Successful emergency medical service training with virtual field trips using video during the COVID-19 pandemic: the Official Development Assistance Project in Uzbekistan

Article information

Korean J Med Educ. 2023;35(4):363-375

Publication date (electronic) : 2023 December 1

doi : https://doi.org/10.3946/kjme.2023.273

Ki Jong Kim¹, Yoo Bin Lee², Woo Chan Jeon¹, Ji Sook Lee³, Hoon Kim¹, Minkyung Oh⁴, Bo Young Yoon^,5,6

¹Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea

²International Development Cooperation Center, Inje University Ilsan Paik Hospital, Goyang, Korea

³Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea

⁴Department of Pharmacology, Inje University College of Medicine, Busan, Korea

⁵Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea

⁶Innovation Center for Medical Education, Inje University College of Medicine, Busan, Korea

Corresponding Author: Bo Young Yoon (https://orcid.org/0000-0002-9635-4799) Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 47392, Korea Tel: +82.51.890.6324 Fax: +82.51.895.1864 email: byyoon@paik.ac.kr

Received 2023 August 10; Revised 2023 September 23; Accepted 2023 September 27.

Abstract

Introduction

Krepel and DuVall [1] defined a field trip as a process in which trainees interact with the setting, displays, and exhibits to obtain experiential learning about ideas, concepts, and subject matter for educational purposes. Field trips are an essential educational strategy for student learning in various fields such as science, social studies, pre-service teacher education, higher education, and continuing adult learning [2-7]. Guided field trips promote deep learning and real-world problem-solving skills [6]. Learners are easily immersed and engaged because actual field trips (AFTs) can invoke positive interests and emotions in them [7]. Although traditional AFTs are strong methods for authentic teaching and learning, they raise concerns about time, logistics, finance, learners’ physical and emotional distress, and safety [4]. Another educational concern is that AFTs cannot provide a standardized curriculum or can cause schedule overload. Therefore, virtual field trips (VFTs) are increasingly being recognized as an effective field trip method as an alternative to AFTs with the development of new technologies and increasing demand for overcoming several issues that AFTs raise [2]. With technological advances, VFTs have expanded to international long-distance field trips, geohazard areassuch as exploding volcanoes or earthquakes, and extraterrestrial environments such as moons or Mars [2,8]. In addition to these special circumstances, it remains debatable whether VFTs can fully replace traditional AFTs [3].

Korea Foundation for International Healthcare (KOFIH) has been conducting invitational training courses since 2007 through the Dr. Lee Jong-wook (LJW) Fellowship Program (currently the LJW School) to continue the late former World Health Organization Secretary-General LJW’s efforts to foster health and medical personnel in developing countries [9]. Investigators conducted projects to strengthen the capacity of medical professionals in the emergency medical service (EMS) system in Uzbekistan, KOFIH, from 2019 to 2023 [10-13]. Originally, this invitational training program provided special lectures, simulation-based skills training, and AFTs to the emergency centers of university-affiliated hospitals, simulation centers of medical schools, departments of emergency medical services, and the national fire and disaster headquarters.

One year after starting the Uzbekistan project, in early 2020 all face-to-face educational activities, including skills lab training and site visits for invitational training programs, were stopped due to the coronavirus disease 2019 (COVID-19) pandemic. The judgement that the pandemic would not end soon led to a search for online education, from primary to higher education. Countries worldwide, not just Korea, quickly adapted to online education with the development of technology and Internet accessibility [14]. The project manager decided to conduct online or hybrid training programs. Lectures were readily available online. Simulation-based skills training was not easy, but was possible because the trainees were already experienced professionals in emergency medicine (EM), and the training of trainers (ToT) model was intended to be used in this project. However, field trips are essential educational strategies for situated learning in higher education, including EMS. Without hands-on training during field trips, emergency medical personnel cannot provide effective emergency medical care to communities in real-world situations. Therefore, the most critical factor in achieving training outcomes was creating VFTs to replace the traditional AFTs that constituted the essential learning activity in the current invitational training project.

The investigators created VFTs using edited videos and expert interviews following the instructional design process and used them as field trips virtually within the entire emergency medical training (EMT) course in Uzbekistan for 3 years. Our research questions are as follows: (1) How satisfied are learners with well-designed VFTs? (2) What should be considered in the instructional design of VFTs to promote learners’ engagement? Based on these research questions, this study verified trainees’ reactions to VFTs for EMT course and identified the factors that promote trainees’ engagement and interrupt immersion in VFTs.

