key: cord-0776962-lhwxohdl
authors: McWatt, Sean C.
title: Responding to Covid‐19: A thematic analysis of students' perspectives on modified learning activities during an emergency transition to remote human anatomy education
date: 2021-12-03
journal: Anat Sci Educ
DOI: 10.1002/ase.2136
sha: 6b6adb5b6663d3f688673a934846a8cba5e00cc5
doc_id: 776962
cord_uid: lhwxohdl

In March 2020, the coronavirus disease 2019 (Covid‐19) global pandemic forced many post‐secondary institutions to move their teaching online, which had a substantial impact on students enrolled in laboratory‐based courses in fields like human anatomy. This descriptive study collected students' perspectives on the transition to remote education, with specific attention to the teaching activities, resources, and assessments used in an undergraduate Clinical Human Visceral Anatomy course at McGill University. Through inductive semantic thematic analysis, student‐held values for effective remote education were identified and grouped into the following themes: (1) preferences for communication, (2) values for remote learning activities and resources, (3) values for remote assessment, and (4) perceived positive and negative impacts of remote education on learning. Students generally valued having clear communication, opportunities for both synchronous and asynchronous learning activities, and flexible assessment formats that maintained alignment with the course outcomes and activities. Many felt that remote education had a net‐negative impact on their learning, course satisfaction, and sense of community. However, there were no significant differences in grades on laboratory quizzes administered before and after the shutdown (P = 0.443), and grades on the remote final examination were significantly higher than those on the in‐person midterm examination (P < 0.001). These findings are discussed in the context of modern educational theories and practices related to remote teaching. Strategies for facilitating a student‐centered environment online are also proposed. Future longitudinal research into skill development, learning outcome attainment, and the evolving perspectives of students and instructors operating in remote education contexts is warranted.

On March 11, 2020, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) that causes coronavirus disease 2019 was declared a global pandemic by the World Health Organization (WHO, 2020). To limit the spread of the virus, government-mandated physical distancing strategies subsequently forced the closure of higher education institutions across the globe (Smith & Pawlina, 2021) , including McGill University on March 13, 2020 (Labeau, 2020) . After a two-week closure and suspension of classes, instructors of undergraduate programs at McGill University were required to transition to remote teaching and resume their classes online by March 30, 2020 (Manfredi & Beauchamp, 2020) . To accommodate this abrupt transition, instructors were encouraged to reduce their course content and were given the freedom to drastically modify their syllabi as they saw fit without university oversight, so long as students were notified of any changes by March 24, 2020.

Courses with laboratory components, including those in human anatomy, were especially burdened with providing online activities to replace traditional hands-on learning environments. Without adequate time or resources to develop comprehensive and effective online laboratory equivalents, most instructors of laboratory-based courses were forced to develop 'stop-gapʼ activities to guide students through to the end of the Winter 2020 semester's content (Evans et al., 2020; Pather et al., 2020) .

Across the anatomy education community, instructors of courses faced with this difficult transition relied upon similar strategies for teaching, such as giving live remote lectures using videoconferencing software or providing pre-recorded lecture presentations (Longhurst et al., 2020; Pather et al., 2020) . Furthermore, while some institutions were fortunate to be able to provide some inperson practical components (Pather et al., 2020) , many were forced to implement the use of digital anatomy resources such as virtual learning environments, cadaver-based images and videos, or threedimensional virtual resources to replicate the practical component of their courses online (Longhurst et al., 2020; Pather et al., 2020) .

Although the rapid transition to these alternative approaches was enacted to ensure that students continued to receive high-quality anatomy education while learning remotely, it brought to light several new challenges and important pedagogical considerations for instructors to navigate (Evans et al., 2020; Franchi, 2020) . As pandemic-era teaching continues, instructors are facing increased pressure to ensure that their teaching approaches evolve beyond emergency 'patches' by thoughtfully integrating evidence-based remote teaching practices (Evans et al., 2020) .

The transition to remote education impacted students to an equal or greater magnitude as the instructors. Namely, the remote context limited their access to physical learning resources, in-person interactions with instructors, peer learning activities, and other potentially formative experiences for future health professionals (Franchi, 2020) . As a result of the widespread campus closures, many students also saw a disruption to their usual study routines for various reasons such as returning to their family homes, increased childcare and homeschooling responsibilities, and the closure of public libraries and other quiet study spaces (Pather et al., 2020) . Coupled with the modified course activities, these changes likely influenced how students navigated the course material and, consequently, their learning. Since many institutions, including McGill University, continued remote course delivery into the post-pandemic academic terms (Manfredi, 2020a, b) , students' perspectives on the remote teaching practices employed as stop-gap measures in the early days of the pandemic can offer valuable insights for educators on how to proceed into the future. Accordingly, they should be examined in context with relevant learning theories in order to establish appropriate strategies for maintaining high-quality learning online.

The present study surveyed physical therapy, occupational therapy, and kinesiology students enrolled in an undergraduate human anatomy course for their feedback on the changes made to the course during the Winter 2020 semester. The aims of the study were to determine and report the students' perceptions of the specific learning activities and assessment measures implemented to facilitate remote delivery in this course; to elicit feedback pertaining to their overall experience during the transition to remote education and while learning online; and to contextualize the students' feedback within related educational theories to inform strategies for future remote education contexts. An inductive thematic analysis of participants' responses was performed to identify semantic themes related to the course elements in an attempt to offer anatomy educators greater insight into the successes and failures of the approaches that were implemented. Findings were used to inform the design of learning activities, assessments, and remote teaching practices in human anatomy at McGill University for the Fall 2020, Winter 2021, and Fall 2021 terms and continue to guide preparations for future disruptions to in-laboratory teaching activities. Core, version 20.21.4.28830 (D2L Corp., Kitchener, Canada) , prior to all face-to-face learning activities. Recordings of the live lectures were also made available to the students via the LMS lecture recording system after the completion of each inperson lecture.

