Critical success results and interpretation
After completing a brief interpretation of our research’s results, we should now target the most essential findings that through discussion will lead us to creating a consistent strategy to strengthen educational effect of e-learning. So, according to our survey, even though during coronavirus crisis online education’s frequency increased, medical institutions were proved to be generally unprepared for fully coordinating the transition process, resulting in:
- Being unable to comply with academic curriculum and thus, postponing or skipping over scheduled lectures or training sessions (44%)
- Changes in professional behavior and attitude of both trainees -due to their lack of active interaction- and faculty members, due to their unsuccessful adaptation to e-learning methods (50%)
We also noticed that residents’ overall assessment of e-learning experience factors (participation, satisfaction, barriers) was mostly average, however they clearly acknowledged digital education’s future potential. From these findings, we deduce that although institutional practice of e-learning was rapid and fulfilled some basic educational standards, the problem lies within regular establishment and training effectiveness of e-learning in the long term.
Key pillars of online education
In regard of these problematic aspects, in this point we can comment that the basic perceptions of trainees for the e-learning platforms and the online mode of training can be categorized in nine (9) key dimensions and pillars. These can serve as the basis for a meta-model for Best Practices for E-learning for Residents Training in COVID-19 pandemic period.
Technical Support: In this category fall various complementary opinions of trainees. Most common concerns related to the availability of internet connection, hardware devices and applications for sophisticated medical activities both in hospital and university grounds. Further technical considerations refer to the availability and cost of different platforms for e-learning and online communication. There is, in general, a demand for offers for both infrastructure and internet service.
Pedagogy: One of the most significant pedagogical issues for residents’ training during COVID-19 is related to the provision of clear structure of curriculum related topics through e-learning education. This is also associated with the need of residents to have available well defined and clear training and learning objectives. Additionally, the enhancement of motivations and active engagement of trainees to meaningful learning content is valued as significant. Thus, practical themes related to the availability and planning of more Lectures, pedagogical activities and practical sessions are becoming significant priorities. The same stands for the need of the trainees to be provided with more clear and more structured presentations. For a Smart technology point of view there is a request for enhancements to improve punctuality, interaction with students during lectures and online exams platforms.
Institutional Support: The majority of our survey’s questionees were either neutral or disappointed (about two thirds in total), when asked about the e-learning support provided by their medical training centers. More specifically, there is a high demand for commonly available facilities, combined with more detailed and flexible time management of the residents’ weekly activities. Taking into consideration the physicians’ hectic workload, it is quite common that their lecture and working hours may overlap, so under those circumstances they should be excused from their learning sessions or compensate the missed work time on another occasion. Healthcare institutions’ e-learning managers should be able to foresee such developments and adjust the existing time schedule. Another issue to be tackled by training centers is the sufficiency and quality of online education software, including modern teaching tutorials, online study guides and antivirus security programs, with the aim of ensuring trainees’ professional and efficient training. In parallel to better software provision, there is an additional need for institutions to handle the increasing information load, such as by separating junior from senior’s e-learning or establishing platforms in which all educational content can be stored.
E-learning platform: Careful thought and planning must be put into the operational advancement of the selected e-learning platform. Especially in the COVID-19 era, during which the conference hall is principally substituted by the platform, methodical actions should be taken so as that the learning experience is not degrading. Our study’s sample expressed an approximately average satisfaction regarding the use of educational platforms. This fact indicates there is still a lot to be done when it comes to the functionality of the e-learning platform. Above all, we need internet connection stability which can be assessed with numerous webtools and is a must for establishing an uninhibited and time-saving educational process. Residents should, also, be able to attend their training sessions on a daily basis by enrolling easily on the e-learning platform in an automatized manner, if possible. A very promising prospect for the extension of the potential capacities of the e-learning platform would be the establishment of online examination or even medical operations’ simulation -using the existing platform, altogether arranged by Saudi Commission for Health Specialties. Last, even when not highly needed, e-learning platforms can always be used in combination with traditional teaching methods.
E-learning strategy: Next, even if all the essential requirements pertaining to the technical use of e-learning software are met, we must also apply some basic principles of how and under which limitations to use the e-learning platform, thus we ought to structure an accurate and specified “e-learning strategy”. In order to clarify and explain further the composition of such a strategy, we will mention a few examples of which components we deem important. First, the teaching process must always take place only during academic-engaged time, that is the time spent at hospital or university grounds or by extension the time aimed strictly at learning; in other words there should be no intentional involvement in training physicians’ private time at home. Second, it is necessary that we ensure there is a minimum set breaktime period between working hours and lecture hours, which will be used for physical and digital transportation to the e-learning environment, as well as for the residents to have a decent rest. By the same logic, various more standards -including academic recognition of e-learning and importance of physical education- can be established, always to guarantee educational efficacy.
