By Sanjeeda Jafar, Shruti Budhani, and Diane Wilson
Hematology I and II are junior- and senior-level courses, respectively, in the medical laboratory science (MLS) curriculum at our historically Black college or university (HBCU). Hematology I (Heme I) focuses on red blood cell (RBC) disorders, and Hematology II (Heme II) deals with white blood cell disorders and disorders of hemostasis. Both courses are 8 weeks long.
Our MLS program prepares students to be medical laboratory scientists. The program identifies competencies for the courses that must be completed as recommended by the accrediting agency. The program is laboratory intensive. MLS students take MLS courses in the spring and fall semesters of their junior year and have a fall session in their senior year. In the spring session of their senior year, students do their clinical practicums at local hospitals or affiliates.
We had planned to convert Heme I to a hybrid design in 2019 with the following goals in mind:
The hybrid design is a blend of online (OL) and F2F (face-to-face) components; it is also referred to as a blended course. A hybrid course avoids the isolation that some students experience with fully OL courses (Garrison et al., 2015). Because of the difficulty students have with hematology, we decided that a blended course was a better option than a fully OL course.
In this article, we describe how the design changes already in place for Heme I were adopted for Heme II. These changes helped us convert Heme II smoothly into a fully remote course by fall 2020 after the university went into remote instruction in March 2020 due to the COVID-19 pandemic. Our findings helped us design Heme II effectively for remote instruction. The design changes were also adopted by other courses (such as MLS 300: Principles of Medical Technology and MLS 305: Introduction to Clinical Chemistry) in the program and enabled us to successfully transition the program to remote teaching.
The lead author of this article designed the courses.
Heme I topics include the anemias and RBC production or erythropoiesis and development, as well as the complete blood count (CBC). First, we established the course goals (Figure 1) to ensure students attained the knowledge and practical aspects of RBC disorders. Then the course was divided into eight modules, each 1 week long. The modules mapped to one or more of the course goals (Figure 2). Each module had its objectives, reading, assignments, quizzes, and videos available to students in Canvas, our university’s learning management system. (For examples of module content, see the objectives for module 1 in Figure 3 and the module contents in Figure 4.) The students were required to attend F2F classes once each week. We had planned for the weekly F2F meetings to be used for labs, in-class exams, quizzes, and group work. By spring 2021, when Heme I commenced, however, we had not yet moved to a hybrid model, so lecture instruction was also provided F2F and students attended F2F classes twice each week as a result.
Module I: Erythropoiesis, RBC morphology, and inclusions (Outcomes 1, 8, 9; Week 1)
Module II: CBC and hemoglobin (Hgb) (Outcomes 2–4; Week 2)
Module III: RBC metabolism and clinical considerations of anemia (Outcomes 5–7; Week 3)
Module IV: Microcytic anemias (Outcome 7; Week 4)
Module V: Macrocytic anemias and hemolysis (Outcome 7; Week 5)
Module VI: Normocytic anemias and membrane disorders (Outcome 7; Week 6)
Module VII: Biochemical disorders and aplastic anemias (Outcome 7; Week 7)
Module VIII: Case study presentations and final exam (Outcomes 1–9)
The student will be able to do the following at the end of Module 1:
Module I contents (prepandemic).
All lectures were presented via PowerPoint slides with animations and other built-in activities. For example, after covering erythropoiesis, the instructor would share hematology slides that showed bone marrow smears, and students would need to identify the RBC precursors that they had just learned about. In our initial design, and as carried out in spring 2020, after a short segment of lecture in the F2F class, students divided into groups and worked on activities such as creating a concept map for hematopoiesis or outlining the steps of RBC maturation. They completed these tasks on physical whiteboards and presented their work. Another engaging activity was accomplished in Module II: After learning about the CBC, students were given different patient scenarios and had to determine whether or not the patient had an anemia.
Once a module was complete, students in the F2F class took summative assessments such as quizzes and exams on the topic covered by that module. These assessments were closed-book exams with both multiple-choice and written-response questions.
