Self-Directed Learning and Feedback with Blended Training in Paediatric Emergencies

Self-Directed Learning and Feedback with Blended Training in Paediatric Emergencies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Self-Directed Learning and Feedback with Blended Training in Paediatric Emergencies Melusi Ngobese, Chauntelle Bagwandeen, Kimesh L Naidoo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7849481/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Introduction Newly qualified medical practitioners (interns) need to be competent in paediatric emergencies. Compromised patient safety and burnout result from sub-optimal training. The utilisation of blended teaching programmes is particularly beneficial where human resources are constrained. Evidence of the impact of blended teaching on self-directed learning (SDL) and feedback is required . Objective of the study To determine perceptions of SDL and feedback amongst interns exposed to blended teaching. Methods A prospective mixed-methods study utilised a validated Assessment Experience Questionnaire (AEQ) to measure perceptions of SDL and feedback among separate cohorts of interns from 202 to 2022 in South Africa (SA). All cohorts were trained in paediatric emergencies with online components and practical skills training. The last cohort included a traditional face-to-face lecture. The first cohort had no face-to-face feedback. A comparative descriptive analysis using independent sample t-tests was conducted to determine differences in AEQ scores between cohorts. Thematic analysis was used to analyse open-ended responses. Results Of the 153 respondents, 54.4% were males, the mean age was 25 years, and 9.7% were foreign-trained. Perceptions of the amount and distribution of study effort and learning, reflecting SDL, were positive across all cohorts. Median scores for study effort, learning, and feedback did not improve with traditional face-to-face lectures. The median scores for perceptions of the quantity and timing of feedback received were significantly higher for face-to-face feedback, p = 0.031. Increased autonomy and flexibility were identified as common positive themes, and the lack of individualised feedback was viewed as the most common negative theme. Conclusion Using blended training that includes technology-enhanced learning in resource-constrained contexts to train in paediatric emergencies is feasible, stimulates SDL, and, when coupled with face-to-face feedback, should replace traditional lectures. However, perceptions of inadequate feedback often occur when there is no face-to-face interaction. Didactic lectures do not improve SDL or feedback. Clinical Training Medical Interns Online Teaching Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Newly qualified medical practitioners (interns) in South Africa must be rapidly upskilled to manage paediatric emergencies during the three months of training. 1 The high childhood disease burden and poor socioeconomic conditions lead to the late presentation of many acutely ill children who require resuscitation and stabilisation in the country's public sector regional hospitals, where interns train. 2 Suboptimal doctor-patient staffing ratios in these hospitals render interns as frontline staff, who are generally the first to identify and manage acute paediatric emergencies. 3 This training has traditionally included face-to-face didactic lectures, skills training and a reliance on on-the-job exposure to emergencies. 4 However, poor training and supervision during internship, including specifically on the teaching of how to manage acute paediatric emergencies, has been documented. 5 The training of interns to be competent in managing paediatric emergencies is dependent on clinician educators. 1 Clinician educators, while performing their primary clinical care responsibilities in these resource-limited hospitals, are tasked with training interns and ensuring a conducive learning environment. The quality and monitoring of this training are conducted by the Health Professions Council of South Africa (HPCSA), which is also responsible for accrediting and regulating intern training. There is no formalised oversight from Higher Education Institutions (HEIs). 1 There is a scant review of the praxis of teaching across intern training institutions, and many interns have complained of feeling inadequately prepared to manage paediatric emergencies. 6 , 7 Expectations from the accrediting bodies, clinicians, and patients for newly qualified medical practitioners to be clinically competent have also led to increased levels of burnout among interns. 8 Self-directed learning (SDL), a component of andragogy, has been advocated as an effective skill for practising doctors and other healthcare professionals. 9 SDL, as defined by Knowles, is a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes. 10 Self-directed learners are characterised by their abilities to manage their learning proactively, possess a strong desire for learning, take responsibility for their learning, engage in an independent learning environment, self-evaluate their learning performance and control their strategies for improvement. 11 This aligns with the recommended educational framework by the accrediting body for intern education in SA. 1 The integral components of this training are to be a motivated, self-directed learner and to transition to become a clinician-educator who can provide adequate training and relevant feedback. 1 The amount and quality of feedback provided to interns, especially in busy regional hospitals in SA, remains a challenge. 4 Technology-enhanced learning (TEL) methods, including blended teaching programmes, can assist busy clinician-educators in providing intern training. 12 These blended programmes require less intensive human resource needs and may be suited to resource-constrained hospitals. TELs have developed independent thinkers and self-regulated learners in many undergraduate and postgraduate programmes managed by HEIs. 12 Following the COVID-19 pandemic, there was a rapid shift in many undergraduate and postgraduate health professions education programmes to utilise TEL. Evidence that this shift in established pedagogical approach to training ensured an adequate development of the required knowledge, skills and attitudes for highly disease-burdened contexts is unknown. It is also not well understood how TEL can support intern training when there is a lack of oversight from HEIs. 13 In many contexts, traditional face-to-face lectures in training on paediatric emergencies have either persisted or clinician-educators reverted to this format, especially where it is equated with direct oversight as required by accrediting authorities. 1 , 5 This study evaluates the perceptions of interns who receive blended training in paediatric emergency care in a resource-limited, high childhood disease-burdened context. There is a specific focus on aspects of developing SDL and receiving feedback, with an evaluation of the importance and role of traditional face-to-face teaching. METHODS Study Design This was a longitudinal mixed-methods study. Data were collected prospectively over three years, from January 2021 to December 2023, at the King Edward VIII (Victoria Mxenge Hospital) teaching hospital, following the introduction of a blended teaching programme on paediatric emergencies. Study setting The study was conducted at a regional /tertiary hospital accredited by the HPCSA to train interns. 1 This hospital in Durban, South Africa (includes 130 paediatric and neonatal beds), caters for children with high rates of malnutrition, HIV and mortality. 14 Many of these children present late in their disease trajectory and require acute emergency care. 15 Study population The study focuses on newly qualified medical doctors(interns). Interns spend the first two years following the completion of their medical undergraduate studies in a 24-month, supervised, paid internship. During these two years, they spend three months in paediatrics, during which they are trained to manage acute emergencies and other aspects of paediatric and neonatal care. Interns, while training, also serve as the first line of medical care in acute care units in regional hospitals and are required to be efficient and skilled in managing a large patient load. 5 Training generally consists of face-to-face lectures at the start of the rotation, followed by practical skills training sessions. Interns are then expected to be self-directed learners and learn ‘on the job’ with supervision. Interns in this study were prospectively recruited at the start of a blended teaching programme that included an online programme developed by 12 paediatricians based at the teaching hospital. This blended teaching programme on acute emergencies included an online self-directed component with embedded question-and-answer sessions. Access to online skills training videos was also provided, along with two face-to-face practical training sessions on paediatric and neonatal resuscitation conducted in a skills laboratory. Interns were given access to the online materials at the start of the paediatric training and were required to work through them independently. Only group online feedback was provided for the first cohort in 2021, and face-to-face feedback was provided for the 2022 and 2023 cohorts. For the last cohort in 2023, a face-to-face didactic lecture was also held for each paediatric emergency topic. Data Collection A specific survey instrument, the Assessment Experience Questionnaire (AEQ) (Appendix A) , was chosen to collect data for this study. The AEQ is a brief survey developed by Gibbs et al. over 15 years ago for postgraduate programmes, and has been validated in numerous research studies across multiple contexts, focusing on evaluating perceptions of effective assessment practices. 