Methods

1. Study participants

The participants were 286 EM physicians who participated in advanced training programs from 2020 to 2022 to empower EMS system in Uzbekistan. The demographic characteristics of the respondents are presented in Table 1. In Uzbekistan, EM doctors, feldshers, and nurses, as a team, ride in ambulances to patients and decide their severity. The patients are then treated onsite or transferred to a hospital by the ambulance. The new EMT course is for EM physicians who accompany ambulances, and is an advanced program for those who have completed basic training. All participants were EM doctors with an average clinical experience of 10.23±10.75 (mean±standard deviation) and ambulance experience of 6.96±8.39 years (Table 1). Compared with those in 2020, trainees in 2021 and 2022 in the EMS training were significantly younger and had shorter clinical careers.

Table 1.

Demographics of Trainees Participating in the 3-Year Emergency Medical Service Training Program

Results

The trainees’ reactions to the VFTs were positive. The investigators decided that a score of 4 or higher on the Likert scale should be considered satisfactory before implementing the EMT course. The total mean score for every questionnaire item was over 4.5 (Table 2). When the reactions were divided into satisfaction, relevance, and engagement, the overall satisfaction and relevance were very high at 4.5 points or more in all years. The scores of engagement items also showed a high score of 4 points or more (standard of satisfactory), but statistically significant differences were observed by year.

Table 2.

Trainees’ Reaction to Virtual Field Trip Sessions in the Emergency Medical Service Training Program

The 286 trainees trained in 15 different sessions over 3 years were divided into two groups, those with more than versus less than 10 years according to their clinical experience. Satisfaction and relevance scores were significantly higher in the more than 10 years group than in the less than 10 years group. Engagement showed similar results for both items (Table 3).

Table 3.

Differences in Trainees’ Reaction to Virtual Field Trip Sessions by Duration of Clinical Experience or Ambulance Staff Experience

When asked to choose two interesting videos and two helpful videos for their jobs in VFTs, they generally tended to choose the same videos as interesting and helpful. VFT locations can be classified into three groups: (1) EMS, (2) emergency centers, and (3) educational institutions (Appendix 1). Many trainees found the emergency medical educational curriculum, facilities, and equipment of the university interesting and helpful (Fig. 1). The most interesting and helpful video was from the Department of Emergency Medical Technicians at Namseoul University (n=132 and 127, respectively).

Fig. 1.

Most Interesting and Helpful Video Clips Included in Virtual Field Trips

The trainees could select the top two videos for each question. Blue box indicates educational institutions. EMS: Emergency Medical Service, MESH: Medical Education and Simulation Center, Hanyang University

Through the open-ended questions, trainees indicated that the VFTs were interesting and helpful because (1) the video showed real things, (2) the contents were easy to understand, and (3) the contents were related to their job (Appendix 3). Trainees stated, “I was impressed with the simulation training facility composed of an environment similar to the actual field,” “Video contents had a sense of reality,” and “It was a good opportunity to experience state-of-art emergency medical system and education system in Korea.” Trainees also stated, “The contents of the lecture were structured in an easy-to-understand way” and “It was a practical help because it was composed of contents that could be applied to my work.” Trainees also requested voice-overs in Russian or Uzbek instead of Russian subtitles in the video clips. Another suggestion was for the VFTs to be available for watching again later.

Discussion

AFT, an important element in invitational training programs, illustrates the Korean context, advanced facilities, and operational methods, because trainees in official development assistance (ODA) project are currently working as experts in their country. However, the COVID-19 pandemic made us find an alternative pedagogy. It was determined that it would be most useful to apply the ToT model, which educates local trainers on training local health professionals. Another pedagogical change was the conduct of VFTs by related institutions and organizations in South Korea.

There are several elements to successful education using VFTs [7]. Authenticity is the core attribute of a field trip. Alignment with the curriculum, interaction with experts as part of the field trip, provision of guidelines, and debriefing for deep knowledge can enhance the authenticity of field trips [15]. We designed the EMT course in the following order: knowledge, skills, and experience. Trainees acquired knowledge and skills before entering the VFTs. Moreover, VFTs are related to trainees’ knowledge, skills, and prior their own experience. These alignments enabled the VFTs to seem real (Appendix 3). Experts from institutions and organizations in Korea were synchronously connected with the Uzbekistan trainees through video conferencing. After VFTs, interactions with others, such as teachers, experts, or peers, can enhance authenticity and deepen learners’ learning experience [7,16]. High satisfaction scores were obtained because we faithfully followed the conceptual model of authentic VFTs with ToT model-guiding onsite and debriefing sessions with a Korean expert in this study.

