Attitudes and concerns of health sciences students in Croatia regarding complete switch to e-learning during COVID-19 pandemic: a survey

Background: Croatia has closed all educational institutions after 32 cases of SARS-CoV-2 infection were conrmed and switched to exclusive e-learning. Health sciences university students may have been particularly disrupted with this change due to lack of practical education. It is not known how health sciences students and schools have adjusted to exclusive e-learning. The aim of this study was to explore attitudes and concerns of health sciences students in Croatia regarding complete switch to e-learning during COVID-19 pandemic. Methods: Eligible participants were students from 9 institutions offering university-level health sciences education in Croatia enrolled in academic year 2019/2010, and participating in e-learning. Data were collected with questionnaire distributed via email during April/May 2020. Results: A total of 2520 students (aged 25.7±7.7 years) responded to the questionnaire (70.3% response rate). General satisfaction with exclusive e-learning was rated with average grade 3.7 out of 5. Compared with previous education, exclusive e-learning was rated with average grade 3.2 out of 5. Compared to classroom learning, equal or higher motivation to attend exclusive learning was reported by 64.4% of participants. With longer duration of exclusive e-learning, equal or higher motivation was reported by 65.5% of participants. Less than half of the students indicated they felt deprived or concerned due to the lack of practical lessons. Most participants indicated that in the future, they would prefer to combine classic classroom and e-learning (N=1403; 55.7%). Conclusions: Most health sciences students were satised with the exclusive e-learning, as well as their personal and institutional adjustment to it. Students’ feedback can help institutions to improve exclusive e-learning experience for students in time of pandemic.

However, only two days later, on March 13, 2020, Croatia had 32 con rmed cases of SARS-CoV-2 infection [4], and Croatian government decided to close all educational institutions in Croatia starting with March 16, 2020.
On April 9, 2020 Croatia had 1,343 con rmed cases of SARS-CoV-2 infection, and 19 deceased due to COVID-19. Epidemiological growth curve remained linear despite the fact that in the meantime Croatia's capital Zagreb suffered from an earthquake with a magnitude of 5.5 Richter on March 22, 2020, causing serious material damage, exodus of people on streets and concerns that this will further fuel the epidemic [4].
Croatian government decided that all school and university lessons need to be delivered via distance teaching and learning needs [5,6]. Initial decision of the Croatian government was to suspend in-person learning in Croatian educational institutions for two weeks, but the closure was extended.
University education was, thus, organized via distance learning, but medical education has been disrupted in a particular way. In medical and health sciences university programs theoretical lessons only can take part via distance learning, as teaching hospitals and clinics have suspended practical parts of students' education, as a measure of curbing the epidemic in health institutions. Organizing practical medical education is particularly challenging in the times of pandemic. It has been acknowledged that focusing on health professional education as a eld of scholarship may not yield a COVID-19 vaccine, or economic crashes, or procurers food where needed, but that such scholarship can help us in advancing understanding of such education [7]. If we neglect what is happening with health professional education in challenging times, we may jeopardize professional development of students and future care of patients.
In the literature, we were unable to nd large-scale studies on national levels about adjustment of health sciences students and institutions to the pandemic. Taking into account the assumptions of studentcentered education [8][9][10][11], which, among other things, emphasizes the importance of the quality of personal learning experience and the circumstances of the COVID-19 pandemic, which are incomparable with previous experiences, it is justi ed to start scienti c research by describing and determining new educational conditions for health sciences students.
Thus, this study aimed to explore attitudes and concerns of health sciences students in Croatia regarding complete switch to e-learning during COVID-19 pandemic.

Study design
This was a cross-sectional observational study.

Setting
The study was conducted in 9 higher education institutions in Croatia that offer university-level programs in health sciences, and are located in cities of Dubrovnik, Osijek, Pula, Rijeka, Split, Varaždin, Zadar and Zagreb. The study was conducted from April 28, 2020 to May 11, 2020.

Participants
The participants were health sciences students of nursing, obstetrical nursing, physical therapy, radiologic technology and diagnostic laboratory medicine studying at participating higher education institutions in Croatia in baccalaureate and master's programs in academic year 2019/2020, who were attending courses at the time of the survey administration. There were no age or sex restrictions for participation. Students that were enrolled, but have completed their courses in previous academic year(s) and did not have an obligation to attend courses were excluded.

