Introduction – doing more with less
The Clinical Laboratory Science (CLS) program at the University of Minnesota is an upper division professional program that teaches the knowledge, critical thinking, and bench skills necessary for graduates to enter the clinical laboratory workforce as technologists, supervisors, or managers (primarily in hospital, clinic, or central reference laboratories) or to enter graduate programs in order to continue their education. The program is housed in the Center for Allied Health Programs within the Academic Health Center, awarding a B.S. degree in Clinical Laboratory Science upon completion. This is an extremely rigorous curriculum during which undergraduate students in their fourth year or post baccalaureate students complete two semesters of intensive lecture and student laboratory coursework, followed by 12 weeks of clinical experience rotations. After successful completion of this curriculum, students are eligible to take a national certification exam. One of the primary disciplines within the clinical laboratory is transfusion medicine (blood bank). An important aspect of transfusion medicine is the immunology of red cell antigens and antibodies as they relate to providing safe and compatible blood products. The “type and cross” procedure familiar to so many through TV programs like ER is actually a much more complicated process of screening every potential blood recipient for antibodies they might possess to one of the more than 500 different red cell antigens, much more than just ABO and Rh. If these unexpected antibodies are detected, they must be identified so that donor blood lacking the corresponding antigen can be provided.
Reagent cells used in antibody identification
The blood bank is not highly automated as are other clinical laboratory departments. The actual “tests” performed are quite straightforward, but critical thinking and problem solving skills are paramount to competently performing the job. Analyzing antibody identification tests to determine the antibody or antibodies present is a technique that requires a lot of practice and exposure. Teaching this skill in a traditional setting requires one-on-one instruction to demonstrate the rules of crossing out those antibodies that are not likely, and the subsequent analyzing of those that are not crossed off to determine the next steps to take in the process. In the classroom setting, this instruction was historically done by the instructor demonstrating the process via pen on overheads which still required extensive tutoring as students experienced confusion over the rules when they actually did the work for the first time. Voiced over PowerPoints using fly-in strikethroughs for crossing out were only marginally better in that the student could replay the instructions at their leisure.
A better teaching tool was needed in which the student could make all of the decisions right from the start, correct or incorrect. This idea was conceived several years ago as a dream project with the intended goal of having students understand and master the process on paper in the lecture course before they came to the laboratory session to perform the actual testing and analysis. This project was given its impetus when the current program expanded to the University of Minnesota Rochester site, presenting the need to deliver the lecture material in an online format. Along with that expansion came an increase in the number of students in both the laboratory and lecture courses with fewer faculty. Now instead of four instructors guiding 20-25 students, two instructors were guiding 35-42 students on the Twin Cities campus alone. Logistics didn’t allow us to bring the students to the required competency level fast enough.
The Solution
Content experts do not typically have the expertise necessary to develop an interactive program with this level of complexity. When an instructional designer was brought on board to help develop the program-wide online curriculum, the opportunity arose for this project to take shape, but other projects took precedence. When the instructional designer left, the work being done came to a halt for a couple of years until a multimedia educator/designer was contracted to again assist in the development of these projects. This was the opportunity to fulfill the dream and the content expert and designer began meeting to plan and implement the project.
This material was definitely not a candidate for a "text and graphics" or even a "movie" type instructional methodology. Instead, students needed to make the same hundreds of choices and receive the same contextualized feedbacks as if they were with an instructor. We also couldn't "break it up" onto a large number of pages as that would not reflect the actual experience students would have in the field where they were required to do all of the crossing out on a single page and come up with a conclusion or requirements for further testing.
One of the extraordinary parts of this project was the determination by both members of the team to come up with the "right solution" rather than just putting something online to assist the students. The instructor (content expert) did not want to sacrifice the quality of the one-on-one instruction. This instruction was seen as having the potential for wider application within the field and was identified as software that should be created at a commercial level. The designer had experience creating commercial educational software so the bar for the final product was set exceptionally high. The initial planning stage required a full exploration of the instructional goals as well as the exact methods used within the classroom and the difficulties students encountered with the concepts. In order to have the highest degree of transference to actual clinical laboratory work, the paper page model was retained along with the hundreds of interactions required in order to complete that page.
After defining the parameters for a successful end product, the requirements needed for successful implementation were determined. This included the details and specifications for how a student would work through the process, and the feedback received. One of the components of one-on-one instruction is that students can make hundreds of potential mistakes and the instructor has to ensure that the feedback is tailored to the exact mistake and sample being investigated. This was one area where flexibility would need to be built into the process. While the initial goal was clear, the exact degree and nature of the feedback would require fine tuning as the process continued. Peer reviews were solicited during various stages of the process, resulting in additional layers of functionality and feedback modifications being implemented without breaking existing functionality.
Only after the goals and specifications were determined did we look at what technology solution to use. Fortunately this project was part of a larger body of work which allowed us to leverage existing code so we could spend more time on the customization required to meet our goals rather than starting from scratch. Though it worked for us, the technology should not determine the educational activity. Had it not met our needs, a different technology would have been evaluated and selected.
