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INTRODUCTION: Online education has become standard for delivering graduate coursework in the medical and allied health professions, yet there is insufficient evidence regarding best practices and preferred methods of delivery for students in graduate clinical nutrition programs. Synchronous or realtime virtual classes vs asynchronous or static formats both have potential drawbacks and benefits. The purpose of this study was to evaluate graduate clinical nutrition student perceptions and learning outcomes using specific delivery modes in online instruction. METHODS: A Qualtrics™ survey was piloted, validated, and disseminated to working health professionals completing master's level study in clinical nutrition at a midwestern university. Qualitative data were imported, coded, noded, and analyzed using Nvivo v.11. Scaled data was analyzed and graphed. RESULTS: The results showed that students perceived significant benefit from synchronous online courses, in terms of interactivity, connectedness to peers and professors, and enhanced learning and accommodation of different learning styles. Evaluation of student learning outcomes from triangulated measures of the e-portfolio, oral comprehensive evaluation, and capstone experience shows improved learning with higher order synthetic capabilities in graduating students and improved professional competency in clinical nutrition and future ability to work as an effective part of the healthcare team. DISCUSSION: The synchronous online environment may provide unique opportunities to foster learning through a variety of modalities and enhance interprofessional interaction in the virtual space. This may lead to improvements in synthetic abilities of practitioners and increased efficacy as part of the healthcare team. J Allied Health 2019; 48(1):61-66.
ONLINE EDUCATION continues to grow and has become a major outlet for delivering undergraduate and graduate higher education courses. The Babson Survey Research Group in their "2015 Online Report Card: Tracking Online Education in the United States," stated that more than one-quarter of higher education students were taking at least one course on-line. In 2015, institutions that offer some form of distance education believe that their on-line offerings are critical to their long-term strategy (77.1% agreeing).1 E-platform learning has become a critical component in providing medical and graduate education.2,3
Online courses are usually offered using three different delivery formats: asynchronous, synchronous, or blended (hybrid) courses. Asynchronous formats typically include written course content, pre-recorded video or PowerPoint presentations, and on-line examinations, but typically any interaction with the instructor is through email or a FAQ website. Synchronous courses mimic traditional brick-and-mortar courses classes and are conducted at a pre-determined time with the instructor available for lecture/discussion and clarification of course content through immediate feedback. Technological advances allow on-line students in synchronous courses to see and hear their instructors, raise "electronic hands" to ask questions, view PowerPoint presentations and an electronic white-board, in addition to real-time interaction with their classmates. Blended or hybrid classes combine pre-recorded presentations or written content with synchronous interface with the instructor. Flexibility in the mode of participation has become widely accepted as superior to traditional methods of teaching.4
Research on the benefits and drawbacks of synchronous vs asynchronous formats demonstrate the merits and pitfalls of both delivery systems.5,6 Asynchronous delivery of course content gave the user more time to comprehend the material because an immediate response was not expected, while synchronous communication was "more like talking" and the students felt "more psychologically aroused and motivated, since this type of communication more closely resembled face-to-face communication."7(p54) Inclusion of best practices in either environment was found to be the best predictor of positive student learning outcomes.8 Sklyar9 compared students delivered either a synchronous web conferencing lecture or similar content deliv- ered in a text-based lecture. The study found that 75% of the students preferred the synchronous format, reinforcing the importance of interactivity. Roblyer et al.10 also noted that students feel a stronger sense of connection to their peers and instructor and stay engaged, while Bonnici et al.11 found that synchronous online delivery accommodated a wide variety of learning styles. Academic performance in the synchronous environment is thought to reflect pedagogical strategies and information assimilation attributes of the student.12
Engagement in the synchronous classroom was found to be much higher than in the asynchronous environment, with improved learning outcomes in allied health professionals.13 Kreber and Kanuka,14 in their investigation of the online environment, wrote that "thoughtful and reflective teacher-practitioners in higher education institutions are realizing that when online learning is effectively integrated, using interactive methods of alternative instructional strategies in combination with face-to-face instruction, the results can be remarkably effective at achieving higher-order learning objectives."14(p124)
The role of interprofessional education (IPE), particularly in the post-baccalaureate phase, has become a primary mandate for teaching allied health and medical students. Several studies have been published regarding online facilitation of learning in the IPE model, and the opportunities that web-based instruction offer to IPE community educators and students in the health professions.15-17 The use of synchronous web-based IPE to develop collaboration and communication skills among a variety of allied health disciplines has merit in maximizing and leveraging technology to enhance practitioner's healthcare team efficacy.18 Implementing problem-based learning, flipped classrooms, and other quality pedagogical approaches in the synchronous environment is also considered best practice for health professions students.19-22
The objective of this investigation was to determine if there was a perceived difference in student preference for courses delivered in synchronous, asynchronous, or hybrid course formats for students enrolled in a graduate program in clinical nutrition. There are a limited number of publications reviewing synchronous online education for graduate students and even fewer for students in clinically based programs of study. Our hypothesis is that having the instructor available in a real-time teaching environment (synchronous lecture) creates a valuable opportunity for students to query the instructor on difficult-to-understand concepts. When this is coupled with asynchronous reading assignments and practice examples, the hybrid format creates superior learning opportunities for students enrolled in the health sciences when compared to asynchronous-only teaching formats.
