Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93

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Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ)

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Schwerpunktreihe / Special Section ,,Peer Assisted Learning‘‘

Cross-year peer-assisted learning using the inverted (‘‘flipped’’)classroom design: A pilot study in dentistry

Cross-year-Peer-Assisted Learning im Inverted-Classroom-Szenario: Pilotprojektaus der Zahnmedizin

Maximilian Quoßa, Stefan Rüttermannb, Susanne Gerhardt-Szepb,∗

a Dermatologie und Allergologie, Kantonsspital Aarau, Aarau, Schweizb Poliklinik für Zahnerhaltung, Carolinum Zahnärztliches Universitäts-Institut gGmbH, Goethe-Universität Frankfurt am Main, Frankfurt am Main

a r t i c l e i n f o

Article History:Received: 3 April 2017Received in revised form: 1 July 2017Accepted: 14 July 2017Available online: 11 October 2017

Keywords:peer-assisted learninginverted classroom modelICMe-learningPOLdentistrytutoringtrainingmentoring

a b s t r a c t

Background: The inverted classroom model (ICM) represents a special combination of online and atten-dance learning. The implementation of the didactic concept of ‘‘peer-assisted learning’’ (PAL) within anICM design has not yet been described in the literature for the field of restorative dentistry.Objective: It was the goal of the present study to develop an ICM offering in a cross-year PAL format(ICM-cyPAL), and then introduce and evaluate it.Method: The pilot project was conducted at the dental clinic at the Goethe University of Frankfurt/Main,where following its conceptual development and implementation with three consecutive cohorts ofstudents in their first clinical semester (the sixth semester at university) the ICM-cyPAL offering wasevaluated. Data on acceptance, tutor effectiveness, group interaction models and learning strategies werecollected using an evaluative instrument.Results: 121 students (tutees) participated in three cohorts. The response rate reached 98.3 %. In total,the offering was given an average rating of 6.97 ± 1.93 (from 1 = unsatisfactory to 10 = excellent). As thetutees explained the attention that the tutors employed gave to the group was ‘‘just right’’ (4.65 ± 1.04;where 1 = too controlling and 4 = just right to 7 = left the group on their own too long) and talked ‘‘justthe right amount’’ (4.54 ± 0.95; where 1 = too much and 4 = just right to 7 = talked too little). The resultsfor tutor effectiveness reached values between 3.26 ± 0.94 and 3.78 ± 0.87; for the evaluation of groupinteraction models average values were obtained from 3.41 ± 0.98 to 3.89 ± 0.73 (on a Likert scale of 1 =do not at all agree to 5 = completely agree). Concerning the surveyed learning strategies, the dimensionsof ‘‘resource management’’ and ‘‘implementation of the learning materials’’ were given the highest andlowest rankings, respectively.Conclusion: The tutees’ ratings of the newly developed and implemented ICM-cyPAL offering in thedental context were mainly positive. The thematic orientation of the structured training program needsto be optimized. The offering itself requires both a high degree of organization and solid financial andstaffing resources.

∗ Corresponding author: S. Gerhardt-Szép, Poliklinik für Zahnerhaltung, Carolinum Zahnärztliches Universitäts-Institut gGmbH, Goethe-Universität Frankfurt am Main,Theodor-Stern-Kai 7, 60596 Frankfurt am Main.

E-mail: S.Szep@em.uni-frankfurt.de (S. Gerhardt-Szep).

http://dx.doi.org/10.1016/j.zefq.2017.07.0071865-9217/

dx.doi.org/10.1016/j.zefq.2017.07.007http://www.sciencedirect.com/science/journal/18659217http://www.elsevier.com/locate/zefqhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.zefq.2017.07.007&domain=pdfmailto:S.Szep@em.uni-frankfurt.dedx.doi.org/10.1016/j.zefq.2017.07.007

M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93 85

a r t i k e l i n f o

Artikel-Historie:Eingegangen: 3. April 2017Revision eingegangen: 1. Juli 2017Akzeptiert: 14. Juli 2017Online gestellt: 11. Oktober 2017

Schlüsselwörter:Peer-Assisted LearningInverted-Classroom-ModellICME-LearningPOLZahnmedizinTutorenSchulungMentoring

