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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 301-304

Challenges in Teaching Palliative Care Module Virtually during COVID-19 Era

Faculty of Health Sciences, School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan

Date of Submission10-Jun-2020
Date of Acceptance07-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
MSc Khairunnisa Mansoor
School of Nursing and Midwifery, Aga Khan University, Karachi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apjon.apjon_42_20

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With the COVID-19 pandemic hitting the global community, routine activities of universities, offices, and industries have been hindered. People are being forced to rethink the ways of working virtually from home for providing education, business, and health services in this social distancing during the COVID era. This sudden shift also posed challenges of online teaching in a private university, in urban Karachi, Pakistan. The Aga Khan University, School of Nursing and Midwifery recently conducted an online palliative care module using a virtual learning environment and Microsoft Teams for Trainee Nurse Interns. Although the first experience of online teaching and learning was a successful venture for faculty and students, in a lockdown situation, numerous challenges were also encountered being a lower middle-income country. The issues of electricity shutdown, Internet connectivity, and quality assurance were anticipated on transition to online pedagogy, but backup plans were formed to make execution promising.

Keywords: COVID-19, palliative care module, virtual teaching

How to cite this article:
Cassum S, Mansoor K, Hirji A, David A, Aijaz A. Challenges in Teaching Palliative Care Module Virtually during COVID-19 Era. Asia Pac J Oncol Nurs 2020;7:301-4

How to cite this URL:
Cassum S, Mansoor K, Hirji A, David A, Aijaz A. Challenges in Teaching Palliative Care Module Virtually during COVID-19 Era. Asia Pac J Oncol Nurs [serial online] 2020 [cited 2021 Aug 5];7:301-4. Available from: https://www.apjon.org/text.asp?2020/7/4/301/295069

For online teaching to be successful and meaningful, the educational resources must be well structured, and the learning experiences must be intended to promote engaging interaction for learners.[1] Online learning or distance education was introduced in developed countries early, however lower middle-income countries have migrated to e-learning technology during COVID-19 breakdown, when many universities were shut down, and online education through digital technology was initiated. The World Economic Forum has reported that many universities in developed countries have adopted the transition to online teaching, smoothly and successfully offering more than 5000 online courses.[2] Online education uses a variety of synchronous (real time) and asynchronous (not real time, independent study articles, video- or audio-recorded PowerPoint sessions) strategies to connect with the participants.[3] Schools of nursing over the world have also incorporated the online education courses in their basic degree and advanced degree program to increase the opportunities for nursing students to continue their education.

Aga Khan University (AKU)[4] offers quality teaching in nursing, medicine, and education. During the past 30 years, the School of Nursing and Midwifery (SONAM) has moved from traditional, lecture-based, teacher-centered classrooms to blended and virtual platforms with the use of a high-fidelity simulation center to complement the skill-based teaching. Every year, Trainee Nurse Interns (TNIs) are offered the palliative and end-of-life care module, in a face-to-face format with a simulation-based activity in the Centre in Medical Innovation. TNIs are recent graduates of a 4-year baccalaureate nursing program who work as interns in the university-affiliated hospitals, as required by the Pakistan Nursing Council before appearing for the licensure examination. TNIs are expected to complete a specific number of continuous nursing education hours offered by the nursing education services in the hospital and TNI modular curriculum by the School of Nursing faculty. This year, with the pandemic, faculty had to alter the modality and offer online teaching for TNIs, as it was deemed necessary for TNIs to complete the curriculum theoretical hours of the internship. AKU-SONAM is based in a low-middle-income country with most of its students coming from resource-constrained families. Therefore, the team came across a set of information technology and resource problems attributing to the low-income nature of the country and other challenges that arise while living in a developing nation. However, it is important to note that these challenges arose in terms of online teaching because students were off campus and could not avail the university learning resource center, computer laboratories, Internet resources, and hostel facilities, where Internet access and connectivity issues are minimized.