According to the original syllabus, students were to be assessed by way of three online laboratory quizzes, a peer-graded reflective writing assignment, a midterm written examination, a final written examination, and a final laboratory examination (see Table 1 ). The online laboratory quizzes were intended to be formative; they used cadaveric images to mimic a laboratory 'bell-ringer' experience and were taken up by the instructor in the classroom to provide students with strategies for answering that style of question ahead of their final laboratory examination. All online laboratory quizzes were administered via the course LMS. Students were given 12 minutes to answer five questions that each required them to: (1) identify an anatomical structure, and (2) answer a second-order question about another anatomical structure. All other assessments were summative. The writing assignment had students reflect on their laboratory experience, body donation, and the use of human cadavers in education. It was administered on the course LMS and peer graded using the 2020 version of the integrated cloud-based software, Peergrade (Peergrade ApS., Copenhagen, Denmark). The midterm examination included a combination of multiple choice, short answer, and drawing questions. The final written examination (cumulative) was originally planned to follow the same format as the midterm examination.

The final laboratory examination (cumulative) was intended to be a traditional laboratory 'bell-ringer' using cadaveric specimens. The questions were to follow the same format as the aforementioned online laboratory quizzes but delivered in person.

Several modifications to the original syllabus were required to accommodate for the disruption caused by the closure of McGill University between March 16 and March 30, 2020 (Manfredi & Beauchamp, 2020) . Notably, the semester was not extended, so the remaining course content was simplified and condensed to fit into the final two weeks of classes, which concluded on April 14, 2020.

The topics disrupted in this course were those pertaining to the anatomy of the abdominal, pelvic, and perineal regions. This content was subsequently condensed into four lectures (instead of eight) for the final two weeks of the semester (instead of four), and the in-person laboratory component was completely eliminated. Table 1 outlines the topics and assessments originally planned for each week of the course and how they were modified in response to the transition to remote delivery.

In place of in-person lectures, a flipped classroom approach was adopted. Videos were made by recording screen-capture of lecture presentations with voice-over using Zoom video conferencing software (Zoom Video Communications, Inc., San Jose, CA), and edited using Camtasia, version 2019.0.10 (TechSmith, Okemos, MI).

Students were given access to the PowerPoint slides (Microsoft Corp., Redmond, WA) and the lecture recordings via the course LMS in advance of their regularly scheduled lecture times. Drawing activities normally performed in lecture were also recorded on video, edited, and posted to accompany the lecture recordings. During the regularly scheduled lecture times (Mondays and Wednesdays), students were invited to participate in full-class sessions with the instructor on Zoom to see a review of the content, ask questions, and discuss topics related to the corresponding lecture recording. Students were encouraged to post questions for discussion or clarification on the LMS discussion board before the synchronous sessions. The instructor was then able to use Zoom to employ screen sharing, polls, and digital whiteboard drawings to clarify concepts and maintain student engagement. Once per week, until the final written examination, the instructor also hosted drop-in online office hours via Zoom where students could meet to discuss topics in greater detail. Each of the synchronous activities was recorded, edited, and made available to students for future viewing. However, any personal or non-academic discussions that arose in the office hours were removed from the recordings for student privacy and confidentiality. All MP4s for video-based resources (lecture recordings, drawings, online lecture discussions, and virtual office hours) were uploaded to YouTube (YouTube LLC., San Bruno, CA) as 'unlisted' links and embedded on the course LMS. One-on-one office hours were also available upon email request but were not recorded or disseminated.

Since it was no longer possible to run in-person laboratory sessions, drastic changes were made to the cadaver-based component of the course. Specifically, two virtual laboratory worksheet documents (interactive PDFs) were created and posted to the course LMS to guide students through the remaining content using cadaveric images, labeling and drawing activities, and links to open-access resources such as YouTube videos and open online image repositories.

The worksheets were written in conversational plain English (with minimal jargon) and organized in a similar manner to the in-person prosection-based demonstrations typically provided in the laboratory. Although these resources were substantially less interactive than the usual in-person laboratory sessions, efforts were made to ensure that they maintained alignment with the revised assessments in the course.

To account for the cancellation of the in-person final laboratory examination, a fourth online laboratory quiz was added, and the weight of the original final laboratory examination was redistributed across the remaining assessments (Table 1) . Furthermore, since all other remaining in-person assessments were suspended by the University, the final written examination was also delivered online.

This modification necessitated changes to the format and parameters of the test to limit academic misconduct and accommodate students with circumstantial inconveniences (i.e., living in different time zones, having limited internet access, etc.), while continuing to serve as a rigorous and fair appraisal of their knowledge. Namely, the instructors were required by the Faculty of Science to allow students 72 hours to complete the examination as 'open book,' without altering the actual length of the original test (designed to require three hours to complete). Therefore, the question array on the final | 725 MCWATT written examination was modified to include more applicationstyle questions that could not be easily answered through internet searches (Thompson & O'Loughlin, 2015) . Similarly, all questions required typed responses (rather than multiple choice) in order to dissuade students from sharing exact answers. Drawing questions were excluded because of software limitations. Some cadaver-based questions (with the same format as the online laboratory quizzes) were also included in the final written examination to further compensate for the loss of the final laboratory examination. No remote proctoring software was implemented, but students were required to agree to a Faculty-mandated statement on academic integrity and reaffirm their commitment to the anatomy laboratory code of conduct (including rules related to the distribution of cadaveric images) before gaining access to the final written examination.

