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Radiography 17 (2011) 235e240

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Radiography

journal homepage: www.elsevier .com/locate/radi

Teaching patient care to students: A blended learning approach in radiographyeducation

Jill Bleiker*, Karen M. Knapp, Ian FramptonCollege of Engineering, Mathematics and Physical Sciences, University of Exeter, Stocker Road, Exeter EX4 4QL, United Kingdom

a r t i c l e i n f o

Article history:Received 26 October 2010Received in revised form13 December 2010Accepted 3 January 2011Available online 28 January 2011

Keywords:Patient careCommunication skillsVideo clipsEducationPsychology

* Corresponding author. Tel.: þ44 (0) 1392 264085E-mail address: j.bleiker@ex.ac.uk (J. Bleiker).

1078-8174/$ e see front matter � 2011 The College odoi:10.1016/j.radi.2011.01.002

a b s t r a c t

Understanding the complexity of the patientepractitioner interaction is a challenging area for radiog-raphy students early in their programmes. A small scale research project was undertaken to developblended learning resources for the teaching of patient care to radiography students. Its purpose was toutilise experiences gathered from interviews with ex-patients to produce video clips of patientepractitioner interactions so that students might gain some insight into the reality of the clinical setting,thus enabling them to link theory with practice. A total of eight interviews with ex-patients were carriedout and the transcripts used to generate scripts which were enacted and filmed by a professional actingcompany. Thematic analysis of the study data initiated the generation of scenarios, which formed thebasis of the videos. Twelve scenes showing patientepractitioner interactions in various parts of a medicalimaging department and four ‘talking heads’ clips were produced. These were loaded onto the uni-versity’s virtual learning environment and made available for viewing together with self-test and eval-uation questionnaires. A pilot study was carried out; evaluation of the videos by second year studentradiographers was positive. The main study was carried out using first year students with similarlypositive findings and the videos are now publically available for teaching purposes. Further work in thispromising area of e-learning could further utilise patients’ experiences, and using the same technology,might offer students of other professions the opportunity to gain vicarious experience prior to their firstencounters with patients and the general public. In conclusion, research leading to the production ofsimulations of real-life patientepractitioner interactions delivered using blended learning is a usefulpedagogical tool in the education of radiography students.

� 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

Radiographers require “a sound understanding of the basicscience that underpins the constantly advancing technology theyuse, but they also need the professional and social skills required tointeractwith patients andwith othermedical professionals.”1 Theselatter skills are taught at the University of Exeter via a patient caremodule delivered in the first year, which falls prior to first clinicalplacement. The current approach to the delivery of psychologyteaching to student radiographers at Exeter is through lectures,seminars and workshops. However, blended learning; “a flexibleapproach that combines face-to-face teaching with remote (usuallyinternet-based) learning”2 is rapidly becoming a way of life inhigher education today.3 Recent studies in the radiography andimaging literature are beginning to demonstrate somebenefits from

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f Radiographers. Published by Else

electronic delivery of teaching; for example Cockbain et al. docu-mented their radiography programme redesign using a blendedapproach.4 Chapman and Oultram found that course material couldbe delivered in a more efficient manner using an e-learning peda-gogy5 and Lorimer and Hilliard noted that the technologies under-pinning blended learning, far from causing students any difficulties,appeared to increase engagement compared with previous tradi-tional delivery.6 In thewider education andhealth literature, Francisand Raftery detected higher levels of satisfaction amongst healthcare studentswho received a blended delivery comparedwith thosereceiving a traditional lecture format,7 and although James Det-weiler noted that students’ motivation and academic skills were asimportant as method of delivery,8 Klein et al. suggest that blendedlearning can in fact produce students with higher motivation tolearn.9 Training Motivation Theory emphasises the direct effect ofmotivation on learning outcomes,10 so clearly it is not just theblended learning pedagogywhich is a factor in student learning, buta complex interplay of method and individual differences. Meltonet al. suggest a multi-faceted framework known as ‘modes of

vier Ltd. All rights reserved.

J. Bleiker et al. / Radiography 17 (2011) 235e240236

engagement’ of which one element is learning content.11 This isdescribed in terms of its flexibility of access and reusability andsome success has been achieved in the use of video-based problem-solving scenarios in a virtual learning environment (VLE)12 wherestudents view a pre-recorded video of a scenario then discussanswers and reach potential solutions.14 Since radiography educa-tion typically comprises both university and placement basedlearning,15 the use of video clips could be usefully exploited to thisend.

