Exploring the activities and outcomes of digital teaching and learning of practical skills in higher education for the social and health care professions: a scoping review

Higher education for health care professionals faces numerous challenges. It is important to develop and apply methods supporting education, especially the practical skills. This scoping review aimed to explore the activities and learning outcomes of digital technology in practical skills teaching and learning in higher education for the social and health professions. Scoping review recommendations and the PRISMA-ScR checklist were applied. Randomized controlled trials published between 2016 and 2021 involving students in higher education who were taking courses in the social sciences and health care and reported interventions with digital technology activities and practices in practical teaching and learning were included. The CINAHL Plus, PubMed, Scopus, ERIC, and Sociological Abstracts/Social Services Abstracts databases were searched. Teaching methods were blended, e-learning or other online-based, and digital simulation-based activities. Teaching and learning environments, methods, resources, and activity characteristics varied, making a summary difficult. Interventions were developed in a face-to-face format prior to digitalization. The outcomes were measured at the knowledge level, not at the performance level. One-third of the studies showed a significant improvement in practical skills in the intervention group in comparison to the control conditions. The use of digital technology in the learning and teaching process have potential to develop of students' skills, knowledge, motivation, and attitudes. The pedagogy of technology use is decisive. The development of new digital methods for teaching and learning practical skills requires the engagement of students and teachers, in addition the researchers.

Furthermore, research has shown that students' perceived stress e.g., fear of making mistakes in clinical placements, is quite high [4]. Thus, it is important to develop and apply methods that can support education, especially the teaching and learning of practical skills.
The term "skills" can mean e.g., clinical examination skills, clinical reasoning skills, and communication skills [5]. Practical skills in health care can include history taking, physical examination and different types of procedural skills, which also require communication skills [6]. The digital teaching and learning of practical skills in higher education for the health care professions can be supportive methods of education. There are many digital teaching and learning modalities, such as online-offline (e.g. where study material, instructions and tasks are delivered online versus offline) [7], e-learning (a type of distance learning) [8], mobile (digital) education, and digital simulation-based [7], as well as blended learning, in which more traditional modalities, such as face-to-face teaching, are integrated with digital recourses [9]. Additionally, the term hybrid learning is often used and referred to as synonymous with blended learning [10].
In a survey concerning dental education in Canada about the use of virtual patients in education, 63% of schools had used virtual patients, and approximately 30% of these had been using virtual patients for more than 10 years [11]. In a study of high-fidelity simulation (defined as high-fidelity manikins, digitally simulated scenarios) in the teaching of nursing students in nursing procedures, both students and teachers were satisfied with the use of the high-fidelity simulation and with the academic outcomes [12]. A flipped classroom model with digital learning as preparation was used instead of peer-based teaching in the context of emergency operation practical teaching for students in human and dental medical training. The students expressed a high level of satisfaction with this model of learning [13]. Digital learning in physiotherapy was studied in a systematic review [8]. The authors concluded that the included studies primarily used blended learning, in which theoretical knowledge was digitally delivered while practical skills training was conducted on campus [8].
The learning environment is important in education [14], and the virtual learning environment (VLE) is equally significant for digital teaching and learning. VLEs can be web-based, providing course-related materials to students. VLEs mostly include assessment, tracking, collaboration, and communication modules that can be accessed by students and teachers regardless of physical location [15]. Furthermore, the framework of a student-centred and competency-based approach to learning, which entails the active engagement of students in the learning process through authentic, meaningful and positive learning experiences [16,17], is important.
Digital teaching and learning, especially virtual patient simulations, have been studied in many health care disciplines [18,19], including medicine, dentistry, nursing, and physiotherapy, with mixed evidence of their effects on knowledge [18,19], clinical reasoning and student satisfaction [18] in comparison to traditional education methods [18,19]. However, no recent reviews appear to include all kinds of digital teaching and learning methods in the practical skills education of students in various health care professions to provide a more complete picture. Thus, to provide a more complete picture, this scoping review aimed to explore the activities and learning outcomes of digital technology in practical skills teaching and learning in higher education for the social and health professions. The specific review questions were as follows: -What were the teaching and learning environments, digital teaching methods, and characteristics of the digital teaching activities? -What were the outcome measures and results of the digital teaching interventions? method studies the five-year study period was chosen in the middle of May 2021, and thus the search was limited to between May 2016 to May 2021) in peer-reviewed journals; studies that involved students in higher education in the field of social and health care; interventions that concerned activities and practices of digital technology in practical teaching and learning; and articles written in English. We decided to include only RCT studies because these still represent the highest scientific level of design and may be more reliable in terms of quality than many other designs.
For Population-Concept-Context descriptions in search terms, see Table 1. Exclusion criteria were as follows: Studies that were not at the PhD, master's, or bachelor's level; studies targeting medical doctors being in "residence" education; being postgraduate education while working at, for example, hospitals; studies targeting medical doctors who were "trainees" in specialist-level education; studies targeting nurses in specialist education that did not include a master's degree; studies targeting veterinary students; or studies combining residents and students.

