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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 58-69

Student perceptions of iBooks as a clinical skills learning resource as compared to learning management software and an online video-hosting site


1 University of Arizona College of Veterinary Medicine, Oro Valley, Arizona, USA
2 Lincoln Memorial University College of Veterinary Medicine, Harrogate, Tennessee, USA
3 Texas Tech University School of Veterinary Medicine, Amarillo, Texas, USA
4 Lincoln Memorial University College of Veterinary Medicine, Harrogate, Tennessee, USA; Wellington Veterinary Hospital, Wellington, Colorado, USA

Date of Submission15-Mar-2021
Date of Acceptance03-Jun-2021
Date of Web Publication15-Sep-2021

Correspondence Address:
Dr. Julie A Hunt
Lincoln Memorial University College of Veterinary Medicine, 6965 Cumberland Gap Pkwy, Harrogate TN.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EHP.EHP_10_21

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  Abstract 

Background: Learning resources to support clinical skills training can be delivered through a number of technology platforms, and listening to students’ preferences can be helpful in leveraging the use of technology in the laboratory. Objective: This study sought to compare students’ preference of clinical skills educational resources delivered by iBooks with that by a learning management system (Blackboard) and a video-hosting website (YouTube). Methods: A survey was conducted among veterinary students (n = 73) who completed their first year of clinical skills training. During the fall semester, they utilized 14 free iBooks, one per clinical skills laboratory, to prepare for fall laboratories. In the spring semester, their learning materials were provided on Blackboard and YouTube. At the end of the academic year, they were surveyed about their experiences and preferences. Results: Students reported a preference for the iBooks to the Blackboard and YouTube resources. This preference was the result of the convenience of having all resources on a single, well-organized platform and having access to iBooks after graduation as a perpetual reference, unlike Blackboard resources that students lose access to upon graduation according to the university policy. Students reported technological issues with iBooks, including downloading problems, at a similar rate as technological issues with Blackboard and YouTube. Conclusion: Educators should be guided by students’ preferences, provided the learning outcomes are similar, when selecting platforms for providing student educational resources. Although the iBooks seem preferable, additional research is necessary to understand how students use the iBooks and how that use impacts their clinical skills course performance.

Keywords: Clinical skills, computer, educational methods, educational resources, iPad, mobile learning, tablet PC, technology-enhanced learning, veterinary laboratory


How to cite this article:
Perkins J, Hunt JA, Anderson SL, Christmann U, Gibbons P, Chapman S, Johnson JT, Dascanio JJ. Student perceptions of iBooks as a clinical skills learning resource as compared to learning management software and an online video-hosting site. Educ Health Prof 2021;4:58-69

How to cite this URL:
Perkins J, Hunt JA, Anderson SL, Christmann U, Gibbons P, Chapman S, Johnson JT, Dascanio JJ. Student perceptions of iBooks as a clinical skills learning resource as compared to learning management software and an online video-hosting site. Educ Health Prof [serial online] 2021 [cited 2021 Nov 29];4:58-69. Available from: https://www.ehpjournal.com/text.asp?2021/4/2/58/325993




  Introduction Top


“Someday, in the distant futures, our grandchildren’s grandchildren will develop new equivalent of our classrooms. They will spend many hours in front of boxes with fires glowing within. May they have the wisdom to know the difference between light and knowledge.”—Plato (Lewis.)

Knowledge alone does not create a competent veterinarian, but a clinical skills training is also imperative in modern veterinary education. However, finding time in the veterinary curriculum to allocate to clinical skills training is challenging, and educators must be efficient about using the time allotted to them. Clinical skills are learned through deliberate practice, which requires goal-based repetitive practice with feedback.[1],[2],[3] One method of maximizing the time for deliberate practice in instructor-supervised clinical skills laboratory sessions is that students review instructional materials before coming to the laboratory. Another method for facilitating additional practice is to allow students to drop in for self-directed study. In laboratories permitting self-directed practice, veterinary educators typically provide models for skills practice, along with educational resources, often in the form of instructional booklets and videos.[4],[5],[6],[7],[8] Rather than being hosted directly on a learning management system, these veterinary clinical skills videos are often hosted on YouTube (YT), a popular online video-hosting platform, because of its ease of use.[5],[8] YT is also a common site for hosting clinical skills videos used for training human medical doctors as well.[9]