The technology utilized for this product was a flash based xml controlled engine delivered via standard web browser. This engine had been created from scratch previously by the developer in order to deliver online interactive modules and was quite robust. It required minimal changes to the engine in order to have all of the features required for the student interactions. Once these changes were made the actual content for the course was defined in text files which the engine parsed and then dynamically created all of the interactions and retrieved all of the images. This allowed us a great deal of flexibility and ensured that edits were able to be done with no programming (which was key for maintainability) as the text files were actually controlling what content was loaded and how the interactions functioned via instructions which the engine loaded once a user accessed the URL. Edits were able to be made via simple text edits and as the images were not embedded new images could be referenced or existing images replaced without programming impact.
The Final Product
The finished module starts out with an introductory lesson that teaches the basics of antibody detection and identification. The rules for successful navigation of the module and those used in the industry for this “exclusion method” of antibody identification are laid out. The antibody problems are then presented in a series of three case based scenarios, each highlighting a patient with a picture and an overview of their diagnosis and laboratory data. The patient information and testing results are presented in the order in which they would occur in the actual laboratory. Once students navigate to the page with the actual antibody testing results and antigenic profiles, they can begin the crossing out exercise at their leisure. The exercises are self-paced and each mouse click results in a strike out of an antigen when appropriate, with immediate feedback as to why the answer was right. Incorrect mouse clicks do not result in a cross out, but immediate feedback is also given as to why the choice is wrong.
Case presentation of patient data and results
Student has progressed midway through line 2, with correct feedback at bottom
After a preliminary identification of the most probable antibody present, the student is taken through additional steps to validate their answer and determine the statistical reliability of the answer through methods commonly used in the industry. Once the antibody identification exercise is complete, the student is again taken back to the patient and given a conclusion to the case, including outcomes of the transfusion. This case based approach is intended to simulate an actual laboratory situation as closely as possible.
The Challenges
This project presented both challenges and opportunities regarding timeline. Initially all seemed reasonable as the end product would be demonstrated at the Clinical Laboratory Educators' Conference, more than a year away. Unfortunately, while this project was a personal priority for both project members, neither was able to give it full priority over their other work so the project had to fit in around existing full time commitments. A constant effort was made to coordinate these openings to allow the various stages of development to proceed requiring both parties to evaluate, revise, and give feedback at each step. As is often the case, the project came down to the wire, requiring many nights and weekends in order to incorporate last minute feedback before the conference. Ideally a project of this scope would be assigned a dedicated appointment with other duties temporarily removed, but that is rarely the case within our budget and time strapped departments, so embarking on this type of work requires a great deal of flexibility and dedication.
It should be noted that this type of project really isn't possible for many departments. It requires a degree of expertise and coordination that is not normally given to the "online transition", where the bar is often set much lower and interactions are limited to those that can be simply accomplished. The "PowerPoint transfer" mindset is strong during these transitions, and while a good deal of material can be translated it is crucial to look at the curriculum and identify those areas which would benefit from more extensive student interaction and deviate from a passive delivery model where it would be beneficial.
Calculating the Impact
The interactive module was used in CLSP 4501 during spring semester 2012. The module is just one component of a semester long course. 61 students on two campuses were randomized into two groups. One group viewed the traditional voiced over PowerPoint module with the instructor doing the crossing out with fly-ins followed by student analysis of a set of three paper antibody problems. The second group used the new interactive module. All students completed a wet lab exercise after completing their respective module. Both the traditional and interactive modules were linked in the course Moodle site, accessible by the appropriate group any time during a one week period preceding the laboratory exercise in which students performed antibody identification on an actual sample. Select laboratory performance parameters were recorded to compare the laboratory success of each group. Both groups also completed a written assessment and survey. The intent is to determine the efficacy of the interactive module in terms of both student performance and satisfaction compared to the traditional delivery method. Both modules were then opened to all students and a subset of students who viewed both modules was blindly selected to be interviewed for a qualitative study. While data has not yet been analyzed, feedback from the students has been very positive. Originally, the hope was to develop a second “mastery” level module but budgetary constraints and the efficacy of this first module will dictate the future direction. The administered survey resulted in student comments indicating the desire for additional “antibody problems”.
What’s next?
The finished product was enthusiastically received at the Clinical Educators' Conference in February 2012 and many educators signed up to receive information about purchasing the product for their institutions. It is hoped that this product may receive further customizations to meet the specific needs of these institutions to account for the analytical variations in practice within the industry and teaching programs.
The product has an application as a refresher course for those clinical laboratory scientists who have not worked in a blood bank for some time and are being cross trained for such.
While the CLS curriculum must retain hands-on laboratory sessions to insure competency of its graduates, modules such as this one have a place. Online education can help us teach and train more students to enter the profession if we can provide quality online simulations that supplement and put into practice the didactic material while demonstrating the laboratory techniques. One paradigm shift in our curriculum is to provide these preparatory educational tools that students can work through in order to reach a level of comfort and competency prior to entering the lab to do “the real thing”. CLS is an expensive program to teach and when the student is successful the first time in a wet lab situation, money is saved, the program is more sustainable, and time can be spent on refining skills rather than teaching the basics. More simulation tools are envisioned in this course but will require that a technology expert be included in the budget.