Humanising case-based learning.

PURPOSE OF THE ARTICLE: Medical undergraduates at St George's, University of London (SGUL) study a weekly clinical case during their clinical science years. Audit of the human stories demonstrated lack of diversity, mono-professionalism, and objectification of some patients. A collaborative partnership with staff, student and patient representation implemented curriculum change, including an inclusive case-writing initiative. We explored whether the reformed written cases supported the development of positive attitudes by sampling perceptions of the cases amongst students. METHODS: Sixteen semi-structured interviews were conducted (Feb-November 2022) with first year medical students. We applied an interpretative phenomenological analysis approach. Verbatim transcripts were coded and analysed to elucidate themes. RESULTS: Four themes were identified: (i) effective learning, (ii) clinical authenticity, (iii) authentic human stories, and (iv) opportunity for rehearsing the role of a doctor. Students perceived the cases as an effective, contextual learning method, with a high degree of clinical authenticity, allowing mentalisation of doctor attitudes and behaviours in relation to patient-centredness, multidisciplinary team working and diversity. CONCLUSION: The results suggest the reformed cases created positive attitudinal change amongst students and supported transition to clinical roles. Memorable human stories had the greatest impact. Dynamic, inclusive, and collaborative case writing initiatives which integrate realism, diversity and multi-professionalism may help to foster positive experiences in students undertaking CBL sessions.

Development and delivery of justice, equity, diversity, inclusion, and anti-oppression concepts in entry-level health professional education: A scoping review: BEME Guide No. 88.

PURPOSE: Justice, equity, diversity, inclusion (JEDI), and anti-oppression (AO) concepts are necessary in healthcare settings to promote culturally safe and high-quality care; however, entry-level healthcare program curricula (EHPPC) may lack adequate integration and/or delivery of these concepts. The primary aim of this scoping review is to identify what guidelines, frameworks, and models (GFMs) are used, and how they are used, to develop and deliver JEDI, and AO concepts in mandatory EHPPC. METHODS: A search of Ovid MEDLINE, Ovid EMBASE, and CINAHL was conducted for studies published in English from 2015 onwards that discuss what GFMs are included in mandatory EHPPC and how they guide the development and/or delivery of JEDI and/or AO concepts. Data from the included studies was collated into themes which were presented in tables and figures and described in narrative summaries. RESULTS: Sixty-one studies from various healthcare programs including medicine, nursing, pharmacy, dentistry, and dietetics were included in this review. Data from the studies were organized into eight categories: GFMs, concepts, methods of evaluation, length and frequency of sessions, modes of delivery, learning activities, and training of curricular developers and facilitators. CONCLUSIONS: GFMs are used in a variety of ways to integrate JEDI and/or AO concepts into health professional curriculum. Variability in the training of developers and facilitators of curricular concepts also exists. Future research is needed to determine if consistent or variable GFMs, as well as JEDI and/or AO developer and facilitator training, would be more effective for students' learning of these concepts.

Integration of behavioral, social, and humanities sciences into healthcare and education and their alignment with medical education programs.

There has been an increasing acknowledgment of the intricacies inherent in health and healthcare processes, leading to a shift in medical education. This change underscores multidimensional, thorough, reflective, and contextual approaches characterized by mutual interaction and change. The perception of health/well-being and illness is transitioning toward acknowledging them as outcomes arising from the complex interplay of individual, social, and environmental/ecosystemic factors. This includes biological, genetic, behavioral, sociocultural, and environmental influences. In line with this changing perspective, the purpose of this article is to provide a general framework for the integration of behavioral, social, and human sciences into Medical Education Programs in Healthcare and Training Processes. The framework presented is based on the following three conceptual and theoretical basis: (1) Complex systems thinking and reflective, contextual healthcare and education practices, (2) Health systems and socio-economic-political framework, (3) Ecosystem framework in health and disease. Our aim in this article is to provide a guide for the integration of Behavioral, Social, and Humanity Sciences into medical education programs and to present examples from around the world.

Using a boundary crossing lens to understand basic science educator and clinical educator collaboration in instructional design.