Electronic books, such as iBooks (Apple, Cupertino, CA), have become a popular all-in-one alternative for delivering digital educational resources, as they can include text, pictures, animations, and videos. A study of students seeking teaching licensure found that instruction with iBooks increased student motivation, interest, excitement, and attention in class when compared with lecture instruction.[10] The use of iBooks to enhance learning is supported by multimedia learning theory, which situates the learner as “a knowledge constructor who actively selects and connects pieces of visual and verbal knowledge” and posits that learning is enhanced with a combination of words and pictures when compared with either alone.[11],[12] Educators in nonveterinary disciplines have praised iBooks for their portable nature and ability to be used without an internet connection.[10],[13],[14],[15] Veterinary educators have developed iBooks for diverse topics, including anatomy,[16],[17],[18],[19] dentistry,[20] surgery,[21] and clinical procedures.[22] Many of these books are available free or at minimal cost on iTunes (Apple, Cupertino, CA). If digital resources are to be widely utilized by students, it is critical to gather data from veterinary students to learn students’ preferences about the type of technology used and how information is delivered within it.

The aim of this retrospective survey was to determine whether first-year veterinary students had a preference between clinical skills educational resources provided via learning management system and video-hosting website, and those via purpose-built interactive iBooks. The secondary aim was to collect student feedback about the iBook resources to guide further development. We hypothesized that students would prefer laboratory information provided via iBooks to information provided on the learning management system and video-hosting website.


  Materials and Methods Top


Our institution has a robust clinical skills training program that spans the first 3 years of students’ veterinary education. Course directors have previously offered well-designed laboratory resources on two platforms, a learning management software (Blackboard [BB], Providence Equity Partners, Providence, RI) and a video-hosting website (YouTube, San Bruno, CA). Examples of the content and organization of these resources for a single laboratory, surgical hand ties, are provided [Figure 1] and [Figure 2]. However, in fall 2019, course directors elected to move all content to iBooks. Students already had iPads at the request of administration for use in the veterinary curriculum and assessment. One advantage of iBooks is that they can be downloaded once and accessed continuously offline. Our institution is located in a rural area where access to reliable, high-speed internet access is lower than national levels.[23] Another advantage of the iBooks was the ability to have all educational materials, including text, pictures, drawings, animations, and videos in a single, comprehensive source without the need to have multiple files for students to access in BB and links to YT.
Figure 1: The organization of the surgical hand tie laboratory landing page on Blackboard contains details about required prelaboratory preparation, reviews the learning objectives for the laboratory, provides written instructions and links to YouTube videos for right- and left-handed surgical hand ties, and provides pictures of correct knots and common errors (half hitches)

Click here to view
Figure 2: The YouTube video for the right-handed surgical hand tie teaches students the square and surgeons hand tie. Left-handed versions are provided in a separate video. Our institution’s Clinical Skills YouTube channel has 180 skills videos posted for students to watch

Click here to view


Fourteen iBooks, one for each clinical skills laboratory session in the fall semester of the first year, were created using iBooks Author, a free tool (Apple, Cupertino, CA). All iBooks were distributed for free to students through iTunesU courses. The iBooks contained original videos, short animations, and illustrations of tasks that clinical skills students encounter in the fall semester clinical skills course. These videos were filmed at the college by the research faculty to ensure that techniques matched what clinical skills faculty were teaching and so that rights and usage of materials were not an issue. The content and topics covered in the iBooks were similar to those covered on BB and YT and included introductory surgical skills materials including information about suture type and handling, surgical instrument identification, and hand ties; psychomotor skills such as palpation techniques; microscopy; animal handling including muzzle application and how to move livestock using flight zones; and basic physical examination skills including animations of equine gaits [Figure 3][Figure 4][Figure 5][Figure 6][Figure 7]. Each iBook also contained interactive widgets and flashcards for student review. The widgets, which facilitate finding content in one place or may walk a student through the learning cycle of a process, contained interactive elements that the students could navigate to view more content. Flashcards could be viewed as stand-alone review materials or as a game, making the iBooks a convenient review tool for students. Five of the 14 iBooks contained quizzes for student review of the material. Laboratory leaders reviewed all iBook materials to ensure the accuracy of materials.
Figure 3: This page from the canine handling and restraint iBook contains an embedded instructional video

