Letter Calling for Pre-Printing

This letter was submitted to the Editor of Perspectives in Medical Education.

Dear Editor,

In their 2018 article, Maggio et al.[1]highlight the benefits of preprinting manuscripts in preprint repositories, which include early discovery, access, and increased opportunities for feedback. Preprinting occurs when a manuscript is hosted in a web-based pre-repository prior to formal submission to a journal. However, our experience over the past 18 months reveals a great deal of confusion about preprinting and a lack of universal acceptance.

In 2020,we implemented a program designed to help faculty new to educational scholarship enhance their ability to disseminate their work. This program includes both peer coaches and a web-based preprint repository, known as the Journal of the Academy of Health Science Educators: A Preprint Repository, or JAHSE:PRE (https://jahse.med.utah.edu/). Indeed, we have found that peer coaching while preparing a manuscript followed by the chance to preprint that manuscript could be particularly helpful for early career scholars or faculty new to education scholarship[2].

While publishers in multiple fields are adopting preprinting [2], we have discovered a great deal of confusion about the pros and cons of preprinting as well as disparity in publishers’ policies regarding preprinting in the field of health professions education. In seeking to resolve this confusion, we sought to document preprint policies at 74 journals within health professions education (e.g. nursing, medicine,pharmacy, dentistry, rehabilitation sciences, nutrition). We culled preprint policies for 33 (45%) journals using journal websites or the List of academic publishers by preprint policy in Wikipedia)[3]. We then obtained information from email solicitations for an additional 27 (36%), leaving us without informationfor14 (19%). Of the 60 journals for which we have information, 45(75%) will review/accept preprinted manuscripts; 9 (15%) do not, and6 (10%) are unclear or make decisions on a case-by-case basis. No wonder there is confusion.

We encourage our colleagues across the health professions to join our call to eliminate this confusion by encouraging all of our journals in the field of health professions education to support and encourage preprinting. The value of preprinting has only become more important during the COVID-19 pandemic[4]. Being able to preprint scholarship prior to formal submission enhances formative review and revision, augments the benefits of peer coaching, and promotes higher quality publications. Preprinting also makes work available to others much more quickly, which can enhance collaboration and uptake of new ideas without compromising the eventual copyright of the final published product.


Members of the JAHSE:Pre Editorial Board

Nena Schvaneveldt, Nancy Lombardo, Eccles Health Sciences Library

Sara Hart, Kara Dassel, Rebecca Wilson, College of Nursing

Linda Tyler, College of Pharmacy

Staci McIntosh, College of Health

Candace Chow, Kathryn Moore, Janet Lindsley, Randy Jensen, Joanne Rolls, Angelo Giardino, Tim Farrell, Virginia Valentin, Boyd Richards, School of Medicine

Sara Lamb, Vice Dean for Education, School of Medicine

Wayne Samuelson, Dean of Medical Education, School of Medicine

Wendy Hobson-Rohrer, Associate Vice President for Health Sciences Education, UHealth

Impact of an Asynchronous Trainee-as-Teacher Curriculum on Teaching Self-Efficacy

A project submitted to the:
Division of Graduate Studies and Research of the University of Cincinnati
in partial fulfillment of the requirements for the degree of
From the Curriculum and Instruction program in the School of Education
In the College of Education Criminal Justice and Human Services (CECH)

By Kathleen Timme, MD
October 29, 2021
Boyd Richards, PhD
Robert Harper, EdD


Physicians are responsible for educating their patients, peers, and health professional learners.  Therefore, it is crucial for trainees to have opportunities to develop and hone teaching skills during training.  Resident-as-teacher curricula have developed in response to this need, but are largely classroom-based with limited opportunities to practice these valuable teaching skills.  In the midst of the COVID-19 pandemic and clinical demands that challenge the feasibility of live classroom-based learning experiences, there is a need for online asynchronous learning opportunities for trainees.  The aim of this study was to investigate the impact of an asynchronous online trainee-as-teacher curriculum on teaching performance and self-efficacy.  Resident physicians enrolled in an elective program featuring four online modules, real-life teaching experiences, and a reflective writing assignment. Participants completed a self-efficacy assessment before and after completion of the curriculum.  They also collected feedback forms from the individuals they taught during the teaching experiences.  We applied the qualitative methodology grounded theory in analyzing the written reflection.  Self-efficacy improved after program completion, with 100% of participants indicating that they felt comfortable teaching patients, colleagues/attendings at or above their level of training, and learners junior to themselves.  Teaching evaluations from patients and small group learners were also favorable.  Key themes from the qualitative portion of the study support that participants gained knowledge about health literacy, small group teaching, and clinical teaching.  This pilot study showed that an online asynchronous trainee-as-teacher program with opportunities for teaching practice and self-reflection fostered development of self-efficacy and improved teaching performance.



