Motivation of teaching reform

Traditionally, teaching activities are undertaken as classroom lectures [1]. The rapid advancement of information technology, especially the increased speed and availability of internet technology, has facilitated increased means for educators to modify the teaching methods used, achieve teaching objectives, and improve teaching standards [2]. Various online teaching techniques have been used to support learning across different subjects [3]. The MOOC (Massive Open Online Course) format allows thousands of people to access a wide variety of course resources on a publicly available web platform anywhere and at any time; the SPOC (Small Private Online Course) enables teachers to increase interaction with students using platform-based resources within appropriately sized classes; micro-courses concisely present classified educational content in the form of short videos; the flipped classroom transfers the learning initiative to the students so that teachers can deliver in-class content with more depth and efficiency, and blended teaching attempts to integrate traditional teaching with online learning. Reforming teaching methods based on “Internet plus teaching” brings new challenges to teachers and requires new ways of thinking.

To meet the demands of cultivating medical practitioners with higher levels of qualification and decision-making capabilities in the field of ethics, while needing to rely on modern teaching methods, the author (hereafter referred to as the teacher) conducted a reform of a Medical Ethics course at Fujian Medical University over a period since 2015 to incorporate online teaching. Before presenting a comprehensive analysis of the implementation of blended teaching, this study also reports the process of reforming teaching practice using the interim methods of the SPOC and the flipped classroom.

Initial attempts and problems found

SPOC with direct recording

The use of a SPOC to teach Medical Ethics from 2015 used learning resources in the form of 40-minute videos and supporting exercises created in a recording studio. These were uploaded to the online course platform for students to access. The course contained 27 class hours, comprising three chapters and replacing classroom teaching with online recorded lectures, that is, 18 hours of traditional teaching, and 9 hours of watching pre-recorded SPOC videos.

After one semester, it was found that the SPOC provided some advantages over traditional teaching. Firstly, to a certain extent, the online self-study format supported students in developing self-discipline [4]. Secondly, the format overcame the limitations of time constraints and room capacities; students could learn online anytime and anywhere, and any student absent due to illness was allowed to catch up [5]. A comparison conducted using the MOOC format showed that there was no significant difference in academic performance between students taught using the MOOC format and those who attended traditional in-class lectures [6]. The online teaching format greatly improves the flexibility of teaching while not negatively affecting the quality of the teaching delivered. Online teaching may additionally help to improve equality in education [7]. With the only pre-requisites being a network and a computer, high-quality education resources can be made accessible to medical students and medical practitioners in remote areas.

There were, however, problems identified in the early implementation of SPOC teaching. The quality of the PowerPoint slides and videos used in pre-recorded lectures was often poor, with the audio and video streams sometimes becoming de-synchronized, negatively impacting students’ concentration [8]. The course platform only recorded student interactions with fixed activities, such as homework and questions, and failed to capture students’ cognitive learning characteristics or make a quantitative assessment of students’ understanding or performance [9], consequently making it difficult for teachers to observe and evaluate the effectiveness of students’ learning in real-time [10]. The presentation of recordings was monotonous and lacked targeted guidance [11]. Single topics or knowledge units had to be segmented across multiple separate videos, affecting the flow and continuity of the teaching. Finally, there was no guarantee that students would actually watch the videos as required, risking those students with poor self-discipline falling behind [12].

Flipped classroom

To overcome the shortcomings of pre-recorded SPOC videos, the teacher introduced the flipped classroom format based on micro-videos to be watched before working through the new material in class. The flipped classroom method was implemented in the teaching of undergraduate-level medical ethics across different years between 2018 and 2020. The format comprised of a resource pool with between 5 and 15 minutes of micro-videos pre-recorded by the teacher. Students completed the learning of declarative knowledge independently by watching micro-videos on the online course platform, discussing the content with classmates online [13], constructing a mind map, and consulting literature resources for learning content [14]. Quizzes were inserted into online videos to test students’ understanding. In the management module of the online platform, teachers could obtain the learning status of each student, including their progress, time spent watching videos and discussing them online, frequency of platform visits, and other completion metrics. This encouraged students to keep up with their learning. In face-to-face classes, teachers used cases to guide students through putting their newly-learned ethical theory into practice, giving them a deeper understanding of how to solve practical problems [15], realizing the internalization of their knowledge into practical ability, and promoting the development of higher-order thinking skills [16]. At the same time, the flexibility of the self-paced learning component of the flipped classroom design addressed the needs of individual students [17], highlighting the autonomy of students in the learning process [18].

Nevertheless, the deficiencies found in the flipped classroom teaching format were that it still relied on students to complete a significant amount of preparation work before class. Some students forgot, got confused, or failed to complete the study in time [19], in turn affecting their subsequent participation in case discussions in the face-to-face sessions. Further, the learning process was predominantly led by the teacher, as the online system did not allow for screening or filtering of comments, students were not fully encouraged to express their personal opinions, and sometimes made meaningless comments without thinking. These aspects of participation were highlighted as requiring improvement [20].

Research question and research objective

To address these problems, further change and improvement in the teaching method were necessary. Using the medical ethics course at Fujian Medical University as an experimental case, this study explores the available options for using online teaching platforms and aids, aiming to optimize students’ online experiences in undertaking disciplined and self-motivated study in combination with offline teaching, as well as to maximize the combined utility of the two formats.

In the second half of 2020, a redesign of the medical ethics course was carried out. Through sequential planning, implementation, evaluation, and reflection, this redesign aimed to make continuous improvements to the teaching methods and quality of active research. More importantly, based on the previous experience of using the SPOC and flipped classroom formats, this stage of the study aimed to find a more effective and generalizable method for the delivery of medical ethics teaching.

Following the outbreak of COVID-19, canceling offline teaching activities in universities became necessary to prevent the spread of the virus [21]. Throughout the pandemic, the design of the medical ethics course changed further within the format of the flipped classroom. In half a year, through implementing blended teaching across the using “micro-classes”, together with online courses, a complete teaching cycle was delivered and evaluated for second-year clinical medical undergraduates. The teaching content included 9 chapters representing 27 class hour units, totaling 1.5 credits.

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