Medical Educator’s Attitudes and Experiences of Teaching Clinical Skills Online to Undergraduate Medical Students: Learning from COVID 19 and Future Implications

Medical Educator’s Attitudes and Experiences of Teaching Clinical Skills Online to Undergraduate Medical Students: Learning from COVID 19 and Future Implications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medical Educator’s Attitudes and Experiences of Teaching Clinical Skills Online to Undergraduate Medical Students: Learning from COVID 19 and Future Implications Ziqiao Qi, Wajeeha Aziz, Ceri Butler This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4629892/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Traditional hands-on instruction of clinical skills in undergraduate medical education faced a paradigm shift with the emergence of COVID-19. Online teaching through virtual learning environments swiftly replaced traditional methods, necessitating an urgent reassessment of clinical skills education. Despite this, a knowledge gap persists regarding the effective delivery and integration of online clinical skills teaching within established medical curricula. This study investigated UK based medical educators and their experiences teaching clinical skills in an online environment enforced by social distancing. From these results we aimed to better understand how aspects of online teaching can be strategically employed within the current landscape of medical education to optimize practical skills acquisition. Methods: A cross-sectional study design employing a survey with closed and open-ended questions was utilized. The survey was hosted through the online survey platform EU Qualtrics and approved by the Education Leads Advisory Group of the Medical Schools Council for further distribution to medical educators. The results were analysed by frequency of answers with accompanying thematic analysis. Results: This study gathered responses from 22 medical educators of various seniority across 11 UK universities. Educators had low levels of knowledge regarding pre-COVID-19 online teaching. During the pandemic, sessions were often conducted remotely, with F2F teaching resuming under strict measures. Educators believed that online teaching, particularly for non-practical skills, offered engagement and flexibility. While the majority preferred a blended approach, there was hesitation in completely replacing F2F teaching. Educators expressed a strong belief in F2F as the most effective means of skills teaching, emphasizing the importance of supervision and hands-on practice. Despite uncertainties, educators acknowledged the benefits of online learning, emphasizing the need for proper resources and training for successful integration into clinical skills teaching. Conclusion: While there is preference for online teaching in non-practical skills, educators continued to express reservations about fully replacing F2F clinical skills teaching due to technological challenges and limited digital fluency. The overall preference among educators leaned towards a blended approaching utilising both modalities, harnessing benefits of online teaching such as flexibility while retaining the advantages of traditional methods. Online teaching synchronous asynchronous face-to-face teaching COVID-19 medical educators clinical skills teaching practical skills blended learning. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Introduction Within the framework of medical curricula, the learning and teaching of clinical skills remain a critical component in undergraduate medical education. Studies have found that clinical skills incompetency can compromise patient safety(1), while heightened competency correlates with reduced healthcare costs, patient morbidity, and mortality rates (2). Acknowledging this, the General Medical Council highlights the significance of robust clinical skills training within medical curricula(3). Traditionally, a “hands-on” approach through close contact small-group clinical skills teaching has been utilised in medical education (4). This approach facilitates guided practice and repetition, enabling students to hone their skills across diverse clinical scenarios (5). This, in combination with early clinical exposure, provides the necessary exposure to help students link theory to practice (6). In March 2020, the World Health Organization declared COVID-19 a global pandemic (7), prompting widespread social distancing measures (8). This significantly impacted medical education, particularly clinical skills training, traditionally reliant on close-contact small-group teaching(4). This shift prompted an urgent re-evaluation of clinical skills education which resulted in the rapid adoption of online teaching. Online teaching is an educational method utilising internet connection and technology to deliver training synchronously (e.g. video conferencing, interactive virtual classes) or asynchronously (e.g. multimedia resources) (see Figure 1). This modality addressed pre-existing challenges, including limited access to demonstrations and concerns regarding consistency (9). Asynchronous online learning, offering flexibility in both mode and location, overcame these challenges, with online clinical skills videos allowing for repeated viewings (10, 11). While sacrificing some flexibility, synchronous online learning provides personalized guidance and retains other benefits of remote education. This paradigm shift reflects the resilience and adaptability of medical education in response to unprecedented challenges. Despite the recent emphasis on online learning prompted by COVID-19, asynchronous teaching in higher education began in the mid to late 1990s in the US(13). However, online teaching remained relatively unpopular as one study found that most students and faculty felt face-to-face (F2F) teaching was better in terms of efficiency, interaction, and overall understanding and could not replace traditional instructor-led training (14). In the context of medical education, medical students did value the flexibility of online learning, but most felt it could not adequately convey practical skills or replace live clinical contact (15). Supporting this, one study found only 28.48% of medical students reported engagement in live online tutorials during COVID (15). Moreover, effective engagement with online learning requires IT proficiency from educators and learners and too much online learning leads to fatigue and disinterest (16, 17). These studies highlight the persistent challenges for students in transitioning to online clinical education, however, the views of educators were not explored in the literature. Therefore, a notable knowledge gap persists regarding the medical educator’s views and perspectives on effective delivery and integration of online clinical skills teaching within established medical curricula. Specifically, there is a need to understand how online teaching can be strategically employed within the current landscape of medical education to optimise practical skills acquisition (18). This study aimed to explore the perspectives and experiences of medical educators based in the UK reflecting on how practical clinical skills were delivered online in response to COVID. Furthermore, we considered how these skills can be taught online and the potential implications for the future of clinical skills education. 2. Methods We adopted a cross-sectional study design employing a semi-structured survey with closed and open-ended questions. Inclusion of open-ended questions enhanced our ability to grasp respondents' genuine feelings and attitudes, potentially uncovering insights beyond our initial expectations. However, recognising the increased effort associated with responding to open-ended questions, most remained multiple-choice questions to improve response rates and facilitate streamlined statistical analysis. The questionnaire comprised five distinct sections. The first section included the consent form and details about the respondent's institution. Subsequent sections were organized based on specific timeframes following the declaration of a nationwide lockdown in March 2020 due to COVID-19. In each section, the questions aimed to explore medical educators' opinions and followed the basic framework adapted from Lippitt et al:(19). Where were we? Where are we now? Where do we want to be? How do we get there? How will we know when we have got there? This survey was hosted through the online survey platform EU Qualtrics and approved by the Education Leads Advisory Group of the Medical Schools Council (ELAG) for further distribution to medical educators. Medical educators affiliated with UK medical schools actively engaged in either the teaching or planning of practical clinical skills education were included in the study. Individuals not involved in these activities were excluded from the study. Following the initial pilot, the survey was distributed to 41 UK medical schools listed by the Medical School Council (MSC). The results were analysed by simple frequency analysis using SPSS with accompanying thematic analysis of open-ended questions. Calculating a precise response rate was not feasible due to the unknown number of clinical skills educators in each medical school. Therefore, we used the number of medical schools that responded as a proxy. 