Abstract
Background
Medical education all over the country has been forced to shift to e-learning, mainly online classes. In this scenario, the medical education department (MEU) of a teaching hospital under a deemed university felt the need to study the satisfaction and usefulness of these classes, as perceived by the undergraduate medical students.
Methods
Questionnaire survey was planned. A specially designed questionnaire was created, keeping in mind, the study objectives. It was validated, and a pilot was conducted, for modifications and to calculate sample size. The questionnaire was administered by email as Google Forms. The responses, which included quantitative and qualitative responses, were analysed, and feedback points noted. Percentage level of satisfaction and usefulness was calculated with 95% confidence interval. To test the statistical significance of the association of satisfaction levels amongst students of different Phases, chi square test was used.
Results
On a scale scoring for satisfaction, 53.6% scored moderate, 31% high, and 15.4% low satisfaction. 49.8% of the students were less satisfied about attending classes from home; 15.7% felt it was better. 57.1% of the students found the concept of online learning moderately useful, 31.4% found it minimally useful, 11.5%, highly useful.
Conclusions
The undergraduate medical students perceived moderate satisfaction and usefulness with the on-going online classes. They expressed the desire to resume routine physical classes, especially for practicals and clinics. Points of improvement of the online teaching-learning programme were also obtained. This study revealed sufficient feedback to be shared with all stakeholders, regarding improvements in the online classes.
Keywords: Medical education, Undergraduate students, Distance learning, Questionnaire, Perceptions
Introduction
The current pandemic situation has been a challenge to the entire range of educational programmes, due to the inability of institutions to open their doors to students. Perforce, the alternative chosen by most has been to conduct online classes. This has been true of medical education too. This is not a bad thing in itself; on the contrary, online learning is considered an integral part of modern education. Many articles have listed the advantages of this modality.1,2 Its utility in medical education has also been documented.3, 4, 5
Our Institute, which is a teaching hospital under deemed University in south India, started delivering its online teaching programme to all phases of the UG students, both didactic and practical/clinical classes, from April 2020. This being relatively unfamiliar territory for the stakeholders (students, teachers, administration), there have been concerns about the effectiveness of the teaching-learning exercise. Hence, there was a felt need for feedback of the new initiative. Student feedback is a recognized method of improvement of any teaching-learning programme.6 This was taken up by the medical education department (MEU). A survey questionnaire being the easiest modality, this was created by the MEU, and used for the study. The aim was to know students' perceptions of online learning, and to get feedback that could help in improving the on-going pattern of online medical education. The objectives were to understand the level of satisfaction and usefulness perceived by the undergraduate medical students for the online teaching-learning classes, and to check the association of these parameters between different phases.
Materials and method
The study proposal was presented in the Institutional Review Board. It was approved, but exempted from Ethics Committee review as it belonged to one of the exceptions viz. ‘Comparison of instructional techniques, classroom methods and curricula’, in accordance with Section 4 (sub-section 4.8) of the ICMR (Indian Council of Medical Research) Guidelines for Biomedical Research.
Study type and setting
Descriptive quantitative study undertaken on the 400 undergraduate medical students (100 in each of 4 Phases) of a tertiary care medical college hospital in South India, conducted via web-based Google classroom platforms and Google Forms.
The current online teaching programme consists of mainly theory classes, as per the existing curricular schedule, delivered via combination of Zoom and an intra-Hospital platform, from a dedicated venue in the hospital. The students are provided with the daily timetable in which adequate weightage is given to each subject. Preclinical (Phase 1) subjects are usually covered in the morning hours and paraclinical (Phase 2) and clinical (Phases 3 and 4) subjects in the afternoons to suit faculty convenience. Few of the latter departments have also started clinical demonstrations via the same platform. A mid-term online sessional assessment (theory, short answer questions) was conducted in July. This was via Zoom platform, to be answered over a 2 h duration. The students answered in pen-paper mode, which was then scanned to PDF format, and uploaded to the respective Google Classrooms.
The study was envisaged after three months of the start of online classes. After planning and due processes detailed below, the actual administration of the questionnaire was in mid-August.