16 The survey consists of 32 items with responses scored with a Likert scale and divided into five subscales :(i) amount and distribution of study effort;(ii) assignments and learning;(iii) quantity and timing of feedback; (iv) quality of feedback; and (v) what you do with the feedback. For the purposes of this study, the first two subscales were specifically used to evaluate perceptions of self-directed learning, and the last three subscales were used to assess perceptions of feedback. In addition to this survey, open-ended questions( on enablers, barriers and suggestions to improve BL) were included to solicit qualitative and demographic data. A pilot was done prior to utilisation to ensure face validity. At the end of every three-month rotation for three consecutive years, all paediatric interns, upon completing this training, were required to fill out an AEQ survey reflecting on the blended training programme in paediatric emergencies. Whilst this data was used to determine programme evaluation, data from all participants who consented to participate in the study were collected for analysis. The AEQ was completed on paper, and the responses were manually entered into an Excel spreadsheet. Specific demographic questions related to age, gender, and the university attended for undergraduate medical studies were also collected. This information was added to identify potential demographic associations in the data. Data analysis Data were entered in MS Excel and analysed in Stata version 15. For each participant, the AEQ scores and sub-scores were calculated. Certain statements are negatively stated and thus receive a reverse score. Where there was missing data, means were computed based on the available data, provided that the percentage of missing data did not exceed 20% of the items. The overall AEQ score was computed as the average of all items. The five sub-scores in the various subthemes (composite and sub-theme scores) were compared across the cohorts of 2020, 2021, and 2022. Comparisons were done based on these cohorts. In addition, comparisons were drawn with age, gender and university origin. Descriptive analysis of the data was carried out as follows: Categorical variables were summarised by frequency and percentage tabulation, and illustrated using bar charts. The mean, summarised continuous variables, standard deviation, median, and interquartile range, along with their distribution, were illustrated using histograms and box-and-whisker charts. The Χ2 test was used to assess the relationships between categorical variables. Fisher’s exact test was used for 2 x 2 tables. The relationship between continuous and categorical variables was assessed by the t-test (or ANOVA for more than two categories). Where the data does not meet the assumptions of these tests, a non-parametric alternative, the Wilcoxon rank sum test (or the Kruskal-Wallis test for more than two categories) was used. Logistic regression was further applied to determine the relationships between the subscales associated with SDL (amount and distribution of study; assignments and learning) and the various subscales associated with feedback. The dependent variable used was both the perceptions of the amount and distribution of study and assignments, as well as learning. The quantity and timing of feedback, the quality of feedback, and the feedback response were independent variables. All inferential statistical analysis tests were conducted at a 5% level of significance (p < 0.05). The open-ended questions were transcribed and analysed by the principal investigator and two additional co-coders (CB and KL), who read the transcripts of the open-ended questions on multiple occasions to familiarise themselves with the data. Specific categories of attitudes were analysed using a qualitative content analysis approach, and thereafter, an inductive coding process was employed to identify patterns in these responses through thematic analysis. The co-coders also coded the transcriptions independently to enhance rigour. The themes were determined independently, and a common set of themes was then established by consensus. 17 The principal investigator and co-coders jointly compared and finalised the sub-themes and labelled them once consensus was reached on the categorisation and naming of both the sub-themes and major themes. Ethics All participants were required to have written informed consent. Institutional approvals were obtained for the retrospective utilisation of routinely collected data. Ethics approval was obtained through the University of KwaZulu-Natal, Human Social Science Ethics Committee, with ethics approval number HSSREC/00005305/2023. Clinical trial number: not applicable. RESULTS Of the 153 interns (median age of 25 years) who participated in the study, 54% were female, and 9.7% had graduated from universities outside SA. Table 1 lists the demographic characteristics of the interns sampled and the distribution of universities in SA from which they graduated. Figure 1 further illustrates the distribution of interns from various universities per year. There were no significant demographic differences between the interns from the three years. Table 1 Demographic characteristics of interns Year 2020 (N = 42) 2021 (N = 52) 2022 (N = 59) p-value Overall (N = 153) Gender Female 23 (57.5%) 22 (43.1%) 35 (62.5%) 0.120 80 (54.4%) Male 17 (42.5%) 29 (56.9%) 21 (37.5%) 67 (45.6%) Age in years Median(Q1-Q3) 26.0(25.0–26.0) 25.0(24.5–27.5) 25.0(24.0–27.0) 0.473 25.0(24.0–27.0) n(Min-Max) 40(23.0–32.0) 51(23.0–32.0) 57(22.0–33.0) 148(22.0–33.0) University Foreign 1 (2.5%) 7 (14.0%) 6 (10.9%) 0.202 14 (9.7%) UKZN 16 (40.0%) 14 (28.0%) 14 (25.5%) 44 (30.3%) WITS 4 (10.0%) 8 (16.0%) 7 (12.7%) 19 (13.1%) WSU 4 (10.0%) 5 (10.0%) 5 (9.1%) 14 (9.7%) SMU 2 (5.0%) 1 (2.0%) 2 (3.6%) 5 (3.4%) UCT 8 (20.0%) 3 (6.0%) 2 (3.6%) 13 (9.0%) UFS 1 (2.5%) 0 (0.0%) 3 (5.4%) 4 (2.8%) UP 1 (2.5%) 4 (8.0%) 5 (9.1%) 10 (6.9%) US 3 (7.5%) 8 (16.0%) 11 (20.0%) 22 (15.2%) | % and p-values based on non-missing cases | * parametric p-value Scores from the AEQ sub-scales related to perceptions of Self-directed learning The median (Q1-Q3) AEQ score for the subscales related to SDL, namely the amount and distribution of the study, was 18 (17.0-19.8), 17.0 (15.0-19.3), and 18.0 (15.5–20.5) for the interns in years 2020, 2021, and 2022, respectively.With regard to assignments and learning the median(Q1-Q3) AEQ scores for this subscale was 22.0(21.0–23.0); 22.0(20.0–23) and 22.0(20.0–23.0) over the for years 2020,2021 and 2022. There were no significant differences in median scores over the three years in both subscales. Table 2 indicates these scores and p-values. Figure 2 illustrates the differences in the AEQ scores ( the amount and distribution of study effort and assignments, and learning) between the three cohorts with box plots Table 2. Median scores of AEQ subscales for perceptions of Self-Directed Learning (Amount and distribution of study effort and assignments, and learning ) Year 2020 (N=42) 2021 (N=52) 2022 (N=59) p-value Overall (N=153) Amount and distribution of study effort Median(Q1-Q3) 18.0(17.0-19.8) 17.0(15.0-19.3) 18.0(15.5-20.5) 0.172 18.0(16.0-20.0) n(Min-Max) 42(14.0-26.0) 52(11.0-27.0) 59(0-29.0) 153(0-29.0) Assignments and learning Median(Q1-Q3) 22.0(21.0-23.0) 22.0(20.0-23.0) 22.0(20.0-23.0) 0.522 22.0(20.0-23.0) n(Min-Max) 42(16.0-30.0) 52(14.0-30.0) 59(0-28.0) 153(0-30.0) Scores from the AEQ sub-scales related to perceptions of Feedback The median (Q1-Q3) scores for quantity and timing of feedback was 17.5(14.3–20.0); 20.0(17.8–22.3) and 20.0(16.0–22.0) for the 2020,2021 and 2022 cohorts respectively .There was a significant difference between the median scores in 2020 and 2021, p = 0.031. Regarding the quality of feedback and feedback responses, there were differences in the median AEQ scores for these subscales; however, these differences were not statistically significant. Table 3 provides a comparison of the AEQ scores, and Fig. 3 illustrates the differences in scores with a box plot. Table 3 Median scores of AEQ subscales for perceptions of feedback (quantity and timing of feedback, quality of feedback, and feedback response) Year 2020 (N = 42) 2021 (N = 52) 2022 (N = 59) p-value Overall (N = 153) Quantity and timing of feedback Median(Q1-Q3) 17.5(14.3–20.0) 20.0(17.8–22.3) 20.0(16.0–22.0) 0.031 19.0(16.0–22.0) n(Min-Max) 42(8.00–28.0) 52(6.00–29.0) 59(0–29.0) 153(0–29.0) Quality of feedback Median(Q1-Q3) 22.0(19.3–24.0) 22.0(20.8–24.0) 22.0(21.0–24.0) 0.461 22.0(21.0–24.0) n(Min-Max) 42(17.0–29.0) 52(0–29.0) 59(0–29.0) 153(0–29.0) Feedback response Median(Q1-Q3) 23.0(20.0-24.8) 24.0(21.8–26.0) 24.0(22.0–25.0) 0.159 24.0(21.0–25.0) n(Min-Max) 42(0–29.0) 52(0–30.0) 59(0–30.0) 153(0–30.0) % and p-values based on non-missing cases | * parametric p-value Table 4 summarises the logistic regression analysis undertaken. Without adjustment, both subscales that assessed the amount and distribution of study and assignments, as well as learning (reflecting SDL), were significantly correlated with all the subscales of feedback. Table 4 Correlation indices between the subscale scores, amount and distribution of learning and assignments /learning with feedback SDL (Self-Directed learning subscales ) Feedback ( subscales ) Correlation P-value Amount and distribution of study effort Quantity and timing of feedback 0.219 0.007 Quality of feedback 0.3220 < 0.001 Feedback response 0.2980 < 0.001 Assignments and learning Quantity and timing of feedback 0.387 < 0.001 Quality of feedback 0.418 < 0.001 Feedback response 0.256 0.001 Thematic analysis of open comments Of the 153 respondents, a total of 298 open comments were analysed, with 102 responses to the question on enablers of blended learning, 104 to barriers, and 92 to suggestions for improvement. The first major theme identified was categorised as ‘Self-directed learning is promoted with blended programmes’. This major theme related to SDL includes four identified sub-themes: (i) Autonomy supported with the learning process, (ii) flexibility is possible with learning, (iii) ease of access to online resources improves with blended training, and (iv) interactive engagement is possible. The second major theme identified was categorised as ‘Practical skills training complements blended training. Within this major theme, we identified three related sub-themes: (i) increased theoretical workload with blended training,(ii) lack of practical clinical exposure to emergency scenarios, and (iii) adding a practical clinical skills component to the training. The third major theme related to feedback, viz, Face-to-face feedback, is essential. The sub-themes within this major theme included (i) Lack of individual feedback, and (ii) providing a feedback session. Table 5 illustrates the major themes and their corresponding sub-themes, along with the proposed relationships between them. Selected quotes have been identified and listed to substantiate these sub-themes and themes. Table 5 Sub-themes and Major themes with relevant quotes derived from analysis of open-ended questions A Priori Open-Ended Questions Subthemes Quotes ( month-year-number of participant) Major Themes Enablers of Blended learning 1. Autonomy is supported in the learning process “It gave the option to do it at your own time, read other sources on your computer quicker than in a class,” 07-2020, PID-037. A. Self-directed learning is promoted with blended programmes 2. Flexibility is possible with learning “Can read anywhere you want, can study on your device, easy to revise, and less stressful”04-2020, PID-003. 3. Ease of access to online resources improves with blended training “Allows for ease of access to much-needed and relevant information” 04-2020, PID-010. 4. Interactive engagement is promoted “They were interactive and allowed for review at a later time; teaching was really good and appreciated.”04-2021, PID-008. Barriers to Blended Learning 5. Increased theoretical workload with blended training “Too many assignments, and it wasn't easy to balance this with calls; some rest time is required.” 