Online physiology teaching for nursing students during the COVID-19 pandemic – strengths, challenges and reinforcement measures

INTRODUCTION

Online teaching-learning methods in higher education are gaining increasing importance;^[1,2] however, their importance in nursing education is debated. Nursing students train to become healthcare professionals whose work involves being ‘present’ in the real world, in real time, and interacting with people face to face. It is argued that online teaching devolves the responsibility among health care professionals to be ‘present.’^[3] The online mode of teaching has its own challenges in terms of infrastructure and resources, especially in a middle-income country like India.^[4] While the use of online methods, for medical and nursing education, was still in the nascent stage in India, the COVID-19 pandemic suddenly forced the education system to shift completely into the online mode.^[5-7] The prolonged lockdown of educational institutions during the pandemic had serious implications,^[8] impacting theory and practical learning, both in medical^[5,9] and nursing^[10-13] education around the world. Some of the implications were the suspension of clinical exposures, electives, formal teaching in wards, and offline opportunities for conference presentations, all being serious detriments to medical student careers.^[5,9-13] It is opined that nursing education after the pandemic will appear different from the pre-pandemic era and that it must be geared toward addressing emergencies like the pandemic.^[14]

The subject of physiology plays a major role in laying the foundation for medical science and has long been recognised as a difficult course. This is due to the inherent nature of the discipline itself and is not related to teaching or student learning. Learning the subject involves understanding dynamic processes, imbibing conceptual framework, and thinking in terms of purpose, cause, and effect.^[15] Considering the nature of the subject, face-to-face, inquiry-based teaching brings in greater student engagement and better interaction. It is, therefore, considered more effective than an online mode of learning.^[3,16]

In India, physiology is taught during the 1^st year of the Bachelor course of Nursing (BSc Nursing), as prescribed by the Indian Nursing Council. First-year nursing students are usually naive to basic medical science subjects and to the online mode of learning. Even with the advantages of online learning, such as learning at the student’s own pace and learning in the comforts of home,^[17] it is indeed challenging to understand a complex subject like physiology in this mode, especially for students in the 1^st year of the nursing course, with little background of human biology.^[3,15,17] Nevertheless, due to the lockdown that the pandemic posed, nursing students in India experienced physiology teaching in the online mode.

With the sudden shift to online mode of teaching many studies were conducted to capture students’ perception of online learning in medical^[13,18 -22] and nursing^[23-25] education. These studies reported several strengths and challenges of the online mode. However, they were cross-sectional studies with 1-time feedback. While the advantages of the blended mode had already been reported before the pandemic,^[3] the blended mode was preferred over the online mode during the pandemic as well due to its greater flexibility,^[19] with Indian medical students perceiving it as the future of medical education.^[25]

Educators have explored several online platforms, tools, and learning resources to make the best out of online teaching during the pandemic.^{[3,18,19,23,26]} In studies before the pandemic, additional online reading materials and multiple-choice question (MCQ) quizzes have proven to improve student mastery of learning outcomes in physiology and were ranked high in the list of learning activities that contributed most to student learning experience.^[3,24,25] Hence, periodic reinforcements such as extra reading material, practice questions and answers, MCQ tests, and revision classes, could help students cope with the new mode of learning during the pandemic. However, there are few studies that have explored these options during the pandemic.^[19]

In the study setting, during the pre-pandemic years, classes and examinations for all subjects, including physiology, were offline. Both students and teachers had no experience with online/blended classes until the pandemic struck. The COVID-19 pandemic necessitated a complete lockdown due to which educational institutions and hostels were shut down and students had online physiology classes, attending from their residences. The pandemic was expected to recede and offline classes were expected to begin sometime during the academic year.

A prospective study during the COVID-19 pandemic capturing the perceptions and concerns about online and blended modes of learning from students and faculty, at multiple time points through the course, was worthwhile. This is especially true in the given setting where both students and faculty were naïve to online teaching-learning. Student perceptions at the beginning and middle of the course could prove to be useful feedback in altering the online teaching-learning methods, to address their concerns. The implementation of and feedback on reinforcement measures such as extra reading material and MCQ quizzes was also worth exploring.

