Digital Code for Teaching Anatomy Online – Joanna Matthan

Jo Matthan (Director of Academic Studies, School of Dental Sciences) talks about the teaching of Head and Neck Anatomy (DEN1101) within the School of Dental Sciences (SDS) at the Faculty of Medical Sciences (FMS), and how the move to online teaching necessitated the development of a specialised Digital Code around the use of cadaveric imagery.

Background

In Present-in-Person (PiP) teaching, students attending this foundational head and neck anatomy course would typically have access to the Dissecting Room for their learning. This would be delivered over a six-month period in their first year on either the Dental Surgery (BDS) or the BSc Oral and Dental Health Sciences degrees. This face-to-face time has been reduced to 12 hours from the approximately 50 hours of hands-on anatomy teaching delivered, which left a considerable amount of content to be covered in the digital format. In normal times, a code of conduct is signed by every student the first time they enter the restricted Anatomy and Clinical Skills Centre teaching facility. This was utilised in a digital format during the pandemic but, due to the major overhaul in teaching delivery, there was no way of reinforcing the messages contained within the code of conduct on a regular basis. It felt like a tall order to expect students to remember and understand a list of statements that is seemingly far-removed from them at the start of their anatomy learning journey, and to retain this volume of information in the digital era.

Due to the highly sensitive nature of working with donated cadaveric material and the associated professional standards and ethical considerations linked to this usage, it was necessary to develop a set of guidance to protect the dignity of donors, whilst simultaneously guiding educators, students and institutions on the manifold issues to consider when transitioning to online cadaveric teaching. The sensitive material (i.e., cadaveric images) would not normally be available to students on an ad hoc basis on their own devices. As this content still needed to be covered to ensure the healthcare professionals received all of the necessary training they needed to practice their profession safely and keep patients safe, questions arose around the potential for covert screen-capture, unauthorised viewing and wider sharing of cadaveric content. Such breaches of professionalism have widespread implications, not merely for the course and programme but potentially for the institution. It became clear that it was necessary to collate clear guidance for staff and students to steer through the digital landscape.

Developing an In-house Digital Code

An in-house digital code was developed as part of the SDS Digital Delivery Working Group – a student-staff collaboration that convened over summer 2020 to specifically mitigate for any anticipated issues that could arise from the shift to online delivery for both students and educators within the School. Three different digital codes were created, each in the form of a holding slide that could be utilised in (1) Cadaveric Anatomy Teaching, (2) Clinical Teaching and (3) Seminar or Lecture-based teaching situations. These slides were circulated to the FMS TEL Group and then circulated for feedback from the other Schools that grapple with similar concerns around donor dignity and patient confidentiality. A basic confidentiality agreement was later put in place institutionally, but this was not specific to anatomy or teaching involving potential breaches of patient information. It was felt that, in the new era of digital delivery, it would be more beneficial to reinforce the message of a common digital code at every learning encounter to clearly communicate to students the expectations and behaviours appropriate for this form of teaching. For this purpose, the Digital Code for anatomy was developed, with the aim of utilising it as a holding slide for every synchronous encounter, and as a recorded slide at the start of each non-synchronous session that included cadaveric content.

Digital Code in Practice

The Digital Code slide is displayed at the beginning of every teaching session, whether synchronous or non-synchronous. In synchronous sessions, it is used as the ‘holding slide’ displayed as students enter the video call. When teaching begins, the slide is also reinforced verbally to signal the start of the learning and shared professionalism code of conduct. In practice, it may feel that the points around ethical standards and professionalism are somewhat overemphasised but, given how important they are, the Digital Code does bear repeating. In non-synchronous sessions, a pre-recorded initial slide is added to every lecture recording to reinforce the message not to view the recording in public and to adhere to the digital code. This is added to all recordings from all contributors.

