Tag: Covid19

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Struggle in the bubble – a prospective study on the effect of remote learning and distance education on confidence in practical surgical skills acquired during COVID-19 | BMC Medical Education

Struggle in the bubble – a prospective study on the effect of remote learning and distance education on confidence in practical surgical skills acquired during COVID-19 | BMC Medical Education

Demographics

A total of 232 out of 244 medical students completed both the baseline and follow-up questionnaire-based surveys, resulting in a response rate of 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Demographic data was comparable between the two cohorts (Table 1).

Table 1 Baseline comparison of the characteristics of participants belonging to the COV-19 and postCOV- 19 cohorts

Improvement in self-confidence for unit 1

First, it was evaluated whether the respective teaching methods in both cohorts resulted in an improvement in the self-confidence of students regarding their surgical skills. While analyzing unit 1 (sterile working), we found that both the COV-19 (Fig. 2A) and postCOV-19 (Fig. 2B) cohorts showed significant improvement in post-course confidence compared to pre-course confidence. This result was observed for all five subcategories of unit 1 (Table 2).

Fig. 2
figure 2

Self-assessment comparing pre- and post-course confidence of COV-19 and postCOV-19. Spider web graphs displaying the difference between pre- (full line) and post- (dotted line) course self-assessment. Unit 1 (sterile working): A (COV-19) + B (postCOV-19); unit 2 (knot tying and skin suturing): C (COV-19) + D (postCOV-19); unit 3 (history and physical): E (COV-19) + F (postCOV-19). COV-19 = cohort of summer semester 2021 (full COVID-19 restrictions), postCOV-19 = cohort of winter semester 2021/2022 (reduced COVID-19 restrictions)

Table 2 Self-assessment of pre- and post-course confidence of unit 1

Improvement in self-confidence for unit 2

While analyzing unit 2 (knot tying and skin suturing), we observed that both the COV-19 (Fig. 2C) and postCOV-19 (Fig. 2D) cohorts exhibited significant improvement in post-course confidence compared to pre-course confidence. This result was similar for all five subcategories of unit 2 (Table 3).

Table 3 Self-assessment of pre- and post-course confidence of unit 2

Improvement in self-confidence for unit 3

Upon analyzing unit 3 (history and physical), we identified that both, the COV-19 (Fig. 2E) and postCOV-19 (Fig. 2F) cohorts, revealed significant improvement in post-course confidence compared to pre-course confidence. This result was observed for all three subcategories of unit 3 (Table 4).

Table 4 Self-assessment of pre- and post-course confidence of unit 3

Having established that both the traditional interactive face-to-face hands-on courses and the newly developed interactive remote learning courses were able to significantly improve the confidence of medical students regarding basic surgical skills, it was necessary to determine the course that resulted in a higher difference between the pre- and post-course confidence and the subgroup of students that would benefit the most from a particular teaching method. Subgroup analysis was performed based on sex (male/female), age group (19–22 years/23–29 years/≥30 years), and prior surgical experience (with and without prior surgical experience) for evaluating the difference between the pre- and post-course self-assessment (Δ self-assessment).

Subgroup analysis

Sex

The cohorts were first stratified based on the sex (male or female) of the participants, and the subgroup that benefited the most from a particular learning method was determined. For unit 1, the mean Δ self-assessment in the COV-19 cohort was significantly higher in male students (1.96) than in female students (1.44) (p = 0.0003). However, in the postCOV-19 cohort, the mean Δ self-assessment was significantly higher in female students (1.57) compared to male students (1.29) (p = 0.0372) (Fig. 3A).

Fig. 3
figure 3

Subgroup analysis comparing pre- and post-course self-assessment (Δ self-assessment). A subgroup (sex: male vs. female) analysis for differences in Δ self-assessment, B) subgroup (age: 19–22 years vs. 23–29 years vs. ≥ 30 years) analysis for differences in Δ self-assessment, C) subgroup (prior surgical experience: with vs. without surgical experience) analysis for differences in Δ self-assessment, D) analysis for differences in Δ self-assessment comparing COV-19 vs. postCOV-19. Data are presented as mean and compared using Student’s t-test or ANOVA. A p-value less than 0.05 was considered statistically significant. Significance is indicated by the following symbols: * p < 0.05, ** p < 0.01, *** p < 0.001, **** p < 0.00001, ns = not significant. COV-19 = cohort of summer semester 2021 (full COVID-19 restrictions), postCOV-19 = cohort of winter semester 2021/2022 (reduced COVID-19 restrictions)

For unit 2, the mean Δ self-assessment in the COV-19 cohort was significantly higher in male students (2.59) compared to female students (2.16) (p < 0.0001), whereas no significant difference between males (1.92) and females (2.01) was observed in the mean Δ self-assessment in the postCOV-19 cohort (p = 0.0813) (Fig. 3A).

Nonetheless, for unit 3, we found that the mean Δ self-assessment was comparable between the female and male groups in both cohorts (Fig. 3A).

Age

The two cohorts were stratified based on age, which resulted in three subgroups: 19–22, 23–29, and ≥ 30 years. For unit 1, we found that the mean Δ self-assessment in the COV-19 cohort was the highest for the participants in the age group of 23–29 years (mean Δ self-assessment = 19–22 years: 1.51; 23–29 years: 1.82; ≥30 years: 1.42). Furthermore, the mean Δ self-assessment was significantly higher in students of ages 23–29 years compared to those in the age group of 19–22 years (p = 0.0234). However, no significant differences in the mean Δ self-assessment were observed between the subgroups 19–22 years and ≥ 30 years (p = 0.8443), as well as the subgroups 23–29 years and ≥ 30 years (p = 0.0761).

By contrast, the mean Δ self-assessment of unit 1 did not vary significantly between different age groups in the postCOV-19 (mean Δ self-assessment = 19–22 years: 1.58; 23–29 years: 1.33; ≥30 years: 1.23) cohort (Fig. 3B).

Considering unit 2, we determined that the youngest (19–22 years) subgroup exhibited the maximum improvement in self-assessment for the COV-19 and post-COV19 cohorts. In the COV-19 cohort, the mean Δ self-assessment was significantly higher in the subgroup with participants aged 19–22 years compared to the subgroup with participants aged 23–29 years (p = 0.0017). However, there was no significant difference between the subgroups with participants aged 19–22 years and ≥ 30 years (p = 0.4096), as well as the subgroups with participants aged 23–29 years and ≥ 30 years (p = 0.5073).

In the postCOV-19 cohort, the mean Δ self-assessment was significantly higher in the subgroup with participants aged 19–22 years compared to the subgroups with participants aged 23–29 years (p = 0.0020) and ≥ 30 years (p = 0.0017). In contrast, there was no significant difference observed between the mean Δ self-assessment of the subgroups with participants aged 23–29 years and ≥ 30 years (p = 0.2499) (Fig. 3B).

Upon analyzing unit 3, the mean Δ self-assessment in the COV-19 cohort was significantly higher in the youngest students (19–22 years) compared to the subgroup with participants aged 23–29 years (p = 0.0061) in COV-19. However, there was no significant difference in the mean Δ self-assessment between the participants aged 19–22 years and ≥ 30 years (p = 0.0934) and 23–29 years and ≥ 30 years (p = 0.9923).

Nonetheless, for unit 3, the mean Δ self-assessment was significantly higher in the subgroup with participants aged ≥30 years compared to subgroups with participants aged 19–22 years (p = 0.0224) and 23–29 years (p = 0.0181) in the postCOV-19 cohort (mean Δ self-assessment = 19–22 years: 1.73; 23–29 years: 1.68; ≥30 years: 2.35). However, no significant difference was noted in the mean Δ self-assessment of subgroups with students aged 19–22 years and 23–29 years (p = 0.9332) in the postCOV-19 cohort (Fig. 3B).

Prior surgical experience

Lastly, the two cohorts were stratified based on prior surgical experience. Students without prior surgical experience showed a significantly higher improvement in their self-assessment of post-course confidence compared to pre-course confidence. This result was found for unit 1 and 2 in the COV-19 (unit 1 = mean Δ self-assessment with surgical experience: 0.58; without surgical experience: 1.74; p < 0.0001; unit 2 = mean Δ self-assessment with surgical experience: 1.65; without surgical experience: 2.14; p < 0.0001) and postCOV-19 cohorts (unit 1 = mean Δ self-assessment with surgical experience: 0.77; without surgical experience: 1.57; p < 0.0001; unit 2 = mean Δ self-assessment with surgical experience: 1.15; without surgical experience: 2.10; p < 0.0001).

However, for unit 3, we observed that the mean Δ self-assessment did not vary significantly between students with and without prior surgical experience in the COV-19 cohort (mean Δ self-assessment with surgical experience: 1.21; without surgical experience: 1.09; p = 0.2242) but was significantly higher for students without surgical experience in the postCOV-19 cohort (mean Δ self-assessment with surgical experience: 1.19; without surgical experience: 1.89; p < 0.0001) (Fig. 3C).