Methods
A survey was constructed using sequential focus groups of graduate students, educators, and preceptors. The research was deemed exempt by the Central Michigan University Institutional Review Board for Human Subjects (#944689-1, approved 08/09/2016). Four focus groups were facilitated by the director of a distance delivered graduate program in clinical nutrition at Central Michigan University. Each focus group was comprised of 7 to 10 graduate students, educators, and preceptors who sequentially refined and clarified a set of open- and closed-ended questions regarding online delivery of educational content at the graduate level. The survey was pilot tested with alumni of a distance graduate program in clinical nutrition and with another set of educators who mainly used face-to-face instruction for education in allied health.
Face value and external and internal validity were measured. The survey was disseminated using email blasts to all students and alumni who were currently or formerly enrolled in an online graduate program in clinical nutrition. Email blasts were sent every 2 weeks for a period of 6 months post pilot testing and validation, until an adequate sample was obtained. The qualitative and scale responses were gathered from Qualtrics™ (Provo, UT, 2017), and scaled responses were analyzed in Qualtrics and graphed in Excel (Microsoft Office 365, Microsoft Corp., Redmond, WA). Responses to openended questions were exported into a Word document and then imported into and analyzed using Nvivo v.11 (QSR International, Melbourne, Australia). Nvivo is a computer program designed to analyze free-form responses to open-ended questions. Themes or "nodes" were obtained from frequency of similar constructs reported by respondents. Results were coded into nodes based on common threads by one investigator to decrease inter-rater variability. The nodes or "themes" were then assessed for consistency by another researcher who was not affiliated with the clinical nutrition program or its constituents. Agreement between the researchers was very high (r=0.93). Threads and themes were then classified based on whether they referred to asynchronous, synchronous, hybrid, and cohort delivery mechanisms. Frequencies measured as valid percent were reported for scaled questions in the survey.
Results
The sample was one of convenience. The results of the questionnaire were evaluated based on their categorization. The questionnaire was disseminated to approximately 537 current or former students, using a listserv. Many of the email addresses were no longer in use, and the response rate for email blasts is known to be low. Despite repeated blasts, the sample size remained small. The sample consisted of 176 respondents or 32.8% of the total population. A 33% response rate is average for email blasts to a defined group.23 The demographics of responders are shown in Table 1. The demographics of responders were not significantly different from nonresponders and are generaliz able to the profession of dietetics, which is mostly female and Caucasian in the United States.
Weighted averages to the question "How would you rate your experience with the synchronous learning environment" were 98.4±18.6 vs 72.2±25.4 for the same question referring to asynchronous environments. Responses were rated using slider scales from 0-100, with 0 being extremely poor and 100 being excellent. The results were significantly different between synchronous and asynchronous experiences ⅝<0.01). When asked an open-ended question about the benefits of synchronous environments for student learning, the vast majority of students fell into the following three categories: interactivity (37%), accountability (36%), and real-time question-and-answer similar to face-to-face (21%). When asked as an open-ended question, "What are the benefits of an asynchronous environment," 71.2% of students fell into one category: flexibility to work on your own time and at your own pace. The remaining 28.8% responded either "ease of scheduling" or "both asynchronous and synchronous have merit based on individual learning preferences" or "less group work." In the open-ended question, "What are the limitations of synchronous delivery," responses fell into two broad categories: "scheduling, time, time zones" or "internet, connectivity, and/or technical issues." Similarly, when asked about the limitations of asynchronous delivery, responses could be classified into two main categories: "lack of interaction" and "need for self-motivation."