Tool: Questionnaire
The MEU devised the tool, following the process for creation of a new questionnaire. Content validity was tested. Cronbach's alpha was not considered since the questions were not similar. Pilot was done, with the intention of finalizing the questions, and to obtain sample size for the study. The process has been documented.
The questionnaire is shown in Appendix 1. It consisted of 20 items, divided into four sections, each of which dealt with a separate aspect. These were as follows: 2 questions related to prior knowledge of online learning; 13, related to baseline data, personal choices, and perceptions; 3, regarding the online assessment; 2, about future plan and suggestions. The majority (17) were multiple choice type questions, mostly with 4 options each. 2 questions were free-text, intended as source of feedback. All the questions were made mandatory. An introduction and consent form were attached along with the questionnaire.
Three questions targeted the primary objective viz. satisfaction and usefulness (Q. 11, 12, 13 in Section II). We categorized the responses to these questions into three groups, representing low, moderate, and high value of the parameter under study, for the purpose of statistical analysis. Specifically, for Q. 12, the first option (“effective and efficient”) was categorized as “highly useful”, the second (“efficient but not effective”), as “moderately useful”, and third (“neither efficient nor effective”) as “least useful”. For Q. 13, a scale question to check level of satisfaction, the scores of 0–3 was categorized as low, 4–7 as moderate, 8–10 as high. These categorizations were decided prospectively, in consultation with the statistician, and were not mentioned in the administered questionnaire.
The questionnaire was sent to 370 students, excluding the 30 who already responded as part of the pilot. It was administered via Google Forms, mailed to the students. Two representatives from each batch were appointed as facilitators in communicating with the students. A time of two weeks was given to get the responses.
Sample size: Based on the proportion of level of satisfaction (23.3%) and usefulness (23.3%) perceived for the online classes as observed in the pilot conducted on 30 students, and with 20% relative precision and 95% confidence, the minimum sample size was calculated to be 316.
Statistical analysis: Percentage level of satisfaction and usefulness was calculated with 95% confidence interval. To test statistical significance of comparison between two groups of students, chi square test was used.
Results
Responses were obtained from 319 students, out of 370 (response rate 86.2%). The phase-wise responses are detailed in Table 1.
Table 1.
Table showing Phase-wise distribution of response rate.
| UG year (Phase) | No. of students to whom questionnaire sent | Respondents | Response % |
|---|---|---|---|
| First | 96 | 84 | 87.5 |
| Second | 95 | 74 | 77.9 |
| Third | 90 | 83 | 92.2 |
| Fourth | 89 | 78 | 87.6 |
| Total | 370 | 319 | 86.2 |
The concept of online classes was known to 60.2% of the students. 25.4% of them had attended recorded theory classes earlier, 6.9% had experienced live streaming theory classes, 6% had attended both recorded theory and practical. 45.1% were aware of online platforms, mainly YouTube and Marrow; 3.1% of the students knew about Zoom and Google Classrooms.
Table 2 lists the preferences for timing and duration of the online classes. It showed a clear choice for the early to late mornings, and 30–40 min sessions. The former preference was based on practical considerations like finishing morning chores to be ready for class, and the latter, on being more alert and fresh during the early hours, avoiding post lunch timing (“sleepy and boring”). Also, the time after classes could be used for studying. The other significant factor was the better net connectivity during morning hours. Table 3 shows the details of device preferences. Laptop was the most favoured device (“greater screen size, lesser eye strain”). Less than half reported connectivity issues, while few reported distractions at home.
Table 2.
Table showing student preferences for online class timings and duration, with the highest in each category in bold font.
| Criteria studied | Options | Percentage Responses n = 319 | |
|---|---|---|---|
| Preferred time for online classes | 1 | 8 am - 12 noon | 137 (42.9%) |
| 2 | 10am - 2pm | 150 (47%) | |
| 3 | 12 noon - 4pm | 15 (4.7%) | |
| 4 | 2 pm - 6pm | 12 (3.8%) | |
| Ideal duration for each online lecture class | 1 | 20 min | 7 (2.2%) |
| 2 | 30 min | 84 (26.3%) | |
| 3 | 40 min | 205 (64.3%) | |
| 4 | One hour | 23 (7.2%) | |
| Ideal duration for each online practical class | 1 | 20 min | 24 (7.5%) |
| 2 | 30 min | 129 (40.4%) | |
| 3 | 40 min | 128 (40.1%) | |
| 4 | One hour | 38 (11.9%) | |
| Ideal duration of break time between online classes | 1 | No break | 13 (4.1%) |
| 2 | 10 min | 113 (35.4%) | |
| 3 | 15 min | 136 (42.6%) | |
| 4 | 20 min | 57 (17.9%) | |
Table 3.
