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Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017)
84–93
Contents lists available at ScienceDirect
Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
j ourna l ho me pa g e: ht tp : / /www.e lsev ier .com/ locate /
ze fq
Schwerpunktreihe / Special Section ,,Peer Assisted
Learning‘‘
Cross-year peer-assisted learning using the inverted
(‘‘flipped’’)classroom design: A pilot study in dentistry
Cross-year-Peer-Assisted Learning im
Inverted-Classroom-Szenario: Pilotprojektaus der Zahnmedizin
Maximilian Quoßa, Stefan Rüttermannb, Susanne
Gerhardt-Szepb,∗
a Dermatologie und Allergologie, Kantonsspital Aarau, Aarau,
Schweizb Poliklinik für Zahnerhaltung, Carolinum Zahnärztliches
Universitäts-Institut gGmbH, Goethe-Universität Frankfurt am Main,
Frankfurt am Main
a r t i c l e i n f o
Article History:Received: 3 April 2017Received in revised form:
1 July 2017Accepted: 14 July 2017Available online: 11 October
2017
Keywords:peer-assisted learninginverted classroom
modelICMe-learningPOLdentistrytutoringtrainingmentoring
a b s t r a c t
Background: The inverted classroom model (ICM) represents a
special combination of online and atten-dance learning. The
implementation of the didactic concept of ‘‘peer-assisted
learning’’ (PAL) within anICM design has not yet been described in
the literature for the field of restorative dentistry.Objective: It
was the goal of the present study to develop an ICM offering in a
cross-year PAL format(ICM-cyPAL), and then introduce and evaluate
it.Method: The pilot project was conducted at the dental clinic at
the Goethe University of Frankfurt/Main,where following its
conceptual development and implementation with three consecutive
cohorts ofstudents in their first clinical semester (the sixth
semester at university) the ICM-cyPAL offering wasevaluated. Data
on acceptance, tutor effectiveness, group interaction models and
learning strategies werecollected using an evaluative
instrument.Results: 121 students (tutees) participated in three
cohorts. The response rate reached 98.3 %. In total,the offering
was given an average rating of 6.97 ± 1.93 (from 1 = unsatisfactory
to 10 = excellent). As thetutees explained the attention that the
tutors employed gave to the group was ‘‘just right’’ (4.65 ±
1.04;where 1 = too controlling and 4 = just right to 7 = left the
group on their own too long) and talked ‘‘justthe right amount’’
(4.54 ± 0.95; where 1 = too much and 4 = just right to 7 = talked
too little). The resultsfor tutor effectiveness reached values
between 3.26 ± 0.94 and 3.78 ± 0.87; for the evaluation of
groupinteraction models average values were obtained from 3.41 ±
0.98 to 3.89 ± 0.73 (on a Likert scale of 1 =do not at all agree to
5 = completely agree). Concerning the surveyed learning strategies,
the dimensionsof ‘‘resource management’’ and ‘‘implementation of
the learning materials’’ were given the highest andlowest rankings,
respectively.Conclusion: The tutees’ ratings of the newly developed
and implemented ICM-cyPAL offering in thedental context were mainly
positive. The thematic orientation of the structured training
program needsto be optimized. The offering itself requires both a
high degree of organization and solid financial andstaffing
resources.
∗ Corresponding author: S. Gerhardt-Szép, Poliklinik für
Zahnerhaltung, Carolinum Zahnärztliches Universitäts-Institut
gGmbH, Goethe-Universität Frankfurt am Main,Theodor-Stern-Kai 7,
60596 Frankfurt am Main.
E-mail: [email protected] (S. Gerhardt-Szep).
http://dx.doi.org/10.1016/j.zefq.2017.07.0071865-9217/
dx.doi.org/10.1016/j.zefq.2017.07.007http://www.sciencedirect.com/science/journal/18659217http://www.elsevier.com/locate/zefqhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.zefq.2017.07.007&domain=pdfmailto:[email protected]/10.1016/j.zefq.2017.07.007
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M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
126 (2017) 84–93 85
a r t i k e l i n f o
Artikel-Historie:Eingegangen: 3. April 2017Revision eingegangen:
1. Juli 2017Akzeptiert: 14. Juli 2017Online gestellt: 11. Oktober
2017
Schlüsselwörter:Peer-Assisted
LearningInverted-Classroom-ModellICME-LearningPOLZahnmedizinTutorenSchulungMentoring
z u s a m m e n f a s s u n g
Hintergrund: Das Inverted-Classroom-Modell (ICM) stellt eine
besondere Kombination zwischenOnline- und Präsenzlernen dar. Die
Implementierung des didaktischen Konzepts des
,,Peer-AssistedLearning‘‘ (PAL) innerhalb eines ICM-Szenarios ist
bis dato im Fach Zahnerhaltungskunde nicht in derLiteratur
beschrieben.Fragestellung: Ziel der vorliegenden Studie war es, ein
ICM-Angebot im Cross-year-PAL-Format (ICM-cyPAL) zu konzipieren,
einzuführen und zu evaluieren.Methode: Das Pilotprojekt wurde an
der Zahnklinik der Goethe-Universität Frankfurt am Main
durchge-führt, indem nach der Konzeption und Implementierung bei
drei aufeinanderfolgenden KohortenStudierender in ihrem ersten
klinischen Semester, dem sechsten Fachsemester, das Angebot des
ICM-cyPAL evaluiert wurde. Daten zur Akzeptanz,
Tutoreneffektivität, Gruppeninteraktionsmuster undLernstrategien
wurden mittels eines Evaluationsinstrumentes erhoben.Ergebnisse: In
den drei Kohorten nahmen 121 Studierende (Tutees) teil. Zur
