Abstract
Introduction
Contact lens (CL) practice is an ever-changing field with clinical knowledge, techniques and equipment continuously evolving. These new developments are backed with clinical trials and research to ensure that practitioners feel confident that there is an evidence base to support these advances. Evidence-based practice is now a crucial part of CL practice, and its importance also filters down to CL education. For example, lectures are one of the most popular tools for an educator but, is standing at the front of a lecture theatre full of students a more effective way of teaching than providing the same material for students to read by themselves? What evidence exists specific to CL education?
Method
An expert panel of educators completed a comprehensive literature review of current evidence of teaching methods in CL training, or if not available then what can be learnt from other health care professional training that could be potentially applicable to CL education.
Results
Due to the amount of evidence available in the overall subject area relating to healthcare education, the initial plan of compiling evidence into one narrative review paper was discarded in favour of producing two linked papers. Here, the first paper details definitions of terminology, and also teaching methods. The second paper focuses on assessment and specific clinical training required to attain CL practice competency. In this first paper, no direct evidence of the spreading and benefit of new education strategies evidence such as flipped classrooms, spaced learning, test-enhanced learning, group work, CBL, PBL, TBL, and reflective practice in CL education was found. The only technique that was widely used in the CL field was case reports and the group discussion of them. Nevertheless, the authors found a consensus of opinion from other disciplines that are transferable to CL teaching and could help students meet the intended learning outcomes.
Conclusion
There is a small amount of evidence supporting CL education, but most of this seems to be related to the practical element of the training. However, there is a lot of evidence in the field of healthcare education from related disciplines which provides additional but important learning tools that may be effectively implemented in CL education.
Abbreviations:
BCLA (British Contact Lens Association), CBL (Case-Based Learning), CL (Contact Lens), CPD (Continuing professional development), EBP (Evidence-based practice), EBT (Evidence Based teaching), EMQ (Extended matching question), HE (Higher Education), IACLE (International Association of Contact Lens Educators), MCQ (Multiple choice question), OSCE (Objective structured clinical examination), OSPE (Objectively structured practical examination), PBL (Problem-based learning), TBL (Team-based learning)Keywords
1. Introduction
Contact lens (CL) education involves the delivery of theoretical knowledge and the development of clinical skills, using a mixture of teaching techniques such as lectures, practical classes, and clinics. Educators use a variety of tools, such as videos and images of real and simulated clinical cases. Furthermore, various aspects of CL training use many different assessment techniques. Questions arise as to the evidence supporting the use or introduction of a particular teaching and/or assessment method and how effective that method is to deliver the information to students and to assess their ability to perform the taught task. These questions concern the field of evidence-based education more generally, importantly in the delivery of health care training and can be applied to every aspect of CL education, from the overall design of a teaching module, the use of a technology, the assessment method and confirmation of individual units of clinical competency. There are two levels of focus in this general arena of evidence-based education [
[1]
]. Firstly, to utilise existing evidence from worldwide research and literature on education (directly derived from research in CL education or from other similar fields potentially applicable to CL education). Secondly, to establish sound evidence where existing evidence is lacking or of a questionable, uncertain, or weak nature.The International Association of Contact Lens Educators (IACLE) embarked on a project to conduct a comprehensive review of the peer reviewed literature for evidence to: (1) support the teaching and assessment methods in CL education: (2) bring a consensus to the field; (3) determine whether incumbent teaching methods helped students meet the intended learning outcomes; and (4) whether there was an absence of evidence that required further investigation.
IACLE assembled a panel of recognised contact lens teaching experts who assessed current teaching and assessment practices and evaluated published scientific evidence to determine what contact lens teaching and assessments could be considered as evidence based. The common hierarchical evidence model of scientific research [
[2]
] was used to judge the importance of evidence. The IACLE evidence-based teaching (EBT) consensus was initially planned as one paper but due to the volume of information collated it has been separated into two papers. The first paper provides a definition of EBT and focuses on teaching methods in CL higher education (HE) which promote learning in the area. The second paper details assessment in CL HE and the teaching of clinical skills required for CL practice.- Wolffsohn J.S.
- Dumbleton K.
- Huntjens B.
- Kandel H.
- Koh S.
- Kunnen C.M.E.