In the EMT course, VFTs were produced using audiovisual media. As video-based delivery methods make learners passive, active elements of learning must be added to the instructional design to keep them engaged. Strategies to promote active learning from educational videos include packaging videos with interactive questions and guiding questions [17]. VFTs are only a part of the EMT course. Investigators can make videos into active learning tools by applying instructional design that includes questioning and guidance in the course.

The next consideration for maximizing trainee learning from educational videos is trainee engagement. Engagement can be induced by shortening the length of the video, using conversational language, speaking relatively quickly and enthusiastically, and emphasizing the relevance of their work to the course [17]. In this study, more experienced trainees tended to feel more satisfied, find the training more relevant to their job, and are more engaged with the VFTs. We suggest that experienced trainees could understand cutting-edge content, be better engaged, and feel more satisfied than inexperienced trainees because the content of VFTs was authentic EMS involving advanced training methods with updated facilities and equipment in their field.

The trainer’s ability is also a critical factor in successful learning. ToT is widely used as an efficient and effective method for overcoming the lack of healthcare professionals in low- and middle-income countries [18]. Although younger, less experienced trainees participated in the EMT course in 2021 and 2022 than in 2020, there was a statistically significant increase in the evaluation score. As the local trainers’ experience as educators increased, their understanding of educational content and their role as facilitators or guidance increased. It seems that the improvement in the local trainer’s competence as an educator overcame the inexperienced trainees’ negative traits regarding learners’ reactions. Most trainees were interested in educational institutes that had updated simulation centers with facilities and equipment (Fig. 1). All trainees were EM physicians and leaders of an EM team. Given that they are educators in their teams and need simulation centers to train together as a team, they were of course interested in the VFTs of educational institutes.

Language barriers, especially in international conferencing and education, usually weaken educational effectiveness. This is a common problem in ODA projects. Thus, interpreters are used to overcome this challenge or a common language such as English is used. When both trainers and trainees do not speak a common language such as their mother tongue, communication difficulties arise and affect the quantity and quality of learning. We prepared video clips with Russian subtitles to address the language barrier problem. However, the trainees asked for a voice-over rather than Russian subtitles. Research on subtitles, dubbing, and voice-overs in foreign films report that the general comprehension of film content and visual scene recognition are achieved equally through subtitling and dubbing [19]. Contrarily, some investigators have suggested that the attention paid to subtitles in the visual channel could divert attention from the audio channel. If there are important clues only in the audio channel, learners cannot pay due attention to it if they are attending to subtitles [20]. In our study, some trainees preferred voice-overs because reading subtitles distracted them from focusing on the audio-visual information. Further research is required on video-based e-learning in foreign languages.

The elements for successful training with the VFTs obtained in this study are summarized in Fig. 2. Although we can consider learners, educators, and content domains, the instructional design of videos is a more flexible domain. Several elements should be considered and adopted in the production of educational videos. In this study, trainees were fully satisfied and engaged because of the successful instructional design.

Fig. 2.

The Elements of Successful Training with VFTs

VFTs: Virtual field trips, Q&A: Question and answer.

This study has some limitations. As this was not a comparative study of AFTs and VFTs, we cannot determine whether VFTs can replace AFTs in healthcare professional training programs. If further studies show that VFTs are more cost-effective or similar in effectiveness to AFTs, they can be applied to ODA educational projects, even after the COVID-19 pandemic ends. If so, it would be possible to improve the quality of health professionals in more partner countries and provide more opportunities for qualified education within the same budget. This will further accelerate the sustainability of local healthcare systems.

Another limitation is that this study focused only on learners’ reactions. To evaluate VFTs that induce effective learning, it is necessary to evaluate the learner’s level of achievement in addition to the learner’s satisfaction. It was difficult to design a reliable learner assessment for a one-week training program that included lectures, skills training, and field trips. To measure the educational effectiveness of VFTs, it is necessary to measure behavioral changes and self-directed learning after returning to work.

In conclusion, it seems that an EMT course that includes VFTs can be a good alternative to EMS training in situations where AFTs are difficult. It is possible to replace AFTs with VFTs by using qualified videos. Successful VFTs must maintain the rules of instructional design to promote learners’ satisfaction, engagement, and learning.

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