3. Results 3.1 Respondent Characteristics From a total of 41 UK medical schools, this study gathered responses from 22 medical educators across 11 UK universities primarily from London, Kent, Surrey, Sussex, Cambridge, Scotland, and Northern Ireland. Roles varied among respondents which included (but were not limited to) Clinical Skills Educators, Senior Clinical Skills Educators, Heads of Clinical Skills, Directors of Education and Heads of Medical Schools. The majority (16/22) of responses came from those with senior positions i.e. those with additional leadership responsibilities other than solely teaching clinical skills. Table 1 Institutional roles of participants Role Number Clinical Skills Educator 7 Senior Clinical Skills Educator 5 Head Of Clinical Skills/Programme Directors 9 Head of School 1 Total 22 3.2 Perceived knowledge of, and experience in, online teaching pre-pandemic Educators considered their experiences of online teaching before March 2020. On a scale of 1 (not experienced) to 5 (very experienced), the average score was 1.96, indicating minimal pre-pandemic exposure to online instruction. 3.3 Shift to online teaching during COVID 3.3.1 Online Clinical Skills Teaching March 2020 – September 2020 Educators described a shift in clinical skills teaching during the first wave of the COVID-19 pandemic as shown in Fig. 2 . Four respondents from different schools reported that all clinical skills teaching was cancelled. Of those where skills teaching resumed, the most common adaptations included the remote delivery of synchronous sessions via platforms like Microsoft Teams and asynchronous online videos and tasks. Only four respondents reported a reinstatement of F2F teaching under strict protocols by implementing measures such as reduced class sizes, hygiene stations, and adherence to personal protective equipment (PPE) guidelines. Furthermore, 11 reported the use of hybrid/blended curricula where for instance, communication clinical/theoretical skills were taught online and practical skills were taught in person under strict social-distancing rules. Two taught clinical skills fully online. One of which was Barts and The London School of Medicine and Dentistry who used a mixture of video resources and synchronous sessions [16]. Notably, University College London Medical School innovatively employed synchronous online sessions, complemented by physical teaching resources sent out to all students to enable remote practical activities to take place using fruits and vegetables [7]. 3.3.2 Challenges and Benefits of Teaching Online Overall, most educators (67%) responded positively to the rapid adoption of online teaching with the rest feeling negative or neutral. Respondents emphasized the positive social aspects of online sessions, citing their ability to maintain connections and social bonds “…with their peers and tutor during a time of great uncertainty.” [9] There were technical difficulties reported alongside the challenges of replicating hands-on experiences, particularly with specialized equipment such as ophthalmoscopes. The remote nature of online teaching and limited supervision proved challenging for the staff to assess student learning, accuracy, and proficiency. However, teaching communication skills and history-taking exercises online were regarded as successful by respondents. This highlighted the potential for online teaching being “ excellent for developing communication skills as video consults which is now common practice in general practice. ” [17] This highlighted a real-world scenario where teaching online may bring greater benefits than F2F. Table 2 Challenges and Benefits of teaching online as reported by medical educators. Some responses have been paraphrased for the points to remain succinct. Challenges Benefits Staff were new to software which led to technological issues in quality and engagement [3] The social aspect of connecting with each other was positive. Students commented that they did not feel like they were missing out. [7] Faculty had difficulty navigating Microsoft teams [5] F2F sessions were more focused due to less theoretical teaching being done online. [8] Poor Wi-Fi connectivity and student visualisation [7] Students were able to practice something (rather than nothing) and maintain connections and a social bond. [9] Some skills were difficult to teach online without specialist equipment. [9] History taking exercises in breakout rooms worked well as well as remote hand washing sessions. [12] We (educators) couldn’t directly observe student technique e.g. ophthalmoscopy. [20] Excellent for developing communication skills with video consults becoming increasingly more common. [17] Students preferred F2F teaching [25] 3.4 Online teaching Post Covid COVID-19 3.4.1 September 2020 onwards From the start of the new academic year 2020/21, 60% of respondents reported incorporating online teaching for clinical skills to some extent. However, only 5% continued to teach exclusively online, with the majority opting for a blended approach of F2F and online teaching. 3.4.2 Advantages of online teaching over F2F teaching Respondents were asked to consider the advantages of online teaching compared to F2F instruction. As indicated in Fig. 3 , 30% felt that online teaching offered creative ways for formative assessments. 33% of respondents chose to provide their comments under the ‘other’ category. Amongst these responses, respondents reported that online teaching, often perceived as inferior, highlighted the importance of topics taught during infrequent face-to-face sessions, aiding students in concentrating their efforts effectively. Additionally, flexibility enabled the efficient delivery of theoretical content preceding practical application, expediting students' progress to the practical stage. Furthermore, an online environment was noted to alleviate pressure for students hesitant to speak up in social settings, encouraging increased participation and questioning. However, most respondents also found the opposite, such that many students were less inclined to contribute. “ Any online teaching that occurs requires a greater sense of involvement from students to share anything they might need help with. It is very easy for certain students not to contribute .” [5] 3.4.3 Competency from online clinical skills teaching Figure 4 shows that the majority of respondents (65%) disagreed with the statement that "online teaching alone can achieve competency." While many acknowledged online teaching's effectiveness for communication skills, clinical reasoning, and theoretical foundations, they emphasized the necessity of F2F instruction, supervision, and practice for honing practical and interpersonal skills to achieve full competency: “To become competent in a practical skill you need to be able to carry that skill out practically a number of times.” [14] “Skill acquisition by definition needs to be practised, and individual feedback needs to be provided.” [10] 3.4.4 Preferences for teaching modality 50% of respondents reported that they would prefer a "sometimes online" teaching modality, while 30% opted for "never online," and 20% favoured "majority-fully online." Those preferring “sometimes online” saw the benefit of online instruction for non-practical elements. This preference was partially attributed to cost efficiency and the capacity to reach larger student cohorts simultaneously. However, they reiterated the essential role of F2F teaching in providing repetition and the feedback necessary to fully master practical procedures. Moreover, some expressed concerns about the difficulty of conducting online formative and summative assessments due to the lack of supervision, which could impede the development of a fully online curriculum. “ I feel that offering meaningful formative/summative assessment can be difficult as the learning of some clinical skills requires the teacher to observe interact steps.” [5] 3.5 The future of clinical skills teaching The majority of educators (89%) agreed that retaining some of the educational changes implemented in response to COVID for future teaching. This was primarily due to the perceived effectiveness of synchronous and asynchronous online sessions for theoretical knowledge and practical session preparation. For asynchronous sessions, respondents noted benefits such as “students complete these at their own pace prior to attending face-to-face sessions” [9]. However, some educators disagreed with continuing changes due to their discomfort with online teaching and concerns about student incompetence from online instruction. Figure 5 demonstrates that 90% of all respondents reported that they would prefer to see mostly F2F teaching with some online elements. These findings reaffirm previous findings, indicating educators' strong preference for F2F teaching. However, they also acknowledge the benefits of online learning, indicating a willingness to incorporate it as a supplement to future F2F teaching. Thinking about the future integration of online teaching for clinical skills, respondents were “cautiously optimistic”, less apprehensive about the unknown and more prepared for change as a result of their experiences during Covid. They reported the potential for online teaching to free up valuable classroom time and maximize practice time for skill consolidation. However, others emphasized the need for additional technology training and increased resources and funding as essential prerequisites for further integration. Lastly, some respondents saw the potential for online teaching in non-practical based education but remained heavily doubtful of any further integration of practical skills: “I think the integration of some online components to clinical skills teaching is exciting and could free up valuable time which could then be spent in the classroom with students.” [9] “… there may be some flexibility within the curriculum moving forwards .... students can do aspects online in their own time. A number of our regular clinical skills teachers were able to continue to teach online but would not in the F2F setting.” [26] 4. Discussion 4.1 Preference for blended learning While studies have explored health education adaptations during the COVID