- et al.
CLEAR – evidence-based contact lens practice.
Contact Lens Anterior Eye. 2021; 44https://doi.org/10.1016/j.clae.2021.02.008
2. Evidence based teaching definition
The approach to teaching based on the best scientific evidence (empirically validated tools and techniques) is known as evidence-based teaching (EBT) [
[3]
]. Several definitions of EBT have been proposed. For example, ‘the conscientious, explicit, and judicious integration of best available research on teaching technique and expertise within the context of student, teacher, department, college, university, and community characteristics’ [[4]
]. This general definition of EBT has been tailored by the IACLE EBT panel to the specific field of CL as, ‘the conscientious, explicit, and judicious integration of best available research in CL related science on teaching and assessment techniques and expertise within the context of CL education.’ An EBT approach is relevant for the education of health-care related professions, which are particularly challenging since students need to learn broad theoretical knowledge and develop practical clinical skills in simulated and real-world clinical settings. This has a direct and important impact on the health care system efficiency [[5]
], including in the field of eye care [[6]
]. Unfortunately, many changes and developments in educational thinking and practice become fashionable or transient and it is unclear if they offer improved or more efficient alternate methods to traditional methods, due to the lack of scientific evaluation of new approaches [[1]
]. However, the effort to drive changes based on EBT in HE [[7]
], is improving [[8]
]. Embracing EBT in CL education will enable students to become successful in HE settings and in their future professional life, developing stronger evidence based practice [[2]
].- Wolffsohn J.S.
- Dumbleton K.
- Huntjens B.
- Kandel H.
- Koh S.
- Kunnen C.M.E.
- et al.
CLEAR – evidence-based contact lens practice.
Contact Lens Anterior Eye. 2021; 44https://doi.org/10.1016/j.clae.2021.02.008
3. Teaching methods in CL HE
Teaching can be defined as an engagement with learners to enable their understanding and application of knowledge, concepts and processes. Teaching is not just delivery, but includes design, content selection, assessment and reflection. Therefore, CL teaching could be considered as that which is undertaken by a CL educator, who has the control over the various elements mentioned in order to help the student learn. Additionally, learning is a process that leads to change, which occurs as a result of experience and increases the potential for improved performance as a CL practitioner and future learning. Teaching and learning are the two sides of the coin that is education, and they are ardently interconnected. The evidence-based teaching promotes learning [
[3]
], so the whole process is meant as evidence-based education (also known as evidence-based teaching and learning) [[9]
].3.1 Blended learning: face-to-face teaching versus flipped classroom
Blended learning is also referred to as technology-mediated instruction, web-enhanced instruction, or mixed-mode instruction. Although there has always been ambiguity about the definition of blended learning [
[10]
], it could be described as an approach to education that combines the use of media, group work and online educational materials and opportunities for interaction online with physical classroom methods. Ideally, blended learning, and more specifically flipped classroom learning, should be approached in a step-by-step fashion [[11]
], but the COVID-19 pandemic forced teachers into web-based teaching and having to adapt the flipped classroom approach very quickly [[6]
]. In the classic lecture format (face-to-face) a topic or subject is first introduced during the contact time in the classroom. Students may follow this with homework in their own time, and with practical training, if that is applicable to the subject matter. The latter being an essential element in CL education and is discussed in the companion paper [[12]
]. The idea that theoretical lecturing or direct face-to-face instruction alone does not make the best use of the available contact time and resources resulted in the concept of ‘flipped classroom’ learning (also known as reverse, inverse, or backwards classroom learning) [13
, 14
]. The most important element of flipped classrooms is that students learn about the subject before class, freeing up contact time with the teacher during class time for practical or higher order thinking activities. In this model it is recognised that the contact time with the teacher in the classroom is precious so should be valued and used well. This supports the idea that students should turn theory into practice but should not be confused with practical classes that offer a hands-on session only. Flipped classroom learning includes the use of materials, media and information and communication technologies [15
, 16
], such as online presentations, videos, audio files, and online tests before the class, as well as preparing presentations, and group work discussions before, during and after class [[17]
]. It has been reported that in order to have equality to access that digital capabilities of learners need to be taught explicitly and should not be assumed. To improve student learning outcomes, digital skills and competencies need to be embedded throughout the curriculum and addressed through learning objectives [- Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
[18]
]. Practical exercises are very applicable to CL education too. The point of a practical exercise is to apply pre-learned thinking to a new, live problem in class. Group discussions and group work is popular with students and leads to better test results [[19]
]. A flipped classroom aims to increase student engagement and learning through completion of pre-readings at home (or in groups) and work on live problems during class time. This approach brings more activities, including some that have been considered homework, into the classroom. In the class, students are engaged in learning with a mentor's guidance [[17]
]. This approach allows students to self-pace (student-centred model) [- Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
[13]
]. High achievers may skip already understood parts, while allowing lower achieving and struggling students to review again, learn from the more advanced students through structured dialogue, and be better prepared when they come to the face-to-face class [17
, - Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
20
, 21
]. Flipped classrooms are a great opportunity for educators with motivation and interest to upgrade their teaching methods by learning new skills and teaching higher-order skills and processing, like analysis or application of knowledge [[22]
]. Educator interest is higher and leads to better use of formal instructional time [23
, - Martinelli S.M.