04-2020, PID-001. B. Practical skills training complements blended training 6. Lack of practical clinical exposure to emergency scenarios “Clinical exposure is more important than theory.” 10–22, PI-006. 7. Lack of individual feedback “Lack of individualised feedback and lack of clinical and interactive teaching” -01-2021, PID-011. C. Face-to-face feedback is essential Suggestions to improve 8. Provide a feedback session “After completion of the block(training), a proper follow-up and feedback should be done.” 04-2020, PID-002. 9. Add a practical clinical skills component to the training “Practical skills sessions complement our training programme and skills”. 04-2020, PID-008. B. Practical skills training complements blended training Code for the quote source: month-year-participant identification number(PID) e.g 07-2020, PID-037 Discussion In this study, the introduction of a blended programme for teaching and learning acute paediatric emergencies in a busy, resource-constrained environment was evaluated prospectively from the perspectives of its impact on self-directed learning and feedback among newly qualified doctors (interns). The measures of SDL were attributed to the subscales on the amount and distribution of study effort and assignments, as well as learning AEQ scores. These sub-scales are centred around aspects of learner autonomy, goal completion, planning and time management, as well as general experience of the assessments, which are all key principles of self-directed learning. SDL is a learning process in which individuals take initiative and responsibility for their own learning. This typically involves identifying their learning needs, setting goals, locating suitable resources, selecting and implementing effective learning strategies, and evaluating learning outcomes. (18) Among the three similarly matched cohorts for gender, age and university origin over three consecutive years, AEQ scores that reflect aspects of SDL were favourable and similar. The responses for all three years were overwhelmingly positive. This finding aligns with international data that supports the move towards a blended environment, incorporating both traditional and online aspects, as being superior to a solely traditional form of training. 19 The qualitative data obtained further enriches these findings, where sub-themes identified from the open-ended responses ( Table 5 ) centred on learning outcomes, where interns identify their own desired outcomes, such as being clinically competent in emergencies and reinforcing knowledge. Autonomy and flexibility of learning were supported in this blended programme. Several of the interns found that access to additional resources was enhanced through online learning, allowing them to engage meaningfully with the resources at their own pace. The flexibility of the online component enabled them to set aside time specifically to complete assignments within their busy clinical workloads. The addition of traditional face-to-face lectures did not affect scores related to SDL in this study. These findings reiterate that blended training on acute paediatric emergencies promotes SDL without the need for traditional face-to-face lectures. The benefits of TEL have been noted in other studies involving healthcare professionals in resource-constrained contexts. 20 , 21 Face-to-face lectures require clinician educators to be present every three months with each new group of interns. Additionally, interns at various geographical sites may not have access to similar, adequately trained, experienced, and willing teachers, and this has been postulated as a reason for the discrepant and inadequate training of interns. 5 , 7 Further clinical educators affiliated with an HEI may not oversee the standard of training, including the use of up-to-date and evidence-based knowledge. 6 , 7 The adoption of blended training of acute paediatric emergencies can be effective in a resource-limited setting such as the site of this study. One advantage of adopting this method of learning is that it frees up more time for clinician educators to attend to other duties and demands. At the same time, interns can participate in the online aspects of the training programme. In South Africa, where clinical and administrative demands overburden the scarce skills of clinician educators, this allows for the ability to free up more time without sacrificing the important task of teaching and supervising interns. These findings can also address the issues facing discrepant intern training across geographically diverse clinical sites. They may support a centralised, validated blended programme that can be developed and supported by clinician educators with links to HEIs 5 , 6 In this study, cohort 1 (year 1, 2020) received no face-to-face feedback regarding their assessments and assignments, while subsequent cohorts in years 2 (2021) and 3 (2022) received face-to-face feedback. AEQ scores related to both the quality and quantity of feedback were significantly lower when the blended training programme did not include a face-to-face feedback session (p = 0.032). The addition of a face-to-face feedback session, rather than an online group feedback, improved perceptions of feedback, and qualitative data clearly reinforced this finding. The lack of face-to-face feedback in the first year was succinctly highlighted, and these responses underscored frustration and dissatisfaction among this cohort, despite the provision of group online feedback. The lack of specifically face-to-face, individual feedback was noted by many participants in the first cohort. Feedback is the input a learner receives that affects their learning process; the ultimate result is for learners to display their understanding, skills, and approach to a particular subject. 22 , 23 Interns require receiving opinions and judgments about their work, including confirmation, criticism, assessment, or suggestions for improvement. 23 These findings thus reiterate the importance of face-to-face feedback in a blended training programme, particularly in training on acute paediatric emergencies, a high-stakes competency. The addition of a face-to-face traditional lecture in the last year made no changes in perceptions of feedback, further reiterating that this form of teaching, when replaced with a blended format, holds no advantage and can be replaced safely. Many clinician educators who insist on this traditional form of teaching, which requires greater resources, need to acknowledge that a blended programme with face-to-face feedback can be introduced in the teaching and learning of clinical emergencies. Whilst participants in this study noted the advantages of increased access to a wider array of online resources with a blended programme, many also identified an associated disadvantage in that excessive theoretical knowledge was perceived as being required. The lack of relevant and timely, symbiotic practical training was an additional concern. Analysis of the open-ended questions revealed these findings, along with the recommendation that blended training should include a practical training component aligned with the online programme. Study limitations and strengths This study was conducted among participants in training within a well-described hierarchical medical culture, and these power dynamics may have resulted in some bias, where full disclosure may not have been possible. 8 This study sampled one teaching hospital in one province in SA and reviewed a three-month training period in a 24-month programme, and thus, findings cannot be fully generalisable. The study did prospectively obtain data over a three-year period and included qualitative data, which may have provided greater insights. Conclusion Using blended training programmes to train interns in paediatric emergencies supports self-directed learning. However, perceptions of inadequate feedback often occur when no face-to-face interaction takes place during feedback sessions. Didactic lectures do not improve SDL or feedback when utilising blended programmes. Using blended training that includes technology-engaged learning programmes in resource-constrained contexts to train in paediatric emergencies is feasible, stimulates SDL, and, when coupled with face-to-face feedback and practical skills training, should replace traditional lectures. These findings support the development of centrally validated and quality-controlled training programmes that HEIs could support for interns across the country. Declarations Acknowledgements The researcher would like to thank the participants who contributed to this study. Author Contributions MN conceptualised the study under the supervision of KLN and CB. MN prepared the manuscript, and KLN and CB reviewed it. The authors read and approved the final manuscript. Conflict of Interest The authors declare no financial or personal relationship(s), which may have inappropriately influenced them in writing this article. Data Availability Statement The data supporting this study’s findings are available from the corresponding author upon reasonable request. Study Funding The authors received no financial support for this article’s research, authorship, and publication. References Health Professions Council of South Africa. Handbook On Internship Training Guidelines for Interns, Accredited Facilities and Health Authorities, 2025. Page 32. https://www.hpcsa.co.za/board/medical-dental/internships; [accessed on 16 July 2025] Bamford LJ, Barron P, Kauchali S, Dlamini NR. In-patient case fatality rates improvements in children under five: diarrhoeal disease, pneumonia and severe acute malnutrition. S Afr Med J. 2018;108 (3 Suppl 1):S33–S37. doi:10.7196/SAMJ.2018.v108i3.12772. Bamford LJ, McKerrow NH, Barron P, Aung Y. Child mortality in South Africa: Fewer deaths, but better data are needed. S Afr Med J. 2018;108(3 Suppl 1):S25–S32. doi:10.7196/SAMJ.2018.v108i3.12779. Bola S, Trollip E, Parkinson F. The state of South African internships: a national survey against HPCSA guidelines. S Afr Med J. 2015;105(7):535-539. doi:10.7196/SAMJnew.7923. Peters F, van Wyk J, van Rooyen M. Intern to independent doctor: basic surgical skills required for South African practice and interns’ reports on their competence. S Afr Fam Pract 2015;57(4):261-266. doi:10.1080/20786190.2014.976954. Burch V, van Heerden B. Are community service doctors equipped to address priority health needs in South Africa? S Afr Med J. 2013 Jul 29;103(12):905. doi: 10.7196/samj.7198. Nkabinde TC, Ross A, Reid S, Nkwanyana NM. Internship training adequately prepares South African medical graduates for community service – with exceptions. S Afr Med J. 2013;103(12):930–934. doi:10.7196/samj.6702. Kgatle M, George J, Dominic F, De Jager P. Prevalence and factors associated with burnout among junior medical doctors at a South African tertiary public sector hospital. Pan Afr Med J. 2024 Apr 24;47:208. doi: 10.11604/pamj.2024.47.208.41865. Li ST, Paterniti DA, Co JP, West DC. Successful self-directed lifelong learning in medicine: a conceptual model derived from qualitative analysis of a national survey of pediatric residents. Acad Med. 2010;85(7):1229–1236. doi: 10.1097/ACM.0b013e3181e1931c. Knowles M. Self-directed learning: A guide for learners and teachers. Cambridge: Englewood Cliffs (1975). Available from https://dokumen.pub/download/self-directed-learning-a-guide-for-learners-and-teachers-0695811169.html (Accessed on 29 August 2025). Roberson DN Jr, Zach S, Choresh N, Rosenthal I. Self-directed learning: a longstanding tool for uncertain times. Creat Educ. 2021;12:1011–1026. doi: 10.4236/ce.2021.125074. Khan N B, Erasmus T, Jali N, Mthiyane P, Ronne S. Is blended learning the way forward? Students' perceptions and attitudes at a South African university. Afr. J. Health Prof. Educ. 2021;13(4):219-222. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S2078-51272021000400004&lng=en. https://doi.org/10.7196/ajhpe.2021.v13i4.1424 (Accessed on 29 August 2025). Lala SG, George AZ, Wooldridge D, et al. A blended learning and teaching model to improve bedside undergraduate paediatric clinical training during and beyond the COVID-19 pandemic. African Journal of Health Professions Education. 2021;13(1):18. https://doi.org/10.7196/AJHPE.2021.v13i1.1447. Ndlovu S, David-Govender C, Tinarwo P, Naidoo KL. Changing mortality amongst hospitalised children with Severe Acute Malnutrition in KwaZulu-Natal, South Africa, 2009 - 2018. BMC Nutr. 2022 Jul 12;8(1):63. doi: 10.1186/s40795-022-00559-y. Sharkey A, Chopra M, Jackson D, Winch PJ, Minkovitz CS. Influences on healthcare-seeking during final illnesses of infants in under-resourced South African settings. J Health Popul Nutr. 2011;29(4):379-387. doi:10.3329/jhpn.v29i4.8455. Miller A, Archer J. Impact of workplace based assessment on doctors' education and performance: a systematic review. BMJ. 2010 Sep 24;341:c5064. doi: 10.1136/bmj.c5064. Creswell JW, Plano Clark VL, Gutmann ML, Hanson WE. Advances in mixed methods research designs. In: Tashakkori A, Teddlie C, editors. Handbook of mixed methods in social and behavioral research. SAGE; Thousand Oaks, CA: 2003. pp. 209–240. Suwannaphisit S, Anusitviwat C, Tuntarattanapong P, Chuaychoosakoon C. Comparing the effectiveness of blended learning and traditional learning in an orthopedics course. Ann Med Surg (Lond). 2021;72:103037. doi: 10.1016/j.amsu.2021.103037. Funke K, Bonrath E, Mardin WA, Becker JC, Haier J, Senninger N, Vowinkel T, Hoelzen JP, Mees ST. Blended learning in surgery using the Inmedea Simulator. Langenbecks Arch Surg. 2013;398(2):335-340. doi: 10.1007/s00423-012-0987-8. Manyazewal T, Marinucci F, Belay G, et al. Implementation and Evaluation of a Blended Learning Course on Tuberculosis for Front-Line Health Care Professionals. Am J Clin Pathol. 2017;147(3):285-291. doi: 10.1093/ajcp/aqx002. Frehywot S, Vovides Y, Talib Z, et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health. 2013;11:4. doi: 10.1186/1478-4491-11-4. Gigante J, Dell M, Sharkey A. Getting beyond "Good job": how to give effective feedback. Pediatrics. 2011;127(2):205-207. doi: 10.1542/peds.2010-3351. van de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT. What is feedback in clinical education? Med Educ. 2008;42(2):189-197. doi: 10.1111/j.1365-2923.2007.02973.x.. Additional Declarations No competing interests reported. Supplementary Files AppendixAAEQQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 01 Dec, 2025 Editor invited by journal 31 Oct, 2025 Editor assigned by journal 29 Oct, 2025 Submission checks completed at journal 29 Oct, 2025 First submitted to journal 13 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7849481","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":553729143,"identity":"8b631a45-0aa1-40ed-adce-61390e655883","order_by":0,"name":"Melusi Ngobese","email":"","orcid":"","institution":"University of KwaZulu-Natal, KwaZulu-Natal","correspondingAuthor":false,"prefix":"","firstName":"Melusi","middleName":"","lastName":"Ngobese","suffix":""},{"id":553729144,"identity":"b1dc2fd6-d218-4a8b-90ec-a07364fe7e7d","order_by":1,"name":"Chauntelle Bagwandeen","email":"","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":false,"prefix":"","firstName":"Chauntelle","middleName":"","lastName":"Bagwandeen","suffix":""},{"id":553729145,"identity":"4857886b-69c8-4906-8229-0ed46d9171b4","order_by":2,"name":"Kimesh L Naidoo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYFACxgYJBoYEOX4GNhK1GEs2EK+FgQGkJXHDAWK1mLMfbrzxoSItcfONtOTPBQx28gz8hx/g1WLZk9hsOeNMjvG2G2kHjGcwJBs2MBwzwKvF4EBimzRvW4XsthvpDck8DMwJQM8R0HL+IVgL4+YZ6Q2HeRjqExiY2T/g13IDbEuO4gaJtIPNPAyHExjYeAjYcuMhyC9pxhJnniUz8xgcN2zj4Skg4LD0h8AQS5bjb08z/sxTUS3Pz398A14t6CYwkJAIRsEoGAWjYBTgBABTGUKxVbCfHQAAAABJRU5ErkJggg==","orcid":"","institution":"University of KwaZulu-Natal, KwaZulu-Natal","correspondingAuthor":true,"prefix":"","firstName":"Kimesh","middleName":"L","lastName":"Naidoo","suffix":""}],"badges":[],"createdAt":"2025-10-13 13:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7849481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7849481/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97370486,"identity":"9789a863-afb0-4c97-ba5a-ef3f2691ff3b","added_by":"auto","created_at":"2025-12-03 16:27:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":159788,"visible":true,"origin":"","legend":"","description":"","filename":"Full2SelfDirectedLearningandFeedbackwithBlendedTraininginPaediatricEmergencies.docx","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/ccd992001c077640d614b29b.docx"},{"id":97342845,"identity":"ac4f7978-ba49-43fe-84ae-ef149bec0ed7","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5771,"visible":true,"origin":"","legend":"","description":"","filename":"7e363c2bfaa4489084d3200f9da76fe1.json","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/1e2aae488115afa8ac6baad2.json"},{"id":97342844,"identity":"40430e4d-f610-4a95-891e-5e5f4d506006","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39760,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixAAEQQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/08ee675e06d3b552380abb7c.docx"},{"id":97342847,"identity":"e13cea1d-69f6-4fc3-b03f-7f094f68ee5b","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95072,"visible":true,"origin":"","legend":"","description":"","filename":"7e363c2bfaa4489084d3200f9da76fe11enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/53a7f75f933bbdec61e9f4f6.xml"},{"id":97342851,"identity":"9351ddea-bed8-485d-b5ad-ddf6c915969d","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15942,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/24c5f16846e71d2e9d3847b4.png"},{"id":97371274,"identity":"c5c20cc6-3f2a-407d-8016-848d0fe16f69","added_by":"auto","created_at":"2025-12-03 16:28:40","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92438,"visible":true,"origin":"","legend":"","description":"","filename":"7e363c2bfaa4489084d3200f9da76fe11structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/c263a21f046cf0dda540be94.xml"},{"id":97342849,"identity":"2593b0a7-4890-49bb-80dd-25937e64e72e","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102134,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/1effb8c1f8d3717dee6a19dd.html"},{"id":97371337,"identity":"93312166-3cf3-4414-9753-a6e84cb0c110","added_by":"auto","created_at":"2025-12-03 16:28:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66068,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of intern participants at undergraduate universities by year\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/0ec31aea06d37b64e574dd6d.png"},{"id":97342842,"identity":"f12bfdb3-ff50-4c78-bb8d-277f9d7b639b","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38766,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBox plot of (SDL perceptions), the amount and distribution of study effort and assignments, and learning AEQ subscale scores per year cohort\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/1bb3c8fdc4982bbc25bf31ae.png"},{"id":97370581,"identity":"d056f7c4-18b4-4e8e-ab49-93e705d029e0","added_by":"auto","created_at":"2025-12-03 16:27:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":44270,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBox plot of the Feedback AEQ subscale scores per year cohort\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/745606e01b08cdcca538068f.png"},{"id":97664769,"identity":"590071b5-4e98-46b0-86dd-825d453f23de","added_by":"auto","created_at":"2025-12-08 09:14:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1256536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/104ae350-e2a2-46be-ab86-f45192b84671.pdf"},{"id":97342841,"identity":"24df23fb-38d5-4774-b8c2-c25db7beb6ac","added_by":"auto","created_at":"2025-12-03 11:34:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":39760,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixAAEQQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7849481/v1/3ae6d5efc9d1f3517b6db395.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Self-Directed Learning and Feedback with Blended Training in Paediatric Emergencies","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNewly qualified medical practitioners (interns) in South Africa must be rapidly upskilled to manage paediatric emergencies during the three months of training.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The high childhood disease burden and poor socioeconomic conditions lead to the late presentation of many acutely ill children who require resuscitation and stabilisation in the country's public sector regional hospitals, where interns train.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Suboptimal doctor-patient staffing ratios in these hospitals render interns as frontline staff, who are generally the first to identify and manage acute paediatric emergencies.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This training has traditionally included face-to-face didactic lectures, skills training and a reliance on on-the-job exposure to emergencies.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, poor training and supervision during internship, including specifically on the teaching of how to manage acute paediatric emergencies, has been documented.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe training of interns to be competent in managing paediatric emergencies is dependent on clinician educators. \u003csup\u003e1\u003c/sup\u003e Clinician educators, while performing their primary clinical care responsibilities in these resource-limited hospitals, are tasked with training interns and ensuring a conducive learning environment. The quality and monitoring of this training are conducted by the Health Professions Council of South Africa (HPCSA), which is also responsible for accrediting and regulating intern training. There is no formalised oversight from Higher Education Institutions (HEIs).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e There is a scant review of the praxis of teaching across intern training institutions, and many interns have complained of feeling inadequately prepared to manage paediatric emergencies.