Perception, knowledge and attitude of learners about the use of 3D technologies in manual therapy education – A qualitative study

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The current paradigm of teaching manual therapy incorporates the traditional ‘See one, do one, teach one’ approach. However, this ‘teacher centred’ approach may not enable learners to develop the complex clinical skills of manual therapy. In this context, 3D technologies such as virtual reality may facilitate the teaching and learning of manual therapy. Hence the aim of the current study was to investigate the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education. Methods : An exploratory qualitative research design using semi-structured interviews was used in this study. A total of ten manual therapy (5 physiotherapy and 5 osteopathic) students (age =32 (Range19-58); 80% female) enrolled in an appropriate physiotherapy or osteopathic degree provided by a New Zealand recognized institution (e.g university or polytechnic) participated in this study. Data saturation was achieved after 10 interviews (average duration: 35 minutes) that provided thick data. A thematic analysis was the method of choice for data analysis. Results : Five factors were identified which appeared to influence participants’ perception of role of technology in manual therapy education. These were (1) Sufficiency of current teaching method; (2) Evolution as a learner (novice to expert); (3) Need for objectivity; (4) Tutor feedback; and (5) Barriers and enablers. These five factors influenced the participants’ perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions (‘no role’ (techstatic) versus a ‘complete role’ (techsavvy)). Conclusion : Although 3D technology may not replace face-to-face teaching, it may be used to complement the traditional approach of learning/teaching to facilitate the learning of complex skills by manual therapy learners. The advantage of such an approach is an area of future research. Manual Therapy Education Physiotherapy Osteopathy 3D Technology Virtual Reality Figures Figure 1 Background Manual therapy (MT) is a specific hands-on approach used by various professions such as physiotherapy and osteopathy. Learners of MT are required to develop complex clinical skills such as clinical reasoning, manual/physical assessments, palpation and patient management which include skilled hands-on treatment 1 . The process of learning clinical manual therapy skills usually incorporates the traditional ‘See one, do one, teach one’ approach. This ‘teacher centred’ approach consists of students observing an expert clinician/tutor performing the techniques on a student, a plastic anatomical model, or a patient 2 , 3 . The underlying assumption is that learners become increasingly independent after observing an expert clinician or teacher 4 . The teacher/expert then proceeds to check the learner’s technique and provide feedback. By providing feedback and guidance, it is believed that the ‘see one, do one’ approach may enable the learners to grasp the varied physical examination, palpation and treatment skills 5 . Nevertheless, this approach has been criticized as an inadequate method in maintaining required patient safety standards. This is due to lack of supervision, reflection on action, performance evaluation and structured feedback 6 . Studies show that between 28% and 42% of medical residents felt inadequately trained to safely perform a medical procedure alone for the first time 7 , 8 . These could be attributed to the traditional (see one do one) teaching methods 8 . A meta-analysis 9 compared the effectiveness of traditional (see one do one) methods of clinical medical education versus simulation based medical education with deliberate practice. The findings from the study clearly demonstrated that not only was student performance better in the simulated group, benefits were observed in long-term retention of skills 9 . Three dimensional (3D) digital technologies such as virtual reality (VR), augmented reality (AR) and mixed reality technologies have been used in several applied fields including teaching and learning 10 . While emersed in a VR environment, the user is completely immersed 10 , an AR system combines or “supplements” real world objects with virtual objects or superimposed information 11 . Further, some VR systems have in-built haptic (sense of touch) devices (e.g., the Geomagic, the Phantom Omni). The addition of haptic feedback in VR environments creates more realistic scenarios, while providing trainees with a safe environment in which they can develop their skill 12 . Few haptic devices are specifically designed to enable the user to grasp virtual objects and provide varying degrees of freedom 13 , 14 . Evidence indicates that 3D technologies in educational settings can improve task completion times, lead to fewer errors and improve student’s motivation to learn 15 . However, the role of 3D technologies in manual therapy education is largely unknown. Research question: What is the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education? Aim/objectives: The aims of the current qualitative study were to: 1) investigate the perceptions, knowledge and attitude of manual therapy leaners about the use of 3D technologies in manual therapy education and (2) explore the barriers and enablers for using 3D technologies as part of manual therapy education. Methods We followed the Consolidated Criteria for Reporting Qualitative Studies guidelines for reporting this qualitative research 16 . Ethical approval for the study was provided by Waikato Institute of Technology’s Research Ethics Committee (WTLR32200721). All participants signed an informed consent sheet prior to participation. Study Design An exploratory qualitative research design using semi-structured interviews was used in this study. The exploratory approach was considered appropriate to enable an in-depth understanding of the use of 3D technology by manual therapy learners 17 . Participants : A total of 10 students enrolled in an appropriate manual therapy course provided by a New Zealand recognized institution such as a polytechnic or university participated in this study. The manual therapy course was delivered under two different settings (1) full-time on campus and (2) ‘block and blended’, where students were on campus during block weeks and did remote learning at other times. An email was sent with study details to various membership bodies and institutions that teach manual therapy with convenience/purposive sampling used to recruit participants. The demographic information of participants is provided in Table 1 . Table 1 Participant demographics Mean Age 32 (range: 19–58) Gender 2 Males 8 Females Profession 5 Physiotherapy Students 5 Osteopathy Students Year of Study 5 Year three 2 Year two 2 Year one 1 Year four Learning Setting 5 Face to face 5 Blend and block Data collection: Data collection methods involved semi-structured interviews via Zoom between August 2021 to February 2022. These were mostly conducted by the primary investigator (PI). As some of the participants were known to the PI, a research assistant conducted interviews with these participants. An interview guide (appendix 1) was developed and used based on professional experience and findings from the literature. The interview guide was piloted before data collection to ensure clarity and to remove possible ambiguity. The average duration of the interviews was 35 minutes. Field notes were taken to facilitate data analysis. All interviews were recorded and transcribed verbatim. A diversity of viewpoints was captured that enabled the study’s findings to achieve data sufficiency/saturation after the tenth interview. Data analysis A thematic analysis was the method of choice for data analysis 18 . Each interview set was initially analysed independently by two investigators. Initial coding was undertaken and assisted by NVivo V.10 qualitative analysis software. Category and theme development from the initial codes was an iterative/analytical process 18 . This involved reading and re-reading the transcripts/memos/field notes looking for patterns in the data (such as differences and commonalities). Memos were written throughout the analytical process and facilitated reflexivity by making it explicit any apriori biases of the researcher, thereby contributing to the credibility of the research. The themes generated were assessed by a third investigator (member checking) for plausibility and explanatory values against the transcripts. Finally, categories (factors) along with the themes were developed from the student interviews. Findings Five factors were identified which appeared to influence participants’ perception of role of technology in manual therapy education. These were; Sufficiency of current teaching method Evolution as a learner (novice to expert) Need for objectivity Tutor feedback Barriers and enablers Sufficiency of current teaching method Sufficiency of current teaching method was a key factor contributing to participants’ perception about the role of technology in manual therapy education. Participants who felt that their current teaching was sufficient believed that technology had no or little role in manual therapy education. “I can’t think of another way of doing it than the way they do it. To me what they do is great but it’s maybe because I’ve never thought about [it]”. (P6). “I feel like it is sufficient…for us to be a better therapist [and] to learn better with our hands” (P2). Participants who perceived the current teaching of manual therapy to be sufficient tended to be osteopathic students learning manual therapy from year one of their program. Being exposed early to hands-on manual therapy courses may have influenced their perception and embedded an established routine for learning. “[The] actual practical part side of it I think is really good, like they have a routine. They’ll show us a technique or like a special test or whatever they do, and then we’ll go away in our little groups and practise that, and I think that’s really like effective. Then the teachers come round and like adjust us if needed and just like help us and give us like random tips and stuff” (P7). Conversely some participants perceived that their current teaching of manual therapy was insufficient and inadequate. “I’d like to say yes but no, not really. I almost feel as if a lot of it is just left up to you to try and work out if you’re doing it right. The tutor can’t feel exactly what you’re doing. They can only look and think it does look you’re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you’re doing it right or what you’re feeling is the correct thing” (P9). Participants who felt that the manual therapy teaching was insufficient were most likely enrolled in a blended learning pathway where they are on campus for block teaching weeks and off-campus during the rest of the learning period. This model of delivery meant that a lot of content was taught in a short period of time. This made them feel that they lacked time to reflect on their learning and made them feel completely ‘overwhelmed’ while trying to grasp the complex manual therapy skills. “The way it’s been working is we have these eight hour long days and we have to cram/study all this information in the morning, have lunch, and then come back and cram the rest of the knee and maybe even the whole lower limb for the rest of the day and we just go away at night just feeling so overwhelmed, and then write an essay on a completely different subject” (P1). Need for objectivity The need for objectivity appeared to contribute towards the perception of participants regarding the role of technology in manual therapy education. Some participants felt that the current teaching paradigm was subjective and lacked reliability with different tutors teaching different things. “I think there’s a bit of confusion between the tutors and how they do things. One would put the hand below the pelvis and one would put it above the lower back for the same technique. I thought to start with that if at least the three tutors agreed, or four tutors, agreed on what they’re teaching us and teach us this at least there’s no like, yeah but you can do it like this” (P4). The use of different approaches by different tutors and an apparent lack of objectivity lead to self-doubt among some participants about their ability and the correct method. “Yeah the palpation or even when getting the tests done to see how it feels, from someone who feels confident in doing it, whereas us students, you know you’re always wondering ‘oh am I doing it right?’ or if things are a bit fiddly” (P3). These participants perceived that technology therefore could enhance their confidence by negating subjectivity. ”… it would definitely be helpful to have something that means you’re more confident and that you’re practising the correct thing when you don’t have the tutor right there. So if there’s some way that it can help it would, yeah. It would be quite helpful” (P3). Participants who required measurements or an objective way to do things were more likely to believe that technology such as VR is required as part of manual therapy education. They were more likely to perceive that VR would guide them to palpate the structure that they need to thereby improve accuracy of palpation. “I almost feel as if a lot of it is just left up to you to try and work out if you’re doing it right. The tutor can’t feel exactly what you’re doing. They can only look and think it does look you’re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you’re doing it right or what you’re feeling is the correct thing” (P9). Further, by enabling to visualise various layers within the body, technology can be a powerful tool especially for visual learners. In turn, this kind of learning experience authentic by enhancing fidelity (realness). for the learners. When presenting examples of the use of VR and how this might enhance understanding and ability to perform skills completely, they responded: “The reason I thought this would be really cool is because the first thing I thought of is if I can see something… then I can sort of match where I’m going. That’s where things stick for me. I don’t know what kind of VR technology you have but if you could see that’s the skin but then under it you’ve got a layer of bones or whatnot then you can match up. I think that would be really good for a lot of visual learners… I think it would be quite powerful in learning” (P8). “It would be really interesting if you could use your hands to move and manipulate the body or even just to touch it, to highlight a particular muscle or muscle group… perhaps it would make it feel a whole lot more real to me” (P1). Evolution as a learner (novice to expert) The perception of role of 3D technology in manual therapy education depended on the expertise level/evolution of the learners. Participants who were early on in their educational journey felt that the current teaching methods (see one, do one approach) to be adequate. They were comfortable learning gross motor skills (e.g. holding a leg) that does not require deeper palpation skills. “At the moment because I’m a first year I’m getting comfortable with touching people and making sure that when you’re holding their leg they feel like she’s got me. That’s what we’re working on at the moment” (P6). Conversely participants who were at the later stage of their educational journey emphasized the need for technology to support the development of finer motor skills required for deeper and subtle palpation. “I’m finding it really difficult because you don’t know what you’re trying to feel. Don’t know what you’re feeling for and trying to translate a description into trying to work out what I’m feeling. I’m actually struggling with that a little bit. Generally the more obvious techniques are great but when it comes to really subtle palpation it’s really difficult to try and understand what you’re meant to be feeling for” (P9). It was noted that participants’ who had already completed manual therapy courses before were likely to perceive that the current teaching methods were adequate and the need for technology to be minimal. Participants with manual therapy experience felt that students who have not done manual therapy before would require more support. “ I have worked in massage now for five years, so I’ve got a lot of palpatory hands on experience but it doesn’t make me like an osteopath or anything, but for some of the school leavers, they come straight out of school and they’ve probably only touched their own skin never mind someone else’s “ (P2). Tutor feedback A key factor mandatory for learner development is feedback from tutors. Most participants felt that the current teaching methods were inadequate and unsustainable as often there is often only one tutor running a teaching session. This meant that they did not receive enough feedback where they could refine their manual therapy skills. “Often we then break off into little groups or pairs to practise it but then it’s very hard for that one tutor to get round all of those pairs to make sure they’re doing it correctly. And often people have questions and then they go caught up talking, so a lot of the time you might be trying to do one practical thing” (P3). “The way they explain things don’t make sense. It might not be the best example but we have to manipulate the cervicals. She said you do it like this and she shows. But we can’t even see the fingers underneath the neck so it’s a bit complicated for us”(P6). Participants that received less tutor feedback explained that they were trying to learn complex manual therapy skills from 2d images or PowerPoints which can be challenging. Hence, they perceived that 3D technology such as VR would be important in enhancing their leaning. “Everything I’m trying to learn is via a PowerPoint or videos which can be challenging. I’m a practical learner so if we don’t do the practical I struggle in connecting stuff where others pick it up quite well. I don’t learn that way” (P8). “Apart from PowerPoints and a few videos or something like that is about the most digital we get I think” (P9). In contrast some participants felt that they received good feedback from their teachers, which meant that they relied less on technology. “He gave us specific landmarks that we would look for. For example, C7 would be the most prominent one that sticks out in forward neck flection and that was a good baseline in order to help us when we would palpate for cervical spine. He would give us points in which they were quite useful for our learning” (P5). Specifically, these participants felt that they learnt more when the tutors placed their hands on top of theirs and showed them how to do a certain technique. This human interaction therefore was key in learning manual therapy. “One thing I found effective with a clinical supervisor I have is we had a patient and he put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me” (P1). “…we were doing a technique called ‘functional’ on the like upper thoracic and the person is lying down, and you like put your hands under and she comes along, she [tutor] came along, and put her hand under our hand and so she could feel where it needed to go and stuff, so that was really good” (P7). Barriers and enablers: Some factors were both barriers and enablers for using 3D technologies as part of manual therapy education. These factors include (1) cost (2) knowledge about technology (3) accessibility and (4) ethical issues. Almost all the participants felt that cost was a significant barrier if technology such as VR to be used in manual therapy education. “I’m sure that the cost of it is one main problem. People even thinking about it. People developing it and being paid to develop it and then people would have to buy that technology” (P6). “The cost. I think that would be a big thing would be the cost really. That would really be the only barrier that I can think of” (P9). The participants believed that the cost on students could be reduced if the institutions could bear some or most of it thereby enabling students to access technology. “I doubt they’ll let us as students take one home because they’re so expensive. If institutions can pay for it so we students can still access it a reduced cost perhaps” (P8). “Obviously that financial one may play a big part so I guess having one of those facilitators such as a support might be necessary” (P5). All participants indicated that they would be keen to try technology if it is available. However, some required further knowledge about technology. They thought that using technology without completely understanding it or if the technology did not work properly, may discourage them from using it. “…People’s knowledge in the tech, around the technology as well if it would be something that people don’t work with a lot and they’re being bombarded with a whole lot of other new information… If it doesn’t work properly the first time it can be rather annoying, or discouraging, would be another barrier to it” (P3). “Yep absolutely, if there was adequate training I would be very open to using it yeah.” (P2). Some participants thought that ease of access could a barrier from using technology such as VR. They felt that using technology for a long time can lead to fatigue and discourage further use. “… [I] don’t know how long you can stay in goggles like this before it gives you a headache” (P6). “ [I] think one thing is that I can get fatigue from being on technology for a while” (P3). In terms of ease of access, internet connection was identified as another barrier. “Maybe internet connections. I don’t know if you need to internet to download specific stuff” (P5). ”Connections, issues, are a big one, I’ve noticed that my connections been shocking so it kind of breaks in and out throughout classes which is tricky. Maybe attitude towards technology, I personally, I don’t mind using it but I know some people don’t enjoy using technology, and I guess accessibility for some people as well” (P4). Few participants were concerned about ethical issues such as cultural responsiveness that may arise using technology such as VR as part of manual therapy education. “There’s got to be like a level of cultural responsiveness or just appropriateness or ethics what would need to, student would have to get. Or it would just have to, the simulation would have to have restrictions” (P1). Conversely, these ethical issues could be overcome by completely explaining the design of VR. “…the only thing I can think of is like consent and making sure people are okay with what they’re seeing and also by enabling limiters so students” (P2). The five factors discussed above in turn influenced the participants’ perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions (‘no role’ (techstatic) versus a ‘complete role’ (techsavvy)). Figure 1 depicts the interplay between the five factors and how they influence the learns position as either being techsavvy or being techstatic. Participants that perceived that technology had no role in manual therapy education tended to view that the current (“see one, do one”) approach was best suited for manual therapy education. “I think the current way manual therapy is taught is sufficient. I don’t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise” (P7). These participants believed that technology cannot replace human interaction and that ‘face to face’ sessions are important to learn the complex manual therapy skills. “Technology has a place, but again I think you can’t replace face to face learning. I think there needs