pandemic ( 15 , 20 ), the present study delves into the specific impact of teaching disruptions on clinical skills educators and their individual experiences during this period. Specifically, it addresses the respondents’ perceptions of the effectiveness and impact of educational interventions implemented in response to the pandemic ( 20 ). A significant finding of this study is the preference for a blended teaching approach over exclusive F2F or online methods. A substantial majority (89%) of educators expressed a desire to integrate elements of online teaching into future clinical skills instruction. This aligns with existing evidence indicating a significant preference for blended learning models for clinical skills acquisition ( 21 , 22 ), which other studies have demonstrated greater knowledge gained compared to either F2F or online modalities alone ( 23 , 24 ). One study conducted at University College London Medical School utilised a diverse, blended approach ( 25 ). They distributed procedural skills equipment kits to students' homes and conducted synchronous teaching sessions, which were praised for their interactive and creative nature ( 26 – 28 ). Findings from Kimmons et al may explain this such that leveraging students' creativity fosters greater creative problem-solving and deeper, contextualized learning, potentially surpassing both passive and interactive learning methods ( 29 ). These findings contrast with those of Kan et al., who employed a similar but asynchronous approach to facilitate hands-on practice for medical documentation ( 5 ). Students were given a pre-workshop assignment, e.g., to write a sample discharge summary which was then reviewed F2F. Asynchronous learning, while offering flexibility, is susceptible to distractions, delayed learning, and learner disengagement due to the absence of immediate feedback and social interaction( 30 ). Furthermore, when asynchronous learning is optional and supplementary to face-to-face or synchronous methods, it may be perceived as less essential. Therefore, students in this study may have concentrated less in the activities and failed to achieve adequate competency. There are, however, several benefits to asynchronous teaching. In our study, educators reported incorporating asynchronous learning by delivering theoretical aspects of clinical skills and preparatory lessons prior to F2F practical sessions. This approach highlighted the flexible, accessible and personalized approach to education, allowing students to study at their own pace thus improving productivity( 31 , 32 ). Some of our respondents have also used the asynchronous approach through video resources and pre-session reading to optimize the efficiency of skills acquisition, such that providing the contextual and theoretical knowledge in advance will allow more time for hands-on practice during F2F sessions. It is important to note that the increased freedom and lack of immediate feedback for students needs to be carefully mediated and supported to mitigate any potential disinterest and disengagement among learners. One way this has been done in the literature is through online discussion forums ( 33 ). Discussion forums are often used in asynchronous online teaching to allow educators to monitor student engagement by reviewing their posts and responses on the discussion board ( 33 , 34 ). Educators can also initiate discussions by posting thought-provoking and relevant prompts ( 33 ). Regardless, studies have found asynchronous learning to be more suitable for mature and self-directed students, although they did not specify if this also applies to practically taught clinical skills content ( 12 , 35 ). It is important to note when discussing the benefits and drawbacks of both synchronous and asynchronous teaching, that whilst findings have been observed across various educational contexts including the present study, their specific application within clinical skills teaching in the wider evidence base remains unexplored, indicating a gap in the current research. 4.2 Advantages for communication skills The efficacy of online teaching for communication skills, particularly history taking and consultation skills has been highlighted by this study. Some respondents utilised online simulation to replicate F2F consultations, where the student undertook a history taking or counselling scenario over live video. One respondent reflected on the increasing prevalence of online consultations in general practice due to social distancing measures. As the use of online consultations continues to grow, teaching to simulate these interactions become increasingly relevant to the healthcare landscape ( 36 , 37 ). Online medical simulation, employing digital technologies to replicate clinical scenarios, offers a safe environment for learners to practice patient care without impacting on patient safety( 38 ). Studies have shown that both synchronous and asynchronous simulations with virtual patients and environments enhance clinical skills and decision-making ( 39 , 40 ). The flexibility, instant feedback, and standardisation of training prepares learners for online consultations akin to face-to-face placements for clinical competency. Furthermore, akin to blended learning, combining online simulation with F2F teaching improves outcomes by offering standardized training in psychologically safe environments for learners prior to face-to-face activities ( 23 , 24 ). 4.3 Barriers to online clinical skills teaching While some respondents showed faith in the blended approach for its flexibility and adaptability in enhancing clinical skills teaching, many remain sceptical about online teaching as a replacement for F2F teaching. Research by Kan et al. on online clinical skills workshops for final-year medical students highlighted the limitations of online platforms in teaching hands-on procedures ( 5 ). They found that such skill could not be taught comprehensively via an online platform, suggesting that while online lessons can elucidate the cognitive reasoning behind clinical skills, they do little to address practical application. Similarly, Önöral and Kurtulmus-Yilmaz's recent study ( 21 ) in a related field concluded that online learning complements does not replace F2F teaching, echoing sentiments from participants in our study. These findings highlight significant drawbacks of online teaching that prevent educators from viewing it as a viable replacement. Many educators valued “hands-on” teaching and believe it to be the gold standard of skills education. In accordance to Bloom’s taxonomy ( 41 , 42 ), it is the physical practice that allows students to traverse the cognitive domain into the psychomotor domain and thereby consolidate skill ( 32 ). For instance, online learning fails to facilitate the development of muscular and neuronal pathways essential for fine motor control, which require extensive physical repetition and immediate error correction, all of which prove challenging to replicate virtually ( 43 , 44 ). Figure 6 is a flow chart demonstrating how Bloom’s Taxonomy could be in utilised in blended teaching for clinical skills practice. Educators can use each online, blended and F2F modalities to help guide learners across each domain. Another crucial consideration is the ramifications of inadequately taught clinical skills and skills incompetence, particularly given the intricate nature of many procedures and their impact on patient safety if performed incorrectly. This concern is echoed in the findings of Shih et al., who utilized Zoom for teaching ophthalmic clinical skills to second-year medical students ( 4 ). Educators from this study emphasized the risks that certain procedures posed if performed incorrectly, underscoring the necessity for thorough instruction that is best facilitated through F2F teaching, to ensure the safety of both the practitioner and the patient. It is essential to recognize that this primarily pertains to procedural clinical skills involving a physical component, and as stated previously, many educators believe online teaching can still effectively develop full competency in communication and online consultation skills. Lastly, this study highlights the persistent challenge of navigating technological barriers in online teaching, as reported by both educators and students. This finding aligns with previous research where educators expressed their concerns regarding widespread difficulties in achieving digital fluency ( 21 )(( 22 , 25 , 45 ). These challenges stem from various factors, including insufficient faculty development, technological issues with hardware and software, limited internet accessibility, and inadequate orientation to digital tools ( 46 , 47 ). When assessing how educators integrate technology within their teaching, we consider the 'Replacement, Amplification, Transformation (RAT)' axis of the PICRAT matrix ( 29 ). The objective being that technology should serve as a means to an end, not as an end itself ( 29 ). During the earliest stages of the pandemic, many educators quickly adopted online platforms as a direct substitute for F2F instruction, often without adapting their pedagogical methods. This approach, exemplified by delivering synchronous lectures via live conferencing software, where the lesson remained unchanged from its face-to-face variant in both content and delivery, underscored the unpreparedness of most health professions schools and institutions for the rapid transition to online learning. Consequently, both educators and learners encountered negative experiences, leading to perceptions that online education has inherent limitations, particularly regarding its ability to facilitate communication and connection and so should only be used in emergencies( 12 , 46 ). Nevertheless, with increased familiarity and skills, this study has demonstrated that technology has the potential to enhance or even transform pedagogical approaches. For instance, the distribution of procedural skills equipment kits to students' homes, which exemplifies a shift in both teaching methodology and modality to accommodate the online learning environment. 