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Students’ and lecturers’ perspective on the implementation of online learning in dental education due to SARS-CoV-2 (COVID-19): a cross-sectional study

Students’ and lecturers’ perspective on the implementation of online learning in dental education... Background: On account of physical distancing measures, universities worldwide are strongly affected by SARS- CoV-2 (COVID-19). Thus, the dental school of Justus-Liebig-University Giessen (Germany) transferred the established “face-to-face” learning to online learning in the spring term 2020. The aim of this study was to assess the students’ and lecturers’ perspectives on the implementation of online learning due to COVID-19, using a questionnaire survey. Methods: After the online period, all students and lecturers were asked to fill out an online questionnaire containing evaluative statements regarding handling, didactic benefit, motivation, and overall assessment.Furthermore, the questionnaire for lecturers contained additional aspects regarding knowledge gain in terms of providing online learning. Besides that, students and lecturers were asked for the amount of online learning in the future curriculum (independent of COVID-19). Data were subjected to regression analysis and T-test (p <.05). Results: 36.8% of students preferred “face-to-face” learning instead of sole online learning. An increase of know how concerning online teaching was observable for lecturers. Both, students and lecturers, want to keep up with online courses in the future curriculum. However, in terms of the optimal amount of online learning a significant difference between students’ and lecturers’ perspective was observed. While students suggested 53.2% (24.9) (mean (standard deviation)) lecturers only stated 38.6% (21.5). Conclusions: Within the limitation of this study, students’ and lecturers’ showed a predominantly positive perspective on the implementation of online learning, providing the chance to use online learning even beyond COVID-19 in the future curriculum. Keywords: Dentistry, Dental education, Online learning, Dental students , Dental lecturers, Questionnaires, COVID-19, Coronavirus * Correspondence: [email protected] Department of Prosthodontics, Dental Clinic, Justus Liebig University, Schlangenzahl 14, 35392 Giessen, Germany Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Schlenz et al. BMC Medical Education (2020) 20:354 Page 2 of 7 Background school of JLU decided to pool all theoretical courses More than 95% of all countries worldwide reported in- over 4 weeks, in April and May 2020, to implement on- fections with the severe acute respiratory syndrome cor- line learning instead of “face-to-face” courses. Thus, pre- onavirus 2 (SARS-CoV-2) described as coronavirus clinical (1–5 semester) and clinical (6–10 semester) disease 2019 (COVID-19) [1–3]. Therefore, most coun- students stayed at home. To make lessons possible, syn- tries put physical distancing measures (e.g., closing of chronous formats such as live online courses were ac- public, cultural, and educational institutions) in place to complished via a new online videoconference system decelerate the infection rate [4–6]. Consequently, dental (Webex Meetings, Cisco Systems, Dusseldorf, Germany). education at universities worldwide is strongly affected Whereas for asynchronous formats, such as dubbed lec- by the COVID-19 pandemic [7, 8] and dental schools tures uploaded to online platforms for self-study, the have to face a new challenge to implement “distance established online platforms Knowledge-Based Medical learning” tools to continue dental education, which is Education (k-MED) and Stud.IP of JLU was used. Fur- strongly demanded by students [9, 10]. thermore, a combination of synchronous and asynchron- Earlier concepts during SARS-CoV-1 infection in 2003 ous formats (e.g. lectures and scripts on online platforms [11, 12] or present recommendations by Wuhan Univer- and “consultation hours” for students’ questions) were sity [13] propose online teaching as a mean of choice to provided. prevent spreading of the virus by students. Even though Before initiating online courses, we contacted the stu- some universities already implemented online courses dent council to ensure that all dental students had the before the COVID-19 pandemic [14], normally dental technical requirements to access online learning from education in Germany features “face-to-face” teaching. home. Furthermore, we started online learning with a But also in other countries, digitalization at dental technical introduction – so-called ‘tech-checks’– in the schools has been characterized as a slow process [14]. first week, to introduce the new videoconference system However, this pandemic does not only create the need to students and to check the sound and image quality. but rather may provide the chance to accelerate digital transformation in medical education [8, 15]. This could Online survey have a positive effect on future dental education even Two online questionnaires (one for students and one for beyond COVID-19. Nevertheless, practical training on lecturers) were designed in cooperation with the Teach- manikins in the preclinical curriculum and patient treat- ing Evaluation Service Center of the JLU and provided ment in the clinical curriculum is indispensable for den- using an online survey tool (LimeSurvey, Hamburg, tal education. That means online learning is only Germany) (Footnotes). The questionnaires contained applicable to theoretical learning content. evaluative statements regarding handling (the way stu- It is accepted that students’ assessments is the import- dents or lecturer deals with online learning), didactic ant factor of the benefits and value of online learning benefit (the way students or lecturer indented online and the evaluation of their attitudes are important fac- learning as helpful regarding dental education), and mo- tors in assessing success [16]. Nevertheless, most studies tivation (the way students or lecturer were enthusiasm solely focussed on students perspectives [17–20]and to for online learning). Furthermore, the questionnaire for the best of our knowledge, no survey regarding the im- lecturers contained additional aspects regarding the im- plementation of online learning in dental education con- plementation and knowledge gain in terms of providing sidered both students’ and lecturers’ perspectives [13]. online learning. All study participants could agree or dis- However, for efficient further development of online agree with the statements using a five-point Likert scale courses both perspectives have to be considered. [21] and were asked whether and to what extent “face- Therefore, the aim of this study was to evaluate the to-face” and online learning differed. For latter partici- students’ and lecturer’s perspective towards our new on- pants could decide whether they prefer online learning line learning courses through two online questionnaires (1), equivalent (2) or “face-to-face” (3). Also, they were (one for students and one for lecturers) in the