Educational enhancement: Considering that teaching is a form of bidirectional communication, we aim to preserve this particular characteristic when “passing through the screen” in online education. More specifically, as shown in this study, residents would like and basically need to know more about what they can do and how they can interact via e-learning. These requests pose the challenge of interactive e-learning and skill-building activities, which are essential for simulating physical education. Towards this direction, special workshops, webinars, and tutorials can be realized, educating physicians in terms of technical skills, e-learning literacy, mentorship and communication. The contribution of state-of-the-art technology to educational enhancement is also of the essence.
Human Factors: In order to optimize e-learning experience, our research also focuses on dealing with particular human factors, which are rather subjective and vary among trainees and healthcare institutions, however they offer a general concept of the trainees’ needs and how we must proceed to sufficiently satisfy them. Human factors mostly incorporate great demand of direct social interaction and free online courses within the academic duty hours, as well as fairer distribution of workload and time schedule. There has also been notice of institutional deficiency, in relation to providing residents with practical medical knowledge, which is independently obtained most of the times, as reported. Such issues must be tackled, by systematically and directly addressing the trainees’ anxieties and problems, e.g. using e-learning platform’s questionnaires.
Content Enhancement: The goal of online education, as it currently works in COVID-19 pandemic, is to temporarily substitute -in the most efficient way possible- physical education, due to an emergency situation. Nevertheless, future prospects should aim at e-learning quality and viability by fundamentally rearranging and enriching educational content. Main themes of content enhancement are the improvement of teaching material and applications, coupled with running more innovative lessons, based on group discussion, active participation, instructive medical tutorials and above all free access to educational material. The topics of the lectures should also be more precise, to-the-point and relevant to trainees’ needs -particularly to their selected specialty and up-to-date medical data (articles, webinars etc.)- so that the lesson has a practical use and the knowledge provided is well-rounded.
Soft Issues: Similar to human factors, soft issues include experiential concerns of highly subjective nature, that residents express about the academic behavior of their medical trainers or instructors during both lectures and training sessions. Problematics situations, in which trainers exhibit professional deficiency, negligence and indifference towards their duties or even overcharge their subordinates in terms of routine medicals tasks, should be addressed. Online education must also be rid of more severe issues, such as work intimidation and harassment of any type.
The pillars above are more analytically presented in Table 10 below.
Table 10: Key dimensions of online education
- Improve internet connection (on and off site)
- Ensure free subscription to or offers for internet applications
- Provide most suitable platforms
- Improve technical setup of e-learning
- Provide modern tablets
- Ensure free access to medical online facilities for all academic members
- Ensure meeting the time schedule
- Provide more e-learning tutorials and applications
- Store all educational material provided in suitable platforms, for national used (e.g. RCOG)
- Provide study rooms (e.g. library) that enable e-learning while at the campus or hospital
- Strictly comply with academic curriculum and adjust lecture topics
- Define clear objectives
- Increase motivation
- More lectures and activities
- More practical sessions
- Smart technology enhancement to improve punctuality, interaction with students during lectures and online exams platforms
- Divide the sessions into 2 groups: junior and senior
- Build skills and competencies for using e-learning platform
- Special workshops, webinars and training courses for digital literacy
- Carefully select/plan mentorships
- Promote interaction via technological upgrades
- Do feedback survey
- Pursue Innovation
- Encourage international communication
- Provide daily/weekly sessions
- Aim at standardizing online education, even after COVID-19, considering the platforms’ complementary impact on medical training
- Facilitate registration
- Arrange timely subscription to e-learning platforms and offer free use to trainees
- Encourage SCFHS interventions for provision of online exams and surgical simulation tools
- Rearrange time schedule: establish minimum break times between lectures and training hours
- Do not violate personal (off work) time with postponed lessons
- Encourage e-learning practice if needed for the academic activity
- Do not underestimate and underachieve in person teaching approach (Integrate with e-learning)
- Promote active engagement in educational process
- Accredit e-learning courses or degrees
- Ensure residents’ effective clinical training in relevance to selected subspecialty
- Do not overload trainees with unreasonable medical duties
- Ensure that training practice does not intervene with medical education and skill building
- Respect trainees’ employment rights
- Increase social interaction between colleagues
- Address work pressure issues
- In any case, provide free courses