5. Conclusion This is the first study that has sought to identify the experiences and perceptions of medical educators towards online clinical skills teaching. During the early stages of the Covid pandemic, clinical skills educators quickly adapted to deliver teaching in a synchronous online capacity. There were mixed responses to this transition with educators reporting a preference for online and blended approaches for non-practical skills such as communication skills and theoretical knowledge as well as preparing students for online consultations. However, they also sought to retain F2F clinical skills teaching to counter technological challenges, limited digital fluency and lack of supervision. Furthermore, many were concerned over issues with student competency, which could have significant ramifications for patient safety. Moving forward, educators reported that a blended approach which harnessed the benefits of online teaching while retaining the advantages of traditional F2F methods would be the most appropriate modality for clinical skills teaching. In order to ensure the successful integration of online or blended teaching across the future medical education landscape, there is a need to realise benefits in digital fluency and the creative utilisation of technology. Abbreviations F2F = Face-to-face, MSC = Medical Schools Council, ELAG = Education Leads Advisory Group of the Medical Schools Council, Declarations Ethical Approval: This research project has been approved by the Brighton and Sussex Medical School Research Governance and Ethics Committee (RGEC) and the Medical School Council via the Education Leads Advisory Group (ELAG). Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available. Participants did not consent for any further use of data. Acknowledgements : We thank all the participants of the current study. We also acknowledge Brighton and Sussex Medical School for their invaluable support and contribution to this paper, which was originally conceptualised as a dissertation for an intercalated master’s degree in medical education. Funding : This article has not had any external funding. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Author information: Ceri Butler and Wajeeha Aziz Department of Medical Education, Brighton and Sussex Medical School Ziqiao Qi East Sussex NHS Healthcare Trust Author Contributions: ZQ and CB led the conceptualisation of the article, ZQ wrote the main manuscript in collaboration with CB and WA. All authors contributed to revising and approving the manuscript, with CB the guarantor of this work.All authors read and approved the final manuscript. References Fernández Alemán JL, Carrillo de Gea JM, Rodríguez Mondéjar JJ. Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students. Nurse Educ Today. 2011;31(8):866-71. Hibbert EJ, Lambert T, Carter JN, Learoyd DL, Twigg S, Clarke S. 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BMC Health Services Research. 2016;16(1):1-12. Gunner CK, Eisner E, Watson AJ, Duncan JL. Teaching webside manner: development and initial evaluation of a video consultation skills training module for undergraduate medical students. Med Educ Online. 2021;26(1):1954492. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. Jama. 2011;306(9):978-88. Kononowicz AA, Woodham LA, Edelbring S, Stathakarou N, Davies D, Saxena N, et al. Virtual patient simulations in health professions education: systematic review and meta-analysis by the digital health education collaboration. Journal of medical Internet research. 2019;21(7):e14676. Aubrey K, Riley A. Understanding & using educational theories2016. Bloom BS, Krathwohl DR, Masia BB. Taxonomy of educational objectives : the classification of educational goals. First edition ed. New York: David McKay Company; 1956. Seymour-Walsh AE, Weber A, Bell A, Smith T. Teaching psychomotor skills online: exploring the implications of novel coronavirus on health professions education. Rural Remote Health. 2020;20(4):6132. Dayan E, Cohen LG. Neuroplasticity subserving motor skill learning. Neuron. 2011;72(3):443-54. De Ponti R, Marazzato J, Maresca AM, Rovera F, Carcano G, Ferrario MM. Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students’ perception. BMC Medical Education. 2020;20(1):332. Schwartzman R. Performing pandemic pedagogy. Communication Education. 2020;69(4):502-17. Daniel M, Gordon M, Patricio M, Hider A, Pawlik C, Bhagdev R, et al. An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64. Medical teacher. 2021;43(3):253-71. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4629892","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321163614,"identity":"af21c582-0d29-4590-ade7-1d28a4e98b42","order_by":0,"name":"Ziqiao Qi","email":"","orcid":"","institution":"East Sussex Healthcare NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Ziqiao","middleName":"","lastName":"Qi","suffix":""},{"id":321163617,"identity":"167e1f88-f912-4931-b1b8-38cb1decc058","order_by":1,"name":"Wajeeha Aziz","email":"","orcid":"","institution":"Brighton and Sussex Medical School","correspondingAuthor":false,"prefix":"","firstName":"Wajeeha","middleName":"","lastName":"Aziz","suffix":""},{"id":321163618,"identity":"52eec985-3f2e-4a29-bf46-1b7b5ca43852","order_by":2,"name":"Ceri Butler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYFACHiAuYGDgl4CLsBGh5YABA4PkDJK1GNwgVgt/A+8x6Q8GNvnGt9ufbvzBYCfPIJGWgFeLxAG+NIkDBmmW2+6cMbvNw5Bs2CCRdgCvFgMGHjOglsMGZjdy2G4zMDAnMEikNxCj5b+B8Yz0Zzd/MNQTreWAgYFEgtkNHobDQC0EHCZxmC/Z4oxBsoEE2C8Gxw3beJ4l4NXC39578EZFhZ0B/+x2oMMqquX52dMM8GphYEZzJ+GIHAWjYBSMglFAGAAAQIM93YNy5tIAAAAASUVORK5CYII=","orcid":"","institution":"Brighton and Sussex Medical School","correspondingAuthor":true,"prefix":"","firstName":"Ceri","middleName":"","lastName":"Butler","suffix":""}],"badges":[],"createdAt":"2024-06-24 11:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4629892/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4629892/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60803696,"identity":"5b69a009-520e-48cc-a4ee-d9909f79f7b2","added_by":"auto","created_at":"2024-07-22 09:33:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":151692,"visible":true,"origin":"","legend":"\u003cp\u003eLearning Modalities demonstrated by overlapping Venn diagrams (Face-to-face, Online, Asynchronous, Synchronous) and examples of each modality such as PBL (Problem-based learning) and CBL (challenge-based learning) (12).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/35b8e94a39485a05999ff9a2.png"},{"id":60803697,"identity":"81e2aaf9-d11e-4342-ad87-c5ff12c38704","added_by":"auto","created_at":"2024-07-22 09:33:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17312,"visible":true,"origin":"","legend":"\u003cp\u003eTeaching modalities adopted by educators for clinical skills education during March 2020 – September 2020\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/0f0347fab17b8bd6fd3cc211.png"},{"id":60803700,"identity":"d467b278-6d31-429c-abb8-caee51d14fb1","added_by":"auto","created_at":"2024-07-22 09:33:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30187,"visible":true,"origin":"","legend":"\u003cp\u003eAdvantages of online teaching compared to F2F teaching.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/4455cf27fde0b8e194ab8565.png"},{"id":60803698,"identity":"5cec31f6-e88c-46fd-b416-31491d11a6f2","added_by":"auto","created_at":"2024-07-22 09:33:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22053,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants’ thoughts on whether online teaching alone can achieve full competency in performing clinical skills.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/11a9d2aece28407310773a34.png"},{"id":60804552,"identity":"709cf81f-305b-4a5b-9407-a32376d56d8e","added_by":"auto","created_at":"2024-07-22 09:41:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":33783,"visible":true,"origin":"","legend":"\u003cp\u003eEducators’ preferences on their ideal blend of teaching modalities.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/c5d764753bf6acf80af0ba6c.png"},{"id":60803699,"identity":"e9fe21ad-4a98-4ace-9722-9b9d8eab8c32","added_by":"auto","created_at":"2024-07-22 09:33:24","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":57082,"visible":true,"origin":"","legend":"\u003cp\u003eReferencing both the cognitive and psychomotor domains of Bloom’s taxonomy (42). To remember, understand and apply i.e. declarative knowledge can be learned through asynchronous, virtual means e.g. video resources, online pre-reading and pre-learning assessments. To analyse, evaluate and create represent procedural knowledge with the purpose of deep learning in mind, thereby requiring a more supported environment that can be provided in a synchronous or F2F environment. Educators can then provide knowledge in the context of experience to help nurture students to create new concepts and even begin to attempt imitation in clinical skills. Lastly, live clinical skills sessions can teach the students to articulate their psychomotor ability in a more precise and efficient manner. Each level of the domain can be individually tested and used for assessment.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/e3ebd744b07aa041c7db2f8a.png"},{"id":96363988,"identity":"7c1dbff0-b733-42ec-b0ef-a5109f351b02","added_by":"auto","created_at":"2025-11-20 10:08:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1087591,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4629892/v1/26453ee4-947b-444e-be3d-a9b3a8f2a595.