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. 2025 May 8;9(3):e70038. doi: 10.1002/aet2.70038

From the lecture hall to the cloud: Theoretical foundations for engaging virtual and hybrid didactics in emergency medicine

Donna Okoli 1,✉, Nicole Schnabel 1, Mary R C Haas 1, Sally Santen 2, Margaret Wolff 3
PMCID: PMC12060783  PMID: 40351344

Abstract

Engaging learners in the virtual or hybrid learning environment requires a combination of interactive content, effective communication, and mastery of function in the virtual space. Teaching in the virtual and hybrid environment presents many challenges but it remains a part of emergency medicine resident didactics, making it imperative that theory underpins our approach to virtual and hybrid learning. Connecting didactic techniques to theory can ensure that innovation promotes the intended learning outcome. This paper will demonstrate how to connect education theory to common didactic techniques implemented in the virtual and hybrid environment.

INTRODUCTION

Emergency medicine (EM) didactics must continuously evolve to meet the demands of a changing learning environment. The Accreditation Council for Graduate Medical Education (ACGME) requires structured didactics for EM residency programs, but does not specify the optimal delivery method, leaving educators to determine the most effective approaches. 1 The COVID‐19 pandemic accelerated the need for adaptation, requiring medical educators to quickly shift to a virtual learning environment. 2 Virtual environments use online platforms (e.g., Zoom, Microsoft Teams) to replicate a classroom experience, while hybrid models blend in‐person and online participation in real time. However, this rapid transition prioritized logistic concerns over best practices for engagement, leaving educators unprepared to integrate active learning techniques effectively. 3 , 4 The lack of structured support for this shift created significant challenges, including the physical disconnect between learners and educators, difficulties in fostering a learning community, increased distractions, and reduced interactivity—especially in large groups. 5 , 6

A more effective approach to virtual and hybrid teaching can help educators maximize the benefits of these modalities, including greater flexibility and more equitable and inclusive access to education. 7 , 8 This is critically important in a specialty where variable schedules can hinder in‐person attendance. 6 , 9 Although the COVID‐19 pandemic has ended, virtual and hybrid learning remains a key component of EM training, underscoring the need for intentional curriculum design in these environments. This paper offers guidance on aligning common didactic techniques with educational theory to enhance virtual and hybrid instruction.

Education theory

Learning theories explain how individuals process and integrate new information into existing mental models. They also explore learner motivation and conditions that enhance it. Since no single theory fully explains learning, we present several that can guide didactic development. Behavioral, cognitive, and experiential learning theories focus on behavior changes, mental processes, and learning through experience. 10 Humanistic theories, such as adult learning theory and self‐directed learning, emphasize personal growth and self‐actualization. 10 Social learning theories highlight the importance of context and community in the learning process. 10 Kolb's work, for example, underscores the active nature of learning through experience. 11 A solid understanding of education theory enables educators to design engaging didactic sessions that achieve intended learning outcomes. In Table 1, outlines key learning theories relevant to EM educators developing didactics for their residents.

TABLE 1.

Education theories relevant to didactic education.

Theory Definition
CLT John Sweller developed CLT in the 1980s. CLT is a model for human memory; we have inputs into our working memory and we organize and chunk information into different schemas that are then stored into our long‐term memory. 12 CLT is composed of intrinsic load (demand created by the complexity of the task), extraneous load (demand created by stimuli not related to the task), and germane load (demand to link working memory to long‐term memory). 13
CT and SCT CT, first described by Piaget, asserts that, “the learning environment is one of experimentation and dialogue, where knowledge is seen within the context of problems to be discussed and solved.” 10 Learners construct knowledge and application through the interpretation and explanation of information in the context of previous experiences and existing knowledge. A key idea in the construction of learning, developed by Vygostsky, is the zone of proximal development (ZPD), where new knowledge for a learner is linked with existing knowledge through scaffolding education. The ZPD describes a learner's ability independently compared to their ability to achieve with guidance from a more skilled individual. 14 A branch of constructivism, social constructivism, is a collaborative learning approach that focuses on how a learning community supports and enhances individual learning. 15
Kolb's Experiential Learning Kolb described learning as knowledge created through the transformation of experience. Kolb describes four main stages of the learning cycle—concrete experience (CE), reflective observation (RO), abstract conceptualization (AC), and active experimentation (AE); that is, learners must be able to involve themselves fully, openly, and without bias in new experiences (CE). They must be able to reflect on and observe their experiences from many perspectives (RO). They must be able to create concepts that integrate their observations into logically sound theories (AC), and they must be able to use these theories to make decisions and solve problems (AE). 16
Mastery learning model and deliberate practice