Table showing the preferred devices to access online classes and connectivity issues faced by students, with the highest in each category in bold font.
| Criteria studied | Options | Percentage Responses n = 319 | |
|---|---|---|---|
| Device preference | 1 | Desktop | 8 (2.5% |
| 2 | Laptop | 216 (67.7%) | |
| 3 | Mobile | 71 (22.3%) | |
| 4 | Tablet | 24 (7.5%) | |
| Connectivity issues (reported by 44.8% of students) | 1 | 75–100% of all classes affected5 | 4 (1.3%) |
| 2 | 50–75% of all classes affected | 23 (7.2%) | |
| 3 | 25–50%% of all classes affected | 61 (19.1%) | |
| 4 | 0–25%% of all classes affected | 55 (17.2%) | |
| Problem attending online classes due to distraction at home | 1 | Always | 16 (5%) |
| 2 | Most of the time | 42 (13.2%) | |
| 3 | Never | 61 (19.1%) | |
| 4 | Sometimes | 200 (62.7%) | |
Preferences for interaction during an online class: 59.6% preferred seeing and verbally communicating with the teacher, while 25.4% preferred only video interaction (seeing the teacher on screen), 12.9%, only audio interaction, 2.2%, neither interaction. Regarding the use of PowerPoint (PPT), 39.5% opined that PPTs had much more importance in online classes, 23.8% felt it had slightly more importance while 12.9% felt it had lesser importance.
Table 4 details the responses to three questions (11, 12, 13 in section II) that were used for the study objectives. Nearly half the students felt that it was worse to attend online sessions from home without peer interaction when compared to regular classes. Online teaching was felt to be moderately useful by 57% students. On the scale scoring, 53.6% indicated moderate level of satisfaction. Table 5 shows the phase-wise associations of the same. These were not statistically significant. Table 6 shows the comparison between students who had prior knowledge of online classes and those who did not, with respect to the perception of usefulness and satisfaction. The latter were equally satisfied as the former with the concept of online teaching when compared to lecture hall teaching, with statistically significant association.
Table 4.
Perception of Usefulness and Satisfaction, with the highest in bold font.
| Criteria | options | Percentage responses n = 319 |
|---|---|---|
| Home vs. Physical class |
|
50 (15.7%) |
|
54 (16.9%) | |
|
159 (49.8%) | |
|
56 (17.6%) | |
| Online vs. Lecture hall teaching |
|
37 (11.6%) |
|
182 (57.1%) | |
|
97 (30.4%) | |
|
3 (0.9%) | |
| Scale rating of overall satisfaction | 1. High | 99 (31.0%) |
| 2. Moderate | 171 (53.6%) | |
| 3. Low | 49 (15.4) |
Table 5.
Phase-wise sub-group analysis of responses related to usefulness and satisfaction.
