|Australasian Journal of Educational Technology
2012, 28(7), 1176-1189.
Blended learning and curriculum renewal across three medical schools: The rheumatology module at the University of Otago
Simon Stebbings, Nasser Bagheri, Kellie Perrie, Phil Blyth and Jenny McDonald
University of Otago
In response to the challenges created by the implementation of a new medical school curriculum at the University of Otago in 2008, we aimed to develop a blended learning course for teaching rheumatology within the existing musculoskeletal course. We developed a multimedia online learning resource structured to support class based problem-based learning (PBL) sessions, and enhance student engagement and promote clinical reasoning. We also aimed to align teaching over three geographically separate campuses, promote more student-centred approaches to learning and meet the challenge of the limited teaching time available for undergraduate learning in the field of rheumatology. Our redesigned course was evaluated longitudinally over eighteen months through student focus groups, Blackboard and Moodle electronic access data, and course evaluation questionnaires. The data collected indicated an overwhelmingly positive response to the changes in teaching methods. Online materials integrated into the new curriculum and combined with in-class PBL and clinical sessions, proved popular with students. Students accessed the newly developed online materials far more frequently than the previously available unstructured content, which they felt to be of limited value or relevance to their studies. Furthermore the blended learning approach allowed delivery of common content across three separate campuses.
Implementation of a new curriculum for undergraduates is frequently challenging. The trend across medical education worldwide is to teach rheumatology within the framework of a musculoskeletal medicine module (Glynne, 2000). The amount of time devoted to this aspect of the curriculum is frequently disproportionately low in terms of the burden of disease in society (Bilderback et al., 2008).
Two further challenges were apparent at the University of Otago. Firstly, in common with many other medical schools (Ozuah, 2002), undergraduates at the University are divided between three distant campuses, located in Dunedin, Wellington and Christchurch for their clinical attachments. This provides a challenge in maintaining a shared curriculum and consistent approach to teaching across these sites. Secondly, the University of Otago has instituted major changes to the medical school curriculum in line with other Australasian Universities, in part determined by recommendations from the Australian Medical Council (AMC 2009). This had resulted in a move to a learner centred rather than teacher centred approach. Students are expected to bring more critical and analytic thinking to interactive sessions.
In order to meet these challenges, it became apparent that a radical approach was necessary to develop rheumatology teaching and learning for future students undertaking their fifth year musculoskeletal attachment. Previously students rated clinical bedside teaching highly, but didactic elements of the course were not well received. In line with the medical school's new curriculum it was decided to replace didactic teaching where core information had been previously been conveyed, with problem based learning (PBL) scenarios undertaken in small groups (Wilson et al., 2006). In the newly designed course, students were to have access to core content, through the online materials, which were explicitly integrated with the face to face PBL sessions in a blended learning format.
Blended learning is an increasingly prevalent term often used to describe the integration of web-based technologies and face to face teaching, when used as an alternative to more traditional course structures (Bonk & Graham, 2006). However, blended learning is arguably an ill-defined concept (Oliver & Trigwell, 2005) and may also refer to the 'blending' learning theories, or even blending different technologies. Probably the most common meaning of blended learning in the literature is some combination of face to face instruction with online teaching (Bliac, Goodyear & Ellis, 2007). According to Garrison (2004):
... the real test of blended learning is the effective integration of the two main components (face-to-face and Internet technology) such that we are not just adding on to the existing dominant approach or method.So, rather than just being supportive, web-based teaching becomes integral to the course. Suggested advantages of this approach include a better learning experience, more consistent content delivery and greater flexibility (Bonk & Graham, 2006). In this paper we adopt the definition suggested by Bliac, Goodyear and Ellis (2007):
'Blended learning' describes learning activities that involve a systematic combination of co-present (face-to-face) interactions and technologically mediated interactions between students, teachers and learning resources.In the new course design, carefully developed online resources would allow students to review and reflect on essential topics prior to their PBL seminars. By introducing a blended learning approach into the medical curriculum and developing a community of enquiry with cognitive, social and teaching presence (Garrison & Anderson, 2003), we hoped to transform traditional didactic medical school teaching to a situation where teachers acted as facilitators of learning and assessors of competency (Ruiz, Mintzer & Leipzig, 2006). It was felt an additional advantage of blended learning would be the provision of consistent course resources to students dispersed across the three campuses of the University.
