A Massive Open Online Course-Based Flipped Classroom Protocol For Pediatric Puncture Skills Training Among Undergraduate Medical Interns

Summary

This protocol describes a MOOC-based flipped classroom approach for training undergraduate medical interns in four core pediatric puncture skills, facilitating pre-class knowledge acquisition and in-class simulation practice.

Abstract

This protocol describes a reproducible teaching model designed to enhance the clinical competency of undergraduate medical interns in performing four essential pediatric puncture skills: thoracic, abdominal, lumbar, and tibial bone marrow punctures. The key procedural approach integrates self-paced, pre-class massive open online course (MOOC) learning with intensive, hands-on, in-class simulation practice. Prior to class, interns complete 10 to 20 min instructional videos covering operation principles, standard procedures, common mistakes, and clinical case analyses, while constructing mind maps to logically organize anatomical and procedural knowledge. During the in-class session, instructional time is completely reallocated from traditional lectures to personalized teacher guidance, peer discussion, and standardized scenario-based simulation practice using high-fidelity pediatric mannequins. The intended application of this protocol is to address the severe time and resource limitations inherent in traditional medical education by maximizing active hands-on practice opportunities. Validation studies indicate that this scalable flipped classroom framework significantly improves medical students' skill mastery, clinical thinking, and theory-practice integration without increasing their overall learning burden, making it highly adaptable for broader clinical skills training programs.

Introduction

Pediatric puncture techniques—specifically thoracic, abdominal, lumbar, and tibial bone marrow punctures—are essential but inherently high-risk clinical skills for undergraduate medical interns. Mastery of these invasive procedures demands standardized, hands-on training to ensure patient safety and diagnostic accuracy¹. However, traditional teaching models heavily rely on a "theoretical lecture plus brief demonstration" approach. This conventional paradigm often results in insufficient practical time, a superficial understanding of operational key points, and poor long-term skill retention, ultimately impeding interns' clinical readiness². Consequently, there is an urgent rationale to shift toward an instructional model that safely maximizes hands-on simulation time while ensuring robust theoretical preparation.

In the wider body of medical education literature, flipped classroom models and Massive Open Online Courses (MOOCs) have increasingly been recognized for their ability to promote active learning and improve clinical competency^1,3. While alternative techniques like standard simulation-based training or purely online Small Private Online Courses (SPOCs) offer some benefits, they often lack a structured mechanism to integrate fragmented theoretical knowledge². The significant advantage of the proposed MOOC-based flipped classroom is that it shifts the cognitive load of knowledge acquisition to the pre-class phase⁴. Furthermore, integrating mind maps—a critical component of our proposed instructional design—promotes structured knowledge integration and key point comprehension, complementing the flexible nature of MOOCs⁵. This combination allows in-class time to be exclusively dedicated to personalized guidance and repetitive hands-on practice, offering a distinct advantage over traditional methods where didactic lectures consume valuable simulation time².

The overall goal of this manuscript is to present a detailed, reproducible MOOC-based flipped classroom protocol specifically tailored for teaching pediatric puncture skills. By explicitly outlining the pre-class MOOC learning phase, in-class simulation practice, and rigorous assessment procedures, this protocol provides a comprehensive instructional blueprint. Readers can evaluate this information to determine whether the method is appropriate for their specific applications; the structured approach detailed herein is highly suitable for medical universities, residency training programs, and clinical simulation centers aiming to optimize teaching time and enhance learning engagement. Ultimately, this protocol addresses the core needs of pediatric clinical skills training and provides a scalable, adaptable model for broader medical education reform.

Protocol

The research protocol was approved by the Medical Ethics Committee of Shenzhen University (Approval No.: SZUGH-2024-032). All participants provided written informed consent after understanding the study purpose, procedures, and potential impacts on academic evaluation.

