Strengthening E-mastering tactics for active understanding in crisis circumstances: a blended-method study in the COVID-19 pandemic | BMC Clinical Training

Quantitative phase success

The common age of the taking part college students in the review was 21.47 ± 2.34, with an age array of 18 to 43 yrs. The the greater part of contributors ended up feminine (62%, n = 319) (Desk 1).

Table 1 Examination of the demographic properties of the participating learners

The descriptive data of the scores for the axes and dimensions of the questionnaire on a conventional scale of to 100, for comparison of axes and proportions in the same unit, suggest that the maximum scores by students were for the Rapid Feed-back and High Expectations axes, with scores of 64.65 and 65.46, respectively. The least expensive score was for the Collaboration Amongst Pupils axis with a rating of 55.90 (Table 2).

Table 2 Regular scores of the studied universities in relation to on line instructing based on the extent of axes and proportions of energetic mastering for the duration of the COVID-19 pandemic (common scale 0–100)

The benefits of the linear regression test in individually examining the connection amongst the Teaching dimension and the Interaction and Learning dimension axes confirmed that for each and every increase in rating in the Large Expectations axis, Varied Skills axis, and Mastering Methods axis, the Educating dimension score raises noticeably by 2.00 and 1.91, respectively (P≤0.001). In the multivariate regression examination similar to these things, the outcomes showed that all axes of the Conversation and Finding out proportions are involved with the Instructing dimension score. Hence, on common, for each unit enhance in the rating on the High Expectations, Diverse Skills, and Understanding Solutions axes, an increase of 1.30 and .44 units in the Training dimension rating is noticed respectively (P≤0.001) (Desk 3).

Desk 3 Partnership in between the training dimension and the sub-dimensions of the conversation and Mastering proportions

In addition, the regression evaluation was done to analyze the partnership amongst Interaction with the subdimensions of Educating and Discovering, and the partnership among understanding and the subdimensions of interaction and teaching. In just one scenario, the collaboration among pupils was not major (P=.262), and in other scenarios, there was a sizeable correlation (P<0.001) (Supplementary Table 1).

Qualitative phase results

All participants were members of the university faculty, with 9 individuals (56.25%) being male, 4 (25%) being associate professors, and the rest being assistant professors. Six (37.5%) were clinical faculty members and the rest were in basic sciences. All had at least 5 years of teaching experience and had planning and executive responsibilities during the COVID-19 pandemic.

Following the final analysis of online teaching by experts, four main domains were identified, including infrastructure, resources, quantity of education, and quality of education, and 16 subdomains, namely, scientific infrastructure, technical infrastructure, communication infrastructure, technology infrastructure, resource savings, increase in personal expenses, increase in university expenses, educational content, timing, continuous education, student participation, interaction, feedback, practical classes, and evaluation, with a total of 84 items generated (Table 4).

Table 4 Main domains, sub-domains, items, and their frequency in online teaching as perceived by experts


Scientific infrastructure

Participants in the study pointed to the importance of online teaching and the need for preparedness for e-learning in teachers and students and their capabilities. Participant 3 emphasized the importance of having a scientific infrastructure for online teaching and the necessity for teachers’ preparedness, saying, “The university did not provide any training for us, and I learned to work with the system through trial and error. It took me a few sessions to learn how to work with e-learning”. Additionally, participant 8 talked about the lack of complete readiness of teachers for online teaching before the COVID-19 pandemic, despite the presence of guidelines for using this method in teaching, “The university had been talking about e-learning for four or five years ago, set up classes, but because it was not mandatory, we did not attend. Personally, I did not go, and I hadn’t worked with its software. Well, the year that COVID-19 emerged and classes became virtual, the first thing I did was read the guide that existed and I learned by trial and error”.

Technical infrastructure

Technical infrastructure problems in universities and educational and therapeutic centers, and the incompatibility of the existing platform with the volume of students, were the issues that the experts pointed to. Participant 1 said, “The infrastructure was present in our college, considering we had a virtual unit before, but it wasn’t enough. The main challenge was the lack of a tablet or laptop or a mobile device to run classes, which was both for teachers and students”.

Communication infrastructure

Issues related to internet disconnection and inadequate access in various geographical areas were noted in this area. Participant 16 emphasized the undeniable impact of internet quality on all aspects of online education and teaching, adding, “One of the main challenges was internet disconnection. For instance, it would suddenly get cut off in the middle of the class and by the time it got reconnected, the class time would be over. The next professor would arrive with the subsequent class, and then we were forced to hastily cover the leftover topics from the previous class at the start of the next session”.

