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Blended Learning in Anatomy Teaching for Non-Medical Students: An Innovative Approach to the Health Professions Education
Available online at www.sciencedirect.com
Health Professions Education ] (]]]]) ]]]–]]] www.elsevier.com/locate/hpe
Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education Olivia Miu Yung Ngana, Taylor Lik Hang Tangb, Aden Ka Yin Chanc, Daisy Minghui Chenb, Florence Mei Kuen Tangd,n a
JC School of Public Health and Primary Care, The Chinese University of Hong Kong (CUHK), Hong Kong b Information Technology Service Centre, CUHK, Hong Kong c Department of Cellular & Pathology, Prince of Wales Hospital, CUHK, Hong Kong d Teaching and Learning Unit, School of Biomedical Sciences, CUHK, Hong Kong Received 15 March 2017; received in revised form 2 November 2017; accepted 2 November 2017
Abstract Purpose: Anatomy is fundamentally an essential curriculum in health professions education. There are various commercial platforms providing learning materials in anatomy; the contents covered in great details are, however, not specifically designed for students majoring in non-medical programmes, such as nursing and pharmacy. To support Anatomy education, this study explored the feasibility of applying blended learning approach composed of narrative animation, interactive revision guide, and gamified quiz in the development of a courseware called electronic Professional Study (ePS). Method: The Cardiovascular system was selected as the pilot theme as it is one of the most commonly diagnosed disorders in the local population. Under the central theme, three micro-modules were developed, including Heart Structure Investigation, Coronary Circulation, and Histology of Blood Vessels. This paper in two parts describes the development and components of the ePS courseware and presents preliminary findings of the evaluation conducted among courseware users. Results: ePS was successfully launched in the university-wide learning platform, Blackboard Learn, where access is available to Pharmacy students attending the Anatomy course. Student's opinion about the courseware was surveyed at the end of the term. Study findings reported that blended learning with gamify components could function as positive reinforcement encouraging selflearning. Conclusions: This study shows that the gamification design elements included in ePS are advocated to address students' needs in Anatomy learning and could be applied in other science-related learning and teaching in the Faculty of Medicine. & 2017 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Micro-module; Anatomy; Health Profession Curriculum; Medical education; e-learning Courseware; Gamification; Hong Kong
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Corresponding author. E-mail address: fl[email protected] (F.M.K. Tang). Peer review under responsibility of AMEEMR: the Association for Medical Education in the Eastern Mediterranean Region https://doi.org/10.1016/j.hpe.2017.11.001 2452-3011/& 2017 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]]
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1. Introduction Anatomy is a fundamental curriculum in health professions education, including medicine and medical health professions (i.e., nursing and pharmacy), which require students to acquire an understanding of the structure and function of human body systems during freshman and sophomore. Cadaver dissection, a major activity in the process of learning anatomy and its benefits, have been widely reported.1 For example, students can gain an accurate perspective of the size and location of an organ, understanding the context of surrounding organs and tissue of which that could not be taught by viewing one organ in a textbook.2 Despite its advantage, cadaver dissection is not a mandatory curriculum for medical professionals who are expected to understand the gross structures and functions of various human body systems.3 In the explosive digital information growth, the adoption of electronic learning (e-learning) materials with the didactic lecture are now increasingly popular in the university teaching practices, especially for health professions education.4–6 There are various commercial platforms providing learning materials in anatomy and the contents cover in great details things that are not specifically designed for non-medical students (i.e. nursing and pharmacy).7 1.1. Blended learning in medical education Blended learning, a type of modern teaching, integrates didactic teaching pedagogy with media-rich technology, where students can gain access to an additional learning medium in supplementary to the formal classroom teaching, tutorials or practicals.8–10 One distinctive advantage of integrating e-learning elements in teaching is that it provides a prior exposure of materials before in-person lectures. It has been suggested that using e-learning materials prior to lectures can help facilitate critical thinking and engage discussion between students and teachers during the class.11,12 1.2. Gamification in health professional education The concept of gamification, which advocates ‘the use of game design elements in non-game contexts,' has been widely adopted in health profession education to
facilitate knowledge acquisition, self-reflection study, and skill practising in training.13,14 Evidence suggests that the gamified pedagogy motivates students to learn in the way of problem-solving15 and expedites learning outcomes.16 In the competitive of the health-related field, gamification shall incorporate complex intervention including setting up questions at varying levels of difficulty and leaderboards to increase the competition among the peers.15
1.3. Integrating blended learning in anatomy and histology teaching: ePS courseware To explore the feasibility of applying blended learning approach with gamification elements in anatomy teaching and learning, an e-learning platform called electronic Professional Study (ePS) was developed. In particular, we selected a topic of the cardiovascular system as a pilot module because it is related to the world's most common non-communicable diseases, cardiovascular diseases, including diseases of the heart and blood vessels. Worldwide, about 17.5 million people die each year, which accounts for an estimated 31% of all deaths, the world's top cause of fatalities.17 In respect to its high incidence and clinical importance, the topic of the cardiovascular diseases is chosen for this study. The best opportunities for scientific progress lies in understanding the detailed mechanisms of cardiovascular diseases at the cell and tissue level and applying this understanding to develop new prevention and intervention strategies.18 In conventional teaching in histology, virtual microscopy was adopted to teach tissue sections using one or more microscope objectives at one or more focal planes. Students nonetheless found it difficult to grasp the understanding as certain tissues appear quite similar, making it difficult for a student to differentiate between them.19 There is another freely available platform called HistoViewer, which provides a central database for cytology and histology courses.20 The pictures do not include labelling, so the students at the beginning learning level do not benefit from the extensive database. This paper in two parts describes the development and components of the ePS courseware and presents preliminary findings of the evaluation conducted among courseware users.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]]
2. Method 2.1. Part I: ePS Courseware Development The overall goal of the cardiovascular system module is to highlight the anatomical structures of the cardiovascular system and its related clinical implications, and histology of the blood vessels. Under the Table 1 The Objective of Each Micro-modules. ePS Courseware Pilot Module: Cardiovascular System Micro-module 1: Heart Structure Investigation – To understand core knowledge of both macroscopic and microscopic structures and functions of the heart – To illustrate clinical implications related to gross anatomy of the heart Micro-module 2: Coronary circulation – To understand blood circulation through the ascending aorta to the heart muscle – To illustrate clinical implication related to coronary circulation Micro-module 3: Histology of blood vessels – To understand the histological structures of blood vessels, the exchange of material between the blood capillaries and surrounding tissues – To illustrate the clinical implication related to microscopic anatomy of blood vessel
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overarching theme of the cardiovascular system, the topic was further sub-divided into three micro-modules, which are (1) Heart Structure Investigation, (2) Coronary Circulation, and (3) Histology of Blood Vessels. Table 1 shows the study objectives under each micromodule. 2.1.1. Components of ePS Each micro-module composed of three elements, including narrative animation, interactive revision guide, and gamified quiz to format instructional content for online and mobile learning. The following parts provide a thick description of each component. 2.1.1.1. Narrative animation. Each narrative animation was selected from SMART imagebase (Nucleus Medical Media Inc., USA) and lasts about 5 minutes.21,22 Articulate Storyline 2 software (Articulate Global, Inc., USA) was adopted to integrate learning contents in a storytelling style. In this regard, ePS adopted the theme of “Future Space City”, linking with the content among each micro-module (Fig. 1a). The main character, Mrs Jackson (Fig. 1b), visits different departments to conduct cardiovascular health risk assessment. The robots, CaMed007 (Fig. 1c) and Micro-bee injector (Fig. 1d) were artificial intelligence to screen health status and diagnose blood vessel disorders, respectively. 2.1.1.2. Interactive revision guide. The revision guide comprised of two parts: (1) a 360-degree simulation of the heart, and (2) histological illustrations.