z u s a m m e n f a s s u n g

Hintergrund: Das Inverted-Classroom-Modell (ICM) stellt eine besondere Kombination zwischenOnline- und Präsenzlernen dar. Die Implementierung des didaktischen Konzepts des ,,Peer-AssistedLearning‘‘ (PAL) innerhalb eines ICM-Szenarios ist bis dato im Fach Zahnerhaltungskunde nicht in derLiteratur beschrieben.Fragestellung: Ziel der vorliegenden Studie war es, ein ICM-Angebot im Cross-year-PAL-Format (ICM-cyPAL) zu konzipieren, einzuführen und zu evaluieren.Methode: Das Pilotprojekt wurde an der Zahnklinik der Goethe-Universität Frankfurt am Main durchge-führt, indem nach der Konzeption und Implementierung bei drei aufeinanderfolgenden KohortenStudierender in ihrem ersten klinischen Semester, dem sechsten Fachsemester, das Angebot des ICM-cyPAL evaluiert wurde. Daten zur Akzeptanz, Tutoreneffektivität, Gruppeninteraktionsmuster undLernstrategien wurden mittels eines Evaluationsinstrumentes erhoben.Ergebnisse: In den drei Kohorten nahmen 121 Studierende (Tutees) teil. Zur Evaluation wurde eineRücklaufquote von 98,3% erreicht. Als Gesamtbeurteilung für das Angebot wurde im Mittel der Wert6,97 ± 1,93 (von 1 = ungenügend bis 10 = exzellent) vergeben. Die Tutees gaben an, dass die eingesetztenTutorInnen sowohl ,,genau richtig‘‘ die Gruppe betreuten (4,65 ± 1,04; wobei 1 = zu bestimmend über 4 =genau richtig bis 7 = ließ die Gruppe zu sehr laufen) als auch ,,genau richtig‘‘ redeten (4,54 ± 0,95; wobei 1= zu viel über 4 = genau richtig bis 7 = zu wenig geredet). Die Ergebnisse zur Tutoreneffektivität ergabenWerte zwischen 3,26 ± 0,94 und 3,78 ± 0,87; zu den evaluierten Gruppeninteraktionsmustern wurdenWerte im Mittel zwischen 3,41 ± 0,98 und 3,89 ± 0,73 (auf einer Likert-Skala von 1 = stimme gar nichtzu bis 5 = stimme voll zu) vergeben. Bei den abgefragten Lernstrategien gab es die höchsten Bewertun-gen für die Dimensionen des ,,Ressourcenmanagements‘‘, die niedrigsten für die ,,Implementation‘‘ desLernstoffs.Schlussfolgerung: Das neu konzipierte und implementierte ICM-cyPAL-Angebot im dentalen Kontextwurde seitens der Tutees hauptsächlich positiv evaluiert. Optimierungsbedarf besteht im Hinblick aufdie inhaltliche Ausrichtung der strukturierten Schulung. Das Angebot an sich erfordert einen hohenOrganisationsgrad und eine gute personelle bzw. finanzielle Ausstattung.

Introduction

The didactic concept of ‘‘peer-assisted learning’’ (PAL) hasproved valuable for many years in dental training and can find itsapplication [1–4] in various designs. Diverse variations [5,6] existwithin the PAL format. For example, according to the educationallevel the student tutors find themselves in related to the fellowstudents (tutees) they are instructing, the terminology includes‘‘same-year PAL,’’ ‘‘cross-year PAL’’ or ‘‘near PAL’’ [5,7,8]. A ‘‘near-peer’’ relationship stands in contrast to a ‘‘cross-year’’ if the trainers(tutors) and the trainees (tutees) in regard to their educational levelare separated by less than one year [8].

The term ‘‘cross-year’’ is accordingly used when both areseparated by more than one year. A conclusive, internationallyexplained and valid nomenclature for the individual possible formsof peer relationships, whether these are related to year of study orsemester, is not available. The literature describes how structuredtraining by the tutors takes on an especially important role in PAL.It is recommended that these should be conducted by experiencedteaching personnel (docents, mentors), since only in this way dothe tutors have the necessary preparation in competence for theirwork in comparison to their fellow students [5].

PAL can be used both in attendance and for online offerings[9,10]. The flipped-classroom (or inverted-classroom) model (ICM)[11–16] represents a special combination of online and atten-dance learning. The implementation of the ICM model has alreadybeen described both in dentistry and medical studies [17–20]. Thisinvolves a particular kind of blended learning offering, whereby aself-study online phase (individual phase) is employed before theattendance phase [12,13]. In the online phase, factual knowledgeis used as a rule, which serves as a foundation for the attendancephase. The attendance phase should subsequently be used for deep-ening the learned knowledge and applying it [12]. Previously, in atraditional setting of lecturing or attendance instruction, factualknowledge has been used in instruction and participants had todeepen and possibly apply this knowledge at home [12].

ICM now switches the assignment of respective tasks to indi-vidual phases [12]. The advantage here is the promotion of active

learning [12]. In the self-study phase and the in-depth discussionin the attendance phase, aspects of active learning (e.g., teamwork,debate, and self-reflection) are encouraged [12]. Active learningincreases learning success, motivation, and positive attitudes, andpromotes higher cognitive learning processes, problem-solvingcompetence, and critical engagement with the training content[12]. Thus, care should be taken that the trainees avoid repeatingthe content of the online phase in the attendance phase.

The course participants must understand that independentpreparation for the attendance phase represents a central part ofthe concept [12]. In the attendance phase, group methods suchas partner work, group discussion, problem-based learning (PBL),think-pair-share, active plenum, buzz group, or snowballing, etc.,can be implemented [12,21]. Active, self-directed learning is thecentral point of the offering. This has been often examined in var-ious designs and described as a theoretical construct consisting ofmultilayered models [22,23].

The offering of an ICM design in the context of dentistry at theGoethe-University in Frankfurt am Main, which combines onlineself-study phases with subsequent attendance instruction in theform of PBL, has recently been cited by the German Rector’s Con-ference as an example of Good Practice [12]. The PBL offering of thesame institution was also examined with regards to acceptance,observed tutor effectiveness and group interaction models [24,25].This offering is based on a docent-centered setting and was con-ducted by experienced dentists who have been active in teachingfor a long time.