Information sources and search strategy
To identify relevant studies, the CINAHL Plus, PubMed, Scopus, ERIC, and Sociological Abstracts/Social Services Abstracts databases were searched on one occasion on the May 20, 2021. The search was defined as within the previous 5 years (May 2016-May 2021) and was conducted with relevant MeSH search terms and free text terms. The search strategy is shown in Table 1.
The PubMed search resulted in 289 hits; CHINAL Plus, 1 hit, which was already included in the PubMed search results, Sociological Abstracts 0 hits, SCOPUS 19 hits which already were in the PubMed search results; and ERIC, 1 hit, which was already included in the PubMed search results.

Selection of sources of evidence
The first author, together with a university librarian, conducted the search. In the first step, eligible abstracts (N = 289) were divided among the participating universities (N = 6) and thereafter screened by two researchers from each university (i.e., AS, AB, ME, AV, RS, IB, HP, AF, DC, SK, CB, CW-G). The COVIDENCE system (https:// www. covid ence. org/) does not reveal the inclusion/exclusion decisions of one screener to the other. If the two researchers came to different conclusions regarding the inclusion/exclusion of the abstract, the decision proceeded to a third person (the first author, who also invited all participating researchers to use the COVIDENCE system), who made the final decision. If the inclusion decision was uncertain, the study was included for the second step, which was full-text reading. The second step was managed in the same manner as the first. The selection of the studies was finally discussed in a whole group meeting (representatives from all six universities) for inclusion agreement.

Data charting process and parameters
The data from the included studies from each university were tabulated by the respective university researchers. Data for the aim-relevant headings were tabulated ( Table 2). The headings were discussed and decided in a whole group meeting. Table 2 includes the following headings: authors, year, country; aim/purpose; participating teachers/educator/developer/ delivering person, qualification; target group for teaching, age, gender, level of education; learning environment and education program; digital teaching experimental intervention; comparison intervention; outcome measures; risks and additional comments (in teaching/problems/disadvantages); main findings.

Method for the synthesis of results
A quality evaluation of the studies was not performed as this scoping review aimed to explore the literature rather than to analyse any intervention effects. The results were reported descriptively, and the study characteristics are presented in Table 2. The results were synthetized in the following topics: teaching and learning environments, digital teaching methods, characteristics of the digital teaching activities, outcome measures or results of the digital teaching interventions.

Selection of sources of evidence
Five databases were included for the search. Figure 1 shows the PRISMA chart detailing the number of studies and the study selection process. Reasons for the rejection of the abstracts (N = 161) and full text papers (N = 93) varied (see Fig. 1).
There were no relevant studies on higher education for the social professions. A total of 49 studies were included in the scoping review. See Table 2 for details on these studies.
In total, 4092 students (mean age 23.5 years) participated in the included studies. The study population included students from the following programs: n = 207 dentistry; n = 2764 medicine; n = 1121 and nursing and midwifery. Students from the 1st to 6th educational years were included, comprising bachelor's and master's levels. The selected studies included a total of 2821 bachelor's students and 104 master's students. The year of study for the remaining 1167 students was unknown.
The study characteristics are presented in detail in Table 2.