challen- asked about the preferred amount of online learning in ging time of the SARS-CoV-2 pandemic. the future curriculum (independent of COVID-19). Finally, demographic questions were asked. Methods The questionnaires were evaluated anonymously, and Teaching concept of the Giessen dental school abstention was allowed for each statement. The study Before the COVID-19 pandemic, practical preclinical was conducted in accordance with the ethical standards and clinical courses were accompanied by theoretical of the Institutional Review Board and the local ethics “face-to-face” courses distributed over a 16-week semes- committee of the JLU (Ref. no. 84/20). ter. The teaching included both preclinical and clinical All dental students participating in the spring term training on manikins. In the spring term 2020, the dental 2020 (n = 299) and all lecturers (n = 47) with at least 1 Schlenz et al. BMC Medical Education (2020) 20:354 Page 3 of 7 year of teaching experience were included in this study. The majority of students felt well prepared by the tech- The online survey started after the end of the online checks but had difficulties to prepare themselves suffi- learning period on May 27, 2020, and participants were ciently in advance for online learning. However, most recruited via e-mail. After 4 and 8 days, a reminder was students agreed that online learning was well-structured sent to all potential participants. The survey was closed and the level of ambition was good, which means that on June 5, 2020. Only fully completed questionnaires they could follow the teaching content and did not feel were included. Statistical analysis was performed using over- or unchallenged. Furthermore, the image and SPSS Statistics (version 24, IBM, Armonk, NY, USA). sound quality were rated positively (Table 2). The distribution of responses was presented as mean Concerning students’ learning preferences, almost all and standard deviation. Data on the three groups hand- students found that online learning was a good option in ling, didactic benefit, and motivation of students’ per- this special time of the COVID-19 pandemic. However, spectives were further statistically analyzed. Therefore, many students stated that they did not feel well prepared principle axis factoring with rotation oblimin was con- for the practical part of the curriculum by solely partici- ducted. Considering the aspects of intrinsic value, scree pating in online learning. A good note was that students plot and content, two factors were applied. Cronbach‘s interacted with lecturers by asking questions through Alpha showed acceptable reliability for pooled data of the online platforms. Even though 36.8% of students pre- handling (.729) and didactic benefit (.659) (Table 1). ferred “face-to-face” courses instead of online teaching Regression analysis was performed to analyze the asso- alone, only 5.6% stated that online learning was not use- ciation with gender and semester for the three groups. ful. More than half of the students agreed that using T-test was applied to analyze data regarding the amount online platforms motivates them to learn (Table 2). of online learning in the future curriculum (p < .05). There was a significant correlation between the aspects handling, didactic benefit, and motivation (Table 3). Fur- Results thermore, the regression analysis of handling, didactic A total of 242 (166 female, 69 male, 7 no answer) stu- benefit, and motivation of students’ perspectives revealed dents completed the questionnaire, which represented a a significant association with semesters (p < .0001). response rate of 80.9%. Concerning gender and semester However, an association with gender was only found for distribution, there were no significant differences com- the didactic benefit. Female students agreed with the pared to the basic group (n = 299, chi-squared test, statements regarding the didactic benefit of online learn- p > .05). Among them, 83.5% participated in all the on- ing significantly more than male students (p = .010). line learning courses and 12.8% stated that they partici- Regarding the technical devices, the majority of stu- pated in the majority of courses. dents used laptop computers (69.8%) for online learning, In general, students assessed the aspects of handling, followed by tablets (16.5%), smartphones (7%), and desk- didactic benefit, and motivation mostly positive (Table 2). top computers (4.6%). Most students participated from Table 1 Factor loadings (pattern matrix) Factor H3: The online learning was structured well. 0.709 0.012 H2: I was able to prepare myself well in advance for the online learning (by script or book). 0.608 0.103 H5: The image and sound quality of online learning was good. 0.578 −0.040 H1: The technical introduction (‘tech-checks’) in the first week of the semester prepared me well for online learning. 0.571 −0.053 H4: The aspiration level of online learning was good. 0.553 −0.106 D1: In the current situation, online learning was a good option for learning the theoretical part of education. 0.262 −0.594 D4: I generally prefer “face-to-face” rather than online learning. −0.076 0.478 D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) continuing with ‘normal’ −0.145 0.477 “face-to-face” learning in winter semester. D2: By participating in the online learning, I feel well prepared for the practical part of education. 0.448 −0.464 D3: In the context of online learning I dare to ask questions more often than “face-to-face”. −0.124 −0.412 Eigenvalues 3.65 1.35 % of variance 36.51 13.46 Cronbach’s alpha 0.729 0.659 Schlenz et al. BMC Medical Education (2020) 20:354 Page 4 of 7 Table 2 Items and descriptive statistics of students’ questionnaire Item Item description MSD N Handling H1: The technical introduction (‘tech-checks’) in the first week of the semester prepared me well for online learning. 4.28 0.97 224 H2: I was able to prepare myself well in advance for the online learning (by script or book). 3.45 1.14 230 H3: The online learning was structured well. 4.31 0.89 230 H4: The aspiration level of online learning was good. 4.42 0.82 233 H5: The image and sound quality of online learning was good. 4.17 0.78 234 Didactic D1: In the current situation, online learning was a good option for learning the theoretical part of education. 4.69 0.7 236 benefit Didactic D2: By participating in the online learning, I feel well prepared for the practical part of education. 3.73 1.02 227 benefit Didactic D3: In the context of online learning I dare to ask questions more often than “face-to-face”. 2.89 1.26 224 benefit Didactic D4: I generally prefer “face-to-face” rather than online learning. 2.98 1.36 233 benefit Didactic D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) 1.39 0.9 231 benefit continuing with ‘normal’“face-to-face” learning in winter semester. Motivation M1: The use of new digital teaching methods (e.g. online teaching) motivates me to learn. 