Most medical students (69.6% of BSS and 62.2% of CS) reported they felt either satisfied or neutral about their transition into e-learning during the COVID-19 pandemic, as shown in table 3. Similar rates were reported previously (8,15–17).
Teachers' performance, students' experience in using e-learning platforms and websites, and accessibility to websites have shown to have a significant impact on student satisfaction in this study, as shown in table 4. Students' satisfaction is higher when their teachers' performance was satisfying. Teacher performance in e-learning is influenced by multiple factors including time-consuming production of e-learning materials which may interfere with the busy schedules of physicians, the availability of technical support during the implementation of e-learning and the wide range of strategies to facilitate e-learning (18,19). The variability in teacher performance can be addressed by designating permanent staff members exclusively in charge of e-learning which can assist teachers by providing details of the programs used in the creation of e-learning content (19). In addition to providing the appropriate infrastructure for teachers, motivational incentives may be encouraging (19,20).
Other studies have shown that students still value face-to-face teaching over video lectures if possible (21,22). This was attributed to their mere shifting to video lectures without exploring the most suitable e-learning method for the subject being taught. For example, when new technology is incorporated into psychiatry undergraduate teaching, it needs to be carefully considered and evaluated. Students' knowledge and gain may be augmented largely by certain methods over others. Each method can have pros and cons and would affect what the students gain differently (23).
In our study, students who found the e-learning website not easily accessible were more likely to be unsatisfied with the online educational process. Student satisfaction was thoroughly studied, five components were set to be the pillars of online teaching which are effectiveness, accessibility, cost-effectiveness, student satisfaction and faculty satisfaction (24).
To examine the effect of anxiety associated with the COVID-19 pandemic on the teaching process, we asked the students to respond to becks anxiety scale. It showed no effect on their level of satisfaction.
More than half of the students that participated in this study stated they gained the same or even better knowledge than what they did before the lockdown. Teachers' performance and students' experience and accessibility to websites have all affected knowledge attainment.
It does not seem to be a consensus in the literature when comparing e-learning and traditional learning. In a systemic review of 50 studies used for testing knowledge gains, 12 of them found significantly higher gains in the online e-learning intervention groups compared to traditional learning. In contrast, 27 did not detect significant differences or mixed results were found (25). Another study revealed that undergraduate students preferred face-to-face learning over the e-learning teaching method. However, all students agreed that e-learning was good at teaching basic knowledge which required higher levels of thinking (26).
A study about e-learning in palliative care showed that 96% of students used e-learning as a preparation tool for their exams (27). Another survey for evaluating the effectiveness of an online teaching module in the pediatric department showed that e-learning is effective at increasing environmental health knowledge of clinical and non-clinical professionals, assessed by a pre-test and a post-test for the clinical expertise acquired from the online modules (28). Others have shown that educational technologies for respiratory care have an important role and that online learning for baccalaureate and higher degrees in respiratory care is promising. However, it is not easier than traditional learning methods, and it showed to be more expensive. Also, learning in respiratory care should include traditional face-to-face instructions (29).
A study about Video-Based Learning showed that the effectiveness of this tool is augmented by the teachers' consideration to manage and maximize students' engagement (30). This suggests that when dealing with large cohorts that teach students from many courses, the development of more specific e-learning materials is required for engagement levels to be maintained. This could take the form of more targeted and specialized cases and quizzes that are more directed and relevant to sub-groups of students.
Adding e-learning resources and utilizing technology to conventional Anatomy and Physiology were vital in mediating engagement and facilitating deep learning of fundamental concepts, adjusting these materials into career-specific teaching resources (how a particular organ system relates directly to their future profession) will aid learners to succeed in their studies and professions (8).
It is worth mentioning that delivering video lectures on campus does not have the benefit of flexibility and accessibility which are major features of e-lectures (23). Another study showed that students described a lack of control, feeling like passive recipients of e-learning and the feeling of being lost (31).
It is important to emphasize the role of the teacher or mentor in fostering the educational process. The teacher has a major role in explaining the content and highlighting concepts to deepen knowledge. This tends to improve knowledge gain and makes students more confident regarding the usefulness of e-learning (23).