Teaching and learning environments
Eighteen studies [24, 30, 34, 36-39, 44, 46, 49, 53, 54, 56, 58, 60, 62, 64, 69] were developed in a face-to-face format and were then transformed to digital format but did not use a virtual learning environment (i.e., there was no platform for content management, lesson planning, engagement, administration, communication). In 21 studies [25, 26, 29, 31, 33, 35, 40, 42, 45, 47, 48, 50-52, 55, 57, 63, 65, 67, 71, 72], the authors did not provide information about the learning environment, and in five studies [27,41,43,59,61,68], the authors only mentioned that an e-learning/online learning system or a learning management system was used. One study reported that a shareable weblink was used but offered no specific information [32]. Regarding the remaining four studies, four different virtual learning environments were used: Basic Burns Management e-learning tool [66], Education in Dermatology [41], the VBLaST-PC system for fundamentals of laparoscopic surgery [70], and the CASUS-a case-based multimedia learning and authoring system for undergraduate, postgraduate and continuing education [28]. Thus, the studies showed substantial variation in the learning environment, making it difficult to draw conclusions of any kind. See Table 2 for more details.

Characteristics of the digital teaching activities
The analysis of the characteristics of digital technology applications is presented according to target groups defined by their profession. Two main approaches characterize all the studies, which dealt either with practical skills as technical skills taught through any digital method or communication in practical skills as nontechnical skills for practice taught through any digital method. Five studies aimed to develop both technical and nontechnical skills.
Dental students practised merely to develop practical technical skills related to the very core of their profession, for example cavity preparations [39] and the creation of mandibular molars [46]. However, in one study [44], the communication in the interaction between students and mentors was assessed.
Nursing and midwifery students practised specifically to develop practical technical skills, which were addressed in all 17 nursing and midwifery studies. These skills were most often described as various skills needed to perform clinical procedures, e.g., nasogastric tube placement [63], intramuscular injections [51], intravenous catheter placement [52], and cardiac auscultation [54]. Safety issues, such as standard safety precautions [45] and operating room fire safety issues [72], were also considered. Practical nontechnical skills training for nursing and midwifery students was reported in two studies. These skills were related to communicating with deteriorating patients before procedures [43] and communication in clinical decision-making [50].

Outcome measures
The outcome measures were categorized by applying the four levels developed by George Miller [73] for the assessment of clinical skills, competence, and performance: 1. Knows (knowledge); 2. Knows How (competence); 3. Shows How (performance); 4. Does (Action). The first two levels, Knows and Knows How, were not easy to distinguish from each other; thus, these were considered as one level in our summary. We also added an Other category, which included e.g., beliefs, attitudes and values.
The outcomes on the Knows/Knows How level were measured with, e.g., the Knowledge with standard precautions questionnaire [45], Knowledge questions on performing urinary catheterization [47], and the Knowledge assessment form in the management of preeclampsia [60]. The outcomes on Shows How level measured e.g., suturing skills [57], or the Creighton Simulation Evaluation Instrument (CSEI) for rater-observation to measure competence in patient scenarios [68]. The Other category included outcome measures regarding students' satisfaction with the digital pedagogical methods [71], feasibility and acceptability of the teaching method [33], level of confidence in practical skills [32], teaching preference and learning experiences [29], attitudes towards digital teaching method [63], anxiety [64], motivation [47], compliance [45], and learning self-efficacy [42]. See Table 2 for more details.

Results of the digital teaching interventions
The results showed that the use of digital technologies in practical skills teaching and learning has a wide range of outcomes. A total of 16 studies [24, 28, 34, 42, 44, 46, 50-52, 54, 59, 62, 64-66, 70] showed that students in the intervention group significantly improved their practical skills compared to the control group of students who studied with traditional teaching methods. There was also a significant trend in the development of knowledge, as 11 studies [31, 32, 35, 40-42, 45, 50, 54, 63, 68] showed that the use of digital technologies, which make learning pathways more flexible, also helped students to acquire and strengthen the knowledge that underpins the acquisition and development of practical skills. Four studies [43,56,61,69] showed the development of students' practical nontechnical skills (communication skills). Furthermore, three studies [52,64,71] showed that students' learning motivation increased, five studies [32,35,47,52,64] showed that students' confidence in their abilities was strengthened, and three studies [51,54,64] showed that the use of technologies in a safe study environment reduced students' anxiety about manipulations that must be performed in the working environment in the future. Four studies [36,42,47,52] also showed an increased level of satisfaction with the learning processes that used innovative methods.
Despite these promising results, 17 studies [25-27, 29, 33, 36-39, 48, 49, 55, 57, 58, 60, 67, 72] showed the same level of practical skill development in the intervention group using digital technologies and in the control group using traditional teaching methods. In three studies [37,48,67], the results of the use of different technologies in the intervention and control groups, such as online courses vs. digital games, were compared, but the learning outcomes were the same in both groups. It should be clarified that in situations where the intervention and control groups showed similar results in the context of skill development, however, there was nevertheless an increase in the intervention group, for example, in the learning motivation or confidence. Two studies [30,53] showed that students in the control group using traditional teaching methods had a higher increase in their practical skills compared to the intervention group using digital technologies. See Table 2 for more details.

