INTRODUCTION
Digital learning tools (DLT’s) are increasingly prevalent in higher education, offering innovative ways to complement traditional classroom instruction. In chiropractic education, DLT integration is particularly relevant due to the hands-on nature of the profession. The growing reliance on web-based platforms in healthcare education has been well documented, with wikis recognized for promoting collaborative learning and constructivist educational approaches, thereby enhancing students’ ability to retain and apply clinical knowledge.1–3 Similar trends have been observed in other healthcare disciplines, where digital resources, including wikis and video demonstrations, have been used to supplement conventional teaching methods.4,5 Research suggests that wikis support learning by fostering collaboration and providing access to diverse educational resources.6 However, no studies have specifically evaluated the use of a wiki site within a chiropractic college and its impact on student performance on practical examinations.
The objective of this study was to examine whether students using our university’s Clinical Education Wiki Site (CEWS) achieved higher performance on practical exams in chiropractic procedure courses. By analyzing patterns of wiki engagement alongside exam scores, we aimed to assess the effectiveness of this digital resource in enhancing clinical competencies.
Additionally, our survey explored students’ perceptions and experiences with the CEWS. This study serves as a follow-up to The Development and Implementation of an On-Demand Wiki Site for Teaching at a Chiropractic College.7 Our university CEWS is designed to be a resource for our Doctor of Chiropractic students. The site is accessible by university students, faculty, and staff with over 3.7 million total views since 2013. There are over 1,291 content pages and 3,009 total pages with detailed procedure descriptions, videos, and pictures of physical exams, orthopedic and neurological exam procedures, chiropractic adjusting procedures, soft tissue therapies, joint mobilization, exercise rehabilitation, and physiological therapeutics.
METHODS
An Institutional Review Board (IRB) approved electronic survey and cross-sectional study of trimester 1 through 7 students was conducted (n=348). We surveyed all students enrolled in our Chiropractic Procedures courses for the Spring 2024 trimester. The survey included 14 questions on students’ use of the CEWS including frequency of usage, experience level with online technology, gender, the perception of how their use of the site impacted their overall education, as well as how it impacted their performance on practical exams (Appendix A). The survey was pretested for face validity (by 2 students who were not part of the survey group and 2 faculty who were not involved in the study) prior to its administration. The students were informed that the survey was anonymous, and that no personal identifying information would be obtained during the administration of the survey. Any student could decline to participate in the survey without consequence, and there were no incentives offered for participation.
This study employed a cross-sectional survey design with retrospective outcome analysis, allowing for the examination of associations between CEWS usage and practical exam performance. To enhance validity, future iterations should incorporate construct validity assessments and pilot testing with a larger sample. Sampling was conducted via convenience sampling of enrolled students, which may introduce selection bias.
Data was collected through an online survey platform and stored on a password-protected computer at the university. The survey link was distributed via email to the target participants. Respondents were given 2 weeks to complete the survey. Data on practical exam performance was collected from our learning management system (Canvas).
Practical exam performance was assessed through standardized practical exams administered at the end of the trimester in Exam Soft, focusing on key competencies such as patient assessment, diagnostic skills, and therapeutic techniques. Additionally, student names were not included in the survey and only student I.D.'s were collected. The authors received de-identified results for analysis. Exams were scored using standardized rubrics by trained faculty evaluators to ensure consistency and objectivity in grading.
All data were analyzed using R Software for Statistical Computing and Graphics (v. 4.3.2).
RESULTS
The survey was distributed to 348 students and 150 responded, for a response rate of 43%.
Comparison of Exam Scores Between Users and Non-Users: The analysis showed no statistically significant difference in exam scores between users and non-users of the Wiki site, with a Mann Whitney U test result of W=2353.5, p=0.931. (Figure 1) The effect size (r = –0.009) and 95% CI [–0.170, 0.152] indicate a negligible effect.
Frequency of Wiki Site Use and Exam Scores: A 1-way ANOVA indicated that there was no statistically significant difference in exam scores among Wiki users based on their frequency of use, F(1, 104)=0.635, p=0.427. (Figure 2) The effect size (η² = 0.018) and 95% CI [0.002, 0.086] indicate a minimal effect.
Gender Differences in Exam Scores: The Mann Whitney U test revealed no statistically significant difference in exam scores between male and female Wiki users, W=1352, p=0.531. 105 students chose to respond to this question. (Figure 3) The effect size (r = –0.075) and 95% CI [–0.268, 0.118] indicate a negligible effect.
Perception Of Practical Exam Performance After Using The Wiki Site: A 1-way ANOVA indicated no statistically significant difference in exam scores by student perception of the wiki site F(1,104)=0.47, p=0.495. 106 students chose to respond to this question. (Figure 4) The effect size (η² = 0.013) and 95% CI [-0.002, 0.086] suggest a small effect.
In summary, the results indicate no statistically significant difference in exam scores between users and non-users of the CEWS; no statistically significant difference in exam scores between users based on their frequency of use; no significant difference in exam scores between men and women, and no statistically significant difference between students’ perception of using the site and their practical exam scores. Seventy-five percent of users reported being satisfied or very satisfied with the overall ease of use of the CEWS.
DISCUSSION
This study aimed to explore the impact of a clinical education wiki site on chiropractic students’ performance in practical exams. While the results indicated a positive experience using the CEWS, the correlation between wiki usage and practical exam performance was not statistically significant. This finding warrants a closer examination of the potential reasons behind the lack of meaningful results and the implications for the use of digital learning tools in chiropractic clinical education.