Technology infrastructure

Software capabilities and actions that learners can undertake through this type of learning were among the topics to which experts referred. Participant 5 spoke about the execution of assigned tasks by students and their uploading onto the electronic system, stating, “A good thing that was done was the tasks we gave to the students, like writing an article with the rules we set for them, or researching a specific topic. After the student uploaded it, we could easily receive them and then evaluation could be done”.


Saving resources

Experts referred to lower teaching costs, commuting, and the possibility of participating in scientific webinars virtually, etc. On this matter, Participant 6 stated, “In my opinion, one of the advantages and opportunities of online teaching is the reduction of costs because neither we nor the students needed to move from our workplace or residence to hold or participate in classes”. Participant 14 mentioned this method as an opportunity to participate in scientific seminars that are held as webinars at various universities in the country, saying, “During this period, we could easily participate in and benefit from various educational webinars held by different universities across the country”.

Increase in personal expenses

The shift from face-to-face to e-learning necessitated the provision of certain facilities, leading to an increase in the personal expenses of learners and teachers. Regarding the necessity of certain facilities for both teachers and students to participate in and hold virtual classes, Participant 5 said, “Naturally, to hold and participate in online classes, some equipment such as a laptop, tablet, or smartphone is needed, which some teachers and students did not have at the beginning and had to acquire. On the other hand, we always needed to be connected to the internet, all of which led to an increase in personal expenses”.

Increase in university expenses

The shift from face-to-face to e-learning and the need to provide facilities also burdened universities with increased costs. Participant 10 added regarding the need for some expenses to be borne by universities to improve the online teaching environment during the COVID-19 pandemic: “Initially, the university’s facilities were very simple and limited, and we had to either procure some facilities from scratch or upgrade our existing ones to address some deficiencies and improve the online teaching environment, and subsequently, improve the quality of learning”.

Quantity of education

Educational content

The ability for teachers to create audio and visual educational content and make it accessible was one of the points mentioned. Participant 7 said, “Initially, materials were uploaded as theory and PDF, but some lessons were such that students could not grasp the content with PDF alone. Various software was used, for example, anatomy teachers would come to the anatomy room, film, cut the videos into pieces, and then use software to reduce the size”.


Attention to time, and the advantages and limitations of e-learning in terms of scheduling, were among the points mentioned: Participant 15 talked about the time limit of the classes in addition to the scheduling limit: “One of the challenges is the limitation and timing of the classes. For instance, a class that I wanted to last more than two hours was not feasible and the connection and session would be cut off without my intention. I had to hold the class at another time when I was busy”.

Continuous learning

E-learning made it possible to teach outside of obligatory times. Participant 8 discussed the opportunity for online teaching at times when there is a possibility of class cancellations, for the continuation of teaching and continuous learning, “In my opinion, it is a good opportunity. For instance, when there are a few days off or one or two days between holidays, usually students from other cities cancel the class to take the opportunity to go home”.

Quality of education

Student participation

Overall, it was stated that student participation in e-learning was less than in-person teaching. (Participant 9) said that student participation in online teaching was less than that in traditional in-person teaching, “The participation in this teaching was less, and I asked questions to keep the students in class. For example, I would ask a short answer question and ask them to answer, or during attendance time or students’ breaks, I would tell the students not to leave the classroom, and use attendance as an excuse”.


In this regard, the experts gave their views on interaction in e-learning: Participant 11 continued with the idea that interaction in online teaching is less than traditional in-person teaching: “If I want to say this honestly, it is better in-person, because in online teaching, you can only be sure of students’ online presence, but real interaction and presence is not recorded”. Participant 10 suggested creating interactive content to increase interaction in online teaching, “We can’t have good interaction in online classes, perhaps by creating interactive content such as storylines”. Participant 12 discussed the difference in interaction in online teaching compared to in-person teaching: “It was less, obviously less. Because the time was limited, the space was limited and there was no visibility. For instance, interest, enthusiasm, that face-to-face connection was not seen, it makes a big difference”.


Regarding the possibility of feedback in e-learning, it was mentioned that feedback to students from teachers was available, but it might not always be immediate and online for various reasons. Participant 9: “Feedback was there during the class or in the form of sending a message to my personal number to the students, but sometimes I might not be able to respond online”. Participant 1 spoke about various methods of receiving and sending teacher feedback to students: “We could give feedback to students in various ways, such as through educational platforms during online classes or through other available messaging systems”.


Regarding the different ways students can access teachers, Participant 14 said: “Now there are many ways to access teachers because they are usually present in all virtual system tools, they have an ID, they have a page and all that, and I do not think there is much difference between in-person and online teaching in this regard”.

Practical classes

The experts pointed to the weakness of learning practical classes through online education. Participant 14 stated, “Generally, clinical work is a very big challenge in online subjects, and we cannot teach all clinical cases online. We cannot do this because one of the reasons is the issue of patient confidentiality”. Participant 10 also said, “Some practical lessons, for example in the laboratory, cannot be taught virtually and online. Let us assume that we put a video for them to see, can we say that they learned the material?