PURPOSE: Collaborations between basic science educators (BE) and clinical educators (CE) in medical education are common and necessary to create integrated learning materials. However, few studies describe experiences of or processes used by educators engaged in interdisciplinary teamwork. We use the lens of boundary crossing to explore processes described by BE and CE that support the co-creation of integrated learning materials, and the impact that this work has on them. MATERIALS AND METHODS: We conducted qualitative content analysis on program evaluation data from 27 BE and CE who worked on 12 teams as part of a multi-institutional instructional design project. RESULTS: BE and CE productively engaged in collaboration using boundary crossing mechanisms. These included respecting diverse perspectives and expertise and finding efficient processes for completing shared work that allow BE and CE to build on each other's contributions. BE and CE developed confidence in connecting clinical concepts with causal explanations, and willingness to engage in and support such collaborations at their own institutions. CONCLUSIONS: BE and CE report the use of boundary crossing mechanisms that support collaboration in instructional design. Such practices could be harnessed in future collaborations between BE and CE.

Validation of the motivated strategies for learning questionnaire and instructional materials motivation survey.

PURPOSE: To validate the Motivated Strategies for Learning Questionnaire (MSLQ), which measures learner motivations; and the Instructional Materials Motivation Survey (IMMS), which measures the motivational properties of educational activities. METHODS: Participants (333 pharmacists, physicians, and advanced practice providers) completed the MSLQ, IMMS, Congruence-Personalization Questionnaire (CPQ), and a knowledge test immediately following an online learning module (April 2021). We randomly divided data for split-sample analysis using confirmatory factor analysis (CFA), exploratory factor analysis (EFA), and the multitrait-multimethod matrix. RESULTS: Cronbach alpha was ≥0.70 for most domains. CFA using sample 1 demonstrated suboptimal fit for both instruments, including 3 negatively-worded IMMS items with particularly low loadings. Revised IMMS (RIMMS) scores (which omit negatively-worded items) demonstrated better fit. Guided by EFA, we identified a novel 3-domain, 11-item 'MSLQ-Short Form-Revised' (MSLQ-SFR, with domains: Interest, Self-efficacy, and Attribution) and the 4-domain, 12-item RIMMS as the best models. CFA using sample 2 confirmed good fit. Correlations among MSLQ-SFR, RIMMS, and CPQ scores aligned with predictions; correlations with knowledge scores were small. CONCLUSIONS: Original MSLQ and IMMS scores show poor model fit, with negatively-worded items notably divergent. Revised, shorter models-the MSLQ-SFR and RIMMS-show satisfactory model fit (internal structure) and relations with other variables.

Twelve tips for creating a longitudinal quality improvement and safety education for early health professions students.

Despite the numerous calls for integrating quality improvement and patient safety (QIPS) curricula into health professions education, there are limited examples of effective implementation for early learners. Typically, pre-clinical QIPS experiences involve lectures or lessons that are disconnected from the practice of medicine. Consequently, students often prioritize other content they consider more important. As a result, they may enter clinical settings without essential QIPS skills and struggle to incorporate these concepts into their early professional identity formation. In this paper, we present twelve tips aimed at assisting educators in developing QIPS education early in the curricula of health professions students. These tips address various key issues, including aligning incentives, providing longitudinal experiences, incorporating real-world care outcomes, optimizing learning environments, communicating successes, and continually enhancing education and care delivery processes.

Twelve tips to virtually operationalize co-creation of educational design.

Co-creation is the active involvement of all stakeholders, including students, in educational design processes to improve the quality of education by embodying inclusivity, transparency and empowerment. Virtual co-creation has the potential to expand the utility of co-creation as an inclusive approach by overcoming challenges regarding the practicality and availability of stakeholders, typically experienced in face-to-face co-creation. Drawing from the literature and our experiences of virtual co-creation activities in different educational contexts, this twelve tips paper provides guidelines on how to effectively operationalize co-creation in a virtual setting. Our proposed three-phased approach (preparation, conduction, follow-up) might help those aiming to virtually co-create courses and programs by involving stakeholders beyond institutes and across borders.

A new practical approach using TeamSTEPPS strategies and tools: - an educational design.