3.78 1.2 235 M mean, SD standard deviation, N number of valid answers (total: N = 242) type of answer: 1 = strongly disagree, 5 = strongly agree home (57.0%) and used wireless local area networks 14.3% of lecturers had experience with online learning (LAN) (87.6%) for connection. Over 95% of students before (e.g. attending trainings or conventions, self- stated that they did not have major problems with an studied, listened to reports from colleges or already internet connection. taught online). In times of COVID-19, most of the lec- A total of 35 (74.5%) lecturers (18 female, 16 male, 1 turers used synchronous online learning formats no answer) responded to the survey. Concerning gender, (54.3%), followed by a combination of synchronous and there was no significant difference compared to the basic asynchronous formats (20.0%) and asynchronous for- group (n = 47, chi-squared test, p > .05). Among them, 6 mats alone (5.7%). Regarding the technical devices, lap- professors, 4 Ph.D. candidates, 1 post-doc, 23 members top computers (51.4%) and desktop computers (34.3%) of the teaching staff, and 1 Associated professor fully were mainly used. In addition to wireless LAN (28.6%), completed the survey with teaching experience between LAN (62.9%) was used for the majority of internet con- 1 and 40 years (median: 8 years, interquartile range: nections with mainly no interruptions in connection 7.08–14.01). (62.9% never, 20.0% in a minority of cases). In 17.1% of In total, 60.0% of lecturers had never dealt with online cases, online teaching took place at home (home office), learning formats before the COVID-19 pandemic. Only while 60.0% of the lecturers conducted online learning Table 3 Items and descriptive statistics of lecturers’ questionnaire Item Item description MSD N Didactic D1: In the current situation, online learning was a good way to teach the theoretical part of education. 4.6 0.56 30 benefit Didactic D2: The theoretical teaching content could be covered just as well by online teaching formats as it would have been 3.52 1.33 29 benefit possible in a classroom course (lecture/seminar). Didactic D3: I found the students during the online teaching to be disciplined and attentive. 4.04 0.87 25 benefit Didactic D4: I feel more uncomfortable using new teaching methods such as online teaching than in “face-to-face” teaching 3.03 1.4 29 benefit such as lectures because I miss direct communication with the students. Didactic D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) the 1.81 1.2 31 benefit continuation of ‘normal teaching’ in the winter semester. Motivation M1: The use of new digital teaching methods (e.g. online teaching) motivates me. 3.93 1.1 30 Motivation M2: The online learning formats are an added value, because I can also use them for other training purposes (e.g. 3.25 1.48 28 conventions). M mean, SD standard deviation, N number of valid answers (total: N = 35) type of answer: 1 = strongly disagree, 5 = strongly agree Schlenz et al. BMC Medical Education (2020) 20:354 Page 5 of 7 courses from their office at the dental clinic. Only 2.9% opinion on those aspects, especially regarding easy of them used specially equipped conference rooms in participation and time effort (Table 4). dental clinics. In terms of the optimal amount of online learning for The results regarding the aspects of didactic benefit further implementation of a curriculum, independent of and motivation are given in Table 3. In the time of COVID-19, a significant difference between students’ COVID-19, online learning was useful as a substitute for and lecturers’ perspective was observed (p = .002). Stu- “face-to-face” learning, as strongly agreed by 57.1% of dents demand 53.2% (mean) (standard deviation: 24.9) of lecturers and agreed by an additional 5.7% of them. The the theoretical part in terms of online learning, while majority of lecturers quickly adapted to online learning. lecturers only want 38.6% mean (standard deviation: Furthermore, many lecturers stated that it was very 21.5) of the theoretical curriculum online. straightforward to transfer their “face-to-face” teaching content to online formats. Moreover, 25.0% disagreed with the need for more support for more time to prepare Discussion online learning courses. Nearly 60.0% perceived the co- During the COVID-19 pandemic, physical distancing operative character during the implementation of online measures are required and have an enormous impact on learning predominantly positive. Regarding the didactic dental education [7, 8]. Because online learning allows benefit, 57.1% agreed with the implementation of online participating in learning activities independent of the lo- learning due to COVID-19 and saw a good way to teach cation [22], the JLU implemented online learning in the the theoretical classes through online courses (54.3% spring semester 2020 to prevent the spread of the virus. strongly agreed, 28.6% agreed) without a loss of content. Thus, most students stayed at home and did not return Although lecturers acknowledged the discipline of the from the spring break. majority of the students, they stated feeling more com- Before initiating online courses, we ensured that all fortable in “face-to-face” teaching. However, most lec- students had unrestricted access to online learning and turers were motivated by using online learning, and questionnaire survey. Furthermore, the high response some even had added value by using the prepared online rate reduces the bias of not representative data. Con- learning courses for training purposes. cerning gender distribution and semester, there were no Regarding knowledge gain before and after online significant differences observed when compared to the teaching, a few lecturers were more favorable for online basic group (chi-squared test, p > .05). All participants teaching afterward, where as the motivation for teaching (students and lecturers) were informed that data collec- was almost unchanged. However, an increase was ob- tion was completely anonymous and did not allow any servable regarding knowledge gain. traceability of the answering person. Thus, the bias in Table 4 demonstrate the overall assessment about the answering was prevented. However, a clear limitation of differences between online and “face-to-face” learning this cross-sectional study is that students and lecturers comparing students’ and lecturers’ perspective. of only one dental school at one point were asked to With regard to the aspects: more modern, tips and participate in this study. Therefore, other universities feedback, queries, and knowledge transfer, a high con- should also be surveyed in future studies. sensus between students and lecturers was noticed. To achieve the highest possible educational success, it Nevertheless, students stated that they had more fun, is important to involve all participants in the teaching could better participate, and invested less time with process [16, 23]. Therefore, the implementation of on- online learning. Obviously, lecturers had a different line learning due to COVID-19 was evaluated using a Table 4 Items and descriptive statistics of overall assessment (students and lecturers) Students’ perspective Overall assessment :Please assess whether Lecturers’ perspective and to what extent “face-to-face” and