Using Logbooks to Enhance Students’ Learning: Lessons From a Mixed-methods Study in an Undergraduate Surgical Rotation

Background: Logbooks are frequently used in medical education to enhance and monitor students’ learning. However, some barriers that may diminish their benefits have been reported. This study aims to evaluate the usefulness of logbooks to students’ learning and identify the factors, which may contribute to their outcomes in learning milieus. Methods: The study used a mixed-methods approach. Quantitative and qualitative data were collected from the medical students in the fourthand sixth-year classes and their teachers in the department of surgery at the Faculty of Medicine at University of Tabuk in the academic year 2016–2017. Data were collected using questionnaires, focused group discussions, and personal interviews. Results: Eighty-nine (49 fourth year and 40 sixth year) students and six teachers participated in the study. Logbooks were perceived as useful to students’ learning by 83.3% of the teachers and 75.3% of the students. Logbooks enhanced students’ learning through identification of areas of weaknesses, encouraged seeing more patients’ problems and reading in-depth about some topics, and improved students’ writing skills. Barriers to learning from logbooks included poor-quality feedback, no opportunities for feedback discussion, and unfair marking. Differences in the students’ perceptions of the usefulness of logbooks were observed based on their learning stage. Conclusion: Logbooks are useful to students’ learning in many aspects; however, certain factors could diminish their benefits. Students’ attitude toward the logbook was more favorable during their early clinical experience. Faculty development programs and careful supervision of students’ work may improve the outcome of logbooks in clinical placements.


Introduction
The use of logbooks to enhance learning is well-known in the educational enterprise, including medicine, where they have numerous advantages to learners, instructors,

Quantitative data
A self-administered questionnaire was developed following a review of the relevant literature of learning from logbooks and written feedback given the study goals. Two versions of the questionnaire were developed; one for students and another for teachers, both were piloted using a selected sample of students and teachers, respectively. Each questionnaire included closed-ended and Likert-type questions with 5-point options for teachers and forced 4-point options for students (to encourage them to provide clear answers) [30]. The final logbook mark and the updated Grade Point Average (GPA) were recorded for each student.
Quantitative data were analyzed using the SPSS computer software (SPSS Inc. Chicago, Illinois) version 16, and responses were presented as frequencies and percentages of the total [31]. Alpha Cronbach statistic was used to assess the internal consistency of the questionnaire's items and validate their results [32]. Correlations were made between the students' perceptions of the usefulness of logbooks to their learning in one hand and their individual characteristics (gender, stage of learning, and level of academic performance [inferred from their GPA and logbook marks]) on the other hand, and significance of results was tested using the independent sample t-test.
The Likert-type questions were analyzed using the Likert-scale method.

Qualitative data
Qualitative data were collected from students and teachers through focus group discussions and personal interviews, respectively. Appointments for the interviews and the focus group discussions were agreed with participants based on their convenient time and place to enhance enrollment. Two faculty members from other departments in the college and the researcher conducted the interviews and the focus group discussions.
Questions posed in the focus group discussions and interviews addressed the main objectives of the study, as mentioned earlier, and prompts were provided wherever needed. Data were transcribed to papers owing to the difficulty of audiotape recording of the focus group discussions, particularly with the female students. Thematic analysis was applied to analyze the qualitative data, which were categorized under common emerging themes [33]. Table 1 shows the number and the distribution of the student participants over the two classes in addition to the participation rates in the questionnaire and focus group discussion rounds. The Alpha-Cronbach reliability score of the students' questionnaire was 0.78, which indicates the homogeneity and consistency of the questionnaire items. The total number of students in both classes = 141. Table 2 shows students' responses to the closed-ended questions. Table 3 shows correlations between the students' perception of the usefulness of logbook and written feedback to their learning on one side and their gender and stage of learning on the other. Table 4 highlights the relationship between the students' perception of the usefulness of logbooks to their learning and their academic excellence. A statistically significant difference in the students' perception of the logbook was noted concerning their stage of learning; the fourth-year students perceived the logbook more positively than their senior counterparts. Gender and academic excellence did not give rise to significant differences.     While all teacher participants perceived their feedback as useful to students, only five (83.3%) indicated that the logbook is useful to students' learning.

Discussion
This study aimed to investigate the usefulness of logbooks to students' learning from students' and teachers' perspectives and how they may influence learning, whether positively or negatively. Study findings will be discussed under three headings: perceptions of the usefulness of logbooks to learning, the role of logbooks as promoters and hinderers of learning, and the role of the individual characteristics of learners in the process.