The laboratory was designed to be F2F. Students needed to review the material in the lab introduction and turn in answers to prelab questions. During the lab, we first demonstrated how to perform an activity, such as the procedure to make blood smear slides (using actual blood and glass slides); students were then asked to make smears that met the established criteria. The second half of the class involved students evaluating peripheral blood smears from actual slides (obtained from hospitals) and describing RBC morphology, enumerating the requested cell counts. As an ancillary to the sample slides examined in class, we assigned RBC and WBC differential simulator cases from MediaLab, a cloud-based platform that provides users with access to scanned images of slides. The university purchased access to the simulators for the students. For each simulator case, students were presented with a case study in which the CBC results, patient age, and sex information were made available. They then viewed images of the peripheral smear from the patient in the case study. The simulator is designed so that students would virtually examine slides as they scrolled through the images; this experience was similar to examining different fields of view using a microscope in the laboratory and allowed them to count as well as record any abnormal cells or morphology. Figures 5–7 show the case simulator introduction (Figure 5), a sample WBC (Figure 6) of the 100 students would identify, and the start of the review (Figure 7).
MediaLab white blood cell identification example.
Note. Once the session has started, students have to identify 100 white blood cells.
Note. At the end of the session, students gets their results, including a video review. Each image listed on the left can be reviewed, and any incorrect results would be highlighted in red (none were incorrect in this example).
We required the students to complete the assignments and score higher than 97% in the WBC simulator. Students received immediate feedback from MediaLab and could review videos for each case study.
In spring 2020, while we were still conducting F2F classes, students completed their labs on blood smear preparation, hematocrit, reticulocyte count, and erythrocyte sedimentation rates using actual blood samples. They also reviewed peripheral blood smears of actual glass slides that we had in our F2F laboratory. Because the students had already made peripheral smear slides and evaluated the prepared smears in our collection, we only needed to design the final laboratory practical exam (described in the following section).
When the university switched to remote instruction, the laboratory final was designed so that students evaluated peripheral smears in MediaLab. Students were given two smears for which they performed the RBC estimate, platelet estimate, and WBC differential count, then they submitted their results to MediaLab. In addition, students were required to submit results to Canvas and comment on whether the slides evaluated had any abnormalities. The written part of the lab exam was administered via Canvas and used the Respondus LockDown Browser With Monitor, which requires that students have their cameras on and are recorded during the exam.
As we had done for Heme I, we established the learning objectives for Heme II (Figure 8). This course had four modules (see Figure 9), each 2 weeks long. Classes were held remotely. We met at the same time as the F2F classes were previously held via Zoom. Students had access to the lecture materials from the course start date. The design we built into the lecture PowerPoint presentations was helpful for keeping the students engaged. To ensure student engagement, students were asked in turn to present from the slides (made by the instructor). Faculty then explained the concept covered and answered any questions.
Module I: Leukopoiesis and white blood cell counts (addresses Outcomes 1 and 2; Week 1)
Module II: Chronic leukemias and myeloproliferative neoplasms (addresses Outcomes 3, 5; Weeks 2–3)
Module III: Acute leukemias and myelodysplastic syndromes (addresses Outcomes 4, 5; Weeks 4–5)
Module IV: Coagulation (addresses Outcomes 7–9; Weeks 6–8)
After we went to completely remote classes, we needed to make changes to the activities built into the PowerPoint slides, which were now presented in files in Canvas. After covering the concept in lecture PowerPoints (during Zoom sessions), students would go to breakout rooms and work on the assignments. Each group then had to discuss their results with the class and upload their work for grading into assignment folders. Students enjoyed their interactions in the breakout sessions, as mentioned in letters that students wrote to the instructor to express appreciation (unsolicited) after the course was over.
Another change instituted was the way in which exams and quizzes were administered. All quizzes and exams were now exclusively online, administered in Canvas (as opposed to the previous in-class exams). We used the Respondus LockDown Browser With Monitor to maintain the integrity of the assessments.