To summarize, the mean Δ self-assessment was the highest in the young (19–22 years) male students without surgical experience in the COV-19 cohort and young (19–22 years) and elderly (≥30 years) female students without surgical experience in the postCOV-19 cohort.

Finally, we compared the mean Δ self-assessment of both cohorts using each unit. Both, the COV-19 (Δ self-assessment: 1.58) and postCOV-19 (Δ self-assessment: 1.46) cohorts showed comparable (p = 0.1485) results for unit 1. For unit 2, the mean Δ self-assessment was significantly (p < 0.0001) higher in the COV-19 cohort (Δ self-assessment: 2.26) compared to the postCOV-19 (Δ self-assessment: 1.98). In contrast, for unit 3, the Δ self-assessment was significantly (p < 0.0001) higher in the postCOV-19 cohort (Δ self-assessment: 1.76) compared to the COV-19 cohort (Δ self-assessment: 1.1) (Fig. 3D).

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Impact of online learning on sense of belonging among first year clinical health students during COVID-19: student and academic perspectives | BMC Medical Education

Struggle in the bubble – a prospective study on the effect of remote learning and distance education on confidence in practical surgical skills acquired during COVID-19 | BMC Medical Education

Online student cross-sectional survey

Demographic characteristics

A total of 179 out of the possible 663 students (27{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} completion) completed the online survey in June 2020. Median age of students was 19 years (IQR 18–28 years) and there were approximately three times as many females as males (Table 1), reflective of the undergraduate health sciences cohort (70{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} female). Student numbers were also reflective of the broader enrolment numbers in the programs (i.e., occupational therapy is the largest program). Just over half (53{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; n = 94) of students had no prior experience in undertaking a Bachelor degree, and 76{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students had not completed any online courses prior to enrolment.

Table 1 Demographic characteristics

Quantitative results to the sense of belonging questionnaire

In terms of students’ sense of belonging to the university, the majority felt ‘quite’ or ‘extremely’ happy with their choice of university (74{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) and felt ‘quite’ or ‘extremely’ welcomed by the university (68{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}). While most students felt respected by both staff (70{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) and students (60{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) at the university, students reported less connectiveness (23.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) to the university. Only 20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students reported they felt they were understood as an individual, and only 13{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} felt they ‘quite’ or ‘extremely’ mattered to others at the university (Table 2).

Table 2 Online learning and Sense of Belonging to the University [1]

Table 3 shows how the online learning experiences impacted on students’ perception of the course; 27{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students felt ‘quite’ or ‘extremely’ connected to staff while 16{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students felt ‘quite’ or ‘extremely’ connected to other students. While 49{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students rated 4 and above for the level of respect that they received from other students and their contribution towards the subject, students who had prior higher education felt less respected than students who had no prior higher education (p = 0.03). When asked how the online subject had contributed to understanding, knowledge/skills in their chosen health profession, about half of the students rated the online subject highly (rating 4 and above). Students who had prior higher education indicated higher ratings of understanding and knowledge/skills compared to students without prior higher education (p = 0.07 and p = 0.03 respectively). There was also a significantly higher proportion of students with no prior higher education who identified the online learning experience as either ‘quite’ or ‘extremely’ likely to impact their intention to continue with their current course (p = 0.001).

Table 3 Impact of online profession-specific subject on perception of the course

Qualitative results

Qualitative findings provided insight into experiences of staff and students during the rapid, unplanned transition to online learning. Student questionnaire responses included two open-ended questions expanding on enablers and barriers to sense of belonging. These yielded 145 enablers and 254 barriers to students’ feeling a sense of belonging. Data were subjected to qualitative content analysis by two authors and categories are presented in Additional file 1.

Three focus groups were conducted: two student sessions, each with two students enrolled in Speech Pathology and Paramedicine, and one academic session with five participants. Four full time academics and one casual academic participated from a total population of nine eligible academics. Using the processes described in the methods, focus group analysis was compared with the survey content analysis and the authors identified synergies between them. Findings were then integrated under a global theme, underpinned by organising and basic themes. The following themes reflect triangulation between academic and student focus group data in addition to survey responses.

Global theme—navigating belonging during the COVID-19 crisis: a shared responsibility

“We are in this together…making the best of this”

This theme explores sense of belonging creation during this period as a shared process, where participants perceived they worked together to get through the crisis. Students and academics encountered many challenges as they transitioned to online learning but despite hard times, were able to engage positively. The global theme revealed students and academics were navigating belonging during the COVID-19 crisis, and this journey was a shared responsibility. Both groups were working to achieve positive student engagement that would in turn create a sense of belonging in first-year students. A strong commitment of working hard to make the best out of this was mutually acknowledged.

Students perceived academics had done “a really good job at making sure we belonged…in those first few weeks that we were on campus but even more so probably while we were in Zoom” (Student-Astrid-Focus Group). Academics perceived students were actively engaged in making online learning work and were collegial and collaborative.

The shared experiences about navigating belonging during the COVID-19 crisis, have been captured under four organising themes: dimensions of belonging, individual experiences and challenges, reconceptualising teaching and learning, and relationships are central to belonging. Within each organising theme, basic themes were identified that provide depth to the organising theme (Fig. 1). Additional files 1 and 2 present a summary of the quotes obtained from the open-ended surveys and focus groups respectively, that contribute to the themes in Fig. 1.

Fig. 1
figure 1

Pictorial representation of the global, organising, and basic themes

Organising theme: dimensions of belonging

This theme outlines that belonging is a multidimensional experience with several facets underpinning participants’ experiences. Students and academics identified several dimensions of belonging in relation to first year students’ experiences, as illustrated by two basic themes that sit under the organising theme: what it means to belong, and layers of belonging.

Basic theme: what it means to belong

This theme explores the idea that belonging at university is underpinned by feeling valued and connected. Academics and students agreed that having a sense of being valued by the university and a desire to have an active connection across all aspects of university life was important for students.

Belonging as a student was gained through a connection with the “vocation” (Student-Claire-Focus Group) or the course and career, and with people who will “be there” (Student-Claire-Focus Group) for them. Furthermore, support of academics was critical to gaining a sense of belonging. It was noted by academics and students, that when students feel they belong at university, they are actively engaged in their learning, and this sense of belonging in turn shapes their overall identity. Students can then “actually sort of relax and become themselves” (Staff-Brooke).

Belonging to their cohort, their course, their future profession, and their university was important for students. One academic noted that the “concept of acceptance” is part of the sense of belonging and goes “both ways” (Staff-Brooke).

Both academics and students agreed that the rapid change to online learning due to COVID-19, meant that developing a sense of belonging was challenged.

Basic theme: layers of belonging

This theme identified layers of belonging reflected in participants’ experiences. Peer, academic and professional layers each contributed to an overall sense of belonging and key examples are provided below.

Peers

Belonging to peers was described as “having that connection to someone that’s going through exactly the same thing as what you’re going through” (Student-Astrid-Focus Group). Students were concerned that when learning moved online that this sense of belonging would be jeopardised by less opportunities for in-person interaction.

Academics

Being connected to academics was perceived by students as directly impacting learning, with one student commenting: “…when they’re not connecting with the teacher, they’re not connecting with the content, they’re not connecting with the feedback. That’s when you develop this sense of feeling like you just don’t belong” (Student-Emily-Focus Group).

Academics perceived it was also important for students to develop a sense of belonging to the university community.

Profession

Belonging to a profession was identified as an important feature of belonging by academics and students. Studying a degree with a clear professional identity facilitated first year students to feel they belonged compared to those undertaking general health science degrees which may have multiple pathways and career options less directly aligned to first year studies.

One academic actively encouraged first year students to belong to their professional association as a way of fostering belonging in first years.

Organising theme—Individual experiences and challenges

This theme outlines that while there are similarities in participants’ experiences, individuals have unique contexts and factors shaping their experiences. Academics and students reflected upon personal impacts of the COVID-19 pandemic on their teaching or learning and how they responded as individuals to the ensuing challenges. Two basic themes emerged: Challenges of transition and recognising different learning preferences.

Basic
theme
—challenges of transition

This theme explored the significant challenges of transitioning to online teaching and learning. For some students, the transition to online learning offered potential benefits of flexibility and reduced travel time. Two of the four students in the focus groups opted for online learning opportunities available in other subjects of study prior to the pandemic to efficiently manage their study and external commitments. Nonetheless, the pandemic brought a raft of personal challenges that diminished these expected benefits. Covid-related changes to family employment, reduced access to childcare support and non-optional home schooling presented new concerns.

Clearly, students missed the opportunity to focus attention on their learning needs when balancing childcare demands and home-schooling during lockdowns.

Unlike a conventional online courses where students choose or plan to be online, the sudden, unexpected, and unplanned move to online study was prefaced by a short period (four weeks) of in-person class time. This initial in-person time was identified as being key to relationship building.

Academics identified positive experiences and challenges during the transition to online learning. The rapid change presented a problem to be solved and individuals could “embrace it and to work effectively…as a team” (Staff-Jane). Quickly strategizing and responding to the demands of online learning required team knowledge, experience, and support. Hence, enhanced team culture was a further positive for academics, being “present for each other” (Staff-Brooke).

