Especificaciones sobre las acciones que afectan a la estructura.

There was a strong tactile and haptic anatomical multimedia theme across all the anatomy teachers, as was discussed in Section 4.4.2 on page 92. The use of tactile and haptic

multimedia can be portrayed by the haptic learning of bones during the three undergraduate years. The students had to tactilely feel and manipulate the set of bones that they were personally loaned by their anatomy teachers. It was the norm for students to palpate the anatomical bones on themselves and on their classmates during the Practical Anatomy

Tutorials in 1st year. Anatomical plastic models were also extensively used as tactile multimedia during the Practical Anatomy Tutorials and occasionally the students were allowed to

manipulate and tug cadaveric specimens with their hands. The zenith of using tactile and haptic multimedia was when the physiotherapy students palpated, physically examined and treated healthy or injured bones and joints of patients during their 2nd and 3rd year clinical

placements in hospitals. Teaching anatomy using many different physical formats is highly recommended for encouraging effective learning of anatomy (Rizzolo et al., 2006). Some of the clinical tasks requiring Kinaesthetic Anatomical Skills are using a goniometer (protractor for measuring joint angles), muscle testing and neurological examination (Mattingly & Barnes, 1994).

Prosections provided significant tactile stimulation for the students. Six of the eight schools of physiotherapy used prosections (pre-dissected cadaveric specimens) and was similar to the practice used in schools of physiotherapy in the USA (Latman & Lanier, 2001; Reimer et al., 2013) and Japan (Kawashiro et al., 2009), where prosections were more commonly used than physiotherapy students dissecting cadavers. The more time efficient prosections were preferred and used more frequently than students dissecting themselves because student dissections were more time consuming and depleted curricular time (Abu-Hijleh, 2010;

Bandaranayake, 2010). The other reason could be that physiotherapists do not need dissection skills in their hospital careers and even some medical graduates do not have dissection skills (Abu-Hijleh, 2010) and do not need dissection experiences (Bandaranayake, 2010; McLachlan, Bligh, Bradley, & Searle, 2004; McLachlan & Regan De Bere, 2004). It must be noted that the need for dissection experiences by medical students has been hotly contested (Dyer & Thorndike, 2000; Pawlina & Lachman, 2004).

The current study used Practical Anatomy Tutorials as the main teaching activity for providing haptic multimedia and differed from the practice in the USA, where cadaveric-based teaching was their main teaching activity for haptic multimedia. The teaching of anatomy in the USA is heavily reliant on teacher-centred lecturing and cadaveric-based teaching (Abdur-Rahman, 2007; Berube et al., 1999; Latman & Lanier, 2001; Mattingly & Barnes, 1994; Melguizo et al., 2007; Prados, Melguizo, Vélez, & Hita, 2007; Reimer et al., 2013; Thomas et al., 2011). Australia too has moved from mainly using didactic lectures to using small-group practical classes to form the bulk of their teaching medium of physiotherapy education (McMeeken, 2007). The Anatomy Practical Tutorials, run in practical rooms and to a lesser extent in the anatomy cadaveric laboratory, were used as a vehicle for promoting the development of kinaesthetic anatomical knowledge and skills. The use of Anatomy Practical Tutorials in the UK could be traced back to the regulatory requirements by the HCPC as satisfying active-learning and student-centred learning (Bithell, 2007; HCPC-Training-Standards, 2009) and the pressure the CSP has placed on physiotherapy schools to run practical skills sessions/tutorials. Schools of physiotherapy wishing to achieve CSP Accreditation of Qualifying Programmes in

Physiotherapy have to provide clear information on practical skill tutorials in terms of the number of tutorials, number and sizes of the practical rooms, number of students per tutorial,

the number of academic staff that will supervise the practical skills tutorials and how the practical skills sessions will be examined (CSP-Accreditation-Supplement, 2016). The CSP and the predecessor of the HCPC has previously set a minimum requirement of 1,000 hours of ‘hand on’ clinical training in hospitals (Bithell, 2007).

There has been interest in better aligning the education of physiotherapy to the learning styles of students to enhance learning (Brown, Cosgriff, & French, 2008; Mayya & Rao, 2004;

Milanese, Gordon, & Pellatt, 2013; Wessel et al., 2009; Zoghi et al., 2010) partly because of the desire to justify the significant costs of running physiotherapy education (Brown et al., 2008). There is a wide range of different types of inventories of learning styles and learning

approaches (Al Maghraby & Alshami, 2013; Mayya & Rao, 2004; Milanese et al., 2013; Wessel et al., 2009; Zoghi et al., 2010) and Kolb’s Learning Style Inventory is the most commonly used in allied health literature (Brown et al., 2008). The VARK inventory, invented by Fleming for eliciting the instructional preferences of students, is of significant interest to the discussion of Kinaesthetic Anatomical Skills because one of the four learning styles (visual, aural, read/write and kinaesthetic) is the kinaesthetic learning style (P. Miller, 2001). The questionnaire of the VARK learning styles has well respected validity and reliability (Brown et al., 2008; Leite, Svinicki, & Shi, 2010). There are 24 possible permutations of the four types of styles because most people have multiple learning styles (Brown et al., 2008; Dissanayaka, 2014;

Majeedkutty, Yang, Suppiah, & Lun., 2015; Rai & Khatri, 2014).

