Collaborative Online Learning in Undergraduate Medical Education: A Scoping Review

Background: Collaborative online learning is an active learning method that stimulates interaction between learners and teachers and fosters interest and motivation in learning in a virtual learning environment. Aim: The primary aim of this scoping review is to examine the extent and nature of academic publications on collaborative online learning in undergraduate medical education. Methods: We used a standardized framework for conducting scoping reviews to identify suitable publications and to analyze the content. Results: Thirty-six published articles from January 1990-March 2019 met the inclusion criteria. There were 16 interventional studies, 8 reviews, 7 commentaries and 5 survey studies. Most work originated in the UK or the US. These studies found that collaborative online learning demonstrated educational value by personalizing learning to t individual needs, promoting social interaction and active learning, and helping to build professional networks Connectivity, ease of use, and accessibility were enablers of collaborative online learning while technical challenges were the main barrier. Conclusion: There is a relatively small but promising body of work currently published on collaborative online learning in undergraduate medical education. Further work and innovation in this area may be forthcoming in response to the need for alternatives to traditional learning in times of crisis.


Background
What is collaborative online learning?
Collaborative online learning is an active learning method that stimulates interaction between learners and teachers and foster interest and motivation in learning in a virtual learning environment (1). Since the advent and popularization of the internet in the 1990s, the growing in uence of digital and social media has reshaped the teaching and learning ecology in medical education. Online learning has been an increasingly popular means to engage learners and teachers in medical education (2,3) particularly as students have access to computer technology in learning, through personal smartphones, laptop computers, and other wireless mobile devices. (4) Collaborative online learning in medical education uses a variety of tools for teaching and learning such as blogs (5,6), Facebook (7,8), Google Sites (6,9), Moodle (10,11), Twitter (7,12), etc. all of which have shown encouraging educational outcomes.
Why is it collaborative online learning important?
Numerous studies have shown that collaborative online learning can supplement conventional teaching practices and provide a more engaging and effective learning environment for teachers and learners (2,(13)(14)(15).
The interactive nature of collaborative online learning encourages active learning and enhances the learning experience by connecting and allowing dynamic creation of knowledge for students in individual and collective levels (16). Students can attain a higher degree of engagement in an online and can engage in team discussions and share their experiences with peers (4). Collaborative learning allows students to feel that they are part of a supportive community where they can share relevant knowledge, give effective feedback, ask for help and support through di cult stages, draw encouragement from other facing similar issues, and work constructively towards a common goal (11,17).
Online collaborative learning improves learning effectiveness (14), cost (2,18), and promotes e cient use of time (4,19). It has been associated with higher academic achievement, deeper levels of learning, and retention of learned information for longer times (11). Online collaborative learning can also train students to be self-motivated (4) and help students to acquire learning skills such as, better problem solving and higher-order critical thinking skills (11). The online platforms are effective for time management and facilitate schedule constraints by providing exibility for students to work on their own time and pace (4).
Collaborative online learning allows learners to co-create learning materials that suit their needs and learning styles. There is also evidence that collaborative online learning in medical education accommodates different learning styles of learners, is responsive to learner needs, and is effective in changing the learning outcomes of learners (19). These outcomes relevant to medical education include competencies like professionalism (5,15,20), and interprofessional collaboration (2,21).
Why do we need to have a scoping review on this topic?
Online collaborative learning is an opportunity for medical education to take advantage of the increasing availability and potential for mobile and technology-driven approaches (6). The application, advantages, and challenges of using collaborative online learning in medical education are currently under-explored (22) and it is important to identify factors that will promote collaborative online learning and foster the effectiveness of this mode of learning in a technologically advanced and information-rich world (13). It is also necessary to develop and implement novel teaching and learning strategies to boost collaborative online learning in medical education (16).
What do we want to explore?
This scoping review aims to examine the extent and nature of research articles published on collaborative online learning in the medical education literature. This will help to inform research directions and pedagogical applications for collaborative online learning in medical education in the future.

Methods
A scoping review is a subtype of systematic review aiming to map the available research studies related to the key concepts underpinning a speci c topic area with time (when it was published), location (country), source (peer-reviewed or grey literature), and or origin (healthcare or academic discipline) (23).
It aims to understand the in uence of such work and the depth and breadth of the eld, to identify gaps in the research studies, and report on the types of research studies that address and inform practice (23). It enables the clari cation of complex areas of inquiry and re nes and expands the essential concepts on the areas of subsequent research studies (2). This is often a preliminary part of an effectiveness review and leads to re ned search strategies etc. (24).
We followed the BEME Guide No. 3 systematic searching for evidence in medical education (24) and Arksey and O'Malley's ve-step framework for interpreting scoping literature reviews (25) to conduct this scoping review.