More of a philosophy, rather than a theory, mastery learning describes that a learner must gain proficiency in a specific skill or task before advancing to more complex tasks. 17 Described by Bloom, this educational strategy is effective due to learners having repetition, feedback, and individualized amount of time to master the task. 17 , 18

Introduced by Ericsson, deliberate practice describes the repetitive process of goal setting, feedback, refinement, and focused practice. Deliberate practice asserts that experts or masters are created from “deliberate practice.” 19 The practice is often supervised by an instructor or mentor to provide feedback to the learner.
OCL Theory OCL theory (also known as collaborativism) was developed by Linda Harasim and describes that knowledge is constructed in the online classroom by students engaging in collaborative discourse. 20 In OCL, the instructor is not merely the facilitator of group discussion, but represents the “science” of the knowledge community and serves to induct the students into the community. 20 OCL is a three phase structured process—idea generation, idea organizing, and intellectual convergence—that culminates with intellectual change and knowledge creation as students engage in the discourse of the online community. 21 , 22 Student‐generated discussion is at the center of the theory. Specifically, the instructor deliberately designs the online environment to scaffold discourse and collaboration to support knowledge construction of the learner. OCL differs from other learning theories in that student generated discussion is at the center of the theory. Unlike traditional in‐person learning, it allows for learners to contribute asynchronously and from different locations through the use of online environments.
SDT SDT, developed by Deci and Ryan, asserts that humans are driven by extrinsic and intrinsic motivation. Extrinsic motivation is driven by an external control that creates demands or requirements and has associated rewards or punishments. Intrinsic motivation causes free engagement in an activity out of interest or inherent satisfaction. SDT asserts that external and, to a larger extent, internal motivations are driven by an individual's need for autonomy, competency, and relatedness to others. 23
SLT SLT was developed by Bandura and posits that human behavior is determined by observing and imitating others, particularly if those behaviors are reinforced by positive consequences. SLT sees instructors as role models, rather than mentors or guides, and asserts that learning occurs through vicarious experiences in a social context. 24
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Abbreviations: CLT, Cognitive Load Theory; CT, Constructivist Theory; OCL, Online Collaborative Learning; SDT, Self‐Determination Theory; SLT, Social Learning Theory.

General principles for effective learning applied in virtual and hybrid lectures

Applying Cognitive Load Theory (CLT) can help educators design engaging and effective lectures specifically for virtual and hybrid environments. CLT explains how information is processed through working memory, as outlined in Table 1. 13 , 25 Educators can apply CLT principles by developing clear learning objectives, using media meaningfully, and demonstrating enthusiasm for the content. 26 To optimize virtual or hybrid instruction, educators should structure content logically, ensuring that it builds progressively over time. Breakout rooms can facilitate discussions, while asynchronous discussion boards provide learners with flexibility to engage at their own pace. This approach helps manage cognitive load by reducing intrinsic and germane loads through clear organization, while minimizing extraneous load by allowing learners to interact on their own schedules. Table 2 highlights key technical and communication strategies to further reduce cognitive load and enhance learning in virtual and hybrid settings.

TABLE 2.

Technical considerations and communication.

Technical considerations Effective communication

  • Reliable platform: Ensure the virtual platform is user‐friendly and reliable.

  • Tech support: Provide technical support to learners, and orient them to the capabilities of the platform.

