Association for Learning Technology Online Newsletter
Issue 4 April 2006   Thursday, April 27, 2006

ISSN 1748-3603

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Feature article
The changing role of Becta
Case studies
Design for multimedia mLearning
Virtual Clinics: online places for problem-based learning
Coaching students for success
Assistive technology: developing a loans scheme for all
Using a Virtual Learning Environment to motivate learners
Project updates
Designing Spaces for Effective Learning
Conference reviews
International workshop on wireless and mobile technologies in education
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Issue 3, January 2006
January 30, 2006
Issue 2
October 24, 2005
Issue 1
August 5, 2005
Virtual Clinics: online places for problem-based learning
by Geraldine Jones, Stuart Miller, Michael England and Tim Bilham

Concept and Context
Virtual Clinics were conceived as a mechanism to bring authentic practice-based learning opportunities to doctors studying at a distance on the MSc/PG Diploma in Sport and Exercise Medicine (SEM) at the University of Bath. This pilot study is the first stage in a larger project that aims to design and develop problem-based approaches for learning about professional clinical practice (see Figure 1).

Figure 1: Project phases

Aims and objectives
The aim of the virtual clinic pilot is to act as a 'proof of concept' providing insights into designing and managing an online problem based learning (PBL) process for learning about clinical practice. The objectives of this pilot phase are to:

  • Implement an online PBL environment that includes: the problem scenario; a set of resources/artefacts that support and add context to the problem and a series of activities for engaging students with learning issues and guiding the cyclical PBL process.
  • Evaluate the usefulness of blending online asynchronous discussion with synchronous meetings for mediating communication among students and tutors.
  • Identify drivers and/or barriers to student and tutor participation and engagement.
  • Identify emerging factors relevant to managing and scaffolding the PBL process.
Design choices

: PBL embodies a socio-constructivist pedagogic approach (Barrows, 1980), which is aligned with the  learning and teaching approach underpinning the SEM programme. Asynchronous online discussion activities framed as "e-tivities" (Salmon, 2002) are already widely used as part of each unit of study. The virtual clinics combine a PBL approach, which seeks to develop cognitive engagement via authentic problems using Salmon's five stage model, which scaffolds competence and collaboration in online groups. The PBL cycle is guided by a series of e-tivities with the dual purpose of both connecting to learning issues as well as creating a social climate for learning. The learning issues embedded in the scenario included aspects of physiology, nutrition, ethics, injury management and team working.

Technology: The School for Health has selected the Moodle VLE for delivering a growing number of its distance learning programmes. A Moodle 'course' delivered the virtual clinic scenario used in this pilot study. A blend of asynchronous discussion and synchronous meetings using discussions were organised with the intention of optimising learner engagement and reducing the total time learners needed to spend on the scenario. The asynchronous discussion periods mapped to the divergent phases (for example, problem exploration) of the PBL process while the synchronous meetings mapped to the convergent phases (for example, summarising current knowledge and planning further learning).

Figure 2: Screen shot of synchronous meeting activities

Learner Needs: Practicing medical professional part-time learners and their tutors are typically 'time poor'; thus it was crucial to make the learning experience as efficient as possible. Our experience of managing collaborative online activities reflected that described by Salmon (2003) and indicated that the optimum duration and level of activity is about five or six activities over a two-week period with a group size of 12 to 15 students.

The problem
: A clinical scenario regarding the role of a team doctor working abroad with a youth karate team was developed based on the personal experience of one of the design team, a tutor clinician. The scenario was analysed and deconstructed into wide range of learning issues which included aspects of physiology, nutrition, ethics, injury management and team working. The scenario was presented to students as a text narrative (Greenhalgh, 1999) together with a series of supporting resources in a variety of media. Activities that scaffolded engagement with learning issues were designed and framed as e-tivities.

Figure 3: Using the topic outline section of a Moodle course to introduce the scenario

The Process: Students engaged with several learning issues in three (two-hour) synchronous meetings and two (one-week) asynchronous discussions (Figure 4). Both the synchronous meetings and the asynchronous discussions were facilitated by two tutor clinicians and a host whose role was to welcome students and encourage participation. At the end of each session each student was asked to produce a summary of the group's discussions and to document reflections on their learning and their own experience of the environment.

