Empirical Research on Technological Pedagogical Content Knowledge (TPACK) Framework in Health Professions Education: A Literature Review

Abstract

In the context of twenty-first-century information and communication technologies, the Technological Pedagogical Content Knowledge (TPACK) framework is a new way of conceptualizing categories of knowledge required by teachers to achieve technology integration in educational practice. The main purpose of this review is to identify research on the TPACK framework in the field of health professions education. Journal empirical studies from 4 databases are included in this review. Of the 76 selected articles, nine met the selection criteria. The findings in the examined papers highlighted four themes: TPACK level measurement, TPACK relationship with other variables, TPACK application, and professional development. Research on the TPACK framework in the health professions education area is still lacking; however, the finding indicates that the TPACK as a theoretical foundation generated positive outcomes that can guide practitioners and researchers’ future practice and investigations.

Introduction

As in many other domains, the need for technology integration is emphasized in education. A few decades ago, the main focus of education was on delivering knowledge to students from the perspective of behaviorism theory; however, as the constructivist approach to education has emerged, the form of education has also shifted, and technology is commonly considered a means to facilitate this pedagogical change [1, 2].

Because the way students learn is undeniably changing, the way we teach them must also be profoundly transformed. Teaching digital natives cannot be conceived without incorporating digital competency into the process [3-5]. Accordingly, educators must adapt to the demands of this change and keep up with technological advances to provide students, on the one hand, with meaningful learning opportunities and prepare them, on the other hand, for the digitalized future [5-7]. Thus, educational managers, leaders, and policymakers must place a higher emphasis on developing the competencies of today’s educators who are influencing actors in the teaching–learning process [8-10], and a crucial figure in the integration of technological resources into their educational practice [9, 11].

Recognizing the importance of teachers in transforming designed curricula into real teaching and learning activities, several educational policies throughout the world have explicitly integrated technological requirements in teacher qualification processes and consider technology as a driving force in influencing educational practice [12, 13]. However, integrating technology into educational activities is not an easy task; for this reason, Technological Pedagogical Content Knowledge (TPACK) framework is one of the most described frameworks in the literature serving as a guideline either to build technology-based teaching activities or to assess instructors’ knowledge and expertise with technology integration [14].

The TPACK framework is a useful construct that conceptualizes the complex relationships between a teacher’s Content Knowledge (CK), Pedagogical Knowledge (PK), and Technological Knowledge (TK). Teachers and educators must take into account, when combining technology and pedagogy in a certain subject area, the different and dynamic intersections of Technological Pedagogical Knowledge (TPK), Pedagogical Content Knowledge (PCK), and Technological Content Knowledge (TCK) [14].

The Technological Pedagogical Content Knowledge (TPACK) Framework

The TPACK is based on the well-known PCK model of Shulman, which considers Pedagogical Content Knowledge (PCK) as a distinguishing feature of the teaching profession. This type of knowledge makes teachers able to combine domain knowledge with appropriate pedagogical approaches so that students may grasp the subject. TPACK has a similar idea, adding technological knowledge as an essential integrated component of the teaching profession [15, 16].

As research findings show, teachers’ knowledge of how to integrate technology in higher education courses appears to be an important basic requirement for the beneficial effects of technology on student learning outcomes [17-19]. In this perspective, Koehler and Mishra [14] have proposed a new way of conceptualizing categories of knowledge required by teachers to achieve technology integration, namely the TPACK framework, which contains three main intersectional components: technology, pedagogy, and content knowledge [14]. The TPACK framework has been proposed not only as a new kind of knowledge for teaching but also as a response to the lack of theoretical guidance for integrating technology into education; since then, the framework has been widely used in research [14, 20, 21].

Pedagogical Content Knowledge (PCK), Technological Content Knowledge (TCK), Technological Pedagogical Knowledge (TPK), and Technological Pedagogical Content Knowledge (TPACK) are all equally important in this framework and are at the core of effective teaching using technology (Fig. 1) [15].

Fig. 1.