- Chen F.
- Mcevoy M.D.
- Zvara D.A.
- Schell R.M.
Utilization of the flipped classroom in anesthesiology graduate medical education: an initial survey of faculty beliefs and practices about active learning.
J Educ Perioper Med. 2018; 20https://doi.org/10.46374/volxx-issue1-martinelli
24
, 22
].There are no publications on the use of a flipped classroom in CL teaching. However, different forms of flipped classroom methods have been used in other modules of optometry education [
15
, 25
, 26
, 27
, 28
, 29
] and more extensively in other fields of medicine where students face similar learning problems [5
, 30
, 31
, 32
, 33
, 34
, - Zhu L.
- Lian Z.
- Engström M.
Use of a flipped classroom in ophthalmology courses for nursing, dental and medical students: A quasi-experimental study using a mixed-methods approach.
Nurse Educ Today. 2020; 85104262https://doi.org/10.1016/j.nedt.2019.104262
35
]. In many cases the flipped classroom was demonstrated to be useful [32
, 33
, 35
, 36
, 37
, 38
] and in other cases it did not affect learning outcomes, [25
, 30
, 39
] although students had a positive attitude towards it [25
, 30
, 33
, 37
, 40
]. In particular, studies have shown that flipped classrooms increase learner satisfaction with the ability to access pre-class assignments (learn at their own pace) and students enjoy the greater focus on discussions and hands-on activities [17
, - Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
20
, 36
]. It should be noted that there is mixed data on the effects of flipped classrooms with regards to long-term knowledge retention and changes in clinical practice behaviours [[36]
]. Studies do, however, show that students perform at least as well as those who attended traditional lectures and no detriment is seen [[17]
]. Some studies show increased retention in flipped classroom settings [- Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
17
, - Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
41
]. There are, however, also arguments against the flipped classroom, such as an increase in time investment, especially by teachers but also by students, and its applicability to some fields of HE [11
, 39
].Student acceptance and motivation is essential for the flipped classroom to be effective [
[21]
]. Students need to have intrinsic motivation and a sense of autonomy to finish pre-work before the class. Some students enjoy working with peers and measured gain in competencies (such as passed tests). Research suggests that successful flipped classroom models foster student motivation intrinsically and extrinsically [17
, - Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
21
]. Students’ motivation to review the materials before class increases with pre-class quizzes [20
, 36
].The social response to the COVID-19 pandemic and the forced move to online teaching did not leave teachers with a choice. Flipped classroom, even full-time online materials had to be developed in a very short time, including for optometry [
27
, 28
, 42
] and the discussion of lack of evidence on knowledge retention was not debated since the alternative was no education at all. Now that planned blended learning has returned it is time to evaluate if the flipped classroom has a future in CL HE [- Fortepiani A.
- Lourdes M.
Implementing an exclusively on-line flipped classroom model in optometry during the pandemic.
