Our study presents a pedagogical framework for DL, which was disseminated efficiently and effectively during the unprecedented times of the COVID-19 lockdown period. To our knowledge, this is one of few studies in the literature, in which the pedagogical framework was strategized by employing learning theories that support DL. In order to derive the initial blueprint, we amalgamated the model of community inquiry by Garrison et al [15, 16], principles of connectivism by Siemens [17-19] [, the and model of online collaborative learning by Harasim [21, 22] (Figure – 1).
The community of inquiry theoretical framework characterises a process of constructing a deep and eloquent (collaborative-constructivist) learning milieu through the development of three interdependent elements – social, cognitive and teaching presence (Figure – 1).
Social presence, as defined by Garrison, is “the ability of participants to identify with the community (e.g. course of study), communicate purposefully in a trusting environment, and develop inter-personal relationships by way of projecting their individual personalities” [15]. Teaching presence is the “design, facilitation, and direction of cognitive and social processes for the purpose of realizing personal meaningful and educationally-worthwhile learning outcomes” [40]. Cognitive Presence is the extent to which learners are able to construct and confirm meaning through sustained reflection and discourse [41]. The community of inquiry model allowed us to efficiently integrate computer and cyber resources as a versatile medium for the delivery of our teaching principles (Figure – 1). Further, the use of this theoretical framework allowed us to generate a “Community of Inquiry” that is composed of instructors and students, the key participants in the educational process.
Next, we integrated precepts from connectivism of Siemens into our pedagogical framework [17-19]. Connectivism considers learning as a multifaceted process that is catalysed by technology and socialization [18]. The foundations of connectivism are fuelled by chaos, connectivity, complexity, and self-organization theories. According to Downes, connectivism also finds its roots in connectionism, associationism, and graph theory [42]. The principles of connectivism as per Siemens [17], are as follows:
- Learning and knowledge rest in the diversity of outlook.
- Learning is a process of connecting specialized nodes or information sources.
- Learning may reside in nonhuman appliances.
- Capacity to know is more critical than what is currently known.
- Nurturing and maintaining connections are needed to facilitate continual learning.
- Ability to see connections between fields, ideas, and concepts is a core skill.
- Currency (accurate and up-to-date knowledge) is the intent of all connectivistic learning activities.
- Decision making is itself a learning process. Choosing what to learn and the meaning of incoming information is seen through the lens of a shifting reality. Although there is a right answer now, it may be wrong tomorrow due to alterations in the information climate affecting the decision.
Therefore, instructors in a connectivist learning milieu guide students to information (that can preferably be accessed with ease) and address queries as required, thereby encouraging students’ learning and sharing on their own accord, through which students inadvertently create a learning community. Students are also spurred to seek out information on the Web, critique the information, and share their findings and opinions within the learning community that they have created (guided by the precepts of community of inquiry theoretical framework discussed above).
Lastly, in order to derive our initial pedagogical framework, we also integrated principles stemming from the model of online collaborative learning by Harasim [21, 22] (Figure – 1). Online collaborative learning theory posits the role of peer discourse as a pivotal process to learning and demarcates erudition as intellectual convergence, accomplished through three progressive stages of group discourse: Idea Generating, Idea Organizing and Intellectual Convergence (Figure – 1). Idea Generating or the first phase, points to divergent thinking within a group; brainstorming, verbalization, creating information, and thus sharing of ideas and positions on a specific topic or problem. Here, the role of the instructor is to facilitate idea generation and encourage active participation by all members of the group. Idea Organizing or phase two, is the initiation of a conceptual change. As students confront novel or singular ideas, which had been encountered or generated by their peers , they begin discussions in a more motivated way, thus clarifying and bundling these many ideas according to their relationship and similarities to one another. Idea organizing behaviour demonstrates intellectual progress and the beginning of convergence, as students discuss and/or debate to select the strongest and weed out weaker positions (using such processes as referencing, agreement, disagreement or questioning). Intellectual Convergence or the third phase, is typically reflected in collective understanding, a collective position (including agreeing to disagree), or a mutual contribution to and construction of shared knowledge. Harasim’s collaborative learning theory is distinct from the constructivist learning theory; nonetheless, “collaborativism” builds on constructivist (Garrison’s theoretical precepts) and connectivistic (Siemen’s theoretical precepts) learning theories by investigating and underscoring the role of discourse as theorized by Lev Vygotsky [43]. In summary, the preliminary architecture of our teaching framework aimed, not only at the delivery of knowledge, but also intended to create a milieu of collaborative learning, concomitantly augmenting student autonomy; or as put better in the words of Holmes and Ramos “to help learners to assume greater control over their own learning, it is important to help them to become aware of and identify the strategies that they already use or could potentially use” [44].