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Expectations from the accrediting bodies, clinicians, and patients for newly qualified medical practitioners to be clinically competent have also led to increased levels of burnout among interns.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSelf-directed learning (SDL), a component of andragogy, has been advocated as an effective skill for practising doctors and other healthcare professionals.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e SDL, as defined by Knowles, is a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Self-directed learners are characterised by their abilities to manage their learning proactively, possess a strong desire for learning, take responsibility for their learning, engage in an independent learning environment, self-evaluate their learning performance and control their strategies for improvement.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This aligns with the recommended educational framework by the accrediting body for intern education in SA.\u003csup\u003e1\u003c/sup\u003e The integral components of this training are to be a motivated, self-directed learner and to transition to become a clinician-educator who can provide adequate training and relevant feedback.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The amount and quality of feedback provided to interns, especially in busy regional hospitals in SA, remains a challenge.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTechnology-enhanced learning (TEL) methods, including blended teaching programmes, can assist busy clinician-educators in providing intern training.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e These blended programmes require less intensive human resource needs and may be suited to resource-constrained hospitals. TELs have developed independent thinkers and self-regulated learners in many undergraduate and postgraduate programmes managed by HEIs.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Following the COVID-19 pandemic, there was a rapid shift in many undergraduate and postgraduate health professions education programmes to utilise TEL. Evidence that this shift in established pedagogical approach to training ensured an adequate development of the required knowledge, skills and attitudes for highly disease-burdened contexts is unknown. It is also not well understood how TEL can support intern training when there is a lack of oversight from HEIs.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In many contexts, traditional face-to-face lectures in training on paediatric emergencies have either persisted or clinician-educators reverted to this format, especially where it is equated with direct oversight as required by accrediting authorities.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This study evaluates the perceptions of interns who receive blended training in paediatric emergency care in a resource-limited, high childhood disease-burdened context. There is a specific focus on aspects of developing SDL and receiving feedback, with an evaluation of the importance and role of traditional face-to-face teaching.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis was a longitudinal mixed-methods study. Data were collected prospectively over three years, from January 2021 to December 2023, at the King Edward VIII (Victoria Mxenge Hospital) teaching hospital, following the introduction of a blended teaching programme on paediatric emergencies.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at a regional /tertiary hospital accredited by the HPCSA to train interns.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This hospital in Durban, South Africa (includes 130 paediatric and neonatal beds), caters for children with high rates of malnutrition, HIV and mortality.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Many of these children present late in their disease trajectory and require acute emergency care.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study focuses on newly qualified medical doctors(interns). Interns spend the first two years following the completion of their medical undergraduate studies in a 24-month, supervised, paid internship. During these two years, they spend three months in paediatrics, during which they are trained to manage acute emergencies and other aspects of paediatric and neonatal care. Interns, while training, also serve as the first line of medical care in acute care units in regional hospitals and are required to be efficient and skilled in managing a large patient load.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Training generally consists of face-to-face lectures at the start of the rotation, followed by practical skills training sessions. Interns are then expected to be self-directed learners and learn \u0026lsquo;on the job\u0026rsquo; with supervision. Interns in this study were prospectively recruited at the start of a blended teaching programme that included an online programme developed by 12 paediatricians based at the teaching hospital. This blended teaching programme on acute emergencies included an online self-directed component with embedded question-and-answer sessions. Access to online skills training videos was also provided, along with two face-to-face practical training sessions on paediatric and neonatal resuscitation conducted in a skills laboratory. Interns were given access to the online materials at the start of the paediatric training and were required to work through them independently. Only group online feedback was provided for the first cohort in 2021, and face-to-face feedback was provided for the 2022 and 2023 cohorts. For the last cohort in 2023, a face-to-face didactic lecture was also held for each paediatric emergency topic.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA specific survey instrument, the Assessment Experience Questionnaire (AEQ) \u003cb\u003e(Appendix A)\u003c/b\u003e, was chosen to collect data for this study. The AEQ is a brief survey developed by Gibbs et al. over 15 years ago for postgraduate programmes, and has been validated in numerous research studies across multiple contexts, focusing on evaluating perceptions of effective assessment practices.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The survey consists of 32 items with responses scored with a Likert scale and divided into five subscales :(i) amount and distribution of study effort;(ii) assignments and learning;(iii) quantity and timing of feedback; (iv) quality of feedback; and (v) what you do with the feedback. For the purposes of this study, the first two subscales were specifically used to evaluate perceptions of self-directed learning, and the last three subscales were used to assess perceptions of feedback. In addition to this survey, open-ended questions( on enablers, barriers and suggestions to improve BL) were included to solicit qualitative and demographic data. A pilot was done prior to utilisation to ensure face validity.\u003c/p\u003e\u003cp\u003eAt the end of every three-month rotation for three consecutive years, all paediatric interns, upon completing this training, were required to fill out an AEQ survey reflecting on the blended training programme in paediatric emergencies. Whilst this data was used to determine programme evaluation, data from all participants who consented to participate in the study were collected for analysis. The AEQ was completed on paper, and the responses were manually entered into an Excel spreadsheet. Specific demographic questions related to age, gender, and the university attended for undergraduate medical studies were also collected. This information was added to identify potential demographic associations in the data.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData were entered in MS Excel and analysed in Stata version 15. For each participant, the AEQ scores and sub-scores were calculated. Certain statements are negatively stated and thus receive a reverse score. Where there was missing data, means were computed based on the available data, provided that the percentage of missing data did not exceed 20% of the items. The overall AEQ score was computed as the average of all items. The five sub-scores in the various subthemes (composite and sub-theme scores) were compared across the cohorts of 2020, 2021, and 2022. Comparisons were done based on these cohorts. In addition, comparisons were drawn with age, gender and university origin. Descriptive analysis of the data was carried out as follows: Categorical variables were summarised by frequency and percentage tabulation, and illustrated using bar charts. The mean, summarised continuous variables, standard deviation, median, and interquartile range, along with their distribution, were illustrated using histograms and box-and-whisker charts. The Χ2 test was used to assess the relationships between categorical variables. Fisher\u0026rsquo;s exact test was used for 2 x 2 tables. The relationship between continuous and categorical variables was assessed by the t-test (or ANOVA for more than two categories). Where the data does not meet the assumptions of these tests, a non-parametric alternative, the Wilcoxon rank sum test (or the Kruskal-Wallis test for more than two categories) was used.\u003c/p\u003e\u003cp\u003eLogistic regression was further applied to determine the relationships between the subscales associated with SDL (amount and distribution of study; assignments and learning) and the various subscales associated with feedback. The dependent variable used was both the perceptions of the amount and distribution of study and assignments, as well as learning. The quantity and timing of feedback, the quality of feedback, and the feedback response were independent variables. All inferential statistical analysis tests were conducted at a 5% level of significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eThe open-ended questions were transcribed and analysed by the principal investigator and two additional co-coders (CB and KL), who read the transcripts of the open-ended questions on multiple occasions to familiarise themselves with the data. Specific categories of attitudes were analysed using a qualitative content analysis approach, and thereafter, an inductive coding process was employed to identify patterns in these responses through thematic analysis. The co-coders also coded the transcriptions independently to enhance rigour. The themes were determined independently, and a common set of themes was then established by consensus.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The principal investigator and co-coders jointly compared and finalised the sub-themes and labelled them once consensus was reached on the categorisation and naming of both the sub-themes and major themes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthics\u003c/h2\u003e\u003cp\u003e All participants were required to have written informed consent. Institutional approvals were obtained for the retrospective utilisation of routinely collected data. Ethics approval was obtained through the University of KwaZulu-Natal, Human Social Science Ethics Committee, with ethics approval number HSSREC/00005305/2023. Clinical trial number: not applicable.