FASEB J. 2021; https://doi.org/10.1096/fasebj.2021.35.S1.04251
6
, 8
]. For most learners the flipped classroom is a new experience that differs from how they have been taught or studied in the past. Educators spend significant time in flipping medical curricula. They can invest 127 % more time in course development and 57 % more time to maintain that course than a traditional lecture [[13]
]. Once developed, maintenance will require less time, though. Students most often cited the preparation time prior to class was burdensome [[20]
]. The success of a flipped classroom model depends on students arriving to class prepared and familiar with the material provided, so that in-class time can be used to apply that knowledge via cases and examples, as well as clarifying knowledge gaps that may still exist. Teachers should avoid to provide too much pre-class work or information [43
, 44
]. To improve student engagement the required pre-class studying time should be no more than 20–30 min and ideally videos should not be longer than six minutes [17
, - Tolks D.
- Schäfer C.
- Raupach T.
- Kruse L.
- Sarikas A.
- Gerhardt-Szép S.
- et al.
An introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions.
GMS Z Med Ausbild. 2016; 33https://doi.org/10.3205/zma001045
45
, Guo PJ, Kim J, Rubin R. How video production affects student engagement: An empirical study of MOOC videos. [email protected] 2014 - Proc. 1st ACM Conf. Learn. Scale, 2014, p. 41–50. https://doi.org/10.1145/2556325.2566239.
46
].3.2 Spaced learning
The concept of spaced learning is one of the most robust phenomena in pedagogy [
[47]
]. It has been shown that retention is enhanced if learning is broken into sessions using temporary intervals [, 49
]. Providing temporary intervals interacts positively with repetition which is an important factor affecting learning and memory. As Romans used to say, repetita iuvant, which translates as ‘repetition helps’. If the repetition is broken by intervals then learning is enhanced, this is known as the space repetition effect [[50]
]. Spaced repetition is very effective for promoting any form of learning and has considerable potential for improving learning in various settings [[51]
]. Spaced repetition has been shown to be effective with learners of all ages and it increases recall irrespective of age [[50]
]. Spaced learning or teaching is an approach through which content is intensively taught multiple times with scheduled breaks when students can perform some physical or distractor activities [[52]
]. The purpose of such activities is to relax the learner and take their mind off the learning material that has just been learnt, but often related to the material. Learners can become overly carried away by distractor activities, and these distractor activities may sometimes occupy their minds when the following teaching session begins. It may also be boring to listen to the same contents of a lecture several times and discuss the same material in the distractor activity. These may be considered the challenging aspects that a lecturer has to deal with in implementing spaced learning. Spaced learning can be an effective strategy that can improve the clinical topic-specific knowledge and clinical skills required in healthcare professionals and for this reason, especially in the last 15 years [[47]
], it has been widely adopted in undergraduate studies, postgraduate studies [53
, 54
, 55
, 56
], residency programmes [[57]
], and continuing professional development programs for health professionals [- Matos J.
- Petri C.R.
- Mukamal K.J.
- Vanka A.
- Vrana K.E.
Spaced education in medical residents: An electronic intervention to improve competency and retention of medical knowledge.
PLoS One. 2017; 12 (e0181418)https://doi.org/10.1371/journal.pone.0181418
55
, 58
]. However, spaced learning is rarely defined in the health profession education literature and poorly implemented in practice [[47]
]. Spaced education has the potential to improve learning in health professionals education and therefore in CL HE. However, no direct evidence is available in this field.3.3 Test enhanced learning
In an educational environment tests can be considered as a method of assessment of students’ knowledge (this will be discussed in detail in the second paper) and as a method to improve learning outcomes during teaching (formative assessment) []. In formative assessment students are provided with constructive feedback so that they can improve their learning performance [
[60]
]. Research in cognitive psychology has established that tests during teaching can affect learning by promoting better long-term knowledge retention, a phenomenon known as the testing effect, or test-enhanced learning [61
, 62
]. In the testing effect, the long term memory is enhanced when some of the learning hours are devoted to retrieval of information from memory [[63]
]. Tests promote the retrieval of information and lead to increased retention more than studying alone does. This is one of the most consistent findings in cognitive psychology [[62]
]. Numerous methods can be used for formative assessment, such as multiple-choice questions, practical assessment, short answer questions, essays, case studies, role play, group discussion, group work presentations, project reports, debates and quizzes [].Taking a test after studying potentiates further study and improves the retention of learning [
64
, 65
]. More specifically, it has been demonstrated that quizzing, not additional reading of the same material, improved subsequent test scores, and short answer questions produced more robust benefits than multiple choice quizzes [[65]
]. Others noted that tests improved retention more than repeated studying [[62]
]. Furthermore, retrieval practice improved meaningful learning and the most frequent way of implementing retrieval practice in a classroom is to have students answer questions [[66]
]. Feedback enhances benefits of tests by informing the learner about their learning performance in relation to the learning outcomes. Feedback helps the learner redirect and refocus the action to achieve learning outcomes by aligning effort and activity with the outcomes. In one study it was noted that feedback enhanced positive effects and reduced negative effects of multiple choice question based tests and therefore, educators should provide feedback when using multiple choice questions [[67]
]. Feedback is a valuable function to correct memory errors and metacognitive errors, as it enhances retention by allowing students to correct initial erroneous responses. Moreover, feedback also doubled the retention of correct low-confidence responses [[67]
].It is clear from the literature that test enhanced learning is a concept linked to the process of remembering concepts and facts, retrieving them from the memory and increasing long term retention of those concepts and facts. There are many ways these concepts can be effectively used during classroom teaching. Some suggestions are provided below:
- 1.Incorporating frequent quizzes into lectures may raise student academic achievements [[68]].