Technological Pedagogical Content Knowledge framework. Reproduced by permission of the publisher,

© 2012 by tpack.org

The Pedagogical Content Knowledge (PCK) represents the appropriate pedagogical knowledge relevant to the teaching of a specific subject. It is an understanding of how pedagogy and content interact and influence one another. In the same way, Technological Content Knowledge (TCK) is the comprehension of how technology and content influence one another. For teachers to teach effectively using technology, mastering the content is not sufficient; they must also have knowledge of how technology might modify the content or its constructed representations. Technological Pedagogical Knowledge (TPK) is an understanding of how technology can help teachers achieve their instructional objectives; this type of knowledge requires taking into consideration the limits and affordances of technologies as well as the disciplinary settings in which they operate. The intersection of these three sets of knowledge is TPACK. Understanding this knowledge is not a matter of juxtaposing technology, pedagogy, and content [15].

Research on the Technological Pedagogical Content Knowledge (TPACK) Framework

The Technological Pedagogical Content Knowledge (TPACK) framework has been embraced by educators and researchers as a useful tool for thinking about and integrating technology effectively by teachers [22]. According to the review conducted by Chai and colleagues [23], while the early TPACK research concentrated on the definition and conceptualization of TPACK components, more recent studies have focused on the application of this concept in the research and development context [23], either to develop technology-based teaching activities [7, 24, 25] or to assess in-service and preservice teachers’ TPACK levels in different educational domains [16, 26-30].

Some researchers have focused on adding or reducing the number of components in the framework, with some arguing that more is needed to reflect the complexities of classroom technology integration [31, 32], and others arguing that fewer are needed to reduce the framework’s complexity [33, 34]. Other studies have highlighted the relevance of the context as a complex, crucial, and under-researched component [35, 36].

A detailed literature review on TPACK revealed that broad usage of the framework has resulted in varied framework interpretations and called into question several of the framework’s foundations [37]. This ambiguity may be related to how technology is seen, resulting in a variety of techniques for evaluating educators’ TPACK and the challenge of defining boundaries and relationships between and among its core components, particularly in terms of measuring and improving TPACK [37, 38].

In almost half of the empirical studies (47.7%, n = 107) reviewed by Willermark [39], the subject was not specified. Moreover, in the review conducted by Voogt and colleagues [37], out of 56 selected articles, only seven contributed to the understanding of TPACK for specific subject domains [37]. Furthermore, Willermark [39] emphasized that in subject-specific studies of his review, science was the subject domain the most studied (15.9%), followed by language (12.1%), mathematics (6.5%), and social studies (2.8%). Other subjects were studied in a few cases, including health or physical education (2.8%). As for TPACK evaluation, self-reporting assessment was the most common approach used to examine TPACK development (71.8%) [39]. In the same vein, Koehler and his co-workers [40], identified 66 studies in which 141 instruments were used to assess teachers’ TPACK knowledge improvement. The most widely utilized measurement methods in TPACK-focused studies were identified as self-report measures, open-ended questionnaires, performance evaluations, interviews, and observations [40].

Having been proposed in response to the lack of theoretical guidance for integrating technology into educational activities, the TPACK framework, since then, has been widely used in research, and it continues to expand. Although the idea of TPACK has attracted interest in research, little is known about the results of TPACK research in health sciences education during the past 10 years. We, therefore, give four primary justifications for why it is crucial to analyze TPACK within the health education profession. First, since the value that technology may bring to the teaching and learning process has been acknowledged, health professionals and educators are expected to be technologically proficient. The TPACK framework is acknowledged to have the potential to address the twenty-first-century educational trend that greatly relies on the integration of technology. Second, studies on TPACK, in many fields of knowledge, aid in its generalizability. Thus, health professions education, for example, can profit from existing TPACK research in other fields while also adding to the development of TPACK theory and findings [23]. Moreover, the need for greater research on a wider range of topics is emphasized by Chai and co-workers [23]. Third, TPACK appears to be applicable to many different fields; however, Willermark’s study’s findings [39] showed that there are not many studies undertaken in the health area. Finally, there has been no review of this kind published in the field of health education. As a result, an examination of the framework’s application in health professions education is required.

The purpose of this study is to add to the growing TPACK body of knowledge by reviewing articles (published in 2005–2022) to identify research issues and outcomes in the TPACK framework use in the field of healthcare professional education.

Methodology

Search Strategy

The current review focuses on TPACK empirical research conducted up to 2022 in the context of health professions education. The research was confined to journal articles published between January 2005 and March 2022 in scientific databases (i.e., Education Resources Information Center (ERIC), PubMed, Scopus, and Web of Science (WOS)). Because the focus of the review is on how the framework has been applied in health education research, theoretical papers that employed the TPACK framework in other professional domains were excluded.