The distinctiveness of the further-developed ICM designdescribed by Tolks [12] of the Frankfurt dental clinic lies in its PAL-based performance. Cross-year peer tutors, who were prepared fortheir activities in structured training before and afterwards, taketheir roles as learning facilitators seriously. The docents take onmentoring tasks to support the peer tutors during their active workas learning facilitators.

It is the goal of the present work to present an evaluationof the students in the previously described situation of the ICM-cyPAL design. It is the first publication of this kind to be evaluatedwithin the context of dentistry research. It is different from

86 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93

previous studies by the Gerhardt-Szep author group [24]. First, andmost importantly, because it employs an ICM design rather than asole PBL offering. Second, learning was supervised by peer tutorsrather than docents.

As a research collective, dentistry students in the first clinicalsemester were chosen, with the following research questions beingthe focus of the pilot study:

1. How do the students evaluate the dental ICM-cyPAL offering andwould they also recommend it to their fellow students?

2. How do the students evaluate the activity of the cross-year peertutors?

The supplementary research questions were:

1. How do the students evaluate the effectiveness of the tutoringand the group interaction model in the ICM-cyPAL offering?

2. How are the individual aspects of self-directed learning(resource management, sequencing and implementation) ratedby the students?

Method

Sample

The dentistry students (total number = 121) in their first clinicalsemester (sixth university semester) were surveyed in three sub-sequent cohorts (WS 2012 to WS 2013) after the conclusion of theICM-cyPAL offering.

An ethics vote was deemed unnecessary after consulting withthe university department’s ethics committee, since the evaluationwas conducted in an anonymous manner.

Conception of the inverted-classroom design

The curricular form of the phantom course for restorative den-tistry in Frankfurt am Main, which took place in the first clinicalsemester (sixth university semester), corresponds to that of ahybrid curriculum in which both conventional (lectures, demon-strations) and modern instruction offerings (inverted-classroommethods = ICM) were illustrated. In the on-site concept, the latterrepresents a combination of electronic (e-learning) and problem-based learning (PBL) (see figure 1).

The self-determined online learning portion refers to thee-learning offering of the Frankfurt Dentistry Initiative (dt: Frank-furter Zahnmedizinischen Initiative, or ‘‘FranZi’’). The modulesthematized in this study (‘‘Toothache clinic: basic and advanced’’)include a total of ten case vignettes, which can be interactivelyworked on step by step. The offering is created with an open-source authoring tool (WebKit Freiburg, Version 3.1/beta) and canbe accessed on the internet without any access limitations at thefollowing URL:

http://elearning.med.uni-frankfurt.de/zahnschmerzambulanz/.

Numerous elements, such as multiple-choice questions, drag-and-drop, drop-down menus, drawing functions, video clips,feedback, and tips are embedded in the offering. During an intro-duction to ICM (see preparatory measures for the tutees), thestudents receive exact instructions on how to handle the elec-tronic patient cases by themselves, before the identical ‘‘patient’’from the e-learning offering is thematized in subsequent PBL meet-ings by the group, along with additional content not representedin the ‘‘toothache clinic.’’ The PBL instruction occurs in the skillslab of the Department for Restorative Dentistry and is conducted in

conformity with the standard established at the University of Maas-tricht in 7 + 1 steps (figure 2) [24].

PBL steps 1 to 5 are worked through in the first meeting, the 6thstep (processing of learning goals) in self-study, and steps 7 and8 (reflection) in the second meeting after around a week. The laststep includes the practical application of skills, whereby the groupdemonstrates the total processed content practically on a modelat up to four simulation units. The tutors also accompany the laststep and thus transfer the theory into practical application. EachPBL meeting lasts 90 minutes, with a total of 180 minutes of collab-oration work per case on site in the group. The group participantsare all ICM novices; the tutors, in contrast, already have experiencewith ICM.

Tutees

All tutees are students of the phantom course for restorativedentistry and are in the sixth university semester or first clinicalsemester of dental medicine study. In their first semester days,prior to the planned ICM offering, they receive an oral introduc-tion (‘‘What does the ICM-cyPAL offering mean?;’’ ‘‘Definition of theeight PBL steps;’’ ‘‘Time parameters;’’ ‘‘Tips for literature research;’’‘‘Distribution of the following roles within the PBL group: PC rep-resentative, timekeeper, discussion leader, writer;’’ ‘‘Role of the cypeer tutors’’), which lasts about 45 minutes.

Tutors and mentors

A total of seven tutors are employed, of which four accompanythe learners (active) in the PBL section of the ICM and three func-tion as observers. The four tutors active in the group are in theeighth (n = 2) or ninth university semester (n = 2) of dentistry study.The three remaining tutors are in the training process, wherebytwo of them belong to the seventh and one to the ninth universitysemester. As graduates of the phantom course for restorative den-tistry in the sixth university semester, all have already obtainedexperience with the ICM offering and additionally receive struc-tured training prior to their activity as tutors in the ICM. Thistraining includes participating for one semester as an observer atongoing ICM meetings.