1. Participant screening, selection, and group assignment

1. Screen potential undergraduate medical intern candidates using the predefined academic and attendance records.
2. Select participants who have successfully completed basic medical courses (anatomy and physiology). Ensure these selected candidates have no prior systematic puncture skills training.
3. Apply exclusion criteria to remove candidates from the eligibility pool. Specifically, exclude students on prolonged sick leave, those with consecutive professional course failures, or those who voluntarily withdraw.
4. Divide the finalized pool of selected participants into two distinct teaching cohorts. Base this division on existing institutional training schedules or academic blocks (e.g., assigning different academic years to different cohorts) to facilitate logistical management.
5. Designate the first cohort as the control group. Assign this group to receive traditional teaching, which includes theoretical lectures, teacher demonstrations, and free practice.
6. Designate the second cohort as the experimental group. Assign this group to receive the MOOC-based flipped classroom teaching protocol.
7. Schedule the specific training sessions for the control and experimental groups on entirely separate dates.
8. Book distinct clinical simulation venues for each group's training sessions.
9. Maintain strict temporal and spatial separation between the two cohorts throughout the duration of the training to prevent cross-group communication and method contamination.

2. Preparation of teaching materials and instructors

1. Draft a standardized teaching script for each of the four puncture skills (thoracic, abdominal, lumbar, tibial bone marrow).
2. Film 10–20 min instructional videos using high-definition cameras based on these scripts. Edit the footage to include slow-motion replays for key procedural steps.
3. Organize each video into four standardized modules: operation principles, standard procedures, common mistakes, and clinical case analysis.
4. Create spreadsheet-based mind map templates pre-populated with key English category headings (e.g., indications, contraindications, anatomical landmarks).
   NOTE: Refer to Supplementary File 1 for the standardized English template.
5. Gather generic sterile puncture kits and generic high-fidelity pediatric puncture mannequins.
   NOTE: Please refer to the Table of Materials for specific commercial equipment details.
6. Select instructors who are attending physicians with at least 3 years of clinical skills teaching experience.
7. Conduct a standardized 4 h training session for all selected instructors using the finalized teaching scripts and assessment rubrics.
8. Require all instructors to perform a mock demonstration and score a sample student video to ensure instructional and evaluative consistency across the teaching staff.

3. MOOC platform configuration

1. Register an institutional instructor account on the Chaoxing Learning Platform (https://www.chaoxing.com).
2. Configure the course dashboard to support video playback, quiz generation, and real-time progress tracking.
3. Upload the finalized instructional videos and the mind map templates (Supplementary File 1) to the course repository.
4. Create separate course groups for the experimental cohort using the platform's standard cohort configuration settings.
5. Assign the appropriate single skill video and mind map task to the experimental group exactly 1 week before the scheduled in-class session.
6. Set the platform task deadlines to 24 h before the class.
7. Configure the tracking system to monitor specific metrics: total video viewing duration (minutes), number of video replays, and post-view quiz scores.

4. Implementation of the MOOC-based flipped classroom (Experimental group)

1. Pre-class stage (1 week before class):
   1. Instruct students to log in to the online platform using their institutional accounts.
   2. Instruct each student to watch the single assigned 10–20 min video corresponding to the weekly puncture skill. Allocate a 6-day window for students to watch the video at their own pace.
   3. Instruct students to complete the post-view quiz on the platform. Mandate an 80/100 passing score.
   4. Direct students to download the English mind map template (Supplementary File 1). Instruct them to summarize key knowledge points and submit the file via the platform.
   5. Access the instructor dashboard 1 day before the class. Retrieve and review the tracking metrics and submitted mind maps to identify common difficulties.
2. In-class stage (90 min):
   1. Allocate a total continuous duration of 90 min to complete this stage. Schedule a standard 10 min break halfway through the session to prevent cognitive fatigue.
   2. Enforce strict sterile techniques. Require hand hygiene per World Health Organization (WHO) guidelines, precise sterile field preparation, and immediate disposal of used needles.
   3. Conduct a 30 min question and answer session to address the common questions identified pre-class. Physically demonstrate difficult operational steps on the simulation mannequin.
   4. Select 3–5 students to present their mind maps to the class for 10 min. Facilitate peer discussion and provide verbal feedback to optimize their knowledge structure.
   5. Divide students into fixed groups of exactly 5 or 6 students. Assign 1 instructor to monitor every 10 students for personalized guidance.
   6. Instruct students to take turns practicing standardized operations on the mannequins for 40 min. Monitor the operations and verbally correct errors in real-time.
   7. Select assessment scenarios from a pre-compiled, standardized pediatric case bank approved by the teaching department. Ensure each scenario follows a fixed template (e.g., patient age, vital signs, primary diagnosis).
   8. Conduct a 40 min scenario simulation assessment. Provide students with the standardized clinical scenario and evaluate performance using anonymous scoring sheets.

