Assessing student perception of the integration of portable wireless ultrasound imaging in undergraduate anatomy education

Anatomy is the foundation of many physiology and healthcare‐related degrees. With limited access to cadavers in many universities, it is essential to investigate techniques that could be utilized to support and enhance the teaching of anatomy. Ultrasound is used clinically to aid the diagnosis of a wide range of conditions by visualizing the anatomy of the patient. While research has investigated the advantages of ultrasound in medical education, the potential benefits of ultrasound in undergraduate bioscience degrees remain to be investigated. The aim of this study was to identify if a portable ultrasound probe that wirelessly attaches to a smartphone or tablet was perceived by students as beneficial for their understanding and learning of anatomy, and to identify if there were any barriers for students partaking in ultrasound sessions. Following five ultrasound‐teaching sessions, 107 undergraduate students completed a 5‐point likert questionnaire on their perception of the integration of portable ultrasound machines in anatomy education. The data indicated that 93% of students perceived that the ultrasound teaching sessions improved their anatomical understanding, 94% perceived that ultrasound increased their ability to understand the clinical relevance of learning anatomy, 97% enjoyed the sessions, and 95% of students believed that ultrasound should be integrated into anatomy teaching. In this study, we also found several barriers for students taking part in ultrasound sessions, including religious beliefs, and lacking adequate background knowledge. In conclusion, these findings demonstrate, for the first time, that students perceive portable ultrasound to enhance their anatomy studies, demonstrating the potential benefit the integration of ultrasound into the anatomy curriculum may serve within undergraduate bioscience courses.


| INTRODUCTION
Anatomy is a fundamental part of many health and bioscience degrees, including Medicine, Dentistry, Allied Healthcare, and Undergraduate and Postgraduate Science Degrees such as Anatomy, Physiology, Exercise Science, Biomedical Science, and Clinical/Medical Science. Anatomical teaching methods require constant revision and analysis to ascertain the most effective teaching tools and approaches (Moxham & Plaisant, 2007). During this analysis, it is important to assess student perception of novel teaching resources. Previous research has shown that if students perceive a teaching modality to be beneficial and enjoyable, it encourages engagement with their studies and ultimately improved overall performance (Jones et al., 2021).
Cadaveric dissection has been the anatomy gold standard teaching tool for over 400 years (Azer & Eizenberg, 2007), and many anatomists argue that cadaver dissection is vital for gaining sound anatomical knowledge (Korf et al., 2008). However, the use of cadaveric dissection has been challenged in recent years due to the rising costs of running a dissection facility and the time-consuming nature of whole-body dissection (Aziz et al., 2002;Biasutto et al., 2006;Korf et al., 2008). Crucially, it has also been stated that no single pedagogical resource is solely viable for effective anatomy education (Estai & Bunt, 2016). Therefore, the use of multiple resources should be used synergistically to promote student understanding of anatomy. As a result of this debate, the field has undergone an expansion of a hybrid teaching approach (Sugand et al., 2010). A hybrid approach combines cadaveric anatomy with other resources, including the use of living anatomy, medical imaging, virtual reality, and computer-based learning (Estai & Bunt, 2016).
As anatomy education practice shifts toward the use of multiple pedagogical resources, it is important that innovative teaching tools, such as ultrasound (US), are thoroughly evaluated for pedagogical value and student perception of the technology before permanent introduction into educational institutions. While ultrasound is an imaging modality typically used in healthcare for diagnostic purposes and procedural guidance; it has also demonstrated its utility as a pedagogical resource in the medical curriculum to teach clinical skills (Solomon & Saldana, 2014;Wittenberg, 2014). In the last 5 years, technological advancement has allowed the development of small, portable, and inexpensive ultrasound probes that can be connected wirelessly to a smartphone or tablet. Traditional ultrasound scanners have previously been inaccessible for routine university teaching due to their high price point and large size (Mullen et al., 2018).