to be that sense of community still, like there’s nothing better than being in class with our classmates” (P4). With a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve “hands on hand” feedback. One participant explains this as: “He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like ‘oh that’s how you do it, that’s how it’s supposed to feel, that’s what you’re doing’ and I could sort of feel through my hands” (P1). Participants on the opposite end of the continuum perceived technology as ‘futuristic’ and an ‘advanced’ way to learn manual therapy. “…if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient… that’s going way advanced” (P2). These participants believed that the repeated practice opportunity that technology offers, provides an ‘objective’ way to learn manual therapy skills. “Oh totally, yeah big time. Now I think it’s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively” (P10). “Technology is awesome, I think most of our learning in manual therapy is self-directed…technology will provide repeated practice opportunity given that we can use them [technology] at home” (P6). Participants’ perception about the role of 3D technologies in manual therapy education can be viewed as on a continuum, from ‘no role’ (techstatic) to ‘complete role’ (techsavvy). Some participants’ perception lay at the extreme ends of the continuum whereas others fell in between the two extremes. Participants that perceived that technology had no role in manual therapy education tended to view that the current (“see one, do one”) approach was best suited for manual therapy education. “I think the current way manual therapy is taught is sufficient. I don’t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise” (P7). These participants believed that technology cannot replace human interaction and that ‘face to face’ sessions are important to learn the complex manual therapy skills. “Technology has a place, but again I think you can’t replace face to face learning. I think there needs to be that sense of community still, like there’s nothing better than being in class with our classmates” (P4). With a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve “hands on hand” feedback. One participant explains this as: “He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like ‘oh that’s how you do it, that’s how it’s supposed to feel, that’s what you’re doing’ and I could sort of feel through my hands” (P1). Participants on the opposite end of the continuum perceived technology as ‘futuristic’ and an ‘advanced’ way to learn manual therapy. “…if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient… that’s going way advanced” (P2). These participants believed that the repeated practice opportunity that technology offers, provides an ‘objective’ way to learn manual therapy skills. “Oh totally, yeah big time. Now I think it’s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively” (P10). “Technology is awesome, I think most of our learning in manual therapy is self-directed…technology will provide repeated practice opportunity given that we can use them [technology] at home” (P6). Discussion The findings from our study indicate that manual therapy learners have different views about sufficiency of current teaching methods; their evolution as a learner; need for objectivity; tutor feedback; and barriers and enablers, which together shape their overall perception about the role of technology in manual therapy education. Such diverse viewpoints amongst manual therapy learners are consistent with learners from other medical professions. Learners who perceived that technology has no or minimal role in manual therapy education alleged that the current way of teaching manual therapy was adequate and the ‘see one, do one’ approach is the best way to deliver this form of education. These participants considered their teachers were effective, had excellent teaching skills and respected them as students. By sharing real life scenarios and demonstrating hands-on techniques, these teachers were ‘preferred’. Although “teacher centred”, preferred teachers had a positive impact for these learners and motivated them in learning manual therapy skills. Hence, the teaching style and the positive interaction that they adopted was considered sufficient by participants. This is in synonymous with findings of previous studies that showed that ‘preferred teachers’ have a critical influence on learner’s academic success, professional and personal development 19 , 20 . Further, these participants perceived that face-to-face teaching was crucial for their learning and ‘nothing could replace human interaction’ 21 . In opposition, some participants felt that technology has a bigger role in manual therapy education and may provide objectivity for their learning. These participants were likely to perceive that the ‘see one do one’ approach has its limitations and current methods for teaching manual therapy was insufficient. These findings concur with randomised controlled trial 9 results that compared ‘best practice’ model with the traditional model of teaching. While the ‘best practice’ model included structured feedback, practice on manikins and Peyton’s ‘four step’ approach; the ‘traditional model’ was the ‘see one do one’ approach. The study showed that the traditional ‘see one do one’ approach had limitations and the ‘best approach’ model resulted in students performing not only in the short term but also in the long term 9 . Tutor feedback was identified as a key factor that determined the perception of participants regarding the role of 3D technology in manual therapy education. Our findings suggest that participants who received less feedback from their tutors perceived that 3D technology such as VR would be important in enhancing their leaning. We suggest that this is not surprising given the difficulty associated with learning complex manual therapy skills. These findings are consistent with previous evidence that feedback assists medical students to get an understanding/feeling for what they do and increases the likelihood of correct performance 22 , 23 . Some participants believed that they get satisfactory feedback from tutors either through role play, or tutors who placed their hands on top of theirs and showed them how to undertake a certain technique. However, evidence dispute these claims reporting that such learning (see one do one) may miss essential components such as self-regulated learning, review at each stage and self-monitoring resulting in less retention of the skill set in the long term 6 , 7 . Lack of opportunity to practice was also highlighted by participants as a limitation of current way manual therapy is being taught. This led those participants to believe that having access to technology may facilitate practice/repetition, which in turn may facilitate their hands-on skill development. These findings concur with previous research which clearly indicate that practice (or lack of it) can influence student outcomes 24 . It is important to note that evidence clearly highlights that technology alone (e.g. simulator training) are not enough to improve skill performance, tutor feedback from an expert teacher is also important to enhance skill performance 9 . Our findings suggest that the expertise level of a learner was an important factor that influenced the perception of role of 3D technology in manual therapy education. Participants who were early on in their educational journey were comfortable without the aid of technology while learning gross motor skills (e.g. holding a leg) that does not require deeper palpation skills. Alternatively, participants who were at the later stage of their educational journey perceived that technology would be essential to support the development of finer motor skills/complex tasks required for deeper and subtle palpation. In this context, a complex task is one that requires: long reaction time or movement time, long hours of practice and high demands on the learner’s attention and memory 25 . Evidence suggests that 3D technologies such as virtual reality may enhance development of complex skills by providing abundant practice repetitions, delivering multi-sensory feedback, individualize challenge, and engage and motivate users with salient, enriched environments 26 . Our findings are therefore consistent with a number of studies that have shown 3D technology such as virtual reality may improve both gross and fine motor skills 27 – 30 . A number of factors were identified as barriers and enablers for using 3D technologies as part of manual therapy education including cost, knowledge about technology, accessibility and ethical issues, which are consistent with existing literature 31 – 36 . Key barriers include concerns about hardware devices such as head mount devices and the time required to learn the technology 36 – 39 . Addressing these barriers may require a collaborative approach from clinicians and developers to meet the specific demands of manual therapy education 40 . For example, the physical assessment/treatment parameters required for a knee joint will be different from that of neck and so on. As highlighted by a recent scoping review (un-published), manual therapy educators may share the clinical reasoning behind a physical assessment procedure enabling the developer to integrate the software parameters that control the degree of physical tasks and challenges to meet the assessment/treatment needs. This step may be crucial to sustain the motivation and engagement of learners over a longer period 15 . To summarise, the views of our participants were polarized with some considering the current teaching model (see one do one) to be sufficient, whereas other participants considering technology to replace current teaching methods. Taking into account both perspectives, it could be argued that the “see one, do one” approach of learning/teaching is still applicable as human interaction is important, however there is scope to build upon and enhanced this with various other learning principles and advanced technology. According to contemporary educational theory, learning happens in a zone referred by Vygotsky as the ‘zone of proximal development’ 41 . Practising beyond these limits without support is similar to practising with increased stress, less confidence and marginal competence 41 . This is considered harmful as this is the zone where learners are not capable and/or not ready for doing things 41 . Yet, this is the zone that learners encounter often with the ‘see on do one’ methodology, especially in the last 2 years where class disruptions due to the COVID-19 pandemic are frequent and face-to-face contact has been minimal. Hence, to ensure that the learners stay competent, strategies in addition to current teaching methods may be required. Using 3D technologies such as virtual reality to complement current teaching methods may represent such additional strategy and may decrease extraneous stress on the leaners. Future research may investigate the addition of technology to traditional teaching methods in improving manual therapy assessment/treatment by manual therapy learners. Strengths and limitations To our knowledge, this is the first qualitative study to explore the perceptions of manual therapy learners on the role of 3D technologies in manual therapy education. The main strength of this study was that it was open to all manual therapy students despite the discipline that they were training in (e.g. physiotherapy, osteopathy, etc). The participants came from different disciplines (physiotherapy and osteopathy); from different pathways of learning (traditional vs blended learning); and different years of learning (first year through final year of learning). This variety in participants resulted in thick/rich data that provided interesting perspectives