The most important consideration was the laboratory for Heme II. Heme II laboratory exercises are mainly slide based, meaning they use glass slides of blood smears. The MediaLab WBC differential and advanced WBC differential simulators had become the main lab exercises instead of ancillary ones. We designed the remote labs to keep them as close to the F2F methodology as possible. Students signed in to their remote Zoom session for laboratory. In the first class involving MediaLab simulations, the instructor logged into MediaLab and demonstrated to the students how to evaluate the peripheral blood smear from the virtual images. At that point, students received their lab assignment by email, which MediaLab uses to send users their assignments. Students then logged into MediaLab and started their exercise. We expected their cameras to be turned on so we could observe them while they performed the lab and answer any questions. At the end of the exercise, students submitted their work to MediaLab. They also recorded their findings and submitted those findings to an assignment folder in Canvas. We found this added task to be beneficial as students were also accountable to us.
We needed to revise some of the content in fall 2020 and introduced a Labster (a company that provides virtual labs) lab on hematology, which involved a hematology analyzer. We used this lab because we felt students had not had sufficient exposure to the hematology analyzer in the F2F lab in Heme I. A major drawback was that students did not experience a lab that involved counting blood cells in a body fluid using a hemocytometer; this task is a required competency for MLS, and students may be asked to perform cell counts during their hospital practicums. However, we made sure that students understood the calculations and watched videos involving cell counts.
Means from grades on the final lecture and lab examinations (practical and written components) were compared using the t-test to see if there were any significant differences.
The only part of Heme I affected by the move to remote instruction in the spring 2020 session was the second lab exam (Laboratory Exam II). Each lab practical exam consisted of a practical part and a written part. As described earlier, for the practical portion, we relied on MediaLab case simulator sessions. The written part was taken in Canvas using Respondus LockDown Browser With Monitor, where students were videotaped during the examination and could not leave the browser during the examination.
It is important to determine whether the higher grades in the practical portion of the lab final affected the final grades. For this purpose, we compared the midterm grades and final grades (Table 2). The midterm grade and final grade means were similar, and there was no significant difference in the values.
Heme II was completely remote. In this section, we discuss the final grades students received in Heme I and in Heme II (Table 3). Two other objective assessment tools discussed are (i) evaluations from hospitals in the clinical practicums and (ii) performance on the American Society for Clinical Pathology Board of Certification (ASCP-BOC) examination. We also compare Heme I and Heme II final grades. Figure 10 shows the criterion for clinical practicum evaluation by our hospital affiliates.
1. General knowledge
3. Personal characteristics
Numerical grade for the practical exam = 40%
Numerical grade for technical skills = 55%
“Soft skills” or affective domain skills demonstrated = 5%
Seven students were enrolled in Heme I in spring 2020 (Table 3). Six of these students took Heme II in fall 2020; they were joined by a returning student (Student 8 in Table 3) who had taken Heme I 2 years prior. Six students were eligible to complete their clinical practicums in spring 2021. Due to our hospital affiliates not being able to accommodate all six students, two students completed their practicums at the university remotely (marked OC in Table 3, which shows the final grades students received in Heme I and Heme II). All students passed both courses. We also present their clinical practicum assessments from our hospital affiliates (marked Hos in Table 3) as well as performance in the hematology subdiscipline of the BOC examination for MLS.
Students 1 and 8 completed their practicums in-house at our university. As these two students were evaluated remotely by means of case study presentations and MediaLab exercises, we could not evaluate their laboratory skills. We were therefore very interested in the evaluations of the four students (Students 2 through 5) who completed their practicums at external sites (i.e., area hospitals that are our affiliates). All of our students received a grade of 90% or higher from the hospitals. We did note that if a student received a grade of 87% or higher in Heme II laboratory, it correlated with a grade of 95% or higher from our hospital affiliates. We also received positive feedback from our hospital affiliates on student performance in hematology. Student 5 was described as outstanding by our hospital affiliate and had the second-highest score in both Heme I and Heme II. So far, three of the six students have taken the BOC examination, and all three passed the hematology subdiscipline.
Medical laboratory scientists, although not at the forefront of the field in terms of visibility to the public like doctors and nurses, are the “bedrock” of laboratories and have been in the spotlight during the COVID-19 pandemic (Behan, 2020; Ibeh et al., 2020). In spite of the message presented concerning the need for additional MLS professionals during the pandemic and beyond, Behan (2020) wrote in a special report that budget cuts by universities have affected the sustainability of university-based MLS programs—the source of the MLS professionals. We had already faced dwindling enrollment in our MLS program prior to the pandemic. Attracting non-MLS majors to MLS courses was one of the reasons we designed a hybrid Heme I course.