Whilst the University has used Blackboard as its learning management system (LMS) since 2001, the rheumatology content made available to students via Blackboard was limited to PowerPoint presentations and Word documents summarising didactic lectures. We were aware, from tracking statistics available from within Blackboard, that students were rarely accessing this information. Quality and presentation of materials, their relevance to student needs and flexible access, have all been identified as characteristics of successful online or web-based learning programs (Sun, Tsai, Finger, Chen & Yeh, 2006). Developing a new blended learning program would also be an opportunity for us to critically review our course materials in relation to these features.
The schema for this approach was as follows:
Students were approached and written consent was obtained from volunteers who wished to take part in a focus group evaluation. Two focus groups were convened, one with students prior to development of the new curriculum and one 18 months after its implementation. Both sessions were semi-structured and were recorded and transcribed. The focus group facilitator posed questions conceptualised from comments and responses to student feedback questionnaires delivered on two occasions over the preceding 12 months. Initial analysis of usage data of existing online materials, together with anecdotal comments from students suggested dissatisfaction with current materials.
Access data relating to the use of Blackboard and different areas of the online course were recorded over the evaluation period. Access data for the new course was analysed and compared with access data to materials, which had previously been available on Blackboard (PowerPoint and Word documents derived from lectures).
Course evaluation questionnaires consisted of a question followed by a 5 point Likert scale. The number and percentages of each response were recorded. An option of free text written feedback was given at the end of the questionnaire. Questionnaires were distributed to students in the final tutorial at the end of each seven-week musculoskeletal course. Questionnaires were voluntary and returned in a sealed envelope by a student representative.
The design of the course and its modes of delivery were developed in conjunction with a specialist in higher education and from review of educational literature. The views of students gained from focus group interviews were incorporated into the design, particularly with respect to modes of delivery.
The course was redesigned to reflect our key aims, namely that students would:
The new blended learning course was carefully structured. Online learning materials were made relevant to examinable clinical problems and were designed specifically to ensure students entered the classroom with the background knowledge required to interpret signs, symptoms and investigations in patients with rheumatic disease. The 18 students were split up into four groups of 4-5 to work together on PBL topics, with a facilitator circulating and summarising the discussion at the end of a one-hour session, which consolidated learning and promoted critical thinking and clinical reasoning.
The new blended learning course was developed to provide a complete course. There were clear learning objectives and a clear examinable curriculum.
Blended learning course design
The following areas were developed and provided within Blackboard for students to access on their own:
Each seminar was designed to be engaging, with photographs, tables, graphs and interactive questions. Each seminar was designed so that it could be readily updated. Seminars were developed as a complete course of study which would obviate the need for student to use textbooks, although suggestions for further inquiry were included for students who wished to explore topics in more depth.
Peer to peer presentations
In the last week of the course, students were required to present a ten-minute topic of their own in groups of 4 or 5 to their peers. They were encouraged to choose topics they felt had not been covered sufficiently in the course. The sessions were conducted by the facilitator in an informal manner, with certificates and a prize for the best presentation. Some of the best presentations were selected for adaptation and upload to the LMS. The format encouraged students to explore some areas in more depth, develop their presentation skills and work as a group. There were positive reinforcements from their peers and the facilitator.
Evaluation was performed using the modalities previously described. Summative assessments before and after the intervention were evaluated. The main purpose of this was to ascertain that students were developing knowledge in the key areas we wished to examine.
Could be made more stimulating and interesting.The opportunity to participate in tutorials was generally rated highly (1-2) but a small proportion rated this poorly (6%).
It would be good if we had more patient examples.
Focus group discussion
A theme of the focus group discussion was that students wanted a structured learning program and desired clarity with regard to learning objectives.
... if we'd had written down a list of what we go through ... at the start, that (sic) might have cleared up some, of what we're meant to be doing.Another theme was a lack of enthusiasm for the existing online learning content. Students were aware of Blackboard but felt that the material available online was uninspiring. Students perceived little value in these materials and felt they did not address their learning needs.
... a formal handout, you know, just something that people can refer back to.
The only time I used Blackboard was to find last years OSCE [Oral Structured Short Case Examination] questions and to find useful online web addresses.Students expressed the feeling that they were under prepared for the end of attachment exams and wanted clearer guidance on what they needed to learn.
There was nothing useful on there.
