{"paper_id":"1ea14f91-ecd5-4630-a695-a99899786f16","body_text":"1\n1 Student perceptions of cardiovascular physiology module format in a preclinical medical science\n2 course\n3\n4 Kristen Scherrer 1¶, Spencer Sullivan1¶, Gary Beck Dallaghan1, Emily Moorefield1\n5\n6 1University of North Carolina School of Medicine at Chapel Hill, NC, USA\n7\n8\n9 *Corresponding author\n10 E-mail: emily_moorefield@med.unc.edu  (EM)\n11\n12\n13 ¶ These authors contributed equally to this work.\n14\n15\n16\n17\n18\n19\n20\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\n21 Abstract:\n22 Positive active learning outcomes require student engagement with foundational, preparatory material \n23 prior to class. The current study involved thorough updating of cardiovascular physiology module \n24 format. It then examined preclinical medical student perceptions, and midterm exam performance, after \n25 using different preparatory module formats that were reviewed prior to participating in interactive \n26 classroom sessions. Modules that were initially created in Articulate Storyline were updated in Articulate \n27 Rise360 and introduced over a 3-year period. Both module styles contained the same cardiovascular \n28 physiology content, but updated Rise360 modules presented content in multiple formats to capture a \n29 variety of student learning preferences and divided each concept into several smaller topics to maintain \n30 student attention. Although midterm exam performance remained unchanged, student evaluations \n31 revealed that the updated Rise360 modules were more helpful with fewer technical issues indicating \n32 that students preferred the interactive online modules to prepare for collaborative classroom exercises. \n33 Students find updated preparatory modules to be more helpful and may therefore be more likely to \n34 engage with them before class and ultimately lead to a more productive interactive classroom learning \n35 experience.\n36 Introduction: \n37 Implementation of active-learning techniques has consistently shown to enhance concept retention and \n38 student achievement [1,2]. One approach to active learning, the flipped classroom, requires that \n39 students acquire foundational knowledge outside of class and then apply this knowledge through higher \n40 order thinking and problem-solving exercises with the support of faculty and peers in class [3, 4]. Thus, \n41 student preparation outside of class is essential for successful implementation of this type of active \n42 learning technique [5]. Faculty-created modules are one way to provide students with foundational, \n43 preparatory content and have the advantage of being customized to cover specific course objectives \n44 useful for interactive classroom exercises. Students are responsible for a thorough and thoughtful \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n3\n45 review of module content prior to class so that they are prepared to actively engage with faculty and \n46 peers during the classroom session.\n47 The current study therefore sought to examine student perceptions of preparatory module format when \n48 learning basic cardiovascular physiology. An initial set of modules on six cardiovascular physiology \n49 concepts was created in roughly the year 2000 using Articulate Storyline, which included audio, video, \n50 and matching questions. Module topics included: membrane potential, cardiac cycle, electrocardiogram, \n51 vascular hemodynamics, cardiac output, and regulation of mean arterial pressure. Each of the six \n52 Storyline module videos had a run time of approximately one hour. Storyline modules were initially well \n53 received; however, as time has progressed they have become technologically outdated as they are not \n54 compatible with popular internet browsers and do not allow for variable speed playback. \n55 Newer modules were created in Articulate Rise360 on the same six cardiovascular physiology concepts. \n56 Although content remained the same, modernized modules presented content in multiple ways \n57 including brief videos allowing variable speed playback, corresponding web-based text and graphics, \n58 interactive images, and multiple-choice check-your-understanding questions. Updated modules also \n59 divided each concept into several smaller topics. For example, cardiac cycle module topics include \n60 events of the cardiac cycle, volumes and pressures of the cardiac cycle, heart sounds, and pressure \n61 volume loops. Updated modules were introduced in a stepwise manner beginning in 2019, when \n62 students were assigned two new Rise360 modules on traditionally more complex topics, the cardiac \n63 cycle and cardiac output, and the original Storyline modules on the remaining topics. Then, beginning in \n64 2020, and in 2021, students were assigned updated Rise360 modules on all six basic cardiovascular \n65 physiology topics. The 2017-18 school years were included as a comparison group since all five modules \n66 assigned were Storyline modules. Herein we examined student, end-of-block evaluations and discovered \n67 that students found the updated Rise360 modules to be more helpful and have fewer technical issues \n68 than the original Storyline modules.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n4\n69 Materials and Methods: \n70 Student perceptions of module format were assessed by examining end-of-block evaluations. In the \n71 evaluations, students rated modules, as well as other modes of instruction, using a 5-point Likert scale \n72 ranging from “not at all helpful” to “extremely helpful”, or by selecting, “Did not use/NA to this block”. \n73 Student ratings were compared across years using the Kruskal-Wallis Test with Mann-Whitney U test for \n74 nonparametric data (IBM SPSS, v24).