Comparative study
of virtual and traditional teaching methods on the theoretical course of ECG in
medical students of emergency department
Seyyed Mahdi Zia Ziabari 1, Zoheir Reihanian 2,
Masoumeh Faghani 3 *, Nazanin Noori Roodsari 4, Ashkan
kheyrjouei 4, Rasoul Tabari Khomeiran 5, Ehsan
Kazemnezhad Leyli 6
1 Department of Emergency Medicine, School of Medicine, Guilan
University of Medical Sciences, Rasht, Iran
2 Road Trauma Research Center,
Department of Neurosurgery, School of Medicine, Guilan University of Medical
Sciences, Rasht, Iran
3 Department of Anatomical Sciences, School of Medicine, Guilan
University of Medical Sciences, Rasht, Iran
4 Clinical Research Development Unit, Poursina Hospital, School of
Medicine, Guilan University of Medical Sciences, Rasht, Iran
5 Department of Medical Surgical Nursing, School of Nursing and
Midwifery, Social Determinants of Health Research Center, Guilan University of
Medical Sciences
6 Department of
Biostatistics, School of Nursing and Midwifery, Guilan University of Medical
Sciences, Rasht, Iran
*Corresponding Author: Masoumeh
Faghani
* Email: mfaghani@gums.ac.ir
Abstract
Introduction: The emergency ward is one of the most important parts of the hospital,
where people's activities can have many effects on the performance of other
wards of the hospital and the satisfaction of patients. Changing lifestyle and
transformation of cyberspace into one of the pillars of modern life has had a
great impact on learning and teaching methods. To compare the level of theoretical emergency learning in medical
students with two virtual and traditional methods.
Materials
and Methods: This quasi-experimental study was conducted on 88 medical students who
started their emergency rotation in two hospitals of Guilan University of
Medical sciences in 2021. Both groups participated in the same exam before and
after the basics of electrocardiogram (ECG), normal ECG, types of blocks,
diagnosis of MI and arrhythmias education. After collecting the information
from the questionnaires, the data analysis was performed via SPSS software with
a significant P<0.05.
Results: Out of 88 students, 56.8% were female, and 43.2% were male. The mean
and median knowledge score before and after education was statistically
significant in two groups (P<0.001). The virtual group represented a higher
average score of knowledge than the traditional group. The student’ grade point
average affected the result of the score after education (P=0.019, β =0.234).
Conclusion: The use of virtual education methods in combination with traditional
methods might help to improve the learning process and knowledge of medical
students in emergency department.
Keywords: Clinical education, WhatsApp, Emergency course, Medical students
Introduction
Clinical
education is important for medical students' curriculum (1). Medical students learn in theory
and bedside in hospitals. Based on the curriculum, students enter the different
clinical departments and pass their education periods in the form of
traditional classes of theory and clinical rounds (2).
Correct
treatment in the emergency ward has an effect on the satisfaction of patients
and the function of another ward of the hospital (3). The admission of people in the
hospital often happens in the emergency ward for their needs and urgent care,
so understanding their problems in this ward is essential (4). In addition, in the emergency
ward, the student faces a large volume of clients with different clinical
complaints, stable and unstable problems, and a wide range of acute and chronic
diseases, so it is necessary to receive related training to deal with them (5). During this part of the medical
student's curriculum, under the supervision of emergency medicine faculty
members, they will learn how to take a history, examine and perform diagnostic
and therapeutic procedures (6). Generally, they learn the main
approach for treatment in an emergency situation, pay attention to the
patient's main complaint, and acquire necessary abilities to face common
referrals.
Clinical
learning in general medicine is divided into two parts. In physiopathology,
students focus on learning about the diagnosis and pathology of diseases. In
the internship and intership, courses focus on the management and treatment of
the disease (7). Hospital-based clerkship is a good
opportunity for medical students to learn treat patients by combining
theoretical and clinical knowledge in the hospital environment under the
supervision of professors (6). The Covid-19 pandemic provided an
opportunity for professors to make better use of virtual education and teach
virtually where the presence of students in the hospital is not required (8,9).