The development of a wireless handheld probe has made the use of ultrasound for anatomy teaching a feasible option across educational institutions due to their relatively low price point and portability. Furthermore, the wireless connection between the probe and a smartphone or tablet provides familiarity to the students (Sheikhtaheri et al., 2018), and allows increased accessibility to students with a limited knowledge of US knobology.
The use of ultrasound and other imaging techniques allows students to gain a better understanding of anatomical spatial relationships, improve the efficiency of dissection, and enhance enthusiasm surrounding anatomy (Pabst et al., 1986;Reeves et al., 2004). Furthermore, ultrasound not only permits for a static evaluation of spatial relationships between anatomical structures but also allows for the dynamic assessment of the different tissues in vivo. Therefore, ultrasound provides additional information that cannot be easily obtained using other pedagogical techniques, including digital anatomy, and cadaveric dissection. In particular, it could be hypothesized that ultrasound may be particularly useful in the teaching of musculoskeletal anatomy, being able to provide real-time biomechanics of joints and muscle actions. This additional information is likely to enhance student education and anatomical knowledge retention. To support the teaching of musculoskeletal anatomy using ultrasound, resources such as the EURO-MUSCULUS/USPRM Protocols for Dynamic Ultrasound Examination of the Joints could be utilized, which provide standardized approaches to correctly perform dynamic ultrasound examinations of major anatomical joints . There has been a growing interest in the incorporation of ultrasound into the medical school curriculum, with several medical schools spanning North America, Canada, and the UK having already implemented the use of ultrasound for early exposure of clinical techniques (Solomon & Saldana, 2014;Wittenberg, 2014). Implementation of ultrasound into the curriculum has varied between institutions. Some have opted for using ultrasound as a hybrid resource (Jurjus et al., 2014;Patel et al., 2017), while others emphasize the importance of ultrasound as a stand-alone clinical skill (Kim et al., 2017;Patel et al., 2017;Walrod et al., 2018). In 2016, the University of Leeds was the first UK medical school to introduce an integrated ultrasound curriculum. They reported that ultrasound teaching was well received, and the students perceived learning how to use ultrasound technology as highly relevant to their future clinical careers (Wakefield et al., 2018), which is consistent with the experience of other schools (Rao et al., 2008;Rempell et al., 2016). However, due to their predominant focus on clinical skill acquisition and ultrasound curriculum development within medical courses, there is inconclusive data to report whether ultrasound aided student understanding or learning of anatomy. However, these studies have concluded that the use of ultrasound improved the student's confidence in identifying anatomical structures (Swamy & Searle, 2012) and helped the student's to comprehend the 3D nature of the human body (Dilley & Smith, 2015).
The consensus in the literature agrees that ultrasound should be integrated into the medical school curriculum to develop early clinical skills and improve the student's point-of-care repertoire in advance of medical qualification (Bahner et al., 2014;Steinmetz et al., 2016;Tarique et al., 2018;Wakefield et al., 2018). However, the literature focuses on ultrasound integration into the medical school curriculum and fails to elucidate the potential benefit of ultrasound in other anatomy-heavy courses, such as allied health and undergraduate bioscience degrees. These courses require a sound anatomical understanding but do not require the same clinical skillset acquired from a medical degree. Despite this, ultrasound may still prove valuable to these students and aid in anatomy learning.
Furthermore, although studying anatomy using cadavers remains the gold standard for anatomical knowledge acquisition (Azer & Eizenberg, 2007), some university courses may lack regular access to cadaveric material, highlighting the necessity for alternative pedagogical resources. The integration of ultrasound within undergraduate bioscience degrees has the potential to provide an interactive and engaging way of elevating anatomical knowledge. It may also have the benefit of providing clinical relevance to the mass theory that the students are required to learn (Swamy & Searle, 2012), while putting the human body into real-life perspective (Dilley & Smith, 2015), beyond textbooks and computer-based learning. In addition, it is important to clarify if there are any specific barriers that may impact students studying bioscience degrees, including background knowledge, religious belief, and equipment.
