Many jobs require graduates to engage in collaboration with other professionals, exhibit creativity in solving difficult problems and manage uncertainties in their careers. In medicine, doctors must work in teams to effectively manage patient care. They are also increasingly expected to work together to solve real-life health care challenges such as managing complex patient problems in a milieu where specialized medical services and manpower are scarce [1].

Over a century has passed since Flexner’s influential report [2], and medical education has undeniably experienced substantial changes, however, traditional medical education fail to cultivate the necessary creativity to handle difficult, ill-defined, or “impossible-to-solve” issues or problems which require multiple stakeholders to collaborate and innovate [3]. By default, pedagogical approaches in medical education tend to emphasize knowledge acquisition, retention, and problem-solving within a limited context [4]. In general, learning in medical school includes 2 types of knowledge: factual and procedural knowledge. Mann comprehensive analysis [5] underscores that sociocultural learning theories, rooted in the work of Vygotsky [6], present a valuable theoretical framework for shaping future medical education.

Significant ramifications arise from major modifications in medical education such as changes in our ways of knowing, changes in the discourse of medical education, changes in our view of medical education, which ultimately impacts the practice of medicine. The recent study by Fernández-Rodríguez found that the traditional teaching and assessment are still overused to the detriment of other teaching methods in medical education [7]. These methods typically measure the knowledge via written examinations focusing individual cognitive knowledge [8], not collaboration and creativity capabilities.

According to Guilford and Christensen [9], creativity is the ability and skill to create novel and innovative things. In Stein [10] classical paper, standard definition of creativity referred as “creative work is a novel work that is accepted as tenable or useful or satisfying by a group in some point in time” [10]. There is no single, agreed-upon definition of creativity due to its multidimensional nature [11]. But most agree that it requires the following 4 skills: the capacity for idea production (or “fluency”), attention to detail (or “elaboration”), originality (or “freshness”), and versatility (or “flexibility”) [12-14]. Kampylis and Valtanen [15] conducted an analysis of the 42 explicit definitions of creativity. Walia conceptualizes creativity as an ongoing act, irrespective of whether it results in a tangible creation [16].

In the context of education, collaborative learning is broadly defined as students working in groups of two or more sharing responsibility for tasks and products [17]. The fundamental factors for collaborative learning include respectful behavior, constructive feedback, a shared objective, acceptance of roles, engagement, and self-awareness [18]. The collaboration has been shown to foster the critical thinking by allowing students to debate ideas, engaging higher-order cognitive reasoning [19]. This highlights the importance of incorporating creativity and collaboration in medical curricula to address the problems in rapidly evolving health care system [20]. It also teaches students to view mistakes as opportunities for improvement when they are pushed to be creative [20].

The reference [21] describe collaborative creativity (CC) as a social process that promotes the creative process in the form of relationships in completing group tasks [21]. The research on CC in medical education research is very limited, even though medical practices require teamwork and creative problem solving [22]. The recent systematic review differentiates CC (explicitly generating new ideas) from creative collaboration (focusing on how people work together, with creativity embedded) [12]. Hill et al [23] emphasize that innovation is not about solo genius [23] but is about the collective genius of collaborative problem solving, requiring 3 capabilities: creative abrasion (idea generation via debate), creative agility (rapid experimentation), and creative resolution (integrative decision-making) [24].

Several other factors impact CC, such as diversity of the team [25,26]; team interaction behaviors and conflict resolution [25,26]; task independence [27,28]; and the online or physical work space [29]. Online learning increased during the COVID-19 pandemic, demonstrating how digital platforms offer real-time cocreation and interaction. The information and communication technologies facilitates collaborative content creation through social contact among users and encourages user-to-user communication and cocreation [24]. Gundogdu and Merc [30] review found that web-based and cloud technologies, simulations, and smart tools help support technology-mediated CC. It was found that student performance is comparable to in-person learning [31]. In terms of questioning behavior and project performance, the online group performed better than the face-to-face group on collaborative tasks [32]. In the creative fields such as design and art, frameworks using technology to promote CC have become more common [33-35]. As higher education continues to expand online, medical programs must adapt to remain globally competitive and foster 21st-century competencies, including collective problem-solving, communication, and creativity [34].