Institutional Review Board approval for this study was obtained from the McGill University Research Ethics Office under proposal number A05-B26-20A (20-05-008) prior to data collection. All participants indicated informed consent before completing the study protocol.

All students who completed the Clinical Human Visceral Anatomy course during the Winter 2020 semester (n = 160) were invited to participate in this study by completing an online questionnaire administered through the course LMS. Students were offered a 2% bonus grade on their final written examination for their participation (worth 0.7% of their final grade), or the opportunity to complete an alternate assignment with an equal time and effort commitment in order to receive the bonus grade without participating in the study.

Students were also informed of their right to abstain from participation without penalty (no bonus grade awarded). Before reading the responses and beginning the analysis, all identifying information was removed from the responses to ensure students' anonymity.

Demographic data such as age and sex were not collected.

A non-validated researcher-generated questionnaire was used to elicit feedback on the learning resources and activities, assessments, communication, and overall learning experience in the course during and after the transition to remote instruction. The questions were targeted at specific aspects of the course so that the studentperceived pros and cons of each could be collected and addressed for future remote education. Table 2 presents each item included in the questionnaire, organized by the course component it evaluated.

The questionnaire was made available three days after the completion of the final examination and remained open for eight days.

Participants were asked to provide a written response to communicate their likes and dislikes regarding their experience with each of the components of the course and explain their perception of how the changes impacted their learning.

The participants' responses were assessed within a realist epistemology using an inductive semantic approach to thematic analysis, according to Braun and Clarke (2006) . This involved six recursive TA B L E 2 Prompts included in the researcher-generated questionnaire steps: (1) familiarization with the data by actively reading all student feedback, (2) generating initial codes from related comments, (3) organizing codes into preliminary thematic groupings, (4) revisiting the data and revising the themes to ensure that they were representative of all responses, (5) naming each theme, and (6) drafting the final report. Each step was revisited as necessary in a repetitious, rather than linear, process. As this was intended to be a descriptive study, the analyses focused on identifying semantic (rather than latent) themes. Moreover, the analyses focused on the strengths and weaknesses of the course elements and teaching strategies, rather than those specific to the instructor. Preliminary codes and themes in the students' feedback were regularly discussed with other McGill University teaching faculty, as each was preparing for their own upcoming remote teaching. Throughout, codes were organized using 'mind mapping' as a visual strategy for exploring relationships between them and forming thematic groupings. The prevalence of themes in the students' feedback was considered; however, the relevance of comments to the research question was prioritized over their frequency of appearance. Positive, negative, and constructive comments that emphasized the same underlying value or subject were included under the same theme.

All statistical analyses of grades were conducted in IBM SPSS Statistics software, version 26 (IBM Corp., Armonk, NY). Anonymized mean grades on pre-and post-shutdown assessments from all students in the course (n = 160) were compared to determine if the transition to online learning and assessment had a significant impact on students' performance. Because the format of the reflective writing assignment was not impacted by the transition to remote education, it was excluded from the grade analysis. Grades on the first and second online laboratory quizzes (pre-shutdown) were averaged together and compared to the combined average grades on the third and fourth online laboratory quizzes (post-shutdown) using the paired-samples t test for within group comparisons. Mean grades on the midterm written examination (in-person) were compared to mean grades on the final written examination (remote), also using the paired-samples t test for within-group comparisons. Effect sizes for these comparisons were calculated using the t-statistic according to the Cohen's d z equation for correlated group comparisons (Lakens, 2013) . Grade data are presented as means, plus or minus their standard deviations. Statistically significant differences were declared at P ≤ 0.05.

In total, 107 (66.8%) students completed the survey and none opted to complete the alternate assignment. Semantic themes in the feedback on individual course elements were identified and the different ways in which the transition to remote education impacted the students and their learning became clear. The feedback was divisible into four semantic themes that described student-held values for successful remote education: (1) preferences for communication,

(2) values for remote learning activities and resources, (3) values for remote assessment, and (4) perceived positive and negative impacts of remote education on learning.

In general, the students felt that strong communication was vital for a successful transition to remote learning, as summarized here by one student: "To me, the important thing is being in the loop and having responsive, flexible, communicative, and reliable professors." The more specific characteristics of effective communication that were identified in the responses largely pertained to the clarity, specificity, and regularity of course-related updates, maintaining openness and compassion in correspondences, and having easy access to the instructor on multiple platforms.

At the onset of the campus shutdown and transition to remote education, staff and students received many emails from the Together, these and other statements indicated the importance students placed on instructors maintaining their personality, compassion, and understanding in the communications and acknowledging the difficulty of the situation. Similarly, since several students reported feelings of isolation and loneliness related to losing their "sense of community" (see section below on perceived impacts of remote teaching on learning), it was suggested that the instructor issue more messages of support and share resources to help students overcome these challenges: 

Despite the rapid transition to remote education, students found the modified course learning activities and resources generally effective:

"I think the whole course was very well managed given the situation … everything was very well organized and … we felt guided, supported and well managed during the crisis." Their specific feedback indicated that they most valued activities and resources that were easy to access, use, and understand; were offered in a variety of formats; had alignment with the visuospatial nature of most course assessments and outcomes in anatomy; and included opportunities for interpersonal engagement.