\n75 In addition, narrative comments that included the word ‘module’ were extracted from open-ended \n76 evaluation questions including, “Please comment about your experiences with content and \n77 organization.”, and “Which methods and/or materials were most helpful? What could have been more \n78 helpful? How?”. Narrative comments were inductively analyzed, and four common themes were \n79 identified: organizational, technical, content, and general, which were further categorized as a ‘pro’ \n80 comment or a ‘con’ comment (see Figure 1 caption for details). Three independent researchers then \n81 deductively categorized themes from the student comments and discrepancies were discussed until full \n82 agreement was reached. Data was anonymously collected and analyzed in aggregate.\n83\n84 Fig 1 Categorization of open-ended responses containing the word ‘module’ for each student cohort. \n85 Data are presented as the percentage of comments in each category (y-axis) as well as the number of \n86 comments in each category (numerical values within bars). Comments containing the word ‘module’ \n87 were extracted and inductively categorized into four themes: technical, content, organizational, and \n88 general. Technical comments discussed technical features like functionality, speed, and browser \n89 compatibility. Content comments discussed the usefulness of the modules and other non-technical \n90 aspects including the amount of detail in the module and organization of an individual module. \n91 Organizational comments discussed the flow of content and instruction throughout the block including \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n5\n92 the timing of modules and their connections with other material. General comments discussed non-\n93 specific, generalized descriptions of modules. Comments were further divided into ‘pro’ and ‘con’ \n94 categories based on whether the overall impression was favorable or not. Some comments included \n95 more than one sentiment and were therefore classified into multiple categories. \n96\n97 Additionally, student performance on the cardiovascular block multiple-choice midterm exam was \n98 analyzed across each year using the Kruskal-Wallis Test to assess comprehension and retention \n99 differences in module format types. The general content and number of questions per topic remained \n100 similar from year to year. \n101 This study was approved by the UNC-Chapel Hill Office of Human Research Studies and conducted under \n102 the guidelines of UNC IRB Study 22-2111. Consent was not obtained because all data were analyzed \n103 anonymously.\n104 Results: \n105 A Kruskal-Wallis test demonstrated that student ratings of module helpfulness increased as additional \n106 Rise360 modules were introduced, H(2) = 35.14, p < 0.001 (see Table 1 for descriptive statistics and \n107 student ratings by year). Mann-Whitney tests were used to compare all groups and showed that module \n108 helpfulness ratings in 2019 were significantly greater compared to 2017-18 (p = 0.022), and in 2020-\n109 2021 they were significantly greater compared to 2019 (p = 0.006) and 2017-18 (p < 0.001). These \n110 findings suggest students were more satisfied with the quality of updated Rise360 modules compared to \n111 original Storyline modules. \n112\nCourse Year 2017 - 2018 2019 2020 - 2021\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n6\nStudents per group (n) 369 180 356\nModule Rating; M (SD) 3.35 (1.24)* 3.62 (1.10)* 3.89 (1.09)*\n113\n114 Table 1 Modules were rated on their level of helpfulness using a 5-point Likert scale by each student \n115 cohort, 2017-18, 2019, and 2020-21. * Statistical Significance using Kruskal-Wallis and Mann-Whitney \n116 tests (p < 0.05). Abbreviations: n, sample size; M, mean; SD, standard deviation.\n117\n118 Analysis of student comments containing the word ‘module’ revealed an increased number of positive \n119 comments in all four categories with the implementation of updated Rise360 modules (Figure 1). \n120 Initially, in 2017-18 when students were assigned only Storyline modules, there was a high number of \n121 comments associated with technology and the majority were negative (39 technical comments total; 37 \n122 con). These comments referenced the inability to access the modules in Chrome and the inability to \n123 view the module at 2x speed, among other functional issues. Over the 3-year incorporation of the \n124 Rise360 modules, the total number of technical comments decreased dramatically (37 con comments in \n125 2017-18 down to 1 con comment in 2020-21) with mostly positive comments by 2020-21 (6 technical \n126 comments total; 5 technical pro) and reference to the ease of use.\n127 The overall number of comments regarding module content did not change drastically during the \n128 module updating period. However, interestingly, the percentage of positive comments for module \n129 content increased each year and in 2020-21, when all the modules assigned were Rise360 format, 85% \n130 of module content comments (75 of 88 total) were positive even though the content presented \n131 remained the same. Student comments regarding organization of content within the block including the \n132 timing of modules and their relationship to other material also decreased in number over time and there \n133 were many fewer negative organizational comments with the introduction of Rise360 modules. General \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n7\n134 comments about the modules did not reference specific features and showed a similar trend with fewer \n135 general con comments after incorporating the Rise360 modules. \n136 Analysis of midterm exam performance across years failed to show any significant difference: 81.2% (SD \n137 8.4) ,78.9% (SD 10.8), 80.7% (SD 9.5) for 2017-18, 2019, and 2020-21, respectively, (H(2) = 4.75, p = \n138 0.093). This finding demonstrates that the newer