Curricular Delivery Redesign
Intentional curriculum design aimed toward preserving all aspects of the program, including role socialization, peer support, and faculty mentoring in addition to the clinical content, was critical to maintaining the quality of the program. The faculty team researched available platforms for elearning. Sources used included a review of literature and benchmarking with local nursing and medical education experts, primary and secondary school teachers, and members of the health care system who were familiar with innovative virtual learning platforms. Different faculty members identified potential virtual platforms. A use case analysis was then conducted by the team using the proposed virtual platforms to allow all faculty the opportunity to test the access as well as to experience the platforms in action. Nontraditional learning modalities and supplemental educational resources were also identified to promote discussion and align with the recommendations by Molloy et al. (2019) on keeping elearning strategies to a short (less than 15 minutes) duration followed by an assessment and faculty feedback. Each learning modality was evaluated using the following criteria: features of the platform, accessibility, ease of use, and cost (Table A; available in the online version of this article).
Learning Modality Criterion Evaluation
The review of available features on each virtual learning platform served as the initial evaluative component for the use case. Captivating, innovative platforms were prioritized as a means to gain learner interest, engagement, and attention. A basic PowerPoint® program with voiceover for a standard didactic lecture exists; however, some platforms offer features that increase the visual stimulation to promote learner engagement. Vyond is a program, for example, that allows the creator to use animation and music to translate a traditional presentation into a story that comes to life (Vyond, 2020). Prezi™ is another example of a presentation platform that uses stimulating graphics and allows video recording of faculty during the presentation to allow for a product that demonstrates increased engagement and effectiveness over traditional PowerPoint (Moulton et al., 2017). Screen-castify is a web extension exclusive to the Chrome web browser that allows users to record their computer screen in real time into a high definition video (Screencastify, 2020). Following the creation, the screencast is downloaded into Google™ Drive and a hyperlink is used for sharing. Preference was given to platforms that were intuitive for users and required few instructions or tutorials.
As the curriculum was converted into elearning, both asynchronous and synchronous education was created. Canvas was selected as the online learning management platform. The platform was free to educators and students/fellows at OSF HealthCare, as a contract/user agreement was already in place. Program faculty created a course, using Canvas to upload documents and create a program schedule with assignments and modules.
One of the most valuable and innovative platforms for this fellowship's elearning was Flipgrid. This web-based and app-based video platform is being used weekly to maintain curriculum in role transition, mentoring, and simulation. After creating a “grid,” or class, for the advanced practice provider fellowship, faculty were able to create a topic of discussion using a written or video-based prompt. Fellows were then able to record a short video (length set by faculty, from 15 seconds up to 5 minutes) to discuss assigned content for the week. Recorded videos are only available to faculty and other fellows in the program. A traditional in-seat weekly session titled “Highs and Lows,” where fellows articulate the best and worst aspects of their last week, either personally or professionally, has been converted to Flipgrid. This activity has been a critical component to continuing the peer mentoring and role transition standards of the program. Fellows and faculty can reply to each post, adding to the interaction and engagement. An ongoing Flipgrid topic titled “Role Transition” is continually available for fellows to post a video journal related to a struggle or challenge they are facing in practice.
Another innovative use of Flipgrid was the creation of case-based simulation experiences. Historically, a simulation for this program includes the use of a standardized participant, or actor, to play the role of the patient. In the prepandemic state, the standardized participant memorizes a script of the patient history and key examination findings, elicited by a fellow over the course of a 15-minute visit. During the pandemic, simulations were created using abbreviated standardized participant scripts, limited to a chief complaint and a brief history in a 2-minute recording using the Flipgrid platform. Using the Canvas learning management system, the Flipgrid simulation case was assigned to fellows for viewing, immediately followed by a private, faculty-proctored question-and-answer session where the fellows can inquire about additional details of the history and physical examination findings, leading them to a final diagnosis and plan of care. The entire case is completed within 15 minutes, aligning with the time allotted for simulation and reflective of the scheduled visit time of 15 to 20 minutes for acute visits in a typical ambulatory clinic.