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOf the 153 interns (median age of 25 years) who participated in the study, 54% were female, and 9.7% had graduated from universities outside SA. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e lists the demographic characteristics of the interns sampled and the distribution of universities in SA from which they graduated. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e further illustrates the distribution of interns from various universities per year. There were no significant demographic differences between the interns from the three years.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics of interns\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (43.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (54.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (56.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0(25.0\u0026ndash;26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.0(24.5\u0026ndash;27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.0(24.0\u0026ndash;27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.0(24.0\u0026ndash;27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(23.0\u0026ndash;32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51(23.0\u0026ndash;32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57(22.0\u0026ndash;33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e148(22.0\u0026ndash;33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eForeign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"9\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUKZN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (25.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWITS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWSU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003e| % and p-values based on non-missing cases | * parametric p-value\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eScores from the AEQ sub-scales related to perceptions of Self-directed learning\u003c/h2\u003e\n \u003cp\u003eThe median (Q1-Q3) AEQ score for the subscales related to SDL, namely the amount and distribution of the study, was 18 (17.0-19.8), 17.0 (15.0-19.3), and 18.0 (15.5\u0026ndash;20.5) for the interns in years 2020, 2021, and 2022, respectively.With regard to assignments and learning the median(Q1-Q3) AEQ scores for this subscale was 22.0(21.0\u0026ndash;23.0); 22.0(20.0\u0026ndash;23) and 22.0(20.0\u0026ndash;23.0) over the for years 2020,2021 and 2022. There were no significant differences in median scores over the three years in both subscales. \u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e indicates these scores and p-values. Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the differences in the AEQ scores ( the amount and distribution of study effort and assignments, and learning) between the three cohorts with box plots\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2. Median scores of AEQ subscales for perceptions of Self-Directed Learning\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Amount and distribution of study effort and assignments, and learning )\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"651\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2020\u003cbr\u003e\u0026nbsp;(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2021\u003cbr\u003e\u0026nbsp;(N=52)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003cbr\u003e\u0026nbsp;(N=59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003cbr\u003e\u0026nbsp;(N=153)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 651px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmount and distribution of study effort\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e18.0(17.0-19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e17.0(15.0-19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e18.0(15.5-20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e18.0(16.0-20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e42(14.0-26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e52(11.0-27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e59(0-29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e153(0-29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 651px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssignments and learning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e22.0(21.0-23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e22.0(20.0-23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e22.0(20.0-23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e22.0(20.0-23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e42(16.0-30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e52(14.0-30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e59(0-28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e153(0-30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eScores from the AEQ sub-scales related to perceptions of Feedback\u003c/h2\u003e\n \u003cp\u003eThe median (Q1-Q3) scores for quantity and timing of feedback was 17.5(14.3\u0026ndash;20.0); 20.0(17.8\u0026ndash;22.3) and 20.0(16.0\u0026ndash;22.0) for the 2020,2021 and 2022 cohorts respectively .There was a significant difference between the median scores in 2020 and 2021, p\u0026thinsp;=\u0026thinsp;0.031. Regarding the quality of feedback and feedback responses, there were differences in the median AEQ scores for these subscales; however, these differences were not statistically significant. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e provides a comparison of the AEQ scores, and Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates the differences in scores with a box plot.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMedian scores of AEQ subscales for perceptions of feedback (quantity and timing of feedback, quality of feedback, and feedback response)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eQuantity and timing of feedback\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5(14.3\u0026ndash;20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0(17.8\u0026ndash;22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0(16.0\u0026ndash;22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.0(16.0\u0026ndash;22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42(8.00\u0026ndash;28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52(6.00\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e153(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of feedback\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0(19.3\u0026ndash;24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0(20.8\u0026ndash;24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0(21.0\u0026ndash;24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.461\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.0(21.0\u0026ndash;24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42(17.0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e153(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeedback response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian(Q1-Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0(20.0-24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0(21.8\u0026ndash;26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0(22.0\u0026ndash;25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0(21.0\u0026ndash;25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en(Min-Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42(0\u0026ndash;29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52(0\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59(0\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e153(0\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;% and p-values based on non-missing cases | * parametric p-value\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e summarises the logistic regression analysis undertaken. Without adjustment, both subscales that assessed the amount and distribution of study and assignments, as well as learning (reflecting SDL), were significantly correlated with all the subscales of feedback.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorrelation indices between the subscale scores, amount and distribution of learning and assignments /learning with feedback\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSDL\u003c/p\u003e\n \u003cp\u003e(Self-Directed learning subscales )\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFeedback ( subscales )\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCorrelation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eAmount and distribution of study effort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuantity and timing of feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality of feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeedback response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eAssignments and learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuantity and timing of feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality of feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeedback response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eThematic analysis of open comments\u003c/h2\u003e\n \u003cp\u003eOf the 153 respondents, a total of 298 open comments were analysed, with 102 responses to the question on enablers of blended learning, 104 to barriers, and 92 to suggestions for improvement. The first major theme identified was categorised as \u0026lsquo;Self-directed learning is promoted with blended programmes\u0026rsquo;. This major theme related to SDL includes four identified sub-themes: (i) Autonomy supported with the learning process, (ii) flexibility is possible with learning, (iii) ease of access to online resources improves with blended training, and (iv) interactive engagement is possible. The second major theme identified was categorised as \u0026lsquo;Practical skills training complements blended training. Within this major theme, we identified three related sub-themes: (i) increased theoretical workload with blended training,(ii) lack of practical clinical exposure to emergency scenarios, and (iii) adding a practical clinical skills component to the training. The third major theme related to feedback, viz, Face-to-face feedback, is essential. The sub-themes within this major theme included (i) Lack of individual feedback, and (ii) providing a feedback session. Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e illustrates the major themes and their corresponding sub-themes, along with the proposed relationships between them. Selected quotes have been identified and listed to substantiate these sub-themes and themes.