Introduction

The Coronavirus disease-19 (COVID-19) pandemic resulted in substantial changes worldwide with its impacts on economy, social life, and education and especially on the health system (1). Countries had to take measures to contain the spread of the virus and to protect public health. The measures taken in education during the pandemic affected all levels of the education system, from pre-school to higher education (1,2). Closing schools to prevent the spread of infectious diseases by breaking the chain of transmission in children and hence in the community is often thought of as an option to contain flu epidemics (3). Indeed, many countries decided to temporarily close schools, universities and other educational institutions during the COVID-19 pandemic (4,5). Academic institutions, like many others, adapted all lectures, meetings and other face-to-face seminars to online teaching to ensure their and students’ safety (6,7). They proceeded to develop strategies to explore this new way of teaching, facilitate adaptation to changes, meet new emerging needs, and support educators and students to work with new technologies (8).

Distance education had to be implemented rapidly to manage the process effectively and to prevent students from experiencing problems such as delayed graduation and lost semester, both in our country and worldwide (9,10). Besides providing several advantages such as saving of time and space and the opportunity to review the lessons and reinforce learning, it caused considerable problems for teachers, students and administrators (11,12). Increased costs for schools and universities, weak infrastructure as well as unfamiliar problems such as inadequate digital teaching opportunities surfaced as barriers to this rapid transition. Some personal and professional problems also occurred among students and educators as adapting to the sudden transition to distance education required extra effort (13,14). In particular, the educators had difficulty transferring the lessons in the curriculum they normally gave face-to-face to online format, finding alternative methods for applied lessons, and measuring and evaluating learning (8).

The advent of COVID-19 required schools to be innovative, flexible and respond quickly to maintain the education of students in the field of health because health sciences teaching required an education system based on theory and clinical practice and should support students’ cognitive, sensory, and psychomotor skills (8). The target here is therefore not only to acquire clinical skills and theoretical knowledge and but also to advance the acquired skills. Students should develop effective cognitive skills and professional competence, communication, decision-making and teamwork skills they will require as they provide healthcare throughout their professional lives (15). The students trained in health schools must therefore be equipped with expert, qualified and qualified knowledge since healthcare provision will directly affect human health. The measures and initiatives the managers of healthcare institutions will take will be decisive in preventing the current problems from causing negative consequences in the future. Thus, determining the current problems in distance education can provide guidance in making the necessary improvements and revisions. This study was carried out to determine the opinions of students in the field of health about distance education during the COVID-19 pandemic.

Methods

Study Design, Setting and Sample

This descriptive and cross-sectional study was carried out between June and July 2021. The study population covered all students (n=2518) attending classes at the Faculty of Health Sciences of a university in Istanbul. The minimum sample size was calculated as 224, with 95% confidence interval (α=0.05) and p=0.8 for ±5% sampling error. The sample included 476 students who agreed to participate in the study.

Data Collection

The data were collected online by sending the data collection tools to the university e-mail addresses of the students via Google Forms. A letter describing the purpose and scope of the study was also sent to students’ e-mail addresses. If willing to participate in the research, they first gave their consent on the informed consent page and were then provided with access to the data collection tools. Students who answered all questions were considered for the research.

Student Information Form

This form, which was prepared by the researchers in line with the literature (16-18), consisted of 14 questions about the sociodemographic characteristics of students and their experiences with distance education during the pandemic.

Student Opinions on Distance Education Survey

This form was also created by researchers based on the literature information (17,19,20) to determine the opinions of students studying in the field of health on distance education. It included 35 questions in two parts: Negative Opinions on Distance Education (19 questions) and Positive Opinions on Distance Education (16 questions). The questions in the form were answered as “yes”, “no” or “partly”.

Ethical Considerations

The permission of the COVID-19 Scientific Research Evaluation Commission under the Ministry of Health, General Directorate of Health Services was obtained before starting collecting data. In addition, ethical approval was given by the Biruni University Ethics Committee on 21 May 2021 (decision no: 2021/51-24).