Basic
theme
:
recognising different learning preferences

This theme identifies experiences of online learning influenced by personal attributes, individual expectations and learning preferences. Such key factors impacted students’ capacity to maintain focus on academic goals after the rapid change to online learning. Some students reflected that barriers were not solely a feature of online learning environments, reporting that competing priorities, including work commitments and limited contact time with staff as pre-existing challenges to belonging. However, some students directly attributed their limited engagement and reduced motivation to the online learning environment.

Students suggested that active engagement “comes down to personality” (Student-Astrid- Focus Group). If a student was not shy they were comfortable to come forward and participate online. Some students perceived clear links between personal discipline, engagement, commitment, and achievement in online learning environments.

Further, students perceived effective (and ineffective) online group functioning reflected personalities of individual members, with some groups/personalities seen as being able to organise whilst other groups lacked leadership and cohesion.

Students who perceived themselves as active engagers reported being drawn towards other students who demonstrated motivation to interact and learn. Other students perceived their personalities or learning preferences were misaligned with the expectations of belonging in online learning environments and focussed upon tasks rather than connection.

Academics recognised student diversity and a need to reflect and re-evaluate expectations of students in online environments. They accepted that some students may be quietly engaging and learning to belong, but this was harder to observe in online compared to in-person learning environments.

Organising theme—relationships are central to belonging

This theme identified the relationship between all parties as a fundamental aspect of creating a sense of belonging. Two basic themes were influential in shaping perceptions of how relationships and connections contribute to belonging: collaboration with peers is fundamental, and effective and regular communication with staff is necessary.

Basic
theme
—collaboration with peers is fundamental

This theme revealed collaboration with student peers was a key element of creating a sense of belonging. The degree of social interaction with student peers and opportunities to create friendships contributed to feelings of belonging. Accordingly, students found it problematic when peers neglected to turn cameras on during classes, making interaction very difficult. Visualisation of peers and use of cameras in online classes impacted students’ opportunities to get to know each other.

Challenges posed by online learning were further highlighted in the student survey through a focus on non-academic aspects of university and campus life. Typically, university campuses offer interactional opportunities through clubs, sport, and shared spaces to learn and socialise. Campus life, students suggested, may facilitate learning and personal development. Absence of this type of interaction was linked to barriers in developing friendships and consequently a lesser sense of belonging as reflected in Additional file 1.

Basic theme—
communication
with academics is necessary

This theme outlined that communicating with academics was a key component of creating a sense of belonging. With less opportunities for peer support, there was stronger reliance on the academic-student connection, although students reported positive and negative interactions with academics during online learning.

Positive interactions and individualised communication with academics enhanced student sense of satisfaction and belonging. Furthermore, students in the focus groups reported a feeling of trust and a bond created by a shared challenge. Survey responses echoed this sentiment, noting that academics were “non-judgmental and supportive” (Student Survey 18) and created a sense of camaraderie. However, when students perceived impersonal communication from academics, they felt less connected or believed that teaching had become a “transaction” (Student-Astrid- Focus Group). Perceived levels of enthusiasm and engagement from academics influenced student’s perceptions of connection and belonging.

Students identified the online environment as a barrier to communication with academics. While systematic and university level communication was perceived as a useful source of information, students prioritised individualised communication from academic staff as key to belonging.

Academics concurred that effective communication was challenged in online environments, missing non-verbal cues and responsivity that characterises a classroom environment. Although the online learning environment provides an opportunity for academics to connect professionally with students, there were students who left their cameras off, with one academic noting they didn’t push this issue because there are many reasons for students choosing this option.

Organising theme: reconceptualising teaching and learning

This theme reveals how academics and students reconceptualised their expectations and modes of teaching and learning, to manage the crisis. It was not easy for academics or students, and many strategies were employed to make it work, with two basic themes emerging: challenges to online teaching and learning, and strategies to engage and connect.

Basic theme:
challenges
of online teaching and learning: “how do I make this work?”

This theme outlined many challenges faced by both academics and students during a rapid change to online mode. With the rapid change to online learning, academics asked themselves, ‘How do I make this work?’.

Managing workload

Academics reported their workload increased significantly, and they “found it a juggling act” (Staff-Louise) to meet their teaching requirements. Administrative loads consequently increased when reduced in-person contact with students led to more electronic communication. Academics needed to up-skill in online teaching in a short time frame and perceived this responsibility as all encompassing.

The rapid switch to online learning attracted significant academic workload, implementing and adapting content to see how material “might play out in a Zoom environment…[where]…everything takes longer” (Staff-Natalie).

Some students noticed a temptation to disengage from online learning, which meant balancing their workload and study demands became a challenge as they also faced significant workload and stressors in their personal lives due to COVID-19.

Class dynamics

Academics and students spoke about the change to classroom dynamics. The online environment was noted as being one in which it was difficult to read the room to see how students were progressing with their work. Others tried to use humour to enliven a class, only to have the Zoom frame freeze, killing the mood they were trying to create. Hence, staff felt teaching online was less conversational, flexible and responsive compared to face-to-face. Moreover, academics missed hands-on practical elements; a big shift for some programs.

Technological challenges

Academics learnt new skills quickly, but often these skills would be challenged when technology failed. Some academics reported a sense of vulnerability due to technological ineptitude but acknowledged that making mistakes in front of students could humanise the experience. Academics also acknowledged that some students did not have adequate technological resources to meet changes in their learning requirements when classes were placed online.

Basic theme: strategies to engage and connect

This theme reflected the strategies academics and students employed to remain engaged and connected. Academics worked hard to enhance online learning and hoped to connect with students and engage them in activities. Students too were active and appreciated academics’ efforts to facilitate engagement and connection. Underlying many of the strategies adopted by academics was a deep concern for student welfare during this time. Therefore, many academics aimed to ensure students were engaged and connected with each other and with the academic team. Academics built in small group opportunities during online teaching so students could connect, learn, and socialise.

Staff also spoke about informing students they could contact staff for support. One staff member described crossing the divide and actively discouraging a ‘them and us’ dynamic between students and staff.

A variety of teaching tools were identified by staff to build connection and promote engagement. Such tools included interactive quizzes, ice breakers activities, integrating reflective practices into activities and ‘drop in’ sessions. Staff also encouraged students to establish social media groups or other group experiences outside the classroom. Some staff members arrived early to zoom classes and left late to enable students to connect informally.

Students appreciated staff attempts to provide these activities. Students found these initiatives helpful, recognising staff placed effort into knowing students personally and focussing on student wellbeing and achievement. Students cited examples of provision of extra resources, mini-lectures, additional question and answer sessions, and fast response times to student queries. Students also initiated their own engagement strategies, including using group and personal messaging over platforms such as Facebook messenger.

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Identifying the challenges of online education from the perspective of University of Medical Sciences Students in the COVID-19 pandemic: a Q-methodology-based study | BMC Medical Education

Struggle in the bubble – a prospective study on the effect of remote learning and distance education on confidence in practical surgical skills acquired during COVID-19 | BMC Medical Education

This cross-sectional analyze was executed using the Q methodology during the subsequent six techniques utilizing Barry and Proops method [19].

Phase 1 and 2: defining the concourse

At this phase, a concourse space was fashioned with the identification of the matter or idea of the analyze. The offered sights on the situation elevated for the concourse can be formed from a assessment of texts and authorities in this field [19].

In this review, the matter and notion for the concourse were being the problems of on the web education and learning all through the COVID-19 pandemic. The concourse provided a collection of various supplies associated to the investigation subject that was mentioned among the students. The pupils (P-established) who also experienced contributed before to the enhancement of the initial set of statements. Thirty-one particular learners participated in semi-structured interviews, and we tried using to establish their subjectivity about the investigation matter working with the Q approach [20].

In this analyze, the concourse (sample of people) provided college students of the University of Health care Sciences (paramedical learners) who had enough data about online training for the duration of the COVID-19 pandemic.

Stage 3: screening and assortment of statements (Q-sample)

In the course of the semi-structured interviews with 31 learners, 70 statements ended up extracted about the perceived difficulties of online schooling. The Q goods ended up picked quite diligently so that things did not overlap, and at the exact time, no point of view need to be missing. Thus, the variety process usually takes the most time and hard work of all the measures of the Q methodology. For that reason, exploration group taken out related unrelated, and ambiguous statements from the Q set. Eventually, 50 statements had been selected.

Phase 4: picked P-established

Students who participated in the concourse (interviews) had been chosen as a sample of individuals to take part in sorting in the Q examine (P-established). In the present study, learners have been picked by purposive sampling to include college students who experienced an academic, skilled, experimental marriage or prior information about the subject of study. This range of samples designed the contributors with much more varied mentalities enter the examine. It is advised that in Q experiments, the variety of members to form statements should really be less than the number of statements close to the analyze issue [21]. In the present examine, the range of individuals who rated the troubles of on the web education packages was 31 (Table 1).