online learning differ MSD N MSD N regarding the following aspects: (1 = online learning, 2 = equivalent, 3 = “face-to-face”) 2.45 0.61 222 More modern 2.5 0.51 30 2.0 0.79 228 More fun 1.57 0.5 30 1.78 0.64 218 More tips of lecturers 1.38 0.61 32 1.78 0.7 229 Queries better possible 1.53 0.72 32 1.89 0.7 229 Better knowledge transfer 1.69 0.64 32 2.69 0.61 230 Easier participation 1.87 0.75 32 2.51 0.69 227 Less time effort 1.72 0.63 32 type of answer: 1 = online learning, 2 = equivalent, 3 = “face-to-face” Schlenz et al. BMC Medical Education (2020) 20:354 Page 6 of 7 Likert scale, the standard procedure for surveys in the and lecturers’ regarding the amount of online learning in field of medicine [17, 19, 24, 25]. the future curriculum was observed, both groups As described by Asiry [25], ease of access is important strongly suggested a continuation of online learning. for online learning. The university ensured that every Furthermore, students in higher semesters rated online dental student had access to online learning before start- learning regarding the aspects handling, didactic benefit, ing online courses. Therefore, it was helpful that the and motivation higher than students in lower semesters. videoconference tool Webex Meeting was app-based, so These are important facts that should be considered in even students without a desktop or laptop computer the future. Currently, synchronous online courses are could participate in synchronous online learning using a used mostly, but in the future a combination of online tablet or smartphone, using a wireless LAN connection. and attendance (“face-to-face”) learning, such as In addition, the tech-checks were helpful and evaluated problem-based learning or flipped classroom methods, mainly positive by students. Therefore, it can be useful can be implemented more in dental education [9, 26]. to implement a technical check before starting with However, as indicated by lecturers, this requires online learning. personnel and financial support [14, 26]. Many students stated that participation in online Subsequent to the online learning period, a step-wise learning was easier compared to “face-to-face” courses. concept back to “face-to-face” teaching started to enable This might explain the high participation in online also practical education during COVID-19 pandemic learning among all semesters. [12]. Therefore, students began to exercise in small Even though most students agreed that online learning groups on manikins and will start to practice on patients at times of COVID-19 pandemic was useful and they in July 2020. This concept is in accordance with the way would not prefer a ‘non-semester’, many students did HongKong University reacted during the SARS-CoV-1 not feel well prepared for practical courses with online outbreak in 2003 [11, 12]. However, compared to past learning alone. These findings are in good accordance outbreaks, today digital technology currently allows for with the literature [9, 10]. Besides theoretical education, an almost real-time record of infections and a sharing of dentistry requires manual training and clinical patient information around the globe [3]. care; therefore, “face-to-face” teaching is important. There is probably no gold standard or one way to deal However, the positive-rated aspects of online learning, with this pandemic situation in the education of dental such as a higher motivation of students, easier participa- students. Even though the increase in COVID-19 cases tion, and less time effort can be used to improve the has slowed down, the authors hypothesize that it will future dental curriculum. take time to return to ‘normal teaching’. Therefore, we Although the required transfer from “face-to-face” better develop new and more flexible concepts/curricula teaching to online learning accelerated the digitalization with a high amount of online learning, without “face-to- process in dental education [8, 15], the complete face” contact. The results of our survey at an early stage changeover showed that students and lecturers had should highlight the steps taken to manage the crisis difficulties in preparing in advance for online learning. and point out the opportunity to minimize the impact of Although over 60% of lecturers at our dental school such outbreaks on teaching in dentistry and be better had no experience with online teaching before the prepared for similar disruptions in the future. COVID-19 pandemic, lecturers adapted very quickly to online learning, and the knowledge gain regarding the Conclusions implementation of online learning was very high. Within the limitation of this study, students’ and lec- Similar to the students, most lecturers also found that turers’ showed a predominantly positive perspective on online learning was a good alternative during the the implementation of online learning, providing the COVID-19 pandemic. However, lecturers had a different chance to use online learning even beyond COVID-19 in opinion about the positive-rated aspects (less time effort, the future curriculum. easier participation, and more fun) by students regarding online learning. Obviously, the transfer from “face-to- Supplementary information face” to online learning was time-consuming and, Supplementary information accompanies this paper at https://doi.org/10. because of various functions in dental clinics, most 1186/s12909-020-02266-3. lecturers cannot work from home. Independent of COVID-19, students indicated a mean Additional file 1. Questionnaire Students. amount of 53.2% (standard deviation: 24.9) regarding the theoretical part in terms of online learning for the future Abbreviations curriculum, and lecturers indicated only 38.6% (21.5). SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; COVID- Even though a significant difference between students’ 19: coronavirus disease 2019; k-MED: Knowledge-based Medical Education Schlenz et al. BMC Medical Education (2020) 20:354 Page 7 of 7 Acknowledgments 8. Abedi M, Abedi D. A letter to the editor: the impact of COVID-19 on The survey was consented with the deanery of the medical faculty of the intercalating and non-clinical medical students in the UK. Med Educ Online. Justus Liebig University Giessen. The authors would like to thank all students 2020;25:1771245. https://doi.org/10.1080/10872981.2020.1771245. and colleagues for supporting this survey. Furthermore, we gratefully 9. Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the acknowledge the support of Christian Treppesch and Susanne Ehrlich from United States. 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Students’ and lecturers’ perspective on the implementation of online learning in dental education due to SARS-CoV-2 (COVID-19): a cross-sectional study

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Abstract