Figure 4: scaffolding for the PBL process

Learner Support: Students new to online learning were encouraged to participate in an online induction (between five and six hours over one week) prior to the pilot. This induction enabled participants to access and familiarise themselves with the VLE and discussion fora, and also provided an opportunity for them to develop skills in online communication and to get to know their peers. Information about the PBL learning and teaching approach, guides to participation and explanations about roles and responsibilities were made available to all participants.

Participants and data: A group of 17 volunteer students already studying on the programme (seven of whom had online learning experience) were recruited to take part in the pilot. The volunteers were asked to participate as if they were students on the programme and to document evaluative reflections about their experience as the pilot progressed. They were also invited to participate in a face-to-face focus group to give feedback on their overall experience. The development team, which included clinical experts and educational developers, shared their observations and reflections while the pilot was in progress. VLE access logs and discussion threads were reviewed to give an indication of the level of participation and the types of interaction taking place.


Student satisfaction
: Approximately 70% of the students who took part in the pilot said they would recommend the virtual clinic to other students on the course. Students commented positively about the nature of the scenario and how it revealed previously unexplored aspects of practice; others commented on the value of working with others. For example:

  • it was interesting to get other people's thoughts and respond to them
  • it is hard work working this way though particularly helpful
  • working in a group is beneficial, making you feel involved in a case?
  • great being online approaching clinical problems together . . . everyone has different ways of looking at problems
  • Quite fun. Need to be able to think clearly despite distractions (so a bit like life really!)

Time to participate and the need to make the learning experience efficient were frequently mentioned in feedback from both tutors and students.

Tutor Satisfaction: Tutors reported that they found managing the synchronous meetings demanding and intensive. Contributory factors included: the volume of messages; the number of parallel learning issues and the need for consolidation before moving on with the case. Tutors also expressed mild disappointment with the students' depth of analysis of the problem scenario, at the end of the pilot.

Levels of Participation: Student accesses and posts decreased over the period of the pilot. This was mainly because some participants were unable to continue due to other commitments. Few students were able to be present at all synchronous meetings: some students only participated in the synchronous meetings and some only participated in the asynchronous discussions. Tutors were notably absent during the asynchronous week-long discussions. Overall there was greater activity during the synchronous meetings than during the intervening week of asynchronous discussion (see Figure 5).

Figure 5: levels of participation
Types of interaction: There were notable differences in the nature of the participant interactions in the asynchronous discussion environment in comparison with the synchronous meetings. These are summarised in Figure 6.
Two hour synchronous meeting One week asynchronous discussions
  • Busy, sometimes stressful
  • Sometimes difficult to keep track of posts if many fora are in use
  • Short posts
  • Large number of posts
  • High degree of tutor direction e.g. questions and narrowing focus
  • High "virtual proximity"
  • More social exchanges 
  • Less busy, less stress
  • Easy to keep track of posts - messages arrive in an alert email from the fora
  • Longer posts
  • Fewer posts
  • More student autonomy
  • Lower "virtual proximity"
  • Few social exchanges  

Figure 6: comparison of characteristics of the asynchronous and synchronous sessions

It seemed that the students were motivated by the 'virtual proximity' to each other and to the tutors created by the synchronous meetings.
Scaffolding with E-tivities: We observed that the e-tivities provided an effective framework for focusing participant activity and for enabling productive exchanges. Although many of the e-tivities were designed prior to running the pilot, some needed to be modified during the pilot in order to adapt to participant progress. Such interventions would not have been efficient outside of this pilot study so consideration needs to be given to how e-tivities might support progress at different rates, perhaps by focusing more on generic consideration of problems rather than on specific learning issues.
Evaluative summary
Drawing on tutor and student feedback both during and after the pilot study, together with the reflections of the development team, a summary of the overall strengths and weaknesses of the pilot were noted (see Figure 7).
Two hour synchronous meeting One week asynchronous discussions
  • Scheduling and scaffolding meant that the group did not spend time self managing
  • Those with little online experience were able to participate
  • Students engaged well with individual summaries and reflections embedded in the process
  • Synchronous meetings seemed to create a "virtual proximity" which may be an enabler for group socialization
  • The authentic nature of the scenario stimulated great interest.
  • Few opportunities for learners to develop skills in independent group work.
  • Less student-centric than some PBL models.
  • Synchronous meetings seem to create expectations of high tutor involvement
  • Synchronous meetings were  only suitable for small groups (<15).
  • Less accommodating of flexible participation than an entirely asynchronous design. 
Figure 7: strengths and weaknesses of the pilot study
Lessons learned