Desk 1 The Q-established statements and issue arrays in the analyze of worries on the net instruction among pupils

Phase 5: Q-sort

At this stage, the normal distribution table in the type of a Likert scale from − 5 to + 5 was developed offline. Suggestions on distributing the expressions on the typical distribution table have been delivered. In the first phase, the intent of the examine is the quantity of statements picked by means of the interview. In the second phase, position the statements in 3 columns: “I agree”, “I have no viewpoint,” and “I disagree. In the third phase, the statements (necessary) are distributed in the ordinary Likert distribution diagram (− 5 to 5+), detailing the motive for deciding upon the two ends of the Likert scale from their issue of look at and lastly moving into the demographic facts. So, in Q, the sorting process is subjective [19]. In other text, sorting things in the regular distribution make it possible for each and every participant to existing their internal standpoint via sorting.

Stage 6: examination and interpretation of components

Students’ knowledge obtained from Q sorting were being entered into PQ-Method program model 2.35. The system of analysis and interpretation was executed in three levels: (a) identification of factors, (b) conversion of elements into element arrays (c) interpretation of variables applying element arrays.

  1. A)

    Element Identification

The extraction of components in PQ-Method software was performed by the subsequent sequential techniques: (a) principal element examination, (b) identification of latent things, (c) varimax rotation and analysis of loading aspects for unique values earlier mentioned 1.00, d) estimation of the percentage of variance described by the discovered variables and (e) differentiation of interpretable components with at minimum two correlated Q forms [22].

  1. B)

    Transform element to element arrays

The correlation among each Q sort and just one discovered element indicates the degree of interaction in between the Q sorts and the recognized factors [19, 23]. The handbook flagging in PQ-Approach program was used for this examine. The correlation coefficients of at the very least .364 had been thought of as the reduce-off issue (the absolute value of the issue load is increased than ((frac2.58sqrtN)). That factor load was 99{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} significant, respectively, and the value of N was equivalent to the quantity of Q statements (N = 50). Sorted for identified elements [24]. Specs specified on a component are employed to create a aspect array for that element. The variable array represents the sorting of that factor (point of watch) applying z-scores. The component array for each individual issue determined the degree to which each individual expression was in the spectrum, so a extra precise interpretation of just about every component (subjectivity) was attained according to the placement of every single expression. (P-worth< 0.05 vs. 0.01) is also determined from the Z score to distinguish expressions [25].

  1. III)

    Factor interpretation using factor arrays

Distinct Q expressions were identified, and factors were interpreted textually. The defining expressions for a factor were those that had a rating value of “+ 5”, “+ 4”, “4-,” 5- “in factor arrays that had different scores (P < 0.05) in a given factor Compared to their scores on other factors, the post-P-set interview was conducted at the end of Q sorting to confirm the diagnosis and interpretation of item subgroups among the identified factors.

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COVID-19 Emergency Funding and California’s Higher Education Systems

COVID-19 Emergency Funding and California’s Higher Education Systems

Additional scholar funding

When half of the federal funds have been earmarked to be handed straight to students for help, institutions could also invest some of their institutional fund part on learners. With each other, public establishments used about $638 million (21{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of complete institutional expenditures) on further funding for pupils (Determine 4). This additional college student funding incorporates further crisis support reimbursements for housing, place, and board other charge refunds and tuition bargains. Most of it (59{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) went for tuition reimbursement, adopted by further economic help (36{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}). One campus we interviewed funded students’ essential desires by funding the university student pantry and furnishing reward playing cards for food items. Several neighborhood schools also forgave college student debts for courses and companies, which enabled pupil re-enrollment.

Auxiliary profits substitute

Numerous non-tutorial resources of campus revenue were impacted by the pandemic. General public establishments spent about $552 million (20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of total expenditures) on replacing them. Campuses described quite a few various resources of missing income in the quarterly experiences, but the most frequent have been parking, foodstuff provider, bookstores, athletics, and childcare facilities. Some significantly less-frequent examples integrated the rental use of campus room by outdoors organizations, police functions, and museums.

Enrollment revenue substitution

Many institutions lost profits due to a drop in enrollment, and though for some campuses it was brief, for other folks it nevertheless persists. Community institutions put in a overall of $370 million (17{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of full expenditures) on changing revenue connected with lessened or delayed enrollment. These include things like dropped earnings from tuition, costs, institutional costs, space and board, enrollment declines, supported investigation, summertime phrases, and summer season camps. Quite a few campuses mentioned dropped tuition profits thanks to enrollment declines in resident and nonresident learners. The 2021 state price range decreased campus funding by 3–5 p.c, which some campuses later claimed in this class. This enabled them to mitigate the effects of the non permanent reduction right until funding was restored and augmented the pursuing 12 months.

Social distancing and wellness

California institutions invested about $370 million (15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of complete expenditures) on making their campuses and college students protected during the pandemic. This bundled the costs of subsidizing off-campus housing or housing expenditures to isolate pupils or present area to stop the distribute of infections, adding class sections and subsidizing meal service to accommodate social distancing, normal campus basic safety and functions like cleaning and private protecting equipment, and purchasing additional instructional gear to limit sharing and give time for disinfection. The biggest part of this income was expended on campus basic safety, which provided individual protecting devices tests and upgrading heating, air flow, and air conditioning systems. Campuses we interviewed outlined working with the funding to purchase provides for lab courses and mail them to students, or to provide PPE kits for in-individual instruction. Many also pointed out incentives to inspire their learners to get vaccinated for instance, a person campus provided $100 reward playing cards that could be used at their campus bookstore.

On the internet instruction

Most classes at most establishments moved on-line. California’s general public colleges and universities put in about $344 million (14{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of total expenditures) on the changeover. This provided offering added engineering components this sort of as laptops or tablets to college students, buying schooling for school and team in on line instruction or having to pay staff members trainers further, and buying devices or software package to permit length learning. Numerous campuses identified that reliable, superior-velocity web connectivity was the most significant barrier to participation in distance schooling. In quarterly studies, quite a few campuses mentioned offering Wi-Fi hotspots to students and school and paying for month to month details ideas on their behalf. Other folks pointed out growing wi-fi companies to campus parking heaps and other close by outdoor spots to allow for school and pupils with out trustworthy net a place to educate and find out.

Other expenses

California’s public institutions also expended $352 million (13{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of whole prices) in other categories. The federal procedures permitted institutions to use the “Other” classification resources to defray charges these types of as dropped income, reimbursement for expenditures by now incurred, technology costs connected with a transition to distance training, faculty and staff members trainings, and payroll. Not all campuses furnished notes for these expenses, but all those that did stated indirect costs, state appropriation losses, outreach to learners, staff wellness, and shipping and delivery materials to learners and faculty. Also, many of the notes suggest goods that could in shape within just other categories—a stage the state auditor designed early in the pandemic (Auditor of the Point out of California 2021). For illustration, some campuses claimed university student parking rate refunds, COVID tracking and tracing, loss of point out appropriations revenue, and publications and materials as “other” paying, when other folks placed them in just one of the 14 core spending classes. In addition, most “other” investing is not annotated, which makes examination extra difficult.

Paying out Designs Varied more than Time

Interviews with campus officials uncovered that less than the CARES Act the principles for institutional paying had been initially unclear. They noted using on the internet facts from the US Division of Instruction, federal webinars, discussions with other establishments, and steering from process places of work to determine correct employs for the funding. The 2nd (CRRSA) and third (ARP) rounds incorporated substantially a lot more funding and arrived with additional calm, clearer regulations, which enabled campuses to address a broader array of wants and claim considerably additional enrollment- and auxiliary-associated shed revenue.

As a result of alterations in policies and probably improvements in want, campuses invested early funding in different ways than later on rounds. While both of those intervals noticed major expense in extra scholar funding, later on investing was distribute extra evenly in between types (Determine 5). From fall 2020 to spring 2021, campuses invested 52 percent of the CARES Act dollars in the scholar funding class, while really small (10{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) went to replacing income (Determine 5). In the subsequent 4 quarters, after rule alterations, a considerably lesser portion went to college student-similar funding (15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), and a a lot bigger proportion went to changing profits (45{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), and social distancing and campus safety (14{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}).

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Flexibility, family time: Why these families stuck with home-schooling amid COVID-19

Flexibility, family time: Why these families stuck with home-schooling amid COVID-19

The large bulk of Canada’s 5.7 million college-aged little ones and teenagers attend in general public colleges, but the variety of college students enrolled in residence-education additional than doubled following COVID-19 strike.

The 2020-2021 faculty yr saw enrolment leap to almost 84,000 pupils from about 41,000 the previous educational yr, in accordance to Data Canada’s latest Elementary-Secondary Schooling Survey.

That period of time marked a rocky, unpredictable time for in-particular person schooling, with officials and students alike grappling with evolving protocols and techniques, new finding out timetables, few or no extracurricular activities and waves of disruption. 

Uncertainty was a essential reason many have cited for picking household-education in the course of the pandemic. 3 parents who took up the practice two years back explain why they are sticking with it.