- 2.‘Summary points’ at the end of a lecture in the class can help students to recall and articulate key elements of the lecture. Students who were asked to write the main points after a formal teaching session had a significant improvement in their recall at the end of the semester [[69]].
- 3.Taking a test before study can improve subsequent learning of that pretested information [[70]].
- 4.Telling students about the effect of test enhanced learning can give students a tool to add to their learning toolkit [[71]].
It has been demonstrated that test enhanced learning is effective in enhancing knowledge recall and retention and transfer in health professions [
[72]
], but there are no studies of test enhanced learning in CL HE. Test-enhanced learning facilitates improved retention of factual knowledge. Contact lens practice is a combination of factual knowledge in addition to the clinical skill of the practitioner. Therefore, using tests to solidify knowledge presents a promising tool for building clinical skills.3.4 Group work
Learning in a peer group is known to be an effective pedagogy and helps to improve learning outcomes and academic achievements [
[73]
]. This is especially useful in health related professions such as optometry where working effectively in a team is essential. Problem-based learning (PBL), cooperative learning, collaborative learning, and team-based learning (TBL) are examples of small-group pedagogies [74
, 75
]. These active learning methods have been used efficiently in health education [76
, 77
] including optometry [78
, 79
, 80
]. Group work improved student learning compared to traditional didactic lectures [[73]
] and provided an opportunity to discuss ideas, share knowledge and learn from peers. Learning in groups enhanced student engagement, teamwork, communication skills and decision making [73
, 74
, 75
]. This can provide the student with opportunities to compare their work with peers. Group discussion improves knowledge retention, self-directed learning and develops critical thinking. These are important for optometry where students have to use critical thinking and adapt to novel situations [[76]
]. Group work can be instituted in a variety of methods. In cooperative group work, the students work independently to complete a specific project by working on different parts of a research project and combining these sections to create a complete assignment [[81]
]. Whereas collaborative learning is more interactive where students discuss a specific problem and solve it within a group [[81]
]. The role of teacher in collaborative learning is as a facilitator while students lead learning themselves. Teachers can promote learning by stimulating discussion in the group and direct the learning towards desired outcomes [[82]
]. PBL group work involves small groups working on solving a case scenario with direct supervision of a teacher and is used extensively in health education [[83]
]. The issues with such group learning is that some students might not participate or contribute effectively to the group task, which can lead to conflicts within the group, especially if marks are awarded equally to all members of the group [[79]
]. Team based learning (TBL) has a more defined procedure [[79]
]. Students in small groups (typically around 4–8 students) are provided with preparatory work in advance, as in the flipped classroom model. The information from preparatory work is then assessed individually and within groups with a fixed assessment method such as multiple-choice questions. Initially, students are asked to answer these questions individually followed by group interactions until all questions are correctly answered. This exercise ensures that students have good understanding before the next stage of group work. The group then complete another similar case in a group setting using the understanding gained from the previous exercise [84
, 85
]. TBL is a structured method of group work where content is learned in advance of application of the knowledge in a group setting. Also, such sessions can be conducted by a limited number of teachers as students are involved in active learning within an already defined framework. A systematic review of TBL studies showed a positive impact of TBL on learning [[76]
]. However, there was only limited acceptance of the method among students compared to traditional didactic lectures. This could be because of the increased demands on students in TBL [[76]
]. In the context of CL teaching, basic clinical skills, such as keratometry, lens insertion and removal for example, in the university setting are learnt by practicing with fellow students. This can be considered a type of small group learning which can be further enhanced by providing students with preparatory materials such as video demonstrations.3.5 Case studies and Case-Based learning (CBL)
Case studies (also known as case reports) are detailed narratives that describe, for scientific, medical or educational purposes, a medical problem experienced by one or several patients [
[86]
]. Typically, case studies are used to highlight new approaches or treatments as well as rare findings or manifestations of ubiquitous conditions []. Although they represent the lowest level of clinical scientific evidence in the evidence pyramid clinical, case studies often serve as a stimulus for further questions and more rigorously designed scientific studies [2
, - Wolffsohn J.S.
