This research aimed to assess the impact of three teaching approaches on practical skill acquisition, namely, if face-to-face, blended or online teaching were equally effective for building student competency and confidence in practical skills requiring auditory training and haptic awareness. Participant satisfaction with each teaching method was also evaluated. Determining whether there is a difference between teaching methods for practical skill acquisition could inform the future of digital health education moving forwards.

Students in the face-to-face and blended learning groups reported greater satisfaction with their assigned learning group, demonstrating greater confidence in their skill knowledge and performance compared to the online learning groups. Previous literature exploring digital and online resource use in medical education have concluded that blended learning is appropriate for theoretical learning; our study further advances knowledge on digitally enhanced practical teaching as it supports blended teaching for the acquisition of skills requiring auditory and tactile training. Our results also indicate that fully online learning is not as effective for the acquisition of such skills. These results were consistent across both gross and sub-competency skill acquisition, indicating that the overall teaching method is a major variable and is likely to be independent of the teaching material.

When sub-competencies were examined across both skills, the online learning group performed poorly on aspects of the taught skill which required haptic awareness (e.g. cuff placement), as well as on technical aspects of the skill that did not require sensory feedback (e.g. site rotation). For example, the online learning group performed poorly at cuff placement during demonstration of BPM, which is a sub-competency requiring visual and palpation skills, the latter of which would not be easily acquired in a fully online format without practice. Additionally, the online learning group performed poorly on technical sub-competencies of SKM, such as knowing that measurement sites need to be rotated and that a minimum of two measurements are required per site. Importantly, these sub-competencies are knowledge based and do not require sensory training. These results lead us to believe that rather than considering what skills are best suited to a given teaching method, the more pertinent point may be to consider the quantity of time spent learning online or the proportion of online learning within a blended format. Although skills requiring certain senses may appear better suited to a given teaching method, the acquisition of both knowledge and skill can suffer if teaching is fully online, which may be attributed to a lack of motivation, poor engagement and reduced feedback [27]. The educational setting itself could also explain some of the between-group differences reported, with a clinical setting leading to productive levels of stress which may benefit learning experience [28].

These considerations could be important in informing the design and development of blended learning materials. Our work could help to inform decisions on pedagogical pathways and educational strategies, as health science education continues to adapt to changing times with pressure on resources such as space and faculty time [29, 30]. Our work has shown that students appear to have the greatest success in all components of a skill (i.e. knowledge as well as competencies) when a blended or fully face-to-face learning approach is offered; however, the overall preference from students is for a blended approach to practical skill teaching, which is similar to previous literature in the area [3, 6, 9, 11,12,13]. This work has already informed a medical school online education strategy and an open educational resource which is available at https://hub.teachingandlearning.ie/resource/depth-digitally-enhanced-practical-teaching-in-the-health-sciences/ and https://tcdmedonline.ie/DEPTH/story.html. Further studies might benefit from deciphering how best to deliver blended learning, for example, giving students the opportunity to choose whether to engage with a proportion of their teaching material online or in person, thereby increasing student control over their studies while maintaining some in-person classes.

The literature on blended learning highlights the benefits of having access to learning materials prior to in-person skill sessions [5]. Receiving expert feedback during in-person practice then helps to consolidate theoretical learning and support students in acquiring the technical skills necessary to perform a skill successfully [5, 9]. In the current study, students allocated to the online learning group choosing not to interact with the online discussion forum raises concerns around the efficacy of online forums in building skill knowledge and highlights the need for real-time feedback when practicing clinical skills. While these findings contrast with those of a meta-analysis which concluded that online learning was as effective as traditional in-person teaching methods [31], there appears to be mounting evidence in the area of practical skill acquisition that a blended approach is preferable and effective. Studies included in the aforementioned meta-analysis [31] reported primarily on knowledge acquisition rather than skill acquisition and teaching methods were assessed mostly through multiple choice questions or tests rather than an examination of a practical competency.

While survey results indicated that those in the fully online group had a more negative learning experience than those in the other two groups, it is worth noting that their experience was not entirely negative, and results may seem less favourable towards a fully online teaching method due to the almost exclusively positive feedback from those in the face-to-face and blended learning groups. For example, no participant in the face-to-face or blended groups disagreed with the statement that the learning method was enjoyable or disagreed with the statement that the learning method helped them to understand the material. This is in comparison to 19% (who disagreed with the statement that the learning material was enjoyable) and 27% (who disagreed with the statement that the learning method helped them to understand the material) in the online group which, although considerably higher than 0% is still a minority of that group (Fig. 5). The results of this work show a divide in the student community, with a tendency for slightly more than half of the participants in the online group to respond positively to statements about the teaching method and the remainder responding either neutrally or negatively. This divide in opinion was not evident in the other two learning groups. Further studies may investigate the reason for the differences in opinions seen in the online groups and critically, whether those who enjoy online learning are more effective online learners.

A strength of this study is its design which ensured that where possible learning materials were appropriate for the teaching method but the same between groups (e.g. a video demonstrating a skill was provided for online learners and the same person demonstrated the skill in the same way in person for those in the face to face group). This design was used to try to ensure that the main variable between groups was the teaching method and not the quality of the teaching material provided. Although there are many other factors that can affect skill acquisition such as learning style and personality [32, 33], the random allocation used in this study would help ensure confounding factors did not affect results. We can have confidence in the results seen since they are consistent between skills examined (BPM and SKM) and between objective and subjective measures (competence and survey results). Another strength is that one competency assessor was blinded to participant group allocation, which helped ensure objectivity in scoring competencies. Finally, our competency results were complemented by participant self-reported survey results, which gives our data an additional dimension, ensuring student perspectives are included.

There are some limitations to our work as well. The fact that teaching in this study was conducted outside of participant course requirements and was therefore not for credit may have negatively affected participants’ motivation to learn. However, as participation was voluntary, it is reasonable to assume a certain level of motivation. We did not measure whether students assigned to the blended or online learning groups engaged with their online learning materials, and the impact of adherence on outcomes. A lack of student engagement with online learning materials has been identified as a major barrier to practical skill teaching and can be explained by low motivation, reduced attention and poor time management (7). We did not measure whether certain components of the blended teaching material led to greater levels of competence than others. It could be argued that it was mainly the face-to-face aspects of the blended learning experience which resulted in higher competence; however, we were not in a position to determine this since each teaching method was developed as a whole and individual components were not designed to be isolated.

Another limitation is the possibility of cross-contamination. Students were encouraged to practice the skills prior to their in-person demonstrations. Although students were randomised into their learning group, they were all recruited from TCD’s School of Medicine and it is therefore possible that friends in different learning groups may have practiced together. Additionally, as all participants were undergraduate students, results are therefore not transferable to a postgraduate cohort.

It is worth noting that for BPM, overall skill competency across all three learning groups was below 50%. Research has shown that the noise of a treadmill or bike, and moving muscles and joints, can interfere with the Korotkoff sounds (the sound listened to during auscultation of the brachial artery when taking blood pressure measurement), making them difficult to distinguish and accurately measure (27, 31). It is therefore possible that each learning group found manually measuring blood pressure during exercise a particularly difficult skill to learn. Providing students with more time to practice the skill and familiarising themselves with the interfering external noise of the exercise bike may have enhanced student success. While students were encouraged to practice the skill at home, they were unlikely to have had a cycle ergometer to hand. Blood pressure measurement during exercise may be a particularly difficult skill to learn and may require additional in-person practice, regardless of teaching approach, to develop the auditory awareness necessary for an accurate measurement.