Only after completing this training semester are they inte-grated as active facilitators in the learning process. Part of theone-semester observation is formed by the reflections of the tutorgroup and the written completion of an evaluation sheet, the useof which has already been published in conventional PBL meetings[25]. In addition, a mentor who is a content expert and has sev-eral years of experience with ICM offerings also takes part in thePBL meetings. The mentors (n = 2) are all scientific colleagues (den-tists) of the Department for Restorative Dentistry and observe thecy tutors who are being employed. At the end of the meeting, around of reflection takes place between the mentor, active cy tutorand the cy tutor still in training. The Spiess evaluation sheet [26]forms the basis of this round of reflection.

Mentor support for each individual cy tutor actively employed inthe PBL accompaniment process is given at least twice in a semester.After each PBL meeting, an exchange additionally occurs betweenthe two cy tutors. According to semester level, the active cy tutorson average are used 16 times as learning facilitators in the PBLportion. A comprehensive training session is held once a year forall persons implemented in the ICM concept, which is led eitherby an internal specially qualified colleague (MME) or by an exter-nal lecturer. The cy tutors were paid 10 EUR per hour, both duringtheir training phase and later during their active employment aslearning group facilitators.

http://elearning.med.uni-frankfurt.de/zahnschmerzambulanz/

M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93 87

Figure 1. methodical overview (shown in a clockwise direction) of the ICM cross-year-peer-assisted learning offering. It began with the group classification (12:00 position),followed by an individual online self-learning phase wherein the electronic patient cases are worked on by students in a self-directed manner (01:00 position). The onlinecase includes defined learning goals. In offline group work (05:00 position), the students, accompanied by the tutors, work on the case again under new aspects (06:00position) and additionally define their own learning goals, which are prepared in a second self-learning phase. In the second group meeting (8:00 position), the content of theprevious self-learning phase is discussed mutually and clarified. At the end of this meeting is a practical implementation of the learned content in SimLab (10:00 position).After completing the first case, the second patient case is released (11:00 position).

PBL cases

Each group (maximum number = 8 students) works on a total oftwo different PBL cases per semester. The content involves diagnos-tics and therapy for toothaches (endodontics), which is thematizedin the oral summative end-of-semester examination. Each PBL caseincludes a total of eight learning goals, which are only known to thetutors and mentors.

When constructing the PBL vignettes, care is taken that these arerelated to the corresponding e-learning case that will be processedby the students in the online phase prior to the PBL. At the sametime, the PBL cases include additional requirements for the pre-pared e-learning content, the solution of which will be interpretedin the group, such that the individual online work is actually

carried out. The groups are accompanied by the tutors in a non-directed manner. This role formation is implemented [24,25] basedon Gerhardt-Szép.

Description of the survey used

A survey is used as an evaluative instrument, which was cre-ated on the basis of the Gerhardt-Szép publication [24,25]. In thefirst portion (n = 18), the survey determines general informationon age, gender, grade on the dentistry pre-examination, number ofprocessed online cases, if or whether they recommend the learn-ing unit to other students, and what rating they would give to the

88 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93

Figure 2. Steps 1-8 of the Frankfurt PBL portion, conceived based on the Harvard or Maastricht requirements, which were offered to the students in ICM format.

online offering. Six items are chosen from the 18 to answer theresearch questions.

In the second part (n = 7 questions), the concept of the inverted-classroom model (ICM) is evaluated. The third part (n = 86)poses questions on personal style of learning based on Aeppli[22]. To answer the research questions, items are selected thatexamine sequencing (step sequence and relaxation phase plan-ning), implementation (structuring and elaboration) and resourcemanagement (information gathering, collaborative work andaid).

The last portion (n = 60) thematizes questions on tutor effec-tiveness, group interaction models, and the PBL, which traceback to studies by Dolmans, Visschers-Pleijers and Gerhardt-Szep[24,25,27,28]. Thus it evaluates all items (n = 12) affecting both tutoreffectiveness and the group interaction model (n = 12). In exam-ining the PBL concept, n = 13 items are taken into account thatexplicitly describe the tutoring activity. The end of the question-naire offers space for free text commentary.

On the basis of the large number of all evaluated items, the rep-resentation of the present study was chosen in reference to theresearch questions; the authors can certainly make a complete listavailable.

Statistical analysis

The evaluation was done in a descriptive manner utilizingNCSS and PASS (version 6.0.2.1., Kaysville, Utah). As a measure of

central tendency, mean values, the median and the standard devi-ation were provided.

Results

Description of sample and response

All 121 dentistry students in the first clinical semester took partin the obligatory event (ICM-cyPAL). The response rate of the surveywas 98.3%.

There were a total of 30 male and 89 female students partic-ipating in the evaluation, with an average age of 24.8 years (±2.72; median: 24). The corresponding grades on the dentistry pre-examination (after the fifth university semester) were evaluated at2.55 (± 0.60; median: 3). Students stated that they had worked onan average of three of ten online cases in the time window from14:00 to 20:00.

Evaluation and further recommendation of the ICM-cyPAL offering

An average value of 6.97 ± 1.93 was given (from 1 = unsatisfac-tory and 6 = sufficient to 10 = excellent) as an overall rating forthe ICM-cyPAL offering. It was recommended to other fellow stu-dents with an average of 3.84 ± 0.83 (from 1 = do not at all agreeto 5 = completely agree). Further results on the ICM concept arepresented in Table 1.

M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93 89

Table 1General evaluation of the implementation of the ICM design, consisting of seven items (if not otherwise obvious from the table: from 1 = do not at all agree, and 3 = undecidedto 5 = completely agree).