The value students placed on resource access was most evident in their feedback related to the flipped classroom design. In general, students perceived the flipped classroom approach as "effective and straightforward," and they valued having the convenience of being able to review the lecture recordings through selfpaced studying before having the instructor summarize the content and delve deeper during the synchronous lecture discussion sessions on Zoom. The following statement details one student's experience with the flipped classroom approach: Other common complaints noted the poor audio and video quality of many of the public resources linked to in the worksheets that made it more difficult to interpret the anatomy. There were also some who expressed a need for better 'chunking' of the written information in the virtual laboratory worksheets into more digestible sections, since they considered the resources to be too long and time consuming: 

Overall, there was a range of perceived impacts of the transition to remote education on students learning in the course. The major themes identified in the analyses were related to knowledge confidence, independent study skills, focus and motivation, and social engagement.

As alluded to in previous sections, students overwhelmingly reported that the loss of the in-person laboratory component of the course had a strong negative impact on their knowledge confidence.

Not only did they report feelings of losing out on the "laboratory experience" as a "rite of passage", but they were also "not as confident with … spatial understandings of areas covered in post-Covid anatomy" and suggested that they would "have a hard time identifying structures on a donor if … asked to do so" under the belief that they are "less likely to remember the structures." Coupled with the decreased motivation

to study for open-book at-home assessments, students suggested that losing the in-person laboratory component "translated to poor retention of some details."

While students broadly believed that the outcome of their learning suffered from the new format of the course, many reported positive impacts on their learning process. For instance, most felt that the course became "more accessible" and "more convenient" through the implementation of additional resources and the adaptation of existing resources so that students could access them from home and use them at their own pace: "I particularly enjoyed that I [could] cover the material … when it was convenient for me as it allowed me to study and learn when I felt emotionally available to receive the information and retain it." Under these more self-directed learning circumstances, a small minority of students reported improvements in their organizational skills, time management, motivation, and ability to focus. Some students claimed to have "learned to be more self-disciplined" and felt "a lot more focused at home … as though I assimilated a lot more information when teaching myself. I felt more motivated to work hard … [and] took the entire pandemic as a source of motivation." Another student was proud of their realization that they "can work from anywhere and keep up good habits." Several students also reported that the support from the instructor and effective reorganization of the course helped to ease feelings of abandonment during the transition and aided their motivation to study.

Although some positive impacts of remote education were mentioned, some students reported no change in their learning, and the vast majority of responses depicted that the transition had a netnegative impact on their overall learning experience in the course.

Since most students were forced to return to their family homes, many reported difficulties adjusting to their new learning environ- 

The results of the comparisons of anonymized student grades between assessments administered before and after the universitywide shutdown are displayed in Table 3 . There was no significant difference detected in average performance on the online laboratory quizzes administered before the shutdown (first and second online laboratory quizzes) versus after the shutdown (third and fourth online laboratory quizzes). However, a statistically significant difference with a medium effect size was detected between grades on the midterm written examination (in-person) and final written examination (remote).

The rapid emergence of Covid-19 caused a multifaceted societal disruption that continues to be felt across the globe. For students, adapting to abrupt changes in educational activities was one of many challenges imposed by the pandemic. This study was con- Although generally understanding of the circumstances, the students felt that the rapid transition to remote education had a netnegative impact on their focus and motivation, social and mental health, and overall confidence in their anatomy knowledge. The loss of in-person laboratory activities was also considered by the students to be detrimental to their spatial understanding of the human body. Their comments indicated that they highly valued and desired

(1) increased social support and strong communication from the instructor, (2) resources and learning activities that were accessible, clear, varied, and collaborative, and (3) assessments that had constructive alignment with the course learning outcomes and activities, and included adequate accommodations for the situation.

The following sections discuss these perspectives within the context of related learning theories and present some strategies to help anatomy instructors maximize the success of their remote teaching during and after the Covid-19 pandemic. These strategies can also be applied to supplement traditional in-person teaching designs, as well as to prepare for teaching in future remote education settings.

It is undeniable that the Covid-19 pandemic changed the lives of students and instructors on both academic and personal levels. Since a disruption of this magnitude has never been seen by the current cohort, they have been forced to confront it without any pre-existing assurances that they "have what it takes" to succeed or that they will be adequately supported. This type of prolonged uncertainty can foster deep anxiety (Reuman et al., 2015) , placing an increased cognitive load on students, and impeding their capacity to effectively engage in learning activities and absorb the content (Schwonke, 2015; Gillett-Swan, 2017; Pather et al., 2020) . Accordingly, facilitating social support structures and strong communication are foundational pillars of successful remote course delivery that can combat these issues.

In the present study, many students reported that they felt physically and socially distant from their peers and the instructor after the transition to remote learning, which eroded the sense of community that had been established earlier in the year. Some even claimed that their remote learning experience challenged their mental wellbeing, contributing to a sense of anxiety that demotivated them from their studies. The relationship between mental wellbeing and anxiety among students learning remotely during the Covid-19 pandemic has been previously quantified (Chandratre, 2020; Cuschieri & Calleja Agius, 2020) , and discussed as a current concern held by the anatomy education community (Pather et al., 2020; Singal et al., 2021; Smith & Pawlina, 2021) . These phenomena are closely tied to the concept of transactional distance, which characterizes the physical, psychological, and social distance between students, their peers, and the instructor in a learning environment, as well as how effective communication strategies and course design can be used to manage it (Moore, 1991; Stone & Barry, 2019; Rhim & Han, 2020) . Courses that are structured to account for learners' individual preferences and circumstances, increase student interactions with their instructor and peers, and implement collaborative activities to promote a community of learning are suggested to reduce transactional distance and improve the learner experience (Rhim & Han, 2020) . Since remote teaching contexts like those experienced during Covid-19 threaten the natural occurrence of these elements by removing inperson interaction (Longhurst et al., 2020) , it is vital that instructors focus on strategies to minimize transactional distance and promote a strong sense of community in remote courses to maximize students' satisfaction and success (Shackelford & Maxwell, 2012; Cuseo, 2018; Baker & Moyer, 2019) .