In
the learning process, teaching and learning are interdependent. Effective
teaching can increase the quality of learning in students (10). Introducing new approaches and attitudes to education, including
blended learning (BL), can be essential in resolving this issue. BL introduced
as a learning method includes traditional and a variety of methods with
specific technologies. BL is a combination of different methods of
communication with technologies such as electronic learning (e-learning),
e-performance support, and knowledge management practices for providing
education (11,12). BL was first formally introduced by Marsh in 2003. Some consider BL as a
combination of traditional and e-learning methods. Researchers showed that it
as a suitable approach to achieve the desired learning goals by using
appropriate technology and tailored to learning styles (13). Nowadays, virtual e-learning is considered the most advanced educational
method that uses advanced technologies through electronic services (14,15).
The hospital environment is one of the most interactive
work environments(16). The interactions between health workers with patients and themselves can
lead to learning and experience of human resources (17). So, learning is the way to create student work and improve efficiency in
an organization like a hospital. Since an organization can achieve its goals
through capable employees, and it might enhance through learning. In addition, the prevalence
of heart patients in the emergency ward is noticeable. It is necessary for
students to learn the basics of electrocardiogram (ECG), normal ECG,
types of blocks, diagnosis of MI and arrhythmia in order to examine heart
patients who go to the emergency ward of the hospital. Therefore, due to the high importance of learning and achieving the best
method of ECG education, we conducted a study to compare virtual and
traditional education of theoretical knowledge of ECG in medical students of the
emergency ward.
Materials and Methods
Data
collecting
This
quasi-experimental study was approved by the Ethics Committees of Guilan
University of Medical Sciences (number: IR.GUMS.REC.1399.548). The inclusion
criteria were: 1- Medical students of Guilan University of Medical Sciences who
have passed the pre-internship exam. 2- Signing the consent form to participate
in the study. Participating are 88 medical students in their 6th educational
years. The sample size was designed with 5% error probability, 95% reliability
and 0.5 relative frequency based on the results of the study by Shaw et al(18). The medical students started their
emergency medicine rotation in Poursina and Razi hospitals, in the second
semester 2020-2021.
Based
on the study design, these medical students divided randomly in two traditional
and virtual education groups. The basics of electrocardiogram (ECG), normal ECG,
types of blocks, diagnosis of MI and arrhythmia were taught in traditional and
virtual classes for two traditional and virtual groups of interns in the
emergency ward. The first group (traditional education=44), which included
students that entered the emergency unit in three consecutive courses, was
first given personal and educational information. Then, they were taught in a
classroom, where students sat together for one session and attended an ECG
analysis class. Several ECGs were provided to the students and explained in
groups by solving problems. For the second group (virtual: n=44), which was the
students of next three educational courses (one month after traditional group),
the educational materials and slides related to the ECG were provided in the
WhatsApp group (a messaging application).
The
research tool was a questionnaire that designed for this research.
Questionnaire questions were designed as multiple choice based on the diagnosis
of normal ECG and emergency heart diseases. The faculty members of medical
schools in Guilan University of Medical Sciences designed this two-part
questionnaire. The first part of questionnaire included medical student’s
demographic such as age, gender, grade point average of previous years of
students. The second part of
questionnaire was consisted fifteen questions about student knowledge related
to normal ECG,
types of blocks, diagnosis of MI and arrhythmia. Before and three days after the education, the students of each group
were tested via the same questionnaire.
The
content validity of questionnaire was approved via the opinions of a panel of
10 experts of faculty members. Using Lawshe rule of content validity; all items
had a value more than 0.62. Also all questions had a Content Validity Index (CVI) of 90% or higher.
The maximum score of student awareness was between 0 to 8. The scores below
33.3% were considered poor, between 33.3% to 66.6% as average, and scores above
66.6% as excellent knowledge category.
Statistical
analysis
The
data were analyzed using SPSS. The mean, standard deviation (SD), minimum and
maximum with a 95% confidence interval (CI) used to determine the learning rate
of medical students in the two educational groups. We used the frequency and
percentage to determine of learning status (poor, moderate, good). Paired
T-test was done to compare the scores before and after the test, and
Independent T-test was done to compare the score changes. Analysis of
covariance was used to determine the difference of two groups by controlling
the variables of grade point average, previous score, gender, and age group.
