Study design and participants
We performed a cross-sectional study (STROBE checklist - Additional file 1) to evaluate the effectiveness of virtual practical sessions in the compulsory Intensive therapy and anaesthesiology (ITA) course among fifth-year medical students both in the Hungarian and German program at Semmelweis University Budapest, Hungary. The study consisted of three parts. An anonymous and voluntary internet-based survey was conducted among our students participating in virtual practices and distance education during the COVID-19 outbreak. Moreover, instructors in charge of virtual sessions during the COVID-19 pandemic were also interviewed through an online questionnaire. Additionally, a multiple-choice knowledge test was filled out on a voluntary basis by students who took part in the virtual practices and also by students, who completed the corresponding practical sessions in the same semester during our traditional bed-side education prior to the restrictions implemented because of the COVID-19 pandemic. The test results of the two student groups were compared.
The Intensive therapy and anaesthesiology (ITA) course
The traditional ITA compulsory course contained five 90-minute long thematic bed-side practice sessions and four 90-minute long simulation sessions (Additional file 2 - Table 1) within a one-week block schedule for each group, supplemented with fourteen 70-minute long lecture sessions held weekly during the spring semester of the 2019/2020 academic year.
The student to instructor ratio was 7:1 or less both during bed-side practices and simulation trainings.
The final exam was administered as an oral exam during the examination period between May 18 and July 3, 2020.
Distance learning during the COVID-19 outbreak
Distance learning and virtual sessions were introduced as a necessity into our curriculum in the middle of the spring semester of the 2019/2020 academic year. Lectures and four of our thematic bed-side practices (introduction, respiratory, shock and anaesthesia trainings) were adapted to virtual sessions. The trauma session was cancelled due to its specific patient population and lack of human resources during the pandemic. Simulation trainings and one bed-side tutorial in the ICU were postponed and then held after the withdrawal of restrictions at the end of the semester, in the same manner as before the restrictions.
Virtual lectures took place through Zoom® (San Jose, California, USA) platform in the same time points, utilizing the same structure as previous face-to-face lectures.
The four virtual thematic practices were conducted at specific time points for a given group through the internet using Zoom® platform. A maximum of 21 students took part in one virtual 90-minute long practice session. A brief PowerPoint® (Microsoft, Redmond, USA) presentation summarizing the principles of the trainings` topic, videos and images showing patients and patient management composed the main framework of a virtual practice with the opportunity of further discussion with students. The same topics were covered as during traditional bed-side trainings. Student engagement was enhanced by using the Poll Everywhere® (San Francisco, USA) application. Moreover, online articles and videos were uploaded to Moodle® (Perth, Australia) learning management system to support learning and understanding of a given topic.
Final exams were conducted in the same manner for students who completed the traditional and distance learning courses.
Students' and instructors' questionnaire
We developed a 20-item questionnaire with 14 Likert-scale questions (graded from 1 to 5), two open-ended questions and four multiple choice questions (Additional file 2 - Table 2) regarding the four virtual thematic practices for our students. The Likert-scale questions and open-ended questions covered the quality of the four virtual trainings, students` self-report of their preparedeness to recognize critically ill patients or being able to manage perioperative situations after completing the virtual sessions, as well as students` opinion about changing bed-side learning to virtual education in the future. Multiple choice questions asked about the students` demographics (age; gender; previous experience in health system).
The instructors received a 22-item questionnaire regarding virtual sessions and distance learning, listed in Additional file 2 - Table 3. 14 Likert-scale questions (graded from 1 to 5) and two open-ended questions covered the quality, strengths and weaknesses of virtual sessions, as well as instructors' opinion about introducing virtual education into our curriculum in the future. Six multiple choice questions asked about demographics (age; gender; experience in education; experience in e-learning as educators; language program; job description).
The questionnaires went through an internal and external validation process based on the recommendations by the Association for Medical Education.5 Validation steps and timing of the questionnaires are specified in Additional file 2 - Table 4.
Knowledge test
A 20-item internet-based multiple-choice test was developed to assess students' knowledge about the topics covered by the four thematic practices (introduction, respiratory, shock and anaesthesia sessions). The questions were reviewed by three experts and educators in the field of anaesthesiology and intensive therapy. Each question consisted of five possible answers and maximum 100 points could be reached. Time for the knowledge test was maximized in 30 minutes. Both students participating in the traditional learning and students taking part in virtual distance learning received the test at the end of the semester, before the oral exams. Taking the test was voluntary and the results did not influence final grades. As the results of final, oral exams depend on multiple subjective factors, they were not incorporated into the study.
Statistical analysis
The results of the questionnaires were analysed using descriptive statistics. We determined the medians and interquartile ranges of the grades at each Likert-scale question, which were graded from 1 to 5. Additionally, continuous variables (age; knowledge test scores; time to complete knowledge test) were described as medians and interquartile ranges (IQR). Categorical variables (gender; language program; students' previous job experience in health care; students' previous work with critically ill patients; instructors' experience in education and e-learning; instructors' job description) were described as numbers and percentages.
The open-ended responses went through a content-analysis and were summarized into categories.
Less than 5% of data were missing; the missing data were excluded from the analysis.
Mann-Whitney U test was applied to compare the answers to four Likert-scale questions between students and instructors regarding the effectiveness and future application of virtual trainings.
In addition, Mann-Whitney U test was used to compare the knowledge test results of students who participated in the traditional bed-side practices and the ones who underwent virtual practice sessions.
Moreover, a binary logistic regression analysis was performed to determine if previous job experience with critically ill patients has an influence on students' self-reported preparedness after completing the course (Additional file 3 - Table 1).
The level of significance was set at p<0.05.
Statistical analysis was performed using SPSS v25.0 (SPSS Inc., Chicago, IL). Figures were created by GraphPad Prism version 8.3.0. (GraphPad Software, La Jolla, CA).