The aim of this study was to identify if a portable ultrasound probe that wirelessly attaches to a smartphone or tablet was perceived by students as beneficial for their understanding and learning of anatomy in an undergraduate science degree. This study is the first study to investigate using new wireless ultrasound technology in anatomy teaching and is the first study to investigate how bioscience students perceive ultrasound to enhance their anatomy education.

| Ultrasound model
An external male volunteer was recruited to act as the ultrasound model for each of the ultrasound sessions. The model was recruited from the University of Bradford Service Users (Patient and Public Involvement and Engagement) group. The ultrasound model was prescanned before taking part to identify any obvious potential pathologies, and was aware that if any incidental findings were observed that they should contact their GP. No incidental findings were seen.
In addition to the external service user, students were given the opportunity to scan each other for the upper limb practical. This was offered if they felt uncomfortable scanning an external participant.
However, only two male students volunteered for their upper limbs to be scanned. Prior to the student volunteering, the students were prescanned and advised that if any incidental findings were observed, to contact their GP. No incidental findings were seen. Based on the risk assessment, high-risk zones (such as abdomen, thorax, and neck) were not permitted to be scanned on students, and must only be scanned on consenting external volunteers who will be pre-scanned.

| Ultrasound training sessions
The 107 student participants took part in five ultrasound teaching sessions, each lasting approximately 30 min. This 30-min session was part of a larger practical circuit within a 2-h anatomy practical where students would study using cadaveric material, anatomical models, and an Anatomage table. Students were in their first or second year of the Clinical Science degree.
F I G U R E 1 Image of the Ballater Medical 3-in-1 ultrasound probe used in this study.
The Clinical Science degree has a clinical focus and a strong emphasis on anatomy, physiology, and employability skills. The course is informed by research and clinical expertise and benefits from being taught by scientists and healthcare professionals from a wide range of specialist areas. The course also provides an opportunity for eligible widening participation students to enter year one of Medicine or other allied healthcare courses. Graduates often progress to postgraduate study, leading to careers in healthcare and industry.
For this research study, students enrolled on the modules, (1) Human Biology, (2) Systems Physiology and Anatomy, and (3) Anatomy and Pathology were able to take part in the study. The aims of these modules are to provide a solid foundation in anatomy. The ultrasound sessions were strategically placed to complement lectures and cadaveric/practical anatomy labs by covering the same topic.
The first session was lecture-based, covering the theory of ultrasound, including how to operate the probe and identify key anatomical structures. A further four sessions provided students with the opportunity to scan a volunteer model. The hands-on sessions were divided into anatomical regions, including a practical introduction to ultrasound, followed by scanning of the upper limb, lower limb, abdominal, and thorax regions. Students used these sessions to familiarize themselves with ultrasound imaging while identifying predetermined anatomical structures within each area of the body (Table 1). All the structures the students were asked to find and identify using ultrasound were familiar to them, and had been taught previously through lectures, dissections, and laboratory-based practical sessions using anatomical models, computer-based learning, and human specimens. Each ultrasound session was run with only a small number of participants (three to six) to ensure each student had an adequate opportunity to practice scanning and so that the whole group could easily view the iPad screen. A staff member trained in ultrasound and with expert knowledge of the anatomy being studied was present to lead each session allowing the students to ask any questions or receive any assistance they needed. To support learning, and emphasize to the students the importance of reproducibility, established ultrasound protocols were used to assess the abdominal (Alty & Hoey, 2013), cardiovascular (Adnan & Rahman, 2021), and musculoskeletal anatomy (Martinoli, 2010;Ozcakar, Kara, Chang, Bayram Carli, et al., 2015;.