Potential Explanations for Non-Significant Results
Several factors may explain the non-significant results observed in this study. First, the level of engagement with the wiki site varied among students, and those who used the site more frequently might have done so sporadically or without fully integrating it into their study routines. This partial engagement might not have been sufficient to produce measurable improvements in exam performance.
Second, the content quality and structure of the wiki site may have influenced its effectiveness. According to Cabrera et al., the success of collaborative platforms like wikis depends heavily on the quality of content and the degree to which it encourages active participation and collaboration.8,9 If the wiki content was not adequately aligned with the practical exam requirements or did not engage students effectively, its impact on performance would naturally be limited.
Comparison to Other Digital Learning Modalities
Several studies have explored the role of instructional videos in clinical skills acquisition. Research has shown video-based learning can enhance students’ understanding and performance in practical examinations.10–13 In veterinary and medical education, instructional videos have been linked to improved student engagement and skill retention.14,15 Similarly, studies by Burton and Carmichael et al. emphasized the positive impact of video resources on student engagement and learning, particularly in developing psychomotor skills.16,17 While our study focused on wiki-based learning, it is worth noting that wikis often incorporate multimedia resources, including videos, to provide a more comprehensive learning experience. According to Luginbuehl et al., video-based learning of physiotherapy skills allowed students the ability to control their own pace of learning while offering standardized and structured on-demand video demonstrations.18 Future research should explore whether a combination of wikis and instructional videos yields superior outcomes compared to the use of either modality alone.
Self-Directed Learning and Student Engagement
The self-directed nature of wikis allows students to access and review educational content at their own pace, a factor that has been positively correlated with improved clinical performance.5,19 We have anecdotal reports from our students that the CEWS helps them review for practical exams and for the National Board of Chiropractic Exams (NBCE), supporting the notion that self-regulated learning can be an effective strategy for skill development in chiropractic education. However, it is important to consider that not all students may be equally adept at self-directed learning. Additional support, such as structured guidelines or faculty mentorship, may be necessary to maximize the benefits of wiki-based learning.20 While anecdotal reports suggest potential benefits for NBCE preparation, future research should empirically evaluate this relationship.
Implications for Chiropractic Education
The results of this study have implications for the design of clinical education curricula in chiropractic programs. Given the positive students’ perceptions and experiences with the CEWS, incorporating structured digital learning resources into the curriculum may enhance student learning outcomes. Additionally, faculty involvement in curating and moderating wiki content may further improve its effectiveness as a learning tool.1,19 Future studies should investigate the optimal strategies for integrating wikis into chiropractic education, including their role in complementing hands-on training and live demonstrations. Although students reported positive perceptions, further studies are needed to determine whether these perceptions translate into measurable academic benefits. Differences in digital literacy and access to technology may influence students’ ability to effectively engage with the CEWS. Addressing these disparities is essential to ensure equitable learning outcomes. Faculty mentorship can also guide students in navigating and applying wiki content effectively, fostering deeper learning and skill development.
Limitations and Future Research
While this study provides valuable insights, limitations must be acknowledged. First, reliance on self-reported data regarding wiki usage introduces the potential for recall bias. Future research employing controlled experimental designs could offer more definitive evidence on the effectiveness of wiki-based learning. Additionally, qualitative methodologies exploring student perceptions and engagement with digital learning tools could yield deeper insights into how these resources support learning.1,21
A more comprehensive approach to integrating digital tools into the curriculum should be considered in future studies. For instance, combining wikis with other digital resources, such as up-to-date instructional videos, may enhance their overall effectiveness. Previous research has shown that blended learning approaches—incorporating multiple digital modalities—can improve clinical skills and knowledge retention more effectively than using a single method.22,23
This study has limitations that may have influenced the results. The sample was restricted to cohorts from one chiropractic college, limiting the generalizability of the findings. Additionally, cumulative grade point averages (cGPA) and attendance were not accounted for, and other unmeasured factors, such as students’ prior knowledge, learning styles, and use of additional study resources, could have impacted outcomes measured by this study.
Future research should aim to replicate this study with larger, more diverse cohorts across multiple institutions to enhance the validity of the findings. Investigating the specific features of wiki content that most effectively contribute to learning could provide valuable insights for optimizing digital tools in chiropractic education. Furthermore, longitudinal studies examining the long-term impact of wiki usage on clinical competency and professional practice would be beneficial in determining the sustained efficacy of this educational approach.
CONCLUSION
In conclusion, while this study did not find statistically significant evidence to support the hypothesis that increased engagement with a Clinical Education Wiki Site (CEWS) improves practical exam performance among chiropractic students, it does contribute to the growing body of literature on digital learning in clinical education. These findings suggest that other factors may have a greater influence on practical examination outcomes. Further research with larger sample sizes and more refined methodologies is recommended to better understand the potential benefits of digital learning tools in chiropractic education. Digital learning tools, including wikis, have shown promise in enhancing educational outcomes across various medical and health science disciplines. As chiropractic education continues to evolve, integrating web-based learning resources like wikis could play a valuable role in fostering student engagement and skill acquisition. Future studies should focus on optimizing these digital platforms to accommodate diverse learning styles and maximize their impact on clinical competence and overall student learning outcomes.
ACKNOWLEDGEMENTS
We would like to thank the participating students at the chiropractic college for their cooperation and support in conducting this study, the faculty involved with the survey validation process, and Leah Grout, PhD, MPH, Associate Research Professor, for conducting the statistical analysis for this study.24