Yeah, I hate doing stuff on the computer.
You can't show that you knew 90 percent of it.
Has the course had helped them to achieve a deeper understanding of the subject?At this time the blended learning content for the course was still being developed and comments from the students reflected some frustration with the 'work in progress'. Examples of free text comments from the evaluation questionnaire relating to the content of the course included:
Has the course helped you to think through clinical problems yourself?
Have the PBL seminars contributed to your understanding of the subject?
Will be good to see how it develops.Overall from the evaluation questionnaire, materials on Blackboard were rated highly with 83% scoring the blended learning content 1 and 2 on the evaluation questionnaires. Comments included:
More material would be better.
Very informative and enjoyable.
Very helpful, especially 10 min (topics) and quizzes.
Excellent great links and very well put together.
Once Blackboard is fully developed it will probably be the main learning tool.In particular course material on Blackboard was felt to be relevant and very up to date. Many felt that it provided enhanced learning opportunities and facilitated learning at their own pace and in their own time. When the students were asked about the future of Blackboard they were very optimistic about its development. They felt that future students would benefit from incorporating it into their daily learning to help prepare them better for their exams.
It could replace textbooks as it's easier to follow and has immediate up to date information.Students also felt that Blackboard was easy to access and utilise.
Blackboard could be the way of the future by meeting all media needs : e-learning, podcasting. It will definitely optimise learning opportunities.
Easy to read format and it is user friendly.The integration of their learning into 'real life' scenarios in the PBL sessions was also appreciated.
Great alternative to clinical work.Free text comments were also fewer. The only comments were that e-learning resources were 'very helpful' and 'pretty good'.
Students felt challenged and motivated to learn (100% rating scoring 1or 2 on the Likert scale). They also found the course gave them a deeper understanding of the clinical area. Students commented that there was significant preparation required outside tutorial time and this was reflected in their evaluations (with 44% rating this as onerous - scoring 1 or 2).
In 2009 four cohorts ('runs') of students completed the course over the academic year. Each attachment was of seven weeks duration (runs 1-4). In 2009 Run 2 (April-May) and 4 (September-October) used the Blackboard materials as an integral part of their learning, whilst students in Run1 (January-March) and Run 3 (June-August) were taught using the old course structure, without specific reference to the Blackboard materials, thus acting as a control group.
Figure 1 demonstrates that since students in Run 3 were accessing the new online materials at high rates as their run progressed despite being a 'control' group. On questioning, this group cited 'word of mouth' from fellow students, as being an incentive to access these materials.
When specific areas of the online course were analysed, the interactive e-learning seminars were most popular, accounting for nearly half of all hits. This implies students were returning to these e-learning seminars on several occasions. Next most popular were the '10 minute topic' audiovisual podcasts, accounting for 17% of access.
Figure 1: Hits on the Blackboard Rheumatology site for 2007-2009
Not all students accessed the online learning resources equally. Reviewing access data in one group of 18 students, one student accessed the site on only two occasions, seven students on 50-100 occasions, and two on more than 100 occasions.
Course convenors decided to change the LMS hosting the course content from Blackboard to Moodle in 2010. The perceived benefits of this move were a greater autonomy in design, and the accessibility of Moodle. It was also easier to update materials on Moodle. The Blackboard LMS was restricted by University IT protocols, which removed much autonomy from the developers of the course. This move proved popular with students, who found Moodle easier to access, as it was separate from the Blackboard course which was structured as a hierarchy for the entire curriculum. An evaluation performed after the move to Moodle confirmed this as a popular (100% rating the course as 1 or 2 on the Likert scale).
In total, MCQ assessment results were available during 2011 for 63 students from the Christchurch campus and 52 from the Dunedin campus. Mean results and standard deviations respectively were 37.35 (±4.55) and 37.54 (±4.65), p = 0.53. The results showed a striking similarity between the two centres.
Figure 2: Hits on the Moodle Rheumatology site by students and mean score in end-of-run MCQ assessment in 2011
The opportunity of a new curriculum allowed us to meet this challenge and explore innovative teaching methods for the teaching of the rheumatology component of the musculoskeletal medicine course. The combination of online teaching resources and PBL allowed much more time for classroom discussion. We have also found time within the course to institute additional clinical teaching as a result of re-prioritising contact time with students. Feedback from students with respect to these changes has been overwhelmingly positive.