Concept Mean Standard deviation Min. Max. Median

The basic concept was explained by the docent at the beginning (e.g.,distribution of tasks in attendance meetings and online activities).

3.91 0.81 1.00 5.00 4.00

The online activities in this learning event were associated with cleartasks and goals.

3.74 0.77 2.00 5.00 4.00

The tasks to be completed in this learning event on the basis of theonline activities were suitable for this medium.

3.70 0.71 2.00 5.00 4.00

I would have learned more if the topics and tasks we worked on onlinewere examined in the attendance meetings.

3.19 0.97 1.00 5.00 3.00

Overall, I learned more through the combination of attendancemeetings and online activities than in simple lectures.

3.38 0.99 1.00 5.00 3.00

I hope that in similar learning events in the future, the traditionalattendance meeting will be supplemented with online activities.

3.47 0.95 1.00 5.00 4.00

Rate the concept between 1 and 10 (6 = sufficient, 10 = excellent). 6.97 1.92 1.00 10.00 8.00

Table 2Evaluation of tutor effectiveness in the ICM design (if not otherwise obvious from the table: from 1 = do not at all agree, and 3 = undecided to 5 = completely agree).

Tutor effectiveness Mean Standard deviation Min. Max. Median

Constructive, active learning: the tutor stimulated us. . .. . . to summarize what we had learnt in our own words. 3.50 0.88 1.00 5.00 4.00. . . to search for links between issues discussed in the tutorial group. 3.61 0.81 1.00 5.00 4.00. . . to understand underlying mechanisms/theories. 3.61 0.86 1.00 5.00 4.00Self-directed learning: the tutor stimulated us. . .. . . to generate clear learning issues by ourselves. 3.74 0.82 1.00 5.00 4.00. . . to search for various resources by ourselves. 3.62 0.93 1.00 5.00 4.00Contextual learning: the tutor stimulated us. . .. . . to apply knowledge to the discussed problem. 3.67 0.85 1.00 5.00 4.00. . . to apply our knowledge to other situations/problems. 3.55 0.86 1.00 5.00 4.00Collaborative learning: the tutor stimulated us. . .. . . to give constructive feedback about our group work. 3.71 0.82 1.00 5.00 4.00. . . to evaluate group co-operation regularly. 3.41 0.88 1.00 5.00 4.00Tutor’s behaviorThe tutor had a clear picture about his/her strengths and weakness as a tutor. 3.26 0.94 1.00 5.00 3.00The tutor was clearly motivated to fulfil his/her role as a tutor. 3.78 0.87 1.00 5.00 4.00Tutor evaluationGive a grade (1–10) for the overall performance of the tutor (6 being sufficient, 10 being excellent). 6.56 2.32 1.00 10.00 7.50

Evaluation of the activities of the cross-year peer tutors

The cross-year peer tutors were scored with an average of6.56 ± 2.32 (from 1 = unsatisfactory and 6 = sufficient to 10 = excel-lent) (see Table 2).

Evaluation of tutor effectiveness and the group interaction model

The results on tutor effectiveness are presented in Table 2, on thegroup interaction model in Table 3, and the information collectedfrom the students on PBL in Table 4. An excerpt from the free textcommentary can be seen in Figure 3.

Rating of the individual aspects of self-directed learning (resourcemanagement, sequencing and implementation)

The results on the rating of individual aspects of the self-directedlearning portion are presented in Table 5.

Discussion

It was the goal of the present study to develop a concept for anICM offering in a cross-year PBL format, and introduce and evaluateit. It was demonstrated that the newly conceived and implementedICM-cyPAL offering in the dental context was mostly evaluated pos-itively from the side of the tutees. The present study is the first workin which the aforementioned ICM setting has been piloted in thedental context.

The motives for implementing an ICM offering in dentistry aremany. The motivations for implementation in the study presentedcoincided in some respect with those that have already been pub-lished in the literature on individual aspects of the design [24]. Forthe present work, the center of causality was the encouragement ofcompetency development with self-activating learning in a modernlearning format.

This is in accordance with the recommendations of various insti-tutions on the national and international level [29–31]. It shouldespecially be pointed out that an ICM offering always includesa didactically planned sequence of partial aspects, which mustbe respectively reconciled with one another [5]. This does notonly mean that the prior online portion should include importantinformation for which successful processing work is realized inpreparation – namely before the subsequent attendance portiontakes place, which in the present study is group work – but alsothat the PBL aspect be deliberately used didactically.

For the Frankfurt Goethe-University location, however, whichhas several years of experience with PBL and as of 2009 hasimplemented one of the first dental open-source e-learning onlineofferings in dentistry teaching, the conception of the ICM-cyPALdesign in the present form represented an almost completely newstructuring of the available partial aspects (PBL and e-learning)[24,32]. In the sense of ICM, these must be coordinated with oneanother. Moreover, this also includes the construction of a struc-tured training program for the participants, since are no referencesfor this on site. In the field of restorative dentistry in Frankfurt,PAL in a cross-year format has existed for more than 30 years,mainly in the context of patient treatment cases, in which students

90 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93

Table 3Evaluation of the interaction model of the ICM design (from 1 = do not at all agree, and 3 = undecided to 5 = completely agree).

