Optometry education, like other health professions, has historically been conducted via contact teaching and learning in classrooms, clinics and laboratories. In 2020, COVID-19 imposed an abrupt move to online learning for higher education institutions. This was performed with little insight into the feasibility and readiness for its adoption within certain contexts, as well as the potential impact on learning. This qualitative descriptive project purposively recruited a representative sample of 30 optometry students from a South African university to explore their experiences of online learning during the COVID-19 pandemic. Data were collected using focus group interviews. The data were audio-recorded, transcribed and analysed thematically. Four themes emerged from the research, namely; learning how to learn online, need for social support, technology dependent, and authentic learning. The key challenges observed were difficulty in transitioning to online learning, independent learning, and not having reliable access to internet connectivity. Gaps in clinical skills resulting from restricted access to contact training and real-world clinical exposure negatively impacted competency development.

Contribution: Pandemic disruptions to routine academic programme activities within higher education institutions have the potential to negatively impact the learning experience for students where institutions and/or students may be unprepared or under-resourced to support such a shift. The results of this study further suggest that exposure to real-world clinical contexts for optometry students should be enabled even under pandemic conditions to promote the development of clinical competencies needed for effective healthcare delivery. Finally, remote online assessments must be designed to support authentic learning so as not to compromise exit-level outcomes, skills and competencies.

Keywords: optometry; online learning; clinical education; technology-based learning; competencies; pandemic responsiveness; online assessments; South Africa.

Introduction

For most health professions training programmes, teaching and learning have historically been conducted via contact teaching methods (Zalat, Hamed & Bolbol 2021). This is because training in clinical procedures is fundamental to competency development for health professionals (Green, Edwards & Tower 2022). However, the global outbreak of COVID-19 in 2020 imposed significant changes to the way society operated; forcing educational programmes around the world to abruptly move to virtual modes of course delivery using online approaches (Nortvig et al. 2020). Online learning, which does not take place in a physical classroom with fellow students or a teacher present, has become more prevalent in institutions of higher learning in recent times (Koksal 2020). Yet, for most health professions programmes, it has not been fully embraced given the need for face-to-face clinical skills training. The continued reliance on face-to-face clinical skills training is underpinned by the need for clinical skills and competency development (Costello et al. 2014).

Optometrists are considered the primary healthcare practitioners of the eye and visual system who provide comprehensive eye and vision care. This includes refraction and dispensing of eyeglasses and other optical corrective devices, detection or diagnosis and management of diseases of the eye, and the rehabilitation of conditions of the visual system (World Council of Optometry n.d.). Consequently, practical (skills-based) and clinical (competencies) training are central to the training of optometrists. However, in the contact-restricted COVID-19 context, practical training sessions at institutions of higher learning were largely suspended, with efforts to achieve some of the required learning outcomes using online approaches. At the University of KwaZulu-Natal in South Africa, teaching and learning swiftly moved to virtual modalities for all programmes after the university adopted an Emergency Remote Online Learning strategy in response to the COVID-19 pandemic in March 2020. For clinical programmes, efforts were made to achieve some of the learning outcomes using video-based instruction and assessment methods, as well as simulation software, where available. In the context of optometry training, clinical skills imply contact with patients within a healthcare setting, which is preceded by practical training in labs aimed at technical skills development for application in the clinical assessment and management of patients.

Making the shift from contact learning to online learning is challenging; potentially impacting the attitudes of students towards the learning project itself (Kreijns, Kirschner & Jochems 2003). This study was undertaken to better understand the online learning experiences of optometry students during COVID-19 as well as the impact of this method of learning on clinical competence. Furthermore, the study sought to explore how external factors relevant to the South African context impacted the online learning experiences of optometry students. Research shows that teaching and learning are influenced by more than teaching methods alone (Azulay Chertok, Barnes & Gilleland 2014). The constructivist approach to learning emphasises an environment in which learning is community-centred; that is, it recognises the importance of social construction of knowledge and connectedness as part of the learning experience (Swan 2005). This is relevant to the COVID-19 pandemic experience, which restricted the movement of persons, effectively removing the social community synonymous with contact learning at universities.

Online learning also demands self-efficacy, which impacts student satisfaction in the online environment (Alqurashi 2016). Lentell (2014) suggested that online learning approaches need to meet user requirements to gain students’ trust and improve their acceptance of this type of learning. Even in a traditional contact learning environment, students’ self-efficacy was found to impact the learning and academic performance of medical students (Hayat et al. 2020). In South Africa, university students are often faced with data connectivity issues that may directly affect their engagement during online learning activities (Hawthorne et al. 2009). Previous research has highlighted the challenge of tools for effective online learning, which are often absent in developing countries (Frehywot et al. 2013). The negative impact of factors such as inconsistent electricity availability and data instability on teaching and learning schedules, even under non-pandemic conditions, has been acknowledged (Capone, De Caterina & Mazza 2017).