Background: On account of physical distancing measures, universities worldwide are strongly affected by SARS- CoV-2 (COVID-19). Thus, the dental school of Justus-Liebig-University Giessen (Germany) transferred the established “face-to-face” learning to online learning in the spring term 2020. The aim of this study was to assess the students’ and lecturers’ perspectives on the implementation of online learning due to COVID-19, using a questionnaire survey. Methods: After the online period, all students and lecturers were asked to fill out an online questionnaire containing evaluative statements regarding handling, didactic benefit, motivation, and overall assessment.Furthermore, the questionnaire for lecturers contained additional aspects regarding knowledge gain in terms of providing online learning. Besides that, students and lecturers were asked for the amount of online learning in the future curriculum (independent of COVID-19). Data were subjected to regression analysis and T-test (p <.05). Results: 36.8% of students preferred “face-to-face” learning instead of sole online learning. An increase of know how concerning online teaching was observable for lecturers. Both, students and lecturers, want to keep up with online courses in the future curriculum. However, in terms of the optimal amount of online learning a significant difference between students’ and lecturers’ perspective was observed. While students suggested 53.2% (24.9) (mean (standard deviation)) lecturers only stated 38.6% (21.5). Conclusions: Within the limitation of this study, students’ and lecturers’ showed a predominantly positive perspective on the implementation of online learning, providing the chance to use online learning even beyond COVID-19 in the future curriculum. Keywords: Dentistry, Dental education, Online learning, Dental students , Dental lecturers, Questionnaires, COVID-19, Coronavirus * Correspondence: [email protected] Department of Prosthodontics, Dental Clinic, Justus Liebig University, Schlangenzahl 14, 35392 Giessen, Germany Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Schlenz et al. BMC Medical Education (2020) 20:354 Page 2 of 7 Background school of JLU decided to pool all theoretical courses More than 95% of all countries worldwide reported in- over 4 weeks, in April and May 2020, to implement on- fections with the severe acute respiratory syndrome cor- line learning instead of “face-to-face” courses. Thus, pre- onavirus 2 (SARS-CoV-2) described as coronavirus clinical (1–5 semester) and clinical (6–10 semester) disease 2019 (COVID-19) [1–3]. Therefore, most coun- students stayed at home. To make lessons possible, syn- tries put physical distancing measures (e.g., closing of chronous formats such as live online courses were ac- public, cultural, and educational institutions) in place to complished via a new online videoconference system decelerate the infection rate [4–6]. Consequently, dental (Webex Meetings, Cisco Systems, Dusseldorf, Germany). education at universities worldwide is strongly affected Whereas for asynchronous formats, such as dubbed lec- by the COVID-19 pandemic [7, 8] and dental schools tures uploaded to online platforms for self-study, the have to face a new challenge to implement “distance established online platforms Knowledge-Based Medical learning” tools to continue dental education, which is Education (k-MED) and Stud.IP of JLU was used. Fur- strongly demanded by students [9, 10]. thermore, a combination of synchronous and asynchron- Earlier concepts during SARS-CoV-1 infection in 2003 ous formats (e.g. lectures and scripts on online platforms [11, 12] or present recommendations by Wuhan Univer- and “consultation hours” for students’ questions) were sity [13] propose online teaching as a mean of choice to provided. prevent spreading of the virus by students. Even though Before initiating online courses, we contacted the stu- some universities already implemented online courses dent council to ensure that all dental students had the before the COVID-19 pandemic [14], normally dental technical requirements to access online learning from education in Germany features “face-to-face” teaching. home. Furthermore, we started online learning with a But also in other countries, digitalization at dental technical introduction – so-called ‘tech-checks’– in the schools has been characterized as a slow process [14]. first week, to introduce the new videoconference system However, this pandemic does not only create the need to students and to check the sound and image quality. but rather may provide the chance to accelerate digital transformation in medical education [8, 15]. This could Online survey have a positive effect on future dental education even Two online questionnaires (one for students and one for beyond COVID-19. Nevertheless, practical training on lecturers) were designed in cooperation with the Teach- manikins in the preclinical curriculum and patient treat- ing Evaluation Service Center of the JLU and provided ment in the clinical curriculum is indispensable for den- using an online survey tool (LimeSurvey, Hamburg, tal education. That means online learning is only Germany) (Footnotes). The questionnaires contained applicable to theoretical learning content. evaluative statements regarding handling (the way stu- It is accepted that students’ assessments is the import- dents or lecturer deals with online learning), didactic ant factor of the benefits and value of online learning benefit (the way students or lecturer indented online and the evaluation of their attitudes are important fac- learning as helpful regarding dental education), and mo- tors in assessing success [16]. Nevertheless, most studies tivation (the way students or lecturer were enthusiasm solely focussed on students perspectives [17–20]and to for online learning). Furthermore, the questionnaire for the best of our knowledge, no survey regarding the im- lecturers contained additional aspects regarding the im- plementation of online learning in dental education con- plementation and knowledge gain in terms of providing sidered both students’ and lecturers’ perspectives [13]. online learning. All study participants could agree or dis- However, for efficient further development of online agree with the statements using a five-point Likert scale courses both perspectives have to be considered. [21] and were asked whether and to what extent “face- Therefore, the aim of this study was to evaluate the to-face” and online learning differed. For latter partici- students’ and lecturer’s perspective towards our new on- pants could decide whether they prefer online learning line learning courses through two online questionnaires (1), equivalent (2) or “face-to-face” (3). Also, they were (one for students and one for lecturers) in the challen- asked about the preferred amount of online learning in ging time of the SARS-CoV-2 pandemic. the future curriculum (independent of COVID-19). Finally, demographic questions were asked. Methods The questionnaires were evaluated anonymously, and Teaching concept of the Giessen dental school abstention was allowed for each statement. The study Before the COVID-19 pandemic, practical preclinical was conducted in accordance with the ethical standards and clinical courses were accompanied by theoretical of the Institutional Review Board and the local ethics “face-to-face” courses distributed