- Dumbleton K.
- Huntjens B.
- Kandel H.
- Koh S.
- Kunnen C.M.E.
- et al.
CLEAR – evidence-based contact lens practice.
Contact Lens Anterior Eye. 2021; 44https://doi.org/10.1016/j.clae.2021.02.008
88
, 89
]. Case-based learning (CBL) is described as an active learner-centred approach for medical students, that helps to develop clinical skills [[90]
]. The reading of published case reports in text books, journals or on websites is important as a part of basic and continuing medical education [[91]
]. The goal of CBL could be considered as a necessary preparation of students for clinical practice through the use of authentic clinical cases [[92]
]. Two recently published meta-analyses showed that CBL is effective for the education of medical students as it improved knowledge, performance, teaching satisfaction as well as the students ability to analyse cases [[93]
]. [[94]
] Developing, writing, presenting and discussing a case report by the learners themselves can further hone learning and communication skills [- Dong H.
- Guo C.
- Zhou L.
- Zhao J.
- Wu X.
- Zhang X.
- et al.
Effectiveness of case-based learning in Chinese dental education: a systematic review and meta-analysis.
BMJ Open. 2022; 12 (e048497)https://doi.org/10.1136/bmjopen-2020-048497
[95]
]. Furthermore, by writing a case study students can improve their experience in researching the literature, scientific writing, understanding evidence-based medicine and improve presentation skills [[96]
]. It is useful if medical education programmes support students in case report writing and clinical teachers encourage and assist students to publish their case reports [[90]
]. Case presentation is reported to be one of the most frequently used clinical teaching and learning techniques [[97]
]. An online survey of 214CL educators world-wide reported, that during the COVID-19 pandemic 46 % of the educators were using the IACLE case reports (https://iacle.org/resources/iacle-case-report-series/) and 32 % were discussing clinical cases with colleagues [[6]
]. To enhance continuing education and avoid the risk of professional isolation for optometrists in practice it has been seen that case-based discussions improved their knowledge and that the peer interaction in case-based continuing education can avoid professional isolation [[98]
].3.6 Problem-based learning (PBL) and team-based learning (TBL)
The concept of problem-based learning (PBL) was developed in the in the late 1960s at McMaster University, Canada [
[99]
]. PBL in medical education involves students working on clinical scenarios with the process facilitated by a tutor [[100]
]. Similar to CBL, PBL is collaborative learning with small groups and a clinical case is often used as a starting point (Table 1) [101
, 102
]. After receiving case information, a discussion starts where students attempt to generate a hypothesis and organise their own leaning process to identify and solve the problem [100
, 102
]. While CBL primarily aims to apply knowledge to provide a solution to a clinical case [[100]
], PBL is used to build knowledge along a problem definition with an open result. Often a single solution is not required as learning from peer-discussion was the goal [[101]
]. It can be conducted without specific preparation for the problem [[102]
]. It is reported that optometry students taking a PBL course are better able to assimilate information about patients, cases or diseases by themselves [[103]
]. As, this method requires students to identify and solve problems, without preparation and with limited support from the tutor, it was suggested as a method for more advanced students [[102]
]. However, there is little evidence for the effectiveness of PBL in optometric education, and it was noted that it might not be possible for all students to solve problems and learn at the same time [100
, 104
]. TBL may include an assessment to ensure that course content is mastered, before or after the students undertake the session [[105]
].Table 1Similarities and differences between problem-based learning (PBL), case-based learning (CBL) and team-based learning (TBL)
[102]
.| Problem-based learning | Case-based learning | Team-based learning | |
|---|---|---|---|
| Advance preparation | No advance preparation | Advance preparation | Advance preparation Individual readiness assurance test |
| Activity | Case based | Case based | Individual or team readiness assurance test; Brief lecture & activity |
| Learning objectives | Written by students | Given to students | Given to students |
| Organisation | Small groups (4–8 students) | Small groups (4–8 students) | Small groups (4–8 students) |
| Learning method | Self-directed | Shared facilitator and self-directed | Shared facilitator and self-directed |
| Role of faculty | Limited guidance | Active guidance | Active guidance |