Statistical Analysis

Statistical analysis were performed using the SPSS 23 software package. Descriptive statistics (percentage, mean, standard deviation) were used to evaluate the data, and the chi-square test was used for inter-group comparisons. Statistical significance was set at p≤0.05.

Results

Their mean age was 20.62±2.21. The majority were female (86.8%) and 2^nd year students (33.2%). Of the students 39.9% were studying in nursing and midwifery departments and 83.6% were living with their families (Table 1).

Most of them used computers while attending online lessons (74.4%) and did not have any problems with internet access (55.7%). Of them 34.2% had no difficulty in understanding the theoretical lessons, 46.6% participated in the laboratory lessons face to face, 38.7% did clinical practice and 48.3% had difficulties in understanding practical lessons. Of them 50.6% deemed the means the university offered to access distance education lessons sufficient, most (44.7%) did not want distance education to continue after the pandemic. Students reported that they were generally satisfied (49.1%) that the lessons were taught via distance education (Table 2).

Their negative opinions about distance education were “Face-to-face education is more useful than distance education” (65.1%), “Applied lessons given with distance education negatively affect my learning” (61.1%) and “I think I am more successful in face-to-face training” (55.5%), respectively. Their positive opinions about distance education were “I have the opportunity to listen to the parts that I missed or did not understand during the lessons” (93.1%), “I have the opportunity to listen to the lessons if I miss them.” (90.3%) and “I can attend lessons wherever there is internet access” (76.7%), respectively (Table 3).

There was a significant difference between the students’ grade and their satisfaction with the distance education provided (p<0.01). 1^st year students were more satisfied with distance education compared to the 2^nd, 3^rd and 4^th year students. No significant difference was found between the students’ age, gender, department, and their satisfaction with distance education (p>0.05) (Table 4). There was a significant difference between students’ gender and their opinions about the continuation of distance education after the pandemic (p<0.05). Male students’ opinions were more in favour of continuation of distance education after the pandemic compared to the female students. No significant difference was observed between students’ age, grade and department and their views on the continuation of the lessons with distance education (p>0.05).

Discussion

Natural disasters, biological problems and wars with their local and global negative impacts on human life have always existed throughout history. It is important to make distance education systems more efficient in keeping with the contemporary technological developments, especially to offer new technical progresses for applied lessons, so that educational activities may be sustained should any of these occur. The current pandemic has provided an opportunity in the form of an inevitable experience to identify deficiencies and faults of the distance education system (21).

Having high satisfaction and successful experiences with distance education can contribute to developing a positive attitude towards distance education by enabling learning efficiency (22,23). In our study, students’ most positive opinions on the Student Opinions on Distance Education Survey were “I have the opportunity to listen to the parts that I missed or did not understand during the lessons”, “I have the opportunity to listen to the lessons if I miss them” and “I can attend lessons wherever there is internet access”, respectively. The students also expressed as positive comments that they improved their knowledge and skills in computer use, were able to save time, found distance education more economical, and had the opportunity to listen to lessons in a comfortable environment at home. The topics in which students expressed the most negative opinions about distance education were “Face-to-face education is more useful than distance education”, “Applied lessons given with distance education negatively affect my learning” and “I find it very boring to be in front of the computer all the time”, respectively. In a similar study by Dinç and Erdoğan (24) evaluating the opinions of nursing students regarding distance education during the COVID-19 pandemic, the most important problems the students in distance education had were technology-related and technical problems, problems with lessons and exams, and personal problems related to learning types. Students expressed the possibility of re-accessing the lessons as an important advantage and the inability to conduct clinical/laboratory practice and the ineffectiveness of the lessons as the most important disadvantages of distance learning (24).