Stage 1: Identifying the Research Questions
To explore the literature on collaborative online learning in medical education, the following research questions were generated: • What is the extent and nature of the academic publications on collaborative online learning in medical education?
• What insights about collaborative online learning have we learned from the literature?

Stage 2: Identifying Relevant Studies
Guided by the research questions and following a consultation with the university medical librarian, we searched for articles using MeSH terms in PubMed and expand the search to relevant terms in other databases. These key terms "collaborat*", "online learning" (MeSH), "eLearning", "internet", "Education, Medical, Undergraduate" (MeSH), "medical education", "undergraduate". We searched these terms in seven electronic databases: PubMed, ERIC, JSTOR, ProQuest (including Australian Education Index, Education, Collection, Medical Database, and PsycINFO) for articles from 1990 to March 2019.
We undertook an additional search of online publications through Google and Google Scholar, and a further hand search of the reference list of all selected articles.

Stage 3: Study Selection
The inclusion criteria for this review were: 1) academic publications published in English; 2) relating to one or more of the three key concepts: "collaborative", "online learning", "medical education", and/or "undergraduate program" 3) involving medical students as the subjects or topic.
We excluded papers based on the following exclusion criteria: 1) solely non-medical education, (e.g. those solely focused on nursing, dentistry, occupation therapy, pharmacy, physiotherapy, etc.) and 2) solely non-undergraduate level of studies (e.g. those solely focusing on postgraduate education, continuing medical education (CME), distance learning with unrestricted participants, etc.).
After the rst screening of title and abstract by the rst reviewer, 183 articles were selected for a full review. Four study team members (PL, JT, HT, KC) conducted the reviews. Each article was screened independently by two reviewers to determine if the article ful lled the inclusion and exclusion criteria. Where there was ambiguity, three team members (PL, JT, HT) reviewed the article together in full, and resolved differences by consensus. Articles that consisted of abstracts or brief discussions were excluded. A ow chart of the article screening process is shown in Fig. 1.
Of the 36 articles, 17 related to all four key areas: "collaborative", "online learning", "medical education", and/or "undergraduate program". Four papers did not speci cally mention collaborative learning but discussed online learning in general including its collaborative features. Three papers did not speci cally mention online learning but addressed it from a wider perspective. Two papers included mix of students from different disciplines including medical students. Ten papers involved undergraduate education to some extent, and eight papers did not specify the level of education.
Stage 4: Charting the Data Key information was extracted by categorizing the nature of the selected articles. The following information was extracted from each of the included studies: • study aims • population, sample size • types, period, location, and duration of the intervention • methods /analysis • reported outcomes Stage 5: Collating, Summarizing and Reporting the Results A thematic analysis was undertaken to identify the key issues addressed in each paper which were then subdivided into themes. Information was tabulated and collated to gain insight into the features of collaborative online learning in medical education.

Results
The Extent and Nature of Research Studies

Characteristics of Selected Studies
Of the 36 relevant papers that underwent a full review, we found that 16 of were empirical studies focused on implementation and evaluation of an education program/element, 5 studies reported survey results on the use of social media, 7 were systematic or scoping reviews, and 8 were expert perspectives on collaborative online learning in medical education. (Table 1) Author Learning design, Effectiveness Table 1 Summary of selected articles The progressive prominence of personal computing and the Internet since the 1990's provided a favorable environment for collaborative learning (26). However, the earliest article related to collaborative online learning in medical education appeared in 2003 with a steady increase in publications since 2007.
In each year, there was an average of 2 to 4 papers published on this topic. (Table 1) Of the 36 included articles, 13 originated in the UK, 11 in the USA, the rest from Australia (three), Brazil (one), Canada (one), Croatia (one), Germany (one), Romania (one), Saudi Arabia (two), Singapore (one), and Switzerland (one). Five collaborative papers were led by the UK and the USA, supported by Australia, Ireland, and Rwanda.
A wide range of journals accepted papers on collaborative online learning in medical education led by Medical Teacher (9 papers), BMC Medical Education (3 papers), and Academic Medicine (2 papers). (