Click here to view
Figure 4: This page from the surgical psychomotor skills iBook includes pictures demonstrating how to create square throws and half hitches

Click here to view
Figure 5: This page from the microscopy iBook contains a widget that allows students to manipulate interpupillary distance

Click here to view
Figure 6: This page from the equine physical examination iBook shows the anatomy superimposed on the live horse

Click here to view
Figure 7: Student survey responses when asked whether they had a preference between YouTube and Blackboard or iBooks

Click here to view


Because of changes in faculty availability, in the spring semester of the first year, new iBooks were not created, and instead, materials were placed on BB and YT, which is how the content of the course had previously been delivered. The iBooks downloaded from the fall semester could be accessed by students on their iPads through the students’ iTunesU account or stored in the students’ “Books” library. The iBook content from the fall semester was considered a building block for many spring laboratories and was suitable to assist students in the spring laboratory sessions. Spring semester clinical skills content included a review of skills from semester 1, more in-depth physical examination skills, advanced knot tying, and suturing skills.

After the study received ethics approval, first-year veterinary students (n = 127) were enrolled at the completion of their spring semester. A course director emailed the students a request to take a 10-min anonymous Qualtrics (Provo, UT) survey evaluating their preference for each type of educational materials. The survey employed several five-point Likert Scales (see Appendix 1[Additional file 1]) to assess the students’ comfort level with the iPad and their preference for each of the different types of instructional materials. Several questions allowed for open-ended responses. The research team also gathered information about any technical difficulties encountered during the use of the learning materials. The full survey is included in Appendix 1. After seven days, a course director emailed a reminder, and the survey was closed 14 days later.

Statistical methods

Likert scale survey data were treated as ordinal data, and responses were described by medians. How students’ previous use of Apple devices impacted students’ preference for BB/YT resources when compared with iBooks was evaluated using the chi-square test. Significance was set at 0.05, and all calculations were performed in SPSS version 26 (IBM, Armonk, NY). Technological issues noted by students were paraphrased, and the frequency reported. Student comments were compiled into tables with illustrative quotes included in the text.


  Results Top


There were 73/127 student responses (57% response rate). Fifty-seven of the students (78.1%) were Apple product users before attending veterinary school. Most students (63, 86%) expressed a preference for the use of iBooks over BB/YT resources (median = clear preference for iBooks), and eight students (11%) expressed a clear or slight preference for BB/YT resources [Figure 7]. Whether students had previously used Apple products did not impact their preference for iBooks over BB/YT resources (P = 0.377).

Students reported that the iBooks were easy to use (median = easy). In comparison, students rated the use of resources on BB and YT neutrally on an ease-of-use scale (median = neutral). Students felt that the iBooks contained about the right amount of content material (median = about right), whereas they reported that the BB/YT content was covered with somewhat too little detail (median = somewhat too little). There were no statistically significant differences between any of these pairs of iBook and BB/YT survey responses.

Students stated that learning objectives in the iBooks were very well defined (median = very well defined), whereas they reported that the BB/YT resources had learning objectives that were moderately defined (median = moderately defined). Students reported that the iBooks were very useful overall (median = very useful) and rated the BB/YT resources as moderately useful overall (median = moderately useful). Students found the iBooks very enjoyable to use (median = very enjoyable) and rated the BB/YT resources as moderately enjoyable to use (median = moderately enjoyable). Survey results are summarized in [Table 1]. Students using iBooks and BB/YT reported using them for approximately 31–45 min at the longest stretch of time. There were no statistically significant differences found between these pairs of iBook and BB/YT survey responses.
Table 1: Survey data summary

Click here to view


Thirty students (41.1%) reported technological problems with their iBooks over the course of the semester. A similar number of students (39, 53.4%) reported technological issues with BB/YT during the semester [Table 2]. Both iBook and BB/YT users who encountered technological problems indicated that these errors only slightly detracted from their overall use (median = slightly for both). Students reported accessing the fall semester iBooks a median of 3–4 times during the spring semester for review or reference purposes.
Table 2: Technological errors reported with iBooks

Click here to view


Students’ comments revealed that they preferred iBooks because the information was all-in-one location, as demonstrated in these sample student comments:

iBooks were 10,000 times better than BB/YT. With iBooks I could easily find what I was looking for, and it was all located within one thing. YT was a mess, and I easily lost track of what I was on and what all I still needed to cover. (#27)

