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J Diagn Med Sonogr. Author manuscript; available in PMC 2016 May 24. Published in final edited form as: J Diagn Med Sonogr. 2010 ; 26(2): 55–63. doi:10.1177/8756479309351575.
Can Hybrid Learning Theory Be Used to Teach Working Sonographers Breast Elastography? Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R), Timothy J. Hall, PhD, Sara Baker, BA, RDMS, RVT, RT(R), Megan Burke, RDMS, RT(R), Laura Knauf, RT(R), and Bridgett Willey, BA, RDMS, RVT, RDCS, RT(R)
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Abstract Hybrid learning is a combination of on-line learning and face-to-face sessions. This research sought to answer the question of “Can Hybrid Learning be Utilized To Teach Working Sonographers to perform breast Elastography?” We designed a hybrid course entitled “Breast Elastography for Working Sonographers.” This course consisted of four on-line training modules, each complete with a post-test and one face-to-face session. After the face-to-face session lectures, participants were interviewed and observed performing elastography on a breast phantom. Our results indicate that this is a successful method for teaching working sonographers breast elastography, in this setting.
Keywords
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Hybrid (blended) learning; elastography; observational case study
Introduction
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A common problem in busy sonography departments, is how to get every songrapher trained on a new technology. Traditionally this has been accomplished by having an applications specialist come in for a one or two day hands – on session to learn about the new ultrasound system upgrade, or the new instrumentation on the ultrasound machine. As sonography departments have grown, and more sonographers are present, a new model has arisen. This new model is sometimes referred to as the training of superusers. In this model, one or two persons are designated to work with the applications specialist, and the superuser(s) will disseminate the new information to the rest of the staff. The problem with this model for training is the lack of time for this task in a busy clinical environment. One solution is to work with a local ultrasound education program or with the medical facility’s Information Technology (IT) department to look at the feasibility of utilizing hybrid (also known as blended) learning methodologies to introduce and teach new technology to working sonograhers. Our institution engaged in a hybrid learning model to teach working sonographers how to perform breast elastography.
Corresponding Author: Carol Mitchell, 600 Highland Ave., MC 3252, Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, WI 53792, 608-263-9033, ; Email: [email protected]
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Background
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Breast elastography is a non-invasive imaging technique that acquires information based on how tissue behaves when manually deformed 1. To perform diagnostic breast elastography, the sonographer gently applies pressure over the area of interest using a “small parts” lineararray transducer 1. The ultimate goal of the examination is to displace the underlying tissue and track the motion using ultrasound echo signals in order to determine its elasticity 2. Early reports of elastography combined with B-mode ultrasound suggest that breast elastography can achieve accuracy that is equivalent to mammography 3. Clinical reports also suggest that the information provided with breast elastography may increase the confidence of “benign” diagnosis and therefore decrease the biopsy rate 4. With this in mind, researchers are hopeful that elastography will offer a new way to provide accurate, safe and cost effective ways to detect breast malignancy, as well as malignancies in other regions of the body 4 . To maximize the potential of this new technology, sonographers need to be properly trained in the technique of breast elastography. Like other techniques in medical sonography, breast elastography is highly operator dependant. Therefore implementing this new technology into clinical practice will require education of clinical sonographers to perform breast elastography correctly 2.
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In order to best use medical resources and personnel, there needs to be an efficient and timely way to teach sonographers this technology. Hybrid learning offers one way to implement breast elastography training. A hybrid course relies on both face-to-face (onsite) and internet-based (on-line) instruction, which is sometimes known as hybrid or blended delivery. When designing a hybrid course, it is generally ineffective to simply post existing materials on-line. Some thought needs to go into which aspects of the course need to be taught on-line, and which would be better taught in a face-face session. If these considerations are not thought through at the beginning of the course design, the course is likely to be unsuccessful. In the medical literature, hybrid learning has been reported with mixed outcomes 5,6.
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One study addressed the specific difficulties encountered by rheumatologists training to perform musculoskeletal ultrasonography 5. A web-based tutoring program was created to help tutor the physicians during a six-month scanning period between the initial basic training course and the final competency assessment 5. This web-based course contained five components: 1) teaching aids, 2) databases containing all standard scans, 3) interaction between the rheumatologist in training and tutors, 4) assessments using multiple choice questions, and 5) images to grade synovitis. The overall reaction of the participants in the study was positive with regards to the educational experience, however, overall operator competency was not achieved. Only 23% of the participating rheumatologists passed the final competency exam 5. The authors determined that limited access to an ultrasound machine and the inability to transfer sonographic images to digital format contributed to the poor outcome. Practical experience
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in prior to taking the basic course, access to necessary equipment, and adequate scanning time are three key factors that the authors feel limited the success of this project 5.
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Bradley et al utilized blended learning to redefine how personnel were trained and oriented to the preceptor role in nursing6. This study delivered content as an on-line course and as an instructor-led course. The primary focus of the on-line course was to provide a foundation of knowledge that prepared the students for the instructor led courses, which focused heavily on action learning activities. After completing the courses, 91% of the respondents stated that the online learning content prepared them for the classroom activities, and 94% of the learners reported improved knowledge of roles and responsibilities of the preceptor 6. Some participants stated that they were somewhat dissatisfied with the online course due to perceived repetition and redundancy between the Web-based content and the instructor-led class content, however, 86% said the blended learning approach improved their overall knowledge and skills about the preceptor role. Similarly, 85% stated that they would enjoy participating in other blended learning opportunities 6.
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By accounting for a variety of learning styles, one can help learners to master material in the way that is most comfortable for them. Utilizing learning style information to assist students in mastery of their studies is not new to the field of diagnostic medical sonography. One ultrasound program has implemented into their program a focus on identifying learning styles utilizing the Productivity Environmental Preference Survey (PEPS) developed by Dunn & Dunn 7,8. Based on the survey results, students are counseled about their learning styles and provided information about how to optimize their study habits. While there would not be time to perform a learning styles inventory on all working sonographers in a laboratory, it would be beneficial to design a hybrid course that would address all learning styles to implement new technology successfully 9.