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medical Educator’s Attitudes and Experiences of Teaching Clinical Skills Online to Undergraduate Medical Students: Learning from COVID 19 and Future Implications","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eWithin the framework of medical curricula, the learning and teaching of clinical skills remain a critical component in undergraduate medical education. Studies have found that clinical skills incompetency can compromise patient safety(1), while heightened competency correlates with reduced healthcare costs, patient morbidity, and mortality rates\u0026nbsp;(2). Acknowledging this, the General Medical Council highlights the significance of robust clinical skills training within medical curricula(3).\u003c/p\u003e\n\u003cp\u003eTraditionally, a “hands-on” approach through close contact small-group clinical skills teaching has been utilised in medical education\u0026nbsp;(4). This approach facilitates guided practice and repetition, enabling students to hone their skills across diverse clinical scenarios\u0026nbsp;(5). This, in combination with early clinical exposure, provides the necessary exposure to help students link theory to practice\u0026nbsp;(6). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn March 2020, the World Health Organization declared COVID-19 a global pandemic (7), prompting widespread social distancing measures (8). This significantly impacted medical education, particularly clinical skills training, traditionally reliant on close-contact small-group teaching(4). This shift prompted an urgent re-evaluation of clinical skills education which resulted in the rapid adoption of online teaching. Online teaching is an educational method utilising internet connection and technology to deliver training synchronously (e.g. video conferencing, interactive virtual classes) or asynchronously (e.g. multimedia resources) (see Figure 1). This modality addressed pre-existing challenges, including limited access to demonstrations and concerns regarding consistency (9). Asynchronous online learning, offering flexibility in both mode and location, overcame these challenges, with online clinical skills videos allowing for repeated viewings (10, 11). While sacrificing some flexibility, synchronous online learning provides personalized guidance and retains other benefits of remote education. This paradigm shift reflects the resilience and adaptability of medical education in response to unprecedented challenges.\u003c/p\u003e\n\u003cp\u003eDespite the recent emphasis on online learning prompted by COVID-19, asynchronous teaching in higher education began in the mid to late 1990s in the US(13).\u0026nbsp;However, online teaching remained relatively unpopular as one study found that most students and faculty felt face-to-face (F2F) teaching was better in terms of efficiency, interaction, and overall understanding and could not replace traditional instructor-led training\u0026nbsp;(14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the context of medical education, medical students did value the flexibility of online learning, but most felt it could not adequately convey practical skills or replace live clinical contact\u0026nbsp;(15). Supporting this, one study found only 28.48% of medical students reported engagement in live online tutorials during COVID\u0026nbsp;(15). Moreover, effective engagement with online learning\u0026nbsp;requires IT proficiency from educators and learners and too much online learning leads to fatigue and disinterest\u0026nbsp;(16, 17).\u0026nbsp;These studies highlight the persistent challenges for students in transitioning to online clinical education, however, the views of educators were not explored in the literature.\u003c/p\u003e\n\u003cp\u003eTherefore, a notable knowledge gap persists regarding the medical educator’s views and perspectives on effective delivery and integration of online clinical skills teaching within established medical curricula. Specifically, there is a need to understand how online teaching can be strategically employed within the current landscape of medical education to optimise practical skills acquisition (18). This study aimed to explore the perspectives and experiences of medical educators based in the UK reflecting on how practical clinical skills were delivered online in response to COVID. Furthermore, we considered how these skills can be taught online and the potential implications for the future of clinical skills education.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWe adopted a cross-sectional study design employing a semi-structured survey with closed and open-ended questions.\u0026nbsp;Inclusion of open-ended questions enhanced our ability to grasp respondents' genuine feelings and attitudes, potentially uncovering insights beyond our initial expectations. However, recognising the increased effort associated with responding to open-ended questions, most remained multiple-choice questions to improve response rates and facilitate streamlined statistical analysis.\u003c/p\u003e\n\u003cp\u003eThe questionnaire comprised five distinct sections. The first section included the consent form and details about the respondent's institution. Subsequent sections were organized based on specific timeframes following the declaration of a nationwide lockdown in March 2020 due to COVID-19. In each section, the questions aimed to explore medical educators' opinions and followed the basic framework adapted from Lippitt et al:(19).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhere were we?\u003c/li\u003e\n \u003cli\u003eWhere are we now?\u003c/li\u003e\n \u003cli\u003eWhere do we want to be?\u003c/li\u003e\n \u003cli\u003eHow do we get there?\u003c/li\u003e\n \u003cli\u003eHow will we know when we have got there?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis survey was hosted through the online survey platform EU Qualtrics and approved by the Education Leads Advisory Group of the Medical Schools Council (ELAG) for further distribution to medical educators. Medical educators affiliated with UK medical schools actively engaged in either the teaching or planning of practical clinical skills education were included in the study. Individuals not involved in these activities were excluded from the study. Following the initial pilot, the survey was distributed to 41 UK medical schools listed by the Medical School Council (MSC). The results were analysed by simple frequency analysis using SPSS with accompanying thematic analysis of open-ended questions. Calculating a precise response rate was not feasible due to the unknown number of clinical skills educators in each medical school. Therefore, we used the number of medical schools that responded as a proxy.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Respondent Characteristics\u003c/h2\u003e \u003cp\u003eFrom a total of 41 UK medical schools, this study gathered responses from 22 medical educators across 11 UK universities primarily from London, Kent, Surrey, Sussex, Cambridge, Scotland, and Northern Ireland. Roles varied among respondents which included (but were not limited to) Clinical Skills Educators, Senior Clinical Skills Educators, Heads of Clinical Skills, Directors of Education and Heads of Medical Schools. The majority (16/22) of responses came from those with senior positions i.e. those with additional leadership responsibilities other than solely teaching clinical skills.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInstitutional roles of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Skills Educator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior Clinical Skills Educator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead Of Clinical Skills/Programme Directors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead of School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Perceived knowledge of, and experience in, online teaching pre-pandemic\u003c/h2\u003e \u003cp\u003eEducators considered their experiences of online teaching before March 2020. On a scale of 1 (not experienced) to 5 (very experienced), the average score was 1.96, indicating minimal pre-pandemic exposure to online instruction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Shift to online teaching during COVID\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Online Clinical Skills Teaching March 2020 \u0026ndash; September 2020\u003c/h2\u003e \u003cp\u003eEducators described a shift in clinical skills teaching during the first wave of the COVID-19 pandemic as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Four respondents from different schools reported that all clinical skills teaching was cancelled. Of those where skills teaching resumed, the most common adaptations included the remote delivery of synchronous sessions via platforms like Microsoft Teams and asynchronous online videos and tasks.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Only four respondents reported a reinstatement of F2F teaching under strict protocols by implementing measures such as reduced class sizes, hygiene stations, and adherence to personal protective equipment (PPE) guidelines. Furthermore, 11 reported the use of hybrid/blended curricula where for instance, communication clinical/theoretical skills were taught online and practical skills were taught in person under strict social-distancing rules. Two taught clinical skills fully online. One of which was Barts and The London School of Medicine and Dentistry who used a mixture of video resources and synchronous sessions [16].