Quick response-code linked video-based objective structured practical examination: Bridging gaps in pharmacology education

Abstract

INTRODUCTION:

Traditional live demonstrations were found to be insufficient in supporting the long-term retention and reproducibility of practical skills among medical students. Thus, we adopted a blended learning approach that included self-created demonstration videos.

STUDY OBJECTIVES:

To determine the effectiveness of using a quick response (QR) code linked to prerecorded demonstration videos for various objective structured practical examination (OSPE) stations by baseline and post innovation test scores and to obtain students’ feedback on this innovative teaching approach.

MATERIALS AND METHODS:

Following IRB approval and informed consent, the students were trained in small-group live demonstrations of OSPE stations. Then, a baseline OSPE assessment (pretest) was done. Instructional demonstration videos on different routes of drug administration were created following a structured checklist. This was linked to a QR code. After 2 months, these videos were uploaded to Google Drive for student access. This was followed by a posttest and students’ feedback. Statistical analysis was done using a paired t-test, and a P < 0.05 was considered significant.

RESULTS:

The posttest scores of 17.54 ± 2.18 (mean ± standard deviation [SD]) demonstrated a significant improvement in student performance compared to the pretest scores of 11.95 ± 6.69 (mean ± SD), with a P < 0.001. In the feedback, a majority (>95%) of students reported that the QR code-linked demonstration videos improved their comprehension of OSPE techniques, agreed that blended learning improved their understanding, and recommended these videos for subsequent batches.

CONCLUSION:

This integrated video-assisted model holds promise for broader application across medical curricula, aiming to enhance skill retention and learner autonomy.

Introduction

In the last few years, after the introduction of the competency-based medical education (CBME) curriculum in 2019–2020 by the national medical commission, medical undergraduate teaching in pharmacology has had to adapt considerably.[1] Although didactic lectures remain the primary mode of teaching, there is an increased emphasis on acquiring practical and communication skills. The routine practical classes, such as those on prescription writing, audit, and dose calculation, focus solely on amassing knowledge and improving critical thinking, thus enhancing the cognitive domain. However, they do not lead to the development of practical or communication skills.[2]

Learning practical skills is an important aspect of medical students’ training that requires effective teaching, learning, and evaluation methods.[3] Relevant practical examination methods are a core component of this evaluation process. One such method is the objective structured practical examination (OSPE). The OSPE is a globally implemented and effective system that assesses competency based on objective testing through direct observation.[4] The term OSPE was formulated from the objective structured clinical examination (OSCE), which was started in 1975 and later modified by Harden and Gleeson in 1979.[5] OSPE comprises several “stations,” in which examinees are expected to perform practical tasks within a specified time frame against criteria/checklist formulated for that particular practical skill, thus demonstrating competency in skills.[6] Several studies have demonstrated that OSPE is a practical, valid, and reliable tool for assessing practical skills across specialities.[6,7]

CBME has been defined as “an outcome-based approach to the design, implementation, assessment and evaluation of an education program using an organising framework of competencies.”[8] It is based on the “Miller’s pyramid” that attempts to move away from the traditional Flexnerian medical education model that was heavily dependent on theoretical knowledge-based assessments, toward examinations that focus more on clinical performance. The Miller’s pyramid model divides the development of clinical competence into four hierarchical processes. The base of the pyramid depicts the “know,” or the knowledge tested by fact recall through routine written tests and traditional multiple-choice questions. The next level represents “knows how” or the interpretation and application of knowledge, assessed by essays, clinical problem-solving exercises, and case discussions. The third tier of the pyramid represents “shows,” or demonstrations of clinical skills, with competency assessed through standardized patient exercises, simulations, and OSPE/OSCEs. Finally, at the top of the pyramid is “does,” or performance assessed by direct observation in the real clinical settings.[9] Thus, medical students attending pharmacology must be competent in skills such as the correct technique for administering injections through the various routes of administration, including the intravenous (IV), intramuscular (IM), and subcutaneous (SC) routes, as well as using an inhaler with or without a spacer.[10]

In this regard, OSPE stations for the above competencies have been developed within the department, along with structured checklists for scoring. Traditional live demonstrations, using small groups, were observed to not fully support the long-term retention and reproducibility of practical skills among medical students, especially when faced with the stress of an exam. Furthermore, due to time constraints and limited teaching faculty, it is impossible to repeatedly revise the entire process at various points in time. To address this issue, we decided to create our own demonstration videos that show the different routes of drug administration, following a preformulated, internally validated structured checklist for each certifiable OSPE station. As videos help grab students’ attention, motivate them to learn, and reinforce their knowledge, this blended learning approach was chosen.