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Utilizing the information gained from the aforementioned studies, the researchers designed a study to evaluate the potential for utilizing a hybrid course to teach working sonographers to perform breast elastography. The authors believed that this course delivery method had potential for success, because working sonographers should already possess the necessary knowledge to know what makes an image technically adequate as well as the scanning expertise to be able to learn breast elastography through a hybrid course model. Noting the success with Bradley et al, the authors designed the online learning modules to provide a foundation of knowledge that would prepare participants for face to face interactions and hands-on scanning sessions on a breast phantom. Since the objective of the on-line learning module was fir participants to master a basic understanding of the clinical use of elastography, each learning module was accompanied by a five point post-test. Each participant was asked to complete the post-test until they received a score of 100 percent. The face-to-face (instructor led) sessions reviewed the use of elastography in clinical trials, so sonographers could see the potential and importance of implementing this new technology into practice. Following this lecture, a second lecture was given, that reemphasized the on-line learning sessions with reviewing seven additional case studies. During the face-to-face session, sonographers were asked to comment , based on the E-mode image, to identify what pathology this case most likely represented. The final component to the face-to-face session was participation in a hands-on scanning session on a breast
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phantom, with immediate feedback, from an instructor, regarding breast elastography image quality and technique. The four foundational on-line modules presented were, 1) physical principles of elastography, 2) correlation of breast elastography with traditional B-mode imaging, 3) breast elastography imaging protocol, and 4) malignant versus benign findings. A detailed description of one of these modules is provided in Appendix A.
Methods This study was designed as an observational case study, and utilized qualitative methods of in-depth interviews, participant observation and post-course survey tools. The research question asked was “Can hybrid learning theory be use to teach working sonographers how to perform breast elastography in a sonography department?”
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An observational case study is a form of qualitative research that examines participants within a particular organization 10 Parts of the organization that become the foci for an observational case study are 1) specific place (i.e. sonography department), 2) specific group of people (i.e. practicing sonograpers) or 3) some activity of the organization (i.e. curriculum planning). In this case, the focus was placed on a particular group, sonographers who rotated through the breast center, and emphasis was placed on curriculum planning to implement a new technology in a busy sonography department. This study was submitted for review to our institutional board. After finding the study exempt from institutional review, the study commenced.
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The primary investigator, along with two student researchers recruited four practicing sonographers who worked in a dedicated breast imaging center. Participants were given an information form and informed that their identity would be kept confidential. All four sonographers recruited were registered with the American Registry of Diagnostic Medical Sonography (ARDMS), and three of the four were registered in the breast specialty. The sonographers ranged in years of experience from two years to 27 years. Years of experience were defined by the year first registered with the ARDMS. Information about the participating sonographers is summarized in table 1. Once recruited to the study and after signing an information form, the sonographers were given a username and password to access the on-line learning modules. After the completion of each learning module, the participants took a five point post-test. Participants took the post-test until they correctly answered all questions. The post-test scores are represented in table 2.
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Once the post-tests were completed, participants attended a face to face (instructor led) training session and hands-on scanning session. There were two lectures given at the face-toface session. The first lecture focused on the use of elastography and a historical account of the clinical trials that had been performed to result in the technology that is being used today. The second lecture was a case presentation lecture that reviewed the standard B-mode findings of malignancy and the characteristics of malignancy with elastography. After each presentation, participants were asked if they thought this case was most likely malignant or benign.
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After the lectures, participants were interviewed and observed in scanning the breast phantom and utilizing the elastography mode. Images were critiqued as to the quality of the elastography image (Figure 1 and 2). Data Collection In-depth individual interviews were conducted with each of the participating sonographers. Open – ended questions were utilized which led to additional questions (Table 3). The interviews were guided to see how sonographers had initially heard or learned about elastography and how they would perform elastography imaging. Open-ended questions led to discussion about how the participants learned sonography, and how they felt about this training session. At the conclusion the primary investigator read back the answers to questions and asked the participants to confirm the answers and reflect on any additional information they wished to share.
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Field notes were taken during the hands-on observation time period. Two sonography students and the primary investigator recorded field notes while the participating sonographer demonstrated their ability to obtain an elastography image on a breast phantom with multiple lesions. The interviews and field notes were then entered into the Ethnograph software and coded to look for emerging themes. One week after the completion of the faceto-face session, participants were asked to complete a post-course survey. The survery asked questions about self assessment and their ability to now perform elastography. Data Analysis
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All data was entered into the Ethnograph software and coded inductively. The data was then analyzed using a deductive approach against published learning theory models for sonographers. The final analysis was the interpretation of these findings in the context of how hybrid learning theory may be used to add to a current knowledge and skill set in adding elastography imaging to the routine breast Sonography evaluation.
Results
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Themes that resulted from the coded data were 1) protocol, 2) technique, 3) former learning/ knowledge, 4) hybrid learning 5) ability to perform, and 6) self evaluation . The code protocol refers to the participant’s knowledge at the time of the face-to-face session regarding what images to take. The protocol that was taught was to perform standard Bmode imaging. If a lesion is found, the lesion should be imaged in both longitudinal and transverse planes, the lesion dimensions should be measured, and color Doppler should be utilized to further delineate blood flow, or lack of blood flow to the lesion centrally or circumferentially. After obtaining the standard B-mode images, participants then described the additional images to obtain in elastography mode (E-mode). The additional images to acquire include, a cine clip in E-mode, and an image with and without lesion size measurements in transverse and longitudinal planes. The second code that emerged was technique. The code technique referred to how to acquire the E-mode images. All participants were able to verbalize in the interview and demonstrate in the hands-on session how to obtain an E-mode image and what technical factors were to J Diagn Med Sonogr. Author manuscript; available in PMC 2016 May 24.
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be considered. The technique described in the hands-on session, and then re-emphasized in the face-to-face session were; 1) obtain and optimize B-mode image, 2) turn harmonics off, 3) lighten your pressure (touch) on the breast (or phantom), 4) ensure that the background breast tissue is uniform in texture and that there is no B-mode image tracking on the E-mode image. These are all imaging characteristics that ensure a good quality E-mode image. Examples of a poor quality and high quality E-mode image are represented in figures 1 and 2. Descriptions collected regarding technique included; utilizing less pressure than with standard 2D B-mode imagning, obtaining a cine clip and measuring the B-mode and E-mode dimensions of the mass. Participants also reported that if one has a high quality E-mode image, there should be no B-mode tracking seen on the display screen and that the background of the E-mode image should not be pixely, but rather should have a nice uniform gray appearance. (Interviews 8/28/2008) (Figure 1 and 2).
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The third theme was former learning/knowledge. This theme referred to knowledge about performing elastography prior to the course, compared to after the course. Participants reported that after participating in a hybrid learning course that they had a much better understanding of what made a “good” E-mode image and how to obtain it. Participants also reported that having to take a post-test for each module forced them to complete the learning moduels, and that these activities made the face-to-face sessions much more meaningfule (Interviews 7/21/2008 and 8/28/208).