Evaluation wurde eineRücklaufquote von 98,3% erreicht. Als
Gesamtbeurteilung für das Angebot wurde im Mittel der Wert6,97 ±
1,93 (von 1 = ungenügend bis 10 = exzellent) vergeben. Die Tutees
gaben an, dass die eingesetztenTutorInnen sowohl ,,genau richtig‘‘
die Gruppe betreuten (4,65 ± 1,04; wobei 1 = zu bestimmend über 4
=genau richtig bis 7 = ließ die Gruppe zu sehr laufen) als auch
,,genau richtig‘‘ redeten (4,54 ± 0,95; wobei 1= zu viel über 4 =
genau richtig bis 7 = zu wenig geredet). Die Ergebnisse zur
Tutoreneffektivität ergabenWerte zwischen 3,26 ± 0,94 und 3,78 ±
0,87; zu den evaluierten Gruppeninteraktionsmustern wurdenWerte im
Mittel zwischen 3,41 ± 0,98 und 3,89 ± 0,73 (auf einer Likert-Skala
von 1 = stimme gar nichtzu bis 5 = stimme voll zu) vergeben. Bei
den abgefragten Lernstrategien gab es die höchsten Bewertun-gen für
die Dimensionen des ,,Ressourcenmanagements‘‘, die niedrigsten für
die ,,Implementation‘‘ desLernstoffs.Schlussfolgerung: Das neu
konzipierte und implementierte ICM-cyPAL-Angebot im dentalen
Kontextwurde seitens der Tutees hauptsächlich positiv evaluiert.
Optimierungsbedarf besteht im Hinblick aufdie inhaltliche
Ausrichtung der strukturierten Schulung. Das Angebot an sich
erfordert einen hohenOrganisationsgrad und eine gute personelle
bzw. finanzielle Ausstattung.
Introduction
The didactic concept of ‘‘peer-assisted learning’’ (PAL)
hasproved valuable for many years in dental training and can find
itsapplication [1–4] in various designs. Diverse variations [5,6]
existwithin the PAL format. For example, according to the
educationallevel the student tutors find themselves in related to
the fellowstudents (tutees) they are instructing, the terminology
includes‘‘same-year PAL,’’ ‘‘cross-year PAL’’ or ‘‘near PAL’’
[5,7,8]. A ‘‘near-peer’’ relationship stands in contrast to a
‘‘cross-year’’ if the trainers(tutors) and the trainees (tutees) in
regard to their educational levelare separated by less than one
year [8].
The term ‘‘cross-year’’ is accordingly used when both
areseparated by more than one year. A conclusive,
internationallyexplained and valid nomenclature for the individual
possible formsof peer relationships, whether these are related to
year of study orsemester, is not available. The literature
describes how structuredtraining by the tutors takes on an
especially important role in PAL.It is recommended that these
should be conducted by experiencedteaching personnel (docents,
mentors), since only in this way dothe tutors have the necessary
preparation in competence for theirwork in comparison to their
fellow students [5].
PAL can be used both in attendance and for online
offerings[9,10]. The flipped-classroom (or inverted-classroom)
model (ICM)[11–16] represents a special combination of online and
atten-dance learning. The implementation of the ICM model has
alreadybeen described both in dentistry and medical studies
[17–20]. Thisinvolves a particular kind of blended learning
offering, whereby aself-study online phase (individual phase) is
employed before theattendance phase [12,13]. In the online phase,
factual knowledgeis used as a rule, which serves as a foundation
for the attendancephase. The attendance phase should subsequently
be used for deep-ening the learned knowledge and applying it [12].
Previously, in atraditional setting of lecturing or attendance
instruction, factualknowledge has been used in instruction and
participants had todeepen and possibly apply this knowledge at home
[12].
ICM now switches the assignment of respective tasks to
indi-vidual phases [12]. The advantage here is the promotion of
active
learning [12]. In the self-study phase and the in-depth
discussionin the attendance phase, aspects of active learning
(e.g., teamwork,debate, and self-reflection) are encouraged [12].
Active learningincreases learning success, motivation, and positive
attitudes, andpromotes higher cognitive learning processes,
problem-solvingcompetence, and critical engagement with the
training content[12]. Thus, care should be taken that the trainees
avoid repeatingthe content of the online phase in the attendance
phase.
The course participants must understand that
independentpreparation for the attendance phase represents a
central part ofthe concept [12]. In the attendance phase, group
methods suchas partner work, group discussion, problem-based
learning (PBL),think-pair-share, active plenum, buzz group, or
snowballing, etc.,can be implemented [12,21]. Active, self-directed
learning is thecentral point of the offering. This has been often
examined in var-ious designs and described as a theoretical
construct consisting ofmultilayered models [22,23].
The offering of an ICM design in the context of dentistry at
theGoethe-University in Frankfurt am Main, which combines
onlineself-study phases with subsequent attendance instruction in
theform of PBL, has recently been cited by the German Rector’s
Con-ference as an example of Good Practice [12]. The PBL offering
of thesame institution was also examined with regards to
acceptance,observed tutor effectiveness and group interaction
models [24,25].This offering is based on a docent-centered setting
and was con-ducted by experienced dentists who have been active in
teachingfor a long time.