In the ever-evolving field of medical education, the incorporation of technology has become essential for engaging and empowering students in their learning journey. The use of quick response (QR) codes in teaching OSPE stations for pharmacology can revolutionze the way medical students acquire knowledge, thereby improving their performance and understanding of various concepts.[11] QR codes have gained popularity due to their practicality and usefulness. The speed, readability, and enormous storage capacity of text, images, and URLs are the primary benefits of QR codes.[12] That is why these videos were linked to a QR code that was freely accessible to students at a later time. We also developed a feedback form to assess the perceptions of medical students regarding this blended learning approach and the demonstration videos.

We believed that this method of learning would help students revise the techniques as needed, favouring a student-centred approach whilst improving their recall, skill, and overall performance. With the following in mind, our study objectives were to determine the effectiveness of using a QR code linked to prerecorded demonstration videos for various OSPE stations, as measured by pre and posttest scores, and to gather students’ perceptions of this innovative learning method using a Likert scale feedback form.

Materials and Methods

This prospective study was conducted among the entire batch of 2^nd-year MBBS students (Batch of 2023) in pharmacology, following approval from the Institutional Review Board and obtaining written informed consent from each student. The students who were absent on the day of the tests and those who did not give informed consent were excluded from the study.

The students were first exposed to the traditional teaching method for OSPE stations. This method involved teaching different OSPE techniques to students through routine, conventional live demonstrations, following structured checklists. These demonstrations were conducted in small groups under the supervision of faculty. One week later, an OSPE exam was conducted for the students. Here, each student was randomly assigned to one of five OSPE stations (i.e., IV, IM, SC, metered dose inhaler (MDI), and MDI with spacer. Each student was given 5 min to demonstrate the technique. Assessment was done using prevalidated, internally validated structured checklists for each OSPE station by the faculty of the department. This was considered the pretest score.

Preparation of the objective structured practical examination videos

Five certifiable skills required for medical students were demonstrated, including IV, IM, SC, and MDI with and without a spacer. First, the script for the videos was created. The videos were recorded in the department facility using a high-end camera phone by a faculty member. For each skill, the video had two parts – the first elaborated on the parts of the equipment used, along with its advantages. The next part was a step-by-step demonstration of the skill following a prevalidated structured checklist. The checklist used for preparing the videos was developed by the department’s faculty and validated through peer review and expert opinion, incorporating input from senior nursing faculty and respiratory therapists. The demonstration was conducted by a postgraduate student from the department, while a faculty member provided instructions via a voice-over. Each video was 6–7 min in duration. Once the videos were created, they were peer-validated and then linked to a QR code. Instructional sheets and checklists used were also linked to the same QR code.

Two months later, all students received access to the QR code, which was uploaded to Google Drive. A repeat exam, similar to the pretest, was conducted 1 week after the videos were released. This was considered the posttest scores. At the end of the posttest, feedback from students was collected using a 3-point Likert scale (agree, neutral, disagree). This was done to gauge their perceptions and get their opinion on this intervention method. An open-ended question was also included in the feedback form for any additional comments. Statistical analysis was done to compare the pre- and posttest scores using a paired t-test. P < 0.5 was considered statistically significant.

Results

The posttest scores of 17.54 ± 2.18 (mean ± standard deviation [SD]) demonstrated a significant improvement in student performance compared to the pretest scores of 11.95 ± 6.69 (mean ± SD), with a P < 0.001 [Figure 1]. In the feedback provided, a majority (96.6%) of students reported that the QR code-linked demonstration videos improved their comprehension of and confidence in OSPE techniques compared to conventional teaching methods. Moreover, 97.7% of students indicated that the blended learning approach provided a deeper understanding of the subject matter. 96.6% of students felt the quality of the videos was good, and they were easily accessible. 98.9% of students found the video content to be clear and concise. 97.7% of the students agreed that they preferred learning via demonstration videos and would recommend it for future batches. Some of the open-ended feedback remarks were as follows:

Figure 1.

Mean objective structured practical examination scores in pre and posttest

“A very good initiative which can be taken forward for the next batches.”

“Helped in better understanding and cleared doubts about OSPE techniques.”

“The video demonstrated the methods step by step, which was very helpful.”

“The quality of the videos was good, and a clear demonstration of each technique was provided.”

“This is good for OSPE preparation.”