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The follow-up question to “How did you initially learn breast elastography?” was, How would you implement the use and teach other staff members how to do breast elastography?” Responses included that this course was great, everyone learns differently and that this format took into account different learning styles with out making one feel that they did not know as much as someone else at the face-to-face sessions. All respondants shared that the face-to-face sessions were beneficial with the practice and the the on-line modules (while helpful to provide background information), there is still no substitute for leaning a sonography technique without the hands-on experience (Interviews 7/21/2008 and 8/28/2008).
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This fourth theme was coded as hybrid. Hybrid referred to the participant’s response to this type of training. What was interesting with this group of responses is that you could start to get a sense of how people learned and what learning style they might be. Dunn and Dunn (1993), described a learning style model in terms of individual reaction to 23 elements. These 23 elements were organized around five strands 8. The five strands were; 1) immediate environment (light, sound, temperature), 2) emotionality (motivation, persistence, responsibility, need for structure), 3) sociologic preferences (learning alone, learning with peers, or learning with authoritative adult, learning in a variety of ways versus pattern or routine), 4) physiologic characteristics (auditory, visual, tactile, time of day, mobility needs) and 5) global versus analytic processing (correlations between light, sound, design, persistence, sociologic preference and intake). When we looked at the responses above, we could see that in general, all liked looking at the information, on their own time and at their own pace, however, all also felt that there was no substitute for hands-on ultrasound training. Also, 3 out of 4, stated that it was good to have a test, because that made them read. One participant stated that they did not want to do bad on the tests, because at the beginning of
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the study, participants were informed that the investigators would be looking at the tests to monitor that everyone completed them and received a score of 100% prior to attending the face-to-face training. Therefore, taking into account Dunn & Dunn’s five strand model one can see that strand-1 evaluates how people learn based on their immediate environment (light, sound, temperature)7–9. Through development of a hybrid learning course with both on-line breast elastography modules and face-face sessions, participants could be in control of their environment at home or in the library, where ever they wanted to review their on-line modules and then take their post-tests.
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With regard to strand-2 emotionality (motivation, persistence, responsibility, need for structure)7–9, participants were allowed flexibility regarding when they did their modules and how fast they completed their modules, with the only guideline that the post-tests had to be completed prior to attending the face-to-face session. Participants were told on the information sheet that the instructors would see their scores and know if they had completed the post-test and achieved a score of 100%. Participants also were informed that they would not be allowed to attend the face-to-face session without completion of the learning modules and post-tests. All were motivated to complete the modules and post-tests by the face-to face course date, the date served as time-frame (structure) for completing and also served as a means for the participants to take responsibility for their own learning.
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Strand-3 sociologic preferences (learning alone, learning with peers, or learning with authoritative adult, learning in a variety of ways versus pattern or routine)7–9 was addressed by providing multiple means to learn the same information. Through completing the on-line post-tests, participants demonstrated that they had at least read and looked up answers to key points that the course instructors felt they needed to know prior to attending the face-to-face session. The information presented in the on-line tutorials covered terminology, technique, clinical importance, and what criteria makes a good E-mode image. Having had this information mastered prior to attending the face-to-face session allowed the course instructors to focus on the performance skills of actually performing breast elastography. It also allowed the participants to ask questions as they performed and to describe why their image was good quality and would provide additional information to the interpreting physician.
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Strand −4 physiologic characteristics (auditory, visual, tactile, time of day, mobility needs)7–9 were addressed in both the on-line and face-to-face sessions. The on-line modules were designed to be interactive and included case studies with ultrasound images. To take into account visual and tactile senses, participants could utilize the mouse to play cine clips associated with exams and also could watch a narrated video on how to perform the exam. All modules were designed to be completed (with the post –test) within 30 minutes. Strand-5 global versus analytic processing (correlations between light, sound, design, persistence, sociologic preference and intake)7–9 were evaluated at the time of the hands-on session. This was evaluated by observing how well the participating sonographers could perform elastography, (which was the ultimate goal of this educational project). By
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evaluating how well sonographers performed the elastography session, we could understand how they processed the information given in the on-line modules and at the opening of the face-to-face session. Participating sonographers all were able to state how to perform the exam on the ultrasound equipment, could perform the steps to add E-mode images and cine clips to the breast imaging protocol, and could state benign and malignant characteristics associated with both B-mode imaging and E-mode imaging. Post-course surveys were administered one-week after the face-to-face session and sonographers responded positively to this course. Results of the post-course survey are shown in table 5.
Discussion
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Advancements in computer technology have made hybrid learning a possibility for educating health professionals in the work environment 11. The intentional design of the curricula, in which multiple learning styles can be addressed, provided a means to educate practicing sonographers how to perform breast elastography. Limitations to this study are 1) only four sonographers participated, 2) all sonographers had some exposure to breast elastography prior to participating in this course, which may have contributed to the success of hybrid learning to implement this technology in this setting and 3) observations were made scanning a breast phantom. Future research on hybrid learning for teach practicing sonographers breast elastography could include multi-center trials comparing the use of this course content and format, along with a formal pre-test, post-test and observation on real patients versus typical one-day hands-on training.
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In summary, we believe that online integration between what is taught in the classroom and the real world of work significantly improves program outcomes and allows busy centers a means to educate all staff in a timely manner on new technology. We also recognize that there is no substitute in ultrasound education for hands-on experience, and therefore, we advocate that while basic knowledge can be taught and mastered prior to the face-to-face session, the face-face session must include adequate time for all participants to have handson experience. During the hands-on experience, time must be made for participants’ questions to be answered, and immediate feedback given at the time of scanning.
References
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1. Hall TJ. Physics Tutorial for Residents: Topics in US. Beyond the Basics: Elasticity Imaging with US. Radiographics. 2003; 23:1657–1671. [PubMed: 14615571] 2. Burnside E, Hall TJ, Sommer A, et al. Differentiating Benign from Malignant Solid Breast Masses with US Strain Imaging. Radiology. 2007; 245:401–410. [PubMed: 17940302] 3. Zhi H, Ou B, Luo B, et al. Comparison of Ultrasound Elastography, Mammography, and Sonography in the Diagnosis of Solid Breast Lesions. J Ultrasound Med. 2007; 26:807–815. [PubMed: 17526612] 4. Zhu QL, Jiang Y, Liu J, et al. Real-time Ultrasound Elastography: Its Potential Role in Assessment of Breast Lesions. Ultrasound in Medicine and Biology. 2008; 34:1–7. [PubMed: 17720302] 5. Filippucci E, Meenagh G, Ciapetti A, Iagnocco A, Taggart A, Grassi W. E-learning in ultrasonography: a web-based approach. Annuals of the rheumatic diseases. 2007; 66:962–965.