Fig. 1. The Features of ePS Narrative Animation. (a) Courseware Theme: Future Space City; (b) The main character, Mrs. Jackson, who lives in the space city and go to the cardiovascular tower for body checkup; (c) A door robot named CaMed007 scans Mrs Jackson’s health status; (d) The Micro-bee injector of the blood vessel robot helps diagnose blood vessel disorders.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Fig. 2. Samples of the 360 Simulation Viewer. (a) The cursor located under the heart navigates the heart at the different direction; (b) The name of the structure will pop out when the pointer is placed on the structure; (c) The internal structures of the heart in in-situ view could be examined when the top “information icon” is clicked; (d) All the names of the structures at in-situ view can be shown when the middle “zoom icon” is clicked.
Fig. 3. Examples of Histological Illustrations. The arrangement of the layers of the wall of the (a) muscular vein; (b) capillary; (c) muscular artery; (d) the histological slide will pop out when the pointer is placed on the name of the structure.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]]
standing of the correlation with functions of the cardiovascular system; Challenging level requires a comprehensive understanding and application of pathological changes of the cardiovascular system. Students would be notified whether they answer the question correctly or incorrectly. We did not provide the answer to incorrect attempts so as to encourage students to revisit the courseware and solve the questions by themselves. Table 2 shows the scoring mechanism in the quiz. Questions score 5, 6, and 9 points at the level of basic, advanced, and challenging, respectively. In each attempt, students could try five questions in each level at a time, and the total possible points are 100 if all questions are answered correctly. Students have unlimited attempts throughout the semester and, in each attempt, questions will be randomly selected from the question bank. The system would record the latest score only. Three book coupon awards were given to students who came out in the top three in the quiz by the end of the academic term.
360-degree Simulation Viewer: to facilitate student understanding in the relationship of anatomical structures with a realistic perception, a plastinated heart was used in the reconstruction of photos of the heart with the 3D interactive viewer. Fig. 2 shows the anatomic atlases revision guide of the heart structure with a 360degree simulation. Blood Vessel Histological Illusstrations: The histological illustrations introduce different types of blood cells in the blood vessels and demonstrate the histological arrangement of the layers in blood vessels as shown in Fig. 3. The histological digital slides of different types of blood vessels were captured from the Digital Slide Boxes (Leica Biosystems Imaging, Inc. USA), the major teaching resource of histology in the institution. 2.1.2. The design of gamified quiz To gamify the quiz, we incorporate competitive interventions to increase students’ engagement in the revision. The quiz was designed in the game format and students were instructed to find out the problems during the transmission of the health data for Mrs Jackson. Our team designed quiz questions in line with the course objectives. Three difficulty levels were set up to address varying students need in the revision: Basic level requires memorization of fundamental knowledge related to the cardiovascular system; Advanced level requires an under-
2.2. Part II: ePS Courseware Evaluation The evaluation phase aims to evaluate the effectiveness of courseware in facilitating enhanced learning outcome by (1) correlating students’ courseware usage activity and class performance; and (2) assessing perceived characteristic and usefulness of the courseware among students. The Courseware was launched on the university-wide learning platform, Blackboard Learn, starting from 15 September to 13 December 2016 for students enrolled in the course of Human Physiology and Anatomy. The scrutiny of weblogs in the tracking system was retrieved to monitor the usage of the micro-modules among students. Also, an anonymous questionnaire was conducted to survey courseware users’ opinion towards the utility and effectiveness of the ePS. By the end of the first semester of the academic year of 2016-17, all year
Table 2 Scoring Mechanism in the Quiz. Level
Number of questions Points for each Total points at in the bank question the level 4 100 4 30 4 20 in each attempt:
5 6 9
25 30 45 100
Times of access
Basic Advanced Challenging Total Points
5
Date
Fig. 4. Temporal Accesses to the Courseware. *Indicates formative assessment date, which was on 12th December, 2016. The solid-lined parenthesis indicates the teaching period of the cardiovascular system module. The first usage peak was noted in the first week of the module; the dotted-lined parenthesis indicates the second usage peak, which was on 30th November, 2016, which was two weeks before the formative assessment.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]] p-Value 0.167 o 0.001 o 0.001 Ha 6.47 22.9 35.8
2 students from pharmacy concentration enrolled in the course were invited to take part in the study.
2.2.1. Data analysis Scrutiny of weblog was downloaded from Blackboard Learn a week after the formative assessment to examine the students’ study pattern through the courseware. Academic grade of the course were collapsed into five categories: A and A- were combined as A range; Bþ , B, and B- were combined as B range; Cþ , C, and C- were combined as C range; Dþ , D, and D- were combined as D range; and F for students who failed the course. Descriptive analyses was used to show participants’ demographics and characteristics and perceived effectiveness of teaching outcome. Chi-square test was used to examine the difference in examination outcomes by courseware usage. The Predictive Analytics Software Statistics SPSS programme version 21.0 was used to analyse all data.
