The Effective Use of Learning Modalities in Healthcare Education
With the rapid acceleration of medical knowledge, continuing education and training are critical in closing the widening gap between provider knowledge and evolving best practices. How do we connect providers with the knowledge and training they need to improve patient outcomes amidst constraints of time, access, and funding? Healthcare providers need a multifaceted educational solution that matches learning objectives with the appropriate educational modalities (methods of learning) and technologies to make training both effective and accessible. We need research-driven training that integrates educational and medical best practices to improve provider skill and quality of care.
This article will cover:
- Current challenges in medical education
- The strengths of various healthcare learning modalities and their ideal use in the educational experience
- How evolving educational technologies can help combat challenges in medical education and improve patient outcomes
Challenges in Medical Education
Medical education is ever-evolving and adapting to fit new healthcare climates and multiple generations of learners. As Phyllis A. Guze, MD, MACP, outlines in “Using Technology to Meet the Challenges of Medical Education,” some of the current challenges in medical education include:
- An explosion of medical knowledge
- Changing healthcare environment
- Keeping patient safety the focus
- Changing societal expectations
- Evolving ethics
- Cost-containment and evidence-based use of resources
- Changing curricular emphasis
- Need for life-long learning
- Diverse learning styles
- Rapidly changing technology1
To respond to these challenges and improve patient and learner outcomes, providers need a multifaceted and multimodal approach to education. As Cook et al. note in “Comparative Effectiveness of Technology-Enhanced Simulation Versus Other Instructional Methods,” “deliberate alignment of objectives and instructional modalities will likely enhance efficiencies for both cognition (eg, optimal management of cognitive load) and costs (time and monetary investment). For example, educators might use less costly interventions (eg, lecture or Web-based learning) for nonskill objectives and reserve simulation for later stages of instruction.”2
When course objectives are clearly outlined and paired with complementary learning modalities and technologies, providers receive a more comprehensive and holistic education that improves outcomes for patients, learners, hospitals, and communities.
Healthcare Learning Modalities
Educational modalities continue to expand alongside learning technologies and medical best practices. Some of these educational modalities include:
- Instructor-based education
- Virtual instructor-led training
- Scenario-based learning
- Simulation-based learning
- Virtual reality
- Self-paced education
- Multimedia learning
- Mobile learning
The application of these modalities overlap and provide multiple variations but can be grouped in 3 main categories: instructor-led education, simulation-based training, and self-paced learning. The success of each of these modalities in improving provider skill and quality of care depends on the educational context in which it is used, suggesting that a blended approach provides the best outcomes for both learners and patients.
Instructor-led education spans traditional classroom education as well as virtual online learning, with the defining feature being that an instructor is present who can provide real-time feedback and interaction with students.
Numerous studies have found that virtual instructor-led learning has the same or improved outcomes when compared to face-to-face learning in the healthcare setting.3The benefits of instructor-led education include increased learner interactivity, satisfaction, engagement, and persistence;4 active discussion and participation; and an environment where learners can receive the necessary practice, repetition, and feedback that are associated with improved learning outcomes.5
The costs in time and resources for in-person instruction make it difficult to scale and disseminate. However, virtual instructor-led instruction provides a cost-effective, scalable, and convenient alternative. With virtual instructor-led training, providers with a mobile phone or internet access can connect with industry experts from virtually anywhere, saving time and financial costs of traveling to symposiums or in-person courses. In addition, virtual classroom learning allows students to connect with instructors and providers across the nation, which can provide diversity that expands providers’ mindsets and understanding.6
A key to the success of any instructor-led learning experience is interactivity and an engaging environment where students are able to receive answers and feedback.5 In virtual environments, a feeling of social presence positively impacts student satisfaction and learning.7 When technologies are incorporated to enhance student participation in online classrooms, “learners report strong positive acceptance, increased attentiveness, and enhanced engagement and enjoyment of the lecture experience.”8 In addition, learners report that the anonymity of a virtual classroom allows them to engage “without fear of embarrassment or being singled out by peers or the instructor.”8
Traditional and virtual instructor-led learning are an effective way to improve learning outcomes and work best when addressing nuanced or complex subjects where student interaction and feedback are essential.3,6,9However, when it comes to detailed protocols, practice-based education, or hands-on learning, simulation-based learning can be a more effective alternative. For knowledge acquisition or basic skill reviews, self-paced learning offers learners a more flexible, affordable, and accessible option.
Simulation-based or scenario-based medical education “evolved as pedagogical strategies to facilitate an active, learner-centered teaching approach.”8In these learning experiences, “the student becomes the lead author of the associated discoveries”10 and is able to practice critical skills in a safe environment. Scenario-based training involves “students navigating a storyline based around a complex problem, running in parallel with case-based learning,”11 in effect applying the teaching approach of problem-based learning12 to an interactive, situated learning environment.13 Often, technology is used in varying degrees to create an immersive experience for the student, ranging from interactive online modules to physical simulations and virtual reality.