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6. Bradley C, Erice M, Halfer D, et al. The Impact of a Blended Learning Approach on Instructor and Learner Satisfaction With Preceptor Education. Journal for Nurses in Staff Development. 2007; 23:164–170. [PubMed: 17666898] 7. Dunn, R.; Dunn, K. Teaching Secondary Students Through Their Learning Styles. Boston: Allyn and bacon; 1993. 8. Dunn, R.; Dunn, K.; Proce, G. Productivity Environmental Preference Survey. Lawrence, Kansas: Price Systems; 1986. 9. Dunn, R.; Klavas, A. Homework Disk for the Learning Syle Inventory. Jamica, New York: St. John’s University’s Center for Teaching and Learning Styles; 1990. 10. Bogdan, RC.; Biklen, SK. Qualitative Research For Education: An Introductio to Theory and Methods. 3rd. Boston: Allyn and Bacon; 1998. 11. Miller, J. Effects of traditional versus learning style-presentations of course content in ultrasound and anatomy on the achievement and attitudes of college students. Doctoral thesis. Jamacia, New York: St. John’s University; 1997. 12. Hebda T. a profile of the use of computer-assisted instruction within baccalaureate nursing education. Computers in Nursing. 1988; 6:22–29. [PubMed: 3277698] 13. Schreiber LW. “ClUES”: clinical learning utilizing educational strategies. J Diagn Med Sonography. 1997; 15:164–166. 14. Miller J, Dunn R. The use of learning styles in Sonography education. Journal Diagn Med Sonogr. 1997; 13:304–308. 15. Regner D, Hesley G, Hangiandreou N, et al. Breast Lesions: Evaluation with US Strain ImagingClinical Experience of Multiple Observers. Radiology. 2006; 238:425–437. [PubMed: 16436810] 16. Garra B, Cespedes EI, Ophir J. Elastography of Breast Lesions: Initial Clinical Results. Radiology. 1997; 202:79–86. [PubMed: 8988195] 17. Hagen-Ansert, S. Textbook of Diagnostic Ultrasonography. St. Louis, Missouri: Mosby, Inc.; 2006. 18. Zhi H, Ou B, Luo B, et al. Comparison of Ultrasound Elastography, Mammography, and Sonography in the Diagnosis of Solid Breast Lesions. J Ultrasound Med. 2007; 26:807–815. [PubMed: 17526612] 19. Feldman. Strategies for interpreting qualitative data. Thousand Oaks: Sage Publications; 1995. 20. Polit, DF.; Hungler, BP. Nursing research: Principles and methods. 6th. Philadelphia, PA: Lippincott; 1995. 21. Silverman, D. Interpreting qualitative data: Methods for analyzing talk, text and interaction. London: Sage Publications; 1993. 22. Stainslaw S. Virtual Palpation. Advance. 2008 Mar.:20–22.
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Appendix A Curriculum Sample Module 4 Benign versus Malignant Characterisitcs.
Learner Objective Author Manuscript
1.
Review cases and state the most likely pathology based on the B-mode and E-mode images.
Module Description This module is a pdf tutorial that reviews multiple benign and malignant pathologies with both standard B-mode images and E-mode images. The post-test focuses on the student’s
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ability to recognize pathology based on B-mode and E-mode ultrasound image characteristics. Post-Test-Sample Questions Participants completed 5 case study questions. 1.
This image most likely represents:
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a.
Cystic breast cancer
b.
Insitu ductal carcinoma
c.
Invasive ductal carcinoma
d. Fibroadenoma 2.
This image most likely represents:
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a.
Cystic breast cancer
b.
Insitu ductal carcinoma
c.
Invasive ductal carcinoma
d. Fibroadenoma
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demonstrates a B-mode image of a breast lesion obtained on a breast phantom that is of poor quality. Note the background is not homogenous and the lesion is not well identified.
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Figure 2.
demonstrates an appropriately scanned E-mode image. Note the homogenous background and easily identified borders of the lesion. This is achieved by applying light pressure while scanning.
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Table 1
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Participating Sonographer Characteristics. Sonographer
# of years of experience
ARDMS Registered
ARDMS registered breast specialty
A
2
X
B
4
X
X
C
19
X
X
D
27
X
X
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100
100
100
C
D
100
A
B
Post – Test Module 1 Score
1
1
1
1
Post – Test Module 1 Attempts
100
100
100
100
Post – Test Module2 Score
1
1
1
1
Post – Test Module 2 Attempts
100
100
100
100
Post – Test Module3 Score
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Sonographer
1
1
1
4
Post – Test Module 3 Attempts
100
100
100
100
Post – Test Module 4 Score
1
2
1
1
Post – Test Module 4 Attempts
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Post Test Scores.
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Table 2 Mitchell et al. Page 14
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Table 3
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Open Ended Interview Questions. Open Ended Questions for Interview at time of Observation 1
How are you going to perform palpation sonography?
2
What is different about the E-mode imaging protocol for you compared to the traditional B-mode imaging protocol?
3
Do you feel that you tailor the exam differently for the E-mode protocol versus the Bmode protocol?
4
How will you perform the exam?
5
What are the elements of a good image for E-mode ultrasound?
6
What are the steps for acquiring E-mode ultrasound data?
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Table 5
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Survey questions and responses. Participants were asked to complete a post-test course survey with a rating scale of −3 (strongly disagree) to 3 (strongly agree). Results are provided in the table below. Only 3 (of four) surveys were returned.
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Survey Question
Mean Rating
Results
Completing the on-line learning materials prior to the face-toface session were helpful.
3
3,3,3
The hands-on session at the face-to-face learning session assisted me with learning how to perform breast elastography.
2.33
3,2,2
I feel that I can state with confidence that I can attain a breast elastography image.
2.33
3,2,2
I can state what makes a good elastography image.
3
3,3,3
I plan to implement breast elastography imaging into all of my breast pathology cases.
2
2,2,2
This course assisted me to learn how to perform breast elastography.
2.66
3,2,3
The on-line post-tests allowed me to demonstrate my mastery of the information presented.
2
2,2,2
I felt confident performing breast elastography protocol on the breast phantom.
