Keywords

1 Introduction

COVID-19 pandemic is driving medical and health sciences colleges to substitute significant parts of the traditional teaching such as classic lecturing with online teaching to maintain social distancing [1, 2]. However, traditional teaching methods have proven effective tools for teaching core knowledge, explaining complex concepts, generating increased learning, enhancing student engagement, and activating self-directed learning [3].

With the development of technology and the enrichments of online educational resources, particularly during the COVID-19 era, medical and health sciences colleges witnessed transformation towards integrating technology within their education and teaching approaches [4]. Recently these colleges have moved towards—HyFlex learning. HyFlex learning combines the terms “hybrid” and “flexible”. Furthermore, HyFlex learning refers to learning that integrates complementary face-to-face and online learning experiences [5, 6].

Experts believe that there will come a time when 80–90% of comprehensive universities will use blended learning, increasing 30% annually [7]. It is essential for medical and health sciences students to ensure that each student develops and continues to refine the basic clinical skills required to provide competent care throughout a lifetime of professional work. Therefore, these colleges strive to continue teaching these skills despite the challenges created by social distancing due to the COVID-19 pandemic through HyFlex learning [8]. A growing body in the literature demonstrated the limitations of online learning. Multiple studies confirmed that internet-based and blended learning in health professions education could be more effective than traditional learning [9, 10]. On the other hand, other studies showed that most students held positive views of combining online learning with face-to-face learning, i.e., using HyFlex learning. A systematic review reported that blended learning could develop clinical competencies among health students [11].

Therefore, HyFlex learning could be favorable and valuable for advanced application in health professions. HyFlex learning methodologies have many advantages over traditional learning methods [6], such as the ability to learn anytime from anywhere, without traveling or spending time away from work, and save on costs [12]. In addition, it allows learners to skip over the information they already know and move on to fewer familiar topics [13]. With the introduction of the new blended learning format—HyFlex learning—several studies have proven its effectiveness in teaching theoretical knowledge [14, 15]; however, fewer studies have reported its effectiveness in clinical practice [15].

Therefore, this study aims to assess the effectiveness of HyFlex learning in clinical practice courses in undergraduate radiography education.

2 Materials and Methods

2.1 Design

Electronic questionnaires were sent to students and graduates of the Department of Medical Diagnostic Imaging in this exploratory cross-sectional study—Fig. 1. The research team pretested this questionnaire by three medical educators and eight students before the start of the study. The feedback was used to improve the survey design and the question's understandability. Data collected from the pilot study was excluded from the results.

The participants were divided into two groups (Fig. 1); group one consisted of the graduates who completed their clinical practice study using face-to-face study mode. Group two members used HyFlex learning simulation-based clinical training learning during COVID-19 pandemic lockdown.

Fig. 1
A flow chart. The total number of 124 participants is divided into two sections of 62 students and 62 graduates. Students receive Hyflex simulation-based training. Graduates receive face-to-face teaching.

Participants enrollment

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Group one was taught using traditional face-to-face clinical practice (CP), where the students were placed at clinical sites. Before training, the students were prepared with theoretical knowledge and lab skills at the university labs. During CP, the clinical tutors, faculty, and clinical preceptors supervised students. Students practice different imaging modalities, ranging from general radiography, computed tomography, magnetic resonance imaging, ultrasound, and nuclear medicine. In addition, they must acquire skills in radiation protection, patient preparation, positioning, protocol selection, image production, and image analysis.

In the HyFlex simulation-based clinical training, various simulation software was introduced to facilitate acquiring clinical skills such as patient positioning, protocol selection, image analysis, and radiographic anatomy.

2.2 The Questionnaire

The survey was designed in two parts. (i) The first section collected the participants' demographic information, including gender, age, year of graduation or expected to graduate, and clinical practice study mode. (ii) The second section captured the participants' perceptions, satisfaction, opinions regarding CP study mode and blended learning effectiveness in course objectives achievement.

The following eight areas were compared between the HyFex (students) and face-to-face (the graduates); active participation, need for help, instructional methods, effectiveness, user friendly, appropriateness of the environments, achievement of the learning objective, and course content were easy to understand. In addition, the following four areas were added to HyFlex such as activities used to substitute face-to-face practice, the effectiveness of HyFlex simulation, online resources, and achievement of clinical practice objectives by online learning.