The ability to effectively teach is important for physicians to practice and master.  Physicians are not only responsible for educating their peers, the next generation of health care providers, and community members, but are also responsible for teaching patients.1,2  It has long been understood that physicians who are able to apply sound educational principles in practice can positively impact patient adherence to their treatment plans and outcomes.3  As a result, preparing residents and students (i.e. trainees) has increasingly become a goal of curricula across the medical education continuum.  Approaches to achieving this goal have evolved with changes in patient care demands and available teaching modalities. One of the most emergent modalities involves online asynchronous learning using internet-based platforms such as YouTube, social media, and learning management systems.  For these newer modalities to be optimally effective, which often lack face-to-face interactions, learners need to have opportunity to reflect during and after their teaching.4,5 The aim of this study is to assess the impact of an asynchronous online trainee-as-teacher curriculum featuring opportunities for reflection on teaching performance and self-efficacy.  The program is referred to as trainee-as-teacher, rather than the narrower resident-as-teacher, due to the goal of generalizing the curriculum to a broader audience of trainees, including health professional students, residents, and fellows.

Background and Review of Literature

The Accreditation Council for Graduate Medical Education recognizes the importance of developing teaching skills during post-graduate training and has made this a required activity within residency and fellowship training programs.6 Residency programs have included resident-as-teacher efforts as early as the 1960s, but the practice gained momentum after the 1990s.7 More recently, consensus guidelines have been developed indicating key components of these curricula.8,9

Traditional resident-as-teacher programs have largely taken place in the live classroom with varying degrees of experiential learning.10  The success of such programs have been made evident by resident satisfaction with curricula, improved resident attitudes towards teaching, and increased performance on objective measures of teaching, such as objective structured teaching examinations and evaluations by learners and faculty.11 Although these earliest efforts featured mostly synchronous learning, there has been a shift towards offering more asynchronous opportunities in recent years, certainly accelerated by the COVID-19 pandemic.12,13,14,15

With increasing clinical demands, clinical training sites located away from the academic hub, and duty hour limitations, residency programs have made efforts to increase asynchronous learning opportunities.16,17  Furthermore, the technologically savvy generation Y and Z learners who are now entering and graduating medical school are accustomed to acquiring knowledge online and on demand.18,19  Medical students value online learning and are increasingly using this modality over traditional resources.20,21 Several health professional education programs have adjusted their teaching strategies to meet these needs and have moved towards asynchronous online trainee-as-teacher content delivery. The online modality has the advantage of flexibility and convenience, in that material can be accessed at any time, and works best when the content addresses a specific need for the learners.22 

Some studies suggest that learners are able to achieve the same educational outcomes in asynchronous online environments as they are in the traditional synchronous classroom.23,24  There have been resident-as-teacher programs that feature a blend of asynchronous and synchronous content delivery, such as a self-guided program in which trainees view videos on teaching at their own pace then later engage in discussion with facilitators.25 Another program took a completely asynchronous approach, reaching learners across different training sites in a dual-campus pharmacy resident teaching program.26  This pharmacy program featured self-paced distance learning with assigned readings, video recordings, and a discussion board.  Participants indicated satisfaction and increased confidence in teaching abilities after participation.