The distinctiveness of the further-developed ICM designdescribed
by Tolks [12] of the Frankfurt dental clinic lies in its PAL-based
performance. Cross-year peer tutors, who were prepared fortheir
activities in structured training before and afterwards, taketheir
roles as learning facilitators seriously. The docents take
onmentoring tasks to support the peer tutors during their active
workas learning facilitators.
It is the goal of the present work to present an evaluationof
the students in the previously described situation of the ICM-cyPAL
design. It is the first publication of this kind to be
evaluatedwithin the context of dentistry research. It is different
from
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(ZEFQ) 126 (2017) 84–93
previous studies by the Gerhardt-Szep author group [24]. First,
andmost importantly, because it employs an ICM design rather than
asole PBL offering. Second, learning was supervised by peer
tutorsrather than docents.
As a research collective, dentistry students in the first
clinicalsemester were chosen, with the following research questions
beingthe focus of the pilot study:
1. How do the students evaluate the dental ICM-cyPAL offering
andwould they also recommend it to their fellow students?
2. How do the students evaluate the activity of the cross-year
peertutors?
The supplementary research questions were:
1. How do the students evaluate the effectiveness of the
tutoringand the group interaction model in the ICM-cyPAL
offering?
2. How are the individual aspects of self-directed
learning(resource management, sequencing and implementation)
ratedby the students?
Method
Sample
The dentistry students (total number = 121) in their first
clinicalsemester (sixth university semester) were surveyed in three
sub-sequent cohorts (WS 2012 to WS 2013) after the conclusion of
theICM-cyPAL offering.
An ethics vote was deemed unnecessary after consulting withthe
university department’s ethics committee, since the evaluationwas
conducted in an anonymous manner.
Conception of the inverted-classroom design
The curricular form of the phantom course for restorative
den-tistry in Frankfurt am Main, which took place in the first
clinicalsemester (sixth university semester), corresponds to that
of ahybrid curriculum in which both conventional (lectures,
demon-strations) and modern instruction offerings
(inverted-classroommethods = ICM) were illustrated. In the on-site
concept, the latterrepresents a combination of electronic
(e-learning) and problem-based learning (PBL) (see figure 1).
The self-determined online learning portion refers to
thee-learning offering of the Frankfurt Dentistry Initiative (dt:
Frank-furter Zahnmedizinischen Initiative, or ‘‘FranZi’’). The
modulesthematized in this study (‘‘Toothache clinic: basic and
advanced’’)include a total of ten case vignettes, which can be
interactivelyworked on step by step. The offering is created with
an open-source authoring tool (WebKit Freiburg, Version 3.1/beta)
and canbe accessed on the internet without any access limitations
at thefollowing URL:
http://elearning.med.uni-frankfurt.de/zahnschmerzambulanz/.
Numerous elements, such as multiple-choice questions,
drag-and-drop, drop-down menus, drawing functions, video
clips,feedback, and tips are embedded in the offering. During an
intro-duction to ICM (see preparatory measures for the tutees),
thestudents receive exact instructions on how to handle the
elec-tronic patient cases by themselves, before the identical
‘‘patient’’from the e-learning offering is thematized in subsequent
PBL meet-ings by the group, along with additional content not
representedin the ‘‘toothache clinic.’’ The PBL instruction occurs
in the skillslab of the Department for Restorative Dentistry and is
conducted in
conformity with the standard established at the University of
Maas-tricht in 7 + 1 steps (figure 2) [24].
PBL steps 1 to 5 are worked through in the first meeting, the
6thstep (processing of learning goals) in self-study, and steps 7
and8 (reflection) in the second meeting after around a week. The
laststep includes the practical application of skills, whereby the
groupdemonstrates the total processed content practically on a
modelat up to four simulation units. The tutors also accompany the
laststep and thus transfer the theory into practical application.
EachPBL meeting lasts 90 minutes, with a total of 180 minutes of
collab-oration work per case on site in the group. The group
participantsare all ICM novices; the tutors, in contrast, already
have experiencewith ICM.
Tutees
All tutees are students of the phantom course for
restorativedentistry and are in the sixth university semester or
first clinicalsemester of dental medicine study. In their first
semester days,prior to the planned ICM offering, they receive an
oral introduc-tion (‘‘What does the ICM-cyPAL offering mean?;’’
‘‘Definition of theeight PBL steps;’’ ‘‘Time parameters;’’ ‘‘Tips
for literature research;’’‘‘Distribution of the following roles
within the PBL group: PC rep-resentative, timekeeper, discussion
leader, writer;’’ ‘‘Role of the cypeer tutors’’), which lasts about
45 minutes.
Tutors and mentors
A total of seven tutors are employed, of which four accompanythe
learners (active) in the PBL section of the ICM and three func-tion
as observers. The four tutors active in the group are in theeighth
(n = 2) or ninth university semester (n = 2) of dentistry study.The
three remaining tutors are in the training process, wherebytwo of
them belong to the seventh and one to the ninth universitysemester.
As graduates of the phantom course for restorative den-tistry in
the sixth university semester, all have already obtainedexperience
with the ICM offering and additionally receive struc-tured training
prior to their activity as tutors in the ICM. Thistraining includes
participating for one semester as an observer atongoing ICM
meetings.
Only after completing this training semester are they
inte-grated as active facilitators in the learning process. Part of
theone-semester observation is formed by the reflections of the
tutorgroup and the written completion of an evaluation sheet, the
useof which has already been published in conventional PBL
meetings[25]. In addition, a mentor who is a content expert and has
sev-eral years of experience with ICM offerings also takes part in
thePBL meetings. The mentors (n = 2) are all scientific colleagues
(den-tists) of the Department for Restorative Dentistry and observe
thecy tutors who are being employed. At the end of the meeting,
around of reflection takes place between the mentor, active cy
tutorand the cy tutor still in training. The Spiess evaluation
sheet [26]forms the basis of this round of reflection.