on the role of 3D technologies in manual therapy education. We followed a robust protocol to reduce bias and enhance credibility of the findings and used COREQ guidelines to improve transparency in reporting 16 . The study is not without its limitations. A key limitation is that all the participants were learners of manual therapy in New Zealand institutions. Hence, the transferability of findings to manual therapy learners in other countries needs to be established through future research. Despite our best efforts, we did not have any participants from the chiropractic profession. However, we are confident that our data has captured different perspectives and may be applicable to any profession that uses manual therapy including chiropractic. Conclusion Participants in this study held a range of views regarding the role of 3D technologies in manual therapy education. Five factors were identified which appeared to influence participants’ perception including: sufficiency of current teaching method, evolution as a learner (novice to expert), need for objectivity, tutor feedback and barriers and enablers. These views and perceptions contributed to two opposing positions “techstatic” or “techsavvy”. However, technology may be used to complement the traditional “see one, do one” approach of learning/teaching to facilitate the learning of complex skills by manual therapy learners. The advantage of such an approach is an area of future research. Declarations Ethics approval and consent to participate Ethical approval for the study was provided by Waikato Institute of Technology’s Research Ethics Committee (WTLR32200721). All participants signed an informed consent sheet prior to participation. Consent for publication No details, images, or videos relating to an individual person was used as part of this manuscript. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the study but are available from the corresponding author on reasonable request. Competing interests The authors declare “no competing interests” (financial and/or non-financials). Author contributions KSK conceived the project and contributed to all aspects of the project including writing the first draft of the manuscript. PA and AA were associate investigators with inputs to the study design. EY helped with data collection (semi-structured interview) and analysis. EF contributed towards participant recruitment. All authors reviewed and approved the final manuscript. Funding This study was funded through an contestable research grant by Waikato Institute of Technology. Acknowledgements Nil. References Michels MEJ, Evans DE, Blok GA. What is a clinical skill? Searching for order in chaos through a modified Delphi process. Medical Teacher. 2012;34(8):e573-e581. doi:http://dx.doi.org/10.3109/0142159x.2012.669218. Easton G, Stratford-Martin J, Atherton H. An appraisal of the literature on teaching physical examination skills. Education for Primary Care. 2012;23(4):246-254. doi:http://dx.doi.org/10.1080/14739879.2012.11494117. Bugaj TJ, Nikendei C. Practical Clinical Training in Skills Labs: Theory and Practice. GMS Journal for Medical Education. 2016;33(4):Doc63-Doc63. doi:http://dx.doi.org/10.3205/zma001062. Kotsis SV, Chung KC. 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Muangpoon T, Haghighi Osgouei R, Escobar-Castillejos D, Kontovounisios C, Bello F. Augmented Reality System for Digital Rectal Examination Training and Assessment: System Validation. Journal of Medical Internet Research. 2020;22(8):e18637. doi:http://dx.doi.org/10.2196/18637. Pritchard SA, Blackstock FC, Nestel D, Keating JL. Simulated Patients in Physical Therapy Education: Systematic Review and Meta-Analysis. Physical Therapy. 2016;96(9):1342-1353. doi:http://dx.doi.org/10.2522/ptj.20150500. Rossettini G, Rondoni A, Palese A, et al. Effective teaching of manual skills to physiotherapy students: a randomised clinical trial. Medical Education. 2017;51(8):826-838. doi:http://dx.doi.org/10.1111/medu.13347. Ullrich S, Kuhlen T. Haptic palpation for medical simulation in virtual environments. IEEE Transactions on Visualization and Computer Graphics. 2012;18(4):617-625. doi:http://dx.doi.org/10.1109/tvcg.2012.46. Howell JN, Conatser RR, Williams RL, 2nd, Burns JM, Eland DC. The virtual haptic back: a simulation for training in palpatory diagnosis. BMC Medical Education. 2008;8:14. doi:http://dx.doi.org/10.1186/1472-6920-8-14. Khaled W, Ermert H, Bruhns O, et al. A haptic sensor-actor-system based on ultrasound elastography and electrorheological fluids for virtual reality applications in medicine. Student Health Technolgical Information. 2003;94:144-150. Published 2004/10/01. Tong Q, Yuan Z, Liao X, Zheng M, Yuan T, Zhao J. Magnetic Levitation Haptic Augmentation for Virtual Tissue Stiffness Perception. IEEE Transactions on Visualization and Computer Graphics. 2018;24(12):3123-3136. doi:http://dx.doi.org/10.1109/tvcg.2017.2772236. Glegg SMN, Levac DE. Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review. Pm r. 2018;10(11):1237-1251.e1231. doi:http://dx.doi.org/10.1016/j.pmrj.2018.07.004. Eun B. The zone of proximal development as an overarching concept: A framework for synthesizing Vygotsky’s theories. Educational Philosophy and Theory. 2019;51(1):18-30. doi:http://dx.doi.org/10.1080/00131857.2017.1421941. Appendix Appendix 1 is not available with this version. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1962125","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2022-08-19 17:14:16","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":166682096,"identity":"492f7076-a3a5-455d-bd78-a78fd2a4267b","order_by":0,"name":"Kesava Kovanur Sampath","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABHUlEQVRIie3SPWuDQBjA8ScE7CJkfcQQv4IiSIYQv4qHYJdL5pYW4nQukm7Fj9FuHT2EuiTtGrglIUPXSiBYCqXXQukLByFbh/uDwgk/7rlDAJ3uH4a/Vp10BMZxhKeJJN3jSCXfB4iVZZudeQlh73rJd83dI5nbV3zdwtgBO1uriG0ufNu8B1KIaYx8IQjrV10vh9hL+2WkIgOkYBUGRCCoi5yJCcPYsOV0EWBUKonztH0p3iB0BPVbzh4+yMkrwEwSkioHQwiwYdC5ETSQu5Sfu8gLqCSJ1cfPaTBs5khuxTQZLlk8k8S3crf2GCZKgnW9XUX7UTgQk2p1zsa+U5DNc3t24fTwVHljX1I+5s8PLhz+Df4QnU6n0333DvywXKZf0EagAAAAAElFTkSuQmCC","orcid":"","institution":"Waikato Institute of Technology","correspondingAuthor":true,"prefix":"","firstName":"Kesava","middleName":"Kovanur","lastName":"Sampath","suffix":""},{"id":166682097,"identity":"054ed492-52d2-4d62-8e45-834ef8df2e22","order_by":1,"name":"Ashokan Arumugam","email":"","orcid":"","institution":"University of Sharjah","correspondingAuthor":false,"prefix":"","firstName":"Ashokan","middleName":"","lastName":"Arumugam","suffix":""},{"id":166682098,"identity":"bbd0ac18-fae2-4018-9e91-7616cc4cbadd","order_by":2,"name":"Esra Yaghi","email":"","orcid":"","institution":"Waikato Institute of Technology","correspondingAuthor":false,"prefix":"","firstName":"Esra","middleName":"","lastName":"Yaghi","suffix":""},{"id":166682099,"identity":"e111105e-9f2e-427c-8ec1-7baf600d86b7","order_by":3,"name":"Emma Fairs","email":"","orcid":"","institution":"Ara Institute of Canterbury","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Fairs","suffix":""},{"id":166682100,"identity":"cedc4c5f-bd16-40b9-9658-153dd6f934ff","order_by":4,"name":"Patrea Andersen","email":"","orcid":"","institution":"Waikato Institute of Technology","correspondingAuthor":false,"prefix":"","firstName":"Patrea","middleName":"","lastName":"Andersen","suffix":""}],"badges":[],"createdAt":"2022-08-14 23:59:06","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-1962125/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1962125/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-023-04497-6","type":"published","date":"2023-07-17T21:42:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":31498727,"identity":"0c2141af-f747-478b-a0a1-a97204b16229","added_by":"auto","created_at":"2023-01-12 19:08:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85268,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFactors influencing and associated with participants’ perception of role of 3D technology in manual therapy education\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-1962125/v2/e8cd04c0dc9c46c0b208de38.png"},{"id":44734426,"identity":"0ce814c4-96a4-4095-b99f-84bf399d37e1","added_by":"auto","created_at":"2023-10-16 22:18:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":460007,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1962125/v2/147d49a8-eb53-4f93-a8fe-a3e449be4fe5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perception, knowledge and attitude of learners about the use of 3D technologies in manual therapy education – A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eManual therapy (MT) is a specific hands-on approach used by various professions such as physiotherapy and osteopathy. Learners of MT are required to develop complex clinical skills such as clinical reasoning, manual/physical assessments, palpation and patient management which include skilled hands-on treatment \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The process of learning clinical manual therapy skills usually incorporates the traditional \u0026lsquo;See one, do one, teach one\u0026rsquo; approach. This \u0026lsquo;teacher centred\u0026rsquo; approach consists of students observing an expert clinician/tutor performing the techniques on a student, a plastic anatomical model, or a patient \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The underlying assumption is that learners become increasingly independent after observing an expert clinician or teacher \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The teacher/expert then proceeds to check the learner\u0026rsquo;s technique and provide feedback. By providing feedback and guidance, it is believed that the \u0026lsquo;see one, do one\u0026rsquo; approach may enable the learners to grasp the varied physical examination, palpation and treatment skills \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNevertheless, this approach has been criticized as an inadequate method in maintaining required patient safety standards. This is due to lack of supervision, reflection on action, performance evaluation and structured feedback \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Studies show that between 28% and 42% of medical residents felt inadequately trained to safely perform a medical procedure alone for the first time \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. These could be attributed to the traditional (see one do one) teaching methods \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. A meta-analysis \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e compared the effectiveness of traditional (see one do one) methods of clinical medical education versus simulation based medical education with deliberate practice. The findings from the study clearly demonstrated that not only was student performance better in the simulated group, benefits were observed in long-term retention of skills \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThree dimensional (3D) digital technologies such as virtual reality (VR), augmented reality (AR) and mixed reality technologies have been used in several applied fields including teaching and learning \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. While emersed in a VR environment, the user is completely immersed \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, an AR system combines or \u0026ldquo;supplements\u0026rdquo; real world objects with virtual objects or superimposed information \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Further, some VR systems have in-built haptic (sense of touch) devices (e.g., the Geomagic, the Phantom Omni). The addition of haptic feedback in VR environments creates more realistic scenarios, while providing trainees with a safe environment in which they can develop their skill \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Few haptic devices are specifically designed to enable the user to grasp virtual objects and provide varying degrees of freedom \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Evidence indicates that 3D technologies in educational settings can improve task completion times, lead to fewer errors and improve student\u0026rsquo;s motivation to learn \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. However, the role of 3D technologies in manual therapy education is largely unknown.