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSub-themes and Major themes with relevant quotes derived from analysis of open-ended questions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eA Priori\u003c/em\u003e Open-Ended Questions\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuotes \u003cem\u003e( month-year-number of participant)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMajor Themes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnablers of Blended learning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. Autonomy is supported in the learning process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It gave the option to do it at your own time, read other sources on your computer quicker than in a class,\u0026rdquo; 07-2020, PID-037.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eA. Self-directed learning is promoted with blended programmes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Flexibility is possible with learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Can read anywhere you want, can study on your device, easy to revise, and less stressful\u0026rdquo;04-2020, PID-003.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Ease of access to online resources improves with blended training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Allows for ease of access to much-needed and relevant information\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e04-2020, PID-010.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4. Interactive engagement is promoted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They were interactive and allowed for review at a later time; teaching was really good and appreciated.\u0026rdquo;04-2021, PID-008.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to Blended Learning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5. Increased theoretical workload with blended training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Too many assignments, and it wasn\u0026apos;t easy to balance this with calls; some rest time is required.\u0026rdquo; 04-2020, PID-001.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eB. Practical skills training complements blended training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6. Lack of practical clinical exposure to emergency scenarios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Clinical exposure is more important than theory.\u0026rdquo; 10\u0026ndash;22, PI-006.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7. Lack of individual feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Lack of individualised feedback and lack of clinical and interactive teaching\u0026rdquo; -01-2021, PID-011.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eC. Face-to-face feedback is essential\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuggestions to improve\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8. Provide a feedback session\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After completion of the block(training), a proper follow-up and feedback should be done.\u0026rdquo; 04-2020, PID-002.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9. Add a practical clinical skills component to the training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Practical skills sessions complement our training programme and skills\u0026rdquo;. 04-2020, PID-008.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB. Practical skills training complements blended training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eCode for the quote source: month-year-participant identification number(PID) e.g \u003cem\u003e07-2020, PID-037\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the introduction of a blended programme for teaching and learning acute paediatric emergencies in a busy, resource-constrained environment was evaluated prospectively from the perspectives of its impact on self-directed learning and feedback among newly qualified doctors (interns).\u003c/p\u003e\u003cp\u003eThe measures of SDL were attributed to the subscales on the amount and distribution of study effort and assignments, as well as learning AEQ scores. These sub-scales are centred around aspects of learner autonomy, goal completion, planning and time management, as well as general experience of the assessments, which are all key principles of self-directed learning. SDL is a learning process in which individuals take initiative and responsibility for their own learning. This typically involves identifying their learning needs, setting goals, locating suitable resources, selecting and implementing effective learning strategies, and evaluating learning outcomes. (18) Among the three similarly matched cohorts for gender, age and university origin over three consecutive years, AEQ scores that reflect aspects of SDL were favourable and similar. The responses for all three years were overwhelmingly positive. This finding aligns with international data that supports the move towards a blended environment, incorporating both traditional and online aspects, as being superior to a solely traditional form of training.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe qualitative data obtained further enriches these findings, where sub-themes identified from the open-ended responses \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e centred on learning outcomes, where interns identify their own desired outcomes, such as being clinically competent in emergencies and reinforcing knowledge. Autonomy and flexibility of learning were supported in this blended programme. Several of the interns found that access to additional resources was enhanced through online learning, allowing them to engage meaningfully with the resources at their own pace. The flexibility of the online component enabled them to set aside time specifically to complete assignments within their busy clinical workloads.\u003c/p\u003e\u003cp\u003eThe addition of traditional face-to-face lectures did not affect scores related to SDL in this study. These findings reiterate that blended training on acute paediatric emergencies promotes SDL without the need for traditional face-to-face lectures. The benefits of TEL have been noted in other studies involving healthcare professionals in resource-constrained contexts.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFace-to-face lectures require clinician educators to be present every three months with each new group of interns. Additionally, interns at various geographical sites may not have access to similar, adequately trained, experienced, and willing teachers, and this has been postulated as a reason for the discrepant and inadequate training of interns.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Further clinical educators affiliated with an HEI may not oversee the standard of training, including the use of up-to-date and evidence-based knowledge.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The adoption of blended training of acute paediatric emergencies can be effective in a resource-limited setting such as the site of this study. One advantage of adopting this method of learning is that it frees up more time for clinician educators to attend to other duties and demands. At the same time, interns can participate in the online aspects of the training programme. In South Africa, where clinical and administrative demands overburden the scarce skills of clinician educators, this allows for the ability to free up more time without sacrificing the important task of teaching and supervising interns. These findings can also address the issues facing discrepant intern training across geographically diverse clinical sites. They may support a centralised, validated blended programme that can be developed and supported by clinician educators with links to HEIs \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, cohort 1 (year 1, 2020) received no face-to-face feedback regarding their assessments and assignments, while subsequent cohorts in years 2 (2021) and 3 (2022) received face-to-face feedback. AEQ scores related to both the quality and quantity of feedback were significantly lower when the blended training programme did not include a face-to-face feedback session (p\u0026thinsp;=\u0026thinsp;0.032). The addition of a face-to-face feedback session, rather than an online group feedback, improved perceptions of feedback, and qualitative data clearly reinforced this finding. The lack of face-to-face feedback in the first year was succinctly highlighted, and these responses underscored frustration and dissatisfaction among this cohort, despite the provision of group online feedback. The lack of specifically face-to-face, individual feedback was noted by many participants in the first cohort. Feedback is the input a learner receives that affects their learning process; the ultimate result is for learners to display their understanding, skills, and approach to a particular subject.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Interns require receiving opinions and judgments about their work, including confirmation, criticism, assessment, or suggestions for improvement.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e These findings thus reiterate the importance of face-to-face feedback in a blended training programme, particularly in training on acute paediatric emergencies, a high-stakes competency.\u003c/p\u003e\u003cp\u003eThe addition of a face-to-face traditional lecture in the last year made no changes in perceptions of feedback, further reiterating that this form of teaching, when replaced with a blended format, holds no advantage and can be replaced safely. Many clinician educators who insist on this traditional form of teaching, which requires greater resources, need to acknowledge that a blended programme with face-to-face feedback can be introduced in the teaching and learning of clinical emergencies.\u003c/p\u003e\u003cp\u003eWhilst participants in this study noted the advantages of increased access to a wider array of online resources with a blended programme, many also identified an associated disadvantage in that excessive theoretical knowledge was perceived as being required. The lack of relevant and timely, symbiotic practical training was an additional concern. Analysis of the open-ended questions revealed these findings, along with the recommendation that blended training should include a practical training component aligned with the online programme.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStudy limitations and strengths\u003c/h2\u003e\u003cp\u003eThis study was conducted among participants in training within a well-described hierarchical medical culture, and these power dynamics may have resulted in some bias, where full disclosure may not have been possible.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This study sampled one teaching hospital in one province in SA and reviewed a three-month training period in a 24-month programme, and thus, findings cannot be fully generalisable. The study did prospectively obtain data over a three-year period and included qualitative data, which may have provided greater insights.