  • Accessibility: Ensure that all materials are accessible to learners with disabilities. (consider closed captioning and alternative text)

  • Anticipate issues: Plan for something to not work and have a back‐up! Simple is sometimes better. The more tools you incorporate, the more opportunity there is for something to go wrong.

  • Know your audience and the methods you will have at your disposal to communicate with them.

  • Consider your body language, facial expressions, and tone when speaking.

  • Consider external factors like room lighting, ambient noise, etc.

  • Use discussion forums: Create forums or chat groups for learners to discuss their thoughts and ideas and to collaborate.

  • Give timely feedback: Provide prompt feedback on learner queries (if possible, have others manage the chat).

  • Be aware of your physical presence: When hybrid, make sure standing you are in a place where you can be seen on camera. Plan for a microphone so users in person and online can hear you clearly. Make sure you check the chat regularly and build in opportunities for them to respond.

  • Be comfortable with silence: There will be an increased amount of silence and that is ok.
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How to optimize didactics for hybrid learning

Beyond the technical and communication considerations, hybrid learning presents unique challenges that require intentional strategies. Building a sense of community, grounded in theories such as constructivism and Social Learning Theory (SLT), helps engage both in‐person and remote learners, ensuring that virtual participants feel fully integrated into the learning experience. 27 To achieve this, hybrid educators must adapt their teaching methods while maintaining the same educational outcomes. Table 3 details several common instructional strategies that can foster a cohesive learning environment for both in‐person and remote learners. Many of these methods are already familiar to educators, but Table 3 highlights the underlying educational theories and provides practical applications for virtual and hybrid settings.

TABLE 3.

Common Learning Techniques Adopted for Virtual and Hybrid Learning. 28

Technique Definition Resources needed in virtual space Theory that underpins the technique How to implement in virtual/hybrid
ARS ARS software allows educators to interact with learners via polls, text responses, or multiple‐choice questions displayed via a mobile or computer device. Software Constructivist, social constructivist Easily integrated into many virtual platforms. This is a good option for hybrid as the same software can be used at the same time by in‐person and virtual learners. This also allows learners to compare their answers to others in the group in a social setting.
CBL CBL uses a guided inquiry method, with defined learning outcomes. 29 The goal of CBL is to prepare learners for clinical practice, through the use of authentic clinical cases. It links theory to practice, through the application of knowledge to the cases, using inquiry‐based learning methods. 30 Breakout rooms Constructivist, social constructivist, mastery learning, online collaborative learning Develop a case based on a “real” clinical scenario. Ensure that case has predetermined learning outcomes.
FC Small‐group learning that involves preclass preparation so that learners are ready to learn. This is followed by a classroom portion with learner‐centered activities. Learners can be tested on the preclass material and then challenged to apply core content to scenarios as a team or in small groups. Breakout rooms SDT, constructivist, online collaborative learning Prework can be completed by both virtual and in‐person learners. For virtual models, groups can utilize breakout rooms to create a small‐group atmosphere. In a hybrid model, utilize virtual learners in their own small group as they cannot easily participate with in‐person participants.
TPS Pose a question to the group. Have learners consider their responses individually. Next, instruct learners to pair with a partner to share responses. Then, randomly call on pairs to share with the group. Virtual seating chart, private chat function Social constructivist Ensure that those in the virtual space know who to pair up with. Consider using the virtual seating chart and private chat function to facilitate sharing.
Games The use of game design elements (e.g., points, leader boards, prizes) to enhance engagement and learning. Software Social learning, SDT For virtual or hybrid choose game platforms that can be utilized on each individual's own device.
Pause procedures (1‐min paper, muddiest point) A brief pause in the lecture/discussion to allow learners to clarify and assimilate new knowledge. One‐minute paper and muddiest point are types of pause procedures. One‐minute paper: pose questions and have learners write down their response. Muddiest point: learner given the opportunity to reflect and obtain clarification on points of confusion. Chat function, word clouds Cognitive load, constructivist Make intentional time in the lecture to allow for this.
VR 31 , 32 Immersive technology that can project learners into near‐realistic environments, which can be augmented to enhance learner proficiency. Software Mastery learning, deliberate practice Learners have access to the virtual simulator and can practice the task in the virtual environment. An AI‐powered virtual ED can provide additional guidance for learners by assessing trainee performance, offering personalized feedback, and recommending learning resources.
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Abbreviations: AI, artificial intelligence; ARS, audience response systems; CBL, case‐based learning; FC, flipped classroom; TPS, think–pair–share; VR, virtual reality.

