Quantitative Phase Results
The average age of participating students in the study was 21.47 ± 2.34, with an age range of 18 to 43 years. The majority of participants were female (62%, n = 319). (Table 1)
Table 1: Here
The descriptive statistics of the scores for the axes and dimensions of the questionnaire on a standard scale of 0 to 100, for comparison of axes and dimensions in the same unit, indicate that the highest scores by students were for the Immediate Feedback and High Expectations axes, respectively with scores of 64.65 and 65.46. The lowest score was for the Collaboration Among Students axis with a score of 55.90 (Table-2).
Table 2: Here
The results of the linear regression test in separately examining the relationship between the Teaching dimension and the Interaction and Learning dimension axes showed that for every unit increase in score in the High Expectations axis, Diverse Talents axis, and Learning Methods axis, the Teaching dimension score increases significantly by 2.00, 1.91, respectively (P≤0.001). In the multivariate regression analysis related to these factors, results showed that all axes of Interaction and Learning dimensions are associated with the Teaching dimension score. So that, on average, for every unit increase in the score on the High Expectations, Diverse Talents, and Learning Methods axes, an increase of 1.30 and 0.44 units in the Teaching dimension score is observed respectively (P≤0.001) (Table-3).
Table 3: Here
Also, the regression analysis was conducted to examine the relationship between Interaction with the sub-dimensions of Teaching and Learning, and the relationship between Learning with the sub-dimensions of Interaction and Teaching. In one case, the collaboration among students was not significant (P=0.262), and in other cases, there was a significant correlation (P<0.001) (Supplementary Tables-1).
Qualitative Phase Results:
All participants were members of the university faculty, with 9 individuals (56.25%) being male, 4 (25%) being associate professors, and the rest assistant professors. Six (37.5%) were clinical faculty members and the rest were in basic sciences. All had at least 5 years of teaching experience and had planning and executive responsibilities during the time of COVID-19.
Following the final analysis of online teaching by experts, four main domains were identified, including (Infrastructure, Resources, Quantity of Education, and Quality of Education) and 16 sub-domains, namely (Scientific Infrastructure, Technical Infrastructure, Communication Infrastructure, Technology Infrastructure, Resource Saving, Increase in Personal Expenses, Increase in University Expenses, Educational Content, Timing, Continuous Education, Student Participation, Interaction, Feedback, Practical Classes, and Evaluation) with a total of 84 items being generated. (Table-4)
Table 4: Here
A- Infrastructure
1- Scientific infrastructure
Participants in the study pointed to the importance of online teaching and the need for preparedness for virtual teaching in teachers and students and their capabilities. Participant 3 emphasized the importance of having a scientific infrastructure for online teaching and the necessity for teachers' preparedness, saying, "The university did not provide any training for us, and I learned to work with the system through trial and error. It took me a few sessions to learn how to work with e-learning". Also, participant 8 talked about the lack of complete readiness of teachers for online teaching before the COVID-19 pandemic, despite the presence of guidelines for using this method in teaching, " The university had been talking about virtual teaching for four or five years ago, set up classes, but because it was not mandatory, we did not attend. Personally, I didn't go, and I hadn't worked with its software. Well, the year that Covid-19 emerged and classes became virtual, the first thing I did was read the guide that existed and I learned by trial and error".
Participant 2 mentioned the existence of online teaching regulations before the COVID-19 pandemic, "In our regulations before COVID, we could do 20% of teaching online, but there was not much enthusiasm, but some teachers did, a few handfuls. But with the start of COVID, we were all caught off guard and had no experience of this kind".
2- Technical infrastructure
Technical infrastructure problems in universities and educational, therapeutic centers, and the incompatibility of the existing platform with the volume of students, etc. were the issues that the experts pointed to. Participant 1 said, "The infrastructure was present in our college, considering we had a virtual unit before, but it wasn't enough. The main challenge was the lack of a tablet or laptop or a mobile device to run classes, which was both for teachers and students".
Participant 6 stated that the university's infrastructure can change or improve considering the circumstances, "The university's infrastructure was not very prepared from the start and took time to get ready. They realized that this system was not designed for testing at all and the system is not ready to accept this volume of students".
