Teaching Stroke Classification

Shaarna Shanmugavadivel
University of Nottingham, UK

Presented at LIMSC, 2007 (Leiden, Netherlands)

and AIMS, 2007 (Bristol)

Ageing and Rehabilitation

 What’s on the table?
 Why this project is important – background

 What the project entailed - project definition

 How it was carried out – methodology

 What did we find? – Results

 Conclusions

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3rd year BMedSci
dissertation
 How important is STROKE?
 THIRD largest cause of death in the UK

 First stroke- 130,000 people in England and

Wales each year
 equivalent to one stroke every five minutes

 single leading cause of severe disability

in the UK

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 Teaching of stroke
 Core topic on HCE curriculum (4th yr)
 BUT clinical diagnosis is not formally taught in
introductory lectures
 tutorials by frequently changing staff at
different sites

 a risk that not all students will gain a core

understanding of stroke diagnosis?

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 Methods of teaching
 Tutorial (current)
 Lectures
 Clinical sessions (ward-based teaching)
 Computer-assisted learning (CAL)
- Lots of evidence FOR computer
assisted learning

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 CAL
 CAL: ‘the process of providing written and visual
information in a logical sequence by the computer, the
focus of which is on instruction’-(Florey 1988)
 allows a self-paced, self-directed approach

 promotes deeper and more retentive learning (Coles

1998)
 immediate feedback and choice to repeat the same
tasks until perfected- consistent teaching
 BUT lack of objective evidence about its
effectiveness in terms of the transfer of
knowledge to the learner (Sittig et al., 1995)

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 AIMS AND OBJECTIVES
 AIM: to develop and evaluate a teaching
package for fourth years on Stroke Classification

 AIM of CAL package: To understand how to

make the diagnosis of stroke using the Oxford
Stroke classification

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 OBJECTIVES
 of CAL package:
To develop an understanding of the different symptoms
and signs seen in stroke

To be able to classify the type of stroke using the Oxford

Stroke classification

To relate the clinical diagnosis to the likely anatomical

lesion and pathology

To understand the importance of the clinical

classification in estimating prognosis

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 RESEARCH QUESTIONS
 Is Stroke diagnosis and classification being
taught adequately enough for students to gain
a core understanding of the concepts?

 Is the addition of CAL delivered

teaching superior to usual traditional teaching
of stroke classification?

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 METHOD
 PHASE 1: Develop an outcome measure, pilot +
make CAL
4 domains
KNOWLEDGE: MCQ assessment
AMOUNT OF TEACHING: on scale 1-5
CONFIDENCE: on scale 1-5
SATISFACTION: on scale 1-5

 PHASE 2: Evaluating the CAL

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 PHASE 1: pilot study
 To answer the first research question
 Power calculation- check sample size to reduce
risk of Type ii error
 Face validity and test-retest reliability using
kappa stats
 All anonymous to avoid bias
 n=36

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 RESULTS OF PILOT
 How much teaching did you receive? 36.1 %
said NONE

 How confident do you feel with classification?

88.9% said UNCONFIDENT

 How satisfied are you with the teaching? 57.1 %

said DISSATISFIED

 For the MCQS- MEAN was 36%

 a ‘soft fail’ in med school terms!
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 POWER CALCULATION
 A two group t-test with a 0.05 two-sided
significance level will have 80% power to detect
the difference between a Group 1 mean of 7.2
and a Group 2 mean of 12, assuming that the
common standard deviation is 5.3, when the
sample sizes in the two groups are 44 and 13,
respectively (a total sample size
of 57).

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 RELIABILITY
 One forum: assessment completed at beginning
and end by same students
 Cohen’s un-weighted kappa statistical test
 observed agreement between the 2 groups:
91.84%, (expected agreement only 27.36%).
 kappa value >0.4 = acceptable
 kappa value for this= 0.89
 This showed good test-retest reliability of
the assessment.
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 PHASE 1: making CAL
 Consists of factual knowledge, real patient
videos, assessments

 Led by Heather Rai

 http://www.nle.nottingham.ac.uk/websites/stroke/

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 PHASE 2: Evaluating the CAL
 3 HCE attachments from Oct-Dec

 1st two: TUTORIAL ONLY (controls)

+ 36 from pilot
 Third: CAL package + TUTORIAL (intervention)

 Reduces risk of contamination

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 RESULTS
 Control n=76 (92), Intervention n= 23 (28)

 Attrition due to non attendance and failure to

implement assessment

 Power calc: 44,13

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 Primary outcome measure
KNOWLEDGE - Mean score out of 20

 CONTROL: mean of 9.87 (8.6-11.1)

 INTERVENTION: mean of 13.26 (10.9-15.6)

 Normally distributed + equal variances

 2-tailed t-test gave mean difference
of 3.39 (0.77-6.0), p=0.0116
(p< 0.05)

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 Secondary outcome measure
 Categorical: perceived amount of teaching,
confidence and satisfaction
 Chi-squared test

 Perceived amount of teaching: 14/23 (60.1%) of

intervention group felt they had enough/plenty of
teaching compared to 24/76 (31.6%)
controls, p = 0.012.

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 Secondary outcome measure
 Confidence: 12/23 (52.2%) of intervention group
were confident, compared to 13/76 (17.1%) in
the control group, p= 0.0018.

 Satisfaction: 14/22 (63.6%) students in

intervention group were satisfied with
teaching, compared to 26/74 (35.1%)
of controls group, p=0.017.

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 Feedback from CAL
 19/19 students enjoyed using the website.

 11 left a free-text response

 7=100% positive feedback, two= constructive
criticism based on areas for improvement and a
further two pointed out minor errors

 Analysis: useful, helpful and

enjoyable, especially videos and
assessments
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 Conclusion
 The addition of CAL in this study enhanced
knowledge acquisition, perceived satisfaction
and confidence in diagnosing and classifying
Stroke.

 Students’ feedback: that this particular CAL

could replace the tutorial completely;
however, this must be explored by
further study.

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 References
 FLOREY C du V(1988) Computer assisted learning in British
Medical Schools; Med Educ. May; 22(3): 180-2

 COLES (1998) The process of Learning in: Jolly B, Medical

education in the Millennium; Oxford University Press, New York

 VOGEL M, WOOD D (2002) Love it or hate it: Medical students’

attitudes to computer assisted learning; Med Educ; 36; 214-5

 SITTIG DF et al. (1995) Evaluating a computer based

experimental learning simulation; Computers in nursing;
13 pp17-24

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 THANK YOU!
 Any questions?

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