Survey
For the purpose of this study, a new questionnaire was developed (Supplementary le 1). Team included in the development of a questionnaire included expertize in pedagogy, psychology and research methodology; the team also included a student representative attending a university nursing program.
The questionnaire has 13 thematic sections (Supplementary le 1). Participants respond to items using a 5-point Likert scale, closed responses, and open questions where participants can write freely their responses. The questionnaire collected information about the following aspects regarding complete switch to e-learning: students' satisfaction with e-learning overall, personal adjustment to e-learning, student perception of institutional adjustment to e-learning, attitudes and concerns of students regarding acquiring knowledge, lack of practical education, completion of their theses, completion of their studies and future employment. The questionnaire also collected demographic information including age, marital status, having children, year of studies, study program (baccalaureate or master's), eld of studies (health sciences profession), work status, full time or part time studying, and institution that a student attends. Information about sex of participants was withheld because of predominance of women among the health sciences students, due to concerns that information about sex would compromise anonymity of men participants.
The survey was created in Google Forms. We piloted the survey on a sample of 25 students attending medical and dental university courses; we did not invite health sciences students for piloting so that we do not need to exclude them from the main study; medical and dental students that participated in piloting belong to the same age demographics, and have also had a complete switch to exclusive elearning. Feedback of students who participated in the pilot testing was used to revise the survey. We analyzed data only from fully completed and submitted surveys.

Survey distribution
Study authors from participating institutions contacted their students via e-mail and invited them to take part in the study. After initial email, three more reminders were sent to students, spaced four days apart.

Sample size
We used a convenience sample of all eligible students attending participating institutions.

Data analysis
We presented data as frequencies and percentages. In the text, responses "completely disagree" and "disagree" were reported in the manuscript as disagreement with the rated statements, and responses "completely agree" and "agree" as agreement; frequency of responses to all items on Likert scales were reported in detail in the tables. We explored associations of students' characteristics with responses using chi-square test. For analyses we used Microsoft Excel (Microsoft Inc., Redmond, WA, USA)

Characteristics of participants
Mean age of participants was 25.7±7.7 years. Most of the participants were in a relationship or single; a fth had children. Students were mostly in the baccalaureate level; the majority were not employed ( Table  1).

Experiences and engagement with e-learning
The average participants' satisfaction with e-learning was 3.7±1.1 out of maximum 5. Students' satisfaction scores ranged from 3.00±1.09 to 4.03±0.9 in individual institutions (Supplementary table 2). Compared with classic learning mode, about a third of participants had neutral opinion, 39.6% found elearning better and 24.9% found e-learning worse (detailed responses are shown in Supplementary table 2).
The majority of participants were satis ed with how fast they have adjusted to e-learning (72.3%) ( Table  2). There were 44.6% of students who indicated that they participate in e-courses with questions and comments just like during regular classes. About half students indicated that they miss classroom lessons (47.5%) and in-person communication with teachers (52.5%). Just over half of the students agreed that e-learning cannot compensate for practical education and seminars (51.7%), while more than half (51.7%) disagreed with the statement that the e-learning is a complete waste of time for health sciences students (Table 2).
Compared to classroom lessons, 48.5% of the participants indicated that they are equally motivated to participate in e-learning, 55.7% indicated that they attend e-learning equally often; 51.1% of participants expressed equal motivation to participate in such lessons the longer the e-learning continued; 43.4% indicated that they felt equally connected with their colleagues and teachers, and 40.8% indicated that elearning required equal time compared to classic classroom lessons (Supplementary table 3).
The majority of students indicated that they have su cient information technology skills to participate in e-learning independently (84.7%), that they have adequate Internet connection at home (83.7%), that they have computer at home that they can use for e-learning without interruption (86%) and that they have other equipment at home, besides computer, that enables them to participate in e-learning (65.8%) (Supplementary table 4).