Description of Study Population
Among the ve studies of surveys on the usage of collaborative online learning, two studies were focused on members of medical associations, in which some members are undergraduate medical students, three studies are based on samples of students in one single university. The sample size ranged from 50 participants to 759 participants generally, with larger sample sizes for surveys than interventional studies.
( Table 1) There were 16 interventional studies on collaborative online learning. There was a wide range of study populations in the studies. Fourteen were based on an intervention at a single university, one was conducted in two different universities, and one targeted a more general population of followers on Twitter and Facebook including medical students. The sample size ranged from 10 participants to 300 participants. While single site studies are easier to conduct it is encouraging to know that a collaborative studies have been undertaken to provide more robust data on effectiveness and validity.
The interventions reported on a variety of applications in different courses. Eight interventions focused on a particular area of study, including a clinical clerkship, biomedical science, cardiovascular system and digestive system, experimental surgery, neuroscience, pathology, physiology, and rural medicine. Two focused on more generic clinical skills, including clinical reasoning, and medical interviewing. Three interventions focused on particular teaching and learning pedagogies, including case-based learning, peer-assistant learning, and problem-based learning. Among the interventional studies, nine studies involved students in the junior years (Year 1 and 2), and four studies involved students in the senior years (Year 3 or above).

Methodological Approaches
The outcome measure of collaborative online learning can be measured by 1) Self-reported satisfaction, 2) Self-reported knowledge gain, 3) Self-reported con dence gain, 4) Self-reported interests in pursuing certain career path, 5) Course evaluation, 6) Data analytics on platform usage (access, posting, duration), 7) Qualitative analysis of content (posts, comments, reactions), 8) Group interaction, student engagement, 9) completion rate of activities, and 10) Academic outcome.

Key Insights from the Literature
Several key educational issues emerged from this review: how collaborative online learning can in uence learning (pedagogy), what modalities are useful in delivering collaborative online learning effectively (eplatforms and apps) and what are the enablers and barriers towards implementation. (Table 1) Pedagogical Perspectives The online mode of learning encouraged more interaction and sharing among students and teachers. It also helped build professional networks (18,20), facilitated curriculum development (15,18) and helped introduce future career paths (18).
The dynamic virtual learning environment provided by collaborative learning applications encouraged student engagement in discussions and active learning. Cheston stated in his review that ten studies reported the use of social media in online learning stimulated interaction and promoted active learning (27).

• Learning Design
Nine articles discussed the learning design of collaborative online learning. Among these, one study suggested that the improved social interaction and sense of community belonging was a feature that made collaborative online learning effective (13). This can be undermined by a complicated and cumbersome design which underscores the importance of the selection of an appropriate application with a user friendly interface (15). Students are concerned about the extra workload imposed by collaborative online learning (9, 10) so ensuring that there is su cient support is a crucial factor in successful online learning design (15). An example of support is pre-launch training and technical support targeting learners and educators with less con dence or ability in using online applications (4,15,27,28).

• Learning effectiveness
Fifteen papers discussed the effectiveness of using collaborative online learning in medical education. Studies showed the sound effectiveness of collaborative online learning (2,4), particularly when using social media (27), forum (13), discussion forum (14).

• E-platforms and Applications
There is a spectrum of e-platforms and applications, or apps, for collaborative online learning. These include blogs, document management systems, instant messaging, learning management systems, media sharing, online discussion, online games, social bookmarking, social networking and wikis. Social networking applications are most frequently discussed in and Facebook and Twitter are the most commonly used. Most of the used applications are commercially developed, with only 1 using a selfdeveloped site for collaborative online learning. (Table 3) Seven studies focused on prevalence of using a particular application in collaborative online learning. Studies found that collaborative online learning applications are useful for knowledge acquisition (29,30).

• Enablers and Barriers
This review found that 6 of the 36 included studies provided reports of the enablers and barriers for using collaborative online learning. Enablers include the accessibility of "any time, any place" learning in the online space provided powerful learning experiences for teachers and learners (18,31,32). Collaborative online learning connects people with common interests (29,31,33). Two articles described the ease of using collaborative online learning. The familiarity in using social media is not only easy but also enables learners to share information online freely (18,29). A further study echoes that the ease of using is an important factor and advantage of successful online learning (34). Among these, several studies also pointed out the cost-effectiveness of using collaborative online learning (2,4,18,35).
One of the key barriers is the technical challenges (29). The ever-evolving online technology provided a novel platform for learning. Though most students in the Web 2.0 generation understand how to use online learning (4) and most applications require little or minimal technical expertise (28,36). Using collaborative online learning platforms demand some competence in handling technical techniques (14,37). Appropriate technical support is still necessary (38). Failure of software and connection to online learning platform (18), un-familiarization of the application (39), the requirement of extra technical supports (2), and time and manpower to develop collaborative learning (14) are technical challenges of using collaborative online learning.
Other barriers of collaborative online learning including the concern of privacy issues (29), quality of information available online (28), di culties with access to information online (28), learners' selfdiscipline (34). In contrast, some also pointed out that cost is a barrier in using such learning strategies (2,27,37)