‘A gift’ of spouse and children time

Lori Kent recalls her son’s response to the prospect of faculty back in fall 2020: no sports, no audio, no field excursions, no solutions. 

“He mentioned to me, ‘They’re getting away almost everything I like about school’… And I assumed ‘It does audio horrible,'” said Kent, who subsequently dove into the world of home-education her son Cameron, who is now almost 14.

A smiling family of three -- a dad, teenage son and mom -- take a selfie next to a canal in Venice, with stone architecture and gondolas in the background.
Lori Kent, seen here with her spouse Bruce and their son Cameron, in Venice in 2022. The pair has blended travel in various nations with their teen’s homeschooling. (Submitted by Lori Kent)

And it really is not just happening in the family’s home in Chestermere, Alta., any more. As the depth of the pandemic has lifted, Cameron’s spouse and children is mixing his experiments with travel. Learning is taking position in Mexico, Turkey, Greece, Italy, Scotland and the United States, just a handful of of the nations around the world the Kents have travelled to this past 12 months.

Swimming in a cenote in Mexico, for occasion, sparked a lesson for the almost 14-12 months-previous on how such sinkholes type. The household watches documentaries and researches historic sites in advance of visits, as they did prior to touring the Acropolis. Converting foreign currencies to Canadian pounds is an ongoing sensible math lesson. A long prepare journey delivers time to catch up on textbook-based mostly perform.

“[Home-schooling is] hard. It can absolutely be discouraging, but it’s quite a lot worth it,” Kent mentioned from a motor home close to Edinburgh last 7 days.

“When he was likely to college, we did not see him that much, and when we did it was speeding to get to faculty, from university, to some kind of extracurricular activity…. To have this time jointly, that is a present.”

A woman in a vibrant headscarf and dress guides a teenage boy as he shapes a small clay bowl in a pottery demonstration.
Kent’s son Cameron, who is in Grade 9, assessments his hand at an ancient strategy of pottery-building in Goreme, Turkey. (Submitted by Lori Kent)

Kent retired very last yr and her partner Bruce followed in early 2022. They experience supported by friends, loved ones and an Alberta college board facilitator they hook up with periodically. She handles language arts, social sciences, wellness and cooking with Cameron, for occasion, while Bruce requires treatment of math, science, organization and economics. 

Although the house-college process has been a learning expertise for them all, their family has most liked the versatility. In the course of a lull last year when Cameron felt weary of workbooks, they shifted gears to an independent analyze — for a few of weeks, he investigated how artificial intelligence is made use of in medicine currently and in which the industry is headed. Then, he offered it to his mothers and fathers.

Adhering strictly to the common way of performing items “will not do the job for all people and there was a ton of it that wasn’t performing for him,” Kent mentioned.

“So now we can do what functions for him and tailor it.”

‘Unschooling’ solution

A self-described “crunchy mother,” Amanda Lajko usually had an curiosity in property-education, but the Toronto dad or mum didn’t try it for her son Ryker until COVID-19 strike, when the shuttering of in-human being schools early on was adopted by a sequence of setbacks, like getting rid of her occupation, slipping ill and multiple moves.

“Just one fewer matter to be concerned about was putting him in a unique faculty board and signing him up for college,” said the single parent. 

A mother sits on a couch next to her son as they read a book together.
Lajko says she’s been surprised at how a lot Ryker has figured out by his possess interests. ‘The fewer I’ve tried using to drive and instill in him to learn, discover, learn, he learned on his possess,’ said the Toronto mother or father. (Craig Chivers/CBC)

Soon after she found Ryker getting disappointed with workbooks tied to the Ontario curriculum, Lajko shifted to an “unschooling” model directed by his passions. While she’s appeared at curriculum anticipations as “a tiny little bit of a manual in the history,” she allows the now 8-12 months-old take the lead.

She describes her son as an avid reader, helped by normal library visits and playing enjoyable, textual content-major movie game titles. Other pursuits ideal now include things like studying Japanese and about anime. 

“The less I have tried out to drive and instill in him to discover, discover, discover, he uncovered on his individual,” Lajko reported. “In some cases he will tell me a little something and I imagine him, but my brain is like ‘Are you sure? Let’s just double-test.’ And each and every time I double-look at, he is appropriate.”

Reading through, cooking alongside one another, day-to-day mother nature walks, going to the foods lender or heading out to do laundry are factors of their weekdays, while Ryker enjoys participate in dates with close friends on the weekend. According to Lajko, he also values tranquil time on his very own: He would not like loud noises nor crowded sites.

When not opposed to her son returning to in-man or woman schooling, Lajko seeks a extra alternate strategy that values “out-of-the-classroom discovering,” she reported. 

“A college that takes all kids’ differences into consideration is what we have to have to strive for moving ahead, simply because faculty correct now? The system is pretty cookie cutter.”

Versatility for lifetime on the farm 

Soon after the crisis studying at the pandemic’s start, Martina Webpage was not thrilled with the prospect of a roller-coaster faculty calendar year forward, nor an unpredictable bus agenda for the hour-extended vacation each early morning and afternoon for her younger son. So, she and partner David Webpage, who are boosting their four children on a farm in rural Alberta, built the swap to dwelling-education.

A smiling family of six -- mom, dad and four children ranging in age from six months old to eight years old -- stands outdoors in a tall grassy field next to a waterway.
Martina Website page is homeschooling her older two small children, James and Madeline, when also caring for her toddler Millicent and little one Merida, held by her husband David. (Submitted by Martina Web site)

Based mostly on her success teaching James, her eldest, from their house close to Sunnyslope, Alta., their 2nd kid — Madeline, now six — followed go well with this fall.

“I never at any time considered I would household-school in my existence. I was like, ‘Home-schooled youngsters are weird. We never want odd young ones,'” Website page recalled. “And right here we are.”

Using loose assistance from Alberta Education’s finding out expectations, she follows a dad or mum-led approach and handles topics like reading through, spelling and math, together with historical past and geography for James, now 8 and in Grade 3. They spend their mornings learning, with occasional breaks for Webpage to are inclined to toddler Millicent or baby Merida. 

Schoolwork is normally accomplished by midday, when the young children get to get pleasure from lunch with father, who normally takes a split from farm do the job so they can eat together. Afternoons are often put in at the library or at distinct things to do (piano classes, gymnastics or hockey) in a close by town. During the fast paced farming months of May well and September, house-faculty may possibly slide a little bit, Page stated, but she also continues with the kids’ math and reading through classes above the summer.

Three children make funny faces as they pose behind a photo cut-out board, their faces peering out from a painting of a goat, a cow and a pig. Farm buildings and structures are seen in the background.
James, Madeline and Millicent Page pose in a farm-animal photo cutout board at the Calgary Farmyard. When juggling two university-aged youngsters, a toddler and a baby are rough now, their mother’s issue is ultimately homeschooling all 4 of her young children. (Submitted by Martina Site)

“We get a large amount of remarks [like] ‘Don’t your children will need to be socialized? Don’t they will need to be with other kids their age?’ But we do heaps of activities,” Web site pointed out. “We have meet-ups [in neighbouring town Three Hills]… You can do rather substantially everything that young children in community university do.”

When her present-day juggling is rough, Page’s biggest issue is sooner or later home-schooling all 4 youngsters. “As they get older and their interests get started to diverge, it will be challenging to cater to everybody,” she reported.

Returning to common faculty remains a possibility, but will count on a much more predictable expertise. Substantial faculty, for occasion, may be a good time.

“They can still have graduation, get their Alberta diploma — which you can however get as a result of residence-education, but it can be a minimal little bit far more easy to do it by an precise college,” Page mentioned. “[We] are ready, I consider, for every little thing to settle down.”

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Postgraduate Online Medical Education during the COVID-19

Postgraduate Online Medical Education during the COVID-19

Introduction

Online learning (eLearning) was gradually incorporated into medical education over the past 20 years, which has paralleled the increased use of eLearning across all workforce sectors.1 A review published in 2006 concluded that eLearning would be “one of the most important developments in the delivery of postgraduate medical education.”1 The authors of that review article, and many others who shared similar views in the early internet era, could not have known how that prediction would be tested. However, as the world came to be immersed in the SARS-CoV-2 (COVID-19) pandemic in 2020, eLearning surely became important in the delivery of postgraduate medical education.

The COVID-19 pandemic caused a massive change worldwide; affecting all areas of workforce including education. This state of emergency has led to many modifications within the healthcare system, such as cancelling elective surgical procedures, reducing the volume of acute-care surgeries, closing all outpatient clinics, limiting the presence of trainees on service and calling-off departmental educational activities.2–6 This resulted in significant interruptions of clinical rotations. In addition, traditional in-person academic activities such as face-to-face teaching and simulation labs were halted; examinations, courses and conferences were postponed on an international level.7,8 Almost overnight, online learning transitioned from its status as a developing option to becoming mandatory if education were to continue.