Given the growing interest within the field of educational research on factors that affect learning outcomes and student satisfaction in online or blended learning in higher education, this research into South African optometry students’ experiences when engaging in online learning under pandemic restrictions was deemed necessary for future planning.

Methods

A qualitative exploratory case study design was used to investigate the phenomena of interest. This design was chosen as qualitative research approaches aim to understand the lived experiences of participants (Neubauer, Witkop & Varpio 2019). The study population included optometry students registered in the 2021 academic year at an institution in South Africa (institution name omitted to maintain integrity of the review process). Students were contacted via email and invited to participate in the study following a process of oral informed consent. A total representative sample of 30 students aged between 18 and 22 years was recruited for the study.

Data were collected by means of four focus group interviews, one for each year of study. The focus group interviews were administered via Zoom, with a maximum of eight students represented per year level. Students were engaged on their online learning experiences during COVID-19. Key lines of questioning included transitioning to online learning, factors that impacted the overall learning experience and impact of remote learning on clinical competence. Interviews were audio recorded and manually transcribed. Confidentiality was maintained by allocating codes to each participant at the beginning of the focus group to ensure data anonymity. The interviews were carried out by the researchers who had undergone prior coaching on how to conduct focus group sessions. Content analysis, as described by Erlingsson and Brysiewicz (2017), was used to draw out meaning units related to the key research questions on online learning experiences. Data were analysed using inductive reasoning (Creswell 2018) and reported descriptively using themes and subthemes, following a process of member checking.

Ethical considerations

Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (HSSREC) (No. HSSREC/00002961/2021).

Results

Thirty optometry students aged between 18 and 22 years old who ranged from the 1st to the 4th year in the programme (Levels 1, 2, 3 and 4, respectively) participated in the research, with four main themes emerging from the results (Figure 1).

Theme 1: Learning how to learn online

Theme 1 reflects the participants’ experiences of the abrupt transitioning to online learning. The theme encompasses two subthemes, namely ‘A new way of learning’ and ‘If it’s to be, it’s up to me’.

Subtheme 1.1: A new way of learning

Most participants reported that the COVID-19-imposed move to online learning was their first exposure to online learning. This resulted in the need for a swift adaptation to this new way of learning:

The adjustment was greater for participants in their first year of study as most had never been exposed to online learning before, with Participant 7 expressing the following:

This rapid adjustment to online learning left some participants feeling overwhelmed and pressured. Many participants reported feeling increased pressure and anxiety as a result:

Participants’ acceptance and preference levels for the new online learning approach differed. Some participants felt that on-campus, contact learning allowed for a more productive, academically orientated environment, while others preferred to learn within the comfort of their own homes:

Although some preferred learning from home, most participants reported an increase in distractions and interference within the home learning environment:

Subtheme 1.2: If it’s to be, it’s up to me!

Subtheme 2 relates to the participants’ experiences of taking responsibility for their learning. While certain participants were able to easily adapt to the shift, others encountered various challenges relating to self-directed learning. The principle of taking responsibility for one’s learning, core to the general principle of online learning, was evident in the responses of the participant:

Taking responsibility for one’s learning was a new concept for most participants, as was learning independently. This was evident in all the years of study:

Theme 2: Technology dependent

This theme highlights the participants’ experiences relating to the demands of online learning, as well as their need for connectedness. It was evident that online learning placed a greater workload demand on the participants than face-to-face lectures:

Participants reported facing pressure from lecturers who expected them to do a lot of work in a short period of time:

Participants further expressed a need to be connected to fellow students and lecturers in order to support their online learning experience. One participant expressed that it helped to speak to someone who could provide support, in particular, being connected to peers who shared the same academic challenges:

The need for connectedness was further evident with many participants expressing a desire for contact sessions to supplement online learning:

Theme 3: Need for social support

This theme reflects core factors that enable online learning, such as access to the internet, which impacted the participants’ learning experience. Poor internet connectivity as well as inadequate data allowances by the institution for online learning during COVID-19 were two major concerns reported by participants, impacting their ability to effectively learn online:

The aforementioned underscores the fact that online learning is technology-dependent, with unequal and unreliable access to the internet posing a challenge for many South African students when forced to engage in online learning.