| Phase | Online class vs Regular class | Usefulness | Satisfaction | ||||||
|---|---|---|---|---|---|---|---|---|---|
| First n = 84 | 1 | Better | 11 (13.1%) | 1 | Highly useful | 7 (8.4%) | 1 | Low satisfaction | 8 (9.5%) |
| 2 | Equal | 13 (15.4%) | 2 | Moderately useful | 55 (65.4%) | 2 | Mod. satisfaction | 46 (54.7%) | |
| 3 | Worse | 37 (44.04%) | 3 | Least useful | 22 (26.1%) | 3 | High Satisfaction | 30 (35.7%) | |
| 4 | Not comparable | 23 (27.3%) | 4 | Cannot comment | 0 | ||||
| Second n = 74 | 1 | Better | 14 (18.9%) | 1 | Highly useful | 13 (17.5%) | 1 | Low satisfaction | 12 (16.2%) |
| 2 | Equal | 10 (13.5%) | 2 | Moderately useful | 33 (44.5%) | 2 | Mod. satisfaction | 34 (45.9%) | |
| 3 | Worse | 40 (54%) | 3 | Least useful | 27 (36.4%) | 3 | High Satisfaction | 28 (37.8%) | |
| 4 | Not comparable | 10 (13.5%) | 4 | Cannot comment | 1 (1.3%) | ||||
| Third n = 83 | 1 | Better | 11 (13.3%) | 1 | Highly useful | 9 (10.8%) | 1 | Low satisfaction | 17 (20.4%) |
| 2 | Equal | 19 (22.8%) | 2 | Moderately useful | 46 (55.4%) | 2 | Mod. satisfaction | 45 (54.2%) | |
| 3 | Worse | 42 (50.6%) | 3 | Least useful | 27 (32.5%) | 3 | High Satisfaction | 21 (25.3%) | |
| 4 | Not comparable | 11 (13.3%) | 4 | Cannot comment | 1 (1.2%) | ||||
| Fourth n = 78 | 1 | Better | 14 (17.9%) | 1 | Highly useful | 8 (10.2%) | 1 | Low satisfaction | 12 (15.3%) |
| 2 | Equal | 12 (15.3%) | 2 | Moderately useful | 48 (61.5%) | 2 | Mod. satisfaction | 46 (58.9%) | |
| 3 | Worse | 40 (51.2%) | 3 | Least useful | 21 (26.9%) | 3 | High Satisfaction | 20 (25.6%) | |
| 4 | Not comparable | 12 (15.3%) | 4 | Cannot comment | 1 (1.2%) | ||||
Table 6.
Table showing the comparison of the perceptions of usefulness and satisfaction between students who had prior awareness of online classes and those who did not.
| Prior to January 2020, were you aware of the concept of online classes? |
Pearson Chi-Square | ||||
|---|---|---|---|---|---|
| No | Yes | Total | |||
| As per your experience so far, the concept of online teaching when compared to lecture hall teaching is | High useful | 15 | 22 | 37 | 0.002 |
| 11.80% | 11.45% | 11.60% | |||
| Moderate useful | 73 | 109 | 182 | ||
| 57.50% | 56.77% | 57.05% | |||
| Least | 39 | 58 | 97 | ||
| 30.70% | 30.21% | 30.41% | |||
| Total | 127 | 192 | 319 | ||
| 100.00% | 100.00% | 100.00% | |||
| On a scale of 1–10 how satisfied are you with the present online classes? (1 being least satisfied) | High | 42 | 57 | 99 | 0.504 |
| 33.10% | 29.70% | 31.00% | |||
| Moderate | 67 | 104 | 171 | ||
| 52.80% | 54.20% | 53.60% | |||
| Low | 18 | 31 | 49 | ||
| 14.20% | 16.10% | 15.40% | |||
| Total | 127 | 192 | 319 | ||
| 100.00% | 100.00% | 100.00% | |||
Table 7 shows the responses to questions about the concept of an online examination. Overall, it was not highly appreciated, with less than a third of the students considering it good, and nearly 60% considering it inferior in terms of effectiveness in testing knowledge. Either of connectivity and/or technical issues was a hindrance in attempting the tests for nearly 70% students.
Table 7.
Table showing the distribution of responses to questions regarding the online assessment (sessional examination) conducted online.