The slide shows 10 dos and don'ts. Do find a quiet place for viewing, switch off from other devices and social media, be mindful many are working from home and disruptions may occur, focus on the session at hand, mute yourself when not speaking and unmute yourself when speaking, raise your hand if you want to ask a question, switch your camera on if possible when speaking. DO NOT view this material/session in a public place, breach confidentiality, take screenshots, use and screen-recording or recording devices to capture these sessions, share material from the sessions, post or discuss sensitive material on social media
The Digital Code slide (download .ppt slide at the end of the post)

The Digital Code slide gives a simple overview of both the required professional behaviours for healthcare professionals and unacceptable behaviours, bringing the more abstract guidance document into clear actionable focus. As a result, students are very clearly aware of the professional expectations expected of them in their chosen field of study, and these regular reminders serve to reinforce this. This is much more effective than simply citing a document which may have only been seen once at the beginning of the course. The existence of this Code is beneficial not only for students who, it is hoped, develop a sense of responsibility with the access to sensitive content, but also for donors, teachers and institutions who can rely on clear guidance but also appreciate that institutions have pre-defined consequences for any breaches – of which none have been reported thus far. Students have displayed high levels of professional conduct throughout the anatomy teaching in SDS and have adopted the digital code without any apparent reluctance or challenges. It is highly likely that, once students return to physical classrooms, this practice will be continued and developed.

Taking it a step further: Developing National Guidance for Online Cadaveric Imaging

Due to manifold misunderstandings on the legislation and guidance around the use of cadaveric images, it became clear at an informal National Designated Individual (DI) / Head of Anatomy Forum (convened to improve communication during the pandemic and consisting of heads of anatomy units and DIs from across the UK, as well as representatives of the regulatory bodies from each country) that educators could benefit from a unified front with regards to digital cadaveric education. A small group from within this informal forum (consisting of representatives from Brighton Sussex Medical School, Newcastle University and University of Nottingham) collated anecdotal and professional experiences with patient confidentiality and social media guidance documentation and developed a three-pronged approach to using cadaveric content online. The first step was to search for guidance from the relevant professional bodies. The Human Tissue Authority (HTA), the national body who regulate teaching related to cadaveric specimens in England, is virtually silent on the use of images of a cadaveric nature, and decisions relating to how images can be used are made by the local HTA DI within institutions. There is also a paucity of guidance on image usage in this context from the devolved nations’ regulatory bodies/inspectors. Some institutions do have some guidance around social media and images, but there is no unified and unambiguous guidance on cadaveric teaching in the online era.

The draft guidance document was circulated to the DI Forum and to the HTA for comments and the final document amended with suggested changes. The current version, along with a suggested PowerPoint slide, is already utilised at SDS for teaching purposes. It has recently been presented at the March 2021 meeting of the Trans-European Pedagogic Anatomical Research Group (TEPARG), at which it proved very popular across the European countries represented, and has been widely lauded for its clarity and utility during this period of intense change. The guidance document, with the digital code appended to it, is now in use across many institutions nationally and internationally and is being reviewed for formal dissemination.

Resources

Human Tissue Authority

TEPARG – Trans-European Pedagogic Anatomical Research Group

Newcastle University Digital Etiquette Guide

Newcastle University Staff – Join our Canvas Community for access to all resources

Download the Slide and Guidance from our Canvas Community

Dealing with extra sensitive data in the Medical Learning Environment (MLE)

Most FMS sites run by the unit contain and maintain personal data that needs to be kept private. Techniques such as securely certified websites and authentication/authorisation portals are usually sufficient in keeping this data safe.

The Challenge

With the introduction of the new year 4 in the MBBS curriculum and the move to more blended learning, a higher degree of sensitive data was required to be stored on the Medical Learning Environment (VLE for MBBS). Year 4 students are now asked to keep electronic records of patients and interactions as part of the Advanced Clinical Experience module. This data contained personal contact details such as address, telephone and email of patients the students would follow on the clinical journey, and let them reflect upon this experience throughout year 4.

So before the start of Year 4, in the summer of 2020, we investigated and implemented an enhanced way of storing this patient information in the MLE.

The Solutions

First we investigated how the data was stored in the backend database. Most information is stored in databases as unencrypted data due to the lack of sensitive nature of the data.

This new data required something else. It was decided that parts of the data that could contain personal patient information should be encrypted, both in transit and at rest.

For parts of the ACE model (the data structure we use for the ACE section of MLE) we replaced the open text fields with this new encrypted field. This now meant that when data was entered and saved, before it was added to the database, the system would replace the open text with a encrypted data set using a secure key. To read the data again it would need the use of the decrypt method, that only the MLE could do by using the secure key.