BACKGROUND: Teamwork has played a critical role in ensuring patients' safety and preventing human errors in surgery. With advancements in educational technologies, including virtual reality, it is necessary to develop new teaching methods for interpersonal teamwork based on local needs assessments in countries with indigenous cultures. This study aimed to design and develop a new method of teaching teamwork in cesarean section surgery using virtual reality; we further evaluated the effects of this method on healthcare professionals' knowledge and attitudes about teamwork. METHODS: This study was designed using the ADDIE instructional design model. The TeamSTEPPS Learning Benchmarks questionnaire was used to assess the educational needs of 85 participants who were members of the cesarean section surgery team. A specialized panel analyzed the extracted needs, and the scenario was compiled during the design stage. Finally, four virtual reality contents were created using 360-video H.265 format, which were prepared from specified scenarios in the development of the educational program. The TeamSTEPPS Learning Benchmarks questionnaire was used to measure knowledge, and the T-TAQ was used to measure the participants' attitudes. RESULTS: Six micro- skills were identified as training needs, including briefing, debriefing, cross-monitoring, I'M SAFE checklist, call-out and check-back, and two-challenge rule. Intervention results showed that the virtual reality content improved teamwork competencies in an interprofessional team performing cesarean section surgery. A significant increase was observed in the mean score of knowledge and attitude after the intervention. CONCLUSION: Through addressing the need for teamwork training, utilizing the TeamSTEPPS strategy, and incorporating new educational technologies like virtual reality, the collaboration among surgical team members can be enhanced.

Examining the pedagogical practices that support cultural proficiency development in graduate health science students.

BACKGROUND: Health disparities are often a function of systemic discrimination and healthcare providers' biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP. METHODS: Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students' implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions. RESULTS: The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students' perception of the training varied substantially (e.g., training range = 1-100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes. CONCLUSIONS: These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.

The significance of a dialectical approach to enrich health professions education.

The Lancet Global Independent Commission has called for a systems-based approach to health professions education. They emphasised the acquisition of collaborative skills, critical reasoning and ethical conduct to prepare students for interprofessional collaborative practice (IPCP). Interprofessional education (IPE) has been put forward as a promising strategy. However, despite the global efforts to incorporate IPE in health professions education curricula, the evidence for a positive impact on IPCP is still inconclusive. This may be related to the misalignment between competency-driven IPE programs that focus on end-stage professional competence and the non-linear development of students' competence that is necessary for the dynamical nature of IPCP. Therefore, we argue that health professions education, and IPE in particular, needs to incorporate these dynamical processes including social and organization sensitivity. We present a conceptual framework that integrates the Cultural-Historical Theory, the principles of dialectical thinking and the concept of metastable attunement. While dialectical thinking is the ability to perceive the complexity of a dynamic reality that is in a state of constant transition, metastable attunement refers to the consequent adjustment to it. The subsequent instructional design employs a dialectical approach to teaching and learning, based on mediating activities and dialectical inquiry. To reach the full potential of this approach, the mediating activities should ensure a continuum of learning across the curriculum. In addition, faculty development needs to focus on the principles of dialectical inquiry as a pedagogy to optimally guide students. Further research into the extent to which healthcare professionals and students think dialectically may inform improvements to the proposed instructional design, the structure of the learning continuum and the essential requirements for faculty development.

Effects of adaptive scaffolding on performance, cognitive load and engagement in game-based learning: a randomized controlled trial.

BACKGROUND: While game-based learning has demonstrated positive outcomes for some learners, its efficacy remains variable. Adaptive scaffolding may improve performance and self-regulation during training by optimizing cognitive load. Informed by cognitive load theory, this study investigates whether adaptive scaffolding based on interaction trace data influences learning performance, self-regulation, cognitive load, test performance, and engagement in a medical emergency game. METHODS: Sixty-two medical students from three Dutch universities played six game scenarios. They received either adaptive or nonadaptive scaffolding in a randomized double-blinded matched pairs yoked control design. During gameplay, we measured learning performance (accuracy, speed, systematicity), self-regulation (self-monitoring, help-seeking), and cognitive load. Test performance was assessed in a live scenario assessment at 2- and 6-12-week intervals. Engagement was measured after completing all game scenarios. RESULTS: Surprisingly, the results unveiled no discernible differences between the groups experiencing adaptive and nonadaptive scaffolding. This finding is attributed to the unexpected alignment between the nonadaptive scaffolding and the needs of the participants in 64.9% of the scenarios, resulting in coincidentally tailored scaffolding. Exploratory analyses suggest that, compared to nontailored scaffolding, tailored scaffolding improved speed, reduced self-regulation, and lowered cognitive load. No differences in test performance or engagement were found. DISCUSSION: Our results suggest adaptive scaffolding may enhance learning by optimizing cognitive load. These findings underscore the potential of adaptive scaffolding within GBL environments, cultivating a more tailored and effective learning experience. To leverage this potential effectively, researchers, educators, and developers are recommended to collaborate from the outset of designing adaptive GBL or computer-based simulation experiences. This collaborative approach facilitates the establishment of reliable performance indicators and enables the design of suitable, preferably real-time, scaffolding interventions. Future research should confirm the effects of adaptive scaffolding on self-regulation and learning, taking care to avoid unintended tailored scaffolding in the research design. TRIAL REGISTRATION: This study was preregistered with the Center for Open Science prior to data collection. The registry may be found at https://osf.io/7ztws/ .