| Criteria studied | |||
|---|---|---|---|
| Concept of online examination | 1 | Outstanding | 19 (6%) |
| 2 | Good | 89 (27.9%) | |
| 3 | Satisfactory | 111 (34.8%) | |
| 4 | Not satisfactory | 100 (31.3%) | |
| Online assessment in terms of effectiveness in testing knowledge | 1 | Far superior | 15 (4.7%) |
| 2 | Slightly superior | 15 (4.7%) | |
| 3 | Equal | 107 (33.5%) | |
| 4 | Inferior | 182 (57.1%) | |
| Difficulties faced during online examination | 1 | Neither connectivity nor technical issues Only | 97 (30.4%) |
| 2 | connectivity issues but no technical issues | 92 (28.8%) | |
| 3 | No connectivity issues but only technical issues | 32 (10%) | |
| 4 | Both connectivity and technical issues | 78 (24.5%) | |
70.5% of the students did not prefer continuation of the online classes in its present form once the pandemic situation resolved. Appendix 2 lists the main comments from the responses in the free text section. These indicated that they preferred regular classes once the pandemic is over as they felt that they were not getting clinical knowledge and interaction with patients and doctors. They also opined that learning being a more active process, classroom atmosphere was more appealing for studies, providing better scope for understanding and clinical development. Many of them also felt lack of peer interaction was a major drawback of online classes. Almost all were concerned about the clinical/practical classes which they felt cannot be replaced by online sessions. But some of the participants felt that online classes gave them freedom to choose learning time and at the same time be in the comfort of their homes with lesser distractions and hence concentrate better. When asked about suggestions to improve the online classes, a large majority of the participants wanted the online classes to be made more interactive.
Discussion
The present pandemic has affected medical education the world over.7,8 This has led to the teaching-learning (T-L) programme being conducted virtually. Institutions in India have been utilizing available facilities to maintain the curricular schedule. The National Medical Commission (NMC) has put forward a module on online learning and assessment, giving guidelines for the same. These include approaches to be used in both synchronous and asynchronous teaching, usage of online instructional videos, online screen based virtual reality simulators etc. They have also encouraged e-assessment modalities such as simulations, MCQs, audio visual triggers like x-rays, projected gross and microscopic images, apart from regular paper-based questions.9
A fallout of this change in modality has been loss of uniformity, as well as quality assurance, of the T-L schedules across the country. One way of resolving this is by getting feedback from the chief beneficiary of the programme viz, undergraduate medical students. Feedback is an acknowledged important component of any T-L programme. One article has called it “the life blood of learning” and helpful to “plan the curriculum and improve upon the teaching and evaluation methodologies”.10 For the present study, we decided to elicit feedback via a survey of the perception of students towards the on-going online classes. Ideally, perceptions are best studied by qualitative methods (direct interview, focus group discussion), or a combination of quantitative and qualitative methods, as this can lead to a better understanding of such issues.11, 12, 13 Unfortunately, the logistical issues with conducting any of the qualitative methods prevented us from considering it. Thus, we settled for the use of questionnaire specially created for the purpose. Utilizing this tool to study student satisfaction has been well established. A “College Student Satisfaction Questionnaire” and a manual for its use were described way back in 1970–71.14,15 In the field of medical education, self-developed and adapted questionnaires have been used for the same purpose.16,17 Literature has already been enriched with similar reports during the present pandemic, with one study from Poland using a questionnaire very similar to ours.18, 19, 20
Baseline data and personal choices
The response rate in our study was 86.2%, with maximum response from the third phase and least from second phase. This was coincidentally similar to the study from a medical college with similar demographics.20
The source of students' prior awareness of online platforms for learning was YouTube and Marrow, which they had mostly used for NEET preparation. Regarding online class timing preferences, the majority choice has been for morning hours with duration not more than 40–45 min for a theory class. This was the same as reported in another study.20 Given the attention span of present generation, and the fact of inadequate supervision in online classes, shorter duration of classes must be seriously considered. In this context, one article describes the likely changes in the education of the so-called “Gen Z”.21
Connectivity issues were a uniform cause of complaint about online classes amongst all reports so far. Interaction with the teacher is an important aspect of physical classes. One way of retaining this to some extent in an online class is by maintaining visual and audio interaction between teacher and students. Nearly 60% of our students preferred both. A focus group discussion (FGD) study reports the feeling that “non-verbal communication like eye contact with the instructor is missed”.12 An article on the relevance of video lectures reports students observation of “feeling that connection with the instructor as if they were in the same space, which results in increased engagement and motivation”.13
Perception of satisfaction and usefulness
One of the questions we asked to attain the study objective was the comparison of satisfaction perceived between home and classroom attendance. Almost half of them felt that attending from home was worse in terms of satisfaction, while those feeling better were least. Comparable studies have reported along similar lines. Those who favoured home have cited the “comfort factor” and “time saving effect”.12,18 Regarding usefulness of online teaching-learning, less than 12% found it “highly useful”, while the majority found it “moderately useful”. Although there is no similar terminology in comparable studies, some useful features have been cited in the FGD study such as “online classes excellent for theory”, “recorded lectures good to understand content”, and “saves time and effort, so learning and performance can improve”.12 Students in another study cited “good utilization of time and reading up on topics which helped to decrease stress about COVID-19”.19
The scale scoring for overall satisfaction showed 31% of students being highly satisfied. In a Polish survey, 73% respondents rated e-learning as enjoyable.18 Other studies did not report this specific parameter.
