynchronous onsite learning.

Figure 6 Mean level of agreement of students and tutors with statements related to the evaluation of the program.

Figure 7 A proposed five-step multimodal blended learning and teaching approach to clinical skills training.

Botma Y, Van Rensburg GH, Coetzee IM, Heyns T. A conceptual framework for educational design at modular level to promote transfer of learning. Innov Educ Teach Int. 2015;52(5):499–509. doi:10.1080/14703297.2013.866051

 Web of Science ®Google Scholar