Mentor support for each individual cy tutor actively employed
inthe PBL accompaniment process is given at least twice in a
semester.After each PBL meeting, an exchange additionally occurs
betweenthe two cy tutors. According to semester level, the active
cy tutorson average are used 16 times as learning facilitators in
the PBLportion. A comprehensive training session is held once a
year forall persons implemented in the ICM concept, which is led
eitherby an internal specially qualified colleague (MME) or by an
exter-nal lecturer. The cy tutors were paid 10 EUR per hour, both
duringtheir training phase and later during their active employment
aslearning group facilitators.
http://elearning.med.uni-frankfurt.de/zahnschmerzambulanz/
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M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
126 (2017) 84–93 87
Figure 1. methodical overview (shown in a clockwise direction)
of the ICM cross-year-peer-assisted learning offering. It began
with the group classification (12:00 position),followed by an
individual online self-learning phase wherein the electronic
patient cases are worked on by students in a self-directed manner
(01:00 position). The onlinecase includes defined learning goals.
In offline group work (05:00 position), the students, accompanied
by the tutors, work on the case again under new aspects
(06:00position) and additionally define their own learning goals,
which are prepared in a second self-learning phase. In the second
group meeting (8:00 position), the content of theprevious
self-learning phase is discussed mutually and clarified. At the end
of this meeting is a practical implementation of the learned
content in SimLab (10:00 position).After completing the first case,
the second patient case is released (11:00 position).
PBL cases
Each group (maximum number = 8 students) works on a total oftwo
different PBL cases per semester. The content involves diagnos-tics
and therapy for toothaches (endodontics), which is thematizedin the
oral summative end-of-semester examination. Each PBL caseincludes a
total of eight learning goals, which are only known to thetutors
and mentors.
When constructing the PBL vignettes, care is taken that these
arerelated to the corresponding e-learning case that will be
processedby the students in the online phase prior to the PBL. At
the sametime, the PBL cases include additional requirements for the
pre-pared e-learning content, the solution of which will be
interpretedin the group, such that the individual online work is
actually
carried out. The groups are accompanied by the tutors in a
non-directed manner. This role formation is implemented [24,25]
basedon Gerhardt-Szép.
Description of the survey used
A survey is used as an evaluative instrument, which was cre-ated
on the basis of the Gerhardt-Szép publication [24,25]. In thefirst
portion (n = 18), the survey determines general informationon age,
gender, grade on the dentistry pre-examination, number ofprocessed
online cases, if or whether they recommend the learn-ing unit to
other students, and what rating they would give to the
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88 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen
(ZEFQ) 126 (2017) 84–93
Figure 2. Steps 1-8 of the Frankfurt PBL portion, conceived
based on the Harvard or Maastricht requirements, which were offered
to the students in ICM format.
online offering. Six items are chosen from the 18 to answer
theresearch questions.
In the second part (n = 7 questions), the concept of the
inverted-classroom model (ICM) is evaluated. The third part (n =
86)poses questions on personal style of learning based on
Aeppli[22]. To answer the research questions, items are selected
thatexamine sequencing (step sequence and relaxation phase
plan-ning), implementation (structuring and elaboration) and
resourcemanagement (information gathering, collaborative work
andaid).
The last portion (n = 60) thematizes questions on tutor
effec-tiveness, group interaction models, and the PBL, which
traceback to studies by Dolmans, Visschers-Pleijers and
Gerhardt-Szep[24,25,27,28]. Thus it evaluates all items (n = 12)
affecting both tutoreffectiveness and the group interaction model
(n = 12). In exam-ining the PBL concept, n = 13 items are taken
into account thatexplicitly describe the tutoring activity. The end
of the question-naire offers space for free text commentary.
On the basis of the large number of all evaluated items, the
rep-resentation of the present study was chosen in reference to
theresearch questions; the authors can certainly make a complete
listavailable.
Statistical analysis
The evaluation was done in a descriptive manner utilizingNCSS
and PASS (version 6.0.2.1., Kaysville, Utah). As a measure of
central tendency, mean values, the median and the standard
devi-ation were provided.
Results
Description of sample and response
All 121 dentistry students in the first clinical semester took
partin the obligatory event (ICM-cyPAL). The response rate of the
surveywas 98.3%.
There were a total of 30 male and 89 female students
partic-ipating in the evaluation, with an average age of 24.8 years
(±2.72; median: 24). The corresponding grades on the dentistry
pre-examination (after the fifth university semester) were
evaluated at2.55 (± 0.60; median: 3). Students stated that they had
worked onan average of three of ten online cases in the time window
from14:00 to 20:00.
Evaluation and further recommendation of the ICM-cyPAL
offering
An average value of 6.97 ± 1.93 was given (from 1 =
unsatisfac-tory and 6 = sufficient to 10 = excellent) as an overall
rating forthe ICM-cyPAL offering. It was recommended to other
fellow stu-dents with an average of 3.84 ± 0.83 (from 1 = do not at
all agreeto 5 = completely agree). Further results on the ICM
concept arepresented in Table 1.
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M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
126 (2017) 84–93 89
Table 1General evaluation of the implementation of the ICM
design, consisting of seven items (if not otherwise obvious from
the table: from 1 = do not at all agree, and 3 = undecidedto 5 =
completely agree).