This study was conducted with the primary objective of assessing the apprehensions, expectations, and challenges that nursing students anticipated initially and experienced at the middle and end of the course, with the online mode of learning physiology during the COVID-19 pandemic. Our secondary objectives were (a) to evaluate students’ perceptions and learning outcomes of the online ‘reinforcement’ provided, in addition to the prescribed classes, to aid learning, (b) to evaluate the faculty perceptions of strengths and challenges of online physiology lectures for nursing students, (c) to evaluate faculty perceptions on strengths, challenges, and utility of the reinforcement measures administered online and (d) to compare student and faculty perceptions on the online, offline and blended modes of learning.

MATERIALS AND METHODS

The program was introduced in a private, not-for-profit, Catholic nursing college in Karnataka state of South India. As per the Institutional policy, only female students are admitted into the course of B.Sc Nursing. Students join the 1^st year of the course after completing 2 years of a pre-university course in science subjects (physics, chemistry, mathematics, and biology). Students qualify for admission through an Institutional level entrance examination and subsequent interview. Physiology, being a 1^st-year subject, includes 60 h of classes and assessments (internal assessments and a final summative assessment), which students must pass by achieving a minimum score of 50%.

Amidst the COVID-19 lockdown, all 1^st year B.Sc Nursing students admitted in the academic year from November 2020 to February 2022 attending physiology classes, aged between 18 and 30 years, were included in the study (n = 100, all females). The study was of a mixed-methods design and was approved by the Institutional Ethics Committee (IEC study ref no: 293/2020 dated 23.10.2020). Written informed consent was taken online on the Microsoft Team platform. Filling out the feedback questionnaires to capture their perceptions was made entirely voluntary.

Workplan

Course plan

The 1^st year of the B.Sc Nursing course followed the physiology curriculum as prescribed by the State University (60 h: 50 theory + 10 practical demonstrations). Due to the pandemic lockdown, the course commenced and continued with theory classes in the online mode. Lectures were delivered by the faculty in an online meeting, on the Microsoft Teams platform, attended by the entire batch of students. Power-point presentations, which were in use for offline teaching, were continued online. Further, there was an increased use of extra videos, images, white whiteboard of PowerPoint, pointers, and stylus to make the classes more interactive and interesting. Faculty interacted with students by asking questions and pausing in between their didactic lectures, providing students opportunities to raise doubts, if any. After the completion of 43 h of online theory classes the lockdown was lifted. Educational institutions re-opened and students returned to the Institution for offline classes [Figure 1].

Resumption of offline classes

As the pandemic receded, 7 h of theory and 10 h of practical demonstration sessions were conducted in the offline mode. MCQ tests remained in the online mode and hence a blended method of teaching was adopted during this period. Reinforcement measures: Several reinforcement measures were introduced during online classes, having anticipated the challenges that students would face with the online mode of learning:

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Figure 1:

Workplan. IA: Internal assessment; MCQ: Multiple choice questions; SA: Summative assessment.

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Practice questions

Each system was periodically uploaded on the Microsoft Teams platform. Questions that have appeared in earlier summative examinations were chosen as sample questions. These questions along with their answer keys (with references), with brief outlines of the physiological concepts, were provided, with the intent to encourage students to prepare themselves for assessments. Only a few sample questions (around 10 questions for each system) were provided; it was by no means a complete list and was meant for self-directed learning.

Periodic online MCQ tests

The MCQ tests were administered after content validation by expert peer review. With prior intimation to students, the 3 MCQ tests were held on the 20^th (December 2021) 40^th (January 2021), and 60^th h (May 2021) of the course (out of 60 h allotted for physiology teaching). They included questions from the portion of the syllabus covered within those respective timeframes. Each test had around 30 MCQ ‘must know’ questions with equal weightage to the 3–4 systems that were provided as syllabus for each of these tests.

Periodic online revision classes

One revision class followed the MCQ test, conducted by the same faculty of physiology who conducted the online MCQ tests (at the 20^th, 40^th, and 60^th h of the course). Revision included discussion of the MCQs and clarification of doubts related to the chapters covered in the respective MCQ tests.

Assessments

The first internal assessment was held online (February 2021), while the second internal assessment (July 2021) and the final summative examination (February 2022) were held offline for students of this academic year. The internal assessments and final summative assessment each out of a total of 38 marks and consisted of long essays, short essays, and short answers which were based on the format prescribed by the state university. The results of these were considered as objective methods of assessing student performance.