  Guiding Framework Top

The faculty's guiding framework was Biggs 3P Model, which they used for creatively contextualizing this online endeavor.[5] Teachers had expertise of offering blended modules and the TNIs also had exposure to a virtual learning environment (VLE) (MOODLE) during their 4-year degree program. This perspective of the teachers' competence and the participants' characteristics acted as a strong indicator for the “presage” phase to initiate this endeavor. Next, the faculty started to “prepare” the learning outcomes, online assessment methods, and virtual teaching pedagogies for the palliative and end-of-life care module, and paired up with e-learning experts, and planned a quick training for all faculties in using MS-Teams. Finally, the “product,” i.e., module was digitally packaged in a HTML5 interactive software and shared with participants through the MOODLE platform, the existing VLE available at AKU.

  Successful Endeavor Top

The successful achievement of the module learning outcomes through online pedagogy reflected that the online module was prepared and executed with quality, promoted evidence-based learning, and created learner's engagement with peers, content, and facilitator. A total of 141 TNIs successfully connected from home, and accessed the module through university VLE, and used Microsoft Teams application for online synchronous classes. TNI accessed the palliative care module resources asynchronously and did self-study (MOODLE and H5P), whereas online lectures, student-led seminar, and virtual simulation were conducted through Microsoft Teams, followed by synchronous and timed online assessment from VLE. Numerous active learning pedagogies including reflective writing, self-assessment quizzes, online seminar, live lectures, voice-over PowerPoint, and virtual simulation were used to promote deeper learning.[6] The success of the online project was evaluated in a dual manner; assessment of learners' performance in online test and their feedback about the module. Of the 141 TNIs enrolled in the course, 130 of them successfully achieved 70% in the online test in the first attempt. Remaining TNIs took the retake examination after additional study days and gained the credit.

To gather learner's opinion about the quality of the palliative care module, TNIs were provided a link on VLE, whereby they wrote feedback about different learning activities in the module and rated each day's learning on a scale of “excellent” to “needs improvement.” Most TNIs rated the online module activities as good and felt that they can study at their own time, from home, and feel independent. As one TNI mentioned, “I like the electronic nature of the course because I can study them whenever I wish to.” Another TNI shared about the voice-over PowerPoint video, “The home health service slides were very interesting and it had information that we did not know about the service our hospital provides.” Overall, most TNIs shared that the palliative module helped them learn about palliative care concepts, whereas some felt that discussing the end-of-life care concepts triggered past experiences and melancholy, reviewing their attitudes toward palliative and end-of-life care concepts. One participant stated that “the virtual seminar on different assessment scales used in palliative care to measure pain, nausea, vomiting and other psychosocial domains was very informative and interactive, as every student in the small group participated and shared their perspective.” Another participant reported that “cultural consideration at the end of life care videos and online discussion forum was engaging.” Thirty percent of TNIs rated the module as excellent and felt engaged and accountable for their learning. One participant stated “virtual simulation on breaking bad news was new and engaging activity, as it gave a sense of realism in challenging our communication skills.” Majority (70%) of the participants felt that the course was delivered in a structured and organized manner and that they were able to complete the learning task efficiently. One TNI specified: “I learnt that in palliative care we should not only focus on physical issues but also spiritual and socio cultural to become holistic.” Another participant specified, “the communication challenge activity was most interesting activity, as it was conceptual and clinical based and the questions were tough to respond, but I learnt a lot.” Another TNI added, “I felt triggered by the self-awareness reflection activity as I never really thought about death and dying for myself before.” Thus, the success of the online module served as an example and became a boost for faculty to keep on working for online modality with blended pedagogy.

  Challenges and Backup Plans Top

Institutions registered with the Higher Education Commission mostly offer face-to-face conventional teaching, and the transition to digital teaching would not be without challenges, due to lack of online infrastructure access, limited access to devices, poor bandwidth, power failure, limited teacher and student technological readiness, as well as online course designing experiences[7],[8] Since this e-learning module was offered to TNIs while they were at their own home settings, technological and Internet issues were anticipated and encountered. Perhaps, if the university campus facilities were available (students' hostel, learning resource center, and computer laboratory), these issues would have been minimal:

  1. The most challenging problem faced by the participants and facilitators both was low Internet connectivity and bandwidth issues that became the source of immense interruption during the online classes. The online feedback from TNIs reported that approximately 43% of the participants experienced Internet and connectivity challenges at some point. The bandwidth issues and technological challenges are reported as one of the major challenges influencing faculty and student readiness to adopt online learning in lower middle-income countries.[8],[9] The faculty had already shared the backup plan with the participants. TNIs were suggested to keep their mobile data packages handy and to inform the facilitator through sending a short message system from their cell phones, when their Internet becomes poor or unstable. However, there was a limitation that some participants were not able to get mobile data packages due to lockdown and closure of shops. Moreover, those participants who were able to upgrade their data package found the modality expensive
  2. Another issue experienced was the frequent electricity fluctuation and shutdown in some parts of the city. Almost 10% of students missed online live classes due to power failure in their respective areas. To tackle this issue, a blend of asynchronous activities was included in the module such as faculty digital videos, online discussion forums, and article reviews. Those students who missed the live classes or virtual seminar were shared the recorded version from the MS-Teams to ensure completion of learning objectives
  3. The last and the most crucial issue was conducting online tests with academic integrity while participants were in their own settings. Study findings suggested that chances of student cheating are significantly high on web-based assessment.[10] To ensure legitimate online assessment, some measures were taken by faculty. The online test paper uploaded on VLE was password protected and time-bound. The online test was opened at a fixed time and 100% of the participants attempted the online test, with the results ranging between 61% and 95%. Each of them received shuffled questions and responses to negate their chances of discussions through phone calls. A mix of multiple-choice and short essay questions were included in the test, so only those familiar with the content could respond to questions in the time allocated. Furthermore, each question was based on a ratio of 1:1 (multiple-choice question:minute) which restricted participants to indulge in other resources for any assistance. All these measures were taken to ensure participants would take the test individually in an ethical manner.

  Conclusion Top

Despite the challenges, the participants and the facilitators both felt that offering the online module was an excellent intervention, in times of COVID-19 pandemic. Most nursing schools are looking forward to experiment online courses post lockdown and pandemic period to stay in business. Pakistani university administration needs to invest in enhancing the capacity building of their faculty and students to learn virtual tools and software available in their contextual locations. More action research on successful models of e-learning is needed to foster virtual programs in the low middle-income countries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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World Economic Forum: The COVID-19 Pandemic has Changed Education Forever. Available from: https://www.weforum.org/agenda/2020/04/coronavirus-education-global-covid19-online-digital-learning. [Last accessed on 2020 Jun 08].  Back to cited text no. 2
Alzahrani AA. The effect of distance learning delivery methods on student performance and perception. Int J Res Educ 2019;43:293-317. Available from: https://scholarworks.uaeu.ac.ae/ijre/vol43/iss1/12/. [Last accessed on 2020 Jun 08].  Back to cited text no. 3
Available from: https://www.aku.edu/academics/Pages/home.aspx. [Last accessed on 2020 Jun 08].  Back to cited text no. 4
Song J. Elements in MOOC-Based College English Learning Environment-Based on Biggs's 3P Model. In 4th International Symposium on Social Science (ISSS 2018). Atlantis Press; May 2018. https://dx.doi.org/10.2991/isss-18.2018.74. Available from: https://www.atlantis-press.com/proceedings/isss-18/25896228. [Last accessed on 2020 Jun 08].  Back to cited text no. 5
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Adnan M, Anwar K. Online learning amid the COVID-19 pandemic: Students' perspectives. J Pedagog Sociol Psychol 2020;2:(1)45-51. Available from: https://www.researchgate.net/publication/342371575_Online_learning_amid_the_COVID-19_pandemic_Students_perspectives. [Last accessed on 2020 Jun 08].  Back to cited text no. 7
Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013;11:4.  Back to cited text no. 8
Saeed H. Sindh Govt Notifies All Universities to Follow Its 6-Point Policy for Online. Available from: https://propakistani.pk/2020/04/17/sindh-govt-notifies-all-universities-to-follow-the-6-point-policy-for-online-classes/. [Last accessed on 2020 Jun 08].  Back to cited text no. 9
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