B (n ¼ 17) 9.59 (4.53) 5.97 (1.49) 3.15 (0.34) A (n ¼ 16) 11.5 (7.16) 7.41 (1.45) 3.58 (0.18)
3. Results 3.1. Demographics of survey participants All enrolled students (n ¼ 53) completed and returned the survey. About 48% were females and 44% of the students had ever used an e-learning courseware prior to this course. The majority of 63% used the courseware 1–2 times during the semester, 27% used it more than 5 times, 8% utilised the courseware as a revision material for examination, and 2% never used the ePS (these were then excluded in the following analysis).
2 0.165 1.00
Kruskal–Wallis H test
3.2. Study pattern for the ePS
a
1 1.00 Exclusion of Outliers 1. Courseware Access 2. SAQ 3. Average GPA
Total (n ¼ 48) Mean (SD, Range) 9.40 (5.91, 0-23) 5.571 (2.22, 0-10) 3.10 (0.53, 1.66-3.91)
3 .444** .699*** 1.00
C (n ¼ 10) 7.90 (5.59) 3.65 (2.21) 2.57 (0.40)
D (n ¼ 3) 8.00 (1.73) 3.17 (1.44) 2.73 (0.12)
F (n ¼ 2) 0.50 (0.71) 4.00 (1.41) 2.07 (0.57)
0.598 o 0.001 o0.001 2.77 25.5 39.3 9.33 (15.3) 4.67 (1.52) 2.29 (0.56) 8.00 (1.73) 3.17 (1.44) 2.73 (0.1) 11.9 (10.8) 3.67 (2.07) 2.65 (0.42) 9.59 (4.53) 5.97 (1.49) 3.15 (0.34) 15.8 (14.4) 7.36 (1.42) 3.58 (0.18) .382** .677*** 1.00 0.127 1.00 1.00 1. Courseware Access 2. SAQ 3. Average GPA
12.1 (10.8, 0-55) 5.69 (2.19, 0-10) 3.11 (0.52, 1.66-3.91)
B (n ¼ 17) A (n ¼ 18)
2 1 Total (n ¼ 53) Mean (SD, Range) Inclusion of Outliers
Table 3 Descriptive and correlation statistic of data.
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Course Grade
C (n ¼ 12)
D (n ¼ 3)
F (n ¼ 3)
p-Value Ha
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Fig. 4 shows periodic access of the courseware throughout the semester. During the course of 21st September to 19th October 2016, regular teaching lectures, practicals, and tutorials cover physiology and anatomy components of the cardiovascular system. By the end of the course, the total hit of the ePS courseware was 669, and the average hit for each student was about 12.6. Two access peaks were noted: First were the teaching period of the cardiovascular system modules at the early term; second frequent access was observed two weeks before the summative examination date held on 12th December 2016.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Table 4 Multiple regression table of factors related to SAQ performance. B
Std. Error
t
95% CI
p-Value
Inclusion of outliers Intercept Courseware Access Average GPA
−2.70 −.032 2.83
1.50 .024 .500
−1.81 −1.35 5.65
(−5.71, .298) (−.080, .016) (1.82, 3.83)
.076 .183 .000
Exclusion of outliers Intercept Courseware access Average GPA
−3.25 −.090 3.16
1.52 .049 .540
−2.14 −1.85 5.85
(−6.30, −.194) (−.188, .008) (2.07, 4.25)
.038 .071 .000
*Outcome variable: SAQ performance
Atude towards ePS content and design Disagree The content is clearly presented
17%
The courseware is easy to use The content fits my need
30% 18%
The 3D simulaon helps me visualise the organ structure beer 2%
5% 4% 0%
66% 32%
The narraon video adds value to my learning 1%
It is favourable to have this courseware fo other topics
78%
4%
The histology illustraon helps me understand the content beer 1%
Agree
83%
22%
The story-driven element movates me to study
The gamified quizz allows me to monitor my study progress
Neutral
50%
32%
67% 74%
24%
78%
21% 10%
85% 61%
35% 20%
40%
60%
80%
100%
Percentage of Respondents
Fig. 5. Attitude towards ePS Content and Design.
3.3. Courseware usage and final examination result Table 3 shows the courseware usage by the final examination result. Overall, the average courseware log-in rate was about 13 times per students. Students from A-range accessed ePS more often than other grade ranges, although the difference was not statistically significant (p ¼ 0.20). Further analysis identified five students attempted the ePS more than 20 times that far exceeded the class average (outliers); of which two students from A range attempted 45 and 55 times, two from C ranges who attempted 28 and 36 times, and one from F range who attempted 29 times. The outliers were then excluded in the further analysis. In the analysis excluding the outliers, the difference of courseware usage by exam performances was statistically significant (p ¼ 0.01) (Table 4). 3.4. Attitudes towards the content of ePS Fig. 5 shows attitudes towards the content of ePS. The majority of 84% and 78% agreed that the
courseware presented the teaching clearly and easy to navigate. About three-fifth found the content helpful in assisting their revision (66%) and monitoring study progress towards the overall course expectation (65%). About half (45%) of the respondents were uncertain about the effectiveness of having a storyline component in the courseware. In general, students favoured adopting e-learning courseware in future (61%).
4. Discussion Study findings reported that slightly more than half were firstly exposed to e-learning courseware in learning Anatomy, suggesting that the application of e-learning courseware in the blended learning for tertiary medical education in Hong Kong, however, remained in its infancy in tertiary education. It is not surprising as the local educational system encouraged a passive spoon-feeding learning method that made students only acquire the knowledge of what their teachers prepared.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Blended learning is increasingly popular and encouraged in tertiary education as a teaching tool, very much because students like to have verbal linguistic, visual spatial and auditory-musical to motivate their intelligence learning process.23,24 Like another study,25 our findings reflected that the self-paced, teacher-led multimedia components were found effective in facilitating the learning process and stimulated cognitive understanding of course content. The active access of the courseware suggested that students found it effective in promoting teaching and learning in this study, as students liked to revisit the ePS from time to time, especially before their examination. The significant correlation between exam performance and courseware usage reinforce the positive utility of the adoption of e-learning in Anatomy and continuous development of the competence of health professional training, especially when the teaching hours are fully occupied for each programme in the tertiary education. The finding also calls for special attention to the existence of both high achievers as well as low achiever students. The delivery of lecture is not the sole goal of teaching, in which that the role of teachers shall empass giving individual assistant and a lot of care to students encountered learning difficulties of the subject.