Effective instructor communication is a major factor that regulates transactional distance during remote education (Moore, 1991; Rhim & Han, 2020) . Students in this study were generally satisfied with the communications they received from the instructor and for many, having easy access to the instructor on multiple platforms (the LMS, Zoom office hours, and email), receiving supportive and empathetic class-wide messages, and having clearly communicated expectations helped to soothe some of their uncertainty and anxiety about succeeding in the course, which motivated them to stay engaged. the University can rapidly fall out of date as circumstances change, forcing both students and instructors to adjust quickly (Pather et al., 2020) . Accordingly, despite potentially not having all of the answers, it is important for a remote instructor to uphold an open, clear, and empathetic line of communication, and be flexible with students in order to maintain their enjoyment, wellbeing, and participation in the course (Chickering & Gamson, 1989) . This should involve regular updates to clarify what is known, what is still developing, and what the students are expected to do in the new course context (Pather et al., 2020) . It could also include non-academic communications such as sharing of support resources, prompting students to reflect on their wellbeing throughout the transition and during remote learning, and encouraging them to reach out to the instructor if they need support.

It is important to note, however, that offering unregulated access to the instructor on multiple platforms, with the added expectation of prompt responses (Ruzycki et al., 2019) , can come at a cost to the wellbeing of an already busy instructor (Watts & Robertson, 2011; Canninzzo et al., 2019; Smith & Pawlina, 2021) . Academic burnout can pose a legitimate concern, especially amid the turbulence of a pandemic-type situation, as instructors work to create new resources and transition their teaching online (Kimball, 1998; Green & Whitburn, 2016) . During remote education, the usual structures of the workday and workweek can dissolve, giving students the perception of unlimited instructor access (Kimball, 1998) . Thus, while it is important to be available and responsive to students during the confusion and isolation that can accompany remote learning, setting clear boundaries is imperative for the instructor to sustain their own productivity and mental wellbeing (Hjálmsdóttir & Bjarnadóttir, 2021) .

One strategy to alleviate the social burden on the instructor is to implement peer-to-peer support systems. Of note, despite the perceived successes in the instructor-student communications related to the course discussed in this study, the feedback indicated that the modified course structure did not facilitate sufficient opportunities for synchronous interactions and discourse between students and their peers. Many felt lonely and disconnected from their peers and missed the opportunity to engage in face-to-face social activities in the classroom, laboratory, and elsewhere on campus. Therefore, while the instructor-student communication approach was strong, the course suffered an increase in its transactional distance by failing to promote an adequately supportive learning community. In addressing this failure, one can turn to a recent review by Rhim and Han (2020) that introduces a set of practical guidelines for effective online learning environments. In addition to transactional distance, the authors suggested consideration of the concept of presence (Rhim & Han, 2020) .

There are three types of presence: cognitive presence, social presence, and teaching presence (Anderson, 2008; Rhim & Han, 2020) . While teaching presence is primarily a function of the instructor, who curates the course material and designs the parameters of the learning activities, cognitive presence and social presence are more focused on the students' interactions with the course material and their peers (Anderson, 2008) . Cognitive presence characterizes a learner's ability to derive meaning from the material through exchanging thoughts and engaging in problem solving discussions with others in the course (Anderson, 2008) . Social presence is the degree to which students are given the opportunity to express their ideas and project their personality within a supportive learning community (Anderson, 2008). These latter two types of presence are driven by interaction and can be enhanced if the instructor designs the course to provide comfortable and interactive learning environments (Sargeant et al., 2006) . In general, increasing opportunities for academic and social interaction is valued by students and has been shown to correlate with a stronger sense of community (Haythornthwaite, 2000; Haythornthwaite et al., 2000b; Shackelford & Maxwell, 2012) . Therefore, these such initiatives should be in the forefront of an instructor's mind during a transition to a potentially isolating remote teaching environment.

The current 'digital age' offers many platforms to facilitate communication and provide social support through online peer-to-peer and instructor interactions. With the increasing acceptance of connectivism as a governing learning theory for the use of online technologies to facilitate peer learning networks, many instructors are seeking digitalbased platforms and strategies that facilitate knowledge sharing opportunities (Flynn et al., 2015; Goldie, 2016; Rhim & Han, 2020) . As per in the course examined in this study, LMS discussion boards can provide a venue for asynchronous interaction (González Moreno, 2011; Green & Hughes, 2013) , while video conferencing services can provide a venue for synchronous large-group, small-group, or one-on-one discussions. Such sessions not only allow the instructor to clarify course content, but also to provide support and important guidance to students on how to manage remote learning (Broadbent & Poon, 2015) .

Furthermore, if used for small-group activities, Zoom can be a tool to alleviate transactional distance through peer-to-peer interaction (Rhim & Han, 2020) . Some students, including many in this study, have suggested the addition of a synchronous small-group component to complement anatomy laboratory material (Srinivasan, 2020) , which could easily be facilitated using the Zoom 'breakout room' feature. Using this tool, the instructor can divide students (randomly or pre-assigned) into separate small-group calls for concentrated discussions or think-pair-share activities (Kaddoura, 2013) , then return them to the original large-group session to summarize.