AUDIENCE RESPONSE SYSTEM

Audience response system (ARS), such as polls or multiple‐choice questions, frequently engage residents in lectures. An ARS promotes active learning, which enhances knowledge acquisition and retention and often allows learners to remain anonymous, ensuring psychological safety. 33 The educational theories that support the success of an ARS are Constructivist Theory (CT) and Social Constructivist Theory (SCT). These theories identify that knowledge is constructed through experimentation, dialogue, and social interaction. 10 , 14 , 34 By using polls and multiple‐choice questions in resident didactics, educators provide residents the opportunity to build knowledge with their peers. Learners actively participate in the learning process by responding to the questions and polls during the didactic session. ARS supports the constructivist and social constructivist ideas of interactive and reflective learning experiences.

CASE‐BASED LEARNING

Case‐based learning (CBL) is a guided inquiry activity with predetermined learning outcomes that guide learners through a case that resembles real‐world scenarios. Each case prompt requires the learner to recall information from memory such as related conditions, pertinent physical examination findings, and treatments. Based on the answers provided the educator can identify the learner's preexisting knowledge and create the zone of proximal development to connect new information to their existing understanding. 14 This is grounded in CT but also employs mastery learning. Cases are scaffolded so that learners are required to demonstrate a baseline level of knowledge before moving into the deeper complexities of the case. 30 CBL cases also integrate social constructivist concepts as learners discuss the case and answer questions in front of the group, thereby sharing their preexisting knowledge and learning from each other.

FLIPPED CLASSROOM

Bergmann and Sams coined the term “flipped classroom” (FC), although the concept first appeared in the literature in the early 2000s. 35 In a FC approach, learners complete prework individually and then engage in a classroom portion that focuses on learner‐centered activities, often involving small groups or teams. Educators may also test learners on the preclass material during the classroom portion. 36 Self‐Determination Theory (SDT) posits that a learner's motivation stems from a need for autonomy, competence, and relatedness to others. In a FC, learners demonstrate autonomy by completing prework independently. During the classroom portion, learners show their competency by sharing knowledge gained from the prework and comparing their understanding with others, which fosters a sense of relatedness. When educators ground FC in SDT, they should clearly define how learners will demonstrate the knowledge gained from prework during the classroom portion. By setting these expectations in advance, educators increase learners' motivation to complete the assigned work, as they will know they must demonstrate their competency. Learners are also motivated by a desire not to stand out from peers who have completed the prework.

THINK–PAIR–SHARE

Frank Lyman developed the active learning method Think–Pair–Share (TPS) in 1981. 37 The technique aims to give all learners the opportunity to think about and share their ideas with the group. The educator poses a question to the learners and gives them a predetermined amount of time to consider their responses. Next, learners discuss their responses in pairs. Finally, the educator invites several pairs to share their responses with the entire group. TPS is rooted in CT, where learners construct knowledge and the educator's role is to facilitate. TPS increases learner interaction and participation, promotes equitable participation among the group, and enhances the quality of discussion. 38

GAMES

Educators often define the use of games or “gamification” in education as the application of game characteristics and benefits to real‐world processes or problems. 39 This is typically interpreted as using game design elements (e.g., points, leaderboards, prizes) to enhance academic performance. 40 Several theories provide a basis for using game elements in medical education. The first is SLT, which asserts that learning occurs when learners observe, imitate, and experience through imagination the actions or feelings of others. 24 Games place learners in a social context where they can observe the actions of their peers and experience the wins and losses of others, learning from both successes and failures. Additionally, SDT aligns well with games. Learners demonstrate relatedness to others by seeing their rank on the leaderboard, and they show competency by earning points or scoring well. If educators consider gamification through the lens of SLT or SDT, they should ensure that learners are identifiable by their points, scores, or leaderboard rankings. Anonymity, in the context of these learning theories, would hinder the learning process. In SLT, anonymity means that learners do not know who is performing well or poorly, leaving them unsure of whom to model their behavior after to succeed. In SDT, anonymity prevents learners from receiving acknowledgment for their competency and diminishes their sense of relatedness to others.