Participant 11 also added, "I definitely consider this an opportunity because we did not have a content production room at all, and for this purpose, a content production room was created. Of course, the first time we made a content production room, it was a very simple and concise room".
3- Communication Infrastructure
The issues related to internet disconnection and inadequate access in various geographical areas was pointed out in this area. (Participant 16) emphasized the undeniable impact of internet quality on all aspects of online education and teaching, adding, "One of the main challenges was the internet disconnection. For instance, it would suddenly get cut off in the middle of the class and by the time it got reconnected, the class time would be over. The next professor would arrive with the subsequent class, and then we were forced to hastily cover the leftover topics from the previous class at the start of the next session".
(Participant 6) noted that the difference in internet quality in different parts of the country is also one of the challenges of online teaching. They said, "We had internet problems as usual, because there was not enough capacity for all these classes to suddenly hold a bunch of online classes. And the next issue was that internet access was different in different places".
4- Technology Infrastructure
Software capabilities and actions that learners can undertake through this type of learning were among the topics experts referred to. (Participant 5) spoke about the execution of assigned tasks by students and their uploading onto the electronic system, stating, "A good thing that was done was the tasks we gave to the students, like writing an article with the rules we set for them, or researching a specific topic. After the student uploaded it, we could easily receive them and then evaluation could be done".
(Participant 7) discussed the possibility of students downloading uploaded files from the electronic system, stating, "The students could easily refer to the system and the page related to the desired course, download them and study them. I think one of the positive features of online teaching compared to traditional and face-to-face teaching is this issue because in these circumstances".
B- Resources
1- Saving Resources
Experts referred to lower teaching costs, commuting, and the possibility of participating in scientific webinars virtually, etc. On this matter, (Participant 6) stated, "In my opinion, one of the advantages and opportunities of online teaching is the reduction of costs because neither we nor the students needed to move from our workplace or residence to hold or participate in classes". (Participant 14) mentioned this method as an opportunity to participate in scientific seminars that are held as webinars at various universities in the country, saying, "During this period, we could easily participate in and benefit from various educational webinars held by different universities across the country, which we would not have been able to attend due to the universities being far from us".
2- Increase in Personal Expenses
The shift from face-to-face to virtual education necessitated the provision of certain facilities, leading to an increase in the personal expenses of learners and teachers. Regarding the necessity of certain facilities for both teachers and students to participate in and hold virtual classes, (Participant 5) said, "Naturally, to hold and participate in online classes, some equipment like a laptop, tablet, or smartphone is needed, which some teachers and students did not have at the beginning and had to acquire. On the other hand, we always needed to be connected to the internet, all of which led to an increase in personal expenses".
3- Increase in University Expenses
The shift from face-to-face to virtual education and the need to provide facilities also burdened universities with increased costs. (Participant 10) added regarding the need for some expenses to be borne by universities to improve the online teaching environment during the COVID-19 pandemic, "Initially, the university's facilities were very simple and limited, and we had to either procure some facilities from scratch or upgrade our existing ones to address some deficiencies and improve the online teaching environment, and subsequently, improve the quality of learning".
C- Quantity of Education
1- Educational Content
The ability for teachers to create audio and visual educational content and make it accessible was one of the points mentioned. (Participant 7) said, "Initially, materials were uploaded as theory and PDF, but some lessons were such that students could not grasp the content with PDF alone. Various software was used, for example, anatomy teachers would come to the anatomy room, film, cut the videos into pieces, and then use software to reduce the size".
2- Scheduling
Attention to time, and the advantages and limitations of virtual education in terms of scheduling, were among the points mentioned: (Participant 15) talked about the time limit of the classes in addition to the scheduling limit, "One of the challenges is the limitation and timing of the classes. For instance, a class that I wanted to last more than two hours wasn't feasible and the connection and session would be cut off without my intention. I had to hold the class at another time when I was busy ". (Participant 6) said on this matter, "Class times were adjusted according to the duties and responsibilities of the teachers. For example, for clinical teachers, the schedule was planned based on their presence in hospitals and educational medical centers, and for the rest of the teachers it was the same".