2.66
3,3,2
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J Diagn Med Sonogr. Author manuscript; available in PMC 2016 May 24. Published in final edited form as: J Diagn Med Sonogr. 2010 ; 26(2): 55–63. doi:10.1177/8756479309351575.
Can Hybrid Learning Theory Be Used to Teach Working Sonographers Breast Elastography? Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R), Timothy J. Hall, PhD, Sara Baker, BA, RDMS, RVT, RT(R), Megan Burke, RDMS, RT(R), Laura Knauf, RT(R), and Bridgett Willey, BA, RDMS, RVT, RDCS, RT(R)
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Abstract Hybrid learning is a combination of on-line learning and face-to-face sessions. This research sought to answer the question of “Can Hybrid Learning be Utilized To Teach Working Sonographers to perform breast Elastography?” We designed a hybrid course entitled “Breast Elastography for Working Sonographers.” This course consisted of four on-line training modules, each complete with a post-test and one face-to-face session. After the face-to-face session lectures, participants were interviewed and observed performing elastography on a breast phantom. Our results indicate that this is a successful method for teaching working sonographers breast elastography, in this setting.
Keywords
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Hybrid (blended) learning; elastography; observational case study
Introduction
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A common problem in busy sonography departments, is how to get every songrapher trained on a new technology. Traditionally this has been accomplished by having an applications specialist come in for a one or two day hands – on session to learn about the new ultrasound system upgrade, or the new instrumentation on the ultrasound machine. As sonography departments have grown, and more sonographers are present, a new model has arisen. This new model is sometimes referred to as the training of superusers. In this model, one or two persons are designated to work with the applications specialist, and the superuser(s) will disseminate the new information to the rest of the staff. The problem with this model for training is the lack of time for this task in a busy clinical environment. One solution is to work with a local ultrasound education program or with the medical facility’s Information Technology (IT) department to look at the feasibility of utilizing hybrid (also known as blended) learning methodologies to introduce and teach new technology to working sonograhers. Our institution engaged in a hybrid learning model to teach working sonographers how to perform breast elastography.
Corresponding Author: Carol Mitchell, 600 Highland Ave., MC 3252, Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, WI 53792, 608-263-9033, ; Email: [email protected]
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Background
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Breast elastography is a non-invasive imaging technique that acquires information based on how tissue behaves when manually deformed 1. To perform diagnostic breast elastography, the sonographer gently applies pressure over the area of interest using a “small parts” lineararray transducer 1. The ultimate goal of the examination is to displace the underlying tissue and track the motion using ultrasound echo signals in order to determine its elasticity 2. Early reports of elastography combined with B-mode ultrasound suggest that breast elastography can achieve accuracy that is equivalent to mammography 3. Clinical reports also suggest that the information provided with breast elastography may increase the confidence of “benign” diagnosis and therefore decrease the biopsy rate 4. With this in mind, researchers are hopeful that elastography will offer a new way to provide accurate, safe and cost effective ways to detect breast malignancy, as well as malignancies in other regions of the body 4 . To maximize the potential of this new technology, sonographers need to be properly trained in the technique of breast elastography. Like other techniques in medical sonography, breast elastography is highly operator dependant. Therefore implementing this new technology into clinical practice will require education of clinical sonographers to perform breast elastography correctly 2.
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In order to best use medical resources and personnel, there needs to be an efficient and timely way to teach sonographers this technology. Hybrid learning offers one way to implement breast elastography training. A hybrid course relies on both face-to-face (onsite) and internet-based (on-line) instruction, which is sometimes known as hybrid or blended delivery. When designing a hybrid course, it is generally ineffective to simply post existing materials on-line. Some thought needs to go into which aspects of the course need to be taught on-line, and which would be better taught in a face-face session. If these considerations are not thought through at the beginning of the course design, the course is likely to be unsuccessful. In the medical literature, hybrid learning has been reported with mixed outcomes 5,6.
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One study addressed the specific difficulties encountered by rheumatologists training to perform musculoskeletal ultrasonography 5. A web-based tutoring program was created to help tutor the physicians during a six-month scanning period between the initial basic training course and the final competency assessment 5. This web-based course contained five components: 1) teaching aids, 2) databases containing all standard scans, 3) interaction between the rheumatologist in training and tutors, 4) assessments using multiple choice questions, and 5) images to grade synovitis. The overall reaction of the participants in the study was positive with regards to the educational experience, however, overall operator competency was not achieved. Only 23% of the participating rheumatologists passed the final competency exam 5. The authors determined that limited access to an ultrasound machine and the inability to transfer sonographic images to digital format contributed to the poor outcome. Practical experience
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in prior to taking the basic course, access to necessary equipment, and adequate scanning time are three key factors that the authors feel limited the success of this project 5.
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Bradley et al utilized blended learning to redefine how personnel were trained and oriented to the preceptor role in nursing6. This study delivered content as an on-line course and as an instructor-led course. The primary focus of the on-line course was to provide a foundation of knowledge that prepared the students for the instructor led courses, which focused heavily on action learning activities. After completing the courses, 91% of the respondents stated that the online learning content prepared them for the classroom activities, and 94% of the learners reported improved knowledge of roles and responsibilities of the preceptor 6. Some participants stated that they were somewhat dissatisfied with the online course due to perceived repetition and redundancy between the Web-based content and the instructor-led class content, however, 86% said the blended learning approach improved their overall knowledge and skills about the preceptor role. Similarly, 85% stated that they would enjoy participating in other blended learning opportunities 6.
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By accounting for a variety of learning styles, one can help learners to master material in the way that is most comfortable for them. Utilizing learning style information to assist students in mastery of their studies is not new to the field of diagnostic medical sonography. One ultrasound program has implemented into their program a focus on identifying learning styles utilizing the Productivity Environmental Preference Survey (PEPS) developed by Dunn & Dunn 7,8. Based on the survey results, students are counseled about their learning styles and provided information about how to optimize their study habits. While there would not be time to perform a learning styles inventory on all working sonographers in a laboratory, it would be beneficial to design a hybrid course that would address all learning styles to implement new technology successfully 9.