Four studies have examined the VARK learning styles of physiotherapy students. About 63% of physiotherapy students in Australia (Brown et al., 2008), 76% of physiotherapy students in Malaysia (Majeedkutty et al., 2015) and 92% of physiotherapy students in western India (Rai & Khatri, 2014) were classified as having kinaesthetic modes, either as single modes or as part of multiple modes, while the kinaesthetic style was the largest single group (percentage of multimodal groups containing a kinaesthetic learning style was not given) in Sri Lanka (Dissanayaka, 2014). The dominance of VARK-based kinaesthetic learning styles is common among health related students, such as occupational therapy and speech students (Brown et al., 2008), nursing students (Meehan-Andrews, 2009) and medical students (Kharb, Samanta, Jindal, & Singh, 2013; Lujan & DiCarlo, 2006). Students doing clinical placements in hospitals are more likely to prefer the kinaesthetic learning style (Majeedkutty et al., 2015).

Learning styles have been contentious because the learning styles are poorly distinguished from abilities and personalities, and has poor interactions with the rest of psychological literature (Sternberg & Zhang, 2001), which makes it hard to know what the learning styles actually mean at a conceptual level. Learning styles are generally poorly defined theoretical

constructs and are said to function without the individual being aware of them (Sternberg & Zhang, 2001), in contrast to the current study where the research participants were aware of kinaesthetic styles. No link of the VARK learning styles to general intelligence was found in literature.

There was not an author in my literature search that identified haptic or kinaesthetic forms as qualifying as a form of multimedia, despite Mayer (Mayer, 2014b) acknowledging that

multimedia may have more than two forms beyond verbal and visual formats. Some poor attempt was previously made to create a theory of schema in the long-term memory governing discrete motor skill learning (Schmidt, 1975), but lacked an explanation how children develop motor schema in the first place (Patrick, 1993) or how either a short-term or working memory processed information. The various authors on multimedia seem to take the perspective that multimedia learning only occurs from paper-based or computer-based learning environments, and ignores practical learning that can occur in a classroom laboratory or in work-based settings. There is a tendency among researchers to undervalue the non-visual components (environmental sounds, human actions, haptic and visceral sensations) of the nonverbal mental system and mostly describe the Dual-Coding theory as having just a verbal system and a visual system (Paivio, 1991). Although the non-visual components of the nonverbal mental system had been mentioned in earlier works of Paivio (Paivio, 1979), it was ignored by Cognitive-Load theory scholars. The ignoring of haptic input is reinforced by that most learning of basic sciences is about facts and not skills (T. M. Scott, 2000). The 4CID model makes a break from all the other learning theories based on the Cognitive-Load theory by emphasising skills and not just knowledge (Merriënboer, Clark, et al., 2002; Merriënboer et al., 1992; Merriënboer & Kirschner, 2013; Merriënboer, 1997). The simultaneous mix of verbal feedback during the teaching of haptic musculoskeletal skills in small groups is a potent form of learning (O’Dunn-Orto, Hartling, Campbell, & Oswald, 2012).

The teaching of kinaesthetic anatomical knowledge during the Practical Anatomy Tutorials was typically embedded in group learning or peep-to-peer learning, where students palpated each other and learnt anatomical knowledge from each other. A group of Cognitive-Load theory scholars have extended the Cognitive-Load theory meant for individual learning to cater for group learning through collaborative learning (F. Kirschner, Paas, & Kirschner, 2009, 2011; P. A. Kirschner, Kirschner, & Janssen, 2014). Collaborative learning works through the students pooling together their working memories (F. Kirschner et al., 2009; Ohtsubo, 2005), in what is referred to as the ‘collective working memory effect’ (F. Kirschner et al., 2011). Each individual has a working memory with a limited capacity and the collective working memory capacity to encode, store and retrieve schema and its automation using the working memories and long-

term memories of many students is so much enhanced and larger when the many students work together on a task (P. A. Kirschner et al., 2014). Collaborative learning derived from the Cognitive-Load theory is said to be ineffective for straight forward recall of information, but works well for more complex tasks that are cognitively more demanding (F. Kirschner et al., 2009, 2011). Collaborative learning allows complex tasks to be mastered through a ‘collective working memory effect’ (F. Kirschner et al., 2011) and the knowledge used individually when the physiotherapy student qualifies as an autonomous physiotherapist. The descriptions of how groups learnt were too limited in the current study to allow for further interrogation of how information was shared, used, managed or regulated (P. A. Kirschner et al., 2014). Cognitive-Load theory based collaborative learning has some vulnerabilities in that it is uncertain what the optimum group size is for encouraging learning or how motivational or social factors influence the Cognitive-Load theory (P. A. Kirschner et al., 2014).