The second part we investigated was to detach any personal patient information from the student’s reflections. Once the student had completed the recording of the patient’s details, the direct link in the website was removed and generic patient information used from that point onwards to identify the individual records. This kept the sensitive information separate from the day to day recording of patient interactions.

The students also uploaded consent forms signed by patients who agreed to take part in the ACE module. Final versions of consent forms highlighted that these would also contained sensitive information.

After further investigation the development team included these static files in the encryption methods used to support ACE. In order to allow students to verify the uploaded consent forms, the MLE allows a short window before encryption and archiving of consent forms takes place. Once this process completes the consent forms are no longer accessible via the website (MLE) and recovery if required is performed by a limited number of staff in FMS TEL.

These methods used may be a little extreme for the day to day data stored on most FMS sites, but the investigations and lessons learned from the ACE data has provided us with options for other sites in the future.

If you are interested in this topic and wish to learn more, please contact:

Dan Plummer, Learning Technologies Developer, dan.plummer@newcastle.ac.uk

John Moss, Technology Enhanced Learning Manager, john.moss@newcastle.ac.uk

Randomness

As part of our Humanising the Online Experience webinar, we suggested the use of name selectors to take the decision-making out of selecting a student to answer a question. We recommend you use this only when you have gotten to know your students well enough to know how they respond to being asked questions by name. Using a randomiser tool can also reduce the feeling that the teacher is ‘picking on’ a particular student too often – both for the teacher and the students!

There are a lot of online tools available, such as:

The slight hitch with using these is that they are not reusable – you need to paste the names in every session.

It’s possible to create one of these yourself using Excel, which you can then save and re-use for the class time and again. A 2-minute tutorial for this, and an example file, is available on the FMS TEL Canvas Community. If you haven’t got access to that community in your Canvas yet, first enroll here.

Of course, you can use these tools for more than just selecting names. You could use this to randomly assign cases for students to study, or assign group roles. You can use them to generate lists of anything in a random order by noting outcomes.

During icebreaker games or other tasks, you may want to try a heads-or-tails or dice-roll randomiser, and there are many other randomising tools available on Random.org.

Case Study: Adapting a course for a larger cohort

Guest post by Sue Campbell from the FMS Graduate School, Module Leader for ONC8024: Chemotherapy Nurse Training.

The Challenge

In December 2020, we were informed that Lancashire Health would be sending their Nursing students to study our course, which was due to start in February 2021. We had already seen an increase in our own numbers so with these additional students we were going to be expecting a much larger cohort than usual. The increase was in part due to the COVID situation and study leave cancellation in the NHS. We needed to investigate if the course structure would be suitable for 50 students instead of the usual 10-15 we had taught in previous years.

What did you do?

We reviewed each activity and imagined how it would work with 50 students. Activities that students completed on their own such as crosswords and quizzes were fine. 

Our main concern were the collaborative wiki tasks – these are pages within Canvas, usually involving a table, that students completed together to create a resource. We wanted to keep these tasks as they encouraged teamwork, but the tasks were not suitable for 50 students to be able to contribute. After discussing the problem with others who have experience of working with larger cohorts we came up with a solution. 

With help from the FMS TEL Team we were able to separate the students into groups of 10-15 students and provide each group with their own collaborative wiki task to complete. Once the course began we experienced registration issues so students were all starting at different times. We decided to adjust the groups so the late starting students would be in the same group and would not feel left behind.

“It’s about finding solutions you are not aware of; groups was a really quick and effective fix for what I envisioned to be a much larger problem.”

We wanted to keep the discussion tasks as they worked well in the past but would they work with large numbers? We went through each discussion task and made changes. 

Where we had previously asked students to discuss three points, we changed so students could choose one discussion they could take part in but were able to view all discussions. 

Modified Discussion Board: Before and After

We decided to change the scenario discussions into branching activities instead. The questions asked in these discussions had only one right answer and were more of a fact checking exercise than something the students discussed. Students could complete the branching activities independently, so cohort size did not matter, but the objective of the task was still achieved. We also added a presentation to summarise the learning from the scenarios which replaced the interaction from the Module Leader that would have usually occurred on the discussion board at the end of the week.