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eResearch question:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat is the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim/objectives:\u003c/h2\u003e \u003cp\u003eThe aims of the current qualitative study were to: 1) investigate the perceptions, knowledge and attitude of manual therapy leaners about the use of 3D technologies in manual therapy education and (2) explore the barriers and enablers for using 3D technologies as part of manual therapy education.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eWe followed the Consolidated Criteria for Reporting Qualitative Studies guidelines for reporting this qualitative research \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Ethical approval for the study was provided by Waikato Institute of Technology\u0026rsquo;s Research Ethics Committee (WTLR32200721). All participants signed an informed consent sheet prior to participation.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eAn exploratory qualitative research design using semi-structured interviews was used in this study. The exploratory approach was considered appropriate to enable an in-depth understanding of the use of 3D technology by manual therapy learners \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eParticipants\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA total of 10 students enrolled in an appropriate manual therapy course provided by a New Zealand recognized institution such as a polytechnic or university participated in this study. The manual therapy course was delivered under two different settings (1) full-time on campus and (2) \u0026lsquo;block and blended\u0026rsquo;, where students were on campus during block weeks and did remote learning at other times. An email was sent with study details to various membership bodies and institutions that teach manual therapy with convenience/purposive sampling used to recruit participants. The demographic information of participants is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (range: 19\u0026ndash;58)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 Males\u003c/p\u003e \u003cp\u003e8 Females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 Physiotherapy Students\u003c/p\u003e \u003cp\u003e5 Osteopathy Students\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 Year\u0026nbsp;three\u003c/p\u003e \u003cp\u003e2 Year\u0026nbsp;two\u003c/p\u003e \u003cp\u003e2 Year\u0026nbsp;one\u003c/p\u003e \u003cp\u003e1 Year\u0026nbsp;four\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 Face to face\u003c/p\u003e \u003cp\u003e5 Blend and block\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection:\u003c/h2\u003e \u003cp\u003eData collection methods involved semi-structured interviews via Zoom between August 2021 to February 2022. These were mostly conducted by the primary investigator (PI). As some of the participants were known to the PI, a research assistant conducted interviews with these participants. An interview guide (appendix 1) was developed and used based on professional experience and findings from the literature. The interview guide was piloted before data collection to ensure clarity and to remove possible ambiguity. The average duration of the interviews was 35 minutes. Field notes were taken to facilitate data analysis. All interviews were recorded and transcribed verbatim. A diversity of viewpoints was captured that enabled the study\u0026rsquo;s findings to achieve data sufficiency/saturation after the tenth interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eA thematic analysis was the method of choice for data analysis \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Each interview set was initially analysed independently by two investigators. Initial coding was undertaken and assisted by NVivo V.10 qualitative analysis software. Category and theme development from the initial codes was an iterative/analytical process \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This involved reading and re-reading the transcripts/memos/field notes looking for patterns in the data (such as differences and commonalities). Memos were written throughout the analytical process and facilitated reflexivity by making it explicit any apriori biases of the researcher, thereby contributing to the credibility of the research. The themes generated were assessed by a third investigator (member checking) for plausibility and explanatory values against the transcripts. Finally, categories (factors) along with the themes were developed from the student interviews.\u003c/p\u003e \u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eFive factors were identified which appeared to influence participants\u0026rsquo; perception of role of technology in manual therapy education. These were;\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSufficiency of current teaching method\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvolution as a learner (novice to expert)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNeed for objectivity\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTutor feedback\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBarriers and enablers\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSufficiency of current teaching method\u003c/h2\u003e \u003cp\u003eSufficiency of current teaching method was a key factor contributing to participants\u0026rsquo; perception about the role of technology in manual therapy education. Participants who felt that their current teaching was sufficient believed that technology had no or little role in manual therapy education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t think of another way of doing it than the way they do it. To me what they do is great but it\u0026rsquo;s maybe because I\u0026rsquo;ve never thought about [it]\u0026rdquo;. (P6).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like it is sufficient\u0026hellip;for us to be a better therapist [and] to learn better with our hands\u0026rdquo; (P2).\u003c/em\u003eParticipants who perceived the current teaching of manual therapy to be sufficient tended to be osteopathic students learning manual therapy from year one of their program. Being exposed early to hands-on manual therapy courses may have influenced their perception and embedded an established routine for learning.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[The] actual practical part side of it I think is really good, like they have a routine. They\u0026rsquo;ll show us a technique or like a special test or whatever they do, and then we\u0026rsquo;ll go away in our little groups and practise that, and I think that\u0026rsquo;s really like effective. Then the teachers come round and like adjust us if needed and just like help us and give us like random tips and stuff\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely some participants perceived that their current teaching of manual therapy was insufficient and inadequate.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;d like to say yes but no, not really. I almost feel as if a lot of it is just left up to you to try and work out if you\u0026rsquo;re doing it right. The tutor can\u0026rsquo;t feel exactly what you\u0026rsquo;re doing. They can only look and think it does look you\u0026rsquo;re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you\u0026rsquo;re doing it right or what you\u0026rsquo;re feeling is the correct thing\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants who felt that the manual therapy teaching was insufficient were most likely enrolled in a blended learning pathway where they are on campus for block teaching weeks and off-campus during the rest of the learning period. This model of delivery meant that a lot of content was taught in a short period of time. This made them feel that they lacked time to reflect on their learning and made them feel completely \u0026lsquo;overwhelmed\u0026rsquo; while trying to grasp the complex manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The way it\u0026rsquo;s been working is we have these eight hour long days and we have to cram/study all this information in the morning, have lunch, and then come back and cram the rest of the knee and maybe even the whole lower limb for the rest of the day and we just go away at night just feeling so overwhelmed, and then write an essay on a completely different subject\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNeed for objectivity\u003c/h2\u003e \u003cp\u003eThe need for objectivity appeared to contribute towards the perception of participants regarding the role of technology in manual therapy education. Some participants felt that the current teaching paradigm was subjective and lacked reliability with different tutors teaching different things.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there\u0026rsquo;s a bit of confusion between the tutors and how they do things. One would put the hand below the pelvis and one would put it above the lower back for the same technique. I thought to start with that if at least the three tutors agreed, or four tutors, agreed on what they\u0026rsquo;re teaching us and teach us this at least there\u0026rsquo;s no like, yeah but you can do it like this\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe use of different approaches by different tutors and an apparent lack of objectivity lead to self-doubt among some participants about their ability and the correct method.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah the palpation or even when getting the tests done to see how it feels, from someone who feels confident in doing it, whereas us students, you know you\u0026rsquo;re always wondering \u0026lsquo;oh am I doing it right?\u0026rsquo; or if things are a bit fiddly\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese participants perceived that technology therefore could enhance their confidence by negating subjectivity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026rdquo;\u0026hellip; it would definitely be helpful to have something that means you\u0026rsquo;re more confident and that you\u0026rsquo;re practising the correct thing when you don\u0026rsquo;t have the tutor right there. So if there\u0026rsquo;s some way that it can help it would, yeah. It would be quite helpful\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants who required measurements or an objective way to do things were more likely to believe that technology such as VR is required as part of manual therapy education. They were more likely to perceive that VR would guide them to palpate the structure that they need to thereby improve accuracy of palpation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I almost feel as if a lot of it is just left up to you to try and work out if you\u0026rsquo;re doing it right. The tutor can\u0026rsquo;t feel exactly what you\u0026rsquo;re doing. They can only look and think it does look you\u0026rsquo;re pressing to hard or light or whatever. It would be really good if there was some way that you could actually have some sort of measurement of exactly how you do it or whether you\u0026rsquo;re doing it right or what you\u0026rsquo;re feeling is the correct thing\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, by enabling to visualise various layers within the body, technology can be a powerful tool especially for visual learners. In turn, this kind of learning experience authentic by enhancing fidelity (realness). for the learners. When presenting examples of the use of VR and how this might enhance understanding and ability to perform skills completely, they responded:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The reason I thought this would be really cool is because the first thing I thought of is if I can see something\u0026hellip; then I can sort of match where I\u0026rsquo;m going. That\u0026rsquo;s where things stick for me. I don\u0026rsquo;t know what kind of VR technology you have but if you could see that\u0026rsquo;s the skin but then under it you\u0026rsquo;ve got a layer of bones or whatnot then you can match up. I think that would be really good for a lot of visual learners\u0026hellip; I think it would be quite powerful in learning\u0026rdquo; (P8).