modules did not directly influence immediate student \n139 learning or retention. \n140 Discussion: \n141 In this study cardiovascular physiology modules were thoughtfully updated with the goal of increasing \n142 student engagement and understanding of foundational cardiovascular physiology concepts. Original \n143 Storyline modules presented each of six cardiovascular physiology concepts as a single video with a run \n144 time of approximately one hour, a format which may be challenging or overwhelming for students to \n145 process and comprehend. Updated Rise360 modules presented topics using multiple learning \n146 modalities, which appeals to a variety of learning preferences and encourages a wide range of students \n147 to interact with content. In addition, Rise360 modules separated each concept into smaller parts to \n148 allow easier navigation, prevent distraction, and facilitate completion without interruption.   \n149 Our analysis of student evaluation ratings and comments revealed that Rise360 modules were more \n150 helpful and had fewer technical issues than the original Storyline modules. Previous research \n151 demonstrates that interactive modules increase student study time [6] which may enhance active \n152 learning classroom activities. In addition to study time, increased usage may also translate into a greater \n153 number of students that engage with the modules at a time when engagement is dwindling [7]. One \n154 limitation of the current study; however, is that our institution’s learning management system was not \n155 configured to track the number of students that opened modules or the amount of time each student \n156 spent interacting with the modules. Although student evaluations suggest there was more engagement \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n8\n157 with the updated modules, we are unable to directly compare student interaction between the different \n158 module styles. \n159 Interactive modules that provide learner control, graphics and videos, and self-assessments have shown \n160 to significantly increase medical student learning of basic science concepts [8, 9]. The present study \n161 confirms that students found the updated Rise360 modules containing these features to be more \n162 helpful. However, regardless of the module format assigned, student performance on the cardiovascular \n163 midterm exam remained unchanged. Our findings are consistent with other mixed results on the impact \n164 of modules [6] and flipped classrooms [4] on promoting knowledge acquisition and retention. \n165 One complicating factor in our study is that overall exam performance has declined over the past several \n166 years, perhaps due in part to the stress of the COVID-19 pandemic. Pandemic-related stress has shown \n167 to negatively impact mental health and exam performance in medical students [10, 11]. It is possible to \n168 consider that students’ cardiovascular midterm exam scores may have also significantly declined if not \n169 for the updated Rise360 modules. Additional research is needed to determine whether this may be the \n170 case and to further investigate specific module features that may enhance student learning.\n171 In conclusion, our findings suggest that careful consideration of preparatory material format is critical \n172 for maximum student satisfaction in preparation for active learning classroom activities. Presenting \n173 preparatory modules in a modern, interactive format with self-assessment improves student \n174 perceptions of the materials. Students find updated preparatory modules to be more helpful and may \n175 therefore be more likely to engage with them before class, which may lead to a more productive \n176 interactive classroom learning experience.\n177 References:\n178 1. Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, Wenderoth MP. Active learning \n179 increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A. \n180 2014; https://doi.org/10.1073/pnas.1319030111\n181 2. Rossi IV, de Lima JD, Sabatke B, Nunes MAF, Ramirez GE, Ramirez MI. Active learning tools improve \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n9\n182 the learning outcomes, scientific attitude, and critical thinking in higher education: Experiences in an \n183 online course during the COVID-19 pandemic. Biochem Mol Biol Educ. 2021; \n184 https://doi.org/10.1002/bmb.21574\n185 3. Street S, Gilliland KO, McNeil S, Royal K. The flipped classroom improved medical student \n186 performance and satisfaction in a pre-clinical physiology course. 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The use of self-learning modules to facilitate learning of basic science \n198 concepts in an integrated medical curriculum. Anat Sci Educ. 2010; https://doi.org/10.1002/ase.177\n199 9. Velan GM, Killen MT, Dziegielewski M, Kumar RK. Development and evaluation of a computer-assisted \n200 learning module on glomerulonephritis for medical students. Med Teach 2002; \n201 https://doi.org/10.1080/01421590220145806\n202 10. Zis P, Artemiadis A, Bargiotas P, Nteveros A, Hadjigeorgiou GM. Medical studies during the COVID-19 \n203 pandemic: the impact of digital learning on medical students’ burnout and mental health. Int J Environ \n204 Res Public Health. 2021; https://doi.org/10.3390/ijerph18010349.\n205 11. Andersen S, Leon G, Patel D, Lee C, Simanton E. The Impact of COVID-19 on Academic Performance \n206 and Personal Experience Among First-Year Medical Students. Med Sci Educ. 2022; \n207 https://doi.org/10.1007/s40670-022-01537-6. \n208\n209\n210\n211\n212\n213\n214\n215\n216\n217\n218\n219\n220\n221\n222\n223\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n10\n224\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 29, 2023. ; https://doi.org/10.1101/2023.05.28.23290652doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}