Perceptions of the usefulness of logbooks to students' learning
The usefulness of logbooks to enhance students learning is frequently reported as mentioned earlier, however, some studies have shown the contrary. For example, Busemann et al. (2011) elaborated on the use of a logbook to enhance students' learning in a surgical clerkship. They reported that <35% of the students perceived logbook as useful to their learning [34]. They argued that, although the logbook is a powerful learning tool, it should be adapted to the students' needs or otherwise may demotivate them and inhibit their learning (e.g., teacher's guidance and structured training).
Although both students and teachers perceived the logbook and written feedback as useful, contrary to their teachers, some students were not pleased with the quality of feedback they received in logbooks, which they often described as unclear, unfair, inconsistent, and does not involve suggestions for improvement. This was evident in some students' comments like: "I used to receive the same comments, no improvement because it did not show me how to do that." SY6F (please refer to the list of abbreviations at the end of the article) "Sometime feedback is contradicting, what is correct for one teacher is not necessarily so for others." SY4F Such discrepancies in the perceptions of feedback between students and teachers are one of the documented barriers to effective use of feedback as a powerful tool for learning. Carless (2006), and Abraham and Singaram (2019) have reasoned discrepancy in the feedback perception to the different interpretations of the feedback message between students and teachers [35,36]. In consonance, Boud and Molloy (2013) have affirmed the importance of interaction and closure of the loop in the feedback process, which depicts feedback as a dynamic process between the feedback parties [37].
However, and in relevance to the context of this study, Rae and Cochrane (2008) highlighted the difficulty of the provision of feedback in modular systems of teaching where, owing to the tight schedules, the feedback provided tend to be summative rather than formative [38]. Also, Dahllof et al. (2004)

Role of feedback
Many students valued the logbook's role in showing them their mistakes and aspects of their work which require revision and correction and, occasionally, suggestions on how to improve [18]. Such benefits coincide with the findings of Barbieri et al. (2015) and are exemplified in the following students' quotes: "It was helpful to know your mistakes and avoid them in the future." SY4F

Provision of opportunities to learn from patients
Many students and teachers indicated that the logbook encouraged seeing more and a variety of cases and learn from them. The logbook and the accompanying feedback were perceived as a trigger for learning. Similar results were shown by Chiesa et al. may find difficulty to report all the cases that they came across in the hospital because their knowledge and skills at that stage are insufficient [14]. They added, junior students engage in a process of socialization due to their unfamiliarity with hospital environments, and may, therefore, overlook some of the cases that they have seen during their training.
Interestingly, Uther and Ooi (2016) have noticed that the students in their series tended to report the same cases regardless of the hospital or season of training. They reasoned such observation to the tendency of students to overlook some cases [48]. Poor students' guidance due to clinicians' heavy workloads and busy schedules, in addition to the burden of data entry and limited opportunities to interact with patients on the learner's side may also be responsible factors [1,9,50]. Likewise, Alabbad et al. (2019) have argued that senior students may benefit from logbooks more than their junior counterparts, where they tend to select cases that provide more significant learning opportunities; however, no correlation to their final course grades was observed [4]. By contrast, Shaban et al. (2018) have noticed that the final-year medical students in their series have seen less than the expected cases and procedures in a shift of emergency medicine [49]. It was argued that students might not learn from the experiences that they encounter in the hospitals, and to prove the contrary, evidence (outcome measure) that learning has ensued should be provided [49]. Watters et al. (2006) commented on the use of a logbook system in a surgical placement and argued that an evidence of learning from the logbook exercise and the contribution of supervisors to students' achievements should be demonstrated [21]. Therefore, careful supervision and mentoring of junior students with their logbook work in addition to claiming students' follow-up exercises (e.g., assignments, write-ups, and case-based discussion) based on their logbooks' entries might be reasonable strategies to heighten their engagement and benefit from the exercise.

Improve writing skills
Many students, also supported by some teachers, indicated that the logbook had improved their writing skills. This applies to the medical terms and knowledge as well as to the English language and grammar. This is highlighted in the following students' that high-quality feedback has to focus on student's work leading to transferable skills rather than just correcting grammatical and spelling errors [51]. Moreover, Bing-You et al.
(1997) indicated that students may tend to disregard feedback that is "stylish" in nature and if there is too much focus on unimportant areas [52]. Therefore, a balanced written feedback that addresses students' work mainly from clinical and disciplinary points of view with attention to the principles of English language and scientific writing is often worth consideration.

Relation to students' future career
A unique advantage of the logbook indicated by some teachers in this study is that it prepares students for their future career; however, students did not mention that. A teacher said: "The nature of exercises in the logbook, e.g., writing medical notes and doing patient follow-up, is the same kind of practice that they would carry out in their future career." T24 It was reported that portfolio work increased students' preparedness to conduct the same tasks in the future and taught them to keep data to perform an audit, all of which have essential implications for their professional life [9,18,21]. For instance, Buckley et al. (2009) argued that keeping a reflective learning document in the undergraduate phase prepare students for the higher stages of training [20]. In the same vein, Shahi et al. (2015) evaluated students' participation in three training settings through analysis of their logbook entries. They reported higher patient engagement and better students' preparedness for future practice in the rural setting [46]. If this information is communicated to the students early in the logbook trial, it might have increased their engagement and benefit from the exercise and perhaps should be considered in future experimentation [18,43]