Online learning also has the advantage of tracking participation and engagement more easily than in a larger classroom setting with objective data such as discussion board comments.27  Effective online programs also have prompts for reflection, to increase learner engagement with the material.28 One concern about asynchronous online learning is limited interaction with instructors and peers, however use of virtual discussion can allow for rich asynchronous communication between learners and teachers at different sites.29 David Schon has also recognized the importance of reflection in professional development, and written reflection after engaging in certain activities provides a format for doing this.30 Schon invites professionals to take time to reflect both in-action and on-action as a way of solidifying learning. Reflection-in-action refers to thinking in the moment about the present situation and various ways to approach it, informed by prior learning and experience.  Reflection-on-action is a retrospective exploration of what happened and how we may approach the situation differently next time. With learning activities taking place outside the classroom, self-reflection becomes a prime way of engaging with curricular content, therefore we have chosen reflective practice as our conceptual framework.  Through reflection, individuals develop a self-concept in regards to their teaching abilities.  Teaching self-efficacy is one’s personal judgement about ability to teach effectively.  In addition to confidence in one’s ability to teach, trainees need to demonstrate competence.  Consensus guidelines for resident-as-teacher curricula recommend including direct observation of teaching with feedback.These expert guidelines also state that trainees should be evaluated on their teaching skills by core faculty, residents/fellows, and medical students.  Although asynchronous online curricula are designed with minimal instructor interaction, there are opportunities to capitalize on the real-life teaching that trainees perform in their clinical work environment, such as providing patient education and small group peer teaching.  In one resident-as-teacher program, residents received feedback from faculty after leading a morning report and noted that this was one of the most positive elements of the curriculum.31  Offering an asynchronous online trainee-as-teacher curriculum alongside a clinical rotation would allow for concurrent opportunities to practice the teaching skills gained through online learning.

Research Question

How will an asynchronous online trainee-as-teacher curriculum with feedback on real-world teaching practice and self-reflection impact trainees’ teaching performance and self-efficacy?


Study Design

This was a convergent design mixed-methods study in which investigators collected data in parallel, analyzed separately, and then merged.   We conducted both quantitative and qualitative assessments to allow for a more in-depth understanding of this impact.

Setting and Participants

K.T. developed an asynchronous online trainee-as-teacher (TAT) curriculum at the University of Utah School of Medicine for residents participating in rural clinical rotations as part of the Rural Underserved Utah Training Experience (RUUTE) program.  This elective opportunity was advertised via email to trainees that had signed up to participate in a rural clinical elective. A total of 3 residents, all in Pediatrics, completed 4-week long clinical rotations with community preceptors in rural settings in the state of Utah.  In addition to their clinical training at these sites, these trainees elected to complete this asynchronous online TAT curriculum. This rural training experience cohort offered a convenient sample for this study in that they were physically distant from the academic hub with time available for professional development activities.  We submitted this study to the University of Utah Institutional Review Board and it met criteria for exemption under non-human subjects research.

Curriculum Development

We selected educational topics based on consensus guidelines for resident-as-teacher programs.32,33  The TAT curriculum was divided into four modules: educating patients, clinical teaching, small group teaching, and giving effective feedback.  Each module consists of a video, article, and podcast episode to review.  K.T. created brief podcast episodes on teaching best practices for this curriculum using her established Teaching In Medicine podcast on Anchor FM.  We selected relevant videos and articles for each topic from peer-reviewed literature and media.  The curriculum also featured two experiential learning activities. One activity was to teach a patient on an aspect of their medical care, performed after completion of the module on educating patients.  The patient then fills out a feedback form on the trainee’s teaching ability and their level of understanding about their medical care after being taught by the trainee (Appendix A).  This form features 9 Likert-scale questions and 3 open-ended questions on teaching ability.  This form was then submitted to the course director to track completion.  The second activity was to give a brief presentation to the clinical team at their site on a topic of their choice and receive feedback forms from attendees of that session (Appendix B).  This was performed after completion of the module on small group teaching.  The form features 11 Likert-scale questions and 2 open-ended questions on teaching ability.  After completion of the four modules and two experiential learning activities, participants then completed a reflective writing assignment on their teaching experiences and future applications (Appendix C).  The trainee participants completed all modules and experiential learning activities at their convenience during their clinical rotation.  K.T. managed the trainee-as-teacher curriculum on the learning management system Canvas.


