Health CareLearning communication from erroneous video-based examples: A double-blind randomised controlled trial
Introduction
Appropriate provider-patient communication is associated with high levels of treatment adherence [1], [2], [3], patient recovery [4], [5], [6], and patient satisfaction [2], [7], [8]. As evidence reveals that successful communication with patients can be learned [9], [10], the question of how to best teach and assess communication skills is a key issue in international healthcare education [11], [12]. This also holds true for medical and other health professions schools in Switzerland [13], [14].
Since Swiss health professions schools are tasked with preparing their undergraduate students for successful interaction with real patients [15], [16], training with simulated patients including structured feedback is a widely used method strongly recommended in the literature [17], [18], [19], [20]. Through this training approach, students become familiar with various communication principles, such as eliciting the patient’s perspective [21] and expressing empathy and concern [22], [23]. However, achieving skilled communication is challenging (mostly due to time- and cost-effectiveness), which is why students must extract maximum benefit from their limited training time [24] with simulated patients [25], [26], [27].
Consequently, we chose an instructional approach with video-based worked examples to prepare students effectively. The use of video material as a teaching aid has several benefits. First, videos are highly valued by learners [28], [29]. Second, compared to text-based presentations, video-based presentations more accurately illustrate communication scenarios by providing ‘approximation to real-life practice’ [28]. Third, this realistic presentation format can facilitate the transfer of newly acquired skills into practice [30]. Alternatively, worked examples refer to how (video-based) learning materials can be scaffolded in order to support initial skills learning [31]. Worked examples usually contain an introduction to a formulated problem including a task (e.g. a bad diagnosis that has to be delivered to the patient) and a demonstration of each solution step required to achieve this task (i.e. effective communication) [32]. This direct, performance-oriented form of instruction, successfully induces [33], [34] schemas (also known as scripts) [35], [36]. Schemas are regarded as knowledge systems consisting of numerous elements of information stored as single units in long-term memory [37]. Consequently, they are essential for reducing working memory load: ‘even a highly complex schema can be retrieved and processed as one information element in working memory’ [38]. Accordingly, communication schemas permit providers to readily act upon given principles [39] by representing easily accessible actions ‘used to select effective and appropriate communication behaviour’ [27].
We postulate that students must be encouraged to develop schemas related to intended communication principles prior to their training with simulated patients. Thus, students can link this theoretical knowledge with their practical training experience, which is a precondition for developing skilled habits [40].
Our literature review on contemplative approaches in the domain of provider-patient communication revealed three prominent observations. First, studies examining the effectiveness of video-based examples often do not implement the materials in worked examples. Further, these studies do not focus on learning that occurs prior to communication training. The relevant studies explore the effects of learners’ own videoed interactions with (simulated) patients including individualised feedback on behavioural change [41], [42] or self-reported learning success [43], [44]. Second, studies that use content presented in a worked example manner inevitably do not focus on healthcare students and their communication skills. Respective studies focus on patients viewing video-based examples with high versus low patient-centred communication [45] or on lecturers studying videos illustrating how to deal with challenges in providing feedback on clinical skills [46]. Only a few studies simultaneously incorporate worked examples (whether or not video-based) and address healthcare students’ acquisition of communication schemas. Third and most importantly, these studies either assess schemas for provider-patient communication [39], [47], [48], [49] or evaluate entire communication skills training programmes, wherein worked-example-related elements are used among other extensive interventions [50]. In the first case, for instance, Hulsman et al. [48] used standardised video cases of provider-patient interactions embedded in a summative assessment to examine students’ abilities to recognise communication skills. In the latter, role-plays [50] or repeated individual supervision [29] were implemented. Hence, due to the scope of those studies, the implemented worked example approaches were not evaluated as a standalone training strategy to prepare healthcare students for communication training.
To summarise, research examining the learning effects of worked example approaches (whether or not video-based) in the domain of provider-patient communication is sparse. Nonetheless, authors from other disciplines have demonstrated that learning from certain formats of worked examples is an effective means for facilitating schema construction, especially when examples are accompanied with further aids. This concept is addressed in the following sections.
A large body of evidence confirms that learning from worked examples is associated with effective schema construction, leading to improved outcomes [51]. This ‘worked example effect’ [51] has been proven in well-structured learning domains such as mathematics and physics [52], [53]. Recent studies have further shown that studying erroneous examples (worked examples that include one or more errors) can foster learning in less structured but more complex domains such as medical diagnosis [54], [55], [56]. Erroneous examples can increase learners’ attention [40], [51] and encourage critical thinking [57]. Consequently, their involvement in the learning process increases [58]. High involvement and elaboration both promote schema construction [59]. Furthermore, studying errors can foster the acquisition of ‘negative knowledge’ [60], or ‘knowing what not to do’ [61]. Such knowledge is devoted to specific tasks and activities [61], [62] and contributes to the formation of schemas [63], [64]. However, studies show that only learners with sufficient prior knowledge profit from erroneous examples [65], [66], since they need to identify the error(s) and understand the correct solution by comparing the erroneous solution with the correct one [54].