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It would be really interesting if you could use your hands to move and manipulate the body or even just to touch it, to highlight a particular muscle or muscle group\u0026hellip; perhaps it would make it feel a whole lot more real to me\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEvolution as a learner (novice to expert)\u003c/h2\u003e \u003cp\u003eThe perception of role of 3D technology in manual therapy education depended on the expertise level/evolution of the learners. Participants who were early on in their educational journey felt that the current teaching methods (see one, do one approach) to be adequate. They were comfortable learning gross motor skills (e.g. holding a leg) that does not require deeper palpation skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At the moment because I\u0026rsquo;m a first year I\u0026rsquo;m getting comfortable with touching people and making sure that when you\u0026rsquo;re holding their leg they feel like she\u0026rsquo;s got me. That\u0026rsquo;s what we\u0026rsquo;re working on at the moment\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely participants who were at the later stage of their educational journey emphasized the need for technology to support the development of finer motor skills required for deeper and subtle palpation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m finding it really difficult because you don\u0026rsquo;t know what you\u0026rsquo;re trying to feel. Don\u0026rsquo;t know what you\u0026rsquo;re feeling for and trying to translate a description into trying to work out what I\u0026rsquo;m feeling. I\u0026rsquo;m actually struggling with that a little bit. Generally the more obvious techniques are great but when it comes to really subtle palpation it\u0026rsquo;s really difficult to try and understand what you\u0026rsquo;re meant to be feeling for\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was noted that participants\u0026rsquo; who had already completed manual therapy courses before were likely to perceive that the current teaching methods were adequate and the need for technology to be minimal. Participants with manual therapy experience felt that students who have not done manual therapy before would require more support.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; I have worked in massage now for five years, so I\u0026rsquo;ve got a lot of palpatory hands on experience but it doesn\u0026rsquo;t make me like an osteopath or anything, but for some of the school leavers, they come straight out of school and they\u0026rsquo;ve probably only touched their own skin never mind someone else\u0026rsquo;s \u0026ldquo; (P2).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTutor feedback\u003c/h2\u003e \u003cp\u003eA key factor mandatory for learner development is feedback from tutors. Most participants felt that the current teaching methods were inadequate and unsustainable as often there is often only one tutor running a teaching session. This meant that they did not receive enough feedback where they could refine their manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Often we then break off into little groups or pairs to practise it but then it\u0026rsquo;s very hard for that one tutor to get round all of those pairs to make sure they\u0026rsquo;re doing it correctly. And often people have questions and then they go caught up talking, so a lot of the time you might be trying to do one practical thing\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The way they explain things don\u0026rsquo;t make sense. It might not be the best example but we have to manipulate the cervicals. She said you do it like this and she shows. But we can\u0026rsquo;t even see the fingers underneath the neck so it\u0026rsquo;s a bit complicated for us\u0026rdquo;(P6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants that received less tutor feedback explained that they were trying to learn complex manual therapy skills from 2d images or PowerPoints which can be challenging. Hence, they perceived that 3D technology such as VR would be important in enhancing their leaning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Everything I\u0026rsquo;m trying to learn is via a PowerPoint or videos which can be challenging. I\u0026rsquo;m a practical learner so if we don\u0026rsquo;t do the practical I struggle in connecting stuff where others pick it up quite well. I don\u0026rsquo;t learn that way\u0026rdquo; (P8).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Apart from PowerPoints and a few videos or something like that is about the most digital we get I think\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast some participants felt that they received good feedback from their teachers, which meant that they relied less on technology.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He gave us specific landmarks that we would look for. For example, C7 would be the most prominent one that sticks out in forward neck flection and that was a good baseline in order to help us when we would palpate for cervical spine. He would give us points in which they were quite useful for our learning\u0026rdquo; (P5).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSpecifically, these participants felt that they learnt more when the tutors placed their hands on top of theirs and showed them how to do a certain technique. This human interaction therefore was key in learning manual therapy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One thing I found effective with a clinical supervisor I have is we had a patient and he put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we were doing a technique called \u0026lsquo;functional\u0026rsquo; on the like upper thoracic and the person is lying down, and you like put your hands under and she comes along, she [tutor] came along, and put her hand under our hand and so she could feel where it needed to go and stuff, so that was really good\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and enablers:\u003c/h2\u003e \u003cp\u003eSome factors were both barriers and enablers for using 3D technologies as part of manual therapy education. These factors include (1) cost (2) knowledge about technology (3) accessibility and (4) ethical issues.\u003c/p\u003e \u003cp\u003eAlmost all the participants felt that cost was a significant barrier if technology such as VR to be used in manual therapy education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m sure that the cost of it is one main problem. People even thinking about it. People developing it and being paid to develop it and then people would have to buy that technology\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The cost. I think that would be a big thing would be the cost really. That would really be the only barrier that I can think of\u0026rdquo; (P9).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants believed that the cost on students could be reduced if the institutions could bear some or most of it thereby enabling students to access technology.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I doubt they\u0026rsquo;ll let us as students take one home because they\u0026rsquo;re so expensive. If institutions can pay for it so we students can still access it a reduced cost perhaps\u0026rdquo; (P8).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Obviously that financial one may play a big part so I guess having one of those facilitators such as a support might be necessary\u0026rdquo; (P5).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll participants indicated that they would be keen to try technology if it is available. However, some required further knowledge about technology. They thought that using technology without completely understanding it or if the technology did not work properly, may discourage them from using it.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;People\u0026rsquo;s knowledge in the tech, around the technology as well if it would be something that people don\u0026rsquo;t work with a lot and they\u0026rsquo;re being bombarded with a whole lot of other new information\u0026hellip; If it doesn\u0026rsquo;t work properly the first time it can be rather annoying, or discouraging, would be another barrier to it\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yep absolutely, if there was adequate training I would be very open to using it yeah.\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants thought that ease of access could a barrier from using technology such as VR. They felt that using technology for a long time can lead to fatigue and discourage further use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; [I] don\u0026rsquo;t know how long you can stay in goggles like this before it gives you a headache\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo; [I] think one thing is that I can get fatigue from being on technology for a while\u0026rdquo; (P3).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn terms of ease of access, internet connection was identified as another barrier.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe internet connections. I don\u0026rsquo;t know if you need to internet to download specific stuff\u0026rdquo; (P5).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026rdquo;Connections, issues, are a big one, I\u0026rsquo;ve noticed that my connections been shocking so it kind of breaks in and out throughout classes which is tricky. Maybe attitude towards technology, I personally, I don\u0026rsquo;t mind using it but I know some people don\u0026rsquo;t enjoy using technology, and I guess accessibility for some people as well\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFew participants were concerned about ethical issues such as cultural responsiveness that may arise using technology such as VR as part of manual therapy education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s got to be like a level of cultural responsiveness or just appropriateness or ethics what would need to, student would have to get. Or it would just have to, the simulation would have to have restrictions\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, these ethical issues could be overcome by completely explaining the design of VR.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the only thing I can think of is like consent and making sure people are okay with what they\u0026rsquo;re seeing and also by enabling limiters so students\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe five factors discussed above in turn influenced the participants\u0026rsquo; perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions (\u0026lsquo;no role\u0026rsquo; (techstatic) versus a \u0026lsquo;complete role\u0026rsquo; (techsavvy)). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the interplay between the five factors and how they influence the learns position as either being techsavvy or being techstatic.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eParticipants that perceived that technology had no role in manual therapy education tended to view that the current (\u0026ldquo;see one, do one\u0026rdquo;) approach was best suited for manual therapy education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the current way manual therapy is taught is sufficient. I don\u0026rsquo;t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese participants believed that technology cannot replace human interaction and that \u0026lsquo;face to face\u0026rsquo; sessions are important to learn the complex manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Technology has a place, but again I think you can\u0026rsquo;t replace face to face learning. I think there needs to be that sense of community still, like there\u0026rsquo;s nothing better than being in class with our classmates\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWith a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve \u0026ldquo;hands on hand\u0026rdquo; feedback. One participant explains this as:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like \u0026lsquo;oh that\u0026rsquo;s how you do it, that\u0026rsquo;s how it\u0026rsquo;s supposed to feel, that\u0026rsquo;s what you\u0026rsquo;re doing\u0026rsquo; and I could sort of feel through my hands\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants on the opposite end of the continuum perceived technology as \u0026lsquo;futuristic\u0026rsquo; and an \u0026lsquo;advanced\u0026rsquo; way to learn manual therapy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient\u0026hellip; that\u0026rsquo;s going way advanced\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese participants believed that the repeated practice opportunity that technology offers, provides an \u0026lsquo;objective\u0026rsquo; way to learn manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Oh totally, yeah big time. Now I think it\u0026rsquo;s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively\u0026rdquo; (P10).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Technology is awesome, I think most of our learning in manual therapy is self-directed\u0026hellip;technology will provide repeated practice opportunity given that we can use them [technology] at home\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; perception about the role of 3D technologies in manual therapy education can be viewed as on a continuum, from \u0026lsquo;no role\u0026rsquo; (techstatic) to \u0026lsquo;complete role\u0026rsquo; (techsavvy). Some participants\u0026rsquo; perception lay at the extreme ends of the continuum whereas others fell in between the two extremes. Participants that perceived that technology had no role in manual therapy education tended to view that the current (\u0026ldquo;see one, do one\u0026rdquo;) approach was best suited for manual therapy education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the current way manual therapy is taught is sufficient. I don\u0026rsquo;t know how else they could do it really. Just putting your hands on and getting used to that and getting better palpation, you can do that through practise\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese participants believed that technology cannot replace human interaction and that \u0026lsquo;face to face\u0026rsquo; sessions are important to learn the complex manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Technology has a place, but again I think you can\u0026rsquo;t replace face to face learning. I think there needs to be that sense of community still, like there\u0026rsquo;s nothing better than being in class with our classmates\u0026rdquo; (P4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWith a strong emphasis on human interaction, they conceptualised manual therapy education as an approach that should involve \u0026ldquo;hands on hand\u0026rdquo; feedback. One participant explains this as:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He put his hands on top of my hands and helped me to feel the pressure I should be applying, or how I should perform a massage stroke. And that was just like sort of mind-blowing for me because I was like \u0026lsquo;oh that\u0026rsquo;s how you do it, that\u0026rsquo;s how it\u0026rsquo;s supposed to feel, that\u0026rsquo;s what you\u0026rsquo;re doing\u0026rsquo; and I could sort of feel through my hands\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants on the opposite end of the continuum perceived technology as \u0026lsquo;futuristic\u0026rsquo; and an \u0026lsquo;advanced\u0026rsquo; way to learn manual therapy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;if you had goggles on and you had a fake patient in front of you, how you would be able to see everything quite clearly and if they had designed some cool gloves then maybe you could actually feel what it would feel like to touch the patient\u0026hellip; that\u0026rsquo;s going way advanced\u0026rdquo; (P2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese participants believed that the repeated practice opportunity that technology offers, provides an \u0026lsquo;objective\u0026rsquo; way to learn manual therapy skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Oh totally, yeah big time. Now I think it\u0026rsquo;s just a matter of time. I think technology such as VR is futuristic and may help learn things objectively\u0026rdquo; (P10).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Technology is awesome, I think most of our learning in manual therapy is self-directed\u0026hellip;technology will provide repeated practice opportunity given that we can use them [technology] at home\u0026rdquo; (P6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from our study indicate that manual therapy learners have different views about sufficiency of current teaching methods; their evolution as a learner; need for objectivity; tutor feedback; and barriers and enablers, which together shape their overall perception about the role of technology in manual therapy education. Such diverse viewpoints amongst manual therapy learners are consistent with learners from other medical professions.\u003c/p\u003e \u003cp\u003eLearners who perceived that technology has no or minimal role in manual therapy education alleged that the current way of teaching manual therapy was adequate and the \u0026lsquo;see one, do one\u0026rsquo; approach is the best way to deliver this form of education. These participants considered their teachers were effective, had excellent teaching skills and respected them as students. By sharing real life scenarios and demonstrating hands-on techniques, these teachers were \u0026lsquo;preferred\u0026rsquo;. Although \u0026ldquo;teacher centred\u0026rdquo;, preferred teachers had a positive impact for these learners and motivated them in learning manual therapy skills. Hence, the teaching style and the positive interaction that they adopted was considered sufficient by participants. This is in synonymous with findings of previous studies that showed that \u0026lsquo;preferred teachers\u0026rsquo; have a critical influence on learner\u0026rsquo;s academic success, professional and personal development \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Further, these participants perceived that face-to-face teaching was crucial for their learning and \u0026lsquo;nothing could replace human interaction\u0026rsquo; \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn opposition, some participants felt that technology has a bigger role in manual therapy education and may provide objectivity for their learning. These participants were likely to perceive that the \u0026lsquo;see one do one\u0026rsquo; approach has its limitations and current methods for teaching manual therapy was insufficient. These findings concur with randomised controlled trial \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e results that compared \u0026lsquo;best practice\u0026rsquo; model with the traditional model of teaching. While the \u0026lsquo;best practice\u0026rsquo; model included structured feedback, practice on manikins and Peyton\u0026rsquo;s \u0026lsquo;four step\u0026rsquo; approach; the \u0026lsquo;traditional model\u0026rsquo; was the \u0026lsquo;see one do one\u0026rsquo; approach. The study showed that the traditional \u0026lsquo;see one do one\u0026rsquo; approach had limitations and the \u0026lsquo;best approach\u0026rsquo; model resulted in students performing not only in the short term but also in the long term \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTutor feedback was identified as a key factor that determined the perception of participants regarding the role of 3D technology in manual therapy education. Our findings suggest that participants who received less feedback from their tutors perceived that 3D technology such as VR would be important in enhancing their leaning. We suggest that this is not surprising given the difficulty associated with learning complex manual therapy skills. These findings are consistent with previous evidence that feedback assists medical students to get an understanding/feeling for what they do and increases the likelihood of correct performance \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Some participants believed that they get satisfactory feedback from tutors either through role play, or tutors who placed their hands on top of theirs and showed them how to undertake a certain technique. However, evidence dispute these claims reporting that such learning (see one do one) may miss essential components such as self-regulated learning, review at each stage and self-monitoring resulting in less retention of the skill set in the long term \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLack of opportunity to practice was also highlighted by participants as a limitation of current way manual therapy is being taught. This led those participants to believe that having access to technology may facilitate practice/repetition, which in turn may facilitate their hands-on skill development. These findings concur with previous research which clearly indicate that practice (or lack of it) can influence student outcomes \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. It is important to note that evidence clearly highlights that technology alone (e.g. simulator training) are not enough to improve skill performance, tutor feedback from an expert teacher is also important to enhance skill performance \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur findings suggest that the expertise level of a learner was an important factor that influenced the perception of role of 3D technology in manual therapy education. Participants who were early on in their educational journey were comfortable without the aid of technology while learning gross motor skills (e.g. holding a leg) that does not require deeper palpation skills. Alternatively, participants who were at the later stage of their educational journey perceived that technology would be essential to support the development of finer motor skills/complex tasks required for deeper and subtle palpation. In this context, a complex task is one that requires: long reaction time or movement time, long hours of practice and high demands on the learner\u0026rsquo;s attention and memory \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Evidence suggests that 3D technologies such as virtual reality may enhance development of complex skills by providing abundant practice repetitions, delivering multi-sensory feedback, individualize challenge, and engage and motivate users with