Perception of efforts invested by a higher education institution towards exclusive e-learning
The majority of participants agreed that their higher education institution adapted quickly to e-learning (68.9%), organized e-learning adequately (68.7%), provided students with training about the teaching tools and software used for e-learning (59.7%), provided timely information regarding the provision of elearning (65.8%), and that information technology o ce or another service was at their disposal for solving possible technical problems related to e-learning (52%). When asked whether their institution had expressed willingness to help students in provision of equipment needed for participation in e-learning, 43.6% students disagreed, while 24.7% agreed (Table 3).
Perception about the structure, implementation and organization of e-learning Most of the students agreed with the following statements about the majority of teachers: they receive timely feedback (69.5%), the teachers' instructions were tailored to e-learning (68.4%), teachers made effort to enable students to follow e-learning more easily (66.9%), teachers veri ed whether students understood the lessons by asking feedback (70.4%), the tasks and activities provided during lessons and homework usually helped students to understand the course material better (55.3%). Most of the participants agreed that teachers have generally organized themselves and adapted to e-learning well (63.4%), and most of them used e-learning software chosen by the institution (74.1%). The majority of students agreed that, generally, teaching materials were adequate for the technical demands of e-learning (67.2%) ( Table 4).
Regarding the teaching modes, based on participants' responses, the majority of teachers provided videoconferences (video-lessons) (55.1%), held classes according to the schedule (70.2%), and followed o cial curriculum (73.1%). When asked about whether some teachers only send them presentations, instead of holding online lectures, 38.5% agreed. A third of the student indicated they felt left to their own devices during e-learning (Table 4).
Expectations related to e-learning, under the circumstances, were ful lled for the majority of students (61%), and the majority indicated they were satis ed with how fast adjustment to the e-learning occurred (69.2%) ( Table 4).
Employment and e-learning More than half of students (55.6%) indicated being currently employed. Only those students got questions about combining employment and e-learning. Among those students, few indicated that due to employment they cannot participate in e-learning (9.6%). The majority indicated that due to employment sometimes they are unable to participate in e-learning (59.7%). There were no predominant answers regarding di culties concentrating on e-learning because of nature of their employment ( Table 5). The majority of students disagreed with the statement they could participate in e-learning at work (59%). Most of the students agreed that e-learning could be a good complement to classic classroom learning once the COVID-19 pandemic is over (63.8%), and that e-learning should be continued for part-time students, even after the COVID-19 pandemic is over (65.2%) ( Table 5).

Concerns regarding the lack of practical education
Although there were no predominant opinions regarding being deprived or concerned because of the lack of practical education (Table 6), almost half of the students (47.4%) agreed that they were afraid that it will not be possible to compensate for the lack of practical education during their studies, and the majority (55.1%) indicated that they were afraid that the lack of practical education will have permanent consequences in terms of their future job preparedness (Table 6).
Concerns regarding the completion of nal/diploma thesis There were 780 (31%) students who indicated that they had already de ned topic of their nal/diploma thesis. Speci c questions shown only to those students indicated that 36.4% of the students were concerned that due to the current pandemic they will not be able to nish the work needed for nalizing their nal/diploma thesis. The majority (55.5%) indicated that they were afraid that due to the current pandemic they will not be able to complete their nal/diploma thesis within the planned time. There were 42.1% students concerned that they may not be able to complete the current academic year due to problems with implementing their nal/diploma thesis. Half (50.2%) indicated they were not afraid for their future employment due to potential problems with nal/diploma thesis, while 31.2% expressed they were afraid in that respect (Table 7).
Consideration about the continuation of education during the pandemic Most (53.9%) of the students disagreed that practical education still needs to be organized during the pandemic; 37.1% agreed that students should have suitable practical roles in health care, so they can help resolve the current pandemic; 37.5% agreed that students preparing nal/diploma thesis should immediately make alternative plans that can be completed under the current circumstances. There were 45.2% of students who agreed that e-learning needs to be improved (Table 8).