Blended learning, however, is not without its drawbacks anddifficulties; not least in terms of defining the concept, whichMartinOliver argues is “ill-defined and inconsistently used”.17 MarkBrodwski has identified four possible pitfalls:

1. Failing to think ahead2. Failing to develop clear training objectives matched to the

appropriate methodologies3. Failing to integrate and prepare the right blend of expert

resources4. Failing to execute a blended implementation approach18

Oliver suggests that the only way it can be redeemed is byapproaching the topic from the perspective of the learner ratherthan the teacher so that evaluation of the student’s experience oflearning becomes the goal of the exercise. This project had thepotential to address Brodwski’s and Oliver’s concerns and to meetthe ongoing commitment in education to place the student at thecentre of what we do. The notion of students as collaborators intheir own learning is becoming well established and is a key aim inhigher education; Barbara Wasson makes this interesting point: “Ibelieve that we are dealing with a new type of student. Technologysavvy students, . organise their own interactions with peers,instructors and the world beyond.”19 It is therefore incumbentupon radiography educators to meet the needs of students on theseterms rather than on their own. Care also needs to be taken toensure that electronic delivery and evaluation does not over-shadow the human element. Beck notes that “Radiography isa ‘people’ profession and it is important that radiography educationkeeps the balance between exciting advances in e-learning andensuring that students develop the necessary interpersonalskills”,20 and a study by Kelly et al. which compared traditionalteaching with instructional videos concluded that videos were bestused to complement rather than replace lecturer demonstration.21

Although clearly there are some disadvantages and limitations,none of these present a case against blended learning per se, merelythat establishing a new model requires careful consideration;planning and evaluation are integral to success in any venture. Asoutlined in the introductory paragraph, students at the Universityof Exeter learn the psychological theory underpinning good patientcare, such as theories of emotion and stress, stereotyping andinterpersonal and communication skills. A blended approach toteaching this would enable them to link theory with practice;observing representations of real-life situations that they are likelyto encounter on placement. Shared problem-solving tasks will helpthem see that often solutions are not straightforward and furtherillustrate the complexity of the psychology of the patient-epractitioner interaction. Previous student feedback at our insti-tution had indicated that radiography students struggled to engagewith the study of health psychology in the first year, finding ita challenge to relate theory to hospital practice and patient carebefore their first engagement with patients. There was, thereforea very real need to find meaningful ways of delivering the syllabusoutside of the conventional lecture and seminar format so as toencourage better, realistic andmore productive involvement. Use ofthe blended learning pedagogy in the form of video clips prior to

first placement could enable students with little or no clinicalexperience to gain vicariously an understanding of some of thenuances of the patient practitioner interaction by offering someinsight into the minefield that is communicating with, and caringfor patients in order to help them benefit from experience withoutnecessarily having to undergo that sometimes painful experiencefor themselves. Albert Bandura in his studies of social behaviourand identificatory learning16 identified a process of learning to copyor model the action of another through observation, and it is uponthis that the project was based.

Aim

The aim, therefore of this project was to incorporate a blendedlearning pedagogy in the form of video clips of patientepractitionerinteractions into the first year patient caremodule at our institutionin order to offer our diagnostic radiography students an enhancedawareness of the complexity of the psychological factors influ-encing both the patient and the practitioner in the course of theirinteraction. Student evaluation of the clips was integral to thisprocess in order to maintain a student-centred approach toteaching and learning patient care. The insights developed fromviewing the clips and problem-based learning tasks should enablethem to offer more empathic, patient-centred care.

Ethics

National Research Ethics Service committee approval was notrequired. Volunteers were not recruited through or from the NHS,so although the project utilised patients’ experiences, healthauthority ethics were not required.

Method

This was a mixed methods design, using a combination ofqualitative methodology in the form of semi-structured interviewswith ex-patients with thematic analysis of the data generated, andquantitative method in the analysis of the students’ evaluations.22

An opportunity sample of volunteers was recruited using posteradvertisements around the university and e-mail requests to theExpert Patients Programme23 and User Involvement Scheme.24

Recruitment of volunteers who were currently in the care of theNHS was constrained by a lack of NHS ethics, a process whichwould have taken several months andwas therefore not feasible fora mini-project of one year’s duration. Informed consent was soughtand documented prior to any interview commencing anda psychologist from the university’s department of ClinicalPsychology was available in case of any distress resulting fromrevisiting perhaps upsetting or traumatic experiences. The dataobtained from the patient interviews was transcribed andthematically analysed using procedures outlined by Boyatzis25 andBraun and Clarke.26 Scenarios were developed, together with theirbasis in psychological theory and quotations for producing thevideo clips obtained from a professional acting company who thenscripted and enacted scenes of patientepractitioner interactions.Additionally, and on receiving further ethical approval, an inde-pendent film maker was commissioned for a series of ‘talkingheads’ videos based on one volunteer’s experiences, as those andher eloquent descriptions were deemed by the authors to bea powerful teaching tool in their own right. Once filming andediting were complete, videos were uploaded onto the university’sVLE for ad-hoc viewing and for incorporation into practicalcommunication skills seminars for first year students, set withina problem-based learning context. An evaluation questionnaire wasdesigned27 consisting of five quantitative (Likert scale) questions,

Table 2Key psychological factors in the patientepractitioner interaction.