In order to get more comprehensive results, broad search terms were used, such as TPACK, health professions, and nursing. The terms were used with Boolean operators, and the language was limited to English. The preliminary search strategy applies the option “topic” in the “Web of Science (WOS)” database, the option “article title, abstract, and keyword” in the Scopus database, TITLE-ABSTRACT is used in the PubMed database, and no option is used in the education-specific database Eric. Research terms and examples of the search equations are provided in Table 1.

Table 1.

Search terms and equations used for electronic search of databases

Research terms	Examples of search equations
	Database	Search equations
• TPCK, • TPACK, • Technological pedagogical content knowledge, • Technological pedagogical and content knowledge, • Health • Health professions, • Medical, • Nursing, and nurse	PUBMED:	(“technological pedagogical content knowledge”[Title/Abstract] OR “technological pedagogical and content knowledge”[Title/Abstract] OR “tpck”[Title/Abstract] OR “tpack” [Title/Abstract]) AND (“health professions” [Title/Abstract] OR nursing [Title/Abstract] OR nurse [Title/Abstract] OR medical [Title/Abstract] OR health [Title/Abstract])
	SCOPUS:	TITLE-ABS-KEY ((“technological pedagogical content knowledge” OR “technological pedagogical and content knowledge” OR “tpck” OR “tpack”) AND (“health professions” OR nursing OR nurse OR medical OR health))

Selection Process

The initial search yielded 78 articles. To be included in the review, articles had to be empirically based research with the intention to use the TPACK framework. After eliminating duplicates, two authors individually examined each of the remaining 46 abstracts to determine whether the article related to the focus of the review. The article was saved for full-text screening in case there were uncertainties after screening. There were 11 articles as a result. Two members of the research team performed full-text screening of the remaining 11 papers using the same inclusion criteria. If there were any doubts, a third opinion of another member of the study team was requested. Screening processes left just nine (9) relevant publications to be analyzed.

Figure 2 provides a flowchart that illustrates the selection process of our review. The relevant studies are presented in Table 2.

Fig. 2.

Flowchart of the selection process

Table 2.

Overview of the selected studies

Authors and year	Location	Population sample	Study aims	Design and approach	Discipline
[41]	Taiwan	Health profession educators Interview with 15 educators and 319 educators responded to the questionnaire	Explore the considerations and influencing aspects for the technological integration of educational curricula for health profession educators (HPEs) based on the technological pedagogical content knowledge (TPACK) framework	A sequential mixed method, qualitative research, and then quantitative research	Health professional education
[45]	Singapore	Registered nurses who were working in general ward units N = 46	Describe the development of a nurse-patient interactive serious game and its effect on improving nurses' self-efficacy and performance in teaching correct inhaler technique	A prospective randomized controlled trial with a pretest post-test design	Nursing
[42]	Canada	Twenty-one athletic therapy educators from all seven CATA-accredited institutions. N = 21 15 educators participated in the individual interviews	Explore athletic therapy educators’ views and attitudes towards the use of digital technologies in athletic therapy courses	An explanatory sequential mixed-methods approach Questionnaire then interview	Athletic therapy education
[43]	USA	Medical educators N = 76	Examine medical educator knowledge of pedagogy and technology to inform the direction of faculty development efforts	Quantitative CSS quantitative	Medical education
[26]	Taiwan	Fifty-one nursing students, N = 21	(a) To determine the contribution of the TPACK model-based writing training program to learners’ learning outcomes; (b) to investigate learners' perceptions and satisfaction with the TPACK model-based writing training program; and (c) to investigate teacher reflections on the TPACK model-based writing training program	A single-group experimental study	Nursing education
[44]	Turkey	301 medical educators from 14 medical schools	Identify the variations in technology integration among Turkish medical educators and analyze them using various variables and technological pedagogical content knowledge	Explanatory Correlational Design Non-experimental quantitative research approach	Medical education
[49]	Canada	15 nursing educators	Explore teaching–learning components that emphasize educators' effective practices in higher education online and apply these practices to courses offered online via Moodle in a post-RN Bachelor of Science program	Participatory action research methods	Nursing education
[47]	Israel	Two cohorts of twenty clinical professionals N = 40	Investigate the attitudes of instructors as they learn to include CoI into their teaching	longitudinal (Program developing)	Medical education
[46]	Australia	205 hundred students	Create an interactive dashboard for providing feedback on clinical abilities in the pharmacy curriculum	Action-based research approach	Pharmacy education

Data Analysis

Based on the analysis of previous research [37, 39], the article synthesis was conducted in three steps; the first step consists of comparing different studies to identify common points in regard to the TPACK application in health professions education. In the second step, the first author examined the article analysis again to determine the article’s precise contribution to the identified themes; in the last step, the synthesis findings were discussed with the second author in order to obtain an agreement.