While notable progress has been made in medical technology, education still lacks sufficient emphasis on creativity, which is crucial for problem-solving in the medical field [22]. Medical education often uses instructional methods such as traditional lecture-based, problem-based learning (PBL) and team-based learning (TBL). While the evidence indicates that structure of the PBL and TBL linked to learning enhancement, evidence of systematic attempts to foster CC remains limited [36-39]. Some researchers explored other creative methods in medical education such as brainstorming [40], concept maps [41], and storytelling [42] but CC still receives minimal attention. This is a critical gap in the literature, since CC (or lack thereof) can impact the medical professional-patient relationship [43], job engagement, satisfaction, and performance [44], and patient safety [45]. Thus, a need exists to create strategies and frameworks that incorporate the CC into medical education especially by leveraging online learning technologies to equip future medical professionals for the multifaced realities of evolving health care.

Therefore, the aim was to develop and test a novel design-based thinking framework for online collaborative creativity (FLOCC). Our research questions were: (1) What existing pedagogical principles could be utilized to create a novel FLOCC for fostering CC skills in medical students? (2) How could this FLOCC be operationalized? (3) What are students’ perceptions and attitudes toward the FLOCC?

This study reports the development and operationalization of a new FLOCC and its preliminary evaluation. The first stage in this process was to consider the conceptual underpinnings and structure of the FLOCC explicitly. The concepts underpinning FLOCC are depicted in Figure 1 and outlined below.

FLOCC integrates the principles of rapid design thinking (RDT) with a sociocultural learning approach, encompassing elements of TBL and PBL. In both TBL and PBL learning takes place through interaction, negotiation, and collaboration in solving clinical problems. Hence, our goal is to identify the convergences of these methodologies within the framework of a collaborative, sociocultural learning grounded in Vygotsky’s sociocultural paradigm [6]. Dolmans et al [46] highlights how combining TBL and PBL could synergistically enhance problem solving skills, RDT framework further orients toward innovation and iterative solution creation. The current evidence supports the efficacy of TBL in enhancing the academic performance among the lower-performing medical students [47], while it may be greater demanding [36,38]. Conversely, PBL, has been linked to the development of a broader range of skills such as interpersonal skills, self-directed learning, planning and analytical skills [39]. However, some researchers have shown no difference between PBL and traditional learning in medical education [48] and caution that PBL effectiveness depends on frequent feedback [49].

Design thinking, defined as “a future-oriented method, process, toolbox or mindset” to promote collaborative and creative learning, adopts a human-centered problem-solving approach [50]. While design thinking has seen growing presence in Science, Technology, Engineering, and Mathematics education [51] but its application in medical education remains very limited. A recent review identified only 7 pertinent studies, 3 involving medical students [50,52]. However, while limited in number, these studies and recent opinion pieces suggest design thinking may be an appropriate framework to foster student, patient, and practitioner outcomes such as self-efficacy, learning experiences, and academic development [53,54]. Furthermore, using design thinking opens up a new area for investigation to help educators understand, measure, and assess the experiences of students to promote creativity [55], to create a new product and/or to establish a way of thinking about problems via the development of a novel product [50].

Common characteristics shared by sociocultural learning methods and RDT include goal orientation, team activity, brainstorming, and problem-solving. From these perspectives, learning is impacted at individual and collaborative levels through active engagement and shared goals [56]; building on knowledge through social interaction, constructive arguments and cooperation with others rather than passive learning [57]. From the social constructivist perspective, learning is more efficient in a group setting as knowledge develops as a result of social interaction and language use [58]; hence, students demonstrate more motivation and self-confidence in collaborative learning environments [59]. Through team conversations, students become more adept at identifying problems and pursuing solutions, leading to the process of problem-solving [60]. When individuals are accountable for building their own knowledge and communicating successfully with others, these activities can favorably influence CC [61].

In alignment with the sociocultural learning paradigm and echoing the integrative perspective of Dolmans et al [46], we propose combining TBL, PBL and RDT within FLOCC , harnessing the strengths of each method: TBL’s accountability and readiness assurance process [62], PBL’s “ill-structured” problem as a stimulus of thinking [63], and RDT’s creative process and quick prototyping [64].

Thus, FLOCC can be viewed as a hybrid pedagogical framework that combines key perspectives from PBL, TBL, and design thinking to tackle complex medical problems with CC skills.

Following conceptualization, our next step was to operationalize FLOCC. The entire study was conducted online due to the COVID-19 pandemic. For operationalizing self-study in individual scaffolds, we provided a project website (Google Sites, Enterprise Standard, Google LLC) hosting explanatory videos about FLOCC and a downloadable Excel spreadsheet for collecting responses (Multimedia Appendix 1) of I1 to I4 individual scaffolds. The individual scaffolds were assigned in an asynchronous online learning format. An overview of the project website and a sample of individual Excel spreadsheets can be found in Multimedia Appendices 1 and 2, respectively.