Integrating basic sciences into clerkship rotation utilizing Kern's six-step model of instructional design: lessons learned.

BACKGROUND: It is generally agreed that basic and clinical sciences should be integrated throughout the undergraduate medical education, however, there is still need for continued formal integration of basic sciences into clinical clerkship in many medical schools across the globe. METHODS: Utilizing Kern's Six-Step Model of Instructional Design, we aimed to develop an intervention that would facilitate cognitive integration of basic and clinical sciences. After problem identification and targeted needs assessment through focused group discussion with the students and faculty, objectives were devised with an implementation plan of using flipped class approach to develop a content-focused and learner-centered teaching strategy. This intervention was piloted in the 2-week cardiology clerkship in Year 5. Evaluation of the content, integration, student and faculty experiences were recorded through in-depth interviews, FGDs and a formative MCQ test. RESULTS: Flipped classroom based integrated sessions were successfully developed. The implementation phase was met with challenges that primarily stemmed from the diverse teaching styles among faculty members, hesitance to deviate from conventional practices, variations in clinic timings, and demanding schedules. Noteworthy observations were in terms of ownership of the project, the need for faculty development in modern student-centered teaching pedagogies, opportunities for content improvement, scheduling of sessions, and suggestion of revisiting fundamental concepts in basic sciences through a brief boot camp-style session at the onset of the clerkship. The role of flipped case model and clinical cases in integrating basic sciences into clinical sciences were appreciated by the students. Standardization in teaching practices was identified as the major challenge by the faculty. CONCLUSIONS: A functional, learner-centered framework of cognitive integration of basic sciences in clinical sciences curriculum of cardiology rotation was developed with a potential to be implemented in other clerkship rotations.

Peer creation and sharing of mnemonics in collaborative documents for pathology education: a pilot study.

BACKGROUND: Mnemonic techniques are memory aids that could help improve memory encoding, storage, and retrieval. Using the brain's natural propensity for pattern recognition and association, new information is associated with something familiar, such as an image, a structure, or a pattern. This should be particularly useful for learning complex medical information. Collaborative documents have the potential to revolutionize online learning because they could increase the creativity, productivity, and efficiency of learning. The purpose of this study was to investigate the feasibility of combining peer creation and sharing of mnemonics with collaborative online documents to improve pathology education. METHODS: We carried out a prospective, quasi-experimental, pretest-posttest pilot study. The intervention group was trained to create and share mnemonics in collaborative documents for pathological cases, based on histopathological slides. The control group compared analog and digital microscopy. RESULTS: Both groups consisted of 41 students and did not reveal demographic differences. Performance evaluations did not reveal significant differences between the groups' pretest and posttest scores. Our pilot study revealed several pitfalls, especially in instructional design, time on task, and digital literacy, that could have masked possible learning benefits. CONCLUSIONS: There is a gap in evidence-based research, both on mnemonics and on CD in pathology didactics. Even though, the combination of peer creation and sharing of mnemonics is very promising from a cognitive neurobiological standpoint, and collaborative documents have great potential to promote the digital transformation of medical education and increase cooperation, creativity, productivity, and efficiency of learning. However, the incorporation of such innovative techniques requires meticulous instructional design by teachers and additional time for students to become familiar with new learning methods and the application of new digital tools to promote also digital literacy. Future studies should also take into account validated high-stakes testing for more reliable pre-posttest results, a larger cohort of students, and anticipate technical difficulties regarding new digital tools.

The iBuddy experience: A digital simulation-based approach to enhance secondary school students' privacy awareness.