It could even be used to incorporate small breaks into synchronous activities for "discussion about totally [non-academic] things," which was a suggestion from one student on how to strengthen the sense of community in this course. These types of short breaks have also been shown to help segment students' attention and sustain their engagement throughout a didactic learning activity (Olmsted, 1999) .

Finally, considering the current students' desire for increased peer-to-peer interaction and the traditional role of a university experience in their social and personal growth (Buote et al., 2007) , social media platforms may present another emerging, but potent, avenue for reducing the transactional distance experienced in an online course. Platforms such as Twitter and Facebook have been shown to be effective, well-received, and heavily used by today's anatomy students (Jaffar, 2014; Hennessy et al., 2016; 2018; Stone & Barry, 2019). Since they are public and not inherently | 733

MCWATT associated with university teaching practices, use of these platforms may encourage students to make social bonds with classmates outside the classroom, bolstering their support networks and reducing feelings of isolation. These benefits make the use of social media platforms a viable option for managing transactional distance and presence, which should be among the top considerations for instructors designing courses for remote delivery. However, measures should be taken to ensure appropriate conduct on these platforms, given the sensitivity of the cadaveric element of anatomy education (Hennessy et al., 2020) .

Remote education can also strain the habitual methods that instructors rely upon to teach under normal in-person circumstances.

Since the majority (if not all) of the students' learning during remote education is conducted in their own homes, acknowledgement and treatment of students as independent learners is of utmost importance (Rhim & Han, 2020) . Therefore, in addition to building a strong learning community with opportunities for interactive knowledge sharing, instructors should consider the autonomy and unique learning processes of their students in their design of the learning activities (Rhim & Han, 2020) . This means providing opportunities for both didactic and experiential learning through various synchronous and asynchronous approaches (Pather et al., 2020; Rhim & Han, 2020) . One method that allows the instructor to easily integrate these priorities is the flipped classroom (Lage et al., 2000; Rhim & Han, 2020) .

The flipped classroom was used as the central teaching approach in this course and was very well received by the students surveyed in the present study. The flipped classroom approach inverts traditional didactic design by having students engage in selfdirected learning activities with curated course resources at home before attending synchronous sessions with their instructor and peers (Lage et al., 2000) . This approach lends itself well to remote teaching contexts, as the provision of asynchronous learning activities allows the students the flexibility to schedule their learning around other personal and academic activities (Fleagle et al., 2018; El Sadik & Al Abdulmonem, 2021) . Studies on the flipped classroom in human anatomy have shown that it is associated with improved performance (Viveka et al., 2017; Chutinan et al., 2018) , namely related to high-order outcomes and knowledge retention (Morton & Colbert-Getz, 2017; Day, 2018) . It is also seen as an approach that supports active learning to promote engagement during synchronous sessions (Bergmann & Sams, 2012; Kim et al., 2014; Sams et al., 2014; Morton & Colbert-Getz, 2017; Chutinan et al., 2018) , maximizing the impact of contact hours with students (Lage et al., 2000; Bergmann & Sams, 2012; Day, 2018) . By removing more didactic content delivery from the synchronous sessions, more time can be spent on addressing students' questions and delving deeper into the content through active approaches (Day, 2018) . This time can also be allocated toward peer-to-peer social learning activities or informal 'wellness check-ins' that help to maintain a sense of community and support during potentially isolating remote learning (Rhim & Han, 2020) . The flipped classroom also gives the instructor the opportunity to make more accurate appraisals of the students' understanding of the material through active discussions and polling activities with the students during synchronous components (Moravec et al., 2010; Prober & Khan, 2013) . This is especially valuable in a remote education context, as many students do not enable their webcam during didactic lectures on Zoom, so the usual visual cues normally used to gauge understanding are lost.

In human anatomy, a major benefit to the flipped classroom approach could be the integration of laboratory-adjacent materials that students can access from home. Offering cadaver-based videos as supplemental at-home learning resources has been shown to increase student satisfaction and lead to improvements in laboratory grades (Poletti et al., 2018; Topping, 2014) . Similarly, students in this study insisted that they would have preferred and benefited greatly from more and higher-quality cadaver-based learning resources. However, findings of this nature are not ubiquitous. Some studies saw no improvement (Mahmud et al., 2011; Koop et al., 2021) or even decreases in performance (Granger & Calleson, 2007; McNulty et al., 2009 ) after incorporating dissection-based videos.

Furthermore, spatial orientation of specimens in videos can be challenging for some students to interpret, which could negatively impact their learning (Homer et al., 2008) . This sentiment was prevalent in the students' feedback in the present study.

Some asked for the inclusion of digital anatomy models to allow for three-dimensional manipulation of anatomical structures, and also suggested that these tools could be used in Zoom breakout rooms to supplement their spatial understanding of anatomical structures (Azer & Azer, 2016) . However, while helpful, these programs can be challenging to use for both the learner and instructor (Doubleday et al., 2011; Attardi et al., 2016) , and the three-dimensional models on monoscopic digital displays may disadvantage learners with low spatial abilities (see Roach et al., 2021 for review) . Given these mixed outcomes, instructors considering providing increased access to cadaveric materials and anatomy digital displays should proceed with caution and ensure that multiple equivalent learning resources are made available to accommodate students' varied learning preferences and abilities. Furthermore, although these online activities can be a cheaper alternative to cadaveric dissection (Chumbley et al., 2021) , anatomy faculty should be mindful of less obvious benefits that could be lost in such a transition (Singal et al., 2020) , including the impact on various nontraditional discipline-independent skills that are commonly attributed to cadaver-based education (Evans & Pawlina, 2021) .