In response to the pandemic, university faculty were asked to quickly convert classes to a remote format (Hughes et al., 2020). We have previously shown that there is no difference in course outcomes for a traditional vs. hybrid Anatomy and Physiology I course in an HBCU setting (Jafar & Sitther, 2021). Because we had already redesigned Heme I, our program benefited from our ability to apply those redesign strategies to other courses in response to the pandemic. Our design of both Heme I and later Heme II involved establishing clear objectives, dividing the courses into modules, mapping the modules to the objectives, and designing careful online assessments.
All students passed both hematology courses. We did find a difference between scores of practical parts of lab exams administered F2F or remotely, but we did not find major differences in course outcomes for courses delivered by either method. One reason for the higher score in the online practical exam could be that students may have retained the answers when they practiced the virtual case simulators. In a F2F lab, students cannot take the results out of the lab after we evaluate and discuss the practice labs. We cannot also exclude the premise that students learned better in virtual simulations.
Although our design of Heme I helped us with the fully remote Heme II, there was always the question of whether our students had been adequately prepared for the clinical practicums. The assessments from the affiliates indicated that the students were prepared.
There have been reports of psychological distress among students taking online courses during the pandemic (Schmits et al., 2021). Even if we consider our course delivery a success, the student perspective could be quite different. To address how students viewed the courses we delivered in the MLS program, students are writing a report on their evaluations of those courses.
An important consideration is that 29% of college teachers do not view online learning as an effective teaching method (Miller et al., 2021). This report may allay some of those concerns from the instructional delivery aspect, especially because the students received positive external reviews.
In conclusion, we find that our students received effective instruction for hematology, as evidenced by the hospital evaluations they received and their performance on the hematology subdiscipline of the ASCP-BOC MLS examination. Our design of Heme I and Heme II helped with effective delivery of these courses in a remote setting. Our findings are the first report of effective remote delivery of hematology courses in an HBCU during the pandemic. We are still waiting for all students to complete their certification examinations, as scores from those examinations will help us assess more fully the knowledge that students retained.
Sanjeeda Jafar (firstname.lastname@example.org) is a professor of practice in the Medical Laboratory Science (MLS) Program in the School of Computer, Mathematical, and Natural Sciences; Shruti Budhani is lab assistant and lecturer in the MLS Program; and Diane Wilson is an associate professor emeritus of biology, all at Morgan State University in Baltimore, Maryland.
Behan, K. J. (2020). Strategies for sustainability of university-based medical laboratory sciences programs. Laboratory Medicine, 52(5), 420–425. https://doi.org/10.1093/labmed/lmaa109
Garrison, G. D., Baia, S., Canning, J. E., & Strang, A. F. (2015). Asynchronous learning approach for the instructional component of a dual-campus pharmacy resident teaching program. American Journal of Pharmaceutical Education, 79(2), 29. https://doi.org/10.5688/ajpe79229
Hughes, M. C., Henry, B. W., & Kushnick, M. R. (2020). Teaching during the pandemic? An opportunity to enhance curriculum. Pedagogy in Health Promotion, 6(4), 235–238. https://doi.org/10.1177/2373379920950179
Ibeh, I. N., Enitan, S. S., Akele, R. Y., & Isitua, C. C. (2020). A review of the COVID-19 pandemic and the role of medical laboratory scientists in containment. Journal of Medical Laboratory Science, 30(1), 68–89.
Jafar, S., & Sitther, V. (2021). Comparison of student outcomes and evaluations in hybrid versus face-to-face Anatomy and Physiology I courses. Journal of College Science Teaching, 51(1), 58–66. Miller, A. N., Sellnow, D. D., & Strawser, M. G. (2021). Pandemic pedagogy challenges and opportunities: Instruction communication in remote, HyFlex, and BlendFlex courses. Communication Education, 70(2), 202–204. https://doi.org/10.1080/03634523.2020.1857418
Schmits, E., Dekeyser, S., Klein, O., Luminet, O., Yzerbyt, V., & Glowacz, F. (2021). Psychological distress among students in higher education: One year after the beginning of the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 18(14), 7445. https://doi.org/10.3390/ijerph18147445
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