Flip the classroom to improve practical skills teaching

Healthcare degrees require the teaching and learning of practical skills, such as how to carry out clinical examinations. In our context, this refers to examinations of the respiratory, cardiovascular, abdominal and neurological systems. However, the principles of our approach are widely transferable to the learning of other practical skills in other disciplines. The teaching and learning of practical skills can be challenging for both the educator and student, so the approach outlined below aims to overcome these challenges and maximise learning.

The challenges

By their very nature, practical skills need a hands-on element to their teaching. However, before a student can perform a practical skill, they must acquire sufficient knowledge of how to accomplish it.

Prior to the pandemic, our 100-minute-long sessions involved a tutor demonstrating the type of examination being taught (for instance, abdominal examination) to a group of 10 to 15 students. The students then had time within the session to practise the newly learned skills in groups of three. They received a handout to support them with this and the tutor circulated around the groups to answer questions and provide feedback. These sessions worked well, but there were a number of challenges and areas needing improvement.

• Inconsistency: With a large yearly intake of students, the practical sessions have to be repeated, using different tutors. This creates potential for inconsistency, with tutors adding or omitting content. This, in turn, worries the students who know they will be assessed on their skills and therefore want to learn the standardised subject matter.
• Lengthy demonstrations: The demonstration may take up a large proportion of the total session, which risks the students becoming disengaged but also leaves little time for them to practise their own skills. It can also be difficult for all students to clearly see every aspect of the demonstration when it is performed live in front of a group.
• Watching versus doing: Demonstration of skills by an expert can make things look easy when, in reality, they are difficult for a novice to master. Thus, students need ample time to practise the skills themselves and learn from their mistakes.
• Information overload: Students arrive with no knowledge, are provided with large amounts of information and then expected to carry out the complex, lengthy examination in just one teaching session. While follow-up sessions are provided, preloading the students with relevant information would be helpful.

The solution

While we were contemplating the best way to meet these challenges, the pandemic hit and forced rapid change. Tutor demonstrations on campus were no longer possible so an alternative was needed. This led to a flipped classroom approach that we have continued to use because of its pedagogical advantages.

All students now have access to an online course-specific platform where they can access course learning materials. Each examination skills session is hosted here.

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Considerations for video demonstrations

Videos demonstrating each examination are created and uploaded to the platform. Some show the whole examination from start to end. Lengthy examinations, such as the neurological examination, are broken down into consecutive bite-sized videos. The videos vary from a few seconds up to 20 minutes long.

Depending on the skill, some are more effective as a complete video, whereas others work better as short consecutive videos. Keeping videos as short as possible without being detrimental to the teaching message is the aim.

Some videos are at real-time speed, allowing the demonstration of communication as well as the clinical examination skills, while some are sped up to allow students to recap the skills at a faster pace. The videos have text pop-ups to highlight and emphasise various aspects.

It is worth including “deep-dive” videos that delve into specific, more complex parts of each practical in more detail. For instance, to integrate anatomy, some of our “deep-dive” videos use anatomical models such as skeletons. Other videos involve talking through aspects of the examination, adding detail and clarity to the demonstrations and supplementing information in the handouts.

Where additional people are featured in videos, for instance, actors playing the role of patients, consent forms and security settings need to be considered and put in place.

Always include subtitles to meet accessibility requirements.

What to include in supporting materials

Detailed written handouts containing a step-by-step guide to each examination are created and uploaded to the platform to accompany the videos. The handouts outline the content and steps of the examination.

They should add detail that cannot be covered by the videos, for instance, aspects to consider when examining a patient with breasts. The videos demonstrate examinations on “healthy” patients so the handouts highlight what abnormalities the students might be looking for in patients with disease.

Students are asked to look at the online content prior to their face-to-face practical so that they are prepared. This means they have much longer to practise their own skills when attending in-person on campus and come armed with questions on areas where they need clarification.

It is worth repeating this message as many times as possible. Students are asked to prepare for their face-face sessions during their introductory lectures and are reminded by notifications throughout the year. The importance of doing this (to maximise their learning during the session) is emphasised. These messages are reiterated during the face-face sessions.

We do not formally check that students have completed the pre-session work but hope that as adult learners they will rapidly see the importance of doing so, with the incentive being success in their practical assessments.

However, there is potential to develop the online content to encourage student engagement in the pre-learning. For example, a short quiz could check students’ knowledge before they move on to practising the skill.

The practical sessions

The practical sessions should start with an introduction from a tutor, which includes logistical aspects such as how the session will run plus any health and safety information needed. The students then have time to practise the skills in their small groups. The session should end by gathering all the students back together to answer any final questions, highlight any important points and discuss the next session.

In our case, the students perform their examinations either on their peers or simulated patients played by actors. However, to be a “patient” a participant information sheet needs to be read and a consent form signed. Our sessions have undergone ethical approval. It is important to have a protocol in case of complications such as a potential medical condition being found during the examinations.

Feedback is provided by student peers and the simulated patients. The simulated patients should focus their feedback on the patient perspective and direct the students to a tutor with regards to clarification of medical knowledge. The tutors must actively circulate, encourage the students to practise, and answer questions. They observe the students practising and provide feedback, demonstrating the skills as required.

The tutors still perform demonstrations, but they can be kept briefer, focusing on specific aspects rather than the whole examination. These might be presented to the whole class or to smaller groups as they practise.

Key considerations for a flipped classroom approach

With a flipped classroom approach, some students will not do the pre-learning required despite lecturers emphasising its importance. It is worth making the online learning materials available during the live sessions, via university or personal devices – we discourage the use of personal devices due to privacy issues around patient examinations. That way, students can refer to the material as an aide-memoire while practising in their groups. The use of online resources will boost your sustainability by removing the need for paper handouts.

Students should then be encouraged to review the online teaching content after their practice session, so the information learned is consolidated before their next practical.

The teaching and learning of practical skills is rewarding but challenging. Regardless of the skill, knowledge is required before it can be performed. We use the flipped classroom to preload students with necessary knowledge, overcome logistical challenges, and maximise the time students have to practise and refine their skills.

Louise Smith is lecturer in clinical skills at the University of Manchester.

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