Because of the requisite use of digital technology in remote learning, one major concern is the distribution of cadaver images online. Misuse and unconsented use of cadaver images and videos threatens the privacy of the body donors and may be antithetical to their wishes (Cornwall et al., 2016) . Such failures to protect body donors and their families can erode public trust in body donation, thereby threatening the overall stability of cadaver-based education (Cornwall et al., 2016) . Considerations should, therefore, be made to ensure that resources used in remote education are protected, and that all body donors have given informed consent for the capture and use of any photographs or videos (Hennessy et al., 2020) .

Distribution of such resources can be especially difficult to monitor in an online learning environment, which presents a problem for security and copyright issues related to non-cadaveric content. For example, one student commented: "I personally block YouTube during the semester for productivity reasons. Because of this I initially struggled watching the lectures (which were posted on YouTube), but I managed to overcome this problem by watching [them] as embedded on a website."

This passage implies that the instructor's lecture material was posted to a third-party website, which is a breach of copyright, according to

Canadian law (Government of Canada, 2020), and a serious threat to the security of anatomical images. Although concerning, the comment also highlights another important consideration-that of the method and format by which remote learning resources are disseminated. Optimally, all course materials should be accessible through a university-approved course management system. However, the students' familiarity with platforms such as YouTube can be beneficial to their learning (Jaffar, 2012; Barry et al., 2016) , which may attract increased use among instructors. Ultimately, the course designer must navigate the balance of risk versus reward to maximize students' learning while protecting the learning resources they choose to share online.

The transition from in-person to remote assessment during the Covid-19 pandemic required instructors to remodel their usual assessment practices to be held online in a way that was fair to the students' changing circumstances, but that also maintained the integrity of the examinations. This necessitated considerations such as how to ensure constructive alignment, promote academic integrity, and concomitantly provide the appropriate accommodations for the situation (Longhurst et al., 2020; Pather et al., 2020) . To address this, some educators increased their reliance on formative assessments (Pather et al., 2020; Singal et al., 2021) , while others modified their approaches to discourage student collusion by changing their question styles, restricting the delivery methods (e.g., time limits, strict schedules of students' access to assessments, randomized questions, etc.), or altering assessment weights (Pather et al., 2020) .

With institutions' continued reliance on online education, even as course delivery approaches slowly return to 'normal' (Manfredi & Beauchamp, 2021) , it is clear that online assessments will present an ongoing challenge for anatomy educators (Evans et al., 2020) .

The major changes to the assessments in the present course included a severe reduction in cadaveric image-based examinations and widespread changes to the question styles used in written examinations. Overall, there was mixed feedback on the success of these strategies and the students' satisfaction with them; however, several insights emerged to improve remote course delivery in the future. While students were generally satisfied with the communication of the learning outcomes, several comments indicated that the new remote learning activities were inadequate to prepare them for the final assessment, or that the final assessment lacked alignment with the new learning activities. These comments hint at a failure in the constructive alignment of the course, which is a challenge that has been discussed by several other anatomy educators (Longhurst et al., 2020; Pather et al., 2020) .

Alignment between the content and format of course learning activities and assessments is important for in-person and remote delivery alike (Cohen, 1987; Biggs & Tang, 2011) . The learning activities and assessments in a course should be designed to, respectively, facilitate and test the students' achievement of predetermined learning outcomes, according to the idea of constructive alignment (Biggs & Tang, 2011) . Most learning outcomes in human anatomy target a student's ability to identify structures and demonstrate an understanding of their spatial and functional relationships, commonly through written and in-person practical assessments, like laboratory bell-ringer examinations (Drake et al., 2014) . Most students in this study felt that knowledge of anatomy developed through lectures and other class activities usually provided adequate preparation for written assessments, while laboratory study using cadavers and models was essential for them to foster a stronger and more practical spatial understanding of the human body. The in-person bell-ringer style of assessment used under normal circumstances is inherently aligned with the typical laboratory-based learning activities but presents other challenges when moved online.

By transitioning laboratory learning activities to remote delivery using cadaveric images or digital models displayed on two-dimensional screens, the physical and stereoscopic threedimensionality of structures was lost. This caused a misalignment between the teaching methods and the desired learning outcomes related to identification and spatial understanding of anatomical structures and relationships (Longhurst et al., 2020) . Although the students in this course were both taught and tested on cadaveric images, which gives the appearance of alignment, they may have been less equipped to orient and understand two-dimensional cadaveric images without the three-dimensional hands-on learning experience that the laboratory would have provided. Viewing physical structures with true stereopsis has been shown to be crucial to learning in human anatomy (Wainman et al., 2018 (Wainman et al., , 2020 , especially for students with low visuospatial abilities (Cui et al., 2017; Bogomolova et al., 2020; Meyer & Cui, 2020; Roach et al., 2021) . Furthermore, in-person laboratory environments have been shown to promote deep rather than surface approaches to learning in anatomy (Smith & Mathias, 2010; McWatt et al., 2021) , which are associated with higher quality learning outcomes (Pandey & Zimitat, 2007) . It is possible that the loss of these features from the course learning activities had a negative impact on students' confidence in their anatomy knowledge and spatial understanding, both of which were reflected in the students' complaints about being tested on cadaveric images in this study and among other groups (Singal et al., 2021) . However, there were no significant differences in grades on the online | 735