Results

Characteristics of the Reviewed Studies

In terms of the regions where studies were conducted, it was found that TPACK studies were carried out in Asia (n = 3), North America (n = 3), Europe and the Mediterranean (n = 2), and Australia (n = 1). As for the research approach of the examined papers, quantitative and mixed methods were the most frequently adopted methods. When we look at the academic journals in which the studies were published, the highest number of TPACK articles (n = 5) were found in discipline-specific journals, two articles were published in educational technology journals, and 2 articles were published in general education journals. With regard to the sample groups analyzed, educators have been addressed in the largest number of articles (n = 5) followed by students and clinical professionals with two articles for each category. Among the five papers that have focused on educator samples, two articles investigated a sample of medical educators. Health professions educators in general, nursing educators, and athletic therapy educators were addressed in one article for each category. Concerning investigated student samples, one article was about nursing students and another was about pharmacy students. As for clinical professionals, registered nurses were addressed in one article and medical clinical professionals were investigated in another paper.

Results of Synthesis

Data synthesis resulted in the elaboration of four main themes: (a) measurement of educators’ TPACK; (b) relationship between TPACK and other variables; (c) application of TPACK, and (d) professional development.

1. Measurement of educators’ TPACK

   Four (4) studies of the examined papers were classified in this theme [41-44]. Three studies measured medical educators’ TPACK [43, 44], one study addressed athletic therapy educators [42], and one study addressed health professions educators [41]. We found that all studies identified participants’ TPACK via the self-reported method, especially the TPACK-based scales (Table 3). The scales used ask educators to reflect on their own knowledge and skills in technology, pedagogy, and content, and how well they are able to integrate these dimensions in their teaching. These scales consist of various items that are categorized into different TPACK domains, including TK, PK, CK, TPC, TCK, PCK, and TPACK. The scale assigns a score to each area, including the overall TPACK. For example, to measure educators’ Pedagogical Knowledge(PK), The scores are based on how much educators agree with statements such as “I feel confident in my ability to assess student performance in the classroom” or “I feel confident in my ability to adapt my teaching to different learning styles.” [42]. An example of Technological Knowledge (TK) items is “I know how to solve my own technical problems” or “I have the technical skills I need to use technology” [30]. For measuring Technological Pedagogical Knowledge (TPK), educators express their agreement with statements like “I can adapt the use of the technologies that I am learning about to different teaching activities” or “I can choose technologies that enhance students’ learning for a lesson” [30]. When it comes to TPACK, items like “I can teach lessons that appropriately combine basic science content, technologies, and teaching approaches [42] are used to measure educators knowledge.” TPACK assessment can serve as a catalyst for professional development opportunities for educators. The assessment can identify areas where educators may benefit from further training or support, allowing for targeted professional development activities that can improve teaching and learning outcomes in health profession education.

   Based on the Technological Pedagogical Content Knowledge (TPACK) framework, the results of these studies showed that participants performed better in Content Knowledge (CK) (M = 6.47, SD = 0.53) and Technological Content Knowledge (TCK) (M = 5.86, SD = 0.93) [41] and poorer in Technological Knowledge (TK) (M = 5.00, SD = 1.09) [41, 43] and Technological Pedagogical Content Knowledge (TPACK) (M = 5.07, SD = 1.19) [41]. Even though respondents reported high levels of Content Knowledge (CK) (M = 6.47), they tend to decline when combined with TCK (M = 5.86), PCK (M = 5.40), and TPCK (M = 5.07) [41]. Further, faculty grade themselves lower on any of the TPACK domains involving technology (with an average of 0.66 lower than those domains that did not contain technology component) and higher on any of the domains involving content (with an average of 0.45 higher than those that did not contain content component) [43]. For the athletic therapy context, the framework was used to assess educators’ knowledge and skills about technology integration in teaching, as well as to guide analysis of the interviews. As such, the TPACK framework facilitated the organization of empirical findings into distinct constructs from the conceptual model. For instance, when a participant provided an example of using technology to teach a specific course topic, it was categorized as Technological Content Knowledge (TCK). Based on the participants responses, the majority of them showed a perceived high level of Technological Knowledge (TK) and Pedagogical Knowledge (PK) [42]. Moreover, it was found that educators who had a higher score of both Technological Knowledge (TK) and Pedagogical Knowledge (PK) were more inclined to utilize more advanced technology-based teaching tools as a component of their teaching methods.