Discussion

Blended learning is a hybrid educational model that combines traditional in-person classroom instruction with online digital learning, integrating the best of both methods for a flexible and effective learning experience.[13] Although the concept of blended learning probably began in the early 2000s, its impact and significance grew significantly during the COVID-19 pandemic. This pandemic affected the normal functioning of virtually all academic institutions globally, as educators struggled to continue medical education and training beyond the confines of a classroom and without the traditional face-to-face teaching experience.[14] Lockdown measures implemented in our country compelled educational institutions to seek alternatives to continue their educational programs without compromising the safety of their students and teachers. That is when it became apparent that the judicious use of technology could solve many of these issues, and this initiated a paradigm shift in the policies of most educational institutions, leading to the rapid introduction of online methods for teaching and assessment.[15,16] Since then, blended learning has been shown to enhance student engagement, knowledge retention, and academic performance across various specialties.[17]

The inclusion of digital technology in medical education appears to be an attractive complement to traditional, lecture-based teaching. This is specifically true for video-based learning, which allows students to learn independently, transforming practical class time into a more student-centred activity.[18] Video-based learning can be categorized in various ways, such as using video lectures with relevant clips from a medical TV series or a movie, or incorporating 360° video simulations. These have been shown to improve confidence and preparedness while reducing anxiety.[19,20] Video-based learning may also take the form of self-created videos directed towards enhancing cognitive, psychomotor and/or affective domains of learning. A study from China utilised student-created videos to enhance competencies in applying communication skills during the care process and found that a blended learning approach, integrating face-to-face learning with recorded videos of communication skills, is feasible and acceptable in social work and healthcare education.[21]

Although several online public videos that teach various drug administration techniques may be available, these may not be tailored to the student’s needs or validated for their content.[22] In contrast, self-created videos enable educators to tailor content precisely, ensure accuracy (addressing safety gaps in public videos), and enhance conceptual relevance and content validity, thereby fostering deeper engagement and targeted learning.[23] Although more time, skill, and resources are required to create high-quality, reliable video content, once it is prepared, these videos can be used for subsequent batches as well to facilitate blended learning. Keeping the above in mind, we planned a study to create our own OSPE demonstration videos that supplement our traditional teaching methodology, to enhance students’ skills and retention of these crucial, certifiable skills. The results of our study demonstrate a statistically significant improvement in test scores following the intervention. This result was similar to that of a study by Hansen et al.,[24] which also used online videos as an intervention to improve skills, retention, and confidence in urinary catheterisation among medical interns.[24] Another recent study among nursing students demonstrated that video-assisted education proved to be an effective and accessible strategy for developing fundamental psychomotor skills in nursing education. It not only enhanced specific procedural competence but also fostered self-efficacy and independent learning.[25]

A QR code is a matrix barcode that stores data – most commonly URLs, text, or photos that can be quickly accessed by QR readers. When a user aims their smartphone camera at the QR code, they are directly connected to the stored data or URL embedded within the code. Although the first QR code was invented in 1994, it has not been used routinely in medical teaching and assessment.[26] A study by Brodie et al.[27] showed that QR codes are reliable tools for increasing accessibility to online resources, including videos, graphics, and immediate feedback, in presentations, posters, and publications. Moreover, they may transform information sharing and promote interactivity in discussions, workshops, and simulations in teacher-less, flipped, or blended classrooms. The speed, readability, and enormous storage capacity of text, images, and URLs are the primary benefits of QR codes.[11,12] That is why we decided to link our videos and supplementary materials to a QR code, which was freely accessible to students.

No educational intervention can be considered complete without obtaining proper feedback. Effective feedback is crucial for fostering continuous learning and improvement, helping learners identify their strengths and weaknesses, and ultimately developing into competent and skilled healthcare professionals.[28,29,30] Thus, to obtain the students’ perceptions on this innovative method of learning, we developed a feedback form using a 3-point Likert scale. The feedback provided by our students was overwhelmingly positive. This finding aligns with the feedback from a study conducted by Jalgaonkar et al.[31] in which a majority (>90%) of the students reported that video-based teaching improved their understanding and retention of procedural steps, prepared them for practical examinations, and increased their confidence in performing OSPE tasks.

Conclusion

Students participating in this study were able to explore the usefulness of our tailored demonstration videos, linked to a QR code, blended with the traditional method of learning, to enhance their confidence, retention, and performance in understanding and demonstrating the steps of certifiable OSPE skills. Thus, the integration of video-assisted learning with traditional pharmacology OSPE training offers a scalable, student-centred approach to reinforce practical competencies. This model holds promise for broader application across medical curricula, aiming to enhance skill retention and learner autonomy.

Challenges

Creating OSPE videos requires a significant amount of time, effort, and preparation. It includes the availability of adequate space, equipment, and repeated practice to create a clear and concise instructional demonstration video. In addition, the content must be reviewed and validated by experts in the field before it can be made accessible to the community.

Statement of submission of similar work

This paper contains original research and has not been published earlier in any journal and is not currently being considered for publication elsewhere.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was funded by the Christian Medical College Fluid Research Fund.