Using a sliding scale to rate the positive attributes of the synchronous virtual classroom, where 0 = not at all important and 100 = extremely important, "attending from wherever you are" was found to be the most highly rated attribute for synchronous delivery (Table 2). Using the same method to query asynchronous delivery, the highest rated attribute was flexibility (Table 2). In contrast, when the sliding scale was used to rate the limitations or deficits, the attribute most often scored highest for synchronous delivery was "connectivity or internetrelated issues." Similarly, for asynchronous delivery," lag time in instructor response" was scored as the greatest limitation (Table 3).
When asked about a mix of synchronous and asynchronous learning, in an open-ended question, the vast majority of students felt that the mix would be optimal. Three major categories emerged: technology ease (39%), learning style accommodation (29%), and ease of scheduling and/or navigation (24%). On a sliding scale, closed-ended question, several themes emerged (Table 4). When asked about cohort delivery of coursework to obtain the MS degree, a variety of issues were raised. Students felt that cohorts would allow a continuous building of skills if they took courses in a prescribed manner. They also felt that it would enhance relationships and friendships with their peers and allow them to feel more connected to faculty, staff, and students in the program. Additional positive attributes to cohort progression were timeliness of program completion, advance planning opportunities, more structure, networking opportunities, faster graduation times, clarity with respect to programmatic goals and objectives, and increased interactivity. Many limitations were also voiced: inability to advance at one own's pace, scheduling conflicts, inability to take a semester off, inconvenience of rigid progression of courses, decrease in the diversity of the student population, increased conflicts between peers or professors, negative impact on work and family, as well as limiting personal time and preference (Fig. 1).
When asked what could be done to improve the delivery of course content, student felt that simulation work, virtual laboratories, immediate availability of course recordings with closed captioning, and availability of the same course in both synchronous and asynchronous formats at the same time would be beneficial (Fig. 2). In addition, some students wanted the course to be available synchronously at the same time in the evenings or weekends but differing by time zone. This would mean offering four courses delivered synchronously, to accommodate the four-time zones just in the US. Because these suggestions were not fiscally or administratively sound, it was difficult to ascertain the viability of these proposed changes. When assessment and evaluation of the capstone experience, oral comprehensive examination, and the e-portfolio were triangulated, there were improvements in synthesis of information, professional competency, and readiness to provide meaningful contributions within the healthcare team.
Discussion
The results of this investigation show that student perceptions and opinions of delivery of course content in clinical nutrition are varied and dependent on learning style of the individual. There were many facets to the responses regarding modes of delivery and potential positive and negative attributes for the three delivery mechanisms: asynchronous, synchronous, and cohort. It is apparent that there is a preference for a more traditional approach among clinicians returning to school to obtain a MS degree. The synchronous environment seems to be preferred for its ability to foster interaction and connectedness between students and faculty. In addition, the feel of the virtual classroom when synchronously delivered provides a more structured approach, favored by students. Engagement, group work, and the interaction of the virtual classroom provides a distinct opportunity that asynchronous delivery does not, namely networking and real-time interactions. In addition, the virtual classroom provides a means for students to have real-time feedback and engage in IPE with peers and professors. Triangulation of the capstone evaluations points to enhanced learning, synthesis of information, and readiness to work in the healthcare team. This will provide future practitioners with better communication and problem-solving skills, which ultimately translates into improved patient care. This supports previous research showing that students wish to have structure, connection, and the ability to engage.24,25
In conclusion, this inquiry into preferred delivery methods for graduate education in the allied health professions clearly shows that students favor the synchronous environment for their learning, networking, and professional development. Evaluation of higher order synthetic capabilities of graduating practitioners revealed enhanced abilities and increased readiness for efficacious contributions to the healthcare team. It is important to consider the advantages of offering multiple modes of delivery to professionals seeking an advanced degree in the health professions, continuing professional education, and/or interprofessional interaction in the virtual space (Table 5). Further research into emerging technologies coupled with needs and preferences of students is required, considering the burgeoning virtual educational environment.
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Published online 1 Mar 2019.
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