Concept Mean Standard deviation Min. Max. Median
The basic concept was explained by the docent at the beginning
(e.g.,distribution of tasks in attendance meetings and online
activities).
3.91 0.81 1.00 5.00 4.00
The online activities in this learning event were associated
with cleartasks and goals.
3.74 0.77 2.00 5.00 4.00
The tasks to be completed in this learning event on the basis of
theonline activities were suitable for this medium.
3.70 0.71 2.00 5.00 4.00
I would have learned more if the topics and tasks we worked on
onlinewere examined in the attendance meetings.
3.19 0.97 1.00 5.00 3.00
Overall, I learned more through the combination of
attendancemeetings and online activities than in simple
lectures.
3.38 0.99 1.00 5.00 3.00
I hope that in similar learning events in the future, the
traditionalattendance meeting will be supplemented with online
activities.
3.47 0.95 1.00 5.00 4.00
Rate the concept between 1 and 10 (6 = sufficient, 10 =
excellent). 6.97 1.92 1.00 10.00 8.00
Table 2Evaluation of tutor effectiveness in the ICM design (if
not otherwise obvious from the table: from 1 = do not at all agree,
and 3 = undecided to 5 = completely agree).
Tutor effectiveness Mean Standard deviation Min. Max. Median
Constructive, active learning: the tutor stimulated us. . .. . .
to summarize what we had learnt in our own words. 3.50 0.88 1.00
5.00 4.00. . . to search for links between issues discussed in the
tutorial group. 3.61 0.81 1.00 5.00 4.00. . . to understand
underlying mechanisms/theories. 3.61 0.86 1.00 5.00
4.00Self-directed learning: the tutor stimulated us. . .. . . to
generate clear learning issues by ourselves. 3.74 0.82 1.00 5.00
4.00. . . to search for various resources by ourselves. 3.62 0.93
1.00 5.00 4.00Contextual learning: the tutor stimulated us. . .. .
. to apply knowledge to the discussed problem. 3.67 0.85 1.00 5.00
4.00. . . to apply our knowledge to other situations/problems. 3.55
0.86 1.00 5.00 4.00Collaborative learning: the tutor stimulated us.
. .. . . to give constructive feedback about our group work. 3.71
0.82 1.00 5.00 4.00. . . to evaluate group co-operation regularly.
3.41 0.88 1.00 5.00 4.00Tutor’s behaviorThe tutor had a clear
picture about his/her strengths and weakness as a tutor. 3.26 0.94
1.00 5.00 3.00The tutor was clearly motivated to fulfil his/her
role as a tutor. 3.78 0.87 1.00 5.00 4.00Tutor evaluationGive a
grade (1–10) for the overall performance of the tutor (6 being
sufficient, 10 being excellent). 6.56 2.32 1.00 10.00 7.50
Evaluation of the activities of the cross-year peer tutors
The cross-year peer tutors were scored with an average of6.56 ±
2.32 (from 1 = unsatisfactory and 6 = sufficient to 10 =
excel-lent) (see Table 2).
Evaluation of tutor effectiveness and the group interaction
model
The results on tutor effectiveness are presented in Table 2, on
thegroup interaction model in Table 3, and the information
collectedfrom the students on PBL in Table 4. An excerpt from the
free textcommentary can be seen in Figure 3.
Rating of the individual aspects of self-directed learning
(resourcemanagement, sequencing and implementation)
The results on the rating of individual aspects of the
self-directedlearning portion are presented in Table 5.
Discussion
It was the goal of the present study to develop a concept for
anICM offering in a cross-year PBL format, and introduce and
evaluateit. It was demonstrated that the newly conceived and
implementedICM-cyPAL offering in the dental context was mostly
evaluated pos-itively from the side of the tutees. The present
study is the first workin which the aforementioned ICM setting has
been piloted in thedental context.
The motives for implementing an ICM offering in dentistry
aremany. The motivations for implementation in the study
presentedcoincided in some respect with those that have already
been pub-lished in the literature on individual aspects of the
design [24]. Forthe present work, the center of causality was the
encouragement ofcompetency development with self-activating
learning in a modernlearning format.
This is in accordance with the recommendations of various
insti-tutions on the national and international level [29–31]. It
shouldespecially be pointed out that an ICM offering always
includesa didactically planned sequence of partial aspects, which
mustbe respectively reconciled with one another [5]. This does
notonly mean that the prior online portion should include
importantinformation for which successful processing work is
realized inpreparation – namely before the subsequent attendance
portiontakes place, which in the present study is group work – but
alsothat the PBL aspect be deliberately used didactically.
For the Frankfurt Goethe-University location, however, whichhas
several years of experience with PBL and as of 2009 hasimplemented
one of the first dental open-source e-learning onlineofferings in
dentistry teaching, the conception of the ICM-cyPALdesign in the
present form represented an almost completely newstructuring of the
available partial aspects (PBL and e-learning)[24,32]. In the sense
of ICM, these must be coordinated with oneanother. Moreover, this
also includes the construction of a struc-tured training program
for the participants, since are no referencesfor this on site. In
the field of restorative dentistry in Frankfurt,PAL in a cross-year
format has existed for more than 30 years,mainly in the context of
patient treatment cases, in which students
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90 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen
(ZEFQ) 126 (2017) 84–93
Table 3Evaluation of the interaction model of the ICM design
(from 1 = do not at all agree, and 3 = undecided to 5 = completely
agree).