The rapid transition from traditional face-to-face to eLearning has transformed the way medical education was delivered and posed many challenges to trainers and trainees involved.4,9 Synchronous and Asynchronous eLearning modalities have been utilized by several institutions during this period. Numerous platforms were utilized for delivering academic content; the most frequently used were ZOOM and Microsoft-Teams.10,11 Innovative teaching modalities took place, including the “flipped-classroom” method, where learners were provided with didactic materials and pre-recorded videos prior to the educational session.11–13 Other strategies were implemented to accommodate for teaching clinical skills and ensuring the continuity of clinical education, achieved through video-recorded surgical procedures as well as providing telehealth patient consultations.11 With regard to evaluation, the most commonly reported assessment method during this period was in the form of multiple-choice questions; other studies reported the conversion of the standard Objective Structured Clinical Examinations (OSCE) to an online version.11,14

Numerous obstacles and challenges have been reported as a result of this massive transition. Trainers, teachers, and educators were required to rapidly adapt to digital technologies; trainees encountered difficulties with poor bandwidth connectivity; accessibility and time management issues were evident, as well as communication challenges due to the lack of non-verbal language.11,15

The resulting global experience with online medical education is being shared primarily as information gathered from user surveys. Although quantitative data are essential, detailed qualitative data are as necessary today as they were in the early studies, to allow comprehensive and reliable investigations of this complex intervention comprising “multiple human components (teachers, learners, etc.) interacting in a nonlinear fashion to produce outcomes which are highly context dependent.”16

Accordingly, we distributed an online survey to postgraduate medical learners and teachers in Riyadh, Saudi Arabia. These data are expected to supplement the expanding total of literature, adding to the reported experiences and possibly contributing to the development of strategies that can resolve specific issues, gaps, and deficiencies in online postgraduate medical education. The aim of this study is to provide qualitative and quantitative assessments of postgraduate online medical education during the COVID-19 pandemic amongst trainers and trainees in Saudi Arabia.

Research Objectives

The research had three main objectives. The first was to describe the experiences, coping, perceptions, satisfaction and preferences for online learning by medical trainers and trainees. The second was to determine how the experiences correlated with perceptions, satisfaction, and preferences. The third and foremost objective was to test the null hypothesis: no difference between trainers and trainees on various aspects of online learning.

Materials and Methods

In this cross-sectional study, a questionnaire was developed through a review of recent publications on online learning during the Covid-19 pandemic in addition to the experiences of the researchers involved. At first, the questionnaires used in previous similar studies were carefully reviewed by the authors. Then, more questions were added based on the experiences of the researchers involved— whom were either active trainers, learning managers or decision makers during the pandemic. The researchers discussed the items of the questionnaire for relevance and finalized only 43 of them.

The questionnaire was pre-tested on a pilot number of potential respondents, with care being taken to exclude them from the main survey. The questionnaire comprised several sections addressing the sociodemographics of participants and measures of experiences, perception, satisfaction, and preferences. Table 1 shows the list of variables used in the research and their corresponding questions. Nominal variables were recorded as multiple-choice questions, while ordinal variables were scored based on a 4-point or 5-point Likert Scale.

Table 1 Variables of the Study

Institutional Review Board (IRB) approval was granted on 1 July 2020 from the local IRB at King Fahad Medical City—under category “Exempt” based on Good Clinical Practice (GCP) Guidelines. The questionnaire included a cover-letter describing the purpose of the study along with a statement of informed consent for research participation—which was developed in accordance with the local IRB guidelines. No participant identifiers were collected as part of our survey and the responses were anonymous. The involved researchers maintained adherence to GCP guidelines throughout the duration of the study.

The questionnaire was distributed by e-mail on August 21, 2020, to 1200 trainers and trainees of academic medical centers within the Riyadh 2nd Health Cluster, which included King Fahad Medical City, Prince Muhammad Ibn Abdulaziz Hospital, Al Yamamah Hospital, King Salman Dialysis Center and three specialized dental centers. The sample size was computed using the Raosoft online formula as 205; based on a total population of trainees and trainers of 1200, alpha error of 0.05, 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} confidence level, and a 2:8 distribution based on the estimated trainee-to-trainer ratio. A follow-up was made 1 week after the initial e-mail via a reminder e-mail and/or phone call. Data received were checked and edited for consistency and accuracy. Open-ended items were coded, except for 2 questions (Q18, Q38) which were analyzed qualitatively. The variable “position” was defined as either “trainee” or “trainer.”— “Trainee” was coded to include residents R1-R4, interns, fellows and pre-scholars; “Trainer” was coded to include consultants, assistant consultants, and program directors.

Statistical analysis was carried out using SPSS v.26 to cross-tabulate frequencies of the variables and test for association using the chi square statistic, with significance being set at 0.05 using 2-sided asymptotic p values. Both the Spearman and the Kendall tau correlation coefficients were computed with a critical value of significance of 0.05 and 2-sided p values. The main objective of the analysis was to determine and explain the differences between trainers and trainees. Where indicated, multivariate logistic regression models were used to test for association while controlling for confounding to determine independent associations.

Results

Study Sample Socio-Demographics (S1–5)

A total of 1200 emails were sent out, of which 207 were returned giving a response proportion of 17{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Table 2 shows the sample characteristics. There were significant differences between trainees and trainers in age, gender, household size and specialty, but only age showed independent association after running a logistic regression model containing all the socio-demographic variables.

Table 2 Sample Characteristics

Transition from Traditional to Online Learning and Changes in Institutional Policies, Procedures, and Support (Q1, 2, 9–14)

Table 3 shows reported transitions and changes due to the pandemic. A high proportion, 82.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, rated their pre-pandemic computer and internet experience as high or medium and there was no significant difference between trainees and trainers. One-quarter, 25.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, had no online learning experience before the pandemic, with a higher proportion among trainees. There was no significant correlation between their pre-pandemic computer and internet competency with pre-pandemic online learning experience. Age was not correlated with the pre-pandemic computer and internet competency but was significantly negatively correlated with pre-pandemic online learning experience (rS= −0.257, P < 0.000).

Table 3 Transition from Traditional to Online Learning and Changes in Institutional Policies, Procedures, and Support

There was a positive correlation between the reports of ‘redesigning teaching courses’ and “change of procedures to accommodate online learning” (rS= 0.360, P < 0.0001). Major or drastic changes were reported in both by 44.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and 39.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of respondents, respectively. The trainees differed from trainers in reporting provision of guidelines before the start of online learning activities (P < 0.024). About 27.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of trainees reported inadequacy, while a higher proportion of trainers, 58.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, reported absence of guidelines. About 70.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of respondents reported a high level of institutional support for online learning with no significant difference between trainees and trainers.

A high proportion of respondents, 80.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, reported coping well or very well with online learning, with no significant differences between trainers and trainees. Coping was negatively correlated with age (rS= −0.151, P < 0.030), positively correlated with the pre-pandemic computer and internet competency (rS= 0.202, P < 0.004) but not correlated to pre-pandemic online learning experience (rS= −0.094, P < 0.177).

The transition from traditional to online learning was associated with stress. About 24.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of trainers reported extreme or major stress compared to 20.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} among trainees, and there was overall significant difference in stress between trainers and trainees. Stress was correlated with the pre-pandemic computer and internet competency (rS=−0.162, P < 0.020), but not with prior experience of online learning or with age; as (rs= 0.035, P = 0.562) and (rs= 0.045, P = 0.453), respectively.

Online Learning During the Pandemic: Experiences, Perceptions and Satisfaction (Q3–8, 15–17, 19)

Zoom was the preferred software by 94.2{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of respondents. All modern equipment were used equally by trainees and trainers; laptops, smartphones and tablets, with desktop computers being the least (9.2{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}). More than half of the respondents, 53.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, reported spending 4 hours or more per day on online learning activities, but there was no significant difference between both groups (P < 0.224). The majority of online learning activities, 92.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, took place at home during quarantine period, with no significant differences between trainees and trainers.

The 2 most popular learning activities were lectures and seminars/webinars accounting for a total 87.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of all activities, but trainees reported more lectures while trainers reported more seminars/webinars. Case presentations/discussions was the most popular form of assessment at 49.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, followed by short oral examinations 15.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and online OSCE 12.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; the rest of the assessment methods were rarely used. It is noteworthy that there were significant differences: trainees reported more case presentations/discussions, 55.8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, while trainers reported more short oral examinations 26.4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and online OSCE 20.8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}.

Overall perception of online learning was very positive or positive, totaling 73{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, with no significant differences between trainees and trainers. Overall perception was correlated with age (rS= −0.0213, P < 0.002), with stress (rS= −0.359, P < 0.00), with coping (rS= 0.672, P < 0.00) and with satisfaction (rS= −0.835, P < 0.000).

On a Likert scale of 1–5, 71.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of respondents were either satisfied or highly satisfied and 3.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} were very unsatisfied, with no differences between trainees and trainers. Satisfaction was correlated with age (rs = −0.136, P < 0.020), Pre-pandemic computer and internet competency (rs = 0.146, P < 0.016), stress (rS= −0.363, P<0.0001), and coping (rS= −665, P < 0.0001) but was negatively correlated to overall perception (rS= −0.835, P < 0.000).