Mobile use in medical education
Electronic devices constitute of mobile phones, tablets, laptops, and desktops. We found that the most used electronic device for e-learning is mobile phones, followed by laptops.
Other studies have also shown the popularity of mobile device usage among students (32,33). Mobile internet devices (MIDs) are becoming very popular in the modern era, which helps to provide many educational opportunities outside the classroom setting for different learners. Learners using MIDs and an internet connection have a wide range of multimedia learning resources readily available, which are collectively known as mobile learning ‘mLearning’ (34). The apparent benefits of students using mobile devices is context-dependent and could be misleading (35,36). The evidence-based medicine in the field of health professions should magnify the evidences on mobile device technicalities to discover how they would aid in learning and patient care (32,35). Students and healthcare professionals believe that mobile usage saves time, making patients' care more efficient and much easier (32,37,38). A recurrent theme was that students were reluctant to use mobile devices in front of patients to avoid being seen as unprofessional and in front of the staff to avoid misinterpreting the reason of device usage (32,39–42).
Just in time learning
Mobile devices can be an efficient tool of learning whereby the device promoted just-in-time learning in the clinical context, repetition of learning, supplementing rather than replacing learning and making use of wasted time so that learning can be done without setback (43,44). Mobile phone use is the simplest way for students to access information quickly during their clinical placements. It may be beneficial to include mobile phone use in medical education in an official manner and to provide students with instruction on professionalism and communication skills. Thus, maintain a professional image in balance with learning and other duties as future healthcare professional (45).
Jordan is a low to moderate-income country which is under substantial national debt, the gross national income precipitate is estimated around 4300 US$ and the National Debt soaring around 95% from gross domestic product, poverty rate is around 15% (46,47). Our study showed that 9% stated that electronic devices cause students' financial burden and 12 % stated that internet connection did cause them financial burden as well. Which is not high when looking at the country's economic status yet it represents a considerable obstacle when shifting toward e-learning, this was clear in other studies (48).
Students recognized streaming applications and YouTube as the most beneficial platforms for learning. Young adults make an extensive use of video in their daily lives (49). The use of level-adapted video-based learning (VBL) is a new and innovative concept that meets the expectations of both teachers and students besides VBL increased the motivation of the students (30,50). Real time interactive tutorials such as streaming have been found to be more beneficial than links to a pre-recorded video of the tutorial (22,23).
Concerns were aroused due to loss of face-to-face interactions which might lead to loss of collaborative experience, relationship building and presentations in front of the audience, which might affect their competitive abilities in their future carriers (51). Therefore, live online sessions should preserve and encourage interactivity and active enquiry (23).
Although WhatsApp was not highly appreciated, still many have reported it as a beneficial tool which secures the two-way interaction and might improve learner's knowledge as it should be more utilized in the future (34,52,53).
In place of a secure educational tool, it uses a two-way option for all users, allows the monitoring of users' activity and message reading and has end-to-end encryption (14,54). Current evidence strongly suggests that WhatsApp is a suitable resource for their purposes and that further research in this area is not warranted (34,55).
When asked about the platforms they would like to see in the future the majority wanted on-site teaching for rounds and clinical sessions and online sessions for lectures, the answers are consistent with the blended learning which seems to have the merits of both face-to-face and distance learning. Medical students tend to support the use of digital technologies in addition to traditional face-to-face instruction, an approach known as 'blended learning' (4,23).
This cross-sectional survey is self-reported, which may cause several limitations and sources of bias. Due to the anonymity of the survey, comparing respondents with non-respondents is not possible. Students living in remote areas may low or no response rate due to the socioeconomic status and difficulties in connecting to the network. Besides that, the survey is somehow long for the respondents, which can create random answers from the students as they lose engagement after spending too much time. Besides, no identification verification is used, which may lead to inaccuracy as the web-based survey can be filled multiple times, can be filled by another person like a family member or a friend, and can be filled by non-medical students who are out of the scope of our study.
Our study aims to draw conclusions that would help in the improvement and continuity of e-learning on national and international levels, especially in the current times of the COVID-19 lockdown. The outcome of the research can be utilized by other universities, medical schools, student affairs office and office of technical support to build the most convenient e-learning website and strategies based on students' feedback, to meet the highest standards.