Communication:Effective, ineffective, facilitative, damaging

Personality:Types/traits, impact on professionalism, impact on patient/practitionerinteraction

Attitudes and impressions, self-awareness:Patient and practitioner

Models of health:Medical model, patriarchal medicine, passive patients

Emotions:Positive/negative, powerful

Aggression:Causes and factors

The therapeutic relationship:Rupture and repair

Stereotyping:Positive, negative, impact on patient care

J. Bleiker et al. / Radiography 17 (2011) 235e240 237

and five qualitative assessment questions. Second year studentsfirst viewed and evaluated the clips on the VLE at a time and placeconvenient to them and were asked to return the questionnaireswithin a week. This formed the pilot study for subsequent evalu-ation by first year students.

Evaluation

The evaluation is exploratory rather than supporting a hypoth-esis. Second year students were asked to view the clips thencomplete a questionnaire aimed at eliciting their views on theusefulness of the videos. Evaluation of the videos was positive andno significant issues were raised in terms of questionnaire design. Aminor modificationwas made for the version for first year studentswho were then asked to complete the questionnaire; again evalu-ation was positive.

Findings

Themain themes and sub-themes are shown in Table 1. Analysisof the data suggested a number of key psychological factors (Table2) which underpin the patientepractitioner interaction and whichformed the basis for the scenarios and subsequent scripts. Clearlythe list is not exhaustive, but will be used to develop the coreteaching of patient care in the future. Quantitative evaluation byfirst year students scored marginally lower over the first threequestions and higher over the second two compared to that of thesecond years (see Figs. 1 and 2). Qualitative comments are outlinedin the results section.

Results

Video clip evaluation (second year students pilot)

A total of ten questionnaires were returned out of 50 givinga 20% response rate. The students were asked to complete a Likertscale with 5 representing excellent and 1 representing poor, witha further five qualitative questions. Fig. 1 outlines the meanresponses for the 10 questionnaires returned. These all fall abovethe average and demonstrate that the video clips were wellreceived by the students.

Video clip evaluation (first year students)

A total of thirty-six questionnaires were returned out of 60giving a 60% response rate. The students were asked to completethe same Likert scale as the pilot study with 5 representing excel-lent and 1 representing poor. Fig. 2 outlines the mean responses forthe 36 questionnaires returned. Again, these all fall above theaverage and demonstrate that the video clips werewell received bythe students. First and second year students were broadly inagreement in their overall impressions of the clips, as were their

Table 1Main themes and sub-themes.

Theme Sub-themes

Communication between practitioner and patient EffectiveIneffectiveBetween departments

Competence Technical/clinicalInterpersonal

Emotions PositiveNegative

Attitudes PractitionerPatient

Therapeutic relationships Rupture and repair

evaluations of content and quality (questions 1e3). The lower scorefrom first year students for quality was related to the poor soundquality of the audio-visual equipment in the seminar room; a factorwhich was out of our control. First years professed a greaterunderstanding of the psychology of patient care (Q4); the fact thatthey were surveyed during delivery of the academic component ofthe course may have a bearing on this, as it should be easier torelate theory to practice more readily. Second year students wouldno doubt struggle to bring to mind some of the pure theory astaught at university almost a year ago. Evaluation of the relevanceof the clips saw first years rating this more favourably.

The students also completed qualitative responses regarding thevideo clips and these are outlined below:

Particularly usefulReactions of staff and student to the different situationsPatient emotions during their reflections after the interactionHow not to deal with patients; learning from their mistakes[staff presumably]Class discussion afterwardsUnderstanding of how small actions can make an impact on thepatientThe fact that the scenarios are based on real events

Not usefulLack of depth to videosOverexaggerated?

Did first year students benefitYes 36 No 0

Suggestions for improvementLonger videosA video from a professional radiographer on how they wouldhave dealt with the situationsBetter quality (unspecified)More scenarios/situations

Other commentsYour [sic] a good teacherReally good/usefulEasy to relate to

Discussion

This study demonstrated positive feedback from studentsexposed to blended learning materials using video clips of patient

Figure 1. Quantitative review of the video clips (pilot study, second year students).

