|Year : 2012 | Volume
| Issue : 2 | Page : 104-108
Perception of nursing students toward integrated methods of teaching the ENT clinical examination in south India
Sivaraman Ganesan1, T Mahalakshmy2, Z Zayapragassarazan3, Pradipta Kumar Parida1, Arul Nisha Sundaraj4, S Gopalakrishnan1
1 Department of ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Medical Education, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 College of nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||27-Sep-2012|
24, III Main Road, Navasakthi Nagar, Koundanpalayam 605 009, Puducherry
Source of Support: None, Conflict of Interest: None
Context: Assessment of integrated teaching methods are lacking in Indian setup of nursing education. AIM: To assess the perception of nursing students towards integrated methods of teaching ENT Clinical Examination. Materials and Methods: Large group teaching was carried out for teaching ENT examination in a theory class of nursing students. This large group teaching included facilitations such as dividing the one hour session into three short sessions of 20 minutes each, group activity, five minute evaluation, and usage of video. The impact was assessed by scoring the group generated checklist, individual response on a short answer question and obtaining a feedback on video teaching and group activity. Results: At the end of the class after three assessments, the overall mean group score was 85.4%. The students showed positive reaction when they were allowed to solve a specific task in groups as reflected by their feedbacks. Authors found that these factors promoted most of the aspects of the cognitive domain in the students, improved the clarity of the student for a complex topic and improved the attention span of the students. Conclusion: These integrated systems worked out well in our setup and can be used regularly in nursing students teaching.
Keywords: Group work, India, integrated teaching methods, mini-assessment, nursing education
|How to cite this article:|
Ganesan S, Mahalakshmy T, Zayapragassarazan Z, Parida PK, Sundaraj AN, Gopalakrishnan S. Perception of nursing students toward integrated methods of teaching the ENT clinical examination in south India. Int J Health Allied Sci 2012;1:104-8
|How to cite this URL:|
Ganesan S, Mahalakshmy T, Zayapragassarazan Z, Parida PK, Sundaraj AN, Gopalakrishnan S. Perception of nursing students toward integrated methods of teaching the ENT clinical examination in south India. Int J Health Allied Sci [serial online] 2012 [cited 2020 Jan 25];1:104-8. Available from: http://www.ijhas.in/text.asp?2012/1/2/104/101711
| Introduction|| |
The importance of nursing education has been well realized since ages in India. The history roles back to 1871 when School of Nursing was started in General Hospital Madras.  Since then, the nursing education has taken leaps and bounds. Although the curriculum of nursing education has transformed along with medical education, nursing education has maintained its identity. Theory classes of nursing education are usually done in the large group, employing the traditional methods. Lecturing for a large group has the main advantage of being cost-time effective.  Traditional methods make the student passive, hinders learning, has difficulty in maintaining the attention span of students, inability to stimulate high level thinking, and lack of interaction within fellow students. , These can be overcome by integrating the methods of teaching such as group work, use of video, dividing the class into multisessions, and 5 min mini-evaluation. Nursing students usually have clinical postings in general medicine, general surgery, obstetrics and gynecology, and pediatrics. ENT, being a specialty subject, will be introduced to them only in class rooms, allotting less time in clinics. Therefore, when they had a theory class on clinical examination methods in ENT, the authors used integrated methods of teaching for the above practical topic to enable them to pick up clinical skills of ENT examination. Group work, 5 min mini-assessment, clinical videos, promoting peer interaction, and splitting the class into three sub-sessions were used to facilitate the large group teaching.
There has been lack of such studies among nursing college students especially from an Indian setup. This study assumes importance as the results might influence the curriculum development of nursing education in India.
This study was designed to assess the perception of nursing students towards integrated methods of teaching ENT clinical examination.