A significant majority of our students did not prefer continuation of the online classes in its present form after the pandemic. This possibly reflects on their attitudes, and deficiencies in the teaching programme (personnel and platform). However, the reasons cited all indicate the former, in addition to lack of clinical training. Many studies have generally reported a moderate to high level of satisfaction. Two Indian studies, one from same geographical area, have reported that nearly half the students want online classes to continue, and be made part of the curriculum, post-pandemic.19,20 Those who were happy with the online T-L schedule, gave similar reasons as in other studies, mainly “freedom to choose learning time” and “home comfort”. Recent pre-pandemic studies on online medical education have generally reported positive feedback.22, 23, 24 It has to be kept in mind that this may not reflect the reality of the present situation wherein most medical colleges may have been pushed into the new modality. However, even a non-medical education study has pointed out the relevance of “learner-instructor and learner–content interactions” as predictors of student satisfaction.25 It was somewhat gratifying to note in our study that prior experience may not be necessary in the acceptance of online learning programmes, in the case of students. In these testing times, this result can be seen as encouraging for the teaching faculty.
Suggestions for improvement elicited similar responses as that in other recent studies viz. “more interactivity”, “less dependence on PowerPoint”, and “recorded material to be uploaded for ready reference”. There was also suggestion to have “frequent MCQs and/or short viva to assess learning”. Although there was no overt criticism of the faculty with regard to taking online classes, it has to be kept in mind that it is a learning curve for the teachers too. The FGD-based study reported suggestions to make online learning an integral, though small, part of medical education.12
Overall, the results of the present study have proven to be a mixed bag for the researchers, as faculty of medical education department. The obvious deficiencies of online classes have been laid bare, but some positive takeaways have also been noted. All of these serve the important role of providing feedback for improvement. Articles on higher education have cited the role of feedback in improving teaching.25,26 The limitations of this study have to be noted too. This is a single institution survey, with only a remotely administered questionnaire as the tool.
Future plans and suggestions
The need of the hour is to look at ways and means to improve the efficacy of online teaching-learning in medical education. As MEU faculty, the authors would certainly want to take the lead in orienting and training Institutional faculty in this modality which has to be looked at as an important link in the chain. A 2013 study had foreseen “an important role for online lectures”.27 A German study in 2016 concluded that” self-directed learning (which included e-learning) can outperform direct instruction”.28 Finally, an editorial in a recent issue of IJME serves as an eye-opener to all of us in the field of medical education with regard to the urgent need to “optimise the development, delivery and implementation of online learning in each university”.29 Applying this to a country like India will be a challenge which can partly be met with the help of student surveys like the present one.
Conclusions
The undergraduate medical students in this study showed moderate level of satisfaction about the current pandemic-induced online teaching-learning programme. They found the home-bound learning useful to a limited extent, in comparison with physical classes. Their perceptions revealed reasonable satisfaction with the theory classes, but concerns about the practical and clinical ones. Most of them were not too impressed with the experience of online formative assessment. This study has unearthed sufficient feedback to initiate discussion regarding improvements in the online classes, including teacher-training in online teaching and assessment. This will be beneficial to all the stakeholders of medical education, especially with the potential for such scenarios in the future.
Disclosure of competing interest
The authors have none to declare.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2021.01.006.
Appendix A. Supplementary data
The following is the supplementary data to this article:
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