The negative experiences in terms of connectivity were widespread among participants, but worse for participants living in areas with poor network coverage:

Power supply also presented a major challenge for participants since load shedding (power cuts) regularly affects South Africans across all communities. As a result of this power instability, many participants missed lectures either because of their devices not being sufficiently charged or because of the interruption in network accessibility:

Theme 4: Authentic learning

This theme comprises two subthemes, ‘Clinical Training with no clinics’ and teaching, learning and assessment.

Subtheme 4.1: Clinical training with no clinics

Almost all participants complained of the lack of access to hands-on practical training and its impact on their clinical skills development. In some cases, participants reported being exposed to the clinical environment (direct patient contact) for the first time during an assessment:

This placed further pressure on the participants who were required to ‘perform’ clinically and their skills be evaluated without the necessary real-world training and exposure to the university clinic.

These negative experiences were highlighted across all year levels with all participants feeling as if they were not given enough time for practical exposure during lockdown, prior to assessments. Participant 15, A second year student said:

Furthermore, access to real patients, critical for clinical competency development, was acknowledged as an unmet, yet essential training need among participants:

Participants further felt that because they did not get to see ‘real’ patients, they suffered significant gaps in clinical competence.

Subtheme 4.2: Student-centred teaching, learning approach and assessment

The need for a student-centred approach, with lecturers accommodating the different learning styles and preferences of students, within an online learning context, also emerged from the data:

This suggests a need for varying modes of delivery and engagement, which address students’ different preferences.

Another student further expressed discontentment with the way assessments were conducted:

Poor scheduling and time allocation of assessments also affected the participants negatively:

Overall, the authenticity of online assessments as a true reflection of learning was brought into question:

Some participants felt disadvantaged by the time constraints of online assessments, where sequential questioning was employed:

Several students also reported feeling deprived of the opportunity to recheck their answers, as well the freedom to choose the order in which they attempt the questions in online-administered tests.

As a result, participants across all levels felt that online assessments results were not a true reflection of their knowledge or academic performance:

Another participant underscored the concerns with online assessments, suggesting that it does not support, measure, or represent true learning:

Discussion

This research set out to better understand optometry students’ experiences of online learning in the context of the COVID-19 pandemic, as well as the potential impact of this shift in learning context for students in clinical training programmes. Participants of all academic levels in this study faced similar challenges with online learning during the COVID-19 pandemic. These challenges centred around the practical needs of students having to adapt to a new way of learning, and the fact that online learning is technology-dependent, which posed a challenge in South Africa’s unequal socio-economic and inconsistent infrastructure context with respect to internet connectivity. Furthermore, being disengaged from traditional learning spaces highlighted the inherent value of social connectedness in supporting the learning process, and called into question the authenticity of virtual learning specifically with respect to assessments and assessment outcomes.

Online learning is technology-dependent learning because it is carried out in a virtual environment. In this study, first-year students felt more intimidated having to adapt to tertiary education via virtual means. They struggled to take responsibility for their learning, a concept relatively new to most of them because high school learners in South Africa are generally monitored and held accountable for attendance and participation in classroom activities, unlike the reality at university even under non-pandemic conditions. Azmat, Ahmad and Mater (2022) conducted a scoping review on the lack of social interaction in online classes during COVID-19, and based on their results, suggested that a lack of social interaction impacted the effectiveness of online learning.

While many students in this study had difficulty adapting to online learning, they found access to online lecture recordings, made available as part of the institution’s remote online learning strategy, advantageous because it afforded them the opportunity to learn at their own pace. However, majority sentiments towards online learning were that even in the context of a pandemic, virtual learning needs to be supported by contact learning in order to enhance the learning experience.

In other parts of the world, the integration of information technology in education has been widely embraced, with blended learning increasingly becoming an integral component of education programmes (Kanwal & Rehman 2017). This may, in part, be the result of more widespread access to the kinds of technology that enables online learning. Studies investigating barriers to online learning (Chigeza & Halbert 2014) reported internet connectivity, access to computers, technical issues and pedagogical approaches as significant challenges (Jones & Issroff 2005). Along with these barriers, unplanned power and network outages, as was the experience of students in this study, also affect students’ ability to connect to online learning platforms. It goes without saying that internet availability or accessibility is essential for students to be able to engage with online learning. Within the South African context, many of these resources are unreliable, which negatively affected students’ experiences during COVID-19 as reported in this study. Connectivity challenges were similarly identified as a barrier to learning in Pakistan, where power cut is also a serious problem (Kanwal & Rehman 2017).