The following contents were face-to-face for graduates and HyFlex for students such as patient positioning, protocol selection, image analysis, and radiographic anatomy [16, 17].

The CP courses are ordinarily offered to the undergraduate radiography students at the Department of Medical Diagnostic Imaging (MDI) in their fourth semester. The study plan consists of five CP courses to complete the graduation requirements. The minimum duration for completing the program is four years spanning eight regular semesters.

2.3 Sampling

The convenience sampling method was utilized to collect the data as it is an effortless way to reach out to the graduates. Participants were invited to participate in the study through emails. A research assistant sent the link to the participants’ emails in the medical imaging program. The invitation included detailed information about the study, study objectives, and a request to confirm their participation before starting the survey. In addition, participants were informed that completion of the survey gave implied consent to participate in the study, and they could withdraw without any consequences.

2.4 Data Analysis

Data were analyzed using a three-point Likert scale. Scores from 1–3 were assigned for these responses, where 1 = ‘Disagree’, 2 = ‘Neutral’, and 3 = ‘Agree’. Satisfaction was measured using twelve questions with a maximum score of 36 indicating satisfaction and a minimum of 12 indicating dissatisfaction. Satisfaction was measured using six questions with a maximum score of 18 indicating satisfaction and a minimum of 6 indicating dissatisfaction. Acceptance was measured using two questions to gauge the participants' opinions regarding HyFlex simulation and face-to-face learning. The data were analyzed using descriptive statistics. In addition, the mean scores of satisfactions and previous experience among students and graduates were compared using an independent sample t-test. A p-value of less than 0.05 was used as the significant level.

2.5 Ethical Consideration

The Research Ethics Committee approved the study at the institution (REC-20-04-26-01).

3 Results

All participants responded to the questionnaires. Most of the respondents were female in HyFlex (n = 59, 95%) and face-to-face learning (n = 50, 81%) environments. In HyFlex learning, 27 (44%) respondents are expected to graduate in 2023, while in face-to-face learning, 19 (31%) graduated in 2017. The demographic details of the respondents are given in Table 1.

Table 1 Participants’ demographic details
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3.1 HyFlex Simulation Learning Effectiveness

A total of n = 27 (44%) agreed that they have actively participated in HyFlex simulation learning (μ = 2.27, SD = 0.728) and that n = 28 (45%) have received support whenever they needed it (μ = 2.35, SD = 0.655). Many of the participants had a neutral opinion about the effectiveness of HyFlex simulation learning compared to face-to-face learning (n = 43, 70%) with a mean value of 1.53 and SD = 0.844. The online tools used to replace hands-on practice were unsatisfactory to 58% of the participants (n = 36) with mean = 1.69 and SD = 0.879). According to 32 (52%) participants, HyFlex simulation learning made the course content easy to understand (μ = 1.71, SD = 0.818). Equal numbers (one-third) of the participants have expressed their opinions about the coverage of blended methods substituting for face-to-face methods. At the same time, the majority were neutral about their effectiveness (questions 9 and 10). Almost double the participants disagreed that the online blended learning resources could not achieve CP and patient care skills learning objectives (questions 11 and 12—Table 2) compared with those who agreed.

Table 2 Effectiveness of blended learning
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3.2 Face-To-Face Learning Effectiveness

The findings showed that most of the participants were satisfied with the environment of face-to-face learning. In addition, the participants agreed on active engagement, support, platform user-friendliness, environment, objective accomplishments, and material comprehension, Table 3.

Table 3 Effectiveness of face-to-face learning
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3.3 Satisfaction with HyFlex Simulation Learning

In terms of design, content, faculty role, and the intention to improve clinical practice, most participants were either neutral or agreed with blended learning in clinical practice courses (questions 1–4). On the other hand, it was clear that the students were disappointed with blended learning regarding the difficulty to gain knowledge and skills (questions 5 and 6 in Table 4). This may be a significant result and merits further investigation to understand the reasons for this negative impression (Table 5).

Table 4 Satisfaction of blended learning
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Table 5 Satisfaction of face-to-face learning
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3.4 Acceptance Towards HyFlex Simulation Learning

Figure 2 shows that none of the participants in both groups agreed that HyFlex simulation learning could replace face-to-face learning, with 76% saying “no” and 24% saying “to some extent”. When students were asked if they felt competent when relying on HyFlex simulation learning in clinical practice, 28% said yes, compared to 80% for face-to-face learning, Fig. 3.