After the preliminary architecture was defined, we modified it using Anderson’s DL model [23, 40]. Anderson proposes that DL has two major actors: learners and instructors, and their interactions with each other and with the content. Learners can interact directly with the content they find and any way they choose. However, they may choose to have their learning sequenced and directed through the assistance of the instructor. These multi-component learning environments allow for the learning of social skills, collaboration, and the development of personal relationships among participants (Figure – 1). However, the community binds learners in time (as happens during live on-campus sessions), and thus forces group-paced learning. This is the key reason why we employed dedicated instructional design strategies of Gagne and Peyton for our virtual live-sessions (Table – 1). This allowed us to successfully create a ‘simulacrum’ of live on-campus sessions when delivering courses employing the DL pedagogical framework. Also, by integrating instructional design strategies, we were able to efficaciously create a learning environment in which students were not only able to interact with the content, but also could tackle questions/problems collaboratively. as well as receive timely and effective feedback from peers/instructors to identify their learning gaps and address them adequately - a learning experience that happens only in the classroom.
In order to appraise the efficiency of our DL framework, we implemented the framework in the delivery of the FEB course. This course not only involves dissemination of knowledge, in terms of different epidemiological and biostatistical principles, but also requires the student to gain practical skills, in terms of the use of statistical software packages to analyse data. The design of our virtual live sessions employed inputs from Peyton’s four-step approach (Table – 1), which allowed the students to rehearse and apply the disseminated concepts.
Didactic teaching, which students generally experience in the classroom, rarely facilitates potentiation of long-term memory [45]. When students “go-over” lecture materials or tutorial problems, maintenance rehearsal or rote memorization occurs, leading to “Surface-learning” [46]. Our pedagogical framework facilitates rehearsal and accelerates “Deep-learning” [47], as the student repeatedly applies the concepts delivered in analysing data. The process is diagrammatically elaborated in Figure - 3. This is one of the key advantages of our designed framework, which to our knowledge, has not been presented by any other study in the literature till date.
We evaluated our pedagogical strategy employing Kirkpatrick’s framework [25]. Evaluation of Level – 1 of our framework was pursued using a questionnaire (Supplementary Table – 1). In this study, we validated the individual items of the questionnaire using EFA (Table – 2). In line, this questionnaire is a tool that can be used for the evaluation of perception for any DL framework designed and implemented in medical education.
As evident from the results, the DL pedagogical framework was positively received by the students (Table – 3). Mean scores (Table – 3) obtained for individual items (Supplementary Table – 1) as those indicated below:
- DL allows me to work at home comfortably,
- In terms of use of time and location, DL is flexible,
- The content of this course meets my expectations,
- I like the content of the course which draws examples from real life,
- I advise other students to take this course, and
- In this course I am pleased with the timely responses to my questions, attested to the fact that students not only had an enriched learning experience through the DL framework, but also alluded to the detail that students engaged with the content in a way that fostered:
- Student-Student Interaction, which is a key component in online learning environments. In fact, modern constructivist and connectivistic theorists [15, 17] stress the value of peer-to-peer interaction in investigating and developing multiple perspectives. In fact, student-led discussion groups and collaborative learning are “reciprocal teaching” and help to develop communities of learning.
- Student-Content Interaction, a major component of formal education and DL. Through the discussion of real-life clinical problems (Table – 1) individual needs of each unique learner was addressed. This is pivotal because in a given cohort, students, including ours [35], avail different learning approaches.