Discussion
The findings of this study showed that digital learning environments (e.g., digital teaching and learning platforms) were not used in nearly half of the studies even though the digital teaching method was applied in all included studies. Teaching methods were blended, e-learning or other online-based, and digital simulation-based. The teaching and learning environments, methods, resources, and characteristics of the activities varied considerably making summary difficult and hindering the conclusions of the effects of any specific digital teaching tool. Half of the studies measured outcomes at the knowledge level and not at the performance level. One-third of the studies showed a significant improvement in practical skills in the intervention group in comparison to the control conditions. However, one-third showed no differences in practical skills between groups, even though confidence and motivation in practical skills were increased when compared to the control group.
Digital teaching and learning environments, methods, and resources varied greatly in the included studies, which have also been reported by others [74]. Additionally, many used digital teaching methods without a digital learning platform as support. The great variation makes it impossible to comment on recommendations for future use for digital practical skills teaching and learning in health care education programs. A well-functioning learning environment [14], especially the digital learning environment, is important in education for digital teaching and learning of practical skills and should be a focus when developing new digital practical teaching methods.
The translation of face-to-face interventions to digital versions does not work well [75]. The empirical experience during the COVID-19 pandemic has also clearly illustrated that the face-to-face format is not directly transferable to the remote learning format and that the alignment of technology use with learning objectives and learning outcomes is not always obvious and does not necessarily lead to better learning quality. In an integrative review Turnbull et al. [75] identified several challenges when translating face-to-face teaching to remote teaching in higher education, e.g., the digital competency of teachers and students and integration of learning tools in a classroom interacting in "real-time" and tools that are used by students at their own pace and in interactions with each other and their teachers over longer periods of time. Teachers' lack of digital skills when adapting face-to-face education to digital format has also been reported by Kenzig [76]. Turnbull et al. [75] further identified successful strategies for translation from face-to-face to digital format, e.g., supporting teachers' and students' digital competency and broadening the face-to-face course with components of blended learning. Using digital learning and teaching in higher education can eliminate geographical proximity and increase the diversity of the student population [77]. Additionally, this characteristic implies that the students can be educated wherever they are for at least part of their program.
Our scoping review showed that the studies' teaching methods were blended, e-learning or other online-based, or digital simulation-based. It emerged that the digital simulation teaching seems to support the students' active learning of skills and competencies in authentic environments. However, the importance of the teacher´s role in supporting the student's commitment and dialogue was not reflected as clearly, despite its importance, especially in blended and distance learning, as recommended within the framework of a student-centred, and competency-based approach to learning to facilitate student engagement in the learning process [17].
The knowledge level of measuring outcome of the teaching intervention was seen in half of the studies. McCutcheon et al. [74] found that 7 of 19 included studies on teaching clinical skills in undergraduate nursing education had some type of performance outcome measure, mostly a checklist of clinical skills needed for a task. They also reported that knowledge, self-efficacy and user satisfaction were measured as was reported in our review. Practical skills must be measured at the knowledge level but to measure outcomes at the performance level should in future research be planned in the study protocol.
Students' general satisfaction with the used digital environments, methods and resources used for practical skills teaching and learning in our review has also been shown in previous descriptive studies [12,13], implying that the students might be more prepared to accept digital methods in practical teaching than the teachers may believe. Furthermore, a systematic review of digital learning effectiveness in the physiotherapy education context [8] revealed that 19 of 21 studies showed significant differences in knowledge acquisition for digital interventions in comparison to control conditions. However, it is possible that the effects were based on only the acquisition of theoretical knowledge rather than practical skills learning, which was delivered on campus [8]. Evidence of the effectiveness of digital teaching in practical skills is conflicting, one systematic review showed positive results for blended teaching [78], and another showed no effects [79] of digitally assisted instruction for the task of physical examination. In our review, which was focused only on digital practical skills teaching and learning, one-third of the included studies showed positive results in knowledge acquisition. However, there were no differences in many of the studies comparing digital teaching methods to traditional classroom educational methods. Obtaining comparable results with digital teaching methods or using the face-to-face method could also be interpreted positively, i.e., digital teaching was not inferior to the face-to-face method. McCutcheon et al. [74] came to a similar conclusion regarding studies on teaching clinical skills to undergraduate nurses. The comparable results should not be underestimated considering the extreme challenge faced by higher education due to COVID-19 in recent years.