Fig.2
A horizontal bar graph presents the acceptance of HyFlex simulation learning. Yes, 0%. To some extent, 24%. No, 76%.

Acceptance of HyFlex simulation learning as a substitute for face-to-face instruction

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Fig. 3
A horizontal bar graph plots participants' views on face-to-face and Hyflex learning methods, respectively. Yes, 80%, 28%. To some extent, 15%, 32%. No, 5%, 40%.

Participants’ views on competence in various educational techniques

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3.5 Comparison Between HyFlex Simulation and Face-To-Face Learning

A two-sample t-test was used to identify statistical significance in the effectiveness and satisfaction of students who experienced HyFlex simulation learning and face-to-face learning. In addition, the scores of 8 questions that analyzed effectiveness in blended learning and face-to-face learning and 6 assessed satisfactions were included. With a mean value of 1.53 and SD = 0.844, most participants (n = 43, 70%) had a neutral opinion regarding how well HyFlex simulation learning is compared to face-to-face learning.

Although respondents who had face-to-face learning scored somewhat higher than those who received HyFlex simulation learning, the t-test revealed a significant effect on the effectiveness and satisfaction of learning in clinical practice (t = ‒0.2071, p = 0.03).

3.6 Discussion

We compared the satisfaction, acceptance, and effectiveness of HyFlex simulation learning with face-to-face teaching methods on clinical practice education in this study. The HyFlex simulation teaching method was well-received by students.

In general, students had a positive opinion about the HyFlex simulation learning method, especially the content, design, rationale, effect of simulation in acquiring knowledge and improving objective achievement. This study's findings are comparable to those of a previous study conducted at Hong Kong University, which found that students had a good acceptance regarding lecture content, design, interaction, and activities [18]. However, the respondent disagrees with the effectiveness of HyFlex simulation compared to face-to-face learning. Several challenges that impede the incorporation of HyFlex simulation learning in clinical practice, such as the quality of learning material, cultural resistance, and overloaded work for teachers and students, could explain this disagreement [11].

The face-to-face replacement by online material was unsatisfactory to the participants (n = 36, 58%) (=1.69, SD = 0.879). These results aligned and supported by a previous study conducted one year ago which revealed that online tools are not enough to engage students in online learning; techno-pedagogical skills can help but certainly will not replace face to face [8].

Students' engagement can affect the student's satisfaction with integrating new teaching methods. Instructors' roles and communication technology can help to improve satisfaction, engagement, and HyFlex's simulation impact on clinical practice education [19, 20].

Another study investigated the experiences and perspectives of nine post-graduate students who took a six-week HyFlex course. While there were some communication issues between students who attended in different ways, the flexibility it provided was appreciated by participants. The use of various elements of video conferencing software and other digital tools was deemed critical to HyFlex's effectiveness [21]. Our students agreed with the prior findings, with 49% saying they were satisfied with the online platform, 47% saying it was user friendly, and 45% saying they could get help anytime they needed it. To meet the student's expectations and increase satisfaction, the author proposes increasing preparation, improving the instruction manual, and providing online support.

With 76% saying “no” and 24% saying “it's clear that neither group believes HyFlex simulation learning can completely replace face-to-face learning”. Education institutes should implement initiatives to boost student participation and satisfaction with these new teaching approaches. For example, HyFlex is a promising teaching method, and the university has invested in the classroom, technology, communication, and training infrastructure to educate students better and meet learning objectives.

3.7 Limitation

Our study had certain shortcomings that need to be investigated further and addressed in future research. Firstly, find out how faculty and clinical instructors feel about employing HyFlex teaching approaches in clinical practice and how satisfied they are using the qualitative approach. Secondly, teachers' and students' challenges in acquiring knowledge and clinical skills should be investigated. Additionally, the number of time students spend using simulation software can indicate their involvement and efficacy. Finally, a long-term investigation of the effects of HyFlex simulation training methods on clinical abilities will be conducted in the future.

4 Conclusion

Due to the significant differences between HyFlex and traditional face-to-face learning, more research is needed to assure student and instructor engagement, satisfaction, and achievement of learning objectives. In addition, HyFlex integration in clinical practice education necessitates careful planning and execution. HyFlex was an excellent approach for improving students’ knowledge gain using simulation software, but it cannot replace hands-on teaching.