Simulation and scenario-based learning in healthcare have been repeatedly shown to improve student and patient outcomes compared with other instructional modalities,2,14,15,16,17,18 even for those who observed but did not actively participate in simulations.19 This form of learning has been shown to exercise medical decision-making skills, improve skill development,8 result in higher learning outcomes,2 lead to increased learner satisfaction and motivation, 2 improve patient outcomes,2 increase provider knowledge,2and build teamwork, problem-solving, and critical thinking skills.20
Features of simulation-based training that lead to learner success incorporate:
- Feedback 8,21,22
- Repeated, deliberate practice 8,21,22
- Curriculum integration 21,22
- Outcome measurement 21,22
- Realism/simulation fidelity8,21,22
- Skill acquisition and maintenance 21
- Mastery learning 21
- Team training/team-focused communication skills 8,21
- High‐stakes testing21
- Adaptability to multiple learning strategies22
- Clinical variation22
- Controlled environment22
- Individualized learning22
The biggest limitations of simulation-based training are cost, provider accessibility,2 and difficulties updating or disseminating new medical information. Life-like physical training simulations require expensive technology that allows a small number of providers to engage in instruction under supervision. In addition, monitoring training quality, integrating new medical best practices, and minimizing variability in instruction can be difficult to regulate across multiple satellite simulations.
Kyaw et al. touted virtual reality as a versatile technology with the potential to transform medical education, noting many studies that demonstrated how it improves provider knowledge and skill.23 In addition, virtual reality does not require supervision, provides consistent instruction, and can cut simulation training costs by up to 50%,24 providing accessible but standardized and high-quality instruction.25
Online scenario-based education provides the most accessible and economical option for providers to receive scenario-based training, along with a wider variability in quality. In addition, online scenario-based training can easily be updated to incorporate emerging best practices and offers quick dissemination and consistent content. As with instructor-based education, interactivity, practice, repetition, and feedback play a key role in successful online scenario-based learning.5
In “Comparative Effectiveness of Technology-Enhanced Simulation Versus Other Instructional Methods: A Systematic Review and Meta-Analysis,” Cook et al. argue “that the benefit of hands-on practice (and thus simulation training) is greater for higher-order outcomes.”2 This makes it ideal for situations where providers need to apply critical thinking and other complex skills to patient assessment and care. However, providers can effectively learn and practice the basic skills that will be synthesized in simulation-based training using other flexible and affordable learning modalities.
Self-paced learning occurs when healthcare professionals are given tools and resources that allow them to learn independently, without an instructor. Students are no longer restricted to textbooks as their main reference materials. CDs, audio-visual, interactive, online, and mobile self-paced learning offer many variations to fit different styles of learning. Due to the range of quality and variability of self-paced learning material, it is difficult to gauge the effectiveness of self-paced education as a broad category. For example, online education has been shown in many studies to be just as effective or more effective than classroom learning.9,25,30 However, a “small number of studies [suggest] some pure e-learning programs (i.e., non-blended approaches) have worse outcomes than traditional learning.”26 Due to this variability, it’s important to address the key characteristics of successful self-paced learning as well as the benefits this learning can produce.
Multimedia learning engages multiple senses and various areas of a student’s cognition that can help maximize learner comprehension.8 Qualities that lead to learner success in self-paced education include:
- High levels of interactivity 5,8
- Integrated lecture objectives 8
- Modular learning (short, digestible educational segments)8,27
- Quality design8
- Reflection, practice, and application28
Among the fastest growing and most popular self-paced learning modalities today are e-learning, mobile learning, and gamification. The benefits of these technologically aided forms of learning include:
- Flexibility and accessibility that fits learner schedules and needs 8,26
- Saved training costs (up to 50%) and time26,32
- Independent learning, learner-centered activities26
- Online communities/collaborative learning environment26
- Easy tracking of improvement, knowledge, and mastery8
- Standardization of course content26
- Increased learner satisfaction 32
- Unlimited access to learning materials26
- Circumvents geographical and scheduling restraints8
- Quick dissemination of scalable education
- Fast skill development, similar or improved knowledge and skills retention 8,26,29
- Content can be updated and maintained in a timely and efficient manner26
These forms of self-paced learning can help providers maximize their learning time and effectiveness.8 E-learning technologies, in particular, “offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives.”30 Mobile learning provides this same sense of tailor-made education and helps medical professionals become more adept at using technology to aid in workplace activities.31 Gamification can enhance learner’s engagement, motivation, and enjoyment of the learning experience.31
The limitations of self-paced learning include risks of social isolation or technology overload8 in addition to less interaction between students and “high dropout rates, lack of accountability of learners or instructors, and lack of hands-on activities.”26 Poorly created or maintained education can also suffer from a lack of proper security, engagement, and quality as well as poor technological design that interferes with student learning and negatively impact student outcomes.26 The limitations of self-paced learning that do not include dynamic technologies, such as textbook-based learning or CD programs, also include a lack of infrastructure to disseminate and share updated information.