Privacy is a central issue in the digitalization of society and directly concerns all Internet users. Privacy education is part of the picture of a more just digital society: it aims at making users more aware of the importance of their data and of the technical and financial tools and processes that involve their personal data. Nonetheless, privacy education is confronted with a paradox: while people perceive the importance of privacy, they seldom take action to actually protect their personal data. iBuddy is a narrative simulation-based session inspired by research evidence about the privacy paradox and aims to (a) enhancing awareness and (b) promoting the uptake of privacy-safe behaviors for secondary and higher students (age range 11-20). The paper presents the design and development of the simulation and of the following modular debriefing, as a case study in evidence-based collaborative instructional design and in the instructional used of digital technology. The evaluation of iBuddy, which combined a post-session satisfaction and perceived learning survey (N = 978) and a follow-up survey (N = 124), provides insights in the novel domain of privacy education. Results suggests that iBuddy sessions are engaging, effective and conducive to medium-term behavioral change, thus indirectly confirming the design assumptions about how to tackle the privacy paradox through a simulation-based approach.

Learning deliberate reflection in medical diagnosis: does learning-by-teaching help?

Deliberate reflection has been found to foster diagnostic accuracy on complex cases or under circumstances that tend to induce cognitive bias. However, it is unclear whether the procedure can also be learned and thereby autonomously applied when diagnosing future cases without instructions to reflect. We investigated whether general practice residents would learn the deliberate reflection procedure through 'learning-by-teaching' and apply it to diagnose new cases. The study was a two-phase experiment. In the learning phase, 56 general-practice residents were randomly assigned to one of two conditions. They either (1) studied examples of deliberate reflection and then explained the procedure to a fictitious peer on video; or (2) solved cases without reflection (control). In the test phase, one to three weeks later, all participants diagnosed new cases while thinking aloud. The analysis of the test phase showed no significant differences between the conditions on any of the outcome measures (diagnostic accuracy, p = .263; time to diagnose, p = .598; mental effort ratings, p = .544; confidence ratings, p = .710; proportion of contradiction units (i.e. measure of deliberate reflection), p = .544). In contrast to findings on learning-by-teaching from other domains, teaching deliberate reflection to a fictitious peer, did not increase reflective reasoning when diagnosing future cases. Potential explanations that future research might address are that either residents in the experimental condition did not apply the learned deliberate reflection procedure in the test phase, or residents in the control condition also engaged in reflection.

Does a deep learning inventory predict knowledge transfer? Linking student perceptions to transfer outcomes.

Students are often encouraged to learn 'deeply' by abstracting generalizable principles from course content rather than memorizing details. So widespread is this perspective that Likert-style inventories are now routinely administered to students to quantify how much a given course or curriculum evokes deep learning. The predictive validity of these inventories, however, has been criticized based on sparse empirical support and ambiguity in what specific outcome measures indicate whether deep learning has occurred. Here we further tested the predictive validity of a prevalent deep learning inventory, the Revised Two-Factor Study Process Questionnaire, by selectively analyzing outcome measures that reflect a major goal of medical education-i.e., knowledge transfer. Students from two undergraduate health sciences courses completed the deep learning inventory before their course's final exam. Shortly after, a random subset of students rated how much each final exam item aligned with three task demands associated with transfer: (1) application of general principles, (2) integration of multiple ideas or examples, and (3) contextual novelty. We then used these ratings from students to examine performance on a subset of exam items that were collectively perceived to demand transfer. Despite good reliability, the resulting transfer outcomes were not substantively predicted by the deep learning inventory. These findings challenge the validity of this tool and others like it.

Challenges in Learning Procedural Skills: Student Perspectives and Lessons Learned for Curricular Design.

Phenomenon: Developing foundational clinical procedural skills is essential to becoming a competent physician. Prior work has shown that medical students and interns lack confidence and competence in these skills. Thus, understanding the student's perspective on why these skills are more difficult to acquire is vital for developing and reforming medical curricula. Approach: This study explored procedural skills learning experiences of medical students with qualitative methods. Through purposive sampling, 52 medical students from the third, fourth, and final years were selected for inclusion. Data were collected using six audio-recorded, semi-structured focus group discussions. Transcripts were manually coded and analyzed using inductive content analysis. Findings: Students provided rich and insightful perspectives regarding their experiences in learning procedural skills that fell into three broad categories: 1) barriers to procedural learning, 2) reasons for learning, and 3) suggestions for better learning outcomes. Students described a range of barriers that stemmed from both patient and clinician interactions. Students were reluctant to make demands for their own benefit during clerkships. The most commonly expressed reason for wanting to learn procedural skills was the desire to be a competent and independent intern. The motivators suggested that students felt empathetic toward interns and visualized a successful internship as a learning goal. Participants suggested peer learning, improved teaching of procedural skills, assessments, and feedback to improve their learning. Insights: This study generated valuable information to promote critical reflection on the existing curriculum and pedagogical approaches to procedural skills development. Medical educators need to sensitize the clinical teachers to student perspectives and what students are really learning to make impactful changes to teaching and learning procedural skills. Students' self-advocacy skills and self-directed learning skills need to be developed for them to seek out learning opportunities and to promote life-long learning. Lessons from this study may also apply to curriculum design in general, especially in teaching clinical skills. Empowering the learner and embracing a learner-centered approach to teaching and learning procedural skills will benefit future clinicians and their patients.