| Assessment
Following the ultrasound sessions, the students were asked to complete a five-point Likert questionnaire on their perception of portable ultrasound in anatomy education ( Table 2). The questionnaire also collected demographic data, including age, gender, ethnicity, and religious beliefs, followed by a series of questions that allowed the students to provide their perspectives within an open-ended response (Table 3). Personal data and student perspectives were recorded to establish any barriers that groups or individuals faced during the ultrasound imaging sessions, and to identify ways in which the sessions could be enhanced to maximize the student learning experience. The questionnaires were anonymous and optional.
T A B L E 1 Summary of ultrasound sessions.

Ultrasound session
Anatomical structures to be identified  (Table 4).
This question was not compulsory; however, all students completed this question. Future studies should offer this as a free text option to further identify the role of religion in ultrasound education. The questionnaire also asked the students if religion posed any barriers to their participation during ultrasound teaching, and 11.9% (n = 13) answered "YES", and 88.1% (n = 94) answered "NO" (n = 107).

| Five-point likert questionnaire
The five-point Likert questionnaire results (  Figure 3A), alongside 94.4% (101/107) of students agreeing that ultrasound increased their ability to understand the clinical relevance of learning anatomy (Mdn = 5.00). Furthermore, 97.2% (104/107) of students reported that they enjoyed learning anatomy using ultrasound (Mdn = 5.00), 96.3% (103/107) agreed that ultrasound is a useful addition for the teaching of anatomy (Mdn = 5.00), and 95.3% (101/106) agreed that ultrasound imaging should be used for anatomical teaching (Mdn = 5.00) ( Figure 3B). In this study, 28.3% (30/106) of students reported that they found it challenging to interpret the ultrasound images. However, 71.8% were indifferent or disagreed with this statement, with 37.8% (40/106) of the students reporting that they could interpret the images without difficulty (Mdn = 3.00; Figure 4). This demonstrates that the majority of students were comfortable interpreting ultrasound images. However, additional steps could be taken to support those that still find it challenging.

| Student perspectives
The use of opened-ended questions allowed a consolidation of student perspectives and identified potential barriers to the use of ultrasound in anatomical education. While the majority of students did not provide any free-text answers to the question enquiring about any barriers that they faced, a summary of the responses, which were provided, is presented in Table 6 and Figure 5. Future studies should conduct a detailed qualitative analysis using interviews to provide a more thorough analysis of student perception to barriers, if any, as opposed to an optional free-text question as part of a questionnaire in which the majority of students who did not encounter any barriers left blank and was only completed by students who did find barriers to their engagement. However, even though the majority did not identify any barriers, it is still important to try to remove any potential barriers for all students.

| DISCUSSION
The five-point Likert questionnaire received positive responses. It is evident that ultrasound sessions were enjoyed by students and that the five sessions were sufficient to allow for the majority of the students to form a positive perception surrounding the use of ultrasound.
Feedback from students suggests that ultrasound provided an interactive and engaging tool to support their anatomical education, which could be successfully incorporated into the future curriculum. The data demonstrated that the majority of students agreed that ultrasound is a useful addition for the teaching of anatomy and that it improved their ability to understand the clinical relevance of learning anatomy. The majority of students also agreed that ultrasound helped their understanding of anatomy and that it should be used for anatomical teaching. However, no data was collected to quantitively assess improvements to anatomical understanding during this study.
