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Since the commercial Internet service began to emerge in early 1990s, there has been an exponential growth in Internet users . The number of Internet users in 2011 was estimated to be 2.7 billion, representing 39% of the world population . In developed countries, the percentage was as high as 77%. Internet has been instrumental in transforming the way we interact with the world and provided unparalleled opportunities for collaborative learning.
Internet was introduced for medical education purposes shortly after its advent . The complexity and breath of medical education content makes the usage of Internet sources a reasonable proposition. Web-based learning was found to enhance medical education in several ways, such as improving learners' satisfaction and learning outcomes [4-6], leading to significant cost savings , and helping meet the challenge of the global decrease in academic teachers .
Acquiring competence in performing respective clinical procedures is fundamental for the professional training of healthcare providers. Students mainly acquired their clinical competency by observing and practising on mannequins and patients during instructor-led pre-clinical and clinical sessions. In addition, the incorporation of various visual aids, such as videotape, slides, posters and models, was found to be very useful in enhancing clinical learning [9-11]. Such visual aids had already been widely used in the pre-Internet era. With the advent and proliferation of Internet, current generation of students are provided enormous opportunities to learn from the vast volume of online electronic visual materials, be it videos, animations, illustrations or photos showing the flow of the clinical procedures [12, 13]. An international survey amongst health educational stakeholders in dentistry showed that various types of online learning tools, such as virtual reality with haptic devices, virtual learning environments, telecommunications and Rich Media, were widely used in institutions .
Students' modes of web-based learning are not limited to e-learning resources provided by their faculties (often not openly accessible to all) or prescribed by the teaching staff, but also include spontaneous information seeking through Internet, a learning style that is common and highly encouraged under the concept of self-directed learning [4, 12, 15]. Whilst the former has been extensively investigated [4, 5], the impact of the latter on medical education is understood to a much lesser extent. As openly accessible Internet visual resources (IVRs) are voluminous, uncontrolled and often uncensored, they may foster or hamper Students' acquisition of clinical competency in one way or another. It remains largely unknown how these resources shape Students' learning experience and affect their learning outcomes.
This study aimed to profile the experience and opinions of undergraduate students in learning clinical procedures through IVR. IVR was defined as visual materials (e.g. videos, animations, graphic illustrations and photos) that were openly accessible on public websites. Pure text materials were not included. The e-learning materials provided by Students' own faculties were not in the scope of this study. This was a qualitative research using focus groups for data collection. This method is exploratory and is particularly useful for a topic that has been hardly investigated . Focus groups allow researchers to capture a wide spectrum of views in rich context using informants' own words and gain in-depth understanding on the study topic.
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Whilst e-Learning has brought revolutionary changes to education of all levels worldwide, clinical Students' exploration of e-resources is far beyond materials provided by their own faculties or those prescribed or recommended by their teachers. Their spontaneous search of resources in the unrestricted environment offered by Internet forms an important part of their self-directed learning. Investigation into this area could potentially shed light into the learning pattern of the current e-generation of students.
Our qualitative investigation into Students' self-study practices showed that students not only used IVRs for understanding and reinforcing key clinical skills taught in the curriculum, but also resorted to it for learning simple procedures that were supposed to be self-learnt or advanced procedures that were not introduced in detail at undergraduate level. IVRs were also used for benchmarking against international peers. This helps to break the isolation of learners, promote collaborative learning and form an online learning community. Such collaborative knowledge acquisition was also advocated in the dental educational initiative known as International Peer Review Project, which was funded by the U21 Health Sciences Group .
Our findings revealed both sides of the coin – Students' approving views and their concerns on IVR. The advantages of IVR are in both learning enhancement and learning delivery. IVR is considered as a valuable addition that enhances Students' self-perceived clinical competency, boosts their confidence in clinical practice and enriches their learning experience. IVR has opened a vast library of clinical materials to students. The availability of a full range of patient cases accommodates Students' diverse learning needs and helps them meet the challenges in patient care. In learning delivery, IVR owns some unique features unmatched by other learning resources, such as universal accessibility, ease in updating content and hyperlink functions that permit cross-referencing to other resources. Students' self-exploration of IVR catalyses the shift towards a learner centred model that puts learners in control of their own learning and is in line with the constructivist learning theory, where learners search and create their own knowledge bases [4, 6, 22].
Amidst many positive comments on IVR, students also raised some concerns, especially the difficulty in judging the scientific quality of IVRs. Some recent studies reviewing learning materials in Internet platforms, such as YouTube, also pointed out varied quality and the existence of questionable or misleading contents [23, 24]. This calls for a need for the transforming role of educators from one of dispensing knowledge to one of guidance and support [6, 25]. In addition, although e-learning is recognised for its advantage in forming interactive learning community, the communication is often asynchronous thus hinders fast exchange of question and direct and immediate feedback. On the other hand, the polarised attitudes of teachers towards IVR might have deterred some students from sharing and discussing IVR with teachers and clarifying over some controversial contents.
Cantonese was chosen as the language for focus group discussions, because it was the mother tongue of most university students in Hong Kong. Even for non-local students, because they need to communicate with patients, most of them were able to speak Cantonese. There was, however, a small number of non-Cantonese speaking students who were excluded from the focus groups, and their views were not profiled in this study. Although confidentiality, anonymity and neutrality were ensured, there may be a chance that some students tended to give some socially desirable answers in a focus group. However, as the topics discussed were not considered as sensitive, giving socially desirable answers might be relatively unlikely in this study. The highly diverse views and experiences students shared in the focus groups supported the participants’ openness and willingness in sharing their thoughts. Transcripts of the focus group discussions were analysed using inductive method (i.e. themes emerging from data), to avoid the pitfalls of our own assumptions and ensured that the views were derived and interpreted from the participants’ perspective.
Clinical faculties in the University of Hong Kong adopted student-centred, self-directed and inquiry-based learning system. Our findings may not be extrapolatable to some universities, especially those using traditional didactic teaching method. This study focused on profiling Students' experience and opinions. Teachers' and administrators’ perspectives on learning clinical procedures through IVR remain another interesting area to be explored in further studies.