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Utilizing the information gained from the aforementioned studies, the researchers designed a study to evaluate the potential for utilizing a hybrid course to teach working sonographers to perform breast elastography. The authors believed that this course delivery method had potential for success, because working sonographers should already possess the necessary knowledge to know what makes an image technically adequate as well as the scanning expertise to be able to learn breast elastography through a hybrid course model. Noting the success with Bradley et al, the authors designed the online learning modules to provide a foundation of knowledge that would prepare participants for face to face interactions and hands-on scanning sessions on a breast phantom. Since the objective of the on-line learning module was fir participants to master a basic understanding of the clinical use of elastography, each learning module was accompanied by a five point post-test. Each participant was asked to complete the post-test until they received a score of 100 percent. The face-to-face (instructor led) sessions reviewed the use of elastography in clinical trials, so sonographers could see the potential and importance of implementing this new technology into practice. Following this lecture, a second lecture was given, that reemphasized the on-line learning sessions with reviewing seven additional case studies. During the face-to-face session, sonographers were asked to comment , based on the E-mode image, to identify what pathology this case most likely represented. The final component to the face-to-face session was participation in a hands-on scanning session on a breast
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phantom, with immediate feedback, from an instructor, regarding breast elastography image quality and technique. The four foundational on-line modules presented were, 1) physical principles of elastography, 2) correlation of breast elastography with traditional B-mode imaging, 3) breast elastography imaging protocol, and 4) malignant versus benign findings. A detailed description of one of these modules is provided in Appendix A.
Methods This study was designed as an observational case study, and utilized qualitative methods of in-depth interviews, participant observation and post-course survey tools. The research question asked was “Can hybrid learning theory be use to teach working sonographers how to perform breast elastography in a sonography department?”
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An observational case study is a form of qualitative research that examines participants within a particular organization 10 Parts of the organization that become the foci for an observational case study are 1) specific place (i.e. sonography department), 2) specific group of people (i.e. practicing sonograpers) or 3) some activity of the organization (i.e. curriculum planning). In this case, the focus was placed on a particular group, sonographers who rotated through the breast center, and emphasis was placed on curriculum planning to implement a new technology in a busy sonography department. This study was submitted for review to our institutional board. After finding the study exempt from institutional review, the study commenced.
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The primary investigator, along with two student researchers recruited four practicing sonographers who worked in a dedicated breast imaging center. Participants were given an information form and informed that their identity would be kept confidential. All four sonographers recruited were registered with the American Registry of Diagnostic Medical Sonography (ARDMS), and three of the four were registered in the breast specialty. The sonographers ranged in years of experience from two years to 27 years. Years of experience were defined by the year first registered with the ARDMS. Information about the participating sonographers is summarized in table 1. Once recruited to the study and after signing an information form, the sonographers were given a username and password to access the on-line learning modules. After the completion of each learning module, the participants took a five point post-test. Participants took the post-test until they correctly answered all questions. The post-test scores are represented in table 2.
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Once the post-tests were completed, participants attended a face to face (instructor led) training session and hands-on scanning session. There were two lectures given at the face-toface session. The first lecture focused on the use of elastography and a historical account of the clinical trials that had been performed to result in the technology that is being used today. The second lecture was a case presentation lecture that reviewed the standard B-mode findings of malignancy and the characteristics of malignancy with elastography. After each presentation, participants were asked if they thought this case was most likely malignant or benign.
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After the lectures, participants were interviewed and observed in scanning the breast phantom and utilizing the elastography mode. Images were critiqued as to the quality of the elastography image (Figure 1 and 2). Data Collection In-depth individual interviews were conducted with each of the participating sonographers. Open – ended questions were utilized which led to additional questions (Table 3). The interviews were guided to see how sonographers had initially heard or learned about elastography and how they would perform elastography imaging. Open-ended questions led to discussion about how the participants learned sonography, and how they felt about this training session. At the conclusion the primary investigator read back the answers to questions and asked the participants to confirm the answers and reflect on any additional information they wished to share.
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Field notes were taken during the hands-on observation time period. Two sonography students and the primary investigator recorded field notes while the participating sonographer demonstrated their ability to obtain an elastography image on a breast phantom with multiple lesions. The interviews and field notes were then entered into the Ethnograph software and coded to look for emerging themes. One week after the completion of the faceto-face session, participants were asked to complete a post-course survey. The survery asked questions about self assessment and their ability to now perform elastography. Data Analysis
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All data was entered into the Ethnograph software and coded inductively. The data was then analyzed using a deductive approach against published learning theory models for sonographers. The final analysis was the interpretation of these findings in the context of how hybrid learning theory may be used to add to a current knowledge and skill set in adding elastography imaging to the routine breast Sonography evaluation.
Results
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Themes that resulted from the coded data were 1) protocol, 2) technique, 3) former learning/ knowledge, 4) hybrid learning 5) ability to perform, and 6) self evaluation . The code protocol refers to the participant’s knowledge at the time of the face-to-face session regarding what images to take. The protocol that was taught was to perform standard Bmode imaging. If a lesion is found, the lesion should be imaged in both longitudinal and transverse planes, the lesion dimensions should be measured, and color Doppler should be utilized to further delineate blood flow, or lack of blood flow to the lesion centrally or circumferentially. After obtaining the standard B-mode images, participants then described the additional images to obtain in elastography mode (E-mode). The additional images to acquire include, a cine clip in E-mode, and an image with and without lesion size measurements in transverse and longitudinal planes. The second code that emerged was technique. The code technique referred to how to acquire the E-mode images. All participants were able to verbalize in the interview and demonstrate in the hands-on session how to obtain an E-mode image and what technical factors were to J Diagn Med Sonogr. Author manuscript; available in PMC 2016 May 24.
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be considered. The technique described in the hands-on session, and then re-emphasized in the face-to-face session were; 1) obtain and optimize B-mode image, 2) turn harmonics off, 3) lighten your pressure (touch) on the breast (or phantom), 4) ensure that the background breast tissue is uniform in texture and that there is no B-mode image tracking on the E-mode image. These are all imaging characteristics that ensure a good quality E-mode image. Examples of a poor quality and high quality E-mode image are represented in figures 1 and 2. Descriptions collected regarding technique included; utilizing less pressure than with standard 2D B-mode imagning, obtaining a cine clip and measuring the B-mode and E-mode dimensions of the mass. Participants also reported that if one has a high quality E-mode image, there should be no B-mode tracking seen on the display screen and that the background of the E-mode image should not be pixely, but rather should have a nice uniform gray appearance. (Interviews 8/28/2008) (Figure 1 and 2).
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The third theme was former learning/knowledge. This theme referred to knowledge about performing elastography prior to the course, compared to after the course. Participants reported that after participating in a hybrid learning course that they had a much better understanding of what made a “good” E-mode image and how to obtain it. Participants also reported that having to take a post-test for each module forced them to complete the learning moduels, and that these activities made the face-to-face sessions much more meaningfule (Interviews 7/21/2008 and 8/28/208).