Due to these limitations, several studies have suggested a blended learning approach—using self-paced education for basic, explicit knowledge gain and review and using lecture and scenario-based learning modalities to refresh, solidify, and apply this information in a social or applied setting—as an effective approach to improve student and patient outcomes.26,30
Pairing Training with Online Technologies
“The explosion of medical knowledge no longer allows physicians to keep in their mind all knowledge that is necessary to provide quality patient care. It is estimated that more than 600,000 articles are published in biomedical literature every year. If a student attempted to keep up with the literature by reading 2 articles per day, in 1 year this conscientious individual would be more than 800 years behind.”1
Just as technology is escalating our need for more responsive, adaptive training, it also provides practical solutions for making that training more accessible for providers. “Technology is not only transforming how we deliver education and training but is expanding our capacity to respond to the needs for higher education and training in a broader sense,” Cheryl Fisher and William A. Sadera note in “Comparing Student Learning and Satisfaction between Learning Environments in Continuing Medical Education.”9 They continue: “With a long history of serving isolated and remote learners, distance learning has now emerged as an effective, mainstream method of education and training that provides flexible learning opportunities in response to learners’ needs.”
The Digital Health Collaboration states that “a global shortfall of 18 million health workers has been estimated by 2030. This shortage is recognized as an important obstacle to the achievement of universal health coverage. . . .. Digital health education has been identified as one of the potential means of addressing these growing challenges.”33 The recent COVID-19 pandemic provides another recent example of the utility of online learning, particularly in quickly disseminating protocols and allowing providers safe access to information without the need for group gatherings. Prior constraints of access, scalability, time, and costs are significantly reduced with online platforms that allow providers to access industry professionals and emerging data on their phones or computers.
As we integrate more technology into healthcare and medical education, it’s important that our focus remains on quality education that improves patient care. The success of students and their ability to improve patient outcomes relies on matching learning objectives with appropriate educational technologies and modalities. As we become more adept at this process, we can provide education that is safe, standardized, and tailored to fit healthcare students’ needs so that they can build the skill and competence necessary to provide quality patient care.
- Guze PA. Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc. 2015;126:260‐270.
- Cook D, Brydges R, Hamstra S et al. Comparative effectiveness of technology-enhanced simulation versus other instructional methods. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2012;7(5):308-320. doi:10.1097/sih.0b013e3182614f95
- Francescucci A, Rohani L. Exclusively synchronous online (VIRI) learning: The impact on student performance and engagement outcomes. Journal of Marketing Education. 2018;41(1):60-69. doi:10.1177/0273475318818864
- Croxton RA. The role of interactivity in student satisfaction and persistence. Journal of Online Learning and Teaching. 2014; 10(2):314-325.
- Cook D, Levinson A, Garside S, Dupras D, Erwin P, Montori V. Instructional design variations in internet-based learning for health professions education: A systematic review and meta-analysis. Academic Medicine. 2010;85(5):909-922. doi:10.1097/acm.0b013e3181d6c319
- Virtual instructor-led training (VILT). Training Industry. https://trainingindustry.com/wiki/remote-learning/virtual-instructor-led-training-vilt/. Updated 2020. Accessed June 3, 2020.
- Richardson J, Maeda Y, Lv J, Caskurlu S. Social presence in relation to students’ satisfaction and learning in the online environment: A meta-analysis. Comput Human Behav. 2017;71:402-417. doi:10.1016/j.chb.2017.02.001
- Moran J, Briscoe G, Peglow S. Current technology in advancing medical education: Perspectives for learning and providing care. Academic Psychiatry. 2018;42(6):796-799. doi:10.1007/s40596-018-0946-y
- Fisher C, Sadera A. Comparing student learning and satisfaction between learning environments in continuing medical education. International Journal of Instructional Technology and Distance Learning. 2011;8.
- Menezes J, Gusmão C, Machiavelli J. A proposal of mobile system to support scenario-based learning for health promotion. Procedia Technology. 2013;9:1142-1148. doi:10.1016/j.protcy.2013.12.127
- Patel K, El Tokhy O. Scenario-based teaching in undergraduate medical education. Adv Med Educ Pract. 2016;Volume 8:9-10. doi:10.2147/amep.s126922
- Duffy TM, Cunningham DJ. Constructivism: Implications for the design and delivery of instruction, In DH Jonassen Handbook of Research for Educational Communications and Technology. 1996. NY: Macmillan Library Reference USA.