Access and Motivation:
Considering that this was a pilot study and that the students were volunteers, the degree of engagement exceeded expectations especially since many of the participants had no previous experience of using computer mediated communication for group learning activities.

Time and efficiency: The number of learning issues that were exposed in a relatively short period of time made for an intense and high paced learning experience. Future implementations will aim to tackle fewer learning issues or will perhaps divide several issues between smaller groups. It is often difficult to schedule interactions so that the pace is appropriate for a particular group of learners. The pilot has indicated that extending the length of the asynchronous sessions and reducing that of the synchronous meetings might fit better with the lives of our busy student population.
Locus of control: There was a noticeable difference in the approach adopted by the tutors in this pilot study, which blended asynchronous and synchronous sessions, compared to the purely asynchronous discussion events held elsewhere on the programme. In the synchronous sessions the tutors adopted a leadership rather then facilitative stance. This may or may not be problematic; however, considering that the pilot virtual clinic was seemingly more demanding of time and effort on the part of the tutors than purely asynchronous discussions, and given that one of the main benefits cited of problem based learning is that it encourages student autonomy, (Savin & Baden, 2000) future plans for the virtual clinics will need to look for ways in which to increase student self direction.This might be achieved in a number of ways including:
  • Allocating more time to the asynchronous sessions to enable more in depth engagement and student autonomy to develop.
  • Sub-dividing into smaller groups.
  • Using the synchronous sessions for a different purpose for example small group presentations of plans and progress with peer review and tutor feedback
  • Exploring different tutor roles in the synchronous sessions, for example as 'guest expert'.
  • Ensuring clarity of guidance to students about the roles and responsibilities. 

Design and development: Building scenarios from real clinical experience was not only beneficial to the students in giving opportunities to observe and analyse clinical expertise, but also to the clinical tutors by facilitating reflection on their own practice experiences. The time required to develop a scenario with activities appropriate to scaffolding the learning process should not be underestimated, and this pilot study yielded valuable information about the resource requirements for scaling up. Working together in design teams not only generated a virtual clinic but also functioned as staff development for the clinical tutors. The requirement for staff development will undoubtedly need to be addressed in different ways as the virtual clinics project develops further.
Future plans
The outcome from the pilot virtual clinic study has encouraged us to extend their development as a component of the SEM programme and use similar PBL approaches to other postgraduate programmes for healthcare professionals.
The next phase of the virtual clinics project will focus on their integration with the existing units of study and will address issues such as how best to assess engagement with the virtual clinics and will examine how effective they are as vicarious experiences of clinical practice. 

Geraldine Jones Programme Development Manager, School for Health, University of Bath

Dr. Stuart Miller Honoury Senior Lecturer, School for Health, University of Bath

Dr. Michael England Honoury Senior Lecturer, School for Health, University of Bath

Mr. Tim Bilham Director, Education Research and Development, School for Health, University of Bath

Barrows, H S & Tamblyn, R M (1980), Problem based learning: An approach to medical education, New York: Springer.
Greenhalgh, T (1999), Narrative based medicine in an evidence based world. BMJ 318:323-325.
Salmon, G (2003), E-moderating: the key to teaching and learning online; London: Routledge Falmer.
Salmon, G (2002), E-tivities: the key to active online learning, London: Routledge Falmer.
Savin & Baden, M (2000), Problem based learning in Higher Education: Untold Stories, SRHE and Open University Press.

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