The iBooks were infinitely better, more organized, and held more information more clearly for use. (#28)

Students also liked the option to access the information indefinitely, including after graduation, as shown in these students’ comments:

The iBooks were a great resource for not only in class learning, but to reference back to over and again in the future when we are practicing and may have forgotten a specific technique. Blackboard does not allow you to access once you are no longer a student, and we’ll lose this very valuable resource. My education was greatly benefitted from having the iBooks and would really enjoy having the resource for later classes. (#50)

I would love to have iBooks for clinical skills from now on. They were very helpful, and I use them to this day while working in a clinical setting and referred back to it often when I needed a resource in the spring while away from school due to COVID. (#63)

Full student comments can be seen in [Table 3].
Table 3: Students’ comments comparing the use of iBooks (fall semester) to Blackboard and YouTube resources (spring semester)

Click here to view



  Discussion Top


As higher education shifts from a teacher-centered to a learner-centered approach, there is an increasing push to personalize education to the individual student’s needs and desires.[24] Educators are called to provide instructional resources that allow digital access at any time of the day or night and materials that provide a more tailored learning experience to promote self-directed learning.[25] Knowles’ self-directed learning theory suggested that providing adult learners with resources that they can choose how to engage with motivates them and leads them on a path of life-long learning.[26] The more interactive nature of the iBooks when compared with learning resources hosted on BB and YT more thoroughly engages learners by allowing the learner to choose, for example, whether or not to click on certain details or widgets on each page based on whether or not the learner needs more information to improve their understanding of that topic.

The use of smartphones and tablets has become ubiquitous in modern society, and generation Z, who represent the bulk of current veterinary students, generally find these devices intuitive to use. The iPad tablet, released by Apple (Cupertino, CA) in 2010, is a popular choice for education with its touch screen, portability, ease of use, and interactive features. The iBooks designed for use in this study worked on any Apple product (iPhones or iPads) and provided students with multimodal interactive content. Multimodality is the interplay between different representations, such as written, visual, and auditory modes. These modes were experienced in different ways by each of the senses, creating a dynamic learning experience for the student. Multimodal approaches enhance a student’s learning experience because the learner engages and interacts with the resource in a way that fits with their individual preference and accommodates any disability that they may possess. Interactive multimodal tools allow users to approach a topic in several ways simultaneously. The iBooks used in this study included written text, pictures, diagrams, charts, and video clips. Multimodal iPad-based teaching methods have been found to enhance learner engagement and keep students on task in anatomy laboratory sessions in human medical education.[27] Viewing iBook resources offers a visual field that connects viewing and manipulation of content, thus creating an active learning environment for the student. iBooks also have the benefit of providing all content in a single source rather than requiring students to use two platforms, BB and YT. Additionally, resources were provided to students as multiple file types within BB; for example, when preparing for a single laboratory session, a student might be required to review a PowerPoint file, a journal article, and several images. When preparing for a laboratory using an iBook, all necessary resources are included in the single iBook. The iBook also allows students to personalize content for later use in their veterinary career using highlight, notation, and search features.

The aim of this study was to determine whether veterinary students preferred interactive clinical skills iBooks or instructional materials provided on a traditional learning management system (BB) and online video-hosting platform (YT). The majority (86%) of students expressed a preference for iBooks, whereas 11% of students preferred resources provided on BB and YT. However, many clinical skills educators report relying heavily on the use of instructional videos instead, often hosted on YT, for the instruction of both veterinary and human medical students.[5],[8],[9] In this study, student comments revealed that their preference for iBooks was due to two reasons. First, students cited the potential use of iBooks as a comprehensive reference indefinitely in the future. Although students did not comment about YT, they also retain access to videos there. However, students lose access to learning management software resources upon graduation, and multiple students commented that they liked having the option to utilize the iBooks after graduation. Second, students appreciated that the iBooks organized all of the sources of the necessary information for each laboratory session into one complete source for them to consult; the iBooks contained written information, diagrams, animations, pictures, and videos to help them better understand the concepts and tasks they would be performing in the laboratory. Although video instruction has proven to be more memorable than text delivery, both to students in general[28],[29] and to veterinary students specifically,[30] our students preferred to have all information in one place, including text, picture, and video resources.