\u003c/p\u003e \u003cp\u003eNotably, University College London Medical School innovatively employed synchronous online sessions, complemented by physical teaching resources sent out to all students to enable remote practical activities to take place using fruits and vegetables [7].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Challenges and Benefits of Teaching Online\u003c/h2\u003e \u003cp\u003eOverall, most educators (67%) responded positively to the rapid adoption of online teaching with the rest feeling negative or neutral. Respondents emphasized the positive social aspects of online sessions, citing their ability to maintain connections and social bonds \u003cem\u003e\u0026ldquo;\u0026hellip;with their peers and tutor during a time of great uncertainty.\u0026rdquo;\u003c/em\u003e [9]\u003c/p\u003e \u003cp\u003eThere were technical difficulties reported alongside the challenges of replicating hands-on experiences, particularly with specialized equipment such as ophthalmoscopes. The remote nature of online teaching and limited supervision proved challenging for the staff to assess student learning, accuracy, and proficiency.\u003c/p\u003e \u003cp\u003eHowever, teaching communication skills and history-taking exercises online were regarded as successful by respondents. This highlighted the potential for online teaching being \u0026ldquo;\u003cem\u003eexcellent for developing communication skills as video consults which is now common practice in general practice.\u003c/em\u003e\u0026rdquo; [17] This highlighted a real-world scenario where teaching online may bring greater benefits than F2F.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChallenges and Benefits of teaching online as reported by medical educators. Some responses have been paraphrased for the points to remain succinct.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChallenges\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenefits\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff were new to software which led to technological issues in quality and engagement [3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe social aspect of connecting with each other was positive. Students commented that they did not feel like they were missing out. [7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaculty had difficulty navigating Microsoft teams [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF2F sessions were more focused due to less theoretical teaching being done online. [8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Wi-Fi connectivity and student visualisation [7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents were able to practice something (rather than nothing) and maintain connections and a social bond. [9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome skills were difficult to teach online without specialist equipment. [9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory taking exercises in breakout rooms worked well as well as remote hand washing sessions. [12]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWe (educators) couldn\u0026rsquo;t directly observe student technique e.g. ophthalmoscopy. [20]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcellent for developing communication skills with video consults becoming increasingly more common. [17]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents preferred F2F teaching [25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Online teaching Post Covid COVID-19\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 September 2020 onwards\u003c/h2\u003e \u003cp\u003eFrom the start of the new academic year 2020/21, 60% of respondents reported incorporating online teaching for clinical skills to some extent. However, only 5% continued to teach exclusively online, with the majority opting for a blended approach of F2F and online teaching.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Advantages of online teaching over F2F teaching\u003c/h2\u003e \u003cp\u003eRespondents were asked to consider the advantages of online teaching compared to F2F instruction. As indicated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, 30% felt that online teaching offered creative ways for formative assessments.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e33% of respondents chose to provide their comments under the \u0026lsquo;other\u0026rsquo; category. Amongst these responses, respondents reported that online teaching, often perceived as inferior, highlighted the importance of topics taught during infrequent face-to-face sessions, aiding students in concentrating their efforts effectively. Additionally, flexibility enabled the efficient delivery of theoretical content preceding practical application, expediting students' progress to the practical stage. Furthermore, an online environment was noted to alleviate pressure for students hesitant to speak up in social settings, encouraging increased participation and questioning. However, most respondents also found the opposite, such that many students were less inclined to contribute.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eAny online teaching that occurs requires a greater sense of involvement from students to share anything they might need help with. It is very easy for certain students not to contribute\u003c/em\u003e.\u0026rdquo; [5]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Competency from online clinical skills teaching\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that the majority of respondents (65%) disagreed with the statement that \"online teaching alone can achieve competency.\" While many acknowledged online teaching's effectiveness for communication skills, clinical reasoning, and theoretical foundations, they emphasized the necessity of F2F instruction, supervision, and practice for honing practical and interpersonal skills to achieve full competency:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;To become competent in a practical skill you need to be able to carry that skill out practically a number of times.\u0026rdquo;\u003c/em\u003e [14]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Skill acquisition by definition needs to be practised, and individual feedback needs to be provided.\u0026rdquo;\u003c/em\u003e [10]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4 Preferences for teaching modality\u003c/h2\u003e \u003cp\u003e50% of respondents reported that they would prefer a \"sometimes online\" teaching modality, while 30% opted for \"never online,\" and 20% favoured \"majority-fully online.\" Those preferring \u0026ldquo;sometimes online\u0026rdquo; saw the benefit of online instruction for non-practical elements.\u003c/p\u003e \u003cp\u003eThis preference was partially attributed to cost efficiency and the capacity to reach larger student cohorts simultaneously. However, they reiterated the essential role of F2F teaching in providing repetition and the feedback necessary to fully master practical procedures. Moreover, some expressed concerns about the difficulty of conducting online formative and summative assessments due to the lack of supervision, which could impede the development of a fully online curriculum.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI feel that offering meaningful formative/summative assessment can be difficult as the learning of some clinical skills requires the teacher to observe interact steps.\u0026rdquo;\u003c/em\u003e [5]\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.5 The future of clinical skills teaching\u003c/h2\u003e \u003cp\u003eThe majority of educators (89%) agreed that retaining some of the educational changes implemented in response to COVID for future teaching. This was primarily due to the perceived effectiveness of synchronous and asynchronous online sessions for theoretical knowledge and practical session preparation.\u003c/p\u003e \u003cp\u003eFor asynchronous sessions, respondents noted benefits such as \u003cem\u003e\u0026ldquo;students complete these at their own pace prior to attending face-to-face sessions\u0026rdquo;\u003c/em\u003e [9]. However, some educators disagreed with continuing changes due to their discomfort with online teaching and concerns about student incompetence from online instruction.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e demonstrates that 90% of all respondents reported that they would prefer to see mostly F2F teaching with some online elements. These findings reaffirm previous findings, indicating educators' strong preference for F2F teaching. However, they also acknowledge the benefits of online learning, indicating a willingness to incorporate it as a supplement to future F2F teaching.\u003c/p\u003e \u003cp\u003eThinking about the future integration of online teaching for clinical skills, respondents\u003c/p\u003e \u003cp\u003ewere \u0026ldquo;cautiously optimistic\u0026rdquo;, less apprehensive about the unknown and more prepared for change as a result of their experiences during Covid. They reported the potential for online teaching to free up valuable classroom time and maximize practice time for skill consolidation. However, others emphasized the need for additional technology training and increased resources and funding as essential prerequisites for further integration. Lastly, some respondents saw the potential for online teaching in non-practical based education but remained heavily doubtful of any further integration of practical skills:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think the integration of some online components to clinical skills teaching is exciting and could free up valuable time which could then be spent in the classroom with students.\u0026rdquo; [9]\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip; there may be some flexibility within the curriculum moving forwards .... students can do aspects online in their own time. A number of our regular clinical skills teachers were able to continue to teach online but would not in the F2F setting.