RESULTS

The students (n = 100, all females) had a mean age of 19.92 ± 1.37 years. The majority of them belonged to the state of Kerala (n = 86) and others to the states of Karnataka (n = 8), West Bengal (n = 3), Uttar Pradesh (n = 1), Jharkhand (n = 1) and Bihar (n = 1) where they resided during the lockdown and from where they attended the online mode of teaching. Ninety-nine students volunteered to provide feedback at the beginning of the course while 96 students responded at the middle and end of the course.

Objective measures of performance (internal assessments and final summative assessments and results of MCQ tests)

The mean scores and pass percentage, in the university-mandated internal assessments, of students for the academic year 2019–2020 (students had attended only offline mode of physiology teaching) and 2020–2021 (study cohort, i.e., students attended most physiology classes online and had a few offline/blended classes) were compared and were not significantly different. Based on the state university (Rajiv

Table 5: Student and faculty responses to closed-ended questions on reinforcement measures.

Questions and options provided	Number of students who expressed this feedback by mid-course (n=96)	Number of students who expressed this feedback by end-of -course (n=96)	Number of faculty who expressed this feedback by end-of-course (n=9)
The practice questions uploaded online periodically after each chapter is motivating me to revise the respective chapters:
Always	23 (25%)	21 (23%)	0
Sometimes	54 (56%)	64 (66%)	3
Rarely	17	11	0
Never	2	0	0
The online periodic revision classes are helping me clarify doubts:
Always	19	37 (39%)*	0
Sometimes	51 (53%)	51 (53%)	2
rarely	24 (26%)	8	1
Never	2	0	0
The intimation to revise for MCQ tests is motivating me to revise the chapters
Always	35 (37%)	26 (28%)	0
Sometimes	49 (51%)	57 (59%)	3
Rarely	9	11	0
Never	3	2	0
Attempting the periodic online MCQ tests is influencing my level of confidence
To a great extent	10	11	0
To some extent	67 (69%)	70 (71%)	3
Not make any difference	15	14	0
Reducing my confidence	4	1	0

*Cochran-Mantel-Haenszel test with P<0.05 was considered statistically significant (using Stata 16 software); P=0.0001. MCQ: Multiple-choice question

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Figure 2:

Comparison of objective measures of performance: Internal assessments and summative assessments. SD=Standard deviation; IA=Internal assessment.

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Gandhi University of Health Sciences) guidelines, a score of 50% and above for a total of 38 marks is considered a pass. The mean scores of the final University exams of the academic year 2020–2021 (21.41 ± 3.66) were significantly better (P = 0.01) when compared to those of the academic year 2019–2020 (20.09 ± 3.5). The pass percentage of the final university exams of the academic year 2020–2021 was 82%, which was higher when compared to 65% of the academic year 2019–2020.

There was no significant difference in the mean scores of the students, out of 30, in the first (19.55 ± 4.26), second (16.15 ± 4.02), and third (24.19 ± 2.97) MCQ tests that were conducted as reinforcement measures Figure 2.

DISCUSSION

The study was conducted in a nursing college where offline was the only mode of teaching until the pandemic hit. Students and nursing educators were caught unaware and had to evolve, adapting to the online platform with teaching-learning methods modified to suit the needs of the hour.^{[13,18,20-22]}

Unlike several cross-sectional studies that captured 1-time student feedback on the online mode of teaching-learning during the COVID-19 pandemic, our study used the novel approach of capturing student feedback at multiple time points through the academic year. Based on the feedback, several interventions were planned to aid better learning outcomes among students. Faculty feedback was taken as well, which seemed to reflect the same ideas as the student feedback.