Students’ attitudes towards distance education during the COVID-19 pandemic appeared to be positive in some studies in the literature (17,25-27). Students described it as advantageous given the circumstances caused by the pandemic, but they also believed that the disadvantages of distance education posed a serious problem for educational activities (28,29). Students found distance education advantageous because it was a precaution against the risk of face-to-face education, offered a time-space advantage and provides equal opportunity in education but also considered it disadvantageous because it eliminated the advantages of face-to-face education (effective communication, social environments, obligation to attend lessons, effective learning) and physical conditions were not sufficient (21). The students believed that online learning limited the consequences of social contact, saved money and energy in transportation to university, and provided an easier learning method, but they also mentioned disadvantages such as the need for technical tools, absence of direct contact with the lecturer/staff, difficulty to provide a quiet environment at home while taking online lessons and more absenteeism compared to traditional education (30). The majority of students thought that their social life came to a halt temporarily during the pandemic. They wanted to follow their lessons remotely due to the pandemic but believed that the exams in the distance education system did not help improve their competencies and they did not want distance education to continue under normal conditions (28). The students found distance learning inefficient for practical lessons and efficient for theoretical lessons, and they were not very content with it due to the lack of mutual communication. The lack of question-answer opportunity in distance education and problems in logging into the system caused negative reactions by the students, while positive reactions were about the opportunity to watch lessons again regardless of time and place (29). The problems that nursing students experience in distance education were related to the problems in the distance education infrastructure of the university, lack of face-to-face education, limited opportunities, and the mood and exam anxiety brought about by the pandemic (10). According to Yılmaz et al. (31), laboratory and practice limitations might negatively affect the efficiency of the lessons in transforming theoretical knowledge into skill in clinical practice lessons. Students’ opinions on distance education may depend on several factors such as the technological infrastructure facilities of the institutions, whether lecturers and students can use technology, educator interactions with students, and technical means or problems of the students. The technological infrastructure of the university where the study was conducted was suitable for distance education, which enabled a fast and successful transition to this process. Besides, synchronization of lessons, supportive attitudes of the lecturers and their openness to communication, and the ability of the institution managers to respond rapidly to these problems seemed to facilitate the process and contributed positively to student satisfaction.

In this study, the technological device the students used the most was computers. The studies conducted by Bakhov et al. (16), Kızıltepe and Kurtgöz (18) and Elfirdoussi et al. (32) obtained similar results. Some other studies, on the other hand, reported that smartphones were mostly used for online access during the COVID-19 pandemic (25,33). According to Şener et al. (34), nursing students could be distracted and lessons could be interrupted if they followed lessons with mobile phones, because of the smaller field of view compared to the computer and incoming messages and calls. Therefore, it is clearly important for students to log into online lessons from a computer for effective learning.

In our study, students stated that having practical lessons via distance education caused difficulties in understanding the lesson. The theoretical hours of the applied lessons were fully given online as part of the measures taken during the pandemic, but the students were required be present during clinical practice and laboratory lessons were held face-to-face, although the hours were reduced in many departments to avoid negative consequences. This seemed to have somewhat relieved students’ concerns about the application. Almahasees et al. (35) found in their study with faculty members and students that the majority of them preferred face-to-face education. In another study (36), the majority of students preferred the theoretical lessons to be conducted online whenever possible while they described face-to-face lessons as more beneficial in applied lessons. According to studies with nursing students, students regarded distance education methods as insufficient for laboratory and clinical applications, which were important components of nursing education (24,27). The reasons why students favoured face-to-face education included the advantages of instant feedback and more effective communication between students and teachers and the fact that certain skills were acquired in practical training. Although face-to-face education was mostly preferred in previous studies, distance education allowed the continuation of education and theoretical lessons (37). However, it was established during the pandemic that face-to-face education and clinical practices were indispensable in applied sciences. Online learning was implemented as a temporary alternative due to COVID-19 and was unlikely to replace face-to-face learning (35). Still, distance education is seen as a necessity in the age of information and technology with increasing prevalence of digitalization.