Virtual patients improve history-taking competence and confidence in medical students.

PURPOSE: Klark is a novel online medical education tool (www.klark-cases.com) where students take histories from virtual patients with common presentations from multiple specialities. We investigated whether Klark could enhance student confidence and competence in history-taking, and whether students find Klark helpful. METHODS: A single cohort of first-year clinical medical students had access to Klark for three weeks. At both ends of the trial, participants were asked to complete feedback forms and participate in two mock Objective Structured Clinical Examination (OSCE) history stations. Outcome measures included self-reported confidence and competence in history-taking, performance in OSCE stations, and qualitative user experience data. RESULTS: Seventy participants successfully completed a case on Klark (mean 18.7), of which 63 (90% user retention) completed  ≥ 2 cases. Self-reported competence (p < 0.001) and confidence (p < 0.001) improved. Participants found Klark to be helpful, impactful, and would recommend it to other students. OSCE scores improved for medical (57% vs. 69%, p < 0.001) and surgical (58% vs. 70%, p < 0.001) histories. CONCLUSIONS: Klark improved competence and confidence in history-taking. Students found it helpful and chose to continue using the platform. By developing confidence and competence at their own pace in the Klark simulated environment, students can then maximise benefit from in-person clinical opportunities.

Using cognitive load theory to evaluate and improve preparatory materials and study time for the flipped classroom.

BACKGROUND: Preclinical medical education is content-dense and time-constrained. Flipped classroom approaches promote durable learning, but challenges with unsatisfactory student preparation and high workload remain. Cognitive load theory defines instructional design as "efficient" if learners can master the presented concepts without cognitive overload. We created a PReparatory Evaluation Process (PREP) to systematically assess and measure improvement in the cognitive-load efficiency of preparatory materials and impact on study time (time-efficiency). METHODS: We conducted this study in a flipped, multidisciplinary course for ~ 170 first year students at Harvard Medical School using a naturalistic post-test design. For each flipped session (n = 97), we assessed cognitive load and preparatory study time by administering a 3-item PREP survey embedded within a short subject-matter quiz students completed before class. Over three years (2017-2019), we evaluated cognitive load- and time- based efficiency to guide iterative revisions of the materials by content experts. The ability of PREP to detect changes to the instructional design (sensitivity) was validated through a manual audit of the materials. RESULTS: The average survey response rate was ≥ 94%. Content expertise was not required to interpret PREP data. Initially students did not necessarily allocate the most study time to the most difficult content. Over time, the iterative changes in instructional design increased the cognitive load- and time-based efficiency of preparatory materials with large effect sizes (p < .01). Furthermore, this increased the overall alignment of cognitive load with study time: students allocated more time to difficult content away from more familiar, less difficult content without increasing workload overall. CONCLUSIONS: Cognitive load and time constraints are important parameters to consider when designing curricula. The PREP process is learner-centered, grounded in educational theory, and works independently of content knowledge. It can provide rich and actionable insights into instructional design of flipped classes not captured by traditional satisfaction-based evaluations.

Integrating diversity, equity, and inclusion principles into instruction: Case studies from the University of Florida's Health Science Center Libraries.

Librarians at the University of Florida Health Science Center Libraries have begun to intentionally incorporate diversity, equity, and inclusion (DEI) principles into teaching during design, implementation, and evaluation. This article uses four case studies to provide an overview of the librarians' approaches to inclusive teaching (1) an annual workshop for Physical Therapy students on the intersection between DEI, health literacy, and patient education; (2) a librarian-taught one-credit course for public health students, which was revised to create a more inviting syllabus and integrate elements of universal design; (3) an annual project for first year medical students highlighting health disparities and community resources; and (4) piloting the application of critical librarianship principles in library standalone sessions on database searching and reference management. Suggestions are provided for other librarians who are interested in developing a culture of inclusive teaching in their own libraries.