Students' suggestions
Having the experience with e-learning, the majority of participants indicated that in the future, they would prefer to combine classic classroom and e-learning (N=1403; 55.7%); 25.4% (N=641) preferred to continue with classic classroom learning, and 18.9% (N=476) would continue with e-learning only.
When asked to provide suggestions on how e-learning could be improved, 913 (36%) students responded.
The most common suggestions/comments were to provide more online lectures instead of posting text of presentations (N=118; 13%), students have way too many tasks and assignments (N=48; 5.3%), teachers need to be engaged more (N=44; 4.8%), online exams need to be introduced (N=35; 3.8%), lectures should be video-taped and videos provided to students (N=27; 2.9%), better communication and availability of professors (N=26; 2.8%), pdf materials for independent learning need to be provided (N=25; 2.7%), teachers need to be educated about using technology (N=24; 2.5%), More details are given in Supplementary table 5.
There were 886 (35%) responses to the question about suggestions for compensating the students for their lack of practical education. The most common suggestions were: providing video-materials/tutorials (N=80; 9%), for students who already work as nurses such compensation is not necessary (N=64; 7.2%), compensating when the circumstances will allow (N=62; 7.0%), compensating with assignments and case studies (N=50; 5.6%), compensating in the next academic year (N=44; 5.0), and teaching in smaller groups of students (N=39; 4.4%). More details are given in Supplementary table 6. Question about providing suggestions for students who could face problems with completing their nal/diploma thesis under the circumstances was responded by 620 (25%) students. The most common suggestions were to extend deadlines (N=65; 10.4%), enable online thesis defense (N=50; 8.0%), change or adjustment of a thesis topic (N=39; 6.3%), ensuring availability of a mentor (N=38; 6.1%), students should conduct research for their theses via online questionnaires (N=38; 6.1%), ensuring cooperativeness of mentors (N=22; 3.5%). More details are given in Supplementary table 7.
Students were also invited to leave any comment that they might have regarding the potential permanent consequences of e-learning, i.e. lack of practical education, on their education and professional development; 637 (25%) students provided a response. The majority of students indicated that there will be no major/permanent consequences of the lack of practical education (N=112; 18%). It was also indicated that students who already work as nurses (N=39; 4.1%) or who have completed nursing high school (N=27; 4.2%) will have less consequences from the lack of practical education compared to other students. More details are given in in Supplementary table 8.

Discussion
The main nding of our study is that the majority of university-level health sciences students in Croatia have adjusted well to the exclusive e-learning during COVID-19 pandemic and that the majority consider that their institutions have adjusted well too.
The COVID-19 has taken the world by the storm; the World Health Organization (WHO) was informed about the emerging threat in China in December 31, 2019 and pandemic was declared on March 11, 2020 [12]. Many governments around the world responded with lockdowns, cessation of classroom education and complete switch to distance learning. However, not all types of education can be successfully implemented via e-learning. This is particularly problematic for all aspects of practical education where experiences are crucial, and skills need to be learned. Medical and health sciences students need contacts with patients to learn necessary skills and to be personally exposed to patient care. Thus, warnings have been voiced about potential consequences of the COVID-19 pandemic for medical education, warning that medical students may be heavily deprived with the lack of practical education, and proposing that medical students could even help during the pandemic [13]. The same arguments can be used for health sciences education. However, despite the explosion of research about COVID-19 [14], few studies have been devoted to exploration of radical changes that the pandemic imposed in medical and health sciences education.
Compton et al. surveyed medical students of Duke-NUS Medical School in Singapore, less than a month after the pandemic onset, and found that about a third of the surveyed 179 students would not prefer to return to the clinical setting; the students' willingness to return to the clinical environment was associated with personal characteristics and students' perceptions about the risk to the healthcare systems [15,16].
Kumar Srinivasan described experiences of medicals students and an anatomy teacher regarding use of a e-learning platform for anatomy tutorials on the Zoom platform during the COVID-19 pandemic in Singapore. The report describes general satisfaction of students, as well as students' feedback about how the lessons and tutorials could be improved [17]. Pather et al. have documented in a qualitative study experiences of anatomy teachers in New Zealand regarding changes in anatomy education during the COVID-19 pandemic, highlighting that the teachers have embraced the change, but also that they were concerned about the lack of student-teacher interaction, as well as about student performance and satisfaction. It is also highlighted that bridges made during the pandemic could impact the future of anatomy education [18].
One such potential "bridge" could be incorporating e-learning into "classic" classroom-based curricula.
Most of the students in our study indicated that in the future they would more appreciate a combination of e-learning and classroom learning, compared to either of those alone. This could be in line with the ndings of a study suggesting that the effect of e-learning in nursing education is situational when compared to conventional learning [19].
While most students in our study agreed that they and their institutions/teachers had adapted quickly to the exclusive e-learning, that they had adequate information technologies at home to participate in the elearning, and that institutions supported them in technological adjustment, this was not unanimous. The indicates that some students and institutions may have needed more time to adjust to exclusive elearning.
Participants' responses indicated that most teachers were engaging with students via video-lectures, on time and in line with the curriculum. However, it appears that some teachers send students only presentations, instead of lecturing online. Indeed, one of the most frequent suggestions regarding improvement of e-learning experience was students' wish that teachers should not only post presentations online for students to study when they want; instead, students wanted video-lectures with teachers. Others suggested that video-taped lectures should be made available to students, so that students can watch and rewind them at their own convenience.
Disruptions caused by the pandemic may prevent some students from completing their research studies planned for their nal/diploma theses. Thus, it was important to hear opinions of students about what could be done for students facing this potential problem. The majority of students suggested extending deadlines. For example, students are usually expected to complete and defend their thesis within the academic year in which they enrolled their nal year of the study program. Otherwise, they need to enroll another year of studies, and pay tuition for this additional study year. Based on students' feedback, participating institutions are now extending those deadlines, enabling students who have faced obstacles in completing their research during the pandemic to do it over longer period of time.
It is commendable that some institutions have offered students help with technology needed for participating in e-learning. Our study did not address the nancial cost of e-learning for students, but it needs to be emphasized that it should not be presumed that all students have all equipment at home that they can use exclusively. Large part of our student body were students studying part-time, which are generally older than students who enroll health sciences programs immediately after high schools. Parttime students are usually health sciences professionals who have completed health sciences high schools in Croatia, and who have been working for a while in health care institutions, now wishing to attain higher education due to adjustment of Croatian professional curricula with EU regulations. Thus, if students have a family, and children, and everyone is expected to work and study at home during the pandemic, the family may not have had, for example, a laptop for each child and each parent at home.
Judging by the students' responses, there were indeed those that did not have all the necessary equipment at home for proper participation in e-learning.
Many students expressed complacency with lack of practical lessons, voicing opinions that this can be compensated once they start working. This could indicate that students are underestimating the importance of practical education during their university studies.
On another note, our study indicates the value of reminders when conducting online surveys. Four days after the invitation to participate in the study we had 47.5% response rate, and a total of 70.3% response rate ve days after the third reminder. Our reminders were spaced only 4 days apart; it is possible that the response to the initial invitation would be somewhat higher even without the reminders, but probably would not be this high.