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The follow-up question to “How did you initially learn breast elastography?” was, How would you implement the use and teach other staff members how to do breast elastography?” Responses included that this course was great, everyone learns differently and that this format took into account different learning styles with out making one feel that they did not know as much as someone else at the face-to-face sessions. All respondants shared that the face-to-face sessions were beneficial with the practice and the the on-line modules (while helpful to provide background information), there is still no substitute for leaning a sonography technique without the hands-on experience (Interviews 7/21/2008 and 8/28/2008).
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This fourth theme was coded as hybrid. Hybrid referred to the participant’s response to this type of training. What was interesting with this group of responses is that you could start to get a sense of how people learned and what learning style they might be. Dunn and Dunn (1993), described a learning style model in terms of individual reaction to 23 elements. These 23 elements were organized around five strands 8. The five strands were; 1) immediate environment (light, sound, temperature), 2) emotionality (motivation, persistence, responsibility, need for structure), 3) sociologic preferences (learning alone, learning with peers, or learning with authoritative adult, learning in a variety of ways versus pattern or routine), 4) physiologic characteristics (auditory, visual, tactile, time of day, mobility needs) and 5) global versus analytic processing (correlations between light, sound, design, persistence, sociologic preference and intake). When we looked at the responses above, we could see that in general, all liked looking at the information, on their own time and at their own pace, however, all also felt that there was no substitute for hands-on ultrasound training. Also, 3 out of 4, stated that it was good to have a test, because that made them read. One participant stated that they did not want to do bad on the tests, because at the beginning of
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the study, participants were informed that the investigators would be looking at the tests to monitor that everyone completed them and received a score of 100% prior to attending the face-to-face training. Therefore, taking into account Dunn & Dunn’s five strand model one can see that strand-1 evaluates how people learn based on their immediate environment (light, sound, temperature)7–9. Through development of a hybrid learning course with both on-line breast elastography modules and face-face sessions, participants could be in control of their environment at home or in the library, where ever they wanted to review their on-line modules and then take their post-tests.
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With regard to strand-2 emotionality (motivation, persistence, responsibility, need for structure)7–9, participants were allowed flexibility regarding when they did their modules and how fast they completed their modules, with the only guideline that the post-tests had to be completed prior to attending the face-to-face session. Participants were told on the information sheet that the instructors would see their scores and know if they had completed the post-test and achieved a score of 100%. Participants also were informed that they would not be allowed to attend the face-to-face session without completion of the learning modules and post-tests. All were motivated to complete the modules and post-tests by the face-to face course date, the date served as time-frame (structure) for completing and also served as a means for the participants to take responsibility for their own learning.
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Strand-3 sociologic preferences (learning alone, learning with peers, or learning with authoritative adult, learning in a variety of ways versus pattern or routine)7–9 was addressed by providing multiple means to learn the same information. Through completing the on-line post-tests, participants demonstrated that they had at least read and looked up answers to key points that the course instructors felt they needed to know prior to attending the face-to-face session. The information presented in the on-line tutorials covered terminology, technique, clinical importance, and what criteria makes a good E-mode image. Having had this information mastered prior to attending the face-to-face session allowed the course instructors to focus on the performance skills of actually performing breast elastography. It also allowed the participants to ask questions as they performed and to describe why their image was good quality and would provide additional information to the interpreting physician.
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Strand −4 physiologic characteristics (auditory, visual, tactile, time of day, mobility needs)7–9 were addressed in both the on-line and face-to-face sessions. The on-line modules were designed to be interactive and included case studies with ultrasound images. To take into account visual and tactile senses, participants could utilize the mouse to play cine clips associated with exams and also could watch a narrated video on how to perform the exam. All modules were designed to be completed (with the post –test) within 30 minutes. Strand-5 global versus analytic processing (correlations between light, sound, design, persistence, sociologic preference and intake)7–9 were evaluated at the time of the hands-on session. This was evaluated by observing how well the participating sonographers could perform elastography, (which was the ultimate goal of this educational project). By
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evaluating how well sonographers performed the elastography session, we could understand how they processed the information given in the on-line modules and at the opening of the face-to-face session. Participating sonographers all were able to state how to perform the exam on the ultrasound equipment, could perform the steps to add E-mode images and cine clips to the breast imaging protocol, and could state benign and malignant characteristics associated with both B-mode imaging and E-mode imaging. Post-course surveys were administered one-week after the face-to-face session and sonographers responded positively to this course. Results of the post-course survey are shown in table 5.
Discussion
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Advancements in computer technology have made hybrid learning a possibility for educating health professionals in the work environment 11. The intentional design of the curricula, in which multiple learning styles can be addressed, provided a means to educate practicing sonographers how to perform breast elastography. Limitations to this study are 1) only four sonographers participated, 2) all sonographers had some exposure to breast elastography prior to participating in this course, which may have contributed to the success of hybrid learning to implement this technology in this setting and 3) observations were made scanning a breast phantom. Future research on hybrid learning for teach practicing sonographers breast elastography could include multi-center trials comparing the use of this course content and format, along with a formal pre-test, post-test and observation on real patients versus typical one-day hands-on training.
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In summary, we believe that online integration between what is taught in the classroom and the real world of work significantly improves program outcomes and allows busy centers a means to educate all staff in a timely manner on new technology. We also recognize that there is no substitute in ultrasound education for hands-on experience, and therefore, we advocate that while basic knowledge can be taught and mastered prior to the face-to-face session, the face-face session must include adequate time for all participants to have handson experience. During the hands-on experience, time must be made for participants’ questions to be answered, and immediate feedback given at the time of scanning.
References
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1. Hall TJ. Physics Tutorial for Residents: Topics in US. Beyond the Basics: Elasticity Imaging with US. Radiographics. 2003; 23:1657–1671. [PubMed: 14615571] 2. Burnside E, Hall TJ, Sommer A, et al. Differentiating Benign from Malignant Solid Breast Masses with US Strain Imaging. Radiology. 2007; 245:401–410. [PubMed: 17940302] 3. Zhi H, Ou B, Luo B, et al. Comparison of Ultrasound Elastography, Mammography, and Sonography in the Diagnosis of Solid Breast Lesions. J Ultrasound Med. 2007; 26:807–815. [PubMed: 17526612] 4. Zhu QL, Jiang Y, Liu J, et al. Real-time Ultrasound Elastography: Its Potential Role in Assessment of Breast Lesions. Ultrasound in Medicine and Biology. 2008; 34:1–7. [PubMed: 17720302] 5. Filippucci E, Meenagh G, Ciapetti A, Iagnocco A, Taggart A, Grassi W. E-learning in ultrasonography: a web-based approach. Annuals of the rheumatic diseases. 2007; 66:962–965.