Kopp et al. [55] and Stark et al. [56] demonstrated that erroneous examples enhance learning when students are provided with additional feedback explaining why a given example is erroneous. More importantly, they indicated that such elaborated feedback fosters learning independently of students’ prior knowledge. An explanation for this finding is provided by van Gog [67], who argues that elaborated information about the errors, just as it does in correct examples, can act as a reference for a performance standard. Correspondingly, learners can infer the correct solution while they also acquire negative knowledge, both of which lead to schema construction.
Self-explanation prompts also increase the effectiveness of example-based learning [59], [68], [69]. Such prompts guide learners to reflect on the given examples by asking them to identify and explain their underlying principles in a self-directed manner [70]. Thus, learners can increase their understanding and gain knowledge that is not directly presented in the learning material [31]. Accordingly, in the context of learning from worked examples, self-explanation prompts have been shown to promote elaboration and schema construction [71]. In this context, worked examples in conjunction with self-explanation prompts have the potential to promote learning not only for correct examples but also for erroneous examples [56]. However, the effectiveness of self-explanation prompts depends on the students’ prior knowledge [72], [73]. Consequently, corresponding elaborated feedback should be provided too [74].
Inspired by previous findings from other disciplines, we aim to clarify whether the worked example effect is applicable to initial learning in the domain of provider-patient communication by implementing an instructional approach using either correct or erroneous video-based examples. To enhance the effectiveness of this approach, both example formats are accompanied by self-explanation prompts and elaborated feedback. Since provider-patient communication is regarded as a complex task [48], not only learning from correct examples, but especially from erroneous examples might help students familiarise themselves with given principles (schema construction) and thus, enhance their initial performance levels on related communication tasks with simulated patients. Consequently, we also aim at exploring whether erroneous examples can facilitate initial communication skills learning more successfully than correct examples, when both formats are accompanied by prompts and feedback. Accordingly, we derived the following hypotheses:
- (1)
Undergraduate healthcare students studying correct or erroneous examples accompanied by self-explanation prompts and elaborated feedback will perform better on a communication task with simulated patients than students from a control group without worked examples.
- (2)
Undergraduate healthcare students studying erroneous examples will exhibit task-related communication principles more appropriately than students studying correct worked examples.
Section snippets
Methods
This study applies a double-blind randomised controlled design to clarify our initial hypotheses. Randomisation was balanced by gender. The participants were assigned either to an experimental group with correct examples, an experimental group with erroneous examples, or a control group without examples. The examples in the two experimental groups were accompanied by self-explanation prompts and elaborated feedback. Blinding of the participants and outcome assessors was achieved by not
Results
The three groups were homogenous with regard to age (χ2(df = 2, N = 36) = 0.13, p = 0.94). The participants reported high interest in provider-patient communication, whereas their prior knowledge was insufficient (Table 2). Importantly, neither the degree of interest in the subject matter nor the level of prior knowledge differed between the three groups (χ2(df = 2, N = 36) = 2.0, p = 0.37); (χ2(df = 2, N = 36) = 0.32, p = 0.85).
Discussion
This study revealed the following findings regarding our initial hypotheses. First, students who were presented with video-based worked examples accompanied by self-explanation prompts and elaborated feedback attained higher learning outcomes compared to students from the control group (supporting Hypothesis 1). In particular, the students confronted with the erroneous examples broke bad news to a simulated patient significantly more appropriately than students from the control group. This
Conflict of interest
The authors declare no conflicts of interest.
Funding
No external funding was received for this study.
Ethical approval
This study does not fall under the Article 2 paragraph 1 (Scope) of the Federal Act on Research involving Human Beings (Human Research Act, HRA). Thus, the independent ethics committee deemed the subject exempt from formal review. The participants of this study provided their confirmed consent for the material to be used for research purposes. Moreover, the undergraduate students in the video-based worked examples consented to have their videos used for teaching and research purposes.
Author contribution
FMS contributed to the conception and design of the study as well as the collection, analysis and interpretation of data and drafted the manuscript. KPS contributed to the conception and design of the study and the interpretation of data. DS contributed to the analysis and interpretation of data. MRF contributed to the design of the study. SG contributed to the conception of the study.
All authors contributed to the critical revision of the paper and approved the final manuscript for
Acknowledgements
We are very grateful to Ulrich Woermann for enabling the selection of the video-based examples, Beate Brem for the training of the simulated patient, and Stefanie Carola Hautz for providing critical advice regarding the editing of the manuscript.
Felix Michael Schmitz, lic. phil, is a research collaborator at the Institute of Medical Education, at the University of Bern, Switzerland. He focuses on usability consulting, lecturing, and research in higher education. He is engaged in several research projects that broadly aim to improve undergraduate healthcare training. In 2013 he entered the PhD programme at the Graduate School for Health Sciences; his thesis investigates instructional approaches in the area of provider-patient
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Felix Michael Schmitz, lic. phil, is a research collaborator at the Institute of Medical Education, at the University of Bern, Switzerland. He focuses on usability consulting, lecturing, and research in higher education. He is engaged in several research projects that broadly aim to improve undergraduate healthcare training. In 2013 he entered the PhD programme at the Graduate School for Health Sciences; his thesis investigates instructional approaches in the area of provider-patient communication.
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