- Student-Teacher Interaction, a key component of both classroom and DL experience, was supported in our framework through live-discussion sessions organized using MS-teams. We ensured that the flow of communication during these sessions was less instructor-centred than in traditional classrooms. This augmented greater learner commitment and participation.
- Instructor-Content interaction focuses on the instructor's creation of content, learning objectives as well as units of study, complete courses, and associated learning activities. In our framework, the students were provided with take home assignments and formative assessments, which allowed the instructors to monitor, construct, and update course content resources and activities; and provide effective feedback.
- Instructor – Instructor, interaction allows instructors to develop professionally and support one another through communities. These interactions encourage instructors to take advantage of knowledge growth and discovery in their own subject area and within the scholarly community of teachers. In our teaching framework, the instructors communicated the obtained student-feedback to the other concerned instructors, such that instructors could effectively identify the learning gaps of the students and tailor the material to be disseminated suitably in future sessions.
- Content-Content, interaction is a new mode of educational interaction in which content is programmed to interact with other automated information sources to constantly update. As the FEB course was delivered through our designed DL framework during the COVID-19 lockdown, a significant part of the instructional material was moulded in a way to inform students about the epidemiology of the pandemic (Table – 1).
In summary, students’ perception indicated that we were able to effectively address our strategized teaching principles through the delivery of the intended learning outcomes. Also, perception of the students effectively attested to the success and versatility of our designed DL pedagogical framework.
Level – 2 of Kirkpatrick’s framework evaluates students’ cognitive development following exposure to the DL pedagogical framework. To address that, in the summative assessment, we compared the performance of the students who experienced the course through the DL modality, to that of the students who experienced FEB through traditional teaching methods. As shown in Figure – 2, performance in the summative assessment of the students experiencing DL was similar to those who were taught through traditional teaching methods. This showed that students’ performance was not affected by the sudden shift from traditional teaching methods to DL modality. Also, the learning process of the students was not impeded when our DL framework was adopted for course delivery; if such would have occurred, it would have affected their performance adversely.
Based on the above observations, the designed DL framework presented a superior pedagogical approach, which, when adopted by any medical school, will have long-term advantages. This aspect is important as a recent study indicated that temperature and latitude do not appear to be associated with the spread of COVID-19, instead school closures and other public health measures seem to have a positive effect [48], which reflects that it is pertinent that medical schools avail the DL modality to address learning needs of students. Further, this can also be elaborated using Bourdieu’s Theory of Practice [49]. Bourdieu developed three intimately related concepts: field, capital, habitus (Refer to Figure – 4 for details of the individual concepts). By applying Bourdieu’s Theory of Practice, the designed framework, when executed and integrated in a competency-based medical curriculum, will allow the medical school to function effectively to deliver medical education, even during unprecedented times as presented by the current COVID-19 pandemia, to attract high achieving students (academic capital), as well as allow a more effective delivery of courses with access to limited infrastructure and human resources (economic capital). This will augment the ranking of the medical school, which has adopted the teaching framework (symbolic capital), as well as facilitate the school in applying and receiving more funding or emoluments (economic capital) in the field of medical education and health professions education research. These aspects will impact the medical school’s values, primacies and curricula (habitus). Furthermore, all the above will be reflected in students the medical school will attract and train (habitus).
While strategizing our DL pedagogical approach, we endeavoured to map it with different learning outcome frameworks. In this regard, we adopted the Dundee three-circle outcome model and the “Scottish Doctor” framework (Figure – 5). The “Scottish Doctor” framework is based on 12 – domains which are integrated in a three-circle model [50]. The rationale for choosing this framework is that the different aspects of healthcare do not function in isolation in this healthcare framework. As shown in Figure – 5, our pedagogical approach attested to several aspects in the “Scottish Doctor” framework either fully or partially. As the different domains are interlinked, we firmly believe that adoption of our DL pedagogical approach in a competency-based medical curriculum will attest to augmentation of patient care in the long run.
Although our DL pedagogical framework has overarching and specific benefits, there are specific limitations in our study that need to be addressed.