Group interaction Mean Standard deviation Min. Max. Median
Exploratory questionsStudents posed adequate questions to each
other to understand thelearning content (e.g., questions on meaning
of concepts, differences,reasons, and concrete examples).
3.59 0.76 2.00 5.00 4.00
What group members said was checked by asking each other
criticalquestions.
3.63 0.73 2.00 5.00 4.00
A group member who was formulating an explanation concerning
theproblem asked in between whether his/her explanation was
right.
3.54 0.77 2.00 5.00 4.00
One explanation did not suffice for the group members;
alternativeexplanations were also given.
3.59 0.78 2.00 5.00 4.00
Cumulative reasoningGroup members elaborated on each other’s
arguments. 3.73 0.74 2.00 5.00 4.00When someone argued something,
then that statement was motivated. 3.89 0.73 2.00 5.00
4.00Explanations of group members were completed with explanations
ofother group members.
3.86 0.68 2.00 5.00 4.00
Students drew conclusions from the information that was
discussed inthe group.
3.82 0.71 2.00 5.00 4.00
Handling conflictsIn the group, some contradictory beliefs on
information concerningthe learning content were present.
3.49 0.92 1.00 5.00 4.00
One or more group members was/were contradicted by the others.
3.41 0.98 1.00 5.00 3.00When someone contradicted a group member,
that person stated acounter-argument.
3.43 0.81 1.00 5.00 4.00
Table 4Evaluation of the general information for the PBL portion
of the ICM design (if not otherwise obvious from the table: from 1
= do not at all agree, and 3 = undecided to 5 =completely
agree).
PBL Mean Standard deviation Min. Max. Median
There was a pleasant working atmosphere in our small group. 3.71
0.92 1.00 5.00 4.00I enjoyed the PBL sessions. 3.44 0.96 1.00 5.00
3.00The PBL tutor. . .. . .makes sure that the group defines
problem issues. 3.76 0.82 1.00 5.00 4.00. . .activates my previous
knowledge. 3.58 0.89 1.00 5.00 4.00. . .encourages me to
contribute. 3.71 0.88 1.00 5.00 4.00. . .responds to contributions
by team members. 3.65 0.86 1.00 5.00 4.00. . .assists me in putting
things into context. 3.49 0.99 1.00 5.00 4.00. . .makes sure that
the group formulates clear learning objectives. 3.79 0.93 1.00 5.00
4.00. . .makes sure that the learning objectives are discussed.
3.86 0.83 1.00 5.00 4.00. . .prevents digression from the topic.
3.53 0.98 1.00 5.00 4.00. . .assists me in visualizing results.
3.54 0.90 1.00 5.00 4.00I feel that the tutor was too strict
(scores 1–2), just right (scores 3–5),or too lenient (scores
6–7).
4.65 1.04 3.00 7.00 4.00
I feel that the PBL tutor has talked too much (scores 1–2), has
talkedexactly as much as needed (scores 3–5), or has not talked
enough(scores 6–7).
4.54 0.95 1.00 7.00 4.00
Table 5Evaluation of the tutees’ learning strategies (from 1 =
do not at all agree, and 3 = undecided to 5 = completely
agree).
Learning strategies Mean Standard deviation Min. Max. Median
Resource managementWhen I have problems understanding something,
I seek additionalinformation (information gathering).
4.05 0.74 1.00 5.00 4.00
There are problems and tasks where I work better alone, and
there areproblems and tasks where I learn better with others
(collaboration andaid).
3.98 0.84 1.00 5.00 4.00
When I have learned something, I try to explain it to my
fellowstudents (collaboration and aid).
3.66 0.92 1.00 5.00 4.00
SequencingI create focal points in my learning (step sequence
planning). 3.67 0.83 1.00 5.00 4.00My learning process is oriented
to the given task (step sequenceplanning)
3.77 0.74 2.00 5.00 4.00
Depending on the type of task or problem, it may be necessary to
planrelaxation phases in the learning process (relaxation phase
planning).
3.69 0.90 1.00 5.00 4.00
ImplementationIn order to structure the learning material, I
often make overviews,tables, and sketches (structuring).
3.56 1.01 1.00 5.00 4.00
I always try to find possible alternatives to assertions and
conclusionsin the class (elaboration).
3.63 0.79 2.00 5.00 4.00
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M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
126 (2017) 84–93 91
Figure 3. Collected extract from the tutees’ free text
commentary.
in the sixth semester assist their fellow students in the
ninthsemester.
The latter instruct their colleagues in the first clinical
(sixth)semester, in that they ‘‘demonstrate’’ live to them all
treatmentprocesses applying to the patients. At the end of the
assistantship,theoretical reflections take place on the treatment
processes thatwere used. The participants do not indeed complete
any structuredtraining program, meaning that the ICM-cyPAL design
presentedin the current study was breaking new ground, including
for theemployed tutors.
The satisfaction of the tutees determined with this offering
isalso reflected in other tutor-led courses [5]. The evaluation of
theICM-cyPAL design, however, with an average of 6.97 ± 1.92 (from1
= unsatisfactory to 10 = excellent), shows that potential for
opti-mization still exists. Based on the free text commentary, it
is evidentthat there were still ambiguities regarding both the
process of thePBL instruction as well as the content related to the
online cases,which were not examined sufficiently in the group
work.