Group interaction Mean Standard deviation Min. Max. Median

Exploratory questionsStudents posed adequate questions to each other to understand thelearning content (e.g., questions on meaning of concepts, differences,reasons, and concrete examples).

3.59 0.76 2.00 5.00 4.00

What group members said was checked by asking each other criticalquestions.

3.63 0.73 2.00 5.00 4.00

A group member who was formulating an explanation concerning theproblem asked in between whether his/her explanation was right.

3.54 0.77 2.00 5.00 4.00

One explanation did not suffice for the group members; alternativeexplanations were also given.

3.59 0.78 2.00 5.00 4.00

Cumulative reasoningGroup members elaborated on each other’s arguments. 3.73 0.74 2.00 5.00 4.00When someone argued something, then that statement was motivated. 3.89 0.73 2.00 5.00 4.00Explanations of group members were completed with explanations ofother group members.

3.86 0.68 2.00 5.00 4.00

Students drew conclusions from the information that was discussed inthe group.

3.82 0.71 2.00 5.00 4.00

Handling conflictsIn the group, some contradictory beliefs on information concerningthe learning content were present.

3.49 0.92 1.00 5.00 4.00

One or more group members was/were contradicted by the others. 3.41 0.98 1.00 5.00 3.00When someone contradicted a group member, that person stated acounter-argument.

3.43 0.81 1.00 5.00 4.00

Table 4Evaluation of the general information for the PBL portion of the ICM design (if not otherwise obvious from the table: from 1 = do not at all agree, and 3 = undecided to 5 =completely agree).

PBL Mean Standard deviation Min. Max. Median

There was a pleasant working atmosphere in our small group. 3.71 0.92 1.00 5.00 4.00I enjoyed the PBL sessions. 3.44 0.96 1.00 5.00 3.00The PBL tutor. . .. . .makes sure that the group defines problem issues. 3.76 0.82 1.00 5.00 4.00. . .activates my previous knowledge. 3.58 0.89 1.00 5.00 4.00. . .encourages me to contribute. 3.71 0.88 1.00 5.00 4.00. . .responds to contributions by team members. 3.65 0.86 1.00 5.00 4.00. . .assists me in putting things into context. 3.49 0.99 1.00 5.00 4.00. . .makes sure that the group formulates clear learning objectives. 3.79 0.93 1.00 5.00 4.00. . .makes sure that the learning objectives are discussed. 3.86 0.83 1.00 5.00 4.00. . .prevents digression from the topic. 3.53 0.98 1.00 5.00 4.00. . .assists me in visualizing results. 3.54 0.90 1.00 5.00 4.00I feel that the tutor was too strict (scores 1–2), just right (scores 3–5),or too lenient (scores 6–7).

4.65 1.04 3.00 7.00 4.00

I feel that the PBL tutor has talked too much (scores 1–2), has talkedexactly as much as needed (scores 3–5), or has not talked enough(scores 6–7).

4.54 0.95 1.00 7.00 4.00

Table 5Evaluation of the tutees’ learning strategies (from 1 = do not at all agree, and 3 = undecided to 5 = completely agree).

Learning strategies Mean Standard deviation Min. Max. Median

Resource managementWhen I have problems understanding something, I seek additionalinformation (information gathering).

4.05 0.74 1.00 5.00 4.00

There are problems and tasks where I work better alone, and there areproblems and tasks where I learn better with others (collaboration andaid).

3.98 0.84 1.00 5.00 4.00

When I have learned something, I try to explain it to my fellowstudents (collaboration and aid).

3.66 0.92 1.00 5.00 4.00

SequencingI create focal points in my learning (step sequence planning). 3.67 0.83 1.00 5.00 4.00My learning process is oriented to the given task (step sequenceplanning)

3.77 0.74 2.00 5.00 4.00

Depending on the type of task or problem, it may be necessary to planrelaxation phases in the learning process (relaxation phase planning).

3.69 0.90 1.00 5.00 4.00

ImplementationIn order to structure the learning material, I often make overviews,tables, and sketches (structuring).

3.56 1.01 1.00 5.00 4.00

I always try to find possible alternatives to assertions and conclusionsin the class (elaboration).

3.63 0.79 2.00 5.00 4.00

M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93 91

Figure 3. Collected extract from the tutees’ free text commentary.

in the sixth semester assist their fellow students in the ninthsemester.

The latter instruct their colleagues in the first clinical (sixth)semester, in that they ‘‘demonstrate’’ live to them all treatmentprocesses applying to the patients. At the end of the assistantship,theoretical reflections take place on the treatment processes thatwere used. The participants do not indeed complete any structuredtraining program, meaning that the ICM-cyPAL design presentedin the current study was breaking new ground, including for theemployed tutors.

The satisfaction of the tutees determined with this offering isalso reflected in other tutor-led courses [5]. The evaluation of theICM-cyPAL design, however, with an average of 6.97 ± 1.92 (from1 = unsatisfactory to 10 = excellent), shows that potential for opti-mization still exists. Based on the free text commentary, it is evidentthat there were still ambiguities regarding both the process of thePBL instruction as well as the content related to the online cases,which were not examined sufficiently in the group work.

