key: cord-0815295-efjyo5c6 authors: Ng, L; Seow, K C; Mac Donald, L; Correia, C; Reubenson, A; Gardner, P; Spence, A L; Bunzli, S; Ito Ramos De Oliveira, B title: eLearning in Physical Therapy: Lessons Learned From Transitioning a Professional Education Program to Full eLearning During the COVID-19 Pandemic date: 2021-03-04 journal: Phys Ther DOI: 10.1093/ptj/pzab082 sha: a0d140774d893b40f7933a70673d9921b1df27b4 doc_id: 815295 cord_uid: efjyo5c6 OBJECTIVE: The objectives of this cross-sectional qualitative study were to explore the perspectives of students enrolled in one physical therapist undergraduate education program in Australia about their experience with transitioning to full eLearning and student recommendations to improve the learning experience during the COVID-19 pandemic. METHODS: Seven focus groups with 28 undergraduate physical therapist students were conducted following the transitioning to full eLearning as a result of strict physical distancing measures. Focus group questions explored the students’ experiences of the transition from face-to-face to full eLearning approach and the students’ recommendations for improving future eLearning experiences. Data were analyzed using inductive thematic analysis. RESULTS: The 3 themes identified were: (1) students presenting heightened negative feelings such as anxiety, stress, and reduced motivation to study; (2) students continuing to value the face-to-face learning, as it provided social support and facilitated feedback from peers and tutors; (3) student recommendations for eLearning included having online lectures and supplementary videos but face-to-face practical classes and developing healthy learning habits such as scheduled times for studying, exercise, and other activities that regulate stress. CONCLUSIONS: The transition to a full eLearning approach in an undergraduate physical therapist education program during the COVID-19 pandemic revealed that students had heightened negative emotions due to the pandemic. Students valued face-to-face practical classes to learn and receive social support from peers and tutors. Student recommendations to future eLearning suggested changes to curriculum development geared toward a greater blended approach to learning. Blended learning may include using online lectures instead of face-to-face lectures and online resources to supplement student learning of practical skills. IMPACT: As higher education moves toward a more blended approach, lessons learned from this study can help educators design future physical therapist education programs. The findings can also assist programs in delivering a full eLearning approach as the COVID-19 pandemic continues. Blended learning may include using online lectures instead of face-to-face lectures and online resources to supplement student learning of practical skills. Impact. As higher education moves toward a more blended approach, lessons learned from this study can help educators design future physical therapist education programs. The findings can also assist programs in delivering a full eLearning approach as the COVID-19 pandemic continues. Universities worldwide have rapidly transitioned to a full eLearning approach during the COVID-19 (SARS-CoV-2) pandemic due to social distancing protocols. 1 A full or complete eLearning approach is defined as "learning with no face-to-face component, that relies entirely on the use of eLearning technology and techniques for the delivery of learning" 2(p4) . For many universities, the transition to full eLearning for all education programs was unprecedented; however, eLearning has already been established as an integral part of 21st century education. 3 eLearning merges pedagogy with computer science and communication technology and is constantly evolving due to advances in each field. 3 Two systematic reviews involving undergraduate health professions students have found that eLearning is associated with positive educational outcomes, including improved knowledge, skills and satisfaction. 2, 4 Regardless of the program delivery modality, physical therapist professional education programs require a combination of effective communication skills, theoretical and conceptual knowledge, and clinical skills including manual and instrumental skills. 5 Previous studies have found eLearning in combination with faceto-face learning is an effective supplementary tool in reinforcing knowledge and skills acquisition in physical therapist education programs. [5] [6] [7] [8] [9] Students in these studies reported satisfaction with the flexibility, accessibility, and interactivity associated with eLearning. However, they also described feeling less motivated and more isolated due to fewer opportunities to communicate with instructors and peers 5 . In response to the COVID-19 pandemic, many physical therapist education programs temporarily moved to a full eLearning approach. This provides a unique Understanding these perceptions can inform future eLearning in physical therapy and other health professional programs in which there are combinations of theoretical and practical learning activities, such as occupational therapy, speech therapy, and nursing. Therefore, the aim of this study was to explore the perspectives of students enrolled in one undergraduate physical therapist education program in Australia about their early experience with full eLearning during the COVID-19 pandemic. A cross-sectional qualitative study was conducted between the April 27 and May 15, 2020 . Focus groups were selected as the method of data collection as they allowed participants to express their perspectives and build on each other's experiences. 