Limitations
One of the study limitations is that we created a completely new questionnaire for this study. We were unable to nd a similar questionnaire in the literature, about exclusive e-learning for health sciences students, or medical students, that we could have adapted to our needs. For transparency, we have reported our manuscript in full in a supplementary le, so that it can be re-used or modi ed.
Secondly, we did not collect data on the sex of participants. However, in university health sciences studies in Croatia there is an overwhelming predominance of women. If we were to collect data on sex, together with all the other personal characteristics that we were collecting, we were concerned that men would be easily identi ed, and thus by avoiding this question we helped preserve participants' anonymity.
Thirdly, our questions were phrased to collect opinion of students regarding "the majority" of teachers and courses. We acknowledge that they may be differences between different teachers and courses that may impact the individual experiences, but in this study we were interested in their opinions and attitudes towards overall experience of exclusive e-learning. Likewise, there may be inherent differences between the institutions that may have in uenced the results, as some schools had more students compared to others. For example, Libertas International University, has created online simulations for students that could be used for exercising practical skills. However, the aim of this study was not to focus on individual results from each school, but to analyze overall collective students' opinion. Each school that participated in this study will analyze separately responses of their own students, to consider students' feedback and suggestions and use it towards improvement of e-learning experience.

Strengths
The main strength of this study is inclusion of 9 out of 10 higher education institutions offering university-level health sciences education in Croatia. Furthermore, the response rate of students was above 70%. Thus, our results should be considered representative for the opinions and attitudes of health sciences students in Croatia.
At the time of writing of this manuscript (end of June 2020), epidemiological situation in Croatia regarding COVID-19 started rapidly worsening after a whole month with zero to few new cases of SARS-CoV-2 infection reported daily in the entire country. On June 25, 2020 there were 95 new cases reported [4], which was the second worse day from the beginning of the epidemic. Thus, health sciences students are not returning to schools for in-person classroom education until further notice. Teachers are expected to complete all classes in this academic year online, and to organize online exams as well. Presently, it is not known for how long this "new normal" may last. Students' feedback obtained in this study can now be used to improve e-learning and enhance student experience.

Page 13/22
Most university-level health sciences students in Croatia were satis ed with the exclusive e-learning during COVID-19 pandemic in early 2020, as well as their personal and institutional adjustment to the new normal in university education. Exploring students' satisfaction and towards e-learning and seeking feedback about measures for improvement can help institutions to improve exclusive e-learning experience for students in time of pandemic.

Consent for publication
Not applicable

Availability of data and materials
Raw data collected within this study are available from the corresponding author on request.

Competing interests
No competing interests were disclosed