Barriers to learning from logbooks
On the other hand, poor-quality feedback, subjectivity in marks and the marking process, and issues related to the logbook structure (e.g., a strictly prescribed format) were perceived as barriers to learning from logbooks. These were reflected in the following students' quotes: "Marking was not fair, and I have received marks from only a few teachers." warned against a bureaucratic one which involves extensive load of data entry [1]. Likewise, Jud et al. (2020) was skeptic about the possibility of using logbooks appropriately to enhance students' learning unless proper guidance and supervision of students in the wards is implemented [17]. Involving enthusiastic physicians and mentors among the hospital staff in regular review and monitoring of their students' work supplemented with faculty development programs were proposed to increase the acceptability of the logbook and feasibility of the process [29,40,53]. Besides, effort should aim to improve the structure of the logbook to adjust the burden of data entry and refine rubrics to add fairness to the marking process [1,18,49].

Stage of learning
The fourth-year students perceived the logbook activity more significantly useful to their learning than the sixth-year students. Al-Haqwi et al. (2012), in a study of feedback in Saudi Arabia, found that medical students' perceptions of feedback were more positive in early undergraduate years, which they attributed to the more prolonged exposure of senior students to weaknesses in the feedback practice. They argued, the longer exposure enabled senior students to produce more accurate judgments about the process than their junior counterparts [54]. As such, students' engagement with the logbook might decrease if careful planning, follow-up, and meticulous measures are not taken to ensure proper implementation of the logbook, and, with time, senior students are more likely affected. This may also point to the possible role of the academic environment and the hidden curriculum, which often sends strong messages about the process and demand further analysis in future studies.

Level of academic performance
No difference was found in the students' perception of the usefulness of logbooks based on their academic performance. This is in contrast to some studies, which indicated that students who have good knowledge and clinical skills and excel in their academic performance appreciate feedback as more useful than their counterparts who are less knowledgeable [52,54]. In addition, it was also noted that high-achieving students concentrate on the feedback message and try to understand the meaning behind it [36]. However, the restricted ranges of GPA and logbook marks may have resulted in poor discrimination among the students' academic abilities and contributed to this finding [24]. Besides, some GPA and logbook marks were missing, and this could have affected the data analysis and the conclusion made out of it.

Gender
Similarly, gender did not give rise to differences in the students' perception of the logbook, which is in line with Fong et al. (2016) [55]. However, there were marked differences in the participation rates in this study between female and male students, particularly in the sixth-year, with a larger number of females being involved (82.4% and 32.4%, respectively, as shown in Table 1). This difference could be interpreted as a more positive attitude, higher interest, and better engagement of female students with the logbook experience than their male counterparts. In contrast, Streeter (2013) showed better engagement of males than females in using a music therapy logbook for patients with neurological disabilities, which they attributed to more confidence and positive attitude that males had toward the logbook activity [56]. Further studies to assess learners' characteristics in engagement with and benefit from logbooks are required.

Limitations
Some factors may have limited the findings of this study and are worth to be mentioned.
The sample size, particularly that of teachers, was small. The study involved students at specific academic years and in selected courses, which may have introduced a selection bias. However, there is no logical reason to expect different results if students at other learning stages in our context were involved. Also, the results of this study might not be generalizable to other settings. Nevertheless, the findings of this study would provide essential data to curriculum planners and course coordinators to set the stage for improving the procedure and outcome of logbooks in our academic environment.

Conclusion
Logbooks are one of the tools that are used to enhance learning in the realm of medical education, where they might foster students' learning through multiple aspects.
It encourages students to see cases in the hospital from which they can learn a lot. It is a mechanism to show them their mistakes and suggest to them plans for improvement.
Besides, it improves their writing skills of medical notes and their use of English.
However, several barriers to effective use of logbooks were also reported. These include: poor-quality feedback, biased marking, absence of dialogue in the feedback process, and problems with the structure and acceptability of the logbook.
To improve students' learning from the logbook, faculty members should be trained on constructive feedback principles. In addition, discussion of the logbook work and careful supervision of students, particularly at the beginning of their clinical training are essential to promote learning from logbooks.

Acknowledgments
The author would like to thank Dr. Mandy Moffat, who kindly supervised this work. He is also grateful to the fourth-and sixth-year students in the college and his colleagues in the department of surgery who shared their precious time during data collection.

Ethical Considerations
This study has been approved by the ethical committee of University of Tabuk. The principles of ethical conduction of research according to the Declaration of Helsinki [26] were followed except that the researcher has participated in data collection because no other suitable alternative was found. The researcher acknowledges that this could have influenced participants' responses in some way.

Competing Interests
The author reports no conflict of interest. The author alone is responsible for all work submitted in this manuscript.

Availability of Data and Material
All relevant data of this study are available to any interested researchers upon reasonable request to the corresponding author.