The assessment strategy included collection of both quantitative and qualitative data in this convergent design mixed-methods study. Investigators collected the following quantitative measures:

  1. Participants completed a Trainee-as-Teacher Self-Efficacy Assessment before and after completion of the curriculum.  This is a 9-item Likert-scale questionnaire addressing comfortability with performing various teaching tasks to different audiences, providing a quantitative measure of confidence in one’s ability to teach (Appendix D).  K.T. created this assessment tool to specifically address the teaching skills that are targeted by this curriculum.  K.T. utilized descriptive statistics to assess difference between pre- and post-assessments.
  • K.T. also collected the feedback forms from patients and colleagues who were taught during the experiential learning activities and then quantified level of agreement on the trainee’s teaching abilities from the perspective of the learner using descriptive statistics. 

While the self-efficacy assessment and feedback forms provided objective information and opportunity to assess curriculum impact, we sought to better understand the effect of this novel asynchronous online teaching modality through qualitative investigation as well. K.T. and T.D. performed qualitative analysis of the written reflective assignment to better understand impact of the intervention that was not anticipated at the study outset.  We selected the written assignment for analysis as this was the prime modality of learner engagement with the course director and where the participant articulated the conclusions that they make after self-reflection.  Each prompt in the written assignment involved sharing thoughts and ideas after reflecting-on-action, aligning with Schon’s reflective practice.  K.T. and T.D analyzed the reflective assignments using principles of grounded theory.34 They reviewed and independently coded the text in a process of focused initial coding.  They performed initial coding line-by-line, labeling concepts that emerged from the data set and allowing for constant comparison throughout the analytic process.  Constant comparison is a process of continuously revising initial codes as one analyzes the data set.  This approach increases credibility and dependability in qualitative analysis.  The use of two investigators initially coding independently was a deliberate choice in order to obtain a more inclusive list of codes, as a single investigator is subject to their own lens and biases.  K.T and T.D resolved these issues and reached agreement on a final code book.  They then used this mutually agreed upon list to go back and re-code the data set.  They next linked the codes to identify themes and build a theory about the impact of an asynchronous trainee-as-teacher program in the theoretical coding phase.


Trainees completed the Trainee-as-Teacher Self-Efficacy Assessment before and after completion of the TAT program (Table 1). After completion of the program, 100% of participants indicated that they felt comfortable teaching patients, colleagues/attendings at or above their level of training, and learners at a training level junior to themselves.  This was a change from pre-program, where only 67% felt comfortable teaching patients, 0% felt comfortable teaching learners above their level of training, and 33% felt comfortable teaching more junior learners even when they were knowledgeable on the clinical topic.  Self-reported comfortability with giving feedback to learners, providing quick clinical teaching, and teaching in small groups increased as well (33%, 0%, 0% pre-program respectively vs. 100%, 100%, 100% post-program respectively).

Table 1

Table 1: Teaching Self-Efficacy Pre-Program vs. Post-Program
Teaching Self-Efficacy Pre-Program vs. Post-Program

Trainees collected evaluation forms from patients after they were taught by the trainee (Table 2).  Each trainee taught one patient, therefore a total of 3 evaluation forms were received.  All patients either strongly agreed or agreed that the resident doctor taught on a relevant topic, covered the topic in appropriate detail, cared about their level of understanding, and spent the right amount of time teaching.  They also strongly agreed or agreed that the resident doctor was knowledgeable on the topic, confident and comfortable teaching, spoke at a volume and pace that was easy to understand, and gave opportunity for questions and answered them well.  Two patients (67%) indicated that the resident doctor stimulated their interest in the topic, whereas one patient (33%) selected neutral for this statement.

Table 2

Table 2: Patient Evaluation of Trainee Teaching
Patient Evaluation of Trainee Teaching

Trainees delivered small group teaching sessions and then collected evaluation forms from the learners in attendance (Table 3).  Learners included preceptors, health professional students, and staff at the clinical site.  The 3 trainees collected a total of 12 evaluation forms.  All learners strongly agreed or agreed that the session objectives were clear, the session was well-organized, appropriate amount of content was covered, and the topic was interesting. All learners also strongly agreed or agreed that the resident was knowledgeable, confident and comfortable presenting, spoke at a volume and pace that was easy to understand, and gave opportunities for questions and answered them well.  92% of learners strongly agreed or agreed that the resident stimulated their interested in the topic and that slides or teaching materials were helpful.  83% indicated that the resident encouraged their participation.