The ambiguities that exist regarding the process of the
PBLinstruction, in view of the fact that all tutees were PBL
novices andonly worked on two cases together during the semester,
are not sur-prising. However, ambiguities in the online cases would
have hadto be thematized previously, for example in step 1
(clarification ofcomprehension questions). The methodical
parameters of the ICMdesign, such that content in the prior online
portion should not berepeated in the attendance instruction, could
have led to misun-derstandings by the tutors. However, after
evaluation of the freetext commentary, it would seem to be not a
matter of repetitionbut rather the explanation of content.
The data collected on the acceptance of the PAL format on
theside of the tutees is in agreement with similar results that
have beendescribed in the literature [5,33]. Solely PBL-based
offerings in thedental context tend to receive higher tutor
evaluations (8.34 ± 1.34)than the combined ICM format (6.56 ± 2.32)
in the present study[25]. This may possibly be explained in that
the PBL offering exam-ined in the work of Gerhardt-Szep (2009) was
a docent-facilitatedmethod and not PAL [32]. It is moreover
interesting that the evalua-tion of tutor behavior on average was
similar, but the evaluation of
the items ‘‘The tutor was clearly motivated to take his role as
‘tutor’seriously’’ (from 1 = do not at all agree to 5 = completely
agree) inthe docent-led PBL format came out higher (4.25 ± 0.83)
than in theICM format.
Both formats realized non-directive tutorial facilitation
[24,25].The tutees in both formats agreed that the group
accompanimentwas just right (from 1 = too controlling, 4 = just
right, 7 = left thegroup alone too much), since the given values
varied only between4.32 ± 0.69 (docent-led POL) and 4.65 ± 1.04
(ICM-cyPAL). For theitem ‘‘I believe the tutor spoke too much (1),
just right (4), too little(7),’’ the ICM format on average received
somewhat higher rat-ings in contrast to the docent-facilitated PBL
offering, which wasevaluated with an average of 4.31 ± 0.68 [32].
Accordingly, it waspossible that the tutees of the ICM offering
were of the opinion thatthe tutors tended to speak just right or
too little, whereas in con-trast in the docent-facilitated PBL
instruction, they had rather toolarge a speaking role. In the free
text commentary on the ICM-cyPALoffering, it is likewise apparent
that the tutees were very satisfiedwith the tutors. The
non-directive facilitation method thereby inprinciple seemed to
have been used correctly.
The ICM-cyPAL design also makes it possible that not only
thetutees, but also the tutors employed could further develop
theirown competence in regard to professional competence,
commu-nication ability, and assumption of responsibility through
theirteaching activity, as was already confirmed by other PBL
offer-ings [5,34]. The offering can thereby employ various
suggested,consensus-formed capabilities from the Society for
Medical Edu-cation for the German-speaking region, and additionally
offers thepossibility of adding or deepening aspects of the
teaching and learn-ing, as embodied in the National
Competence-based Learning GoalsCatalog for Dental Medicine (NKLZ)
and in international profilerequirements [30,35].
In the authors’ view, the longitudinal training of involved
tutorsis an essential precondition for the success of the ICM-cyPAL
offer-ing. Structured training approaches, however, as a measure
ofensuring the quality of the teaching in the PBL context, have
onlyseldom been published [5]. Only structured content-related
train-ing led by experienced persons and constructed in several
steps or
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92 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen
(ZEFQ) 126 (2017) 84–93
levels will give the tutors the competence edge necessary for
theiractivity with regard to their fellow students, who mostly find
them-selves at a similar study level [5]. For this reason, from
time to timeboth mentors and persons further educated in the
teaching wereincluded in the present training program.
The leadership of the project was also undertaken by a spe-cial
medically qualified dentist at the Department for
RestorativeDentistry. Work by the scientific personnel was not
financiallysupported. In this context, the fact should be
highlighted that inthe format described, the work of the tutors was
paid during theentire training phase. To strengthen the offering,
care must betaken that new longitudinal training sessions continue
to be held,on the basis of the withdrawing tutors who leave the
universityafter the conclusion of their studies. Recruiting new
tutors provesto be unproblematic, since there was always enough
interest onthe side of the students who had completed the 6th
semester andhad become familiar with the ICM concept. Available
mentors pre-sented a more difficult matter, since personnel changes
here alsomade it necessary to constantly instruct the newly
employed sci-entific colleagues.
The results on tutor effectiveness in the dimensions of
construc-tive, active, context-dependent and collaborative learning
show atendency to overlap with studies by Gerhardt-Szép [24],
althoughthe setting and tutors employed were implemented in a
differ-ent manner. Differences in low average ratings were
evaluated inthe dimensions ‘‘behavior of the tutor’’ and
‘‘self-directed learning.’’For the first (‘‘The tutor was clearly
motivated to take his role as‘tutor’ seriously’’), the tutors on
average were given lower values incomparison with the Gerhardt-Szép
study (4.25 ± 0.83) [24,25].
This may among other things be rooted in the fact that the
cytutors were exposed to an increased burden during the course
ofthe semester, leading to a possible decrease over time in their
moti-vation. On the other hand, the content may also have placed
themunder excessive demands for which they were not sufficiently
pre-pared as tutors in the context of the prior training. But the
freetext commentary shows that ambiguities in the prior online
con-tent could not be clarified sufficiently during group work. The
tutorswere not prepared for it, and possibly felt they were under
too muchpressure. It is possible that the tendency toward lower
values onthe item ‘‘The tutor stimulated us to generate clear
learning goals’’(self-directed learning) of 3.74 ± 0.82 compared to
the Gerhardt-Szép study (4.02 ± 0.68) may be explained in a similar
manner.Docent-supervised PBL accordingly makes it possible, as a
resultof the high competence of the available participants, to more
easilygenerate ‘‘clear’’ learning goals [24,25]. This finding
should be betterimplemented in the training process for tutors in
future ICM-cyPALofferings.