Therefore, it must be acknowledged that these results are purely based on the students' perception. The collection of student perception data is consistent with the previous data collected from medical institutions which have also trialed the incorporation of ultrasound for anatomy teaching into their curricula (Wakefield et al., 2018). The T A B L E 3 Questions included in the questionnaire used to gather student perspective and identify barriers to the use of ultrasound in anatomy education. The results of this study are positive and in favor of the incorporation of ultrasound in anatomy education. However, 28.3% of students found it challenging to interpret the images, 34.0% gave a neutral response, and 37.8% did not find it challenging to interpret images (n = 106). The large number of neutral responses suggests that many of the students may have been able to interpret the images, but this came with some difficulty, which is not unexpected when learning a new skill. If ultrasound was to be integrated into the curriculum, additional measures could be put in place to further support students to ensure that the whole cohort could benefit from US teaching. Positioning of the US probe and its interpretation are skills that require practice not only to interpret the images but also to operate the probe correctly to achieve a clear view. This is an important aspect that must be taught early to students, as beginners often find this aspect of ultrasound challenging due to the spatial orientation of scanning planes (Ricci, Abdulsalam, & Ozcakar, 2019) and the presence of acoustic artifacts (Ricci, Soylu, & Ozcakar, 2019). Therefore, for ultrasound to be beneficial for improving student understanding and learning of anatomy, it would be recommended that regular teaching sessions are distributed longitudinally throughout undergraduate bioscience and medical curricula (Smith & Barfoot, 2021), as part of a hybrid anatomical teaching approach, which covers both theoretical and practical aspects of ultrasound and places emphasis on areas of which students regularly find challenging.  (Schindler et al., 2017), but this needs to not come at the expense of other teaching resources. However, for these findings to be instrumental in resulting in change within the field, it needs to be clarified if this teaching tool is beneficial for student learning and if the student perception remains that it is a useful addition long-term. Future studies should investigate whether student perception changes and whether the use of this novel US teaching resource does enhance learning with a measurable output.
This study also identified that 93.2% of students perceived that ultrasound helped their understanding of anatomy. However, this is the first time that the majority of the students have ever used an ultrasound probe, and they will be comparatively inexperienced in anatomy. Therefore, it would be difficult for them to make the judgment as to how effective ultrasound was in their learning of anatomy.
Future research should control for this by conducting this research in students with various anatomical backgrounds, from inexperienced to experienced, and compare a group that uses an ultrasound machine against a control group that does not use ultrasound. This will provide valuable information as to whether ultrasound does, in fact, help anatomical understanding.
This study demonstrated that students perceived the use of a novel handheld ultrasound probe attached to an iPad useful for their F I G U R E 2 Sliding scale chart to illustrate all responses collected from the five-Point Likert questionnaire, the results are presented as percentage (%) values.
F I G U R E 3 Five-Point Likert questionnaire results. (A) 93.2% of students either agreed or strongly agreed that ultrasound helped their understanding of anatomy (n = 104, Mdn = 5.00). (B) 95.3% of students either agreed or strongly agreed that ultrasound imaging should be used for anatomical teaching (n = 106, Mdn = 5.00).
anatomical education. However, this study used a cohort of Bioscience students who, unless they complete further study, will be unlikely to operate an ultrasound probe in their careers. While it is likely that US was able to assist their learning, it could be hypothesized that they could have benefitted equally by observing a competent sonographer demonstrating the anatomy. However, it could be argued that due to the nature of this US probe attaching directly to an iPad, there is already familiarity with the resource, and therefore students can learn from exploring in a hands-on environment, and this may encourage greater engagement.
During this study, we only had one iPad and handheld ultrasound probe available. Future practice should use multiple ultrasound probes to allow several small groups of students to work with multiple ultrasound models of different genders to overcome barriers of students who may not feel comfortable scanning those of the opposite gender.
Small groups (n < 5) are optimal for the students to gain hands-on experience with US imaging to improve their confidence in using the probe and interpreting images. Using the handheld probe that wirelessly connects to a smartphone or tablet also means that the entirety of the equipment required to provide ultrasound teaching is portable and inexpensive for the university, in comparison to traditional ultrasound scanners, and there is familiarity for the students using the technology.
While there have been a small number of studies investigating the use of ultrasound in medical education, this is the first study to assess the use of ultrasound imaging as beneficial to undergraduate bioscience students. The open-ended questions included in our questionnaire allowed students to highlight barriers to participation that arose and how they could be overcome.