| Inquiry style | Open inquiry | Guided or structured inquiry | Guided or structured inquiry |
| Number of sessions | Multiple sessions | Single sessions | Single sessions |
| End of session | Student presentations | Wrap-up by faculty | Wrap-up and peer evaluation |
In two studies where a modified TBL was integrated into the clinical training of ophthalmology students, it was shown that performance, self-study, teamwork, class engagement and satisfaction of the students were enhanced [
106
, - Huang Z.
- Li M.
- Zhou Y.
- Ao Y.
- Xin W.
- Jia Y.u.
- et al.
Modified team-based learning in an ophthalmology clerkship in China.
PLoS One. 2016; 11 (e0154250)https://doi.org/10.1371/journal.pone.0154250
107
]. When comparing TBL to PBL in medical education, students preferred the structured TBL sessions as they found them more conducive to learning, engagement and participation [[108]
]. When digital TBL was integrated into health curricula of postgraduate nursing and optometry students reported high satisfaction and engagement [[109]
]. TBL has been suggested as a possible replacement of PBL to establish standardised small group learning in medical school [- Currey J.
- Sprogis S.K.
- Burdeu G.
- Story I.
- Considine J.
- O'Donnell M.
- et al.
Stakeholder acceptance of digital team-based learning.
Nurse Educ Pract. 2020; 46 (102833)https://doi.org/10.1016/j.nepr.2020.102833
[110]
]. However, beside the evidence from other health care professions and optometric education in general, there are currently no studies that explicitly address the advantages and disadvantages of PBL, CBL, and TBL in CL education. Nevertheless, it seems very likely that the findings from other disciplines are transferable to CL teaching.3.7 Reflective practice
Reflective practice in education facilitates integration of practical skills with theoretical knowledge [
[111]
] and can help learners understand their clinical experiences within a wider context [[112]
], strengthening connections between experiences, knowledge and judgement [[113]
]. Reflection has also been shown to yield improvements in skillsets such as critical thinking [[114]
] and can help in promoting communication between students and teachers [[115]
]. The role of reflection is underpinned by some of the best-known theories of experiential learning [[116]
], and supported through research within contextual healthcare learning settings. Despite the merits of self-reflection, engaging healthcare students in such activities has proven challenging for some educators [[117]
]. Here some of the popular approaches to reflection, its use within optometric education, and areas which may benefit from additional research, are discussed.Reflection is not a stand-alone practice. Additional components, such as feedback from stakeholders (for example, supervisors, peers or patients), and setting of goals or objectives, can help structure reflection. Others have emphasised that reflection is not merely a review of past actions followed by a plan for the future, but that critical reflection also requires the challenging of existing beliefs and knowledge [
[118]
]. Various approaches to reflection have been trialled, including journal-keeping [119
, 120
], electronic logs, and group reflection. Whilst the merits of written reflection have been well documented [[121]
], reflection can take other forms too. For example, supervisors can encourage student reflection through asking open-ended questions about experiences [[112]
], or through role playing [[122]
], and workshops [[123]
]. In addition to differences in format, reflection may take place at different timepoints, for example immediately after the experience or even much later [[112]
]. Whilst feedback is a familiar concept within healthcare training, it appears that reflection is an under used approach [[112]
]. Furthermore, it remains unclear which is the best way to assess reflection. Inconsistencies in defining reflection and differences in standards can make assessment challenging [[124]
].Several models of reflection exist in the education setting [
[125]
]. One of the simplest and most successful reflective models is based on three questions: ‘what’, ‘so what’, ‘now what’ []. The first question in the reflective model stands for “What is the problem?” [[127]
], and refers to a description of the experience that may be a clinical experience, or a case study or a lesson [[128]
]. The second question of the reflective model stands for “So what could I have done to make it better?” [[127]
] and it refers to an analysis of significant aspects of this experience [[128]
]. The third question of the reflective model stands for “Now what do I have to do to make things better?” [[127]
], and refers to the way in which the experience and reflection will inform future practice.[[128]