over a 16-week semes- committee of the JLU (Ref. no. 84/20). ter. The teaching included both preclinical and clinical All dental students participating in the spring term training on manikins. In the spring term 2020, the dental 2020 (n = 299) and all lecturers (n = 47) with at least 1 Schlenz et al. BMC Medical Education (2020) 20:354 Page 3 of 7 year of teaching experience were included in this study. The majority of students felt well prepared by the tech- The online survey started after the end of the online checks but had difficulties to prepare themselves suffi- learning period on May 27, 2020, and participants were ciently in advance for online learning. However, most recruited via e-mail. After 4 and 8 days, a reminder was students agreed that online learning was well-structured sent to all potential participants. The survey was closed and the level of ambition was good, which means that on June 5, 2020. Only fully completed questionnaires they could follow the teaching content and did not feel were included. Statistical analysis was performed using over- or unchallenged. Furthermore, the image and SPSS Statistics (version 24, IBM, Armonk, NY, USA). sound quality were rated positively (Table 2). The distribution of responses was presented as mean Concerning students’ learning preferences, almost all and standard deviation. Data on the three groups hand- students found that online learning was a good option in ling, didactic benefit, and motivation of students’ per- this special time of the COVID-19 pandemic. However, spectives were further statistically analyzed. Therefore, many students stated that they did not feel well prepared principle axis factoring with rotation oblimin was con- for the practical part of the curriculum by solely partici- ducted. Considering the aspects of intrinsic value, scree pating in online learning. A good note was that students plot and content, two factors were applied. Cronbach‘s interacted with lecturers by asking questions through Alpha showed acceptable reliability for pooled data of the online platforms. Even though 36.8% of students pre- handling (.729) and didactic benefit (.659) (Table 1). ferred “face-to-face” courses instead of online teaching Regression analysis was performed to analyze the asso- alone, only 5.6% stated that online learning was not use- ciation with gender and semester for the three groups. ful. More than half of the students agreed that using T-test was applied to analyze data regarding the amount online platforms motivates them to learn (Table 2). of online learning in the future curriculum (p < .05). There was a significant correlation between the aspects handling, didactic benefit, and motivation (Table 3). Fur- Results thermore, the regression analysis of handling, didactic A total of 242 (166 female, 69 male, 7 no answer) stu- benefit, and motivation of students’ perspectives revealed dents completed the questionnaire, which represented a a significant association with semesters (p < .0001). response rate of 80.9%. Concerning gender and semester However, an association with gender was only found for distribution, there were no significant differences com- the didactic benefit. Female students agreed with the pared to the basic group (n = 299, chi-squared test, statements regarding the didactic benefit of online learn- p > .05). Among them, 83.5% participated in all the on- ing significantly more than male students (p = .010). line learning courses and 12.8% stated that they partici- Regarding the technical devices, the majority of stu- pated in the majority of courses. dents used laptop computers (69.8%) for online learning, In general, students assessed the aspects of handling, followed by tablets (16.5%), smartphones (7%), and desk- didactic benefit, and motivation mostly positive (Table 2). top computers (4.6%). Most students participated from Table 1 Factor loadings (pattern matrix) Factor H3: The online learning was structured well. 0.709 0.012 H2: I was able to prepare myself well in advance for the online learning (by script or book). 0.608 0.103 H5: The image and sound quality of online learning was good. 0.578 −0.040 H1: The technical introduction (‘tech-checks’) in the first week of the semester prepared me well for online learning. 0.571 −0.053 H4: The aspiration level of online learning was good. 0.553 −0.106 D1: In the current situation, online learning was a good option for learning the theoretical part of education. 0.262 −0.594 D4: I generally prefer “face-to-face” rather than online learning. −0.076 0.478 D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) continuing with ‘normal’ −0.145 0.477 “face-to-face” learning in winter semester. D2: By participating in the online learning, I feel well prepared for the practical part of education. 0.448 −0.464 D3: In the context of online learning I dare to ask questions more often than “face-to-face”. −0.124 −0.412 Eigenvalues 3.65 1.35 % of variance 36.51 13.46 Cronbach’s alpha 0.729 0.659 Schlenz et al. BMC Medical Education (2020) 20:354 Page 4 of 7 Table 2 Items and descriptive statistics of students’ questionnaire Item Item description MSD N Handling H1: The technical introduction (‘tech-checks’) in the first week of the semester prepared me well for online learning. 4.28 0.97 224 H2: I was able to prepare myself well in advance for the online learning (by script or book). 3.45 1.14 230 H3: The online learning was structured well. 4.31 0.89 230 H4: The aspiration level of online learning was good. 4.42 0.82 233 H5: The image and sound quality of online learning was good. 4.17 0.78 234 Didactic D1: In the current situation, online learning was a good option for learning the theoretical part of education. 4.69 0.7 236 benefit Didactic D2: By participating in the online learning, I feel well prepared for the practical part of education. 3.73 1.02 227 benefit Didactic D3: In the context of online learning I dare to ask questions more often than “face-to-face”. 2.89 1.26 224 benefit Didactic D4: I generally prefer “face-to-face” rather than online learning. 2.98 1.36 233 benefit Didactic D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) 1.39 0.9 231 benefit continuing with ‘normal’“face-to-face” learning in winter semester. Motivation M1: The use of new digital teaching methods (e.g. online teaching) motivates me to learn. 