   In the Turkish context, using the TPACK practical scale, medical educators were divided into three clusters based on their level of technology integration. First, was the activity-based cluster with thirty-eight percent (38%) of medical educators, with a higher skill for using technology in the teaching process. Second, was the student-based cluster with thirty-two percent (32%) of participants using technology mostly for understanding the learners than for understanding subject content. Third, the topic-based cluster with 29% of participants. When compared to other clusters, the topic-based cluster had a higher mean for using technology in the subject area [44].

2. Relationship between TPACK and other variables

   In some studies, the relation between TPACK scores and other components of technology integration was studied. Aspects of technology integration, such as educators’ views and attitudes towards using digital technologies for teaching, seniority, the teaching department [42, 44], and educators’ teaching methods [42], have been found to be associated with TPACK of teachers. The levels of Technological Knowledge (TK) and Pedagogical Knowledge (PK) in the sample of athletic therapy educators appeared to be associated with the perceived value of technology integration. Educators with a high level of Pedagogical Knowledge (PK) and Technological Knowledge (TK) valued the role of digital technologies in enhancing learning. They used technology more deeply than those with low levels of Pedagogical Knowledge (PK) and Technological Knowledge (TK), who did not perceive technology to be as useful, and focused on using it as a mere tool to deliver course content to students [42]. Further, of all studied factors (TPACK scores, gender, academic degrees, learned technology in teaching, teaching experience, and school policy), TPACK and school policy were the strongest factors affecting educators’ technology integration in their curriculum [41].

3. Application of TPACK

   Another type of TPACK research theme in health professions education is the use of the framework to build courses and programs. Based on the TPACK framework, Tai and colleagues [26] developed an online English writing course for nursing students. The TPACK framework was used to design a course that integrated content knowledge, pedagogical knowledge, and technology into a whole solution to help learners become familiar with the genres and grammatical features of the General English Proficiency Test. The content was EFL writing skills, and the Internet and Web 2.0 are techniques used for interactive teaching and learning activities. Online writing is an example of Technological Content Knowledge (TCK), and online collaborative learning is an example of Technological Pedagogical Knowledge (TPK). The results revealed significant improvements in students’ writing skills. Regarding learners’ perceptions of this TPACK-based writing course, the qualitative data revealed three issues: the learners were favorable about the design of the online writing technology; they preferred the teacher’s response to that of their peers; and they disliked the practice required by indirect feedback. For the teachers, the course was perceived as being significant, but it was rigorous on both the learning and teaching sides [26].

   Chee and his co-workers [45] presented in their study the creation and assessment of a nurse-patient interactive serious game aimed at increasing nurses’ self-efficacy and performance in teaching proper inhaler technique. The TPACK framework is used as the guideline of the game creation. In this study, three major bodies of knowledge—3DHive (Technological Knowledge), instructional design (Pedagogical Knowledge), and Content Knowledge on proper inhaling technique—were synthesized and applied within the nurse-patient interactive game.

   Participants are evaluated in terms of performance, identifying and correcting the standardized patient’s inhaler technique errors, self-efficacy in performing inhaler technique teaching, and the participants’ perceptions of the serious game. The experimental group had a considerably greater percentage of individuals with perfect performance scores than the control group (65.21% vs. 21.74%, P < 0.01). The experimental group’s post-test self-efficacy means scores increased considerably (P < 0.001) after the intervention, and were significantly higher (P < 0.05) than the control group’s post-test means scores. The 7-point Likert scale assessment revealed that the participants felt very positively about the serious game, with an overall perception mean score of 6.05 (SD = 0.19) [45].

   Over a 3-year period, Bartlett and his colleagues [46] applied the TPACK framework to create a technological tool, the University of Sydney Pharmacy Dashboard, which was iteratively developed. Based on the TPACK model, the focus of this work is on technological and pedagogical knowledge, which will be integrated with tutors’ content knowledge derived from practice experience, as well as a tutor handbook to improve teaching consistency. Over time, student performance and satisfaction have been shown to improve. Overall, from the initial year of implementation, 2018 (M = 4.05, SD = 0.78); to the second year, 2019 (M = 4.12, SD = 0.61); and most recently, 2020 (M = 4.38, SD = 0.62), the student satisfaction average has demonstrated consistent progress. Student satisfaction mean was statistically significant when compared to 2018 and 2019 (X² = 16.15, P < 0.0001) [46].