\u0026rdquo; [26]\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Preference for blended learning\u003c/h2\u003e \u003cp\u003eWhile studies have explored health education adaptations during the COVID pandemic (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), the present study delves into the specific impact of teaching disruptions on clinical skills educators and their individual experiences during this period. Specifically, it addresses the respondents\u0026rsquo; perceptions of the effectiveness and impact of educational interventions implemented in response to the pandemic (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA significant finding of this study is the preference for a blended teaching approach over exclusive F2F or online methods. A substantial majority (89%) of educators expressed a desire to integrate elements of online teaching into future clinical skills instruction. This aligns with existing evidence indicating a significant preference for blended learning models for clinical skills acquisition (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), which other studies have demonstrated greater knowledge gained compared to either F2F or online modalities alone (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne study conducted at University College London Medical School utilised a diverse, blended approach (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). They distributed procedural skills equipment kits to students' homes and conducted synchronous teaching sessions, which were praised for their interactive and creative nature (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Findings from Kimmons et al may explain this such that leveraging students' creativity fosters greater creative problem-solving and deeper, contextualized learning, potentially surpassing both passive and interactive learning methods (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These findings contrast with those of Kan et al., who employed a similar but asynchronous approach to facilitate hands-on practice for medical documentation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Students were given a pre-workshop assignment, e.g., to write a sample discharge summary which was then reviewed F2F. Asynchronous learning, while offering flexibility, is susceptible to distractions, delayed learning, and learner disengagement due to the absence of immediate feedback and social interaction(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Furthermore, when asynchronous learning is optional and supplementary to face-to-face or synchronous methods, it may be perceived as less essential. Therefore, students in this study may have concentrated less in the activities and failed to achieve adequate competency.\u003c/p\u003e \u003cp\u003eThere are, however, several benefits to asynchronous teaching. In our study, educators reported incorporating asynchronous learning by delivering theoretical aspects of clinical skills and preparatory lessons prior to F2F practical sessions. This approach highlighted the flexible, accessible and personalized approach to education, allowing students to study at their own pace thus improving productivity(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome of our respondents have also used the asynchronous approach through video resources and pre-session reading to optimize the efficiency of skills acquisition, such that providing the contextual and theoretical knowledge in advance will allow more time for hands-on practice during F2F sessions. It is important to note that the increased freedom and lack of immediate feedback for students needs to be carefully mediated and supported to mitigate any potential disinterest and disengagement among learners. One way this has been done in the literature is through online discussion forums (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Discussion forums are often used in asynchronous online teaching to allow educators to monitor student engagement by reviewing their posts and responses on the discussion board (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Educators can also initiate discussions by posting thought-provoking and relevant prompts (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegardless, studies have found asynchronous learning to be more suitable for mature and self-directed students, although they did not specify if this also applies to practically taught clinical skills content (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). It is important to note when discussing the benefits and drawbacks of both synchronous and asynchronous teaching, that whilst findings have been observed across various educational contexts including the present study, their specific application within clinical skills teaching in the wider evidence base remains unexplored, indicating a gap in the current research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Advantages for communication skills\u003c/h2\u003e \u003cp\u003eThe efficacy of online teaching for communication skills, particularly history taking and consultation skills has been highlighted by this study. Some respondents utilised online simulation to replicate F2F consultations, where the student undertook a history taking or counselling scenario over live video. One respondent reflected on the increasing prevalence of online consultations in general practice due to social distancing measures. As the use of online consultations continues to grow, teaching to simulate these interactions become increasingly relevant to the healthcare landscape (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnline medical simulation, employing digital technologies to replicate clinical scenarios, offers a safe environment for learners to practice patient care without impacting on patient safety(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Studies have shown that both synchronous and asynchronous simulations with virtual patients and environments enhance clinical skills and decision-making (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The flexibility, instant feedback, and standardisation of training prepares learners for online consultations akin to face-to-face placements for clinical competency. Furthermore, akin to blended learning, combining online simulation with F2F teaching improves outcomes by offering standardized training in psychologically safe environments for learners prior to face-to-face activities (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Barriers to online clinical skills teaching\u003c/h2\u003e \u003cp\u003eWhile some respondents showed faith in the blended approach for its flexibility and adaptability in enhancing clinical skills teaching, many remain sceptical about online teaching as a replacement for F2F teaching. Research by Kan et al. on online clinical skills workshops for final-year medical students highlighted the limitations of online platforms in teaching hands-on procedures (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). They found that such skill could not be taught comprehensively via an online platform, suggesting that while online lessons can elucidate the cognitive reasoning behind clinical skills, they do little to address practical application. Similarly, \u0026Ouml;n\u0026ouml;ral and Kurtulmus-Yilmaz's recent study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) in a related field concluded that online learning complements does not replace F2F teaching, echoing sentiments from participants in our study. These findings highlight significant drawbacks of online teaching that prevent educators from viewing it as a viable replacement. Many educators valued \u0026ldquo;hands-on\u0026rdquo; teaching and believe it to be the gold standard of skills education. In accordance to Bloom\u0026rsquo;s taxonomy (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), it is the physical practice that allows students to traverse the cognitive domain into the psychomotor domain and thereby consolidate skill (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). For instance, online learning fails to facilitate the development of muscular and neuronal pathways essential for fine motor control, which require extensive physical repetition and immediate error correction, all of which prove challenging to replicate virtually (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e is a flow chart demonstrating how Bloom\u0026rsquo;s Taxonomy could be in utilised in blended teaching for clinical skills practice. Educators can use each online, blended and F2F modalities to help guide learners across each domain.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnother crucial consideration is the ramifications of inadequately taught clinical skills and skills incompetence, particularly given the intricate nature of many procedures and their impact on patient safety if performed incorrectly. This concern is echoed in the findings of Shih et al., who utilized Zoom for teaching ophthalmic clinical skills to second-year medical students (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Educators from this study emphasized the risks that certain procedures posed if performed incorrectly, underscoring the necessity for thorough instruction that is best facilitated through F2F teaching, to ensure the safety of both the practitioner and the patient. It is essential to recognize that this primarily pertains to procedural clinical skills involving a physical component, and as stated previously, many educators believe online teaching can still effectively develop full competency in communication and online consultation skills.