The reality of remote online learning during the pandemic meant that social aspects that support learning in a traditional context were often absent. Reports from the participants of this study confirm that learning is a social activity. Where learning occurs in interaction with others the overall learning experience is enhanced, in keeping with the findings by Hrastinski (2009). It is not surprising, therefore, that most participants in this study demonstrated a negative attitude towards online learning during COVID-19, which in part, was because of their feeling isolated from their usual learning support network. This is further supported by the findings of Baber (2021) that social interaction has a positive, significant impact on the effectiveness of online learning. COVID-19 restrictions on physical interaction between students and their teachers therefore lead to a sense of isolation, with some participants indicating that they would better retain content if they were exposed to face-to-face lectures instead of online. Dominant factors that create an enabling learning environment have been observed as educator’s presence in online settings, interaction between students and teachers, content taught and connections between online and offline activities, among others (Moule, Ward & Lockyer 2010).

One positive aspect of the COVID-19 online learning experience was students’ flexibility while learning from home, such as being able to do the work in their own time because they were able to access lecture recordings anytime. Regarding assessments, participants reported needing sufficient time to understand a question before attempting an answer: a reality they were not afforded during online assessments. When adequate time for taking assessments is compromised, as was the experience of participants in this study, students feel stressed and overwhelmed, similar to findings from other studies (Suresh, Priya & Gayathri 2018). As a result, some participants in this study felt that online assessments were not a true reflection of their learning, suggesting that students did not fully understand the content taught online despite being able to achieve positive assessment results. This is against the principle of ‘assessment for learning’.

Additional findings from this study were that a lack of exposure to the clinical setting, as well as access to real patients as a result of lockdown regulations negatively impacted students’ clinical competency development as well as hands-on familiarity with clinical equipment. This is in keeping with the theory of online learning, which argues that this type of learning is most effective when supported by physical tools that are used to produce knowledge (Hrastinski 2009). Virtual simulation makes students feel as if they lack critical knowledge, resulting in a lack of confidence in the clinical environment (Acosta et al. 2018). Participants in this study were rightfully concerned that they did not get adequate exposure to real patients with genuine eye problems because of COVID-19. Similar findings emerged from a study by Bączek et al. (2021), where other health science students in Poland complained of a lack of interaction with patients, which negatively impacted skills development. Despite differing preferences among participants in this study most of them reported that they would choose contact learning over online classes when given the choice, as it facilitates a more rich, authentic learning experience.

Conclusion

The need for educational programmes to continue to deliver teaching and learning in the face of a global pandemic poses several challenges for low- and middle-income countries, which may not be ‘pandemic-ready’ in terms of being able to swiftly shift to online learning without compromising students’ learning experiences. The results of this study indicate that where students face challenges accessing the necessary learning technologies, this could have serious consequences for learning. To avoid any potential negative impact on learning and competency development in clinical programmes specifically, key resources for engaging in the ongoing educational project must be addressed. These include reliable and available access to the internet along with devices such as smartphones or computers. Furthermore, where simulation software or virtual alternatives are available, these can be used to partially compensate for the lack of access to the clinical environment, which will support the development of essential clinical skills. Furthermore, when designing teaching and assessment activities, the authenticity of students’ learning should be foremost in mind. On a positive note, online learning appears to support students taking personal responsibility for their learning, which is important for the personal and professional development of health professionals. While this study focused specifically on optometry students in South Africa, the findings may also be relevant to other countries or health professions programmes in the developing world.

Acknowledgements

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

D.G., T.P., N.M., N.V., S.M., U.M., Z.M. and D.v.S. contributed to the research as well as the manuscript preparation, with D.v.S. supervising the seven co-authors in this honours research project.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The dataset is retained by the researchers with any unique identifiers removed for confidentiality purposes.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

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Original Research

Optometry students’ experience of online learning during the COVID-19 pandemic

Davina Govender, Tarryn Pillay, Nandipha Maci, Nokukhanya Vilakazi, Snenkosi Mthethwa, Umar Mansoor, Zweli Manquzi, Diane van Staden

Abstract

Introduction

Methods

Ethical considerations

Results

Theme 1: Learning how to learn online

Subtheme 1.1: A new way of learning

Subtheme 1.2: If it’s to be, it’s up to me!

Theme 2: Technology dependent

Theme 3: Need for social support

Theme 4: Authentic learning

Subtheme 4.1: Clinical training with no clinics

Subtheme 4.2: Student-centred teaching, learning approach and assessment

Discussion

Conclusion

Acknowledgements

Competing interests

Authors’ contributions

Funding information

Data availability

Disclaimer

References