4.1. The 360-degree spatial simulation viewer Learning of anatomy, the cadavers and plastinated specimens for in-depth teaching and learning of the detailed anatomic structures in the human body systems, remained crucial although there is an increased trend for the shift of virtual learning environment.3,26–28 Students are allowed to view specimens within the assigned period of the office hours and could only view the Atlas of the Anatomy in self-revision after office hours. The findings from the course evaluation suggest that the design of 360-degree spatial simulation viewer is an effective tool to help enhance their understanding of the relationship of the anatomical structures of the heart structure and coronary heart circulation in the selfpaced study.29 Students also regarded ePS useful passing the “Spot Examination”, the written examination for the structure identification.
4.2. The integration of narrative description in teaching microscopic anatomy Difficulty in studying the microscopic anatomy and histology of the cardiovascular system were commonly reported among Pharmacy students, mainly because of limited access and time to examine the microscopic structures.19 The courseware addresses the barrier by incorporating the anatomical illustrations of the blood vessels with sectioned sample captured from Digital Slide Box as shown in Fig. 4. With the narrative description, about 95% of students agreed the micromodule is helpful in understanding the study of the microscopic anatomy, suggesting similar application to other body systems in the future.
4.3. The intrapersonal gamified quiz in the self-reflection Gamified designed for the teaching tool in Pharmacy curriculum has gained wide attention,30 which can be categorised into team-based learning,31 case-study learning,32 or problem solved learning.33 Unlike the existing design, the quiz is designed in a game format at the individual-based, challenging student's fundamental concept of the cardiovascular system. Compared to other game structures34,35, ePS lacked feedback mechanism that did not provide guidance correcting wrong concepts which, however, are of students’ favour.36,37 In response to the issue, we will further address and modify the quiz with the real-time feedback after the answer submission.
4.4. Study limitation This study is limited in several ways. Firstly, the examination covers a topic other than a cardiovascular system, and the examination grade does not fully reflect the effectiveness of the courseware; thus, a high or low number of access of ePS does not directly predict examination performance considering other variables, such as students learning difficulties. Secondly, the security of the weblog is limited to accessing the number of attempts students made to log into the courseware yet failed to factor in the duration of the courseware.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]]
4.5. Conclusion This study provides an example of adopting blended learning in Anatomy teaching to facilitate active learning among students. There is no evidence to support the view that the use of ePS can improve the students’ performances; the study nevertheless provides an insight into how micro-modules work to strengthen teaching and learning qualities. Further research is needed to explore another parameter in the refinement of teachings, such as faculty support and course structure. Acknowledgements We would like to express our deepest appreciation to the Dissecting Laboratory of the CUHK for providing professional input that has significantly assisted in the development of the project. We also thank the Blue Bay Company and the SMART imagebase for providing material contents of the ePS and support to our team.
Disclosure Ethical approval: Ethical approval has been obtained from the institutional review board for research involving human subjects. Funding This work was supported by the Chinese University of Hong Kong (CUHK) under the scheme of Micro-module Courseware Development Grant. The funder had no roles in study design, data collection, analysis and interpretation, and in the writing of the report. Other disclosure None. References 1. Singh V, Kharb P. paradigm shift from teaching to learning gross anatomy: meta-analysis of implications for instructional methods. J Anat Soc India 2013;62:84–89. 2. Louw G, Eizenberg N, Carmichael SW. The place of anatomy in medical education: amee Guide no 41. Med Teach 2009;31: 373–386. 3. Yeager VL. Learning gross anatomy: dissection and prosection. Clin Anat 1996;9:57–59. 4. Hua L, Goodwin D, Weiss A. Traditional vs. blended learning of pharmacology. Optom Educ 2013;39:28–34.
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Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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25. Liaw S-S, Huang H-M, Chen G-D. Surveying instructor and learner attitudes toward e-learning. Comput Educ 2007;49(4): 1066–1080. 26. Falah J, Khan S, Alfalah, T, et al. Development and evaluation of virtual reality medical training system for anatomy education [Studies in Computational Intelligence]. In: Arai K, Kapoor S, Bhatia R, editors. Intelligent Systems in Science and Information. Cham: Springer; 2014. 27. Riederer BM. Plastination and its importance in teaching anatomy. Critical points for long-term preservation of human tissue. J Anat 2014;224:309–315. 28. Fruhstorfer BH, Palmer J, Brydges S, Abrahams PH. The use of plastinated prosections for teaching anatomy—The view of medical students on the value of this learning resource. Clin Anat 2011;24:246–252. 29. Azer SA, Azer S. 3D Anatomy models and impact on learning: a review of the quality of the literature. Health Prof Educ 2016;2 (2):80–98. 30. Aburahma MH, Mohamed HM. Educational games as a teaching tool in pharmacy curriculum. Am J Pharm Educ 2015;79:59. 31. Allen RE, Copeland J, Franks, AS, et al. Team-based learning in US colleges and schools of pharmacy. Am J Pharm Educ 2013;77:115. 32. Reddy IK. Implementation of a pharmaceutics course in a large class through active learning using quick-thinks and case-based learning. Am J Pharm Educ 2000;64:348–354. 33. Novak S, Shah S, Wilson JP, Lawson KA, Salzman RD. Pharmacy students' learning styles before and after a problembased learning experience. Am J Pharm Educ 2006;70:74. 34. Prensky B. Digital Natives, Digital Immigrants, Part II: Do They Really Think Differently? On the Horizon. NCB University Press; 2001. 〈http://www.marcprensky.com/writing/Prensky% 20-%20Digital%20Natives,%20Digital%20Immigrants%20-% 20Part2.pdf〉. Accessed 01 February 2017. 35. McGrath N, Bayerlein L. Engaging online students through the gamification of learning materials: the present and the future.