While the response to the item on difficulties of online learning was 39.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 15.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} reported technical problems as the most common problem, with trainers reporting 22.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and trainees reporting 12.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. A question on challenges and opportunities presented by online learning revealed that 39.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} agreed that online learning presented challenges and opportunities while 15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} thought it did not; however, this item had a non-response of 42.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}.

Comparison of Online to Traditional Face to Face Learning (Q20–32)

Respondents were asked to compare online to traditional learning on 12 items using a 5 point the Likert scale. These items were highly correlated. In total, the proportion, of “strongly agree” varied between 19.8–47.8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} among trainees and 8.2–35.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} among trainers. Significant differences between trainees and trainers were observed in 6 out of 12 variables. Learners were more satisfied with learner to teacher communication 35{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 30.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; teacher to learner communication 39{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 17{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; reduction in academic stress 72.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 62.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}; overall satisfaction 57.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 39.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, and academic stimulation 66.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 75.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Trainers agreed that online learning had less stress 62.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 72.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and that it gave more time to teachers 75.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} vs 66.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}.

A wide diversity of subjective responses was given to the open-ended item asking for what was missed from traditional learning. The most common factors being interaction and associated items, like body language and engagement. Other subjective responses related to classroom dynamics such as good teaching, attention, understanding, explanation and concentration. Others related to the need for human contact such as commitment, passion and activity. The rest of the responses were more objective and measurable such as clinical practice, supervision, time, communication, verbal feedback, and workshops. Some responders said nothing was missing.

Preferences Regarding Online Learning (Q33–38)

The reports on preferred time for online learning activities showed variability with no significant differences between trainees and trainers. The highest was evening hours after work 30.4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} closely followed by afternoon working hours 29.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, morning working hours 22.2{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, and night after work 15.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Weekends were the least popular 2.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Most respondents, 86{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, preferred the duration of online learning activities of not more than 2 hours with no significant difference between trainees and trainers. Lectures and case discussions were preferred by 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of both trainees and trainers as the most effective online learning activities. Respondents considered multiple choice questions 54.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and problem-solving questions 28.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} as the most effective assessment methods. With regards future preferences, 64.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} preferred combining traditional and online methods but a respectable proportion of 25.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} preferred continuing eLearning as the sole method of education. A negligible proportion of 9.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} wanted discontinuing online learning and returning to traditional methods.

Many respondents did not answer the item about what aspects of online education should continue post pandemic. Lectures and case presentations/discussion were the most mentioned, but these did not come with online learning. Five preferred returning to the traditional methods. One wanted “everything in online learning to continue post-pandemic”.

Discussion

Differences Between Trainers and Trainees

Online medical education is not new; however, the rapid switch to exclusive online learning worldwide required institutions to take a deep dive into what was previously considered a complementary educational tool. Although most publications are related to medical school education, several considerations and issues are common among all educational levels.11,17 Our research adds to the increasing number of reports documenting issues and perceptions in response to the transition to online learning during the COVID-19 pandemic.

The major null hypothesis of this study states that there was no difference between trainees and trainers on all variables relating to online learning within our study. Knowing the differences is important for tailoring future online activities to suit the abilities and expectations of trainees and trainers alike. Gender differences were not significant in our study; however, a generation gap was obvious from the data. The trainers being older differed in being more married, having larger households and specialties. Besides socio-demographic variables, trainees and trainers had significant differences on 11 variables that can be grouped as transition from traditional to online learning, online assessment activities, and comparison to traditional learning.

Transition to eLearning, Stress, Coping, Perception and Satisfaction

In the transition to online learning, trainees had more years of prior experience with online learning, which reflects the generation gap. The trainees, being younger, are well versed in computer technology and internet use compared to older trainers.

Several variables were correlated with age as the underlying determining factor. Previous experience of online learning by trainees (younger in age) has made their transition to pandemic online learning easier. Younger age explains better coping with online learning through its positive correlation with pre-pandemic computer and internet competency. The younger trainees had lower overall perception, which may be related to having less experience in learning methods and outcomes in general.

A recent literature review summarized barriers and solutions to developing and implementing online learning programs for medical students and postgraduate trainees in global settings; however, they were not complicated by the challenges of a worldwide pandemic.17 Time and infrastructure issues were 2 barriers during such comparatively relaxed environment in studies reported from 2006 through 2015. A pre-pandemic United States national survey of 214 internal medicine residency program directors reported that synchronous online learning was used by 40{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and asynchronous learning by 72{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of programs.18 The asynchronous programs were considered to be more accommodating of resident schedules and duty hour restrictions. However, even in those non-urgent settings, faculty development was considered to be less than adequate (30{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) or non-existent (56{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) by 86{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of respondents. In our survey, 74{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of trainers reported being provided with few (18{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) or no (56{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) guidance prior to implementing online learning. Trainees in our study were more prepared; however, barely one-third (33{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) had received adequate guidelines before embarking on their online learning activities. Conversely, a survey study at the College of Pharmacy (COP) at King Saud bin Abdulaziz University for Health Sciences in Saudi Arabia reported that almost two-thirds of the students believed that the COP was well prepared for the complete transition to online learning during the COVID-19 pandemic.19 In our study, the trainees were more aware of guidelines before the start of online learning—they must have sought sources other than the trainers. Most likely, they looked for or demanded the guidelines.

As with any transition from the familiar to the new, the introduction of online learning was associated with stress. The trainers experienced more stress with eLearning, which is explained by their shorter experience with online learning before the start of the pandemic. A focus group study of 60 undergraduate medical students’ perceptions of online learning was carried out in Qassim region of Saudi Arabia during April and May 2020. The study reported that, similar to observations in most studies of online learning, technical issues were common barriers.15 The authors emphasized that providing technology training courses to teachers is essential. Deficiencies in these skills could contribute to stress during the transition period. In our study, almost one-fourth (24{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) of teachers experienced major or excessive stress while transitioning to an online learning setting; while only 4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} had a negative coping experience once learning activities were underway.

Our results indicated that perception of online learning was positively correlated with coping, which is logical, and was negatively related to stress, which is understandable. Its negative correlation with overall satisfaction is explainable by the clash between the ideal of a high perception and the actual satisfaction from the reality of the experience. Indeed, as online teaching methods are being regarded as an efficient tool for learning, the quality of eLearning was expected to be comparable to traditional methods; and learning outcomes were not expected to be compromised.19 Most reports of experiences after the transition to online learning in medical education are also related to medical school education.20 For example, a survey study involving pre-clinical students was carried out at the University of California at San Diego during March and April 2020. They reported that, in general, students believed the quality of instruction and their ability to participate were negatively affected by remote learning.21 However, the short interval that has transpired since the start of the pandemic did not make-way for examining online learning outcomes achieved by students, with either positive or negative attitude towards it. Furthermore, in November 2020, 30 residents in a Mexican general surgery residency program (PG1-PG5) participated in a study surveying their experience after transitioning to online learning since April 2020.22 Although the academic and organizational level was considered higher than that provided by traditional learning, by 47{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and 67{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of participants, most (57{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) were neutral about whether there was a concomitant increase in their academic performance; and whether the changes had been more useful for their training (53{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) compared with their previous training. A systematic review of 29 qualifying articles examined the impact of COVID-19 on all aspects of surgical training, including the transition to online learning.23 Acknowledging decreased hands-on surgical experience; patient exposure was ubiquitous, which was in some cases accommodated partially by simulations and telemedicine. Although two studies reported 65{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} and 82{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of trainees had favorable opinions of their online learning; in one study, 65{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of trainees believed that even their theoretical training had been negatively affected.

Online Learning and Assessment Activities

Trainees differed from trainers in preferences of learning activities. Trainees had a higher proportion of lectures, while trainers had a higher proportion of seminars/webinars. There were notable differences between trainees and trainers regarding assessment activities; trainees mentioned highest participation in case presentations/discussions, while trainers mentioned more short oral examinations and online OSCE. The differences in describing the activities that took place are difficult to explain, since they experienced the same learning activities. There is a possibility that the question item was not understood by one or both groups; they may have indicated their preferences instead of their observations or the preferences biased the observations. We have no data on the distribution of respondents by hospital. It is possible that trainers who responded to the questionnaire were from hospitals that practiced online learning differently from other hospitals to which most trainees belonged.

OSCE assessment was not commonly reported by our study participants. The fact that 15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of teachers and 9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students reported it as an assessment method and did not recommend it for the future, suggesting that they may have had a negative experience. Although OSCE has been in use for many years, its effectiveness and role continues to be examined. Some pre-pandemic studies on OSCE assessments for medical students reported higher stress and difficulty levels compared to traditional assessments.24 However, positive experiences of OSCE use in medical school have also been reported. A small survey study in a teaching hospital in Dammam, Saudi Arabia, reported that 63{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of students and 80{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of faculty believed that OSCE provided a fair assessment of clinical skills; and approximately two-thirds agreed that it was an enjoyable experience.25 Postgraduate students have also reported positive experiences with OSCE. In 2012, a survey of 66 internal medicine residents’ perceptions of OSCE was examined in Saudi Arabia, after implementation of OSCE as part of the final clerkship exam in 2008.26 On a 5-point Likert scale with 5 indicating strong agreement, the mean score was 4.5 for items asking if the exam was well administered, well structured and if staff guidance was helpful. The mean agreement score for the items asking whether OSCE was stressful was 3.5 and was 2.3 for intimidating. The authors concluded that the overall perception of the residents towards OSCE was favorable and encouraging.