The ambiguities that exist regarding the process of the PBLinstruction, in view of the fact that all tutees were PBL novices andonly worked on two cases together during the semester, are not sur-prising. However, ambiguities in the online cases would have hadto be thematized previously, for example in step 1 (clarification ofcomprehension questions). The methodical parameters of the ICMdesign, such that content in the prior online portion should not berepeated in the attendance instruction, could have led to misun-derstandings by the tutors. However, after evaluation of the freetext commentary, it would seem to be not a matter of repetitionbut rather the explanation of content.

The data collected on the acceptance of the PAL format on theside of the tutees is in agreement with similar results that have beendescribed in the literature [5,33]. Solely PBL-based offerings in thedental context tend to receive higher tutor evaluations (8.34 ± 1.34)than the combined ICM format (6.56 ± 2.32) in the present study[25]. This may possibly be explained in that the PBL offering exam-ined in the work of Gerhardt-Szep (2009) was a docent-facilitatedmethod and not PAL [32]. It is moreover interesting that the evalua-tion of tutor behavior on average was similar, but the evaluation of

the items ‘‘The tutor was clearly motivated to take his role as ‘tutor’seriously’’ (from 1 = do not at all agree to 5 = completely agree) inthe docent-led PBL format came out higher (4.25 ± 0.83) than in theICM format.

Both formats realized non-directive tutorial facilitation [24,25].The tutees in both formats agreed that the group accompanimentwas just right (from 1 = too controlling, 4 = just right, 7 = left thegroup alone too much), since the given values varied only between4.32 ± 0.69 (docent-led POL) and 4.65 ± 1.04 (ICM-cyPAL). For theitem ‘‘I believe the tutor spoke too much (1), just right (4), too little(7),’’ the ICM format on average received somewhat higher rat-ings in contrast to the docent-facilitated PBL offering, which wasevaluated with an average of 4.31 ± 0.68 [32]. Accordingly, it waspossible that the tutees of the ICM offering were of the opinion thatthe tutors tended to speak just right or too little, whereas in con-trast in the docent-facilitated PBL instruction, they had rather toolarge a speaking role. In the free text commentary on the ICM-cyPALoffering, it is likewise apparent that the tutees were very satisfiedwith the tutors. The non-directive facilitation method thereby inprinciple seemed to have been used correctly.

The ICM-cyPAL design also makes it possible that not only thetutees, but also the tutors employed could further develop theirown competence in regard to professional competence, commu-nication ability, and assumption of responsibility through theirteaching activity, as was already confirmed by other PBL offer-ings [5,34]. The offering can thereby employ various suggested,consensus-formed capabilities from the Society for Medical Edu-cation for the German-speaking region, and additionally offers thepossibility of adding or deepening aspects of the teaching and learn-ing, as embodied in the National Competence-based Learning GoalsCatalog for Dental Medicine (NKLZ) and in international profilerequirements [30,35].

In the authors’ view, the longitudinal training of involved tutorsis an essential precondition for the success of the ICM-cyPAL offer-ing. Structured training approaches, however, as a measure ofensuring the quality of the teaching in the PBL context, have onlyseldom been published [5]. Only structured content-related train-ing led by experienced persons and constructed in several steps or

92 M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93

levels will give the tutors the competence edge necessary for theiractivity with regard to their fellow students, who mostly find them-selves at a similar study level [5]. For this reason, from time to timeboth mentors and persons further educated in the teaching wereincluded in the present training program.

The leadership of the project was also undertaken by a spe-cial medically qualified dentist at the Department for RestorativeDentistry. Work by the scientific personnel was not financiallysupported. In this context, the fact should be highlighted that inthe format described, the work of the tutors was paid during theentire training phase. To strengthen the offering, care must betaken that new longitudinal training sessions continue to be held,on the basis of the withdrawing tutors who leave the universityafter the conclusion of their studies. Recruiting new tutors provesto be unproblematic, since there was always enough interest onthe side of the students who had completed the 6th semester andhad become familiar with the ICM concept. Available mentors pre-sented a more difficult matter, since personnel changes here alsomade it necessary to constantly instruct the newly employed sci-entific colleagues.

The results on tutor effectiveness in the dimensions of construc-tive, active, context-dependent and collaborative learning show atendency to overlap with studies by Gerhardt-Szép [24], althoughthe setting and tutors employed were implemented in a differ-ent manner. Differences in low average ratings were evaluated inthe dimensions ‘‘behavior of the tutor’’ and ‘‘self-directed learning.’’For the first (‘‘The tutor was clearly motivated to take his role as‘tutor’ seriously’’), the tutors on average were given lower values incomparison with the Gerhardt-Szép study (4.25 ± 0.83) [24,25].

This may among other things be rooted in the fact that the cytutors were exposed to an increased burden during the course ofthe semester, leading to a possible decrease over time in their moti-vation. On the other hand, the content may also have placed themunder excessive demands for which they were not sufficiently pre-pared as tutors in the context of the prior training. But the freetext commentary shows that ambiguities in the prior online con-tent could not be clarified sufficiently during group work. The tutorswere not prepared for it, and possibly felt they were under too muchpressure. It is possible that the tendency toward lower values onthe item ‘‘The tutor stimulated us to generate clear learning goals’’(self-directed learning) of 3.74 ± 0.82 compared to the Gerhardt-Szép study (4.02 ± 0.68) may be explained in a similar manner.Docent-supervised PBL accordingly makes it possible, as a resultof the high competence of the available participants, to more easilygenerate ‘‘clear’’ learning goals [24,25]. This finding should be betterimplemented in the training process for tutors in future ICM-cyPALofferings.