In: Carter H, Gosper M, Hedberg J, eds. Electric Dreams. Proceedings ascilite; 2013: 573–577. 36. Amir B, Ralph P. Proposing a theory of gamification effectiveness. In: Companion Proceedings of the 36th International Conference on Software Engineering. New York, NT: ACM; 2014: 626–627. 37. Bowser A, Hansen D, Preece J, He Y, Boston C, Hammock J. Gamifying citizen science: a study of two user groups. In: Proceedings of the 17th ACM conference on Computer supported cooperative work & social computing. New York, NT: ACM; 2014: 137–140. Olivia Miu Yung Ngan is a post-doctoral fellow at the JC School of Public Health and Primary, the Chinese University of Hong Kong, Hong Kong Taylor Lik Hang Tang is the assistant computer officer at the Information Technology Services Centre, the Chinese University of Hong Kong, Hong Kong
Aden Ka Yin Chan is a lecturer of the Department of Anatomical and Cellular Pathology, Prince of Wales Hospital
Daisy Minghui Chen is the assistant computer officer at the Information Technology Services Centre, the Chinese University of Hong Kong, Hong Kong Florence Mei Kuen Tang is a lecturer of the School of Biomedical Sciences, the Chinese University of Hong Kong, Hong Kon. She is also a registered veterinary surgeon and sits at the Veterinary Surgeons Board of Hong Kong
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
Health Professions Education ] (]]]]) ]]]–]]] www.elsevier.com/locate/hpe
Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education Olivia Miu Yung Ngana, Taylor Lik Hang Tangb, Aden Ka Yin Chanc, Daisy Minghui Chenb, Florence Mei Kuen Tangd,n a
JC School of Public Health and Primary Care, The Chinese University of Hong Kong (CUHK), Hong Kong b Information Technology Service Centre, CUHK, Hong Kong c Department of Cellular & Pathology, Prince of Wales Hospital, CUHK, Hong Kong d Teaching and Learning Unit, School of Biomedical Sciences, CUHK, Hong Kong Received 15 March 2017; received in revised form 2 November 2017; accepted 2 November 2017
Abstract Purpose: Anatomy is fundamentally an essential curriculum in health professions education. There are various commercial platforms providing learning materials in anatomy; the contents covered in great details are, however, not specifically designed for students majoring in non-medical programmes, such as nursing and pharmacy. To support Anatomy education, this study explored the feasibility of applying blended learning approach composed of narrative animation, interactive revision guide, and gamified quiz in the development of a courseware called electronic Professional Study (ePS). Method: The Cardiovascular system was selected as the pilot theme as it is one of the most commonly diagnosed disorders in the local population. Under the central theme, three micro-modules were developed, including Heart Structure Investigation, Coronary Circulation, and Histology of Blood Vessels. This paper in two parts describes the development and components of the ePS courseware and presents preliminary findings of the evaluation conducted among courseware users. Results: ePS was successfully launched in the university-wide learning platform, Blackboard Learn, where access is available to Pharmacy students attending the Anatomy course. Student's opinion about the courseware was surveyed at the end of the term. Study findings reported that blended learning with gamify components could function as positive reinforcement encouraging selflearning. Conclusions: This study shows that the gamification design elements included in ePS are advocated to address students' needs in Anatomy learning and could be applied in other science-related learning and teaching in the Faculty of Medicine. & 2017 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Micro-module; Anatomy; Health Profession Curriculum; Medical education; e-learning Courseware; Gamification; Hong Kong
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Corresponding author. E-mail address: fl[email protected] (F.M.K. Tang). Peer review under responsibility of AMEEMR: the Association for Medical Education in the Eastern Mediterranean Region https://doi.org/10.1016/j.hpe.2017.11.001 2452-3011/& 2017 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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1. Introduction Anatomy is a fundamental curriculum in health professions education, including medicine and medical health professions (i.e., nursing and pharmacy), which require students to acquire an understanding of the structure and function of human body systems during freshman and sophomore. Cadaver dissection, a major activity in the process of learning anatomy and its benefits, have been widely reported.1 For example, students can gain an accurate perspective of the size and location of an organ, understanding the context of surrounding organs and tissue of which that could not be taught by viewing one organ in a textbook.2 Despite its advantage, cadaver dissection is not a mandatory curriculum for medical professionals who are expected to understand the gross structures and functions of various human body systems.3 In the explosive digital information growth, the adoption of electronic learning (e-learning) materials with the didactic lecture are now increasingly popular in the university teaching practices, especially for health professions education.4–6 There are various commercial platforms providing learning materials in anatomy and the contents cover in great details things that are not specifically designed for non-medical students (i.e. nursing and pharmacy).7 1.1. Blended learning in medical education Blended learning, a type of modern teaching, integrates didactic teaching pedagogy with media-rich technology, where students can gain access to an additional learning medium in supplementary to the formal classroom teaching, tutorials or practicals.8–10 One distinctive advantage of integrating e-learning elements in teaching is that it provides a prior exposure of materials before in-person lectures. It has been suggested that using e-learning materials prior to lectures can help facilitate critical thinking and engage discussion between students and teachers during the class.11,12 1.2. Gamification in health professional education The concept of gamification, which advocates ‘the use of game design elements in non-game contexts,' has been widely adopted in health profession education to
facilitate knowledge acquisition, self-reflection study, and skill practising in training.13,14 Evidence suggests that the gamified pedagogy motivates students to learn in the way of problem-solving15 and expedites learning outcomes.16 In the competitive of the health-related field, gamification shall incorporate complex intervention including setting up questions at varying levels of difficulty and leaderboards to increase the competition among the peers.15
1.3. Integrating blended learning in anatomy and histology teaching: ePS courseware To explore the feasibility of applying blended learning approach with gamification elements in anatomy teaching and learning, an e-learning platform called electronic Professional Study (ePS) was developed. In particular, we selected a topic of the cardiovascular system as a pilot module because it is related to the world's most common non-communicable diseases, cardiovascular diseases, including diseases of the heart and blood vessels. Worldwide, about 17.5 million people die each year, which accounts for an estimated 31% of all deaths, the world's top cause of fatalities.17 In respect to its high incidence and clinical importance, the topic of the cardiovascular diseases is chosen for this study. The best opportunities for scientific progress lies in understanding the detailed mechanisms of cardiovascular diseases at the cell and tissue level and applying this understanding to develop new prevention and intervention strategies.18 In conventional teaching in histology, virtual microscopy was adopted to teach tissue sections using one or more microscope objectives at one or more focal planes. Students nonetheless found it difficult to grasp the understanding as certain tissues appear quite similar, making it difficult for a student to differentiate between them.19 There is another freely available platform called HistoViewer, which provides a central database for cytology and histology courses.20 The pictures do not include labelling, so the students at the beginning learning level do not benefit from the extensive database. This paper in two parts describes the development and components of the ePS courseware and presents preliminary findings of the evaluation conducted among courseware users.