PAUSE PROCEDURES

Pause procedures involve short, strategically placed 2‐ to 3‐min breaks in a lecture, where educators give learners opportunities to ask questions, summarize content, or engage in discussion. Ideally, educators plan these pauses at 10‐ to 15‐min intervals throughout the lecture, focusing on specific tasks. This simple technique requires little preparation but offers significant benefits. CT and CLT support the use of pause procedures. CLT posits that pausing positively affects performance and retention. 41 As learners develop schemas for new knowledge in their working memory, pause procedures help facilitate this process by providing time to connect new information to existing knowledge. 10 Learner attention peaks at 15 min. 42 By incorporating pause procedures, educators can improve content retention in both short‐term and long‐term memory.

VIRTUAL REALITY

Virtual reality (VR) is a digital learning method that provides highly realistic learning with repeatable learning experiences in a protected learning environment and has unique applications in virtual learning. 43 VR environments can often be more convenient and scaled for distribution to a wide array of learners. 44 While VR environments can be used in‐person with the use of headsets and controllers, it can also be used to specifically facilitate online learning, in which learners are in separate locations interacting in a shared virtual environment. VR is a platform for both mastery learning and deliberate practice to be implemented. Mastery learning hinges on learners gaining a specific level of proficiency prior to advancing to more complex and sophisticated tasks. 18 VR allows learners to advance at their own pace and undergo multiple repetitions of a task until they demonstrate mastery. Deliberate practice emphasizes focused and repetitive practice to improve specific skills through the use of feedback and reflection. 19 Through VR, learners can practice a task, receive immediate feedback, and refine their skills, which leads to continuous improvement over time. A budding field of application is the integration of VR with artificial intelligence (AI). AI can enhance the VR learning space with enhanced personalization of the learning environment, performance analytics and feedback, and use of group simulations. AI enhanced VR guides the learner in the construction of knowledge and skill acquisition, impacting their learning trajectories and behaviors. 45

Less commonly used active learning techniques

There are many, less commonly used learning techniques that can be employed to create a more active didactic session. The Center for Excellence in Learning and Teaching (CELT) at Iowa State has compiled a list of 226 active learning techniques. 46 In Table 4, we have chosen 10 that you can incorporate into your next didactic session.

TABLE 4.

Less commonly used active learning techniques.