3- Continuous Learning
Virtual education made it possible to teach outside of obligated times. (Participant 8) discussed the opportunity of online teaching at times when there is a possibility of class cancellations, for the continuation of teaching and continuous learning, "In my opinion, it's a good opportunity. For instance, when there are a few days off or one or two days between holidays, usually students from other cities cancel the class to take the opportunity to go home ". (Participant 7) discussed continuous learning in the sense that students always have access to educational content, "In virtual and online education, considering that educational content is available to the student and they can listen to it over and over, it's as if they always have the teacher by their side and continuous learning exists".
D- Quality of Education
1- Student Participation
Overall, it was stated that student participation in virtual teaching was less than in-person teaching. (Participant 9) said that student participation in online teaching was less compared to traditional in-person teaching, "The participation in this teaching was less, and I asked questions to keep the students in class. For example, I would ask a short answer question and ask them to answer, or during attendance time or students' breaks, I would tell the students not to leave the classroom, and using attendance as an excuse".(Participant 8) added that the number of students directly affects their level of participation, "Online teaching is good for classes with a small number, like 5 or 6 students, but it is not suitable for classes with a large number".
2- Interaction
In this regard, the experts gave their views on interaction in virtual education: Participant 11 continued with the idea that interaction in online teaching is less than traditional in-person teaching, "If I want to say this honestly, it's better in-person, because in online teaching, you can only be sure of students' online presence, but real interaction and presence is not recorded". (Participant 10) suggested creating interactive content to increase interaction in online teaching, "We can't have good interaction in online class, perhaps by creating interactive content like storylines ". (Participant 12) discussed the difference in interaction in online teaching compared to in-person teaching, "It was less, obviously less. Because the time was limited, the space was limited, there was no visibility. For instance, interest, enthusiasm, that face-to-face connection was not seen, it makes a big difference".
3- Feedback
Regarding the possibility of feedback in virtual education, it was mentioned that feedback to students from teachers was available, but it might not always be immediate and online for various reasons. (Participant 9): "Feedback was there during the class or in the form of sending a message to my personal number to the students, but sometimes I might not be able to respond online". (Participant 15) spoke about various methods of receiving and sending teacher feedback to students, "We could give feedback to students in various ways, such as through educational platforms during online classes or through other available messaging systems" (Participant 10) spoke about the difference in feedback in in-person versus online education, "We give feedback to the student at the very moment in in-person teaching, and the impact that face-to-face feedback has may not be achieved by voice alone or a message".
4- Access
Regarding the different ways students can access teachers, (Participant 14) said: "Now there are many ways to access teachers because they are usually present in all virtual system tools, they have an ID, they have a page and all that, and I don't think there is much difference between in-person and online teaching in this regard". (Participant 5), on the ease of students' access to teachers depending on the teachers themselves, said "Perhaps this access was easier in many ways, for example, it was easier for non-native students, and of course, it depends on the teacher".
5- Practical Classes
The experts pointed to the weakness of learning practical classes through online education. (Participant 14) stated, "Generally, clinical work is a very big challenge in online subjects, and we can't teach all clinical cases online.We can't do this because one of the reasons is the issue of patient confidentiality". (Participant 10) also said about this, "Some practical lessons, for example in the laboratory, cannot be taught virtually and online. Let's assume that we put a video for them to see, can we say that they learned the material?"
6- Evaluation
(Participant 9) talked about the problems related to holding exams and the lack of readiness of teachers and students in this regard, "Usually we assigned part of the grade to the tasks we gave to students, which again were not very reliable because someone else could have done it for them, but we had to trust them". (Participant 8) spoke about the problems related to online exams, "Firstly, they had informed us at the time of the online exam that the students were gathering in groups and were taking the exam together and consultatively, and on the other hand, they were taking screenshots of the questions. Given the nature of the educational content, there is a limitation of questions in some topics, and this way, our entire question bank was leaked ".