Discussion
We sought to answer two questions with this scoping review: • What is the extent and nature of the academic publications on collaborative online learning in medical education?
• What insights about collaborative online learning have we learned from the literature

The Extent of Research Studies
The 16 empirical studies of implementation showed that there is an increasing trend of using collaborative online learning in medical education but the relatively low prevalence of articles may suggest that medical educators are hesitant to adopt it until its effectiveness is well-proven or until the technological and pedagogical barriers are overcome. On the other hand, the steady number of papers published each year, shows that there is ongoing interest and implementation of this learning mode. In particular, there is potential for furthering its use in specialty-speci c courses, medical skills training, and pedagogical development.
The majority of relevant studies were conducted in the UK and the USA, which may indicate that online learning started earlier, became more popular and gained more attention in those countries. The absence of empirical studies from Asia, Europe, and other regions is surprising, given the high smartphone penetration and high rate of technology adoption in Asian countries, for example. It may be that such innovations have just not been formally evaluated and published as this review was restricted to English language publication and did not cover the papers presented in medical education conferences and webbased publication. On the other hand it might also signify the potential of exploring how collaborative online learning in medical education is used in different cultural settings. The internet has no boundary, and online learning also has no geographical restriction which creates immense potential for collaborative work to explore how collaborative online learning in medical education can be pushed beyond current practices. Medical educators are encouraged to publish their work as a means of dissemination, networking and globalizing medical education.

The Nature of Research Studies
From this review, we found that the studies on the topic have been limited in scope with mostly small scale studies involving relatively small sample sizes. These may be pilot studies and perhaps some unsuccessful studies might not be reported. However, as the nature of online learning is geared towards large populations of learners, there is good potential for future interventions involving more learners resulting in studies with better validity for extrapolation and generalization of ndings.
Our review showed that intervention studies are more popular in junior years than in senior years in medical school. This might be due to the junior years are more relevant and suitable for online learning, which can cater to larger classes. This indicated that the novel online learning pedagogy is more popular among the foundation years as it gives more space for teachers and learners to explore new technology that could enhance their learning experience. In the clerkship years, the nature of teaching would require more patient-based learning and require more face-to-face contact. However, with the recent COVID-19 outbreak, many institutions have been forced to nd alternatives to face-to-face teaching and there may be many new collaborative online learning innovations born from this crisis in both clerkship and preclerkship settings.
A range of qualitative or quantitative research methods were used in the studies included in this review including one that used social network analysis (SNA) to understand the effectiveness of collaborative online learning. This approach provided a visual analysis of how learners collaborate online and helped to identify problem areas that require further attention and intervention. New research questions and corresponding research methods and approaches to analysis, such as SNA, adopted from other disciplines or domains, can help to understand the issues from other perspectives and further the scope of research.
As suggested by some reviewed articles, it would be interesting to expand the research in collaborative online learning by exploring how students interact with each other. This is an era of Web 2.0 and 3.0, researchers and medical educators must be upfront to the emerging development of technology and keep abreast of the demands and expectations of the learners. The exploration of new applications that t the needs of online learners is crucial. (36) Strengths and weaknesses This scoping review included many empirical studies, which show the current usage of collaborative online learning in medical education and provide good insights into understanding how the intervention Page 46/50 works. Those large scale surveys provided a macro-view on the extent of usage of collaborative online learning in medical education. The literature reviews on the topic provided an overview of the existing literature related to the topic. Many scoping reviews exclude opinion papers and commentaries, however, they are the ones that can give a more general understanding of the issue and provide an overview of how collaborative online learning is situated in the medical education and medical profession. Limitations of this scoping review include: absence of any quality assessment of the selected articles so there was no relative weighting or importance among the papers, restriction to English language papers, exclusion of conference papers and web-based publications, di culty with synthesis of information due to the heterogeneity of sources.

Conclusions
Collaborative online learning has good educational value that can encourage active learning and enhance student engagement. The selected studies highlighted the importance of learning design, especially providing su cient support for learners and teachers when introducing new technology to optimize the learning experience and outcomes. Social networking applications have a leading role. The exploration of using a commercially developed application and adopting its function for education would be a challenging but rewarding pedagogical breakthrough. Technological challenges remain a notable and constant barrier for collaborative online learning and will continue to require ongoing support for teachers and learners. With the relatively small body of work currently published on collaborative online learning in medical education, further work and innovation in this area may be forthcoming in response to the need for alternatives to traditional learning particularly in times of crisis.  Figure 1 Flowchart of the screening process