Prior to the COVID-19 pandemic, a small number of postgraduate training programs reported their experiences with virtual OSCEs.27 Subsequently, when the UCL medical school in London canceled face-to-face assessments in response to COVID-19, an online 18-station timed OSCE was convened.27 Assessments were similar to those used in traditional OSCE, including clinical communication skills, written communication, practical skills, examination skills, and professionalism. The authors shared 12 practical tips compiled from their experience and from the literature that can help in the design and delivery of online OSCE. The Harvard School of Dental Medicine developed an online OSCE during the COVID-19 pandemic using the Zoom eLearning platform, because it featured breakout rooms where private mini-sessions could be created by the host.14 Students signed-in and were allocated to their breakout rooms; then progressed through the rooms when the allotted time had passed. Most students thought the online OSCE was as successful as traditional OSCEs, and all students believed they were able to completely demonstrate their knowledge. Examiners also had positive impressions of the online OSCE and emphasized the importance of calibrations and run-throughs prior to launch. Technical issues were the only difficulties encountered. The authors believed there was value in moving the in-person assessments online in the post-pandemic era.

Comparison to Traditional Learning

Trainees differed from trainers on 6 out of 11 items comparing online to traditional learning. Trainees were more apt to agree that online learning was better for teacher-learner communication, reducing academic stress, overall satisfaction and academic stimulation, whereas the trainers disagreed. These disagreements are explainable by the phenomenon of the generation gap considering the experience with computers and the internet, which is higher in the younger trainees. Trainers agreed more than trainees that online learning gave more time to teachers. This is understandable because online learning saves transient time between events such as movement to and within the hospital.

A recent meta-analysis of studies reported from 2000 to 2017, which compared online with offline undergraduate medical education, reported that knowledge and skills were significantly improved with online learning.28 Although not all studies in the review signify that online learning was more effective, none concluded that online learning was less effective than traditional learning. A single-center US study after the COVID-19 pandemic began included 81 emergency medicine and internal medicine residents. They reported that participants preferred in class interactions with peers (85{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) and lecturers (80{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}); with 62{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} reporting decreased engagement with lecturers during online conferences.10 Residents were significantly more engaged in other tasks during online conferences compared with in-class attendance. In our study, 35{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of participants disagreed that online learning was academically more stimulating compared with traditional learning settings.

Changes in communication opportunities may contribute to decreased acceptance or effectiveness of online learning. An Egyptian survey (N = 78) and focus group (N = 25) study examined faculty perceptions of medical school responses to the COVID-19 pandemic. They reported that communication issues between faculty and students led to student detachment.29 Almost two-thirds (63{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) of our teachers disagreed that online learning enhanced teacher-learner communication, and 57{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} did not agree that it improved learner-teacher communication. Although our students expressed more positivity, only 39{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} believed learner-teacher communications were improved in the online setting, and 35{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} believed teacher-learner communication was improved.

A survey of 538 clinical years (fourth through sixth year) medical students was performed in all medical schools across Jordan; less than 2 months after a state of emergency was proclaimed in response to the COVID-19 pandemic in 2020.30 Over half of the participants (62{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) reported poor interaction with instructors as a drawback, with only 14{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} reporting better interaction in an online learning setting. More students would prefer a hybrid approach in the future whether they were satisfied (22{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), neutral (24{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), or dissatisfied (29{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) with the online learning; and a return to traditional learning was preferred by more students dissatisfied with online learning (15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) compared with neutral (4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) and satisfied (1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) students. The majority of our teachers and students advocated for hybrid (65{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) or online only (26{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) education in the post-pandemic period; accordingly, efforts to maximize the benefits provided by online education are warranted.

A cross-sectional study in India included 55 postgraduate surgery residents who were without previous exposure to online teaching; the study was performed 1 month after transitioning to online didactic training during the COVID-19 lockdown.31 The transition included an orientation program for all teachers and residents. Individual items on the quality of online teaching did not indicate perceived superiority of either online or traditional learning; however, the authors considered the overall quality perception of online teaching to be favorable. The participants in our study were almost exclusively involved in theoretical learning and teaching. Transitioning to online education in this capacity does not require the capabilities, infrastructure, and inputs that are required to provide online clinical training. Overall, one-half of our study participants disagreed that online learning was better for teaching skills, with a higher percentage of teachers sharing this view (63{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) compared with students (45{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}). Similarly, a survey study of medical schools was conducted in Libya in mid 2020; stating that over half (55{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) of the participants disagreed or strongly disagreed that online learning can be used for teaching clinical aspects of medical sciences.32

Recommendations

A review of 14 studies on adaptive processes to the COVID pandemic in undergraduate and residency programs concluded that re-modulating the educational approach provided positive opportunities for personal and professional growth.11 However, the authors acknowledged that these qualitative narrative studies did not systematically analyze the characteristics and results of the changes that were introduced. They also believed that many of the enhancements that were described would require economic inputs that are not achievable in many parts of the world. Another study also suggested that the shift toward online education may have a lasting positive impact.33

The historical use of online videos for teaching procedural skills to postgraduate medical learners was exemplified when a systematic review was able to identify 20 qualifying articles published between 2009 and 2019.34 In the pre-pandemic period, the use of online videos was considered complementary to the more traditional teaching models. Virtual lectures could allow expert educators to disseminate beneficial knowledge to programs that do not have that level of expertise. Within an institution, cross-disciplinary education may be facilitated. It is considered that on demand virtual asynchronous lessons can be an inexpensive way to improve both access and content quality.35 These authors also believed that cross-institutional virtual collaborations can be part of a low-cost time conservative strategy; providing specialized training that otherwise may not be available in the learners’ institutions.

Several recommendations have emerged as medical training had to be adjusted for the limitations of COVID-19 on a global scale. Telehealth initiatives have been launched and/or expanded in several settings. When permitted by their institutions, residents can benefit from participating in virtual patient visits, reviewing charts and engaging in patient counseling under the supervision of the attending physician.36 Studies for examining the benefit of incorporating telemedicine into resident curricula are warranted. A few programs have responded to the pandemic by creating virtual video-based clinical training.37 A US undergraduate surgical education curriculum developed in response to the pandemic, emphasized the importance of using an interactive live-streaming platform for surgical experience, as well as patient-facing telehealth visits.38 The authors concluded that their virtual surgical education could be expanded for use in the post-pandemic era. Accordingly, institutions could benefit from cooperating on the development of valid strategies to incorporate clinical training into their postgraduate educational programs. Cleveland Clinic in Abu Dhabi constructed a 3-level pandemic response approach for developing and facilitating interventions determined to be necessary to maintain residency training.39 Online didactic education was supplemented by converting rounds to virtual platforms. However, their detailed framework description awaits assessment of its effectiveness and resident perceptions and satisfaction.

It is evident that currently published studies must be examined for their contributions to online learning development and implementation strategies in the future. Surveys such as our study can provide the basis for undertaking additional studies; to identify and adopt creative methods for effective online learning delivery and assessment. Tracking and identifying student skill gaps has become even more essential in a setting with reduced clinical learning opportunities. Innovation opportunities triggered by the pandemic should be taken advantage of; virtual and augmented reality technologies may be particularly important for teaching practical skills such as emergency interventions and surgical techniques.

In summary, our study adds to the baseline provided by numerous other studies of online learning experiences during the first few months of the COVID-19 pandemic. These early publications should be followed with additional studies, where details of program design and modifications in response to these initial observations are shared and realistic assessments of program effectiveness are performed. The availability of adequate qualitative details can contribute to collaborative participation in developing standardized strategies that can overcome the challenges of the pandemic and increase the quality of medical education in the future.

Limitations of the Study

The actual study sample of 207 was adequate according to calculations, but the researchers had been ambitious sending out 1200 questionnaires to capture as much diversity as possible. The relatively low response proportion of 17{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} is explained by the general digital fatigue in the society, because people receive many research questionnaires through the social media. The sampling could have been more representative if it was stratified to account for differences between training hospitals and academic centers. The study could have been enriched by additional qualitative research on some variables to obtain more in-depth understanding of online learning, which is a new phenomenon.

Conclusion

The main finding of the study is the difference between trainees and trainers in their experiences with online learning. This is explained by the generation gap in the acquisition and use of modern technology between the older trainers and the younger trainees. Overall, there was high proportions of coping, perceptions and satisfaction with online learning. The majority of the respondents also preferred continuing online learning combined with traditional methods in the post-pandemic period.

Acknowledgments

Dr. Valerie Zimmerman for her great work in reviewing the manuscript.

Disclosure

The authors report no conflicts of interest in this work.

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