- Additionally, complement in person training with e-learning methods if preferred by trainees
- Instructors: focus on training students with emphasis on motivation, mentorship, acknowledgment, and experiential education
- Exhibit professional conduct
- Radically address soft issues and adjust academic behavior
- Eradicate pathological phenomena in workplace: discrimination, psychological pressure, abuse, harassment, and any type of misconduct
- Keep the lectures to-the-point
- Focus on group discussion, and interactive learning
- Provide medical tutorials
- Pose practical questions
- Prioritize lecture topics, according to selected specialties
- Improve the materials & the applications used for comfortable, efficient & flexible e-learning
- Point out more case studies
- Purchase more question banks
- Seek feedback from trainees
- Exploit SCFHS learning material
- Hold more webinars
- Experiment with new applications
- Invest in making the content interesting and archived into free access library
Our contribution: E-learning Quality enhancement model & Maturity Model
Based on the analytical categorization of the nine key pillars, mentioned above, in this section we will proceed with introducing a new, multi-functional, strategic model for “Quality enhancement of e-learning process in medical institutions during COVID-19 pandemic”. This model, displayed at Figure 2, consists of six priority levels, the necessity of each decreases from bottom to top. Level 1 contains technical support; level 2 includes e-learning platform along with e-learning strategy; level 3 contains content enhancement and so on. For levels that include more than one parameter, each one has equal value to the other.
The above model is also one of our research team’s main contributions in context of restructuring online education during COVID-19 pandemic and is realized by analyzing our research goal into key dimensions and then classifying those into defined levels. As for its value, the recommended strategy can be utilized in various ways. First of all, it can be implemented by medical institutions and medical training centers as an operational framework for improving the existing e-learning methods and maximizing effectiveness not only of typical teaching with lectures but also of healthcare simulation courses.
Towards this purpose, the model can, also, serve as a foundation for complementary restructuring actions, aimed at preserving the accomplished enhancement of e-learning process. It would be very beneficial that medical directors or instructors in charge of e-learning arrange a regular assessment of the model’s key parameters through open dialogue or indirect interaction with the trainees – using for example the existing polling tools of e-learning platforms or even questionnaires that maintain residents’ anonymity. As a result, any complaints or unfulfilled goals will be reported and if possible addressed, so that there is a tactical review of the model.
Another critical effort would be the establishment of online education as a mandatory tool not only during the COVID-19 era but also in the long-term, as our findings also confirmed. Undoubtedly, physical education is irreplaceable regarding its educational value, still e-learning can be: first, necessary in emergency situations such as the current pandemic; and second, plenty helpful as a supplemental teaching method under normal circumstances.
However, redeveloping online learning structure and strategy cannot possibly be an immediate change, because of a lack of infrastructure, resources, human force and probably time availability. Still, we acknowledge the frequent necessity of instant e-learning use, as it is at present due to coronavirus crisis. Thus, we need an additional theoretical model, which accompanies the one introduced at Figure 2. To be more specific, in the previous model we examined e-learning enhancement, according to defined levels (one to six), which in fact are comprised of one or two specific key pillars (technical support, institutional support, etc.). In this point, we need to look into the development of e-learning setting priority measures in each “level”, thus defining “stages”.
In other words, the improvement of online education in medical institutions can be studied as a temporally-evolving developmental process and be divided into “stages”. Since there is a need for fast development, any upgrading efforts should start with “stage 1” for example -so that there is a prompt result- and, if finished, move on to the next, less crucial stages. Based on this reasoning, we suggest a “Maturity Model for E-learning Effectiveness in Medical training” (Figures 3), capable of optimizing e-learning impact and value and offering practical guidelines on how to proceed to each stage.
In Figure 3, we can see our Maturity Model’s basic components:
- We define three (3) “Maturity stages”, all of which require fulfilling specific measures of every key pillar (levels one to six).
- When the model is applied, priority is given to the earlier stage and lowest level, that is stage 1, level 1. Moving on to the next stages, theoretical effectiveness of online education for medical trainees increases.
In order to demonstrate our strategy’s concept in a more comprehensive way, we provide two indicative models (Figure 4 and 5) which refer to specific measures for the development of e-learning platform and strategy (L2) and content enhancement (L3) accordingly.
To sum up, we firmly believe that combining Quality enhancement model with Maturity Model can serve as a management tool and therefore, turn residents’ experience of online education into optimal medical practices.