4. TPACK in professional development

   In order to provide insight into how to increase community of inquiry (CoI) implementation in medical courses, Nave and colleagues [47] extended the Technological Pedagogical Content Knowledge (TPACK) model to include assessment knowledge as another key component of adopting CoI, which focuses on instructors’ knowledge and comprehension of assessment. In addition, an in-depth analysis of forum usage was introduced to offer a novel tool, the Diagnostic Tool for Learning, Assessment, and Research (DTLAR). DTLAR’s core is an in-depth analysis of discourse content and participants’ reflections on their experience within a CoI. TPACK principles guided the selection of CoI subjects. CoI interactions took place between the face-to-face meetings and focused on TPACK-related topics. At the end of the program, 72% of participants valued the contribution of CoI to learning, and 78% felt confident enough to use CoI in their instruction. In comparison to CoI focusing on Pedagogical Content Knowledge(PCK), the two technological CoI (focusing on TCK and TPK) contained more positive statements (P < 0.05) [47]. The tool was created to help learners monitor their own progress, instructors to evaluate the progress of their students, and researchers to assess and compare the learning outcomes of various student groups and programs.

   A course designed for nurse educators to teach online was another professional development experience. Kraglund-Gauthier et al. [48] conducted a participatory action research study with 15 nurse educators who teach online courses, with the goal of “building capacity in pedagogy and the teaching–learning process in online courses.” They offered a TPACK-based professional development course with three phases: planning, action, and reflection. In this study, the three elements of Koehler and Mishra’s [15] TPACK framework were used to guide discussion and explain participants’ ideas during the action research evaluation phase. The purpose of the TPACK is to highlight educators’ understanding of the three components as not being only distinct, but rather combining to form TPACK.

   Community, instructors, classrooms, interpersonal relationships, and supports emerged as five themes for teaching online with technology. They stressed the importance of creating a community of learners and practicing, while the teacher’s theme focused on their requirements and abilities to teach online. They concluded that the ideal class size was 20–30 students and that they must be active and engaged, as well as building their knowledge through scaffolding activities such as discussion. Respect between students and instructors, as well as the concept of cooperation, was part of the interpersonal relationships theme. The final theme, “supports,” emphasized the need for a technology and pedagogy coach to provide high-quality courses and instruction [49]. The TPACK framework highlights the challenges that arise when incorporating technology into teaching and stresses the significance of having adaptable knowledge in order to effectively use technology in the classroom.

Table 3.

Overview of TPACK measurement tools

Authors	What is measured?	Scales	Reliability and validity
[44]	Medical educators TPACK	TPACK-Practical Scale (Yeh, Hsu, Wu, Hwang and Lin, 2013)	-Cronbach’s alpha reliability coefficient was 0.89
[42]	Athletic therapy educators TPACK	Adapted scale from existing TPACK questionnaires and suitably modified (Archambault & Barnetta, 2012; Schmidt et al., 2009)	-Expert validation appraisal
[43]	Medical educators TPACK	Modified version of [30] TPACK survey	-Cronbach alpha from 0.78 to 0.93 for the subscales of the 7 TPACK domains
[41]	Medical educators TPACK	Modified version based on the work of Chai, Ng, Li, Hong, and Koh (2013)	-Cronbach’s coe ficients ranged from 0.70 to 0.85 for subscales and total items -The content validity index (CVI) was 0.85

Discussion

The purpose of this article is to dress a detailed picture of TPACK research in the field of health professions education. Analysis of the articles revealed that they have made considerable contributions to the implementation of the TPACK framework in health professions education context. The nine papers fall into four theme categories: TPACK measurement, relation between TPACK and other variables, TPACK application, and professional development. Studies predominantly reported positive results.

As for assessing TPACK, the scales used to assess teachers’ TPACK in this review are based on the teachers’ self-assessment. Educators are asked to reflect upon their knowledge of the following TPACK domains: TK, PK, CK, TPC, TCK, PCK, and TPACK. The use of the TPACK framework provides two insights: The first is that it allows for the detection of gaps in teacher knowledge areas based on self-assessment using TPACK scales. The second is that the issues identified reflect teachers’ understanding and should be addressed in responsive training programs for both in-service and preservice teachers.