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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2. Method 2.1. Part I: ePS Courseware Development The overall goal of the cardiovascular system module is to highlight the anatomical structures of the cardiovascular system and its related clinical implications, and histology of the blood vessels. Under the Table 1 The Objective of Each Micro-modules. ePS Courseware Pilot Module: Cardiovascular System Micro-module 1: Heart Structure Investigation – To understand core knowledge of both macroscopic and microscopic structures and functions of the heart – To illustrate clinical implications related to gross anatomy of the heart Micro-module 2: Coronary circulation – To understand blood circulation through the ascending aorta to the heart muscle – To illustrate clinical implication related to coronary circulation Micro-module 3: Histology of blood vessels – To understand the histological structures of blood vessels, the exchange of material between the blood capillaries and surrounding tissues – To illustrate the clinical implication related to microscopic anatomy of blood vessel
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overarching theme of the cardiovascular system, the topic was further sub-divided into three micro-modules, which are (1) Heart Structure Investigation, (2) Coronary Circulation, and (3) Histology of Blood Vessels. Table 1 shows the study objectives under each micromodule. 2.1.1. Components of ePS Each micro-module composed of three elements, including narrative animation, interactive revision guide, and gamified quiz to format instructional content for online and mobile learning. The following parts provide a thick description of each component. 2.1.1.1. Narrative animation. Each narrative animation was selected from SMART imagebase (Nucleus Medical Media Inc., USA) and lasts about 5 minutes.21,22 Articulate Storyline 2 software (Articulate Global, Inc., USA) was adopted to integrate learning contents in a storytelling style. In this regard, ePS adopted the theme of “Future Space City”, linking with the content among each micro-module (Fig. 1a). The main character, Mrs Jackson (Fig. 1b), visits different departments to conduct cardiovascular health risk assessment. The robots, CaMed007 (Fig. 1c) and Micro-bee injector (Fig. 1d) were artificial intelligence to screen health status and diagnose blood vessel disorders, respectively. 2.1.1.2. Interactive revision guide. The revision guide comprised of two parts: (1) a 360-degree simulation of the heart, and (2) histological illustrations.
Fig. 1. The Features of ePS Narrative Animation. (a) Courseware Theme: Future Space City; (b) The main character, Mrs. Jackson, who lives in the space city and go to the cardiovascular tower for body checkup; (c) A door robot named CaMed007 scans Mrs Jackson’s health status; (d) The Micro-bee injector of the blood vessel robot helps diagnose blood vessel disorders.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Fig. 2. Samples of the 360 Simulation Viewer. (a) The cursor located under the heart navigates the heart at the different direction; (b) The name of the structure will pop out when the pointer is placed on the structure; (c) The internal structures of the heart in in-situ view could be examined when the top “information icon” is clicked; (d) All the names of the structures at in-situ view can be shown when the middle “zoom icon” is clicked.
Fig. 3. Examples of Histological Illustrations. The arrangement of the layers of the wall of the (a) muscular vein; (b) capillary; (c) muscular artery; (d) the histological slide will pop out when the pointer is placed on the name of the structure.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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standing of the correlation with functions of the cardiovascular system; Challenging level requires a comprehensive understanding and application of pathological changes of the cardiovascular system. Students would be notified whether they answer the question correctly or incorrectly. We did not provide the answer to incorrect attempts so as to encourage students to revisit the courseware and solve the questions by themselves. Table 2 shows the scoring mechanism in the quiz. Questions score 5, 6, and 9 points at the level of basic, advanced, and challenging, respectively. In each attempt, students could try five questions in each level at a time, and the total possible points are 100 if all questions are answered correctly. Students have unlimited attempts throughout the semester and, in each attempt, questions will be randomly selected from the question bank. The system would record the latest score only. Three book coupon awards were given to students who came out in the top three in the quiz by the end of the academic term.
360-degree Simulation Viewer: to facilitate student understanding in the relationship of anatomical structures with a realistic perception, a plastinated heart was used in the reconstruction of photos of the heart with the 3D interactive viewer. Fig. 2 shows the anatomic atlases revision guide of the heart structure with a 360degree simulation. Blood Vessel Histological Illusstrations: The histological illustrations introduce different types of blood cells in the blood vessels and demonstrate the histological arrangement of the layers in blood vessels as shown in Fig. 3. The histological digital slides of different types of blood vessels were captured from the Digital Slide Boxes (Leica Biosystems Imaging, Inc. USA), the major teaching resource of histology in the institution. 2.1.2. The design of gamified quiz To gamify the quiz, we incorporate competitive interventions to increase students’ engagement in the revision. The quiz was designed in the game format and students were instructed to find out the problems during the transmission of the health data for Mrs Jackson. Our team designed quiz questions in line with the course objectives. Three difficulty levels were set up to address varying students need in the revision: Basic level requires memorization of fundamental knowledge related to the cardiovascular system; Advanced level requires an under-
2.2. Part II: ePS Courseware Evaluation The evaluation phase aims to evaluate the effectiveness of courseware in facilitating enhanced learning outcome by (1) correlating students’ courseware usage activity and class performance; and (2) assessing perceived characteristic and usefulness of the courseware among students. The Courseware was launched on the university-wide learning platform, Blackboard Learn, starting from 15 September to 13 December 2016 for students enrolled in the course of Human Physiology and Anatomy. The scrutiny of weblogs in the tracking system was retrieved to monitor the usage of the micro-modules among students. Also, an anonymous questionnaire was conducted to survey courseware users’ opinion towards the utility and effectiveness of the ePS. By the end of the first semester of the academic year of 2016-17, all year
Table 2 Scoring Mechanism in the Quiz. Level
Number of questions Points for each Total points at in the bank question the level 4 100 4 30 4 20 in each attempt:
5 6 9
25 30 45 100
Times of access
Basic Advanced Challenging Total Points
5
Date
Fig. 4. Temporal Accesses to the Courseware. *Indicates formative assessment date, which was on 12th December, 2016. The solid-lined parenthesis indicates the teaching period of the cardiovascular system module. The first usage peak was noted in the first week of the module; the dotted-lined parenthesis indicates the second usage peak, which was on 30th November, 2016, which was two weeks before the formative assessment.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
O.M.Y. Ngan et al. / Health Professions Education ] (]]]]) ]]]–]]] p-Value 0.167 o 0.001 o 0.001 Ha 6.47 22.9 35.8
2 students from pharmacy concentration enrolled in the course were invited to take part in the study.