]Kolb’s learning cycle [
[116]
] is one of the best-known models of learning. The cycle begins with concrete experience, which, in the case of CL could be the assessment of CL fitting. The next stage is reflection, this may involve reflecting on one’s performance, and may incorporate the use of feedback. The individual may then begin to understand why an event occurred and have ideas about how to change outcomes in future. These new ideas, knowledge, and reflection are then used to trial different approaches.Another model is the Gibb’s reflective cycle [] that, as with most models of reflection, begins with a description of the experience, involves reflection about feelings in relation to the experience which includes an evaluation of positive and negative aspects, before leading to an action plan. Gibb’s cycle encourages individuals to consider how they might act to achieve a different outcome. Compared to many other models of reflection, Gibb’s reflective cycle involves a greater number of steps and detail.
Atkins and Murphy [
[125]
] proposed their own framework for reflective practice comprising five elements: i) Awareness of the experience including positive or negative aspects; ii) Describing the situation, including specific events that occurred; iii) Analysis of feelings and knowledge, that is, identifying limitations of knowledge and considering alternatives; iv) Evaluation of knowledge, that is, did it resolve or explain the problem; v) Identify if any learning has occurred.While some healthcare professions benefit from a body of published research demonstrating contextual applications of reflective practice, there is no research describing its use within CL educational settings and very few in the optometric field. In a study that investigated reflective journal writing by optometry students following a clinical experience, benefits were found in staff-student communication [
[115]
]. Further, communication which occurs outside the time-pressured clinical environment can allow staff to spend longer addressing student questions and to refer to points which may have arisen but not been fully addressed at the time. Optometry student communication skills have been shown to improve by methods such as reflection on clinical cases, background reading and making entries into an online reflective journal prior to small group workshops, which involved activities such as student discussions and role playing [[130]
].Reflection is a key element of some of the best-known theories of experiential learning. Benefits may include the development of critical thinking skills and promoting active engagement with the learning process. Structure can be added to reflection by using feedback and goal setting but the literature highlights how incorporation of new knowledge or challenging of current beliefs is needed to reflect critically [
[116]
]. Despite the existence of many models of reflection within the pedagogical literature, few reports outline their efficacy within optometric settings and there is nothing in the CL setting, hence further research is needed to optimise efficacy of learning.4. Conclusion
New teaching techniques and environments have emerged over the last few decades based upon scientific evidence such as flipped classrooms, spaced learning, test-enhanced learning, group work, clinical case studies, CBL, PBL, TBL, and reflective practice. Most of these techniques found wide applications in the education of healthcare-related professions since they could potentially be very useful for students who need to learn a broad theoretical knowledge and develop practical clinical skills. A discrete body of evidence has demonstrated these techniques and environments being particularly useful in health professions education and more specifically in the optometric HE. Notwithstanding these premises, in this review, no direct evidence of the spreading and benefit of these strategies in CL education was found. The only technique used widely used in the CL field, especially during the COVID-19 pandemic, was case reports and the group discussion of them. Nevertheless, the IACLE panel engaged in this review found a consensus from findings in other disciplines that are transferable to CL teaching and could help students meet the intended learning outcomes. However, further investigation into the efficacy of this direct application in the CL field would be required and beneficial for the entire community of CL educators, or other disciplines that wish to adapt this approach of evidence-based teaching.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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Published online: February 15, 2023
Accepted:
February 8,
2023
Received:
February 8,
2023
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