Participant 9 talked about the problems related to holding exams and the lack of readiness of teachers and students in this regard: “Usually, we assigned part of the grade to the tasks we gave to students, which again were not very reliable because someone else could have done it for them, but we had to trust them”. Participant 8 spoke about the problems related to online exams: “First, they had informed us at the time of the online exam that the students were gathering in groups and were taking the exam together and consultatively, and on the other hand, they were taking screenshots of the questions. Given the nature of the educational content, there is a limitation of questions in some topics, and this way, our entire question bank was leaked”.

Strategies for enhancing active learning

One of the solutions that participants referred to was the pathology of e-learning. An analysis of approximately three years of university performance in using e-learning and identifying weaknesses can be the most important solution for strengthening e-learning. Participant 8 “Given that universities and stakeholders were not prepared for this pandemic, the sudden and emergency use of e-learning naturally faced numerous challenges and weaknesses. However, the crucial point is that the medical education system should have the necessary resilience for the next crisis situation. To achieve this goal, identifying weaknesses and damages that our e-learning has had during this period is very essential”. Participant 11: “The important point is that the education system’s readiness to deal with crisis situations should be constantly monitored and evaluated and not be limited to a short period after the pandemic”.

Another solution identified in this research is improving internet quality. Most interviewees believed that poor internet speed has been a fundamental problem in e-learning. Participant 16: “Some students living in remote areas and having less access to appropriate internet had doubled e-learning problems”, Participant 1: “This issue even affected educational equity as these students could not effectively participate in classes”.

Producing effective educational content is another solution to strengthen e-learning. Accordingly, it is necessary for faculty members to use diverse and attractive content to achieve the goal of enhancing students’ learning. (Participant 7): “Over time, professors moved toward producing varied content, including films, slides, podcasts, sounds, clips, etc. For instance, anatomy professors would go to the dissection room and film, then break the films into pieces and use special software to reduce their size, and upload them to the system”.

The use of blended learning methods combining in-person and virtual instruction was proposed to enhance student evaluation. One of the participants stated, “The primary issue with e-learning was assessing the students while minimizing the chance for student dishonesty and cheating. To address this problem, I usually allocated a portion of the score to students’ assignments”.

The use of process-oriented evaluation was another solution proposed by participants in this research. “Continuous and ongoing evaluation can reduce the challenges of virtual assessment. Part of the students’ final score could be based on assignments and activities throughout the term, and the rest based on the end-of-term exam”.

Based on participants’ feedback, the lack of guidelines and instructions for e-learning was one of the main challenges when e-learning became mandatory. Consequently, expediting the process of preparing and publishing e-learning guidelines, as well as their constant review, were identified as some of the most significant proposed solutions. Another proposed solution is to continue blended learning even after the pandemic ends. Participants believed that the quality of teaching could be improved through e-learning if it is used alongside in-person instruction. However, opinions varied regarding its continuation. Some professors suggested that a specific percentage of each course’s sessions be held virtually. Another perspective was to use e-learning to provide supplementary educational content and assign students tasks. Some participants proposed that theoretical educational materials be prepared as standard educational content and provided to students before class. Then, during in-person classes, this content should be analyzed and discussed for deeper learning.

One of the main challenges of e-learning is the interaction between the teacher and the student. Many interviewees suggested that interventions aimed at enhancing teacher-student interaction are crucial for improving the quality of e-learning. To increase interaction with students, some professors used strategies such as question-and-answer sessions, inviting student participation, assigning grades for student engagement, and creating interactive content. (P8): “To encourage participation, I would call out a student’s name and ask for their opinion. However, some students claimed that their microphone was not working, or the sound was not coming through, or they would give similar excuses”. In addition, identifying and utilizing e-learning systems that offer numerous measures to engage students can be helpful.

Many interviewees believe that adequate acculturation regarding the proper use of online education for all stakeholders, including students and their families, teachers, education managers, and experts, is crucial. Some participants considered the lack of proper acculturation as the main reason for resistance from some teachers and students against the use of the e-learning platform. Participant 7 stated, “In the beginning of using online education, some students were unable to participate effectively in the classes due to lack of cooperation from their families”. Finally, the success of each of the above solutions requires the management of resources and infrastructure. Almost all interviewees identified the lack of equipment and infrastructure as problematic. For example, one of the professors (Participant 14) stated, “Initially, we had problems both in electronic communication infrastructure and equipment. However, fortunately, this challenge turned into an opportunity. Because universities had to invest to rectify the deficiencies. Afterwards, with the utilization of this, all treatment centers were equipped with e-learning systems and educational equipment”.