| Materials and Methods|| |
Seventy (64 female and 6 male), second-year BSc nursing students were exposed to the intervention. Objectives of the class were that students should be able to enumerate the principles of ENT examination. The session was 1 h theory class with availability of one specialist doctor and two nursing tutors. The lesson planning was done by the specialist doctor and reviewed by three other faculties of the department. The lesson plan was also reviewed and shared with the two nursing tutors. They were also briefed before the class about their role is moderating the small group discussion. The class was divided into 12 self-managed groups consisting of 6 each. Two nursing tutors were assigned to six groups each, to facilitate the theory class. It was a large group teaching, and students rearranged themselves for small group discussion in between the session. During the small group discussion, the group leaders of each group were asked to ensure participation of all group members in the group activity. One hour lecture was divided into three short sessions (20 min each) each covering the various aspects of ENT examination such as ear, nose, and throat examination. Initially, ear examination was taught to them by lecture with the aid of Microsoft PowerPoint presentation with pictures of the various ENT instruments. Following this, the ear examination was projected in a video format. The video was prepared in the department of ENT with the help of the senior faculty members in our institute based on the chapter - 'Clinical Methods in ENT' (chapter 74) in fifth edition to Textbook of Diseases of Ear, Nose and Throat - by P. L. Dhingra.  Videos of the ENT examination were captured using healthy volunteers. The validity of the contents in the videos was obtained from three experts with experience in teaching ENT for more than 5 years. The theory and video session was followed by a group work in which the groups were asked to enumerate the sequence of the ear examination based on the theory and video session. The group work also served as 5 min mini-assessment. Similarly, examinations of nose and throat were taught to the students by a lecture format followed by a video. The groups were asked to generate the sequence of each examination at the end of each session. To summarize, ENT clinical examination was taught by integrating the teaching methods such as lecture, usage of video, splitting the lecture into sub-sessions, group work with 5 min mini-assessment.
The session was evaluated using (1) written individual assessment in which each student wrote a written test which included ten short answer questions without revealing the identity of the student (individual assessment), (2) the group work done by the students was evaluated using the checklist prepared by them at the end of the group discussion (group assessment), and (3) and the feedback from each student using a few open ended questions (feedback). The individual and group assessments were scored by using a key prepared by the three facilitators of the session. The key was also face validated and reviewed by two senior professors of the department. Both the individual and group assessments evaluated the cognitive domain (recall, comprehension, and application). Hence there were 64 scores (expressed as percentage marks) from the individual assessment and 12 scores (expressed as percentage marks) from the group assessment. These marks were entered and analyzed in Microsoft Office Excel 2007 and OpenEpi Version 2.3 software. These percentage marks were summarized using mean and standard deviation. The group's scores in ear, nose, and throat examination were compared using the one-way ANOVA and the post hoc test. The overall group score and scores on the individual assessment were compared using an unpaired t-test.
The general feedback provided qualitative data with respect to the perception of students on the use of integrated methods in teaching. These qualitative data obtained were analyzed using manual content analysis. The content analysis was done by the second author and reviewed by the first and third author. In the content analysis, broad categories were generated and the frequency of the student giving similar feedback was expressed as percentages.
Ethical principles such as obtaining written informed consent, maintaining confidentiality, ensuring voluntary participation after a briefing session, clarifying their doubts/apprehension during briefing session and maintaining anonymity were adhered throughout the research.
| Results|| |
This large group teaching included facilitations such as dividing the 1 h session into three short sessions of 20 min each, group activity, 5 min evaluation, and usage of video. The impact was assessed by scoring the group generated checklist, individual response on a short answer question and obtaining a feedback on video teaching and group activity.
In our study, we found that the groups scored 95.5% (SD 4.7), 69.4% (SD 23.4), and 85.6% (SD 17.1) in the ear, nose, and throat examination group activity, respectively. The difference in the score was statistically significant (P = 0.002). In the post hoc test, it was found that the difference was significant between ear and nose, ear and throat examination scores. The difference between nose and throat examination scores was not statistically significant [Figure 1]. The groups score in throat examination, which was covered at the end of the session, was reasonably good, indicating that the interventions helped in maintaining the concentration and interest throughout the session. These indirectly show that the intervention improved the attention span of students. The mean of the overall score obtained by the groups was 85.4 %marks (SD = 8.9). The mean of the individual's score was 63.8% (SD = 25.1). This difference in the individual performance and groups performance was statistically significant (P = 0.004) [Figure 2].
|Figure 1: Group scores in the three sub-sessions. Significant with P = 0.002 using one-way ANOVA|
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|Figure 2: Comparison of group scores and the individual scores. Significant with P = 0.004 using an un-paired t-test|
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The cognitive domain of learning has certain subsets such as knowledge, comprehension, application, analysis, synthesis, and evaluation. Overall, the students felt positive about using video in large group teaching. In the feedback, student on an open-ended questionnaire, 71% students self-reported that their understanding (comprehension) improved after seeing the videos. Students also opined that video teaching enhances their knowledge (26.1% students), improved their application (24.6% students), created an interesting learning experience (21.7% students), and has also added clarity to the lecture (40.6% students) [Table 1]. These indicate that students self-perceived an improvement in the cognitive domain. The majority of students (56.5%) agreed that video teaching is a useful tool in a large class room, 32% strongly agreed, 10% remained neutral and nobody disagreed, to the use of video as a useful teaching tool [Table 2].
|Table 1: Feedback of students on the integration the methods of teaching|
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The other responses from the group are described below and the specific observation from every group was interesting and worth mentioning.