10 Ethical approval was granted by the Human Research Committee at Curtin University (HRE2020-0182 household in front of their web camera to receive instant feedback from tutors or asynchronous feedback on video assignments students were asked to submit. Additional videos were created to supplement practical classes, such as chunked lectures (ie, grouping of lectures into short, meaningful videos for online delivery) and additional clinical skills demonstrations that were previously only delivered faceto-face. Tutors joined all separate breakout groups at different times to discuss student queries and provide feedback on their activities. From a total of 600 physical therapist students enrolled in the first, second, and third years of the 4-year program, purposive sampling and snowball sampling methods via email and word-of-mouth were used to recruit the sample. To capture a diverse range of perspectives and experiences, we recruited students from the first 3 years of the program, international and local students, high-school entry and mature-age students, and a proportion of women to men that reflected the wider student population for the program (60:40). All had attended face-to-face practical classes at the physical therapy school in the 6 weeks prior to the transition to full eLearning. Figure) . Aligned with the aims of the study, the guide explored full eLearning experiences using the phenomenological interview framework outlined by Bevan. 13 Bevan's framework covered 3 main domains: contextualization ("Tell me about your learning experience since moving to eLearning"), apprehension of the changes ("Tell me about your current study habits/strategies"), and clarification of changes ("Describe how your study habits/strategies changed since we moved to eLearning"). Two additional questions covered the barriers and enablers for eLearning to further investigate student perceptions regarding teaching practices and student learning with full eLearning. The guide was revised following the initial focus group interview and one more question and sub-question were added to seek further clarity on the information provided. (6) result reporting. 14, 15 Four researchers, all trained in qualitative analysis, were involved in the coding process. Two were experienced qualitative researchers and physical therapists (K.S., B.O.). Two were 4th year undergraduate physical therapist students (L.M. and . Data from each focus group were coded by at least 2 researchers. Where one researcher was involved in the participants' courses in a given focus group, they were not involved in the coding of data from that focus group. Coded data were discussed and refined in meetings with the research team resulting in the construct of a coding tree (Tab. 1). Once a refined coding tree had been agreed on, it was applied to all focus group transcripts by K.S. Three researchers (B.O., L.M., C.C.) cross-coded the transcripts to check that all relevant data was accurately captured. A qualitative data management software (NVivo 12, QSR International, Melbourne, Australia) was used to support the organization of coded data. Patterns between and within codes were discussed and challenged by the research team, drawing on their theoretical knowledge of andragogy, content knowledge of physical therapy teaching and learning, and experiences as both tutors and students. Through this process, preliminary themes were generated. Themes were reviewed by the research team for accuracy and clarity in comparison with the raw data. Saturation was achieved after five focus groups; 2 additional focus groups were conducted to challenge, confirm and clarify the preliminary themes. A total of 28 physical therapist students with a mean age of 23.5 (SD = 5.0) years participated. Sixteen were female (57%); and 7 (25.0%) were in the 1st year, 13 (46.4%) were in the 2nd year, and 8 (28.6%) were in 3rd year of the program. Five participants (17.9%) were international students who had moved to Australia to attend university. The demographics of the participants are presented in Table 3 . Three overarching themes were identified: (1) heightened negative feelings; (2) faceto-face learning is important; and (3) recommendations for eLearning. These themes are described below, supported by quotes as presented in Table 4 . Although the design of a qualitative study such as this one prevents inference regarding the generalizability of the findings, we have provided an indication of the frequency with which each finding was endorsed within focus groups. Participants from all year groups expressed negative feelings toward the challenges imposed by the rapid transition to eLearning due to the COVID-19 pandemic. This included feeling anxious, stressed, and overwhelmed due to the perceived increase in workload, the perceived effects of "excessive" screen time, reduced motivation to learn, and feeling worried about mental health in the context of global uncertainty about the future course of the pandemic. Several participants, from 4 out of 7 focus groups, felt that their workload had increased. For example, one year-1 student described how self-directed learning activities were taking up more time than usual and "eating into" their personal time (Q1). Difficulty in establishing study/life balance while learning from home was reported by a year-2 student who described the "blurring of lines" (Q2). Another year-2 student described how "screen fatigue" caused them to lose motivation during learning tasks (Q3). Participants