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUsing blended training programmes to train interns in paediatric emergencies supports self-directed learning. However, perceptions of inadequate feedback often occur when no face-to-face interaction takes place during feedback sessions. Didactic lectures do not improve SDL or feedback when utilising blended programmes. Using blended training that includes technology-engaged learning programmes in resource-constrained contexts to train in paediatric emergencies is feasible, stimulates SDL, and, when coupled with face-to-face feedback and practical skills training, should replace traditional lectures. These findings support the development of centrally validated and quality-controlled training programmes that HEIs could support for interns across the country.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researcher would like to thank the participants who contributed to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMN conceptualised the study under the supervision of KLN and CB. MN prepared the manuscript, and KLN and CB reviewed it. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or personal relationship(s), which may have inappropriately influenced them in writing this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study’s findings are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for this article’s research, authorship, and publication.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHealth Professions Council of South Africa. Handbook On Internship Training Guidelines for Interns, Accredited Facilities and Health Authorities, 2025. Page 32. https://www.hpcsa.co.za/board/medical-dental/internships; [accessed on 16 July 2025]\u003c/li\u003e\n\u003cli\u003eBamford LJ, Barron P, Kauchali S, Dlamini NR. In-patient case fatality rates improvements in children under five: diarrhoeal disease, pneumonia and severe acute malnutrition. S Afr Med J. 2018;108 (3 Suppl 1):S33\u0026ndash;S37. doi:10.7196/SAMJ.2018.v108i3.12772.\u003c/li\u003e\n\u003cli\u003eBamford LJ, McKerrow NH, Barron P, Aung Y. Child mortality in South Africa: Fewer deaths, but better data are needed. S Afr Med J. 2018;108(3 Suppl 1):S25\u0026ndash;S32. doi:10.7196/SAMJ.2018.v108i3.12779.\u003c/li\u003e\n\u003cli\u003eBola S, Trollip E, Parkinson F. The state of South African internships: a national survey against HPCSA guidelines. S Afr Med J. 2015;105(7):535-539. doi:10.7196/SAMJnew.7923.\u003c/li\u003e\n\u003cli\u003ePeters F, van Wyk J, van Rooyen M. Intern to independent doctor: basic surgical skills required for South African practice and interns\u0026rsquo; reports on their competence. S Afr Fam Pract 2015;57(4):261-266. doi:10.1080/20786190.2014.976954.\u003c/li\u003e\n\u003cli\u003eBurch V, van Heerden B. Are community service doctors equipped to address priority health needs in South Africa? S Afr Med J. 2013 Jul 29;103(12):905. doi: 10.7196/samj.7198.\u003c/li\u003e\n\u003cli\u003eNkabinde TC, Ross A, Reid S, Nkwanyana NM. Internship training adequately prepares South African medical graduates for community service \u0026ndash; with exceptions. S Afr Med J. 2013;103(12):930\u0026ndash;934. doi:10.7196/samj.6702.\u003c/li\u003e\n\u003cli\u003eKgatle M, George J, Dominic F, De Jager P. Prevalence and factors associated with burnout among junior medical doctors at a South African tertiary public sector hospital. Pan Afr Med J. 2024 Apr 24;47:208. doi: 10.11604/pamj.2024.47.208.41865.\u003c/li\u003e\n\u003cli\u003eLi ST, Paterniti DA, Co JP, West DC. Successful self-directed lifelong learning in medicine: a conceptual model derived from qualitative analysis of a national survey of pediatric residents. Acad Med. 2010;85(7):1229\u0026ndash;1236. doi: 10.1097/ACM.0b013e3181e1931c.\u003c/li\u003e\n\u003cli\u003eKnowles M. Self-directed learning: A guide for learners and teachers. Cambridge: Englewood Cliffs (1975). Available from https://dokumen.pub/download/self-directed-learning-a-guide-for-learners-and-teachers-0695811169.html (Accessed on 29 August 2025).\u003c/li\u003e\n\u003cli\u003eRoberson DN Jr, Zach S, Choresh N, Rosenthal I. Self-directed learning: a longstanding tool for uncertain times. Creat Educ. 2021;12:1011\u0026ndash;1026. doi: 10.4236/ce.2021.125074.\u003c/li\u003e\n\u003cli\u003eKhan N B, Erasmus T, Jali N, Mthiyane P, Ronne S. Is blended learning the way forward? Students\u0026apos; perceptions and attitudes at a South African university. Afr. J. Health Prof. Educ. 2021;13(4):219-222. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext\u0026amp;pid=S2078-51272021000400004\u0026amp;lng=en. https://doi.org/10.7196/ajhpe.2021.v13i4.1424 (Accessed on 29 August 2025).\u003c/li\u003e\n\u003cli\u003eLala SG, George AZ, Wooldridge D, et al. A blended learning and teaching model to improve bedside undergraduate paediatric clinical training during and beyond the COVID-19 pandemic. African Journal of Health Professions Education. 2021;13(1):18. https://doi.org/10.7196/AJHPE.2021.v13i1.1447. \u003c/li\u003e\n\u003cli\u003eNdlovu S, David-Govender C, Tinarwo P, Naidoo KL. Changing mortality amongst hospitalised children with Severe Acute Malnutrition in KwaZulu-Natal, South Africa, 2009 - 2018. BMC Nutr. 2022 Jul 12;8(1):63. doi: 10.1186/s40795-022-00559-y.\u003c/li\u003e\n\u003cli\u003eSharkey A, Chopra M, Jackson D, Winch PJ, Minkovitz CS. Influences on healthcare-seeking during final illnesses of infants in under-resourced South African settings. J Health Popul Nutr. 2011;29(4):379-387. doi:10.3329/jhpn.v29i4.8455.\u003c/li\u003e\n\u003cli\u003eMiller A, Archer J. Impact of workplace based assessment on doctors\u0026apos; education and performance: a systematic review. BMJ. 2010 Sep 24;341:c5064. doi: 10.1136/bmj.c5064.\u003c/li\u003e\n\u003cli\u003eCreswell JW, Plano Clark VL, Gutmann ML, Hanson WE. Advances in mixed methods research designs. In: Tashakkori A, Teddlie C, editors. Handbook of mixed methods in social and behavioral research. SAGE; Thousand Oaks, CA: 2003. pp. 209\u0026ndash;240.\u003c/li\u003e\n\u003cli\u003eSuwannaphisit S, Anusitviwat C, Tuntarattanapong P, Chuaychoosakoon C. Comparing the effectiveness of blended learning and traditional learning in an orthopedics course. Ann Med Surg (Lond). 2021;72:103037. doi: 10.1016/j.amsu.2021.103037.\u003c/li\u003e\n\u003cli\u003eFunke K, Bonrath E, Mardin WA, Becker JC, Haier J, Senninger N, Vowinkel T, Hoelzen JP, Mees ST. Blended learning in surgery using the Inmedea Simulator. Langenbecks Arch Surg. 2013;398(2):335-340. doi: 10.1007/s00423-012-0987-8.\u003c/li\u003e\n\u003cli\u003eManyazewal T, Marinucci F, Belay G, et al. Implementation and Evaluation of a Blended Learning Course on Tuberculosis for Front-Line Health Care Professionals. Am J Clin Pathol. 2017;147(3):285-291. doi: 10.1093/ajcp/aqx002.\u003c/li\u003e\n\u003cli\u003eFrehywot S, Vovides Y, Talib Z, et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health. 2013;11:4. doi: 10.1186/1478-4491-11-4.\u003c/li\u003e\n\u003cli\u003eGigante J, Dell M, Sharkey A. Getting beyond \u0026quot;Good job\u0026quot;: how to give effective feedback. Pediatrics. 2011;127(2):205-207. doi: 10.1542/peds.2010-3351. \u003c/li\u003e\n\u003cli\u003evan de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT. What is feedback in clinical education? Med Educ. 2008;42(2):189-197. doi: 10.1111/j.1365-2923.2007.02973.x.. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Clinical Training, Medical Interns, Online Teaching","lastPublishedDoi":"10.21203/rs.3.rs-7849481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7849481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNewly qualified medical practitioners (interns) need to be competent in paediatric emergencies. Compromised patient safety and burnout result from sub-optimal training. The utilisation of blended teaching programmes is particularly beneficial where human resources are constrained. Evidence of the impact of blended teaching on self-directed learning (SDL) and feedback is required\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine perceptions of SDL and feedback amongst interns exposed to blended teaching.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective mixed-methods study utilised a validated Assessment Experience Questionnaire (AEQ) to measure perceptions of SDL and feedback among separate cohorts of interns from 202 to 2022 in South Africa (SA). All cohorts were trained in paediatric emergencies with online components and practical skills training. The last cohort included a traditional face-to-face lecture. The first cohort had no face-to-face feedback. A comparative descriptive analysis using independent sample t-tests was conducted to determine differences in AEQ scores between cohorts. Thematic analysis was used to analyse open-ended responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 153 respondents, 54.4% were males, the mean age was 25 years, and 9.7% were foreign-trained. Perceptions of the amount and distribution of study effort and learning, reflecting SDL, were positive across all cohorts. Median scores for study effort, learning, and feedback did not improve with traditional face-to-face lectures. The median scores for perceptions of the quantity and timing of feedback received were significantly higher for face-to-face feedback, p = 0.031. Increased autonomy and flexibility were identified as common positive themes, and the lack of individualised feedback was viewed as the most common negative theme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing blended training that includes technology-enhanced learning in resource-constrained contexts to train in paediatric emergencies is feasible, stimulates SDL, and, when coupled with face-to-face feedback, should replace traditional lectures. However, perceptions of inadequate feedback often occur when there is no face-to-face interaction. Didactic lectures do not improve SDL or feedback.\u003c/p\u003e","manuscriptTitle":"Self-Directed Learning and Feedback with Blended Training in Paediatric Emergencies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 11:34:27","doi":"10.21203/rs.3.rs-7849481/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-01T13:54:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-31T14:21:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-29T09:11:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-29T09:10:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-13T13:14:49+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":"8510add2-b5bf-46a3-bc78-e6d2398dbfcb","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T11:34:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 11:34:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7849481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7849481","identity":"rs-7849481","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}