3.78 1.2 235 M mean, SD standard deviation, N number of valid answers (total: N = 242) type of answer: 1 = strongly disagree, 5 = strongly agree home (57.0%) and used wireless local area networks 14.3% of lecturers had experience with online learning (LAN) (87.6%) for connection. Over 95% of students before (e.g. attending trainings or conventions, self- stated that they did not have major problems with an studied, listened to reports from colleges or already internet connection. taught online). In times of COVID-19, most of the lec- A total of 35 (74.5%) lecturers (18 female, 16 male, 1 turers used synchronous online learning formats no answer) responded to the survey. Concerning gender, (54.3%), followed by a combination of synchronous and there was no significant difference compared to the basic asynchronous formats (20.0%) and asynchronous for- group (n = 47, chi-squared test, p > .05). Among them, 6 mats alone (5.7%). Regarding the technical devices, lap- professors, 4 Ph.D. candidates, 1 post-doc, 23 members top computers (51.4%) and desktop computers (34.3%) of the teaching staff, and 1 Associated professor fully were mainly used. In addition to wireless LAN (28.6%), completed the survey with teaching experience between LAN (62.9%) was used for the majority of internet con- 1 and 40 years (median: 8 years, interquartile range: nections with mainly no interruptions in connection 7.08–14.01). (62.9% never, 20.0% in a minority of cases). In 17.1% of In total, 60.0% of lecturers had never dealt with online cases, online teaching took place at home (home office), learning formats before the COVID-19 pandemic. Only while 60.0% of the lecturers conducted online learning Table 3 Items and descriptive statistics of lecturers’ questionnaire Item Item description MSD N Didactic D1: In the current situation, online learning was a good way to teach the theoretical part of education. 4.6 0.56 30 benefit Didactic D2: The theoretical teaching content could be covered just as well by online teaching formats as it would have been 3.52 1.33 29 benefit possible in a classroom course (lecture/seminar). Didactic D3: I found the students during the online teaching to be disciplined and attentive. 4.04 0.87 25 benefit Didactic D4: I feel more uncomfortable using new teaching methods such as online teaching than in “face-to-face” teaching 3.03 1.4 29 benefit such as lectures because I miss direct communication with the students. Didactic D5: I do not think that online learning is useful and would have preferred a ‘non-semester’ and (if possible) the 1.81 1.2 31 benefit continuation of ‘normal teaching’ in the winter semester. Motivation M1: The use of new digital teaching methods (e.g. online teaching) motivates me. 3.93 1.1 30 Motivation M2: The online learning formats are an added value, because I can also use them for other training purposes (e.g. 3.25 1.48 28 conventions). M mean, SD standard deviation, N number of valid answers (total: N = 35) type of answer: 1 = strongly disagree, 5 = strongly agree Schlenz et al. BMC Medical Education (2020) 20:354 Page 5 of 7 courses from their office at the dental clinic. Only 2.9% opinion on those aspects, especially regarding easy of them used specially equipped conference rooms in participation and time effort (Table 4). dental clinics. In terms of the optimal amount of online learning for The results regarding the aspects of didactic benefit further implementation of a curriculum, independent of and motivation are given in Table 3. In the time of COVID-19, a significant difference between students’ COVID-19, online learning was useful as a substitute for and lecturers’ perspective was observed (p = .002). Stu- “face-to-face” learning, as strongly agreed by 57.1% of dents demand 53.2% (mean) (standard deviation: 24.9) of lecturers and agreed by an additional 5.7% of them. The the theoretical part in terms of online learning, while majority of lecturers quickly adapted to online learning. lecturers only want 38.6% mean (standard deviation: Furthermore, many lecturers stated that it was very 21.5) of the theoretical curriculum online. straightforward to transfer their “face-to-face” teaching content to online formats. Moreover, 25.0% disagreed with the need for more support for more time to prepare Discussion online learning courses. Nearly 60.0% perceived the co- During the COVID-19 pandemic, physical distancing operative character during the implementation of online measures are required and have an enormous impact on learning predominantly positive. Regarding the didactic dental education [7, 8]. Because online learning allows benefit, 57.1% agreed with the implementation of online participating in learning activities independent of the lo- learning due to COVID-19 and saw a good way to teach cation [22], the JLU implemented online learning in the the theoretical classes through online courses (54.3% spring semester 2020 to prevent the spread of the virus. strongly agreed, 28.6% agreed) without a loss of content. Thus, most students stayed at home and did not return Although lecturers acknowledged the discipline of the from the spring break. majority of the students, they stated feeling more com- Before initiating online courses, we ensured that all fortable in “face-to-face” teaching. However, most lec- students had unrestricted access to online learning and turers were motivated by using online learning, and questionnaire survey. Furthermore, the high response some even had added value by using the prepared online rate reduces the bias of not representative data. Con- learning courses for training purposes. cerning gender distribution and semester, there were no Regarding knowledge gain before and after online significant differences observed when compared to the teaching, a few lecturers were more favorable for online basic group (chi-squared test, p > .05). All participants teaching afterward, where as the motivation for teaching (students and lecturers) were informed that data collec- was almost unchanged. However, an increase was ob- tion was completely anonymous and did not allow any servable regarding knowledge gain. traceability of the answering person. Thus, the bias in Table 4 demonstrate the overall assessment about the answering was prevented. However, a clear limitation of differences between online and “face-to-face” learning this cross-sectional study is that students and lecturers comparing students’ and lecturers’ perspective. of only one dental school at one point were asked to With regard to the aspects: more modern, tips and participate in this study. Therefore, other universities feedback, queries, and knowledge transfer, a high con- should also be surveyed in future studies. sensus between students and lecturers was noticed. To achieve the highest possible educational success, it Nevertheless, students stated that they had more fun, is important to involve all participants in the teaching could better participate, and invested less time with process [16, 23]. Therefore, the implementation of on- online learning. Obviously, lecturers had a different line learning due to COVID-19 was evaluated using a Table 4 Items and descriptive statistics of overall assessment (students and lecturers) Students’ perspective Overall assessment :Please assess whether Lecturers’ perspective and to what extent “face-to-face” and online learning differ MSD N MSD N regarding the following aspects: (1 = online learning, 2 = equivalent, 3 = “face-to-face”) 2.45 0.61 222 More modern 2.5 0.51 30 2.0 0.79 228 More fun 1.57 0.5 30 1.78 0.64 218 More tips of lecturers 1.38 0.61 32 1.78 0.7 229 Queries better possible 1.53 0.72 32 1.89 0.7 229 Better knowledge transfer 1.69 0.64 32 2.69 0.61 230 Easier participation 1.87 0.75 32 2.51 0.69 227 Less time effort 1.72 0.63 32 type of answer: 1 = online learning, 2 = equivalent, 3 = “face-to-face” Schlenz et al. BMC