Strategies for Enhancing Active Learning:
One of the solutions that participants referred to is the pathology of virtual education. An analysis of about three years of university performance in using virtual education and identifying weaknesses can be the most important solution for strengthening virtual education. (Participant 8) "Given that universities and stakeholders were not prepared for this pandemic, the sudden and emergency use of virtual education naturally faced numerous challenges and weaknesses. But the crucial point is that the medical education system should have the necessary resilience for the next crisis situations. To achieve this goal, identifying weaknesses and damages that our virtual education has had during this period is very essential". Another participant (Participant 3) believed, "Now is the best time for analysis and review teams to form with the participation of all stakeholders and solutions to overcome these damages are identified". (Participant 11), " Important point is that the education system's readiness to deal with crisis situations should be constantly monitored and evaluated and not be limited to a short period after the pandemic".
Another solution identified in this research is improving internet quality. Most interviewees believed that the poor internet speed has been a fundamental problem in virtual education. (Participant 16), "Some students living in remote areas and having less access to appropriate internet had doubled virtual education problems", (Participant 1): "This issue even affected educational equity as these students could not effectively participate in classes".
Producing effective educational content is another solution to strengthen virtual education. Accordingly, it is necessary for faculty members to use diverse and attractive content to achieve the goal of enhancing students' learning. (Participant 7) : "Over time, professors moved towards producing varied content, including films, slides, podcasts, sounds, clips, etc. For instance, anatomy professors would go to the dissection room and film, then break the films into pieces and use special software to reduce their size, and upload them to the system".
The use of blended learning methods combining in-person and virtual instruction was proposed to enhance student evaluation. One of the participants stated, "The primary issue with virtual learning was assessing the students while minimizing the chance for student dishonesty and cheating. To address this problem, I usually allocated a portion of the score to students' assignments”.
The use of process-oriented evaluation was another solution proposed by participants in this research. "Continuous and ongoing evaluation can reduce the challenges of virtual assessment. Part of the students' final score could be based on assignments and activities throughout the term, and the rest based on the end-of-term exam".
Based on participants' feedback, the lack of guidelines and instructions for virtual learning was one of the main challenges when virtual education became mandatory. Consequently, expediting the process of preparing and publishing virtual learning guidelines, as well as their constant review, were identified as some of the most significant proposed solutions. Another proposed solution is to continue blended learning even after the pandemic ends. Participants believed that the quality of teaching could be improved through virtual education if it is used alongside in-person instruction. However, opinions varied regarding its continuation. Some professors suggested that a specific percentage of each course's sessions be held virtually. Another perspective was to use virtual education for providing supplementary educational content and assigning students' tasks. Some participants proposed that theoretical educational materials be prepared as standard educational content and provided to students before class. Then, during in-person classes, these contents should be analyzed and discussed for deeper learning.
One of the main challenges of virtual education is the interaction between the teacher and the student. Many interviewees suggested that interventions aimed at enhancing teacher-student interaction are crucial for improving the quality of virtual education. To increase interaction with students, some professors used strategies such as question-and-answer sessions, inviting student participation, assigning grades for student engagement, and creating interactive content. (P8): "To encourage participation, I would call out a student's name and ask for their opinion. However, some students claimed that their microphone was not working, or the sound was not coming through, or they would give similar excuses". In addition to this, identifying and utilizing virtual learning systems that offer numerous measures to engage students can be helpful.
Many interviewees believe that adequate acculturation regarding the proper use of online education for all stakeholders, including students and their families, teachers, education managers, and experts, is crucial. Some participants considered the lack of proper acculturation as the main reason for resistance from some teachers and students against the use of the virtual education platform. Participant 7 stated, "In the beginning of using online education, some students were unable to participate effectively in the classes due to lack of cooperation from their families". Lastly, the success of each of the above solutions requires the management of resources and infrastructure. Almost all interviewees identified the lack of equipment and infrastructure as problematic. For example, one of the professors (Participant 14) stated, "Initially, we had problems both in electronic communication infrastructure and equipment. But fortunately, this challenge turned into an opportunity. Because universities had to invest to rectify the deficiencies. Afterwards, with the utilization of this, all treatment centers were equipped with virtual education systems and educational equipment ".