Also, the Chi-square test was used to compare the performance of learning
status with a significant level of P <0.05.
Results
Data
from demographic part of questionnaire revealed that the medical students had
an age range of 24-26 years (mean 24.5±0.66), 43.2% of males (n= 38), 56.8%
females (n = 50). There was no significant difference in the frequency
distribution of gender (P=0.667) and age (P=0.131) between two studied groups with Chi Square test.
Because the number of medical students introduced to the ward is determined
directly by the medical school, all students were included in the study.
The mean students' grade point average (GPA) was 15.1 ± 4.35 in traditional and
15.1 ± 34.27 in virtual groups. Independent t test revealed that there were not
statistically significant differences between the mean of GPA in the medical
students of two groups (P=0.808).
Mann Whitney U Test was used for comparison of
knowledge score before and after three days of education in two groups (Figure
1). A statistically significant
differences was found between groups (P= 0.001) and in each group (P<0.001).
The virtual group, either before or after education, illustrated a higher mean
knowledge score. In both virtual groups and traditional education, education
had a significant effect on the knowledge (P<0.001). The incremental changes
in the traditional group (27.1 ± 48.1) were slightly more than in the virtual
group (19.1 ± 18.1), but this difference was not statistically significant
(P=0.168). However, a significant difference was seen in the percentage of
learning score changes in the traditional method compared to the virtual group
(P=0.041) (Table1).
Figure 1. Comparing the average knowledge
score before and after three days of education, and its changes in virtual and
traditional methods.
Table 1. Comparison of knowledge score
before and three days after education and its changes in the two studied groups.
SD: standard deviation, *:
significant with Mann Whitney U Test, ** significant with Wilcoxon Test.
The
frequency distribution of knowledge status before and after education between
two groups was statistically significant, P<0.001 and P<0.004,
respectively. The virtual group had a better score before and three days after
the education than the other group. In general, in both groups, the knowledge
status has had significant positive changes, so that in the virtual group, the
percentage of good status has increased from 34.1% to 54.5%; this increase was
in the traditional group from 6.8% to 22.7% (P<0.001). In addition, 82% of
students had good clinical skills, and this percentage did not represent a
statistically significant difference between the two study groups (P<0.999)
(Table2).
Table 2. Comparison of knowledge score
before and three days after education and its changes in the two studied
groups.
|
|
Education Type |
||||
|
Virtual Score(SD) |
Traditional Score(SD) |
Total Score(SD) |
P value |
||
|
Status
of knowledge before
education |
Weak |
7(15.9%) |
19(43.2%) |
26(29.5%) |
<0.001* |
|
Average |
22(50%) |
22(50%) |
44(50%) |
||
|
Good |
15(34.1%) |
3(6.8%) |
18(20.5%) |
||
|
Mean
Rank |
53.5 |
35.5 |
- |
||
|
Status
of knowledge after
education |
Weak |
2(4.5%) |
3(6.8%) |
5(5.7%) |
0.004* |
|
Average |
18(40.9%) |
31(70.5%) |
49(55.7%) |
||
|
Good |
24(54.5%) |
10(22.7%) |
34(38.6%) |
||
|
Mean
Rank |
51.41 |
37.59 |
- |
||
|
P
value |
<0.001** |
<0.001** |
<0.001** |
||
SD: standard deviation, *: significant with Mann Whitney U Test, **
significant with Wilcoxon Test.
According
to the results of this study, 81.8% of the students of the virtual and
traditional group had good clinical skills and there was no statistically
significant difference in the two groups(P=0.999). The results showed the
difference in the before-education scores of the students in the two groups was
statistically significant, to prevent the effect of this score on the research
results, the covariance analysis was used to measure the effectiveness of the
education methods by adjusting the effects of the gender, the before education
score and the GPA. The results of covariance analysis showed that after
controlling the covariate variables (before education score, GPA, and gender),
that did not affect the educational groups (p=/119, β=0.373, Partial Eta
Squared = 0.029) (Table3).