from all focus groups (7/7) described feeling unmotivated to learn. For example, one year-3 student talked about the importance of the physical 14 environment in getting into the "learning mindset" (Q4). A similar sentiment was described by a year-1 student who suggested that watching a lecture in bed was less engaging than watching from a designated workspace (Q5). Concerns about the current uncertainty in the world were expressed by many students (from 4/7 focus groups) and this was especially evident among international students. For one year-3 international student, uncertainty about the future made them question their ability to practice physical therapist skills for examinations (Q6). A year-2 student also described feeling overwhelmed and worried about mental health due to constantly having to readjust study plans (Q7) (Tab. 2, quotes 1-7). Participants emphasized the important role that face-to-face social interactions had in feeling more engaged and motivated to learn, and they perceived that face-to-face learning was critical for developing practical skills. Face-to-face learning was linked to the ability to obtain peer and tutor feedback in a timely manner, as well as having peers to practice on, and getting more "value for the money" spent for the course. A large proportion of participants from all focus groups (7/7) believed that their learning environment-that is, external factors conducive to teaching and learning, such as their social (eg, peer support), organizational, cultural, and physical environments 16 -were intertwined with their ability to share information and feel more engaged and motivated to learn. For example, one year-1 student described how the "energy" they got from the social interactions on campus facilitated their engagement in learning (Q8). Some perceived that "being social" online took more 15 effort and was less enjoyable, as described by one year-2 student (Q9). The lack of separation between home and the classroom was previously reported by a year-2 student who felt that it interfered with ability to study (Q2). Virtual working groups, in which students could see and hear each other, were considered a poor substitute for face-to-face interactions due to perceived reduced collaboration. Many participants expressed their dissatisfaction with noncollaborative peers who chose not to share their web cameras and microphones or participate in discussions. One year-1 student believed that students would be less reluctant to speak during face-to-face classes (Q10). The inability to attend face-to-face practical skills classes was a primary concern among participants from 7 out of 7 focus groups who perceived reduced opportunities to practice. All participants agreed that face-to-face practical skills classes were essential. For example, one year-3 student explained that "practicals help cement the theory knowledge" and were difficult to learn from videos (Q11). Participants from all year groups experienced difficulties in translating written and video instructions into practical skills. For example, a year-1 student attributed difficulties to the lack of adequate tactile cues while practicing (Q12). Many participants (7/7 focus groups) emphasized the importance of peer and tutor feedback for enhanced learning. For example, a year-3 student believed that peer feedback was different, as they could comment on mistakes and suggest different approaches (Q13). When compared to face-to-face classes, the participants from 6 out of 7 focus groups found it harder to obtain tutor feedback through eLearning due to limited tutor availability and asynchronous timing between self-directed activities and feedback. One year-1 student explained that instantaneous feedback provided in face-to-face learning allowed them to correct techniques instantly as opposed receiving online feedback on assignments a couple of weeks later (Q14). Participants who lived by themselves or who did not have a suitable person available to practice on during classes were also concerned about the reduction in opportunities to practice or about not learning as effectively. For example, one year-3 student who lived alone believed that learning was hindered without "human contact" and discussing techniques with peers (Q15). Finally, international students expressed concerns about not receiving the standard of education they expected. One year-2 international student explained that they perceived face-to-face learning as "more value for the money" (Q16) (Tab. 2, quotes 8-16). Based on their recent experience with eLearning, most participants expressed their preference for a blended learning approach in the future, where theory and interactive lectures remained online and practical skills were delivered face-to-face. Their main recommendation for enhancing eLearning experiences was to advise students on developing healthy eLearning habits. The majority of participants (7/7 focus groups) indicated a preference for blended learning, perceiving that this approach would allow more time to comprehend lecture content via online lectures and consolidate information through face-to-face practical classes. A year-3 student for example, preferred the online delivery of the "theory side of the program" and suggested that they only really needed to go on campus for the practical skills training (Q17). All participants opted for face-to-face practical skills classes, supplemented by practical skills videos. Another year-3 student explained that the value of this combination was due to the option of watching videos in preparation for