We need to carefully examine our existing methods in digital practical skills teaching and learning to introduce more effective and user-friendly new methods. Future studies could include case-study design investigations that explore concrete cases and descriptions of how lecturers have developed students' practical skills in different study formats (blended and online learning, etc.). The COVID-19 period has brought about the rapid development of various digital learning and teaching solutions, but the workload of lecturers during the transition from face-to-face to online formats has been very substantial, and there has been no opportunity to scientifically record events from which to draw evidence-based conclusions and publish them in peer-reviewed journals. Therefore, a case-study design would be a more appropriate format for delivering additional results to the research community and developing discussions about students' skills development in blended and online learning settings.
Our scoping review has some strengths. A rigorous and comprehensive search strategy was developed during several meetings with the author group. This search strategy, while implemented for a scoping review, would also have been appropriate for a systematic review. The search itself was conducted by library staff who were specially educated for these purposes. The evaluation of the included studies and writing of the results were performed by the author group, thus avoiding a bias that could have emerged if only one or two individuals had done the same work. Furthermore, the number of included studies was high, and all the studies offered higher evidence levels as judged by their design, i.e., randomized controlled design. Thus, the internal validity of our results could be considered high with one exception: We did not evaluate the quality of the included studies, which could have been low, thereby causing problems with internal validity.
There are some additional limitations as well. We limited the inclusion period to studies published no more than 5 years before the search and published in English. No grey literature was included. The 5-year limitation was decided in an authors' meeting due to the presumably fast development of methods in the digital teaching and learning of practical skills. Had the 5-year limit produced only a few results, we would have increased the limit to 10 years. Nonetheless, the more recently developed methods are more relevant to today's teachers than the older methods. We included only RCTdesigned studies because of the high scientific level of design characteristics and their quality. However, a true RCT design in the education intervention context can be problematic in several ways. For example, the blinding of the participants is very difficult in the education context, intervention contamination between groups occurs, and it is seldom possible to have a control condition without any education intervention since the curriculum must be followed. These all are thus limitations of this scoping review. The English language requirement and grey literature exclusion may have influenced the results. However, we were able to include 49 studies, giving our scoping review quite high reliability. Using numerous filters could be a problem, but we consider that in our case, the limitations caused by filters are not highly problematic.
The studies included in our scoping review represent a global sample, meaning that the results could possibly be generalized to health and social education programs in the dentistry, medicine, nursing, and midwifery fields. However, the studies were carried out in a certain local context, implying that there are probably several context-related variables that can affect the results and thus possibly decrease the generalizability of this review. Furthermore, unfortunately, no studies on other health and social education programs were found during our 5-year study period.
The theoretical knowledge can be easier and more effectively taught and learned through digital resources than practical skills teaching. Thus, the development of digital teaching methods for practical skills must first identify the real problem areas for this kind of teaching rather than beginning with an existing model and content developed for campus-based teaching. We should learn to include the end-users in the development of digital teaching methods, much as they are included in the development of new mobile and other digital interventions in health care research today. In our case, the end-users are the students and teachers, not the patients or clients.

Conclusions
The teaching and learning methods comprised three categories, blended, e-learning/online and digital simulation-based, but the used digital tools used varied greatly, as did the learning environments, making it difficult to draw conclusions. The use of digital technology, in the learning and teaching process can contribute to the development of not only of students' skills but also their knowledge, motivation, and attitudes. The authors of the study would like to highlight that the pedagogical factor of how technology is used is decisive. Furthermore, the results suggest that there are positive implications for using digital practical skills teaching and learning methods, but the digital methods may be at their best when used alongside with more traditional face-to-face methods. The development of new digital methods for teaching and learning practical skills also requires engaging students and teachers, not only researchers.