Medical Education (2020) 20:354 Page 6 of 7 Likert scale, the standard procedure for surveys in the and lecturers’ regarding the amount of online learning in field of medicine [17, 19, 24, 25]. the future curriculum was observed, both groups As described by Asiry [25], ease of access is important strongly suggested a continuation of online learning. for online learning. The university ensured that every Furthermore, students in higher semesters rated online dental student had access to online learning before start- learning regarding the aspects handling, didactic benefit, ing online courses. Therefore, it was helpful that the and motivation higher than students in lower semesters. videoconference tool Webex Meeting was app-based, so These are important facts that should be considered in even students without a desktop or laptop computer the future. Currently, synchronous online courses are could participate in synchronous online learning using a used mostly, but in the future a combination of online tablet or smartphone, using a wireless LAN connection. and attendance (“face-to-face”) learning, such as In addition, the tech-checks were helpful and evaluated problem-based learning or flipped classroom methods, mainly positive by students. Therefore, it can be useful can be implemented more in dental education [9, 26]. to implement a technical check before starting with However, as indicated by lecturers, this requires online learning. personnel and financial support [14, 26]. Many students stated that participation in online Subsequent to the online learning period, a step-wise learning was easier compared to “face-to-face” courses. concept back to “face-to-face” teaching started to enable This might explain the high participation in online also practical education during COVID-19 pandemic learning among all semesters. [12]. Therefore, students began to exercise in small Even though most students agreed that online learning groups on manikins and will start to practice on patients at times of COVID-19 pandemic was useful and they in July 2020. This concept is in accordance with the way would not prefer a ‘non-semester’, many students did HongKong University reacted during the SARS-CoV-1 not feel well prepared for practical courses with online outbreak in 2003 [11, 12]. However, compared to past learning alone. These findings are in good accordance outbreaks, today digital technology currently allows for with the literature [9, 10]. Besides theoretical education, an almost real-time record of infections and a sharing of dentistry requires manual training and clinical patient information around the globe [3]. care; therefore, “face-to-face” teaching is important. There is probably no gold standard or one way to deal However, the positive-rated aspects of online learning, with this pandemic situation in the education of dental such as a higher motivation of students, easier participa- students. Even though the increase in COVID-19 cases tion, and less time effort can be used to improve the has slowed down, the authors hypothesize that it will future dental curriculum. take time to return to ‘normal teaching’. Therefore, we Although the required transfer from “face-to-face” better develop new and more flexible concepts/curricula teaching to online learning accelerated the digitalization with a high amount of online learning, without “face-to- process in dental education [8, 15], the complete face” contact. The results of our survey at an early stage changeover showed that students and lecturers had should highlight the steps taken to manage the crisis difficulties in preparing in advance for online learning. and point out the opportunity to minimize the impact of Although over 60% of lecturers at our dental school such outbreaks on teaching in dentistry and be better had no experience with online teaching before the prepared for similar disruptions in the future. COVID-19 pandemic, lecturers adapted very quickly to online learning, and the knowledge gain regarding the Conclusions implementation of online learning was very high. Within the limitation of this study, students’ and lec- Similar to the students, most lecturers also found that turers’ showed a predominantly positive perspective on online learning was a good alternative during the the implementation of online learning, providing the COVID-19 pandemic. However, lecturers had a different chance to use online learning even beyond COVID-19 in opinion about the positive-rated aspects (less time effort, the future curriculum. easier participation, and more fun) by students regarding online learning. Obviously, the transfer from “face-to- Supplementary information face” to online learning was time-consuming and, Supplementary information accompanies this paper at https://doi.org/10. because of various functions in dental clinics, most 1186/s12909-020-02266-3. lecturers cannot work from home. Independent of COVID-19, students indicated a mean Additional file 1. Questionnaire Students. amount of 53.2% (standard deviation: 24.9) regarding the theoretical part in terms of online learning for the future Abbreviations curriculum, and lecturers indicated only 38.6% (21.5). SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; COVID- Even though a significant difference between students’ 19: coronavirus disease 2019; k-MED: Knowledge-based Medical Education Schlenz et al. BMC Medical Education (2020) 20:354 Page 7 of 7 Acknowledgments 8. Abedi M, Abedi D. A letter to the editor: the impact of COVID-19 on The survey was consented with the deanery of the medical faculty of the intercalating and non-clinical medical students in the UK. Med Educ Online. Justus Liebig University Giessen. The authors would like to thank all students 2020;25:1771245. https://doi.org/10.1080/10872981.2020.1771245. and colleagues for supporting this survey. Furthermore, we gratefully 9. Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the acknowledge the support of Christian Treppesch and Susanne Ehrlich from United States. J Dent Educ. 2020;84:718–22. https://doi.org/10.1002/jdd. the Teaching Evaluation Service Centre of the Justus Liebig University 12163. Giessen. In addition, we like to thank our biostatistician, Dr. Johannes 10. Desai BK. Clinical implications of the COVID-19 pandemic on dental Herrmann, for the statistical analysis. education. J Dent Educ. 2020;84:512. https://doi.org/10.1002/jdd.12162. 11. Smales FC, Samaranyake LP. Maintaining dental education and specialist dental care during an outbreak of a new coronavirus infection. Part 1: a Authors’ contributions deadly viral epidemic begins. Br Dent J. 2003;195:557–61. https://doi.org/10. MAS and NSW conceptualized the study, developed the methodology and 1038/sj.bdj.4810723. wrote the manuscript. AS participated in designing the study and collecting 12. Smales FC, Samaranyake LP. Maintaining dental education and specialist the data. BW and NK reviewed the manuscript. 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BMC Medical Education – Springer Journals

Published: Oct 9, 2020

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