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6. Bradley C, Erice M, Halfer D, et al. The Impact of a Blended Learning Approach on Instructor and Learner Satisfaction With Preceptor Education. Journal for Nurses in Staff Development. 2007; 23:164–170. [PubMed: 17666898] 7. Dunn, R.; Dunn, K. Teaching Secondary Students Through Their Learning Styles. Boston: Allyn and bacon; 1993. 8. Dunn, R.; Dunn, K.; Proce, G. Productivity Environmental Preference Survey. Lawrence, Kansas: Price Systems; 1986. 9. Dunn, R.; Klavas, A. Homework Disk for the Learning Syle Inventory. Jamica, New York: St. John’s University’s Center for Teaching and Learning Styles; 1990. 10. Bogdan, RC.; Biklen, SK. Qualitative Research For Education: An Introductio to Theory and Methods. 3rd. Boston: Allyn and Bacon; 1998. 11. Miller, J. Effects of traditional versus learning style-presentations of course content in ultrasound and anatomy on the achievement and attitudes of college students. Doctoral thesis. Jamacia, New York: St. John’s University; 1997. 12. Hebda T. a profile of the use of computer-assisted instruction within baccalaureate nursing education. Computers in Nursing. 1988; 6:22–29. [PubMed: 3277698] 13. Schreiber LW. “ClUES”: clinical learning utilizing educational strategies. J Diagn Med Sonography. 1997; 15:164–166. 14. Miller J, Dunn R. The use of learning styles in Sonography education. Journal Diagn Med Sonogr. 1997; 13:304–308. 15. Regner D, Hesley G, Hangiandreou N, et al. Breast Lesions: Evaluation with US Strain ImagingClinical Experience of Multiple Observers. Radiology. 2006; 238:425–437. [PubMed: 16436810] 16. Garra B, Cespedes EI, Ophir J. Elastography of Breast Lesions: Initial Clinical Results. Radiology. 1997; 202:79–86. [PubMed: 8988195] 17. Hagen-Ansert, S. Textbook of Diagnostic Ultrasonography. St. Louis, Missouri: Mosby, Inc.; 2006. 18. Zhi H, Ou B, Luo B, et al. Comparison of Ultrasound Elastography, Mammography, and Sonography in the Diagnosis of Solid Breast Lesions. J Ultrasound Med. 2007; 26:807–815. [PubMed: 17526612] 19. Feldman. Strategies for interpreting qualitative data. Thousand Oaks: Sage Publications; 1995. 20. Polit, DF.; Hungler, BP. Nursing research: Principles and methods. 6th. Philadelphia, PA: Lippincott; 1995. 21. Silverman, D. Interpreting qualitative data: Methods for analyzing talk, text and interaction. London: Sage Publications; 1993. 22. Stainslaw S. Virtual Palpation. Advance. 2008 Mar.:20–22.
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Appendix A Curriculum Sample Module 4 Benign versus Malignant Characterisitcs.
Learner Objective Author Manuscript
1.
Review cases and state the most likely pathology based on the B-mode and E-mode images.
Module Description This module is a pdf tutorial that reviews multiple benign and malignant pathologies with both standard B-mode images and E-mode images. The post-test focuses on the student’s
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ability to recognize pathology based on B-mode and E-mode ultrasound image characteristics. Post-Test-Sample Questions Participants completed 5 case study questions. 1.
This image most likely represents:
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a.
Cystic breast cancer
b.
Insitu ductal carcinoma
c.
Invasive ductal carcinoma
d. Fibroadenoma 2.
This image most likely represents:
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a.
Cystic breast cancer
b.
Insitu ductal carcinoma
c.
Invasive ductal carcinoma
d. Fibroadenoma
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demonstrates a B-mode image of a breast lesion obtained on a breast phantom that is of poor quality. Note the background is not homogenous and the lesion is not well identified.
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Figure 2.
demonstrates an appropriately scanned E-mode image. Note the homogenous background and easily identified borders of the lesion. This is achieved by applying light pressure while scanning.
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Table 1
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Participating Sonographer Characteristics. Sonographer
# of years of experience
ARDMS Registered
ARDMS registered breast specialty
A
2
X
B
4
X
X
C
19
X
X
D
27
X
X
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100
100
100
C
D
100
A
B
Post – Test Module 1 Score
1
1
1
1
Post – Test Module 1 Attempts
100
100
100
100
Post – Test Module2 Score
1
1
1
1
Post – Test Module 2 Attempts
100
100
100
100
Post – Test Module3 Score
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Sonographer
1
1
1
4
Post – Test Module 3 Attempts
100
100
100
100
Post – Test Module 4 Score
1
2
1
1
Post – Test Module 4 Attempts
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Post Test Scores.
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Table 2 Mitchell et al. Page 14
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Table 3
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Open Ended Interview Questions. Open Ended Questions for Interview at time of Observation 1
How are you going to perform palpation sonography?
2
What is different about the E-mode imaging protocol for you compared to the traditional B-mode imaging protocol?
3
Do you feel that you tailor the exam differently for the E-mode protocol versus the Bmode protocol?
4
How will you perform the exam?
5
What are the elements of a good image for E-mode ultrasound?
6
What are the steps for acquiring E-mode ultrasound data?
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Table 5
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Survey questions and responses. Participants were asked to complete a post-test course survey with a rating scale of −3 (strongly disagree) to 3 (strongly agree). Results are provided in the table below. Only 3 (of four) surveys were returned.
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Survey Question
Mean Rating
Results
Completing the on-line learning materials prior to the face-toface session were helpful.
3
3,3,3
The hands-on session at the face-to-face learning session assisted me with learning how to perform breast elastography.
2.33
3,2,2
I feel that I can state with confidence that I can attain a breast elastography image.
2.33
3,2,2
I can state what makes a good elastography image.
3
3,3,3
I plan to implement breast elastography imaging into all of my breast pathology cases.
2
2,2,2
This course assisted me to learn how to perform breast elastography.
2.66
3,2,3
The on-line post-tests allowed me to demonstrate my mastery of the information presented.
2
2,2,2
I felt confident performing breast elastography protocol on the breast phantom.
2.66
3,3,2
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