classes (Q18). Regarding online lectures, most participants (7/7 focus groups) reported they had already been watching prerecorded and online live lectures prior to the move to full eLearning. A year-2 student clarified that their preference for recorded lectures was due to its flexibility, ability to pause and rewind as needed, and time efficiency (Q19). After experiencing full eLearning, there was a clear preference (7/7 focus groups) for online lectures (ie, interactive eLectures), during which they could interact with peers and teaching staff, instead of prerecorded lectures. In fact, many participants (5/7 focus groups) found it easier to interact with peers and teaching staff during lectures through interactive eLearning platforms rather than face-to-face. For example, a year-2 student appreciated being able to ask questions "on the spot" without feeling as thought they were disrupting others (Q20) (Tab. 2, quotes [17] [18] [19] [20] . According to the participants, the top healthy eLearning habits were: establishing a schedule (6/7 focus groups), taking breaks from studying (6/7 focus groups), exercising and regulating stress (3/7 focus groups), and having a dedicated study space at home (3/7 focus groups). For example, one year-1 student reported they had established a routine by following their usual course timetable and behaving like 18 "an internal student" (Q21). For a year-3 student, having a routine helped give them a sense of belonging and purpose (Q22). Participants recommended taking breaks to avoid excessive screen time and inactivity while studying. Another year-3 student described that having breaks helped them focus better on learning (Q23), whereas a year-2 student highlighted the importance of taking breaks to exercise and regulate stress (Q24). Having a dedicated study space at home was also deemed helpful to get into the right frame of mind, as described by a year-2 student (Q25) (Tab. 2, quotes 21-25). At the conclusion of focus group interviews 4 or 5 weeks after transitioning to full eLearning, 28 undergraduate physical therapist students reported perceived heightened negative feelings about the rapid transition to eLearning and the perceived increased workload, excessive screen time, reduced motivation and the current uncertainty in the world. Based on their experiences, students recommended that future eLearning in an undergraduate physical therapist program include a blended learning approach in which lectures are delivered online and practical classes remain as face-to-face on campus to enable student interaction and immediate feedback from peers and tutors. Furthermore, participants provided advice on how students can optimise their learning during full eLearning by establishing a schedule for studying, taking breaks and exercising to regulate stress, as well as having a dedicated study space. The temporary introduction of a full eLearning approach in this physical therapist education program appeared to heighten the level of negative emotions in response to the COVID-19 pandemic. In addition to experiencing rapid changes in learning activities and uncertainty within the program, many students had experienced changes in other aspects of their life including loss of employment or their social support network (eg, social gatherings, amateur sports). Changes in other aspects of their lives is likely to have impacted the psychosocial wellbeing of students. Although we did not specifically assess aspects of the students' psychosocial health, it is worth noting that during this pandemic, there has been a rise in clinically significant symptoms of depression and generalized anxiety symptoms in the Australian adult population. 13 Symptoms of depression and anxiety were more evident among those who had lost jobs, were socially isolated, or were in a vulnerable condition. 17 Interestingly, none of the students expressed their concern with contracting COVID- where this study took place were low relative to many other countries. To put it in perspective, at the start of the interview period on April 27, 2020, 566 people had contracted COVID-19 in the institution's city, and 6720 people in the whole of negative consequences of COVID-19 at the university level will be critical to manage students' mental health and maximise their learning experience. Such evidencebased strategies need to involve guidance on mental health strategies and referral services to appropriate mental health care. Guidance on the benefits of maintaining a routine, staying connected with others, and exercising were widely divulged by government and non-government agencies as restrictions took place, and reinforced by the participants in our study. 13 In addition to these recommendations, universities need to consider expanding on their student support or referral services to mental health care to understand the nature of the psychological adjustments that resulted from altered social support and opportunities to participate during this exceptional world-wide pandemic. 1 Additional efforts and investments in sustainable mental health care have already been implemented by different governments around the world, and this is likely to be considered and provided at the university level too. 20 A blended approach to eLearning in a physical therapist education program is supported by literature and appears to be consistent with contemporary approaches to higher education. [5] [6] [7] Firstly, many of the participants in the focus groups preferred online lectures over face-to-face didactic lectures and found interactive lectures more beneficial. 