2.2.1. Data analysis Scrutiny of weblog was downloaded from Blackboard Learn a week after the formative assessment to examine the students’ study pattern through the courseware. Academic grade of the course were collapsed into five categories: A and A- were combined as A range; Bþ , B, and B- were combined as B range; Cþ , C, and C- were combined as C range; Dþ , D, and D- were combined as D range; and F for students who failed the course. Descriptive analyses was used to show participants’ demographics and characteristics and perceived effectiveness of teaching outcome. Chi-square test was used to examine the difference in examination outcomes by courseware usage. The Predictive Analytics Software Statistics SPSS programme version 21.0 was used to analyse all data.
B (n ¼ 17) 9.59 (4.53) 5.97 (1.49) 3.15 (0.34) A (n ¼ 16) 11.5 (7.16) 7.41 (1.45) 3.58 (0.18)
3. Results 3.1. Demographics of survey participants All enrolled students (n ¼ 53) completed and returned the survey. About 48% were females and 44% of the students had ever used an e-learning courseware prior to this course. The majority of 63% used the courseware 1–2 times during the semester, 27% used it more than 5 times, 8% utilised the courseware as a revision material for examination, and 2% never used the ePS (these were then excluded in the following analysis).
2 0.165 1.00
Kruskal–Wallis H test
3.2. Study pattern for the ePS
a
1 1.00 Exclusion of Outliers 1. Courseware Access 2. SAQ 3. Average GPA
Total (n ¼ 48) Mean (SD, Range) 9.40 (5.91, 0-23) 5.571 (2.22, 0-10) 3.10 (0.53, 1.66-3.91)
3 .444** .699*** 1.00
C (n ¼ 10) 7.90 (5.59) 3.65 (2.21) 2.57 (0.40)
D (n ¼ 3) 8.00 (1.73) 3.17 (1.44) 2.73 (0.12)
F (n ¼ 2) 0.50 (0.71) 4.00 (1.41) 2.07 (0.57)
0.598 o 0.001 o0.001 2.77 25.5 39.3 9.33 (15.3) 4.67 (1.52) 2.29 (0.56) 8.00 (1.73) 3.17 (1.44) 2.73 (0.1) 11.9 (10.8) 3.67 (2.07) 2.65 (0.42) 9.59 (4.53) 5.97 (1.49) 3.15 (0.34) 15.8 (14.4) 7.36 (1.42) 3.58 (0.18) .382** .677*** 1.00 0.127 1.00 1.00 1. Courseware Access 2. SAQ 3. Average GPA
12.1 (10.8, 0-55) 5.69 (2.19, 0-10) 3.11 (0.52, 1.66-3.91)
B (n ¼ 17) A (n ¼ 18)
2 1 Total (n ¼ 53) Mean (SD, Range) Inclusion of Outliers
Table 3 Descriptive and correlation statistic of data.
3
Course Grade
C (n ¼ 12)
D (n ¼ 3)
F (n ¼ 3)
p-Value Ha
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Fig. 4 shows periodic access of the courseware throughout the semester. During the course of 21st September to 19th October 2016, regular teaching lectures, practicals, and tutorials cover physiology and anatomy components of the cardiovascular system. By the end of the course, the total hit of the ePS courseware was 669, and the average hit for each student was about 12.6. Two access peaks were noted: First were the teaching period of the cardiovascular system modules at the early term; second frequent access was observed two weeks before the summative examination date held on 12th December 2016.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Table 4 Multiple regression table of factors related to SAQ performance. B
Std. Error
t
95% CI
p-Value
Inclusion of outliers Intercept Courseware Access Average GPA
−2.70 −.032 2.83
1.50 .024 .500
−1.81 −1.35 5.65
(−5.71, .298) (−.080, .016) (1.82, 3.83)
.076 .183 .000
Exclusion of outliers Intercept Courseware access Average GPA
−3.25 −.090 3.16
1.52 .049 .540
−2.14 −1.85 5.85
(−6.30, −.194) (−.188, .008) (2.07, 4.25)
.038 .071 .000
*Outcome variable: SAQ performance
Atude towards ePS content and design Disagree The content is clearly presented
17%
The courseware is easy to use The content fits my need
30% 18%
The 3D simulaon helps me visualise the organ structure beer 2%
5% 4% 0%
66% 32%
The narraon video adds value to my learning 1%
It is favourable to have this courseware fo other topics
78%
4%
The histology illustraon helps me understand the content beer 1%
Agree
83%
22%
The story-driven element movates me to study
The gamified quizz allows me to monitor my study progress
Neutral
50%
32%
67% 74%
24%
78%
21% 10%
85% 61%
35% 20%
40%
60%
80%
100%
Percentage of Respondents
Fig. 5. Attitude towards ePS Content and Design.
3.3. Courseware usage and final examination result Table 3 shows the courseware usage by the final examination result. Overall, the average courseware log-in rate was about 13 times per students. Students from A-range accessed ePS more often than other grade ranges, although the difference was not statistically significant (p ¼ 0.20). Further analysis identified five students attempted the ePS more than 20 times that far exceeded the class average (outliers); of which two students from A range attempted 45 and 55 times, two from C ranges who attempted 28 and 36 times, and one from F range who attempted 29 times. The outliers were then excluded in the further analysis. In the analysis excluding the outliers, the difference of courseware usage by exam performances was statistically significant (p ¼ 0.01) (Table 4). 3.4. Attitudes towards the content of ePS Fig. 5 shows attitudes towards the content of ePS. The majority of 84% and 78% agreed that the
courseware presented the teaching clearly and easy to navigate. About three-fifth found the content helpful in assisting their revision (66%) and monitoring study progress towards the overall course expectation (65%). About half (45%) of the respondents were uncertain about the effectiveness of having a storyline component in the courseware. In general, students favoured adopting e-learning courseware in future (61%).