salient, enriched environments \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Our findings are therefore consistent with a number of studies that have shown 3D technology such as virtual reality may improve both gross and fine motor skills \u003csup\u003e\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA number of factors were identified as barriers and enablers for using 3D technologies as part of manual therapy education including cost, knowledge about technology, accessibility and ethical issues, which are consistent with existing literature \u003csup\u003e\u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Key barriers include concerns about hardware devices such as head mount devices and the time required to learn the technology \u003csup\u003e\u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Addressing these barriers may require a collaborative approach from clinicians and developers to meet the specific demands of manual therapy education \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. For example, the physical assessment/treatment parameters required for a knee joint will be different from that of neck and so on. As highlighted by a recent scoping review (un-published), manual therapy educators may share the clinical reasoning behind a physical assessment procedure enabling the developer to integrate the software parameters that control the degree of physical tasks and challenges to meet the assessment/treatment needs. This step may be crucial to sustain the motivation and engagement of learners over a longer period \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo summarise, the views of our participants were polarized with some considering the current teaching model (see one do one) to be sufficient, whereas other participants considering technology to replace current teaching methods. Taking into account both perspectives, it could be argued that the \u0026ldquo;see one, do one\u0026rdquo; approach of learning/teaching is still applicable as human interaction is important, however there is scope to build upon and enhanced this with various other learning principles and advanced technology. According to contemporary educational theory, learning happens in a zone referred by Vygotsky as the \u0026lsquo;zone of proximal development\u0026rsquo; \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Practising beyond these limits without support is similar to practising with increased stress, less confidence and marginal competence \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. This is considered harmful as this is the zone where learners are not capable and/or not ready for doing things \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Yet, this is the zone that learners encounter often with the \u0026lsquo;see on do one\u0026rsquo; methodology, especially in the last 2 years where class disruptions due to the COVID-19 pandemic are frequent and face-to-face contact has been minimal. Hence, to ensure that the learners stay competent, strategies in addition to current teaching methods may be required. Using 3D technologies such as virtual reality to complement current teaching methods may represent such additional strategy and may decrease extraneous stress on the leaners. Future research may investigate the addition of technology to traditional teaching methods in improving manual therapy assessment/treatment by manual therapy learners.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is the first qualitative study to explore the perceptions of manual therapy learners on the role of 3D technologies in manual therapy education. The main strength of this study was that it was open to all manual therapy students despite the discipline that they were training in (e.g. physiotherapy, osteopathy, etc). The participants came from different disciplines (physiotherapy and osteopathy); from different pathways of learning (traditional vs blended learning); and different years of learning (first year through final year of learning). This variety in participants resulted in thick/rich data that provided interesting perspectives on the role of 3D technologies in manual therapy education. We followed a robust protocol to reduce bias and enhance credibility of the findings and used COREQ guidelines to improve transparency in reporting \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The study is not without its limitations. A key limitation is that all the participants were learners of manual therapy in New Zealand institutions. Hence, the transferability of findings to manual therapy learners in other countries needs to be established through future research. Despite our best efforts, we did not have any participants from the chiropractic profession. However, we are confident that our data has captured different perspectives and may be applicable to any profession that uses manual therapy including chiropractic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eParticipants in this study held a range of views regarding the role of 3D technologies in manual therapy education. Five factors were identified which appeared to influence participants\u0026rsquo; perception including: sufficiency of current teaching method, evolution as a learner (novice to expert), need for objectivity, tutor feedback and barriers and enablers. These views and perceptions contributed to two opposing positions \u0026ldquo;techstatic\u0026rdquo; or \u0026ldquo;techsavvy\u0026rdquo;. However, technology may be used to complement the traditional \u0026ldquo;see one, do one\u0026rdquo; approach of learning/teaching to facilitate the learning of complex skills by manual therapy learners. The advantage of such an approach is an area of future research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was provided by Waikato Institute of Technology\u0026rsquo;s Research Ethics Committee (WTLR32200721). All participants signed an informed consent sheet prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo details, images, or videos relating to an individual person was used as part of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the study but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare \u0026ldquo;no competing interests\u0026rdquo; (financial and/or non-financials).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKSK conceived the project and contributed to all aspects of the project including writing the first draft of the manuscript. \u0026nbsp;PA and AA were associate investigators with inputs to the study design. EY helped with data collection (semi-structured interview) and analysis. EF contributed towards participant recruitment. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded through an contestable research grant by Waikato Institute of Technology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMichels MEJ, Evans DE, Blok GA. What is a clinical skill? Searching for order in chaos through a modified Delphi process. \u003cem\u003eMedical Teacher. \u003c/em\u003e2012;34(8):e573-e581. doi:http://dx.doi.org/10.3109/0142159x.2012.669218.\u003c/li\u003e\n\u003cli\u003eEaston G, Stratford-Martin J, Atherton H. 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The zone of proximal development as an overarching concept: A framework for synthesizing Vygotsky\u0026rsquo;s theories. \u003cem\u003eEducational Philosophy and Theory. \u003c/em\u003e2019;51(1):18-30. doi:http://dx.doi.org/10.1080/00131857.2017.1421941.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Appendix ","content":"\u003cp\u003eAppendix 1 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Manual Therapy, Education, Physiotherapy, Osteopathy, 3D Technology, Virtual Reality","lastPublishedDoi":"10.21203/rs.3.rs-1962125/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1962125/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e: Manual therapy is a specific hands-on approach used and taught by various professions such as physiotherapy and osteopathy. The current paradigm of teaching manual therapy incorporates the traditional ‘See one, do one, teach one’ approach. However, this ‘teacher centred’ approach may not enable learners to develop the complex clinical skills of manual therapy. In this context, 3D technologies such as virtual reality may facilitate the teaching and learning of manual therapy. Hence the aim of the current study was to investigate the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: An exploratory qualitative research design using semi-structured interviews was used in this study. A total of ten manual therapy (5 physiotherapy and 5 osteopathic) students (age =32 (Range19-58); 80% female) enrolled in an appropriate physiotherapy or osteopathic degree provided by a New Zealand recognized institution (e.g university or polytechnic) participated in this study. Data saturation was achieved after 10 interviews (average duration: 35 minutes) that provided thick data. A thematic analysis was the method of choice for data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Five factors were identified which appeared to influence participants’ perception of role of technology in manual therapy education. These were (1) Sufficiency of current teaching method; (2) Evolution as a learner (novice to expert); (3) Need for objectivity; (4) Tutor feedback; and (5) Barriers and enablers. These five factors influenced the participants’ perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions (‘no role’ (techstatic) versus a ‘complete role’ (techsavvy)).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Although 3D technology may not replace face-to-face teaching, it may be used to complement the traditional approach of learning/teaching to facilitate the learning of complex skills by manual therapy learners. The advantage of such an approach is an area of future research.\u003c/p\u003e","manuscriptTitle":"Perception, knowledge and attitude of learners about the use of 3D technologies in manual therapy education – A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2023-01-12 19:08:45","doi":"10.21203/rs.3.rs-1962125/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-11T11:45:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-24T07:56:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7aa701c3-73ea-42cb-9922-083b8cb91ac8","date":"2022-12-21T17:28:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2e4f612d-36c7-483a-8e1d-3664c273a205","date":"2022-12-15T21:41:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d8bec6d5-69c2-490e-860b-5cd2a6e6f121","date":"2022-12-15T18:07:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-15T16:46:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3fab4800-f878-46be-a159-3d816d0e255d","date":"2022-12-15T16:42:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-12-15T16:31:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-12-15T16:22:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-11-29T08:52:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-11-29T08:49:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2022-11-15T10:04:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"897c12c1-9003-41d2-84d9-7e01bb6ea162","owner":[],"postedDate":"January 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T21:59:55+00:00","versionOfRecord":{"articleIdentity":"rs-1962125","link":"https://doi.org/10.1186/s12909-023-04497-6","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2023-07-17 21:42:08","publishedOnDateReadable":"July 17th, 2023"},"versionCreatedAt":"2023-01-12 19:08:45","video":"","vorDoi":"10.1186/s12909-023-04497-6","vorDoiUrl":"https://doi.org/10.1186/s12909-023-04497-6","workflowStages":[]},"version":"v2","identity":"rs-1962125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1962125","identity":"rs-1962125","version":["v2"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}