MCWATT laboratory quizzes administered before and after the Covid-19

shutdown (Table 3) , and the final examination grades (remote) were markedly higher than the midterm examination grades (in-person) (Table 3) . This was not overly surprising, given that previous research has shown that assessment modality does not significantly influence student achievement in anatomy (Attardi & Rogers, 2015) , and it is, therefore, unclear if the use of two-dimensional cadaveric images in the learning activities and assessments put students at an actual performance disadvantage (Inuwa et al., 2012; Sagoo et al., 2021) . However, it is equally unclear if all of the desired learning outcomes were attained, as the ability to identify anatomical structures on two-dimensional images may not offer reliable evidence of spatial understanding (Gonzales et al., 2020) or other nontraditional discipline-independent skills (Evans & Pawlina, 2021) . In a rapid transition with such a drastic impact on the context of anatomy teaching as that experienced during the Covid-19 shutdown, these considerations are easy to overlook. However, instructors should critically reflect on the learning outcomes that they can and should target as the pandemic continues, then carefully design their course activities and assessments for truly student-centered constructive alignment (Loughlin et al., 2021; Smith & Pawlina, 2021) .

Constructive alignment is fundamentally a student-centered approach to educational design, in that it places the focus on what the student does and gains from the experience, rather than what the teacher intends (Biggs & Tang, 2011) . While attempting to maintain or re-establish this focus in a new remote learning climate, it is important to consider the fundamental changes to the students' learning and testing environment that have occurred. Crucially, this requires acknowledgement that non-academic factors will uniquely affect each student as they participate in their schooling and assessments from home and lose the physical separation between their academic and personal lives (Pather et al., 2020) .

Given the complex and varied situations that each student may be subjected to, assessment accommodations should be made to ensure that personal and situational factors do not impede a student's success. Students in the present study were very appreciative of the Faculty's decision to extend the examination time from a strict three-hour session to a three-day period. As intended, this relieved the stresses of internet instability, employment and family obligations, and time-zone differences for many, allowing them to focus on their performance (Longhurst et al., 2020) . However, some students suggested that the extended examination time merely sustained their stress over three days instead of three hours. Others mentioned that the flexible open-book format decreased their motivation to learn the content since they could instead rely on their notes, textbooks, and internet searches. Coupled with the potential grade inflation observed on the final examination, comments such as these raise the important issues of both student engagement and academic integrity.

As mentioned before, many of the assessments used by anatomy educators during the Covid-19 pandemic were modified with academic integrity as a central concern (Pather et al., 2020) . While there is still no consensus on best practices for the remote delivery of assessments during a pandemic (Kirkwood & Price, 2014; Longhurst et al., 2020; Pather et al., 2020) , one strategy that was well-received by students in this study was to include mostly open-ended or short-answer questions. This approach was implemented to minimize academic misconduct since answers were more difficult to search online, although it is unclear if this was successful. However, the written format did allow students to explain their thinking more clearly and to obtain part marks. Some noted that this process was rewarding and allowed them to reflect on the knowledge they had gained in the course. Given the importance of having adequate reflection time for students to consolidate information (Kolb, 1984) , strategies that maximize opportunities for reflection should be eagerly pursued in remote education (Rhim & Han, 2020) . In terms of assessment, reflection is central to the concept of formative assessment, which is the implementation of assessments as learning activities (Evans et al., 2014) . Through systematic low-stake assessments, such as the online laboratory quizzes administered in this course, students are able to familiarize themselves with a course's examination format, reflect on their current understanding, and consolidate their knowledge to advance that understanding (Rolfe & McPherson, 1995; Krasne et al., 2006) . Especially during a rapid transition to remote teaching, formative assessments can be valuable for maintaining students' engagement while simultaneously preparing them for a new and unfamiliar examination format (O'Byrne et al., 2008; Franchi, 2020; Pather et al., 2020) .

While the findings herein center upon the unique experiences and opinions of students, who should always be at the center of an instructor's considerations, they only depict a snapshot of time in the rapidly evolving context of the Covid-19 pandemic. Namely, the feedback was obtained in the early stages of the pandemic, and the students' opinions are likely to have changed during their sustained exposure to remote education and the evolving teaching strategies they experienced over the past year and a half. Furthermore, those Another potential limitation of the present study is that the thematic analyses were conducted by a sole coder (S.M.), who was also the instructor for the course. This could have increased the possibility of interpretation bias during the coding and refining of themes. However, the data were discussed with the coder's anatomy teaching colleagues and reviewed multiple times by the author in a specific effort to ensure that the evaluation process was recursive, comprehensive, and objective (Braun & Clark, 2006; Kiger & Varpio, 2020 ).

The Covid-19 pandemic has had an immeasurable effect on how anatomy is taught and studied across the globe. In March 2020, the initial rapid transition to remote education presented an immediate challenge to students and instructors alike. This study captured a portion of the student experience during that transition and identified Widespread interinstitutional analyses that evaluate the evolution of students' perspectives on remote teaching practices and achievement over time are certainly warranted. Additional assessments of instructors' perspectives and teaching strategies used during the Covid-19 pandemic will also facilitate a more wellrounded discussion surrounding the challenges and opportunities of remote delivery of human anatomy education.

The author would like to thank the students and undergraduate course assistants for their patience and hard work during the difficult and unanticipated transition to remote education. Thank you also to the teaching assistant, Frank Niro, who demonstrated noteworthy compassion and dedication to his students throughout the course, to the anatomy teaching faculty at McGill University for their insights and diverse interpretations of potential themes, and to Kate Murphy for pre-reading this work.

The author does not have any conflict of interest to declare.

Sean C. McWatt https://orcid.org/0000-0002-2958-1756

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