5. Implementation of traditional teaching (Control group)

1. In-class stage (90 min):
   1. Allocate a total duration of 90 min to complete this stage. Schedule a standard 10-min break halfway through the session.
   2. Enforce the exact same sterile technique and safe needle handling requirements as used for the experimental group.
   3. Deliver a 30-min theoretical lecture. Utilize presentation slides and blackboard writing to explain puncture principles, indications, contraindications, and steps.
   4. Perform a 30-min complete operation demonstration on the simulation mannequin. Instruct the students to observe the demonstration and take notes.
   5. Instruct students to engage in independent free practice on the mannequins for 60 min. Circulate the room to provide touring guidance.

6. Skill mastery assessment

1. Blind two independent evaluating teachers to the students' group allocations by requiring all students to wear identical uniforms without group identifiers.
2. Provide the evaluators with anonymous scoring sheets to record the scores during the scenario simulation assessment.
3. Assess student skill mastery using a 100-point scale comprising four sections: pre-operation preparation (20 points), operation process (50 points), aseptic technique (15 points), and complication management (15 points).
4. Categorize the final scores into three predefined tiers: "excellent" (90–100 points), "good" (80–89 points), and "needs improvement" (<80 points).

7. Questionnaire administration

1. Administer a self-designed, completely anonymous questionnaire to all participating students immediately after the completion of the in-class stage.
2. Distribute the questionnaire via a digital survey link (or paper forms) to ensure standardized data collection and maintain strict respondent anonymity.
3. Instruct students to rate teaching satisfaction using a 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied) across five dimensions: teaching method, teaching model, instructor, pre-class resources, and in-class activities.
4. Instruct students to rate their learning ability improvement on a 1–10 scale (1 = no improvement, 10 = significant improvement) across seven specific indicators. Define scores of 8–10 as "significant improvement."
5. Provide additional specific questions exclusively to the control group to assess their independent pre-class preview behaviors (e.g., "Did you preview puncture-related knowledge before class?").
6. Instruct students to rate their perceived learning burden on a 1–10 scale (1 = severe burden, 10 = no burden). Define scores of 8–10 as "no additional burden."

8. Statistical analysis

1. Input the collected skill assessment scores and the anonymous questionnaire responses into statistical analysis software (e.g., SPSS version 26.0).
2. Compare the categorical data between the experimental and control groups using chi-square tests.
3. Analyze the continuous data (with non-normal distributions) using Mann-Whitney U tests.
4. Calculate the intraclass correlation coefficient (ICC) to evaluate the inter-rater reliability between the two independent evaluating teachers.
5. Report the 95% confidence intervals (CIs) for all key outcome variables. Define statistical significance strictly as a P-value of < 0.05.

Results

Baseline characteristics

A total of 127 students were initially enrolled, of whom 122 were included in the final analysis after the exclusion of 5 students. The final analyzed sample comprised 61 students in the experimental group and 61 students in the control group. As shown in Table 1, no significant differences were observed between the experimental group (n = 61) and the control group (n = 61) regarding gender (male 33/61 vs. 31/61), age (22.2 ± 1.1 year...

Discussion

The MOOC-based flipped classroom protocol provides a structured and reproducible framework for pediatric puncture skills training, emphasizing the transition from passive knowledge reception to active procedural mastery. By fundamentally reallocating instructional time and space, this methodology addresses the common limitations of traditional clinical education, such as insufficient practice time and superficial understanding of key operations. The success of this approach is rooted in several interconnected methodologi...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Alcohol Cotton Pads	Winner Medical Co., Ltd.	WN-AC70	Medical-grade 70% isopropyl alcohol pads for pre-puncture skin disinfection; individually sealed to ensure aseptic conditions.
Disposable Sterile Syringe	Jiangsu Kanghua Medical Equipment Co., Ltd.	KH-5ML	Used for routine fluid extraction and injection during pediatric puncture skills training; single-use and individually sterilized.
Pediatric Thoracentesis Training Manikin	Shanghai Yilian Medical Simulation Tech	YL-PTM-02	High-fidelity simulation manikin for practicing thoracic puncture with realistic anatomical landmarks and repeatable needle insertion.