4, 5 However, learning practical skills through physical face-to-face interactions encourages social engagement and feedback which was highly valued among the undergraduate physical therapist students in our study. Previous evidence has supported that students prefer face-to-face learning of practical skills in physical therapist education programs. 5 As experienced by the students in this study, in acquiring physical skills, online resources such as videos can be highly beneficial and act as supplementary material rather than primary learning activities. 21 Having a blended approach with online lectures and electronic resources combined with face-to-face practical classes in health professional programs should be kept in mind for future pandemics. It is worth noting that physical therapy has traditionally been considered a 'hands-on' profession, but during the pandemic many physical therapist consultations have also transitioned to an online telehealth model. 22 The COVID-19 pandemic may provide an impetus to change how aspects of physical therapist education programs are taught and delivered in the future, such as including the training in communicating with patients via videoconferencing platforms. The World Health Organization also recommends greater investment into information and communication technology to deliver education to health professionals, use resources more strategically, and plan for evolving requirements. 2, 4 Health professional educational institutions seeking to adopt new technologies will need to provide the infrastructure and support to its staff in their transition. The successful implementation will be dependent on the provision of a skilled information technology workforce to support students and staff in using a range of technological tools. Educational institutions will also need to consider that although staff may spend less time in face-to-face teaching, additional staff time will need to be committed for developing and designing eLearning approaches. 2, 4 Despite the fact that the students in our study preferred online lectures, many still attended the university library or buildings to attend online classes. Participants in this study missed the opportunity to attend university and saw the campus environment as a place not only for learning but also to gain social support from peers. Therefore, it seems that there is still a place for physical university campuses in higher education. One of the aims of this study was to report recommendations for eLearning from the This study focused on the early perceptions of students on full eLearning. Future longitudinal research analyzing students' perceptions over time is recommended to investigate sustained changes and behaviours. Additionally, this study did not analyze the influence of full eLearning on student education outcomes in a physical therapist education program, which is another area that requires further investigation. As we think about the future of physical therapist professional education in the era of COVID-19 and beyond, it will be critical to concurrently examine perceptions of The authors acknowledge the anonymous reviewers whose valuable commentary served to strengthen this manuscript. This study was approved by the Human Research Committee at Curtin University (HRE2020-0182). There are no funders to report for this study. Tables Tell me about your learning experience since moving to eLearning Tell me about your current study habits/strategies Describe how your study habits/strategies changed since we moved to eLearning What are the enablers to eLearning? What are the barriers to eLearning? What would improve your experiences of eLearning? If you had a choice between eLearning and face-to-face learning, which would you choose? Why? Semistructured interview guide on student experience of eLearning during COVID-19. "Face-to-face teaching I think, especially for physiotherapists, is really irreplaceable… as an international student, it's more value for the money." (P20, Y2). COVID-19: 20 countries' higher education intra-period digital pedagogy responses ELearning for undergraduate health professional education -a systematic review informing a radical transformation of health workforce development Building an inclusive definition of e-learning: An approach to the conceptual framework Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction Physiotherapy students' perspectives of online e-learning for interdisciplinary management of chronic health conditions: a qualitative study A blended learning approach to palpation and ultrasound imaging skills through supplementation of traditional classroom teaching with an e-learning package Online technology use in physiotherapy teaching and learning: a systematic review of effectiveness and users' perceptions Focus groups. A practical guide for applied research Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups The SAGE Encyclopedia of Qualitative Research Methods. Thousand Oaks A Method of Phenomenological Interviewing Thematic analysis Using thematic analysis in psychology Improving Environments for Learning in the Health Professions Mental Health of people in Australia in the first month of COVID-19 restrictions: a national Survey How mental health care should change as a consequence of the COVID-19 pandemic Using E-learning to support clinical skills acquisition: Exploring the experiences and perceptions of graduate first-year preregistration nursing students -a mixed method study COVID-19 and the Advancement of Digital Physical Therapist Practice and Telehealth