Branching Activity

Tips

  • Ask for advice – I spoke with the FMS TEL and Programme Teams and they provided several solutions I wasn’t aware of. I also spoke with our DPD, Victoria Hewitt for marking help
  • Consider running the module twice a year if numbers/demand remains too high to sustain within one cohort
  • Branching activities will work regardless of numbers so we can easily roll those over year after year now
  • Groups in Canvas is easy to turn on/off and adjust depending on numbers

What might you do differently next time?

We shall wait and see the student feedback but we are currently in week 5 of the course and so far it is going well and the group work is successful. Some things we are thinking about are:

  • We have a lot of activities, but they are now largely peer to peer or independent tasks so to bring back the teacher presence I would like to include more videos and presentations
  • We do provide a general Q&A discussion board, and for the rest of the course we are also introducing fortnightly, 10 minute 1:1 Q&A bookable slots via zoom for any students preferring a one-to-one discussion with the tutor.

Resources:

FMS TEL Webinar – Humanising the Online Experience

This webinar ran twice on 11th March 2021, and we were happy to see colleagues from across the faculty and NUMed in attendance.

The webinar covered:

  • Setting and maintaining expectations for online teaching and interactions.
  • How to make your synchronous sessions feel more like PiP interaction.
  • Simple strategies to be more present in non-synchronous aspects of your course.

You can find the resources from the webinar – including the recording and links to further reading – on the FMS TEL Community in Canvas.

View all FMS TEL Webinars

Ethical Framework for Digital Teaching and Learning

In December 2020 I had the opportunity to attend the Association for Learning Technologies’ Winter Conference. One of the presentations at the conference really struck a chord with me and I would like to share a synopsis of what was discussed.

Presenters Sharon Flynn, Natalie Lafferty, John Traxler, Bella Abrams, and Lyshi Rodrigo sat on a panel discussing an Ethical Framework for learning technology. They discussed what they perceived as the biggest issues around ethical teaching and learning digitally.

One of the primary concerns driving the development of an Ethical Framework is the inevitable power relationship learning technologies create between teachers and their students. For example, how can monitoring work in the right way, where it is not there as a policing tool, but rather as a tool for aiding engagement and learning. One of the panellists suggested a simplified form of terms and conditions could go a long way to pacifying student concerns over any form of monitoring.

There are inherent principles about trust and reliability in the digital world. This is evident in many sectors but likely not more than in the surveillance culture of the digital world. We have, therefore, the responsibility to help protect students, and colleagues, as we become more aware of ethical challenges in the digital world.

Another concern relates to fair access. What ethical role does the institution have in ensuring all students have access to the digital tools, such as laptops and broadband internet? What is considered adequate and equitable? How logistically can this be accomplished? And, this is not simply a problem for students. Some teachers will also experience digital tools poverty. This would also include training for students and teachers in the systems, programs, and tools they would be expected to use. (Something that Newcastle University is working hard to ensure exists to support students and teachers in the unique set of circumstances following of from Covid-19.)

Another question brought up was what constitutes harm? This question would be at the heart of an Ethical Framework. How do we as institutions identify harm caused by digital teaching and learning and mitigate it? For example, how does proctoring and the use of e-resources impact students. What about productivity measures? These could potentially be arbitrary and misrepresent what really matters. Some people think these are easy solutions for the current challenges, but they invite the need for an Ethical Framework.

The implications of GDPR and its potential successor also impact the need for an Ethical Framework. Professional bodies are not necessarily thinking of the problems related to approaches like proctoring. So, any Ethical Framework must be rooted in context of principles and be ever aware of the needs and where importance lies withing various other cultures.

This all leads to the need to develop an Ethical Framework for teaching and learning digitally. The panellist suggested that we start from a position of respect and use our values to build an Ethical Framework including student voice.

This summary of the impetus and content of what may be needed in an Ethical Framework for teaching and learning online is certainly worth considering as we enter into the new normal that will likely contain more online teaching than we had pre-Covid. I would be interested to hear (reply below) what you think about what the ALT panellists had to say and what your views on such an Ethical Framework should and could be.