Results show differences in terms of the highest and lowest scores of the TPACK domains. These variations echoed the challenges educators face in understanding the dynamic equilibrium that should exist among technology, pedagogy, and content when integrating the different components of TPACK into their teaching practices. Participants may be highly scored in Technological Knowledge but when asked to assess their knowledge and skill in using technology to teach specific content (TCK), or to choose suitable learning activities that align with the specific learning goals of a subject area, they may grade themselves lower [41, 50]. These results indicate that educators possess sufficient subject matter expertise, but require more training in incorporating technology into the educational process. Although this review was specific to health profession education, similar findings have been found in other disciplines’ educational contexts [50-52]. Specifically, Koehler and Mishra [14] have taken care to stress that, for meaningful technology integration, Technological Knowledge (TK) must be integrated into the other two types of knowledge rather than merely being placed as an overlay to them.

The four articles classified in this theme used the self-reported method. It is not surprising, given that the self-reported method is one of the most commonly used approaches in the literature [23, 38, 39]. Although self-reports can be used to quickly collect data from large samples of people, they do not reflect real-world classroom performance. It also depends on the honesty of the survey respondents; as such, they may reflect the disparity between what educators do and what they say about what they do; that is between perceived and real TPACK enactment [38]. Accordingly, less is known about how teachers use their TPACK in their real classroom activities [17]. In this respect, assessing the practical and real competence of health professions teachers in classrooms is highly recommended.

TPACK assessment helps educators to identify their strengths and weaknesses in integrating technology into their teaching practices. Assessing educators’ TPACK is essential for improving the quality of healthcare education and ensuring that educators are equipped with the knowledge and skills necessary to effectively integrate technology into their teaching practices.

Regarding the relationship between TPACK and other variables, TPACK is linked to other components of technology integration, such as educators’ views and attitudes towards using digital technologies for teaching [42, 44] and educators’ teaching methods [42]. This is in accordance with Niess [53], who underlined that TPACK development implies attitudinal change, technological skill acquisition, and the creation of pedagogical ideas for technology integration. Educators’ TPACK and school policy are found to be the strongest factors affecting educators’ technology integration in their curriculum. In this light, educators’ attitudes regarding the pedagogical use of Information and Communication Technologies (ICT) in the classroom can predict their TPACK, and their TPACK level can predict their teaching method when it is in an ICT-based activity context [54]. In order to fill the gap in the research, additional studies focusing on variables other than gender, department, seniority, and attitude towards technology in the context of health professions education should be conducted.

The TPACK framework was adopted to design a technology-based course for nursing students to develop their English writing skills. According to the findings of the paper, the TPACK model proposes an effective teaching strategy for significantly improving nursing students’ writing performance in all areas [26]. Similar research in business education revealed further benefits of using TPACK in course design [55]. Based on the success of this TPACK framework application in course design, other research in health profession education may be undertaken. Instructors can use TPACK to improve current courses and create new ones using other academic subjects, educational approaches, and technologies.

As suggested by the authors, the TPACK model has the potential to benefit healthcare programs in other institutions beyond this one. The model’s Technological Knowledge could be applied to other types of technology, such as Interactive White Boards. Similarly, the Pedagogical Knowledge could be adapted to different approaches, such as Problem Based Learning. As for Content Knowledge, writing tasks could be designed around clinical topics, enabling nursing students to become more familiar with medical terminology and writing conventions.

The TPACK framework, as it has been reported in this review, also has the potential to be an advantageous tool for educational software design and development in the health professions domain [45, 46]. The framework provided a method for the team to incorporate technology into teaching the inhaler technique, and the results were positive. If technology is to contribute more to education, designing, developing, and evaluating learning environments are critical, and the TPACK framework should be used more extensively in this field [23]. As technology advances, greater amounts of data can be tracked, resulting in pedagogical interventions by teachers. The use of dashboards for effective feedback to aid students’ self-regulated learning is one such intervention [46]. Dashboards in education are one example of how learning analytics can be applied in practice. The goal of learning analytics is to gain insight into how learning occurs and how it can be improved through the use of data. This includes measuring, collecting, and analyzing data for the purposes of understanding and optimizing learning and the environments in which it occurs.