Technique Definition Resources required in virtual space Theory that underpins the technique Example of how to use in residency didactics
Polar opposites Examine two written‐out versions of a theory, where one is incorrect and the other is incorrect. In deciding which is correct, learners will have to examine the problem from all angles. None Constructivist Residents receive two prompts with a patient who is hypotensive. One of the prompts correctly illustrates features of a patient with cardiogenic shock and the residents must decide which prompt has the patient with cardiogenic shock.
Directed paraphrasing Learners are asked to paraphrase part of a lesson for a specific audience and/or a specific purpose. None Social theory Residents are taught about bowel obstruction and then must paraphrase the important points of their lesson as if they were speaking to a patient who has a bowel obstruction or the surgical consulting resident.
Ranking alternatives Educator gives a situation and learners think up as many alternative courses of action (or explanations of the situation) as possible. Compile list. In groups, rank them by preference. None Social constructivist Residents are asked to compile a list of antibiotics for a specific condition and rank them by preference (which may be influenced by the medication's side effects, contraindications, resistance patterns, etc.)
Picture prompt Show learners an image with no explanation and ask them to identify/explain it and justify their answers or ask learners to write about the image using terms from a lecture. Also works well as group activity. Do not give the “answer” until they have explored all options first. None Constructivist Residents are given a picture of a rash and must identify the cause with justification. Residents are given a CT scan image with an abnormal finding and must identify the abnormality using terms from a lecture about CT radiology.
Misconception check Allows educators to discover class's preconceptions. Useful for introducing new concepts to learners or gauging their understanding on difficult concepts. None Constructivist Residents are asked prior to the start of a lecture on patient safety their perceptions of safety in their ED. Can also be used with controversial topics such as nasogastric tube in awake patients with small bowel obstruction or giving patients with corneal abrasion tetracaine on discharge home.
Harvesting After an educational experience/activity, ask learners to reflect on “what” they learned, “so what” (why is it important and what are the implications) and “now what” (how to apply it or do things differently). None Constructivist Consider this activity after morbidity and mortality case presentations to foster meaningful reflection.
Memory matrix Identify a key taxonomy and then design a grid that represents the interrelationships. Keep it simple at first. Avoid trivial or ambiguous relationships, which tend to backfire by focusing learners on superficial kinds of learning. None Cognitive load, deliberate practice, mastery learning Consider using this technique to teach ECG. Start with a normal ECG and then build matrix out to learn common abnormalities (STEMI, Brugada, Wellens, SVT, Vtach, etc.)
Pass the problem Divide learners into groups. Give the first group a case or a problem and ask them to identify (and write down) the first step in solving the problem or analyzing the case (3 min). Pass the problem on to the next group and have them identify the next step. Continue until all groups have contributed. Breakout rooms. Multiple facilitators Social theory, SDT, constructivist Choose a case and highlight four to five points of tension or decision making in the case. An example could be a case in which there is a sick child and the parents wish to take them home against medical advice. Points of tension in the case include the ethics, communication, medical decision making, etc. Give each point to a different group of residents and have them work the case from that point then pass between the groups.
Lecture reaction Divide the group into four groups after a lecture: questioners (must ask two questions related to the material), example givers (provide applications), divergent thinkers (must disagree with some points of the lecture), and agreers (explain which points they agreed with or found helpful). After, share out answers with the entire group. Breakout rooms Constructivist Residents have a lecture given by a consultant on how they manage the case (e.g., lower GI bleed). Trainees break into groups of questioners, example givers, divergent thinkers, and agreers. Discussion should highlight the differences in how the ED might approach management compared to the consulting service and how to broach those discrepancies.
Assertion agreement Pose an assertion at the start of class that learners vote on agreement; then revisit the same question after the class lecture/discussion has explored the concept more deeply. ARS Constructivist Have presentations on controversial topics (i.e., lidocaine with epinephrine for finger lacerations, contrast‐induced nephropathy). Open the lecture with the agreement statement and ask again at the end of the lecture to determine if learners' opinions have changed.
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Abbreviation: ARS, audience response system.

CONCLUSIONS

Virtual and hybrid learning environments will continue to be utilized for the foreseeable future within emergency medicine didactics. The major benefit is that these learning environments enhance flexibility for learners and educators. Educators should familiarize themselves with the education theories that underpin didactics education. There is not one specific theory that best suits didactic education, but educational theory should align with educational methods and intended learning outcomes. The virtual and hybrid learning environments pose unique challenges that should be recognized by educators so that they can be overcome before becoming detrimental to learners. Active learning techniques can be used to engage the audience and can be readily adapted for use in the virtual and hybrid learning space.

AUTHOR CONTRIBUTIONS

Literature review: Donna Okoli, Nicole Schnabel. Drafting manuscript: Donna Okoli, Nicole Schnabel, Mary R. C. Haas, Sally Santen, Margaret Wolff. Critical revision of the manuscript for intellectual content: Donna Okoli, Nicole Schnabel, Mary R. C. Haas, Sally Santen, Margaret Wolff.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Okoli D, Schnabel N, Haas MRC, Santen S, Wolff M. From the lecture hall to the cloud: Theoretical foundations for engaging virtual and hybrid didactics in emergency medicine. AEM Educ Train. 2025;9:e70038. doi: 10.1002/aet2.70038

Supervising Editor: Sam Clarke

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