The results of the group interaction model show a tendency tooverlap in all dimensions with the Gerhardt-Szép studies [24,25].Negligible tendential differences from the Gerhardt-Szép study [23]in the form of lower ratings (3.59 ± 0.76) were found for the item‘‘The participants asked questions in the group adequate to under-stand the teaching content’’ (survey questions) (4.08 ± 0.68). Here,the cy tutors had to stimulate the group with corresponding con-cepts. Possibly the ‘‘non-directive’’ facilitative model here that wasprovided to the tutors was misinterpreted, meaning in the futurethis should be introduced in a strengthened manner in the frame-work of training measures.

Information on the learning strategies used by the tutees showthat, especially for the dimensions ‘‘collaboration and aid’’ or‘‘structuring,’’ there is a need for optimization. In comparison tothe Aeppli study [22], which was conducted with an identical eval-uation instrument, the average values given to the two dimensionsmentioned above (from 1 = do not at all agree to 5 = completelyagree) had a score that tended to be higher on average than in thepopulation examined here.

Thus, the dentistry tutees’ learning could be supported in futurestrategies in the area of resource management or structuringin order to improve the conditions for motivated, self-directedlearning, which seems to be indispensable for the successful imple-mentation of an ICM format. The ICM format includes grantingthe tutees more freedom in their learning and ensuring that theythemselves understand the measures for self-direction [22]. Thisfreedom might also place excessive demands on the students, how-ever [22].

Accordingly, it seems to be of decisive importance that the stu-dents offer just as much direction, explanation and aid throughtutors as they need for successful and self-directed learning [22].Aeppli [22] thus requires the offering of a problem-based approach,since this may allow the learners to ‘‘. . .not only show more self-directed learning behavior and thus gain experience in self-directedlearning, but rather also reach a higher level of learning successdue to the deeper examination of the learning content’’ [22]. It isexactly this approach that was realized in the present ICM-near-PAL offering, although learning success controls did not representany of the content of the study. This should follow in subsequentexaminations.

Response to research questions

1. As a total evaluation of the ICM-cyPAL offering, an averagevalue of 6.97 ± 1.93 was given (from 1 = unsatisfactory and 6= sufficient to 10 = excellent). Recommendation to other fellowstudents was given an average of 3.84 ± 0.83 (from 1 = do not atall agree to 5 = completely agree).

2. The activity of the tutors was on average evaluated at 6.56 ± 2.32(from 1 = unsatisfactory and 6 = sufficient to 10 = excellent).

3. The highest average values (3.78 ± 0.87) were given in the frame-work of the dimension ‘‘tutor effectiveness’’ in the item ‘‘The tutorwas clearly motivated to take his role as tutor seriously’’ (from 1= do not at all agree to 5 = completely agree). The sub-dimensionof ‘‘self-directed thought’’ received the highest values on average.The highest average values (3.89 ± 0.73) were in the frameworkof the dimension ‘‘group interaction model’’ in the item ‘‘Whena group participant argued something, the statement was dis-cussed in an active manner’’ (from 1 = do not at all agree to 5 =completely agree). The sub-dimension of ‘‘cumulative argumen-tation’’ received on average the highest values. The tutees agreedthat the group supervision during the PBL design was just right(from 1 = too controlling, 4 = just right, 7 = left the group alonetoo much), since the values given amounted to 4.65 ± 1.04 onaverage. For the item ‘‘I believe the tutor spoke too much (1),just right (4), too little (7),’’ the ICM-cyPAL format received anaverage of 4.54 ± 0.95.

4. The learning strategies surveyed on average had the high-est values in the dimensions ‘‘resource management’’ (‘‘WhenI have problems understanding something, I seek additionalinformation’’), and the lowest in ‘‘implementation’’ (‘‘In order tostructure the learning material, I often make overviews, tablesand sketches’’).

Limitations

Limitations can be determined in that the present study utilizeda purely subjective course evaluation on the side of the students,and no data on knowledge growth was collected. This limits itsusefulness for potential replications. Also, since the evaluationwas conducted in an anonymous manner, no correlations withgrades from the dental pre-examination could be calculated.Additionally, the offering was evaluated as something ‘‘new,’’ so itssignificance may possibly be limited due to the Hawthorne effect.

M. Quoß et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 126 (2017) 84–93 93

The low population size and missing validation of the evaluationinstrument must be optimized further in additional studies.

Conclusion

In summary, it can be determined that the ICM-cyPAL offer-ing in the dental context of a tutee survey pointed to a positiveevaluation, however, its effectiveness must be investigated in fur-ther controlled studies. The offering itself requires a high degree oforganization and good personnel and financial resources.

Support and acknowledgement

The project was supported on the basis of a fellowship bythe Association for the Promotion of Science and Humanities inGermany (dt.: Stiftung für die Deutsche Wissenschaft) 2012. Thanksare due to Cambridge Editing (Frankfurt, Germany) for professionaltranslating the manuscript.

Conflict of interest

None declared.

Survey

The complete survey may be requested from the authors.

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