In fact, a technology-based environment with a strong theoretical foundation is required to provide high-quality training, especially in health professions education, where the use of technology is gathering pace both within and outside of the classroom.

There is a need for faculty development in technology and pedagogy to help educators teach more effectively in the digital era. As such, using TPACK based on its strengths to conceptualize teaching with technology would be beneficial. Our findings indicated that a TPACK-based, well-planned professional development program can change participants’ willingness to incorporate technology in their teaching [38]. It is widely acknowledged that technical proficiency alone does not guarantee the development of teaching competence in using technology. As a result, the emphasis should instead be on developing knowledge that takes into account other components such as pedagogy and content, as well as their interaction.

The purpose of the TPACK framework is to make educators aware of the three components as not being only distinct, but also combining to form TPACK. Instead of teaching teachers how to use a technological tool outside of the classroom, teachers should be taught how to use it in a content-specific context with appropriate pedagogical strategies. Content-centered approaches prioritize the creation of links that connect technology, subject matter or content, and teaching methods or pedagogy. The results of this review support this approach to training based on the TPACK model; therefore, the development of teachers’ knowledge of how to teach with technology needs to be developed in the context of the teachers’ act of teaching a specific content.

Although different strategies for developing this type of teacher knowledge have been reported in the literature, design processes, or learning by design, can be considered the first strategic line for developing TPACK among educators [21, 38, 56]. Nonetheless, according to a study conducted in the USA, 283 (30%) of teacher educators had not adopted TPACK, and 242 (32%) reported not knowing about TPACK [57]. Due to the positive outcomes of this framework’s application, its use to improve health professions educators’ skills should be encouraged, and future research on the factors that influence its application could be of great interest.

In health profession education, TPACK can be used to ensure that educators have the necessary knowledge and skills to integrate technology in a way that supports the development of students’ learnings like clinical reasoning, decision-making, and patient care skills. For example, the TPACK framework can guide educators in selecting appropriate learning activities based on the content learning objectives (Pedagogical Content Knowledge or PCK), and selecting and using appropriate technologies to support the teaching of this specific content, such as simulation or virtual patient cases (Technological Content Knowledge or TCK).

According to the results of this review, all studies fall into the measurement, development, and application of TPACK categories. With the exception of the study presenting the DTLAR, all studies repeat the descriptions of structures that have been previously described by prior studies. Furthermore, no studies have been conducted to develop and validate a new TPACK assessment instrument in the context of health professions education. When it comes to TPACK research population samples, most studies focus on students, educators, and professionals, but no paper has focused on prospective educators in health professions education, a crucial category that provides insight into the future of health profession education. Due to the limited research in the health domain context, and in order to fill this literature gap, further TPACK-based research needs to be conducted. Future research can explore the relationship between TPACK and other aspects that have not yet been investigated in health professions education, such as pedagogical beliefs, expectations, context, social media use, and more.

As a limitation of the present study, we only looked at journal articles indexed by the four databases, with limited keywords; as a result of these restrictions, there might be other published studies on TPACK that were not included in this review.

Overall, these findings could point researchers and practitioners on the right path for future TPACK research in health professions education. They can be as well beneficial in creating and planning TPACK professional development programs.

Conclusion

The review’s findings highlight TPACK’s potential to have a positive impact on health profession education and how it can be useful to assess educators’ level of pedagogical, technological, and content knowledge. TPACK can assist educators in designing technology, pedagogy, and content knowledge into courses, and developing educational software. The framework is also beneficial for faculty development in technology and pedagogy, which is required to allow health professions educators to teach more successfully in the digital era.

The TPACK model is maintained by the empirical studies analyzed in this review as an effective and reliable framework to direct the research on the integration of technology in the classroom. Although earlier educational technology review studies have identified research challenges and trends in TPACK research, this study adds to the body of knowledge by providing a comprehensive picture of TPACK studies in the area of health professions education. However, the low number of included studies in this review suggests that there is still a need for more research on TPACK in health education in order to fill this knowledge gap and produce more beneficial findings.

Author Contribution

D.A conceived the idea of the article and wrote the manuscript; data research and articles screening were carried out by A.E, S.E, and O.M. F.S and HK provided the critical feedback of the work.

Availability of Data and Material

A descriptive table of the selected articles’ characteristics was included in the article.

Declarations

Ethics Approval and Consent to Participate and for Publication

Not applicable.

Conflict of Interest

The authors declare no competing interests.