A new cohort of fellows was onboarded during the transition to elearning. Usually, fellows are greeted in person by their senior cohort of fellows as they create a unique and memorable first day. Through Flipgrid, the senior fellows recorded a Flipgrid topic about their experiences as a new provider to help normalize the fears that new fellows may be facing.
In addition to scheduled lectures, prerecorded voice-over presentations were created using the aforementioned platforms Vyond and Screencastify. Both platforms were chosen for their captivating visual content and ability to be used for various content. A novel tactic for the use of Vyond was the creation of an animated, visually stimulating short film that depicted the steps to creating SMART (Specific, Measureable, Attainable, Realistic, Time-bound) goals (Doran, 1981). The fellows were assigned viewing of the Vyond video through a hyperlink embedded in Canvas and were then asked to create their own SMART goals. Screencastify was used to create short presentations (under 10 minutes to facilitate engagement) followed by a group discussion assignment through the Canvas discussion board. Another use of Screencastify for the advanced practice provider fellowship during the pandemic was to teach the primary care providers the nuances of the Medicare wellness examination by visually demonstrating how to document the visit in the electronic medical record.
As faculty considered ways to engage fellows and stimulate conversations in unconventional asynchronous learning modalities, podcasts were explored as a viable option based on feedback from previous fellows. Podcasts can augment current content covered by program faculty and create self-directed learning (Hurst, 2019). One example was a medical podcast hosted by an infectious disease physician, taking the listener through an interesting patient presentation and clinical course. Another assigned podcast by a professor of clinical neurology walked through causes, differentiation, and treatment of tremors. In each case, the fellows were assigned to listen to the pod-casts and engage in group discussion or debate on Canvas to provide reflection and embed learning.
To incorporate the program content of professionalism, TEDTalks were used to stimulate learning. TEDTalks are engaging lectures under 18 minutes with a goal of generating ideas and conversation (TEDTalk, n.d.). Fellows were asked to choose a TEDTalk to summarize and then respond to others in a Canvas-housed discussions. Fellow choices ranged from learning how exercise impacts neurological function to debating on whether health care systems are prepared for digital health. Expanding discussion threads of learner responses demonstrated the effectiveness of learning and achievement of the curricular objectives.
Preliminary feedback has been collected in the 4 weeks since implementing the curriculum online. Kirkpatrick's and Kirkpatrick's (2016) programmatic evaluation is historically used for this fellowship program, and Level 1 (reaction) and Level 2 (learning) data were collected anonymously from the fellows during elearning. Written permission was obtained from all fellows for sharing of aggregate data. All virtual platforms have achieved a mean score of 4.6 or higher on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) in regard to ease of use and a benefit to learning. Table 1 includes a brief synopsis of evaluative feedback using fellow responses. All the fellows adapted well to the multiple virtual platforms and required minimal technical assistance to access. The Canvas learning platform had occasional glitches that necessitated a restart of the program, possibly due to increased Internet usage nationally. Some fellows in more rural locations had difficulty uploading Flipgrids given limited broadband Internet speed and required a second attempt to upload their videos successfully.
Preliminary Feedback From Fellows Regarding Virtual Learning Modalities
Anecdotal faculty observations indicate the Flipgrid simulation was beneficial for fellow learning and provided a degree of realism to patient case studies. While faculty determined that learning objectives were achieved through fellow performance and discussion, it is not a replacement for the interaction achieved in a traditional simulation.
The ANCC requested each program director to submit an action plan for compliance with Practice Transition Accreditation Program standards during the COVID-19 pandemic. The ANCC response to our submission was noted as the following: “The OSF HealthCare Primary Care Fellowship Program despite these uncertain times has developed strategies to maintain the integrity of their fellowship through innovation, creativity, and collaboration. They are demonstrating compliance with the standards while also excelling their program forward with innovation during this pandemic” (L. Pierce, personal communication, April 22, 2020). Formalized programmatic quality outcomes derived from midprogram and end-of-program evaluative measures, as well as the comprehensive competency evaluation rubrics, will continue to be used as more definitive measures of success for the program and its changes in curricular delivery.