The results of the group interaction model show a tendency
tooverlap in all dimensions with the Gerhardt-Szép studies
[24,25].Negligible tendential differences from the Gerhardt-Szép
study [23]in the form of lower ratings (3.59 ± 0.76) were found for
the item‘‘The participants asked questions in the group adequate to
under-stand the teaching content’’ (survey questions) (4.08 ±
0.68). Here,the cy tutors had to stimulate the group with
corresponding con-cepts. Possibly the ‘‘non-directive’’
facilitative model here that wasprovided to the tutors was
misinterpreted, meaning in the futurethis should be introduced in a
strengthened manner in the frame-work of training measures.
Information on the learning strategies used by the tutees
showthat, especially for the dimensions ‘‘collaboration and aid’’
or‘‘structuring,’’ there is a need for optimization. In comparison
tothe Aeppli study [22], which was conducted with an identical
eval-uation instrument, the average values given to the two
dimensionsmentioned above (from 1 = do not at all agree to 5 =
completelyagree) had a score that tended to be higher on average
than in thepopulation examined here.
Thus, the dentistry tutees’ learning could be supported in
futurestrategies in the area of resource management or
structuringin order to improve the conditions for motivated,
self-directedlearning, which seems to be indispensable for the
successful imple-mentation of an ICM format. The ICM format
includes grantingthe tutees more freedom in their learning and
ensuring that theythemselves understand the measures for
self-direction [22]. Thisfreedom might also place excessive demands
on the students, how-ever [22].
Accordingly, it seems to be of decisive importance that the
stu-dents offer just as much direction, explanation and aid
throughtutors as they need for successful and self-directed
learning [22].Aeppli [22] thus requires the offering of a
problem-based approach,since this may allow the learners to ‘‘. .
.not only show more self-directed learning behavior and thus gain
experience in self-directedlearning, but rather also reach a higher
level of learning successdue to the deeper examination of the
learning content’’ [22]. It isexactly this approach that was
realized in the present ICM-near-PAL offering, although learning
success controls did not representany of the content of the study.
This should follow in subsequentexaminations.
Response to research questions
1. As a total evaluation of the ICM-cyPAL offering, an
averagevalue of 6.97 ± 1.93 was given (from 1 = unsatisfactory and
6= sufficient to 10 = excellent). Recommendation to other
fellowstudents was given an average of 3.84 ± 0.83 (from 1 = do not
atall agree to 5 = completely agree).
2. The activity of the tutors was on average evaluated at 6.56 ±
2.32(from 1 = unsatisfactory and 6 = sufficient to 10 =
excellent).
3. The highest average values (3.78 ± 0.87) were given in the
frame-work of the dimension ‘‘tutor effectiveness’’ in the item
‘‘The tutorwas clearly motivated to take his role as tutor
seriously’’ (from 1= do not at all agree to 5 = completely agree).
The sub-dimensionof ‘‘self-directed thought’’ received the highest
values on average.The highest average values (3.89 ± 0.73) were in
the frameworkof the dimension ‘‘group interaction model’’ in the
item ‘‘Whena group participant argued something, the statement was
dis-cussed in an active manner’’ (from 1 = do not at all agree to 5
=completely agree). The sub-dimension of ‘‘cumulative
argumen-tation’’ received on average the highest values. The tutees
agreedthat the group supervision during the PBL design was just
right(from 1 = too controlling, 4 = just right, 7 = left the group
alonetoo much), since the values given amounted to 4.65 ± 1.04
onaverage. For the item ‘‘I believe the tutor spoke too much
(1),just right (4), too little (7),’’ the ICM-cyPAL format received
anaverage of 4.54 ± 0.95.
4. The learning strategies surveyed on average had the high-est
values in the dimensions ‘‘resource management’’ (‘‘WhenI have
problems understanding something, I seek additionalinformation’’),
and the lowest in ‘‘implementation’’ (‘‘In order tostructure the
learning material, I often make overviews, tablesand
sketches’’).
Limitations
Limitations can be determined in that the present study
utilizeda purely subjective course evaluation on the side of the
students,and no data on knowledge growth was collected. This limits
itsusefulness for potential replications. Also, since the
evaluationwas conducted in an anonymous manner, no correlations
withgrades from the dental pre-examination could be
calculated.Additionally, the offering was evaluated as something
‘‘new,’’ so itssignificance may possibly be limited due to the
Hawthorne effect.
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M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)
126 (2017) 84–93 93
The low population size and missing validation of the
evaluationinstrument must be optimized further in additional
studies.
Conclusion
In summary, it can be determined that the ICM-cyPAL offer-ing in
the dental context of a tutee survey pointed to a
positiveevaluation, however, its effectiveness must be investigated
in fur-ther controlled studies. The offering itself requires a high
degree oforganization and good personnel and financial
resources.
Support and acknowledgement
The project was supported on the basis of a fellowship bythe
Association for the Promotion of Science and Humanities inGermany
(dt.: Stiftung für die Deutsche Wissenschaft) 2012. Thanksare due
to Cambridge Editing (Frankfurt, Germany) for
professionaltranslating the manuscript.
Conflict of interest
None declared.
Survey
The complete survey may be requested from the authors.
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den Modellstudiengang inkl. einer Statusanalyse der Dozentenroll.
-e und Umsetzung der Methode
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