Table 3. Results of analysis of covariance the effect of educational
methods on learning after adjusting for the effects of previous grade, GPA and
student gender.
|
Parameter |
B |
Standard error |
Sig. |
95% Confidence Interval |
Partial Eta Squared |
Observed Power b |
|
|
Lower Bound |
Upper Bound |
||||||
|
Intercept |
-0.076 |
1.374 |
0.956 |
-2.808 |
2.657 |
0.000 |
0.050 |
|
[Group=1.00] |
0.373 |
0.273 |
0.119 |
-0.098 |
0.844 |
0.029 |
0.343 |
|
[Group=2.00] |
0 a |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
[Group=1.00] |
-0.181 |
-0.217 |
0.406 |
-0.612 |
0.250 |
0.008 |
0.131 |
|
[Group=2.00] |
0 a |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
Learning
score-0 |
0.512 |
0.074 |
0.000 |
0.365 |
0.658 |
0.368 |
1.000 |
|
GPA |
0.234 |
0.097 |
0.019 |
0.040 |
0.428 |
0.065 |
0.660 |
a: This parameter is set to zero because it is redundant, b: Computed
using alpha = 0.005.
The
students' GPA had statistically significant effects on their score after
education (P=0.019, β =0.234) with the effect Partial Eta Squared of 0.065
(based on the division of the effective coefficient of Partial Eta Squared, the
values coefficient greater than 0.14 is remarkable). The percentage of
knowledge score changes in male students had a statistically significant
difference between the virtual and traditional methods. Men of the traditional
group had a higher percentage change, 55%compared to 17% (P=0.026). This
percentage was not statistically significant in females, 33% compared to 20%
(P= 0.391). There were not statistically significant differences between the
two genders by type of education and GPA (Table 4).
Table 4. Comparison of the percentage of
knowledge score changes in the two studied groups in terms of GPA and student gender.
|
|
Education
Type |
||||||
|
Virtual |
Traditional |
Total |
P
value |
||||
|
GPA |
≤15 |
Percentage
of scores changes |
Mean±SD |
52.63±10.8.25 |
77.46±95.24 |
64.76±101.67 |
0.097* |
|
Median |
20.00 |
50.00 |
25.00 |
||||
|
Percentile 25 |
14.29 |
20.00 |
14.29 |
||||
|
Percentile 75 |
50.00 |
100.00 |
66.67 |
||||
|
15< |
Percentage
of scores changes |
Mean±SD |
22.52±22.00 |
33.15±31.75 |
27.95±27.64 |
0.209 |
|
|
Median |
18.33 |
33.33 |
33.33 |
||||
|
Percentile 25 |
0.00 |
0.00 |
0.00 |
||||
|
Percentile 75 |
40.00 |
60.00 |
40.00 |
||||
|
P value |
0.0595** |
0.130 |
0.171 |
|
|||
|
Gender |
Male |
Percentage
of scores changes |
Mean±SD |
41.93±110.43 |
49.07±39.02 |
45.31±83.21 |
0.026* |
|
Median |
17.14 |
55.00 |
29.17 |
||||
|
Percentile 25 |
0.00 |
25.00 |
0.00 |
||||
|
Percentile 75 |
36.67 |
66.67 |
66.67 |
||||
|
Female |
Percentage
of scores changes |
Mean±SD |
33.94±38.36 |
57.91±89.09 |
46.41±69.91 |
0.391 |
|
|
Median |
20.00 |
33.33 |
25.00 |
||||
|
Percentile 25 |
14.29 |
14.29 |
14.29 |
||||
|
Percentile 75 |
45.00 |
66.67 |
50.00 |
||||
|
P value |
0.393 |
0.421 |
0.946 |
||||
SD: standard deviation, *: significant with Mann Whitney U Test, **
significant with Wilcoxon Test.