As students navigated through the course, their feedback reflected student perceptions as captured by other cross-sectional studies on online teaching during the pandemic. Among the strengths that students expressed, time management and the liberty to study at their own pace in the comforts of homes emerged as the dominant ones. Both the students and faculty appreciated the use of technology to keep nursing education going through the pandemic and the use of various online tools to keep teaching/learning interesting.^{[18,19,23,25,27]} As the year progressed, an increasing number of students felt that the online mode was more difficult and their confidence in the use of technology is reduced. Poor internet accessibility was the biggest challenge as expressed by both students and faculty. This was reported by similar studies on the delivery of nursing and medical education during the COVID-19 lockdown in many developing countries.^{[18,23,27-31]} In the current study, concurrent to a few others, reduced interest of students in the subject and reduced interaction with teachers were reported by both students and faculty. Students had added concerns related to health, due to stress and constant exposure to screens.^[20,23,25] Even among medical students, studies from other countries and a multicentric study in India have shown similar findings in strengths and challenges in the online mode of physiology teaching.^{[13,23,24,32-34]}

Despite the challenges of purely online learning, nursing students wished for online classes to be continued during the pandemic.^[13,31,35] However, given a choice, both students and the faculty preferred the offline mode, especially for a subject like physiology. This could be because physiology is perceived to be best understood with both didactic teaching and face-to-face interactive learning, as it provides more opportunities for questions and answers, discussion time, and easier communication with peers and teachers.^[13,19] Many other studies have reported students’ opinions that online teaching could never substitute an in-class environment of physiology teaching, which was reflected in their learning outcomes.^[3,16] However, this study showed that the learning outcomes did not suffer due to online/blended learning. It must be noted that the poor student attitude toward online learning was not a reflection of dissatisfaction with the subject of physiology. The effectiveness of forcing students to consume physiology learning material online, in preparation for a final summative assessment, can be questioned, especially in an era when most online content sought by students is for more relaxing purposes such as entertainment.^[3]

With the experience of the blended mode of learning, toward the end of the course, the students opined that it could be a good way forward. The faculty also felt that blended mode could be a good futuristic approach if the offline and online modes could be meticulously planned to complement each other.^[19,25] Studies comparing the various modes of learning (offline/online/blended) have shown that blended teaching of physiology showed better student outcomes and student satisfaction, when ‘core physiology concepts’ are taught offline and ‘extension learning objectives’ are covered using online activities.^[3] With the exposure to this mode of learning, which was new and of short duration, it was understandable that students reported difficulty in switching between modes, a concern echoed by the faculty.

Capturing student feedback on the online mode of learning during challenging times, at 3 time points, enabled the investigators to provide timely feedback to both students and faculty, to aid learning. This approach has been little explored in studies on the online mode of teaching during the pandemic. The concerns raised were addressed by the physiology course coordinators for the BSc Nursing course by encouraging students to maintain a positive attitude, to clarify doubts during online lectures even if they must interrupt the lecture, and to make notes as much as possible. Faculty was also addressed by the course coordinators and briefed on the challenges faced by the students. They were advised to take appropriate measures that were feasible in the given situation.

Extra help to assist students in coping with the new mode of learning was provided in the form of reinforcement measures. Both students and faculty felt that the reinforcement measures had value during the difficult situation and aided learning. The consistent scores of MCQ tests reveal that the students were constantly driven to study in response to the reinforcement measures. However, the faculty expressed that after the implementation of MCQ tests, students seemed more prepared for objective type assessments, rather than explaining concepts in the form of essays. During the pandemic emergency where educators and students struggled to cope, a few studies did show the benefits of extra reading materials and quizzes in the online mode.^[24,25]

Their performance in the internal assessments and the final summative assessment, which were the objective measures of student performance, show that the student performance did not match their perceptions and that students were able to cope with the change in learning mode during the pandemic.

CONCLUSION

This prospective study captured student perspectives on the online mode of learning, on a periodic basis. Student expectations about the online mode of learning were met only in the aspect of time management. Both students and faculty expressed several strengths such as better comfort, effective use of online teaching-learning tools, and effective time management. The challenges expressed were bad network connectivity, learning difficulties, lack of face-to-face interaction, and health issues. Planned reinforcement measures seemed to aid student learning. Efforts were made to address challenges, captured through feedback taken at the beginning and mid-course, by discussion with faculty, and advice to the students in the middle of the course. Even though both teachers and students adapted to the online mode of teaching-learning, both preferred a completely offline mode, particularly for physiology. They opined that a blended mode could be implemented with meticulous planning. The final summative assessment scores showed that online/blended learning could work without compromising student learning outcomes, despite their concerns about the new mode of learning. A blended model for physiology teaching has been proposed which requires further validation.