J. Bleiker et al. / Radiography 17 (2011) 235e240238

experiences both before and after placement. Students agreed thatthe clips contained useful and relevant material and that there wasa positive impact on their understanding of the psychology ofpatient care; some useful suggestions for improvement made aspart of the evaluation could be taken forward to subsequentresearch. Whilst this was a small scale project focussed aroundradiography student education, a good response to requests forvolunteers willing to be interviewed elicited a wide range ofexperiences; a larger study could increase the scope and richness ofdata. A positive response bias from the interviewees had beenanticipated prior to commencement of the interviews, but this wasunsubstantiated and awide range of experiences, both positive andnegative were elicited which produced data rich in substance. Theresults of the study offer empirical support for the conclusions

Figure 2. Quantitative review of the video

drawn by Cockbain et al.,4 although Chapman and Outram’ssuggestion that the blended approach offers efficiency savings forlecturers5 is questioned as the role merely shifts from teacher tofacilitator. It would also appear that it is the nature of the blendedlearningmaterial which impacts upon the student experience: PaulCatley’s work with online quizzes highlighted issues surroundingengagement with online course materials.28 The pitfalls of theblended learning pegagogy noted by Brodwksi18 have been revis-ited; planning and delivery of the patient care module have beenadapted in the light of this study and its findings including thefeedback elicited as part of the evaluation process. Whilst thehindsight gained from clinical placement may have played a part inthe positive evaluation of second year students, it would appearthat evaluation from first year students supported the findings

clips (main study, first year students).

J. Bleiker et al. / Radiography 17 (2011) 235e240 239

from the second year pilot study. This would suggest that video-based learning is a useful tool in its own right, but use of formativeassessment as part of any further evaluation could perhaps furtherenrich quantitative evaluation of the video clips and foster inde-pendent learning through the use of self-test questions andproblem-based learning. The use of patients’ accounts of theirexperiences in this study, which taps into those “aspects of humanexperience . not easily captured in quantitative or . qualitativeresearch”29 is an aspect of the methodology of this study whichcould also be of further interest. Bleakley, who cites Bruner’s workson narrative30 to support his approach, uses narrative enquiry inthe field of medicine to understand a patient’s experience of illness.He notes and rejects criticisms of this ostensibly ‘soft’ approach, incontrast with the so-called ‘hard’ sciences, illustrating for example,the expressing of the turbulent emotions of a patient with cancer.31

The reflexive nature of the narrative method offers a furtheradvantage to learning more about this approach and it links aresearch methodology with another objective in radiographyeducation; that of engaging the students with reflective practice;a key component of both their clinical and academic practice.Donald Sch}on explains the need for this in order to afford “intel-lectual rigour in professional practice”. He suggests that competentpractitioners know more than they can say and describes a tacit“knowing in practice.”32 Of course reflective practice is enshrined inthe codes of conduct of both the Society of Radiographers33 and theHealth Professions Council.34 In summary, this project wasdesigned to provide a tool for our students’ use, both as part ofproblem-based learning seminars and for ad-hoc use e there area series of self-test questions accompanying the videos on the VLE(intranet). In addition, the videos are publically available on theuniversity’s webpages where they are free to use for evaluation ofthe usefulness of the blended learning approach more specifically.Moreover, Rider et al. suggest bringing patients’ perspectives intothe assessment of the learners35 which could augment this inter-esting area of research.

Conclusions

In conclusion, this small scale project set out to utilise theexperiences of patients who had undergone medical imaging inorder to produce an e-learning tool for student radiographers. Wehave outlined the process of gathering information from ex-patients and using it to create dramatised versions of events.Themes have been elicited which enable the linking of psycholog-ical theory with clinical radiographic practice. Evaluation by bothstage 1 and stage 2 students was positive; of particular value to thestudents were:

� Gaining insight into a patient’s feelings via observation of andreflections upon their experiences whilst undergoing x-raysand scans,

� Enabling students to visualise situations yet to be experienced,� Equipping them to relate patient care theory to practice.

Suggestions for improvement included clips showing clearanswers to some of the issues raised; however it is felt that pre-senting the clips as a problem-based learning pedagogy facilitatesdeeper learning. The clips are arranged so that each scene is pairedwith the ‘patient’s’ reflections which can act as a guide. Finally, thisproject has provided a useful pedagogic tool for the delivery ofpsychological theory to health care students at the University ofExeter. It is hoped that by dissemination through the university’swebsite, and the HEA,36 both the video clips and the method bywhich they were produced can be offered more widely in healthcare education.

Conflict of interestThere are no actual or perceived conflicts of interest in this

study.

Acknowledgements

Grateful thanks go to: The willing volunteers who gave up theirtime to share their experiences and without whom this projectwould not be possible, Dr. Christine Heales, Mrs Sophie Willis andthe Medical Imaging team at the University of Exeter for theirsupport and advice, Gillie Stoneham and Emma Brown at ActorFactor (www.actorfactor.co.uk), Timothy Cooper, Radiology Edu-cation and CPD Lead, Torbay General Hospital, First and second yearstudents on the B.Sc. Medical Imaging (radiography) course at theUniversity of Exeter Mrs Vera Mitchell from the User InvolvementScheme The Higher Education Academy Psychology Network whogranted the funding and who support the submission of this articlefor publication. (http://www.psychology.heacademy.ac.uk).

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