- Firstly, in this study we have evaluated only the first two levels of Kirkpatrick’s framework. However, levels – 3 and 4 of the framework, corresponding to “Did the intervention bring about a change in behaviour?” and “Did the intervention influence performance?”, respectively, still need to be evaluated (Figure – 1). However, in order to pursue these evaluations, long-term studies are warranted, where the DL framework needs to be adopted across courses in both preclinical and clinical phases of curriculum, following which the effect of this intervention has to be assessed using suitable tools. For assessment of level – 3 of Kirkpatrick’s framework, behavioural analysis of the ward rounds of students, exposed to the DL framework across different courses in the curriculum, needs to be pursued. In this regard, the methodology of Sanson-Fisher et al can be employed [51]. Evaluation of level – 4, i.e. effect of the intervention on clinical practice, can be pursued using a strategy analogous to Seeley and Harding [52]. Here, one group of students (the experimental group) will be exposed to the DL pedagogical approach in different courses in the curriculum. A second group of students (the control group) will attend courses delivered using traditional teaching methods. Dedicated multiple-choice question assessments and objective structured clinical examinations (OSCE) will be used to evaluate knowledge and skills. Results will indicate if the experimental group shows improved post-intervention clinical practice compared with the control group.
- Secondly, although our DL framework has been able to provide an enriched learning experience to students in the FEB course, will it be able to do the same across all the courses, specifically in those courses which involve the delivery of practical skills through laboratory sessions, such as anatomy and physiology. To address this issue, we have implemented the DL framework in the delivery of structure-function courses, where precepts of anatomy and physiology are disseminated. Results from this study are awaited and will form the basis of future scholarly communications.
- Thirdly, one of the reasons we were able to successfully implement our teaching approach within a limited frame of time can be attributed to the presence of well-structured e-learning and cyber resources at our university, which we have alluded to, in the methodology. However, “Can our framework be adopted effectively by medical schools with limited access to such resources?”, is a question that still needs to be addressed. One of the cost-effective strategies for medical schools with limited access to e-learning and cyber resources, will be to implement social media applications (SMA) such as YouTube channels and WhatsApp discussion groups in the delivery of courses through DL modality. In fact, our previous study indicates that these two SMA are regularly used by medical students in their learning process [18]. Additionally, instructors with limited access to e-learning resources can employ virtual classroom modules such as WizIQ (https://www.wiziq.com) , which provide flexibility of pricing.
- The fourth aspect, which one needs to consider, is the issue of proctoring assessments in courses delivered through the DL approach. We were able to circumvent this issue with ease as the FEB course, in which the DL approach was adopted, employed open book assessment, which does not require strict proctoring measures. However, for courses where other forms of assessments are required to assess competency, instructors can use dedicated DL proctoring modules such as Examity and ProctorU, as these modules can be integrated easily with the LMS and gives instructors the ability to self-manage the scheduling of proctored events. Also, these modules offer different levels of proctoring service depending on the needs of the instructor and the type of exam being given. These levels include, AA - automated authentication only; Level 0 - authentication by a live person; Level 1 - recording and random review of tests; Level 2 - recording and review of all tests; and Level 3 - live continuous proctoring.
- Lastly, it needs to be assessed if our teaching framework will be effective in the delivery of courses involving patient exposure. One of the ways to address this aspect will be to integrate the principles of telemedicine in our framework. A fundamental strategy for healthcare surge control is “forward triage” or the sorting of patients prior to their arrival in the emergency department [53]. Direct-to-consumer (or on-demand) telemedicine, a 21st-century tactic to forward triage that permits patients to be competently screened, is equally patient-centred and advantageous to self-quarantine, and it safeguards patients, clinicians, medical students and the community from exposure. It allows physicians and patients to connect 24/7 using smart devices. Respiratory symptoms, which may be initial signs of COVID-19 infection are among the complaints generally appraised with this approach. Health care providers can effortlessly obtain complete travel and exposure histories. Automated screening algorithms are usually built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers. In line, if precepts of telemedicine are integrated into our framework, especially in our virtual live online sessions, students will be able to interact safely with patients, even during the COVID-19 pandemic. However, this requires further investigation.