4. Discussion Study findings reported that slightly more than half were firstly exposed to e-learning courseware in learning Anatomy, suggesting that the application of e-learning courseware in the blended learning for tertiary medical education in Hong Kong, however, remained in its infancy in tertiary education. It is not surprising as the local educational system encouraged a passive spoon-feeding learning method that made students only acquire the knowledge of what their teachers prepared.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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Blended learning is increasingly popular and encouraged in tertiary education as a teaching tool, very much because students like to have verbal linguistic, visual spatial and auditory-musical to motivate their intelligence learning process.23,24 Like another study,25 our findings reflected that the self-paced, teacher-led multimedia components were found effective in facilitating the learning process and stimulated cognitive understanding of course content. The active access of the courseware suggested that students found it effective in promoting teaching and learning in this study, as students liked to revisit the ePS from time to time, especially before their examination. The significant correlation between exam performance and courseware usage reinforce the positive utility of the adoption of e-learning in Anatomy and continuous development of the competence of health professional training, especially when the teaching hours are fully occupied for each programme in the tertiary education. The finding also calls for special attention to the existence of both high achievers as well as low achiever students. The delivery of lecture is not the sole goal of teaching, in which that the role of teachers shall empass giving individual assistant and a lot of care to students encountered learning difficulties of the subject.
4.1. The 360-degree spatial simulation viewer Learning of anatomy, the cadavers and plastinated specimens for in-depth teaching and learning of the detailed anatomic structures in the human body systems, remained crucial although there is an increased trend for the shift of virtual learning environment.3,26–28 Students are allowed to view specimens within the assigned period of the office hours and could only view the Atlas of the Anatomy in self-revision after office hours. The findings from the course evaluation suggest that the design of 360-degree spatial simulation viewer is an effective tool to help enhance their understanding of the relationship of the anatomical structures of the heart structure and coronary heart circulation in the selfpaced study.29 Students also regarded ePS useful passing the “Spot Examination”, the written examination for the structure identification.
4.2. The integration of narrative description in teaching microscopic anatomy Difficulty in studying the microscopic anatomy and histology of the cardiovascular system were commonly reported among Pharmacy students, mainly because of limited access and time to examine the microscopic structures.19 The courseware addresses the barrier by incorporating the anatomical illustrations of the blood vessels with sectioned sample captured from Digital Slide Box as shown in Fig. 4. With the narrative description, about 95% of students agreed the micromodule is helpful in understanding the study of the microscopic anatomy, suggesting similar application to other body systems in the future.
4.3. The intrapersonal gamified quiz in the self-reflection Gamified designed for the teaching tool in Pharmacy curriculum has gained wide attention,30 which can be categorised into team-based learning,31 case-study learning,32 or problem solved learning.33 Unlike the existing design, the quiz is designed in a game format at the individual-based, challenging student's fundamental concept of the cardiovascular system. Compared to other game structures34,35, ePS lacked feedback mechanism that did not provide guidance correcting wrong concepts which, however, are of students’ favour.36,37 In response to the issue, we will further address and modify the quiz with the real-time feedback after the answer submission.
4.4. Study limitation This study is limited in several ways. Firstly, the examination covers a topic other than a cardiovascular system, and the examination grade does not fully reflect the effectiveness of the courseware; thus, a high or low number of access of ePS does not directly predict examination performance considering other variables, such as students learning difficulties. Secondly, the security of the weblog is limited to accessing the number of attempts students made to log into the courseware yet failed to factor in the duration of the courseware.
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001
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4.5. Conclusion This study provides an example of adopting blended learning in Anatomy teaching to facilitate active learning among students. There is no evidence to support the view that the use of ePS can improve the students’ performances; the study nevertheless provides an insight into how micro-modules work to strengthen teaching and learning qualities. Further research is needed to explore another parameter in the refinement of teachings, such as faculty support and course structure. Acknowledgements We would like to express our deepest appreciation to the Dissecting Laboratory of the CUHK for providing professional input that has significantly assisted in the development of the project. We also thank the Blue Bay Company and the SMART imagebase for providing material contents of the ePS and support to our team.
Disclosure Ethical approval: Ethical approval has been obtained from the institutional review board for research involving human subjects. Funding This work was supported by the Chinese University of Hong Kong (CUHK) under the scheme of Micro-module Courseware Development Grant. The funder had no roles in study design, data collection, analysis and interpretation, and in the writing of the report. Other disclosure None. References 1. Singh V, Kharb P. paradigm shift from teaching to learning gross anatomy: meta-analysis of implications for instructional methods. J Anat Soc India 2013;62:84–89. 2. Louw G, Eizenberg N, Carmichael SW. The place of anatomy in medical education: amee Guide no 41. Med Teach 2009;31: 373–386. 3. Yeager VL. Learning gross anatomy: dissection and prosection. Clin Anat 1996;9:57–59. 4. Hua L, Goodwin D, Weiss A. Traditional vs. blended learning of pharmacology. Optom Educ 2013;39:28–34.
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Aden Ka Yin Chan is a lecturer of the Department of Anatomical and Cellular Pathology, Prince of Wales Hospital
Daisy Minghui Chen is the assistant computer officer at the Information Technology Services Centre, the Chinese University of Hong Kong, Hong Kong Florence Mei Kuen Tang is a lecturer of the School of Biomedical Sciences, the Chinese University of Hong Kong, Hong Kon. She is also a registered veterinary surgeon and sits at the Veterinary Surgeons Board of Hong Kong
Please cite this article as: Ngan OMY, et al. Blended Learning in Anatomy Teaching for Non-medical Students: An Innovative Approach to the Health Professions Education. Health Professions Education (2017), https://doi.org/10.1016/j.hpe.2017.11.001