For team scaffolds (T1 to T4), Google Sheets (Enterprise Standard, Google LLC, USA) was used to collect team responses simultaneously and in real-time. A sample of the Team Google Sheets can be found in Multimedia Appendix 3. In addition, a YouTube (Google) video on prototyping was also included [73].

The overall flow of FLOCC is captured in Figure 3.

This study was conducted according to the Declaration of Helsinki, approved by Nanyang Technological University institutional review board (IRB 2020-08-036) before its commencement. Students who participated in this study provided full informed consent. The participants were recruited through class announcements and email correspondence. Participation in the study was voluntary, and it was conducted as an extracurricular activity outside of regular school hours. To show their appreciation for taking part in the study, each participant received SGD $50 (US $38.67). The study data are anonymous, and no images of the manuscript or supplementary material identify individual participants.

In total, 85 years 1‐3 MBBS students (38 males, 47 females; aged 18‐22 y) participated in 2 studies. A total of 44 students participated in study 1 (21 males, 23 females; aged 18‐22 y), and 41 in study 2 (17 males, 24 females; aged 19‐22). The mean age in each study and the overall sample population (n=85) was 20.3 (SD 0.9) years. All participants completed the survey.

Initial Cronbach α for the factors self and emotions, synergistic social collaboration, distributed creativity and time regulation and achievement were 0.42, 0.88, 0.63 and 0.66 respectively. Items 2 “I feel self-conscious when I present my ideas to other people”, 21 “We felt pressured to create something original”, and 27 “We felt pressured to complete the activity on time” were discarded as their contribution lowered the respective factors Cronbach α <0.70 [82]. Upon their removal, the Cronbach α values improved [83], resulting in a refined 28 item instrument (Multimedia Appendix 4) with α values were 0.75 (self and emotions), 0.88 (synergistic social collaboration), 0.75 (distributed creativity) and 0.74 (time regulation and achievement).

Overall, the study findings (based on refined 28-item instrument) indicated that most students in the total sample (n=85) had positive views of FLOCC across all 4 factors (70%‐92%) (Table 1). Distributed creativity (mean 5.97, SD 0.14) and synergistic social collaboration (mean 5.68, SD 0.2) displayed higher mean scores, followed by time regulation and achievement (mean 5.44, SD 0.22) and self and emotions (mean 5 SD, 0.3). These trends were consistent in both studies (study 1, n=44; study 2, n=41), where distributed creativity and synergistic social collaboration emerged with higher mean scores than the other 2 factors (Table 2).

The Levene’s test showed equality of variances (P>.05) for all factors but the Shapiro Wilk test revealed nonnormally distributed data (P<.05) for 3 factors (distributed creativity in studies 1 and 2 respectively; and synergistic social collaboration in study 2). This meant that statistical calculations related to these nonnormal distributed groups were subjected to the Mann Whitney U test and eta squared effect size (Ƞ²), and the rest of the normally distributed groups were subjected to the independent samples t test and Cohen d effect size (Table 3). There was no statistical difference on 3 factors (self and emotions, synergistic social collaboration, and distributed creativity) between the study 1 and study 2 (P=.12, P=.39 and P=.35, respectively; Table 3). However, the factor time regulation and achievement was statistically significant (P=.001; Table 3). Effect size estimates showed larger variability between studies 1 and 2 in self and emotions and time regulation and achievement (Ƞ²=0.34 and 0.72, respectively) than in synergistic social collaboration and distributed creativity (d=0.01 for both).

Thematic analysis of the free-text responses identified 4 main themes: learning experiences, collaborative responsibilities, perceived skill development, and technical challenges. Quotes are given below to exemplify the open comments.

This paper reported the development and evaluation of a novel FLOCC intervention that draws on TBL, PBL and RDT principles to encourage CC in medical students. This paper provided sufficient details of the intervention to ensure clarity and replicability. The evaluation data from 85 participants indicate a high level of acceptability for FLOCC. Student responses also suggest that the FLOCC offers students with the opportunity to acquire, hone, and demonstrate their CC skills given the right tools, flexibility, and appropriate educational support.

We drew on design thinking principles for the foundation of FLOCC, as recent literature has suggested that design thinking may be an appropriate framework to foster student, patient, and practitioners’ outcomes such as self-efficacy, learning experiences, and academic development [50,52-54]. However, unlike previous studies, we did not base FLOCC exclusively on design thinking principles. Instead, we used a blended approach that draws on sociocultural learning (PBL and TBL) principles to develop a robust conceptual framework. The evaluation results suggest that FLOCC was effective in assisting students in fostering CC skills. Furthermore, the adaptation of the ASCC instrument facilitated the measurement the CC outcomes [75].