Only one group missed Retromolar Trigone in their checklist examination. The importance of Retromolar Trigone was emphasized in the class specifically and it has been well taken by the rest.
Some perceptional error was also noticed in the response sheets. The frequency of tuning fork, "512" Hz have been interpreted as '5 to 12 Hz', 12 Hz and absent responses by four groups. Rest eight groups have documented 512 Hz correctly. It is a fact that 512 Hz was only verbally told to the students and not written for visually anywhere during the class. Similarly, the word Thudicum was only verbally spelt during the class, not projected or written. Wrong spellings in various forms such as "rudiculum" (three responses), "tunicum" (two responses), "cuticle", "tuniculum" (two responses), "tudiculum", "cuniculum" were documented in 10 groups. Only two groups were able to correctly spell the word thudicum. It is always better to use visual aid such as black board, white board, overhead projector, etc.
When two questions were coupled in the form of "please generate the checklist for throat/oropharynx examination", we found that four groups did not answer the second part.
Two groups generated a meaningful "alternate" checklist for nose examination, otherwise rest all the groups have generated a similar checklist that was projected during the session.
Only seven groups were able to answer the subject covered in the last 15 min of the class. The students may be fatigue or the concept was too quickly covered at last moment may be the reason for the above.
| Discussion|| |
In our class, every group had six students each who were exposed to 15 min of lecture and video on ear examination followed by the 5 min mini-assessment. This was designed using the guidelines for group work in a classroom in such a way to change the pace of the lecture, to encourage peer interactions and for team work to solve a single notified problem.  The students had three such sessions. At the end of the class after three assessments, the overall mean group score was 85.4%. The students were also happy when they were allowed to solve a specific task in groups as reflected by their feedback. Strikingly, the higher scores from groups (as compared with individual scores) may be attributed to the obvious reasons performing better in groups, interaction among group members, one best student leading in every group, etc. Nevertheless, individual response is very important and significant, when it comes to real practical situations. In addition, it should be noted that the individual responses were also good with a mean of 63.8% marks. The group interaction could have benefited the individuals. By dividing a large class room into small groups in turn enhances attention span, promotes discussion, brings out individual group leaders, peer interaction, etc.
Using clinical videos eliminates the need of a real patient, promotes sequential structured visualization of the clinical steps in an orderly manner in a theory class, makes the session interesting and appealing (especially postprandial!). The ability to pause, rewind, and replay allows the student for comprehension. It replaces monotonous lecture, promotes the acquisition of cognitive learning, clarity of communication, grabs the complete attention of students, and shows real life examples. Videos are attractive, benefit the visual learners, provide a break in the lecture, and are effective learning methods according to Brecht et al. Nevertheless, three students in our study have indicated that video teaching cannot be a replacement for real situations, as it involves the psychomotor, environmental, and patient physical factors, point well taken.
Peer interactions have been promoted in our study by group work. This allows them to discuss with each other, critically comment on the lecture, to shy out individual feelings in small groups, to compete with other groups, to clarify their doubts and so on. There was no significant difference between the groups which suggested that handling of class with these integrated tools has led to a hybrid environment and reflected as very good outcomes. Peer interaction makes sure that every student is engaged, directed toward appropriate learning, avoids isolation of any student, improves individual responsibility, and motivates other individuals. There are various studies including meta-analysis showing the positive impact of group work on student performance, marks, attitude toward student learning and persistence/retention. 
Mini-assessment was administered as a group work at the end of every 15 min. This would help students to recognize gaps in their learning and would encourage them to use new material in practice.  It is noted that the learner's concentration decreases and reaches a low point at the end of 15-20 min and a break by means of change of activity or a group activity brings back the attention to early high level.  Hence the lecture was divided into three sessions (20 min each) such as ear, nose, and throat examination. The session included a group activity at the end of every session, so that the concentration of students regain to a high level. It was observed that group performed better in ear examination which was dealt in the initial 20 min of the 1 h class. The group's performance in the throat examination group activity was good with score of around 85%. This shows that student's concentration was reasonably maintained throughout the lecture, which could be attributed to the group activity every 15-20 min.
| Conclusion|| |
The authors found that the integrated systems of teaching promoted most aspects of the cognitive domain in the students, improved the clarity of the students for a complex topic, and improved the attention span of the students. These integrated systems worked out well in our setup and can be used regularly in nursing students teaching especially in a large group.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]