\u003c/p\u003e \u003cp\u003eLastly, this study highlights the persistent challenge of navigating technological barriers in online teaching, as reported by both educators and students. This finding aligns with previous research where educators expressed their concerns regarding widespread difficulties in achieving digital fluency (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)((\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). These challenges stem from various factors, including insufficient faculty development, technological issues with hardware and software, limited internet accessibility, and inadequate orientation to digital tools (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen assessing how educators integrate technology within their teaching, we consider the 'Replacement, Amplification, Transformation (RAT)' axis of the PICRAT matrix (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The objective being that technology should serve as a means to an end, not as an end itself (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). During the earliest stages of the pandemic, many educators quickly adopted online platforms as a direct substitute for F2F instruction, often without adapting their pedagogical methods. This approach, exemplified by delivering synchronous lectures via live conferencing software, where the lesson remained unchanged from its face-to-face variant in both content and delivery, underscored the unpreparedness of most health professions schools and institutions for the rapid transition to online learning. Consequently, both educators and learners encountered negative experiences, leading to perceptions that online education has inherent limitations, particularly regarding its ability to facilitate communication and connection and so should only be used in emergencies(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Nevertheless, with increased familiarity and skills, this study has demonstrated that technology has the potential to enhance or even transform pedagogical approaches. For instance, the distribution of procedural skills equipment kits to students' homes, which exemplifies a shift in both teaching methodology and modality to accommodate the online learning environment.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis is the first study that has sought to identify the experiences and perceptions of medical educators towards online clinical skills teaching. During the early stages of the Covid pandemic, clinical skills educators quickly adapted to deliver teaching in a synchronous online capacity. There were mixed responses to this transition with educators reporting a preference for online and blended approaches for non-practical skills such as communication skills and theoretical knowledge as well as preparing students for online consultations. However, they also sought to retain F2F clinical skills teaching to counter technological challenges, limited digital fluency and lack of supervision. Furthermore, many were concerned over issues with student competency, which could have significant ramifications for patient safety.\u003c/p\u003e \u003cp\u003eMoving forward, educators reported that a blended approach which harnessed the benefits of online teaching while retaining the advantages of traditional F2F methods would be the most appropriate modality for clinical skills teaching. In order to ensure the successful integration of online or blended teaching across the future medical education landscape, there is a need to realise benefits in digital fluency and the creative utilisation of technology.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eF2F = Face-to-face, MSC = Medical Schools Council, ELAG = Education Leads Advisory Group of the Medical Schools Council,\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e This research project has been approved by the Brighton and Sussex Medical School Research Governance and Ethics Committee (RGEC) and the Medical School Council via the Education Leads Advisory Group (ELAG).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets generated and/or analysed during the current study are not publicly available. Participants did not consent for any further use of data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e:\u0026nbsp;We thank all the participants of the current study. We also\u0026nbsp;acknowledge Brighton and Sussex Medical School for their invaluable support and contribution to this paper, which was originally conceptualised as a dissertation for an intercalated master’s degree in medical education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This article has not had any external funding.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/h3\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCeri Butler and Wajeeha Aziz\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Medical Education, Brighton and Sussex Medical School\u003c/p\u003e\n\u003cp\u003eZiqiao Qi\u003c/p\u003e\n\u003cp\u003eEast Sussex NHS Healthcare Trust\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZQ and CB led the conceptualisation of the article, ZQ wrote the main manuscript in collaboration with CB and WA. All authors contributed to revising and approving the manuscript, with CB the guarantor of this work.All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFern\u0026aacute;ndez Alem\u0026aacute;n JL, Carrillo de Gea JM, Rodr\u0026iacute;guez Mond\u0026eacute;jar JJ. Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students. Nurse Educ Today. 2011;31(8):866-71.\u003c/li\u003e\n\u003cli\u003eHibbert EJ, Lambert T, Carter JN, Learoyd DL, Twigg S, Clarke S. A randomized controlled pilot trial comparing the impact of access to clinical endocrinology video demonstrations with access to usual revision resources on medical student performance of clinical endocrinology skills. BMC medical education. 2013;13(1):1-10.\u003c/li\u003e\n\u003cli\u003eRubin P, Franchi-Christopher D. 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Medical teacher. 2021;43(3):253-71.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Online teaching, synchronous, asynchronous, face-to-face teaching, COVID-19, medical educators, clinical skills teaching, practical skills, blended learning. ","lastPublishedDoi":"10.21203/rs.3.rs-4629892/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4629892/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTraditional hands-on instruction of clinical skills in undergraduate medical education faced a paradigm shift with the emergence of COVID-19. Online teaching through virtual learning environments swiftly replaced traditional methods, necessitating an urgent reassessment of clinical skills education. Despite this, a knowledge gap persists regarding the effective delivery and integration of online clinical skills teaching within established medical curricula. This study investigated UK based medical educators and their experiences teaching clinical skills in an online environment enforced by social distancing. From these results we aimed to better understand how aspects of online teaching can be strategically employed within the current landscape of medical education to optimize practical skills acquisition.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA cross-sectional study design employing a survey with closed and open-ended questions was utilized. The survey was hosted through the online survey platform EU Qualtrics and approved by the Education Leads Advisory Group of the Medical Schools Council for further distribution to medical educators. The results were analysed by frequency of answers with accompanying thematic analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study gathered responses from 22 medical educators of various seniority across 11 UK universities. Educators had low levels of knowledge regarding pre-COVID-19 online teaching. During the pandemic, sessions were often conducted remotely, with F2F teaching resuming under strict measures. Educators believed that online teaching, particularly for non-practical skills, offered engagement and flexibility. While the majority preferred a blended approach, there was hesitation in completely replacing F2F teaching. Educators expressed a strong belief in F2F as the most effective means of skills teaching, emphasizing the importance of supervision and hands-on practice. Despite uncertainties, educators acknowledged the benefits of online learning, emphasizing the need for proper resources and training for successful integration into clinical skills teaching.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWhile there is preference for online teaching in non-practical skills, educators continued to express reservations about fully replacing F2F clinical skills teaching due to technological challenges and limited digital fluency. The overall preference among educators leaned towards a blended approaching utilising both modalities, harnessing benefits of online teaching such as flexibility while retaining the advantages of traditional methods.\u003c/p\u003e","manuscriptTitle":"Medical Educator’s Attitudes and Experiences of Teaching Clinical Skills Online to Undergraduate Medical Students: Learning from COVID 19 and Future Implications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-22 09:33:19","doi":"10.21203/rs.3.rs-4629892/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9609c76-ee64-479c-bb0b-3ea3759456a9","owner":[],"postedDate":"July 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T10:24:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-22 09:33:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4629892","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4629892","identity":"rs-4629892","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}