Ultrasound image interpretation was identified as challenging by some students. To overcome this in the future, students requested opportunities for independent learning sessions where they could explore ultrasound imaging by themselves or by peer examination. To support this learning, there are numerous pedagogical techniques to reinforce student knowledge. These include the integration of mnemonics and metaphorical videos to aid in retention (Jacisko et al., 2022) and the integration of artificial intelligence to aid scanning technique by marking the different anatomical structures (Ozcakar, Tok, et al., 2022). Peer examination is already a popular and established method used in anatomy education (Rees et al., 2004), but it can present discomfort when examining sensitive areas of the body (Rees et al., 2005). In addition, the portability and ease of use of the probe could permit learning through play as a means to enhance ultrasound skill and 2D to 3D anatomy visualization (Merlin Hofmann & Naro, 2021). This could be an ideal way to help the students improve their confidence and skills in both anatomy and ultrasound during future curriculum development. Independent learning time could take away the anxiety that students experience in an active group teaching scenario (Cooper et al., 2018) and give them a chance to familiarize themselves using a constructivist approach (Dong et al., 2021). Students also suggested that taking screen captures of the ultrasound images in the sessions to revisit would help to improve their interpretive skills and solidify their anatomical understanding. Scanning themselves or a consenting individual would allow this to be possible.
However, caution must be taken here surrounding General Data Protection Regulation (GDPR) and image retention policies. Therefore, the authors of this study recommend that working groups collaborate to develop guidelines for the use of image acquisition and screen capture of ultrasound sessions.
Integrating independent learning sessions alongside a longitudinal integration into the curriculum could also overcome religious barriers faced by some students. In this study, 11.9% (13/107) of students F I G U R E 4 Percentage of students that found interpreting ultrasound images challenging. 28.3% of students either agreed or strongly agreed that they found interpreting images challenging. 34.0% neither agreed nor disagreed. 37.8% strongly disagreed or disagreed that they found it difficult to interpret the ultrasound images (n = 106, Mdn = 3.00).
reported that their religion posed a barrier to participation. Overall, our results are favorable toward the use of US for anatomy education in undergraduate bioscience courses. Ultrasound can provide students with a live view of structures, spaces, and relationships within the body, allowing them to comprehend the 3D nature of human anatomy (Dilley & Smith, 2015). It also offers an opportunity to enhance anatomical teaching in addition to traditional teaching methods and resources. However, the use of ultrasound in anatomy education has received some resistance. It has been argued that implementing ultrasound into the curricula would be challenging due to large cohort sizes accessing equipment, the need for trained facilitators, cultural concerns, and limited time in an often already crowded anatomy curriculum (Royer & Buenting Gritton, 2020). As an example, the University of Leeds found it challenging to recruit enough qualified facilitators and access equipment when integrating US into their medical curriculum. They decided to train staff from their anatomy and clinical skills department and enter a partnership with an ultrasound company to ensure enough equipment was available for the student cohort (Wakefield et al., 2018). Establishing ultrasound and integrating its use into the undergraduate bioscience and medical curriculum may have challenges, but recent advancement in hybrid anatomical teaching and small and inexpensive portable ultrasound probes suggests there is a place for ultrasound in anatomical education. These findings support further research to develop an optimal program for teaching anatomy utilizing portable handheld ultrasound probes in both undergraduate bioscience and medical degrees. To develop optimal curricula, barriers will need to be addressed, including cultural and ethical considerations alongside the implementation of infrastructure to ensure ultrasound is successfully integrated longitudinally throughout anatomy curricula.

| CONCLUSIONS
This is the first study to investigate the potential benefit of portable and handheld ultrasound in undergraduate bioscience education. The results from this study demonstrate that ultrasound using a portable ultrasound probe that wirelessly attaches to a smartphone or tablet is perceived as beneficial in student understanding and learning of anatomy. The data reported that 93% (97/104) of students believed that ultrasound helped their understanding of anatomy, and 95% (101/106) believed that ultrasound using portable and handheld machines that attaches to a smartphone or tablet should be used for the teaching of anatomy.