- Larsen K, McInerney C. Preparing to work in the virtual organization. Information & Management. 2002;39(6):445-456. doi:10.1016/s0378-7206(01)00108-2
- Hwang S, Kim M. A comparison of problem-based learning and lecture-based learning in an adult health nursing course. Nurse Educ Today. 2006;26(4):315-321. doi:10.1016/j.nedt.2005.11.002
- Rahmani A, Mohammad A, Moradi Y. Effectiveness of scenario-based education on the performance of the nurses in the critical cardiac care unit for patients with acute coronary syndrome. International Journal of Medical Research & Health Sciences. 2016, 5, 8:218-224.
- Sperl-Hillen J, O’Connor P, Rush W et al. Simulated Physician Learning Program Improves Glucose Control in Adults With Diabetes. Diabetes Care. 2010;33(8):1727-1733. doi:10.2337/dc10-0439
- Steinemann S, Berg B, Skinner A et al. In Situ, Multidisciplinary, Simulation-Based Teamwork Training Improves Early Trauma Care. J Surg Educ. 2011;68(6):472-477. doi:10.1016/j.jsurg.2011.05.009
- Mundell W, Kennedy C, Szostek J, Cook D. Simulation technology for resuscitation training: A systematic review and meta-analysis. Resuscitation. 2013;84(9):1174-1183. doi:10.1016/j.resuscitation.2013.04.016
- O’Regan S, Molloy E, Watterson L, Nestel D. Observer roles that optimise learning in healthcare simulation education: a systematic review. Advances in Simulation. 2016;1(1). doi:10.1186/s41077-015-0004-8
- Chan Z. Role-playing in the problem-based learning class. Nurse Educ Pract. 2012;12(1):21-27. doi:10.1016/j.nepr.2011.04.008
- Issenberg S, Mcgaghie W, Petrusa E, Gordon D, Scalese R. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. doi:10.1080/01421590500046924
- Kyaw BM, Saxena N, Posadzki P, Vseteckova J, Nikolaou CK, George PP, Divakar U, Masiello I, Kononowicz AA, Zary N, Tudor Car L. Virtual reality for health professions education: Systematic review and meta-analysis by the Digital Health Education Collaboration. J Med Internet Res. 2019;21(1):e12959. doi: 10.2196/12959
- Health Scholars. Evidence brief: Health Scholars’ fire in the ORTM virtual reality simulation. July 15, 2018. Accessed November 1, 2018. https://healthscholars.com/fire-in-the-or-evidence-paper/
- Lea M. How virtual training is set to change nursing education. HealthTech. May 20, 2020. Accessed June 1, 20202. https://healthtechmagazine.net/article/2020/05/how-virtual-training-set-change-nursing-education.
- Cook D, Levinson A, Garside S, Dupras D, Erwin P, Montori V. Internet-Based Learning in the Health Professions. JAMA. 2008;300(10):1181. doi:10.1001/jama.300.10.1181
- Ruggeri K, Farrington C, Brayne C. A global model for effective use and evaluation of e-learning in health. Telemedicine and e-Health. 2013;19(4):312-321. doi:10.1089/tmj.2012.0175
- Abbasi K, Hazrati M, Mohamadi NP, Rajaeefard A. The effect of learning via module versus lecture teaching methods on the knowledge and practice of oncology nurses about safety standards with cytotoxic drugs in Shiraz University of Medical Sciences. Iran J Nurs Midwifery Res. 2013;18(6):483‐487.
- Lawn S, Zhi X, Morello A. An integrative review of e-learning in the delivery of self-management support training for health professionals. BMC Med Educ. 2017;17(1):183. Published 2017 Oct 10. doi:10.1186/s12909-017-1022-0
- Dunleavy G, Nikolaou CK, Nifakos S, Atun R, Law GCY, Tudor Car L. Mobile digital education (mLearning) for health professions: a systematic review and meta-analysis by the Digital Health Education collaboration. Journal of Medical Internet Research. 2019. doiI: 10.2196/12937
- Ruiz JG, Mintzer MJ, Leipzig RM. The impact of e-learning in medical education. Academic Medicine. 2006;81(3): 207-212.
- Ventola CL. Mobile devices and apps for health care professionals: uses and benefits. P T. 2014;39(5):356‐364.
- Tarpada S, Morris M, Burton D. E-learning in orthopedic surgery training: A systematic review. J Orthop. 2016;13(4):425-430. doi:10.1016/j.jor.2016.09.004
- Car J, Carlstedt-Duke J, Tudor Car L, Posadzki P, Whiting P, Zary N, Atun R, Majeed A, Campbell J, Digital Health Education Collaboration. The need for overarching evidence synthesis. J Med Internet Res. 2019;21(2). doiI: 10.2196/12913