Other studies highlight that more supervision may be appreciated when working with students from different educational backgrounds [53], and that facilitators play an important role in creating a positive learning environment [84]. Hence, we incorporated a specific survey item to measure students’ perceptions about the quality of the facilitation received from instructors leading the FLOCC. The qualitative data from the open comments indicated that students valued effective facilitation. Similarly, we added a factor “Self and Emotions.” Although feelings and emotions can influence the quality of creative outputs [39,47], these are rarely assesses in design thinking models and CC. The importance of these factors to learning was reflected in the students’ open comments.

To the authors’ knowledge, this is the first study to measure the 4 factors of CC in the context of medical education. This study’s new observations were that students (overall population) perceived higher emphasis on Distributed Creativity (78/85, 92%) and Synergistic Social Collaboration (75/85, 88%) followed by time regulation and achievement (68/85, 80%), and self and emotions (59/85, 70%). This suggests that PBL, TBL, and RDT theoretical perspectives, along with selected technologies of FLOCC, enabled a virtual environment where participants could actively engage in teams to practice collaboration, communication, collective knowledge generation, design thinking, and collaborative problem solving. These observations may come from the ability to relate their educational background and experiences to the creativity trigger, and the perceived proximity from working virtually with other students in the same discipline [85]. On the other hand, previous studies have reported forming interdisciplinary and multidisciplinary teams can be beneficial, depending on the nature of the task [86,87]. Therefore, it would be interesting to provide a trigger that could be beyond students’ educational background and form multidisciplinary teams to measure the effects of the FLOCC process on outcomes of CC.

When comparing 2 studies, results showed no significant differences in any of the variables tested, except hose pertaining to time regulation and achievement. This suggests that FLOCC is successful in fostering teamwork and scaffolding the multifaceted creative process, regardless of problem type, time periods, or study population. Based on these findings, the FLOCC structure is robust and may be safe for use in other contexts. Regarding differences in perceived time regulation and achievement, we believe that these differences are a result of the technical difficulties encountered in study 1 and the fact that certain students may find the online environment challenging. Previous research indicated that challenges associated with technology, students, and facilitators are not necessarily barrier to CC, but rather as opportunities to enhance it through problem solving, being considerate of others, and appreciating the teacher’s effort [30].

There were several limitations in this study. First, it involved volunteer medical students from a single medical school in Singapore. The views of more students at different levels of medical education, and from other medical schools could be gathered in future research. Second, participants were experienced with TBL, self-selecting and may have had more of an interest in design thinking and collective collaboration than typical medical students. Consequently, participants of this study may have different views on group work and differing group decision-making skills. However, the sample size was reasonable for an exploratory “proof of concept” and acceptability study. As is often the case with online education, it is difficult to separate out student satisfaction with the content and pedagogy of teaching as opposed to the quality of internet connections and technical difficulties. The current evidence is mainly based on the students’ self-reported data about their experience with FLOCC. Future research could investigate whether FLOCC is effective and efficient in nurturing CC skills for medical education or practice, as compared to established pedagogies such as PBL and TBL.

Realistically, CC skills cannot be developed in a short time. Therefore, we suggest that the principles underpinning FLOCC should ultimately be used in a curricular (rather than one-off) basis if fostering collective creativity is a priority in medical education.

FLOCC in the digital environment opened up new possibilities such as the opportunity to understand the “precise mechanisms” needed to acquire and apply new or innovative knowledge. The framework also underpinned the monitoring of individual and team creativity processes in an organized manner. This is important because if the collection of data is unorganized, comprehending and analyzing the stakeholders’ reflections would become challenging and almost impossible to measure and to provide feedback [56]. In the context of medical education and practice, this might influence the past, present and future interpretations of appropriate patient care [64]. Educators can leverage FLOCC as a model to design and modify learning activities that further CC and connect the classroom to real-world settings. Testing this framework face-to-face, with other educational intra and interdisciplines (engineering, sciences, business, and others), and a larger sample size may also form part of future studies.

The FLOCC model, which integrates the design thinking and sociocultural learning methods (PBL and TBL), holds considerable promise as a framework for cultivating CC in medical education. Further research is needed to evaluate its effectiveness across intermultidisciplinary teams and diverse creativity triggers, thereby uncovering its full potential.