According to this study, there was a significant difference between the students’ satisfaction with distance education with their grade years. The 1^st year students were more satisfied with the distance education compared to 2^nd, 3^rd and 4^th year students. This difference may be explained by the different knowledge level and set of skills that students at each grade level have. Durgun et al. (26) found different results in their study examining students’ opinions on distance education where the Student Opinions on Distance Education Survey mean score was the lowest in the 1^st and the highest in the 3^rd year students, with a statistically significant difference between the mean scores of these two groups. This finding of the study was attributed to the fact that 1^st year students had inadequate knowledge in both theoretical and applied lessons and might think that they would not feel competent when they moved to the next grade (26). Another study (38) on the experiences and opinions of higher education students on distance education during the COVID-19 epidemic also reported different results compared to this study: 1^st year students found distance education less useful and less interesting than the students in other grade levels. Students in the 3^rd and 4^th years are more experienced than 1^st and 2^nd year students and know what is expected of them in terms of learning outcomes. Since 1^st year students are at the beginning of a new education, they need to make more efforts to adapt to the learning process. The authors concluded that 1^st and 2^nd year students might need more support than the 3^rd and 4^th year students when switching to distance education (38). There were many studies in the literature showing that students’ attitudes towards distance education did not differ significantly by their grade level (14,24,39).

In the current study, female and male students differed significantly in their opinions on whether lessons should still be via distance education after the pandemic: male students wanted distance education to continue after the pandemic more than female students. There was, however, no significant difference between students’ satisfaction with distance education by age, gender and department variables. The results of the previous studies indicating that gender (14,26,39) and age (14) were not significantly correlated with distance education satisfaction were similar to the results of this study. On the other hand, there were also study results suggesting significant relationships between age (24,40), gender (40-42) and department (43) and student opinions on distance education unlike this study. Comparing students’ views on distance education by gender, it was concluded that male students had more positive opinions on distance education (40,41,43). We are in the opinion that the higher level of satisfaction of male students can be explained by their higher technological literacy level than that of female students (42).

Study Limitations

The study was limited to the students who were studying at the faculty where the research was conducted and who agreed to participate in the research. Therefore, the results could not be generalized to the whole population. In addition, these findings were obtained from student self-reports and not all students were included. The strength of the study was that it included the experiences from the beginning of the changes in the education system to normalization within the scope of the measures taken in the COVID-19 pandemic, and the use of the questionnaire that was prepared by the researchers after the pandemic. Previous related studies generally used data collection tools developed before COVID-19 and the studies were conducted while the pandemic was still ongoing.

Conclusion

Based on the study, the students did not experience significant problems with distance education during the COVID-19 pandemic and benefited from the advantages of distance education. They thought that face-to-face education was more beneficial than distance education during the pandemic, and that having practical lessons with distance education affected their learning negatively. A great majority of the students expressed that they had the opportunity to listen or repeat the lessons if they missed or when there were parts they did not understand, and that they could attend the lessons wherever there was internet access. Half of the participants deemed the means offered by the university for access to lessons sufficient. Most of them had difficulties in understanding the practical lessons with distance education and did not want the lessons to continue with distance education after the pandemic. The students participated more in laboratory lessons than clinical practice in this process. The 1^st year students reported the most satisfaction with distance education, while male students wanted to continue distance education more than female students after the pandemic.

It is always important to be prepared for distance education for the sustainability of education. Also, establishing large-scale simulation laboratories for applied lessons, evaluating student opinions on a department basis, and continuing to benefit from the advantages of distance education may be important in increasing the quality of education and student satisfaction. We suggest that further studies be conducted on the students who received education during the pandemic to examine the opinions on the positive and negative aspects of distance education after graduation.

Ethics

Ethics Committee Approval: In addition, ethical approval was given by the Biruni University Ethics Committee on 21 May 2021 (decision no: 2021/51-24).

Informed Consent: Obtained.

Peer-review: Externally peer reviewed.

Authorship Contributions

Surgical and Medical Practices: G.K., A.K., N.K.B., Concept: G.K., A.K., N.K.B., Design: G.K., A.K., N.K.B., Data Collection or Processing: G.K., A.K., N.K.B., Analysis or Interpretation: G.K., A.K., N.K.B., Literature Search: G.K., A.K., N.K.B., Writing: G.K., A.K., N.K.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.