As technology is integrated into the learning process, it is important to consider what learning opportunities it creates. Koschmann has proposed that technology, instead of creating additional opportunities for individualized learning, should create opportunities for collaborative learning.[31],[32] By providing learning materials in advance of clinical skills laboratory sessions, and iBooks that are able to be quickly consulted for review during the laboratory session if desired, the time during laboratory can be directed primarily or entirely toward interaction with fellow learners, to share tips for successful task completion, and with instructors who can provide specific feedback for success. This optimization of the use of laboratory time results in efficiency in skills learning and in the use of faculty time and institutional resources, as well as allowing institutions to better meet students’ learning needs. Considering the limitations and concerns with animal welfare, ethics, and client concerns, students’ time spent in clinical skills laboratories should be maximized with hands-on learning in order to enable students to acquire the practical skills listed in the American Veterinary Medical Association’s clinical competencies outcomes[33] and entrustable professional activities.[34]

iBooks, BB, and YT all came with some technological issues. There were multiple student reports of iBooks that were difficult to download, disappeared after being downloaded, would not open, or had the content mysteriously change into that of a different iBook later. Most of these issues were easily resolved once students learned how to use iTunesU. Students also reported similar rates of technological issues with BB and YT, including broken links or videos embedded in BB that would not open. Students felt that for all platforms, the issues inconvenienced them only slightly. Both iBooks and YT have previously been successfully used to provide instructional content to veterinary students for other clinical skills laboratories.[5],[8],[35] The majority of students today are familiar and proficient with digital technology and are able to tolerate simple technological errors that arise; however, having technical support available is also critical.

This study’s limitations included its enrollment of a single cohort at one veterinary school. Multiple cohorts or a multi-institution design would have strengthened its generalizability. Additionally, the ideal study would have had a crossover design, where one group would have utilized iBooks in the fall and BB and YT in the spring, whereas the other group used iBooks for spring laboratories and BB and YT in the fall. However, as this was an opportunistic retrospective study, that design was not used. As there were a broad variety of topics covered in both the fall and spring laboratories, we feel that the results are still valid. This study also did not collect preference data from course instructors, as the materials were designed for use by students. However, in general, course instructors are most pleased with whatever materials lead to students coming into the laboratory being as prepared as possible to perform the laboratory tasks. Although results suggest that students prefer the iBooks to the BB and YT resources, the initial creation of the iBooks took additional time and resources. The success of programs to create new educational resources will depend on a strong administrative and faculty commitment to create and maintain these resources. Although early adopters have reported benefits that make these resources appear superior, ensuring faculty commitment over the long term is necessary and will depend on institutional and administrative support, professional rewards, and personal satisfaction. Additional research is necessary to understand how students use the iBooks and how that use impacts their performance in the clinical skills course.


  Conclusion Top


Students indicated a preference for iBooks to resources provided on the learning management software (BB) and video-hosting website (YT) because of the convenience of having all of their resources in one comprehensive source and the promise of having access to the iBooks as a resource following graduation. iBook features including availability without internet access, interactive widgets, search functions, highlighting, notation, and quizzes also may be useful to students both inside and outside the laboratory setting. Educators should be guided by students’ preferences when selecting platforms for providing student educational resources in support of curriculum, as these preferences lead to better prepared students in the laboratory and at assessment time.

Acknowledgments

The authors would like to acknowledge Jill Castek for her assistance in providing editing assistance during the drafting of this article.

Financial support and sponsorship

This research was supported by an intramural grant from Lincoln Memorial University College of Veterinary Medicine.

Conflicts of interest

This research has not been presented or published elsewhere. There are no conflicts of interest.

Author contributions

The article has been read and approved by all authors. All coauthors meet the criteria for authorship, and all authors believe the article to represent their honest work. Jamie Perkins secured research funding, created the iBooks, supervised the research students, received ethics approval, designed the study and survey instrument, and wrote several drafts of the article. Julie A. Hunt contributed content to the iBooks, designed the study and survey instrument, received ethics approval, analyzed the data, wrote several drafts of the article, and served as corresponding author. Stacy L. Anderson contributed content to the iBooks, assisted with design of the study and survey instrument, and provided critical edits to the article. Undine Christmann, Philippa Gibbons, Seth Chapman, Jennifer T. Johnson and John J. Dascanio contributed content to the iBooks and provided critical edits to the article.







 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Materials and Me...
Results
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