Table 3

Table 3: Learner Evaluation of Trainee Small Group Teaching
Learner Evaluation of Trainee Small Group Teaching

The reflective writing assignment was divided into three parts: insight gained from teaching patients, insight gained from small group clinical teaching, and future approaches to clinical teaching. For the lessons learned on teaching patients, 11 codes were identified across the three writing assignments.  7 of these codes were identified in more than one of the participants’ writing samples: cultural competency, framing the discussion, health literacy, previous exposure to the topic, reflective learning, teach-back method, and use of handouts while teaching patients.  A few themes emerged from the data set.  Participants felt that they gained knowledge and skills related to health literacy that allowed them to educate patients of varying health literacy levels and cultural backgrounds.  These tools included the teach-back method, use of handouts, and ways to frame the discussion.  There also was acknowledgement of previous exposure to the topic of health literacy in medical school, but that revisiting the concept in real-world experiences provided opportunities for application of what was learned.

For insight gained from small group teaching, 12 codes were identified across the three writing assignments.  6 of these codes were identified in more than one of the participants’ writing samples: challenges to effective teaching, future opportunities for application, qualities of a good presentation, relevance to audience, self-reflection, and teaching environment.  One of the themes that emerged was that learners were able to identify the challenges to effective small group teaching and the characteristics of high quality presentations and effective learning environments to avoid these challenges.  They were also able to utilize self-reflection to increase awareness of their own skill set and develop ideas for future use. Lastly, 14 codes were identified for the section on future approaches to clinical teaching.  8 of these codes were identified in more than one of the participants’ writing samples: communication with learner, educational tools, feedback, growth mindset, knowing your learner, reflection on past approaches, teaching pearls, and time constraint.  One key theme was that participants realized the importance of effective communication and feedback for learner growth and development.  They were also able to reflect on their past approaches, incorporate feedback, and identify ways to improve moving forward, thus showing a growth rather than fixed mindset.  Finally, they noted that time is the main barrier to effective clinical teaching and came up with strategies to mitigate this, such as educational tools and quick teaching pearls.


Physicians are responsible for the education of their patients, peers, learners, and community. Thus, effective and efficient teaching in the clinical learning environment is a crucial skill that should be honed in training. The current milieu calls for asynchronous opportunities in medical education. K.T. hypothesized that meaningful learning could occur in an asynchronous online trainee-as-teacher curriculum through independent review of curated resources, experiential learning opportunities, and deliberate self-reflection. By employing a mixed methods approach in this study, investigators hoped to better understand impact of this curricular approach on teaching self-efficacy and performance.

One of the distinguishing features of this program is that the participants had minimal interaction with the course director.  They were provided with module resources and reviewed those independently.  They received brief written feedback from the course director after submitting learner evaluations and the written reflection, but did not have synchronous experiences with an instructor as is more typical in curricula for trainees.  Despite this, participants were able to increase teaching self-efficacy.  Most impressive was the impact on comfortability with teaching colleagues above their level of training, teaching under time constraints, and teaching in small group settings.  Perhaps the opportunities to teach their preceptors in the real-life clinical setting contributed to comfortability with these more advanced teaching skills.

Another strength of this program was the opportunity to teach patients and learners in real, rather than simulated, encounters.  These activities were performed after participants reviewed modules on teaching patients and teaching in small groups.  The modules equipped the participants with the necessary skills and the experiential activities gave them timely opportunities to practice.  Patient and learner evaluations forms were overwhelmingly positive.  The high teaching self-efficacy ratings were triangulated by learner agreement with the trainee’s knowledgeability and confidence in the topic.  One limitation is that the patient and learner feedback forms are subject to acquiescence or agreement bias, in that learners may have responded more positively than they truly felt.  This may have been influenced by the assumption that responses would eventually be reviewed by the participant.

The convergent mixed methods design allowed for simultaneous collection of qualitative data, to also address the question of curriculum impact.  Grounded theory, the qualitative methodology employed, is inductive in that the process is theory generating.  We utilized this approach as we were unsure of what the impact of this novel curriculum would be at the outset.  Qualitative analysis of the reflective