Discussion
The last few decades have seen a shift from traditional medical
education to online education, virtual networks or e-learning (19). Distance or online education has
been used as an important educational feature in different countries in the
past years (20,21) and according to statistics, almost
30% of students of USA have used distance education courses during their
bachelor's degree (22), but in reality this type of
education in medical education not widely used in some country.
In this study, the experiences of clinical medical students in
e-learning were conducted through social media training via WhatsApp application, which is a new approach to teaching in the
medical school of Guilan University of Medical Sciences during the COVID-19
pandemic. According to the results, the post test scores of medical students
have increased significantly in both groups. It seems that education alone is
effective at the level of knowledge of clinical medical students. Of note, the
knowledge’s score of clinical medical students who participated in virtual
groups was higher than those who received a traditional education (face to
face). In the current study, it was shown that changes in knowledge scores in
male students were more in the virtual group compared to the traditional
one.
Contrary to our study, researchers showed that the score of using
the first principle of education in the traditional educational group was
increased significantly from the virtual educational group (23). Of note, learning is a personal
characteristic, and people have own progress in learning according to their
abilities, so it seems that there is a difference in the score of the first
principle of education in e-learning and traditional education group. Koenigs
et al., stated that students' attitudes toward the learning environment affect
behaviors and the quality of learning outcomes (24). Also, other researchers found that
if the first principle of education is used in e-learning, that could motivate
learners (25). Other study showed that e-learning
could facilitate the learning process (26). According to similar studies the
result of present study suggested the blended method as the most effective one
to improve learning quality (27).
Researchers represented that the traditional teaching method is
reliable for achieving educational goals. The new generation of medical
students have access to high standards and valuable digital resources. New
teaching methods and e-learning alone are not a solution for teaching skills.
So, the traditional learning method mixed with e-learning may help student
learning process (28) and the digital valuable resources
can be well used as a combined learning strategy. Because virtual education has
provided a new environment for learning and reduces traditional educational
limitations such as time and place limitations (29). Therefore, the virtual training
method might be useful for people who do not have enough time for face-to-face
training.
Indeed, Wu et al. results showed a significant difference in the
score of students in the theoretical courses. The results of their study
indicate that the kind of virtual education, the use of interactive animations
due to the activities involving students in education have a better impact on
the understanding of the scientific content, and promote their knowledge (30). Other researchers suggested that
e-learning environments may use as part of blended learning and improve of
clinical skills quality (31). In contrast to our results, some
studies revealed that there was no significant difference in the mean of total
scores before education between the virtual and traditional groups (32).
It is expected that virtual education can partially replace the
traditional method of providing theoretical knowledge but not clinical
knowledge and skills (33). In this era, there is a great
emphasis on life time learning and effective education. Social networks and
E-learning resources in medical education facilitate the learning process for
medical professionals, so the effective use of these technologies in medical
education might help achieve valuable results (34,35). The availability, the independency
of time, and the place of e-learning have led to its widespread use by
students. It noted that the pervasiveness of e-learning requires contexts and
infrastructures, the preparation of which requires time, money, and extra
planning (35).
Conclusions
According to the results of this
study, the average and mean score of knowledge in the medical students who
participated in WhatsApp groups was significantly higher than others who had
received traditional training. It seems that the virtual education method in
combination with the traditional may improve the learning process in medical
students. It seems that e-learning has a significant role in learning
theoretical courses in the future, but it may not be an entire replacement for
practical and face-to-face learning. So, it suggests that a combined approach
(traditional and e-learning) will be the most appropriate method for future
medical education.
Author contribution
SMZZ conceptualization, writing - review & editing, ZR
assistant researcher, MF writing - review & editing, NNR
methodologist/assistant researcher, AK data curation, writing - original
draft, RTK assistant researcher, EKL methodologist, assistant
researcher. All authors confirmed the final version of the paper.
Ethical approval and Funding
This work was supported by the Guilan University of Medical
Sciences (Ethic numbers:
IR.GUMS.REC.1399.548). No funding was received for research, authorship
and the article publication.
Conflict of interest
There are no potential conflicts of interest.
Acknowledgment
The authors thank the Vice Chancellor for Technology Research of
Guilan University of Medical Sciences for approving of this research.
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