Students were initially wary of blended learning and showed little enthusiasm for the proposed developments. It is recognised that some students are not comfortable with using computers as a primary source of learning (Sun et al., 2006). Furthermore, negative experiences of existing course material posted on Blackboard, in a poorly organised, unstructured, file repository format may well have influenced students in their attitude to the proposed developments. A previous study assessing attitudes of students to blended learning in rheumatology noted that only one third of students felt that this would be a useful learning tool (Wilson et al., 2006). Poor quality instructional design for online learning is recognised as having a negative impact on the use made of such materials by students, but this is issue not limited to web-based learning (Cook, 2007).
Despite these initial negative attitudes to blended learning, as the course was developed and new materials were integrated into the course, students rapidly adopted the course into their learning structures. This was demonstrated by far greater access to the new materials when compared with previously available material on Blackboard. Enthusiastic feedback was also elicited in focus groups. An interesting and unexpected development was that word of mouth resulted in students who had completed the course prior to the development of the new module accessing the course repeatedly and in large numbers prior to their end of year exams.
Small-group, problem-based learning sessions were received initially with little enthusiasm by the students, though most medical schools in Australasia have implemented PBL based courses for undergraduates. PBL is not without controversy, with most knowledge based assessments showing little advantage in PBL. In addition the underlying educational principles and theory behind PBL have been questioned (Colliver, 2000). However, motivation of students and the generic analytical skills of future doctors are felt to be fostered better by the PBL approach (Wood, 2003). Once instituted as part of the integrated course, our students found PBL an enjoyable and relevant experience, particularly after exposure to key topics from the blended learning materials.
One suggested advantage of blended learning is that it allows flexible learning, where students can choose when and where they access the course materials. Interestingly, although our students appreciated opportunities for self-paced learning, some felt that learning done outside class hours added to their perceived workload, and this was highlighted by responses to the evaluation questionnaires. Not all students are comfortable with using online resources and this was demonstrated by the widely variable access to materials. Blended learning should be seen as part of a blended educational approach and not a 'one size fits' all resource.
We chose not to compare the results of summative assessments before and after the developing the new course. Previous studies have shown that PBL does not necessarily improve performance in summative assessments (Colliver, 2000). It has been suggested that evaluation of blended learning is best undertaken through a peer review process and assessments of learner satisfaction, content and usability. We did evaluate student performance in their end of attachment MCQ at two campuses (Figure 2). These results were strikingly similar. We feel that this provides evidence that our goal of achieving delivery of common core knowledge at distant sites was achieved. Furthermore, students commented that they felt well prepared for their end of attachment assessments, which were devised to assess knowledge of the core content we had included on Moodle.
Our case study demonstrates that a blended educational approach can prove a popular and worthwhile teaching method. We hope to continue to evaluate and further develop the rheumatology course during coming years using a design-research framework. Our future aims are to identify specific elements of the course which may help medical students to recognise, appreciate and appropriately manage a range of rheumatological conditions. In this way we hope to prepare students for future medical practice where rheumatological conditions will commonly be encountered.
Bilderback, K., et al. (2008). Design and implementation of a system-based course in musculoskeletal medicine for medical students. The Journal of Bone & Joint Surgery, 90(10), 2292-2300. http://dx.doi.org/10.2106/jbjs.g.01676
Bliac, A., Goodyear, P. & Ellis, R. (2007). Research focus and methodological choices in studies into students' experiences of blended learning in higher education. The Internet and Higher Education, 10(4), 231-244. http://dx.doi.org/10.1016/j.iheduc.2007.08.001
Bonk, C. J. & Graham, C. R. (Eds.) (2006). Handbook of blended learning: Global Perspectives, local designs. San Francisco: Wiley.
Colliver, J. A. (2000). Effectiveness of problem-based learning curricula: Research and theory. Academic Medicine, 75(3), 259-266. http://journals.lww.com/academicmedicine/Abstract/2000/03000/Effectiveness_of_Problem_based_Learning_Curricula_.17.aspx
Cook, D. A. (2007). Web-based learning: Pros, cons and controversies. Clinical Medicine, 7(1), 37-42. http://www.ingentaconnect.com/content/rcop/cm/2007/00000007/00000001/art00011
Garrison, D. R. & Kanuka, H. (2004). Blended learning: Uncovering its transformative potential in higher education. The Internet and Higher Education, 7(2), 95-105. http://dx.doi.org/10.1016/j.iheduc.2004.02.001
Garrison, D. R. & Anderson, T. (2003). E-learning in the 21st century: A framework for research and practice. London: Routledge/Falmer.
Glynne J. A., Herrick, A. & Marsh, D. (2000). Musculoskeletal medicine and surgery. Churchill Livingstone.
Laurillard, D. (2002). Rethinking university teaching: A conversational framework for the effective use of learning technologies (2nd ed.). p.99. Routledge Falmer, London and New York.
Longmore, M., Wilkinson, I., Turemezei, T., et al (2007). Oxford handbook of clinical medicine, 7th Ed. Oxford University Press.
Oliver, M. & Trigwell, K. (2005). Can blended learning be redeemed? E-Learning and Digital Media, 2(1), 17-26. http://dx.doi.org/10.2304/elea.2005.2.1.17
Ozuah, P. O. (2002). Undergraduate medical education: Thoughts on future challenges. BMC Medical Education, 2, 8. http://www.biomedcentral.com/1472-6920/2/8
Pearce, K. & Scutter, S. (2010). Podcasting of health sciences lectures: Benefits for students from a non-English speaking background. Australasian Journal of Educational Technology, 26(7), 1028-1041. http://www.ascilite.org.au/ajet/ajet26/pearce.html
Reeves, T., McKenny, S. & Herrington, J. (2011). Publishing and perishing: The critical importance of educational design research. Australasian Journal of Educational Technology, 27(1), 55-65. http://www.ascilite.org.au/ajet/ajet27/reeves.html
Ruiz, J. G., Mintzer, M. J. & Leipzig, R. M. (2006). The impact of e-learning in medical education. Academic Medicine, 81(3), 207-212. http://journals.lww.com/academicmedicine/fulltext/2006/03000/the_impact_of_e_learning_in_medical_education.2.aspx
Sandars, J. (2009). Twelve tips for using podcasts in medical education. Medical Teacher, 31(5), 387-389. http://dx.doi.org/10.1080/01421590802227958
Sun, P.-C., Tsai, R. J., Finger, G., Chen Y. & Yeh, D. (2006). What drives a successful e-learning? An empirical investigation of critical factors influencing learner satisfaction. Computers & Education, 50(4), 1183-1202. http://dx.doi.org/10.1016/j.compedu.2006.11.007
Wilson, A. S., et al. (2006). Development of an interactive learning tool for teaching rheumatology -- a simulated clinical case studies program. Rheumatology, 45(9), 1158-1161. http://rheumatology.oxfordjournals.org/content/45/9/1158.full.pdf
Wood, D. F. (2003). Problem based learning. BMJ, 326, 328. http://dx.doi.org/10.1136/bmj.326.7384.328
Woolf, A. D., Walsh, N. E. & Akesson, K. (2004). Global core recommendations for a musculoskeletal undergraduate curriculum. Annals of the Rheumatic Diseases, 63(5), 517-524. http://dx.doi.org/10.1136/ard.2003.016071
|Authors: Simon Stebbings, Rheumatologist and Senior Lecturer|
Department of Medicine, Dunedin School of Medicine
University of Otago, PO Box 913, Dunedin 9054, New Zealand
Nasser Bagheri, Research Fellow, Department of Public Health
School of Medicine and Health Sciences, University of Otago, Wellington
PO Box 7343, Wellington South, New Zealand
Kellie Perrie, Registrar in Rehabilitation Medicine
Southern District Health Board, Dunedin Hospital
Dunedin 9054, New Zealand. Email: email@example.com
Phil Blyth, Senior Lecturer, eLearning in Medicine
Department of the Dean, Otago School of Medical Sciences
University of Otago, Dunedin, New Zealand. Email: firstname.lastname@example.org
Jenny McDonald, Lecturer, Higher Education Development Centre
University of Otago, Dunedin, New Zealand. Email: email@example.com
Please cite as: Stebbings, S., Bagheri, N., Perrie, K., Blyth, P. & McDonald, J. (2012). Blended learning and curriculum renewal across three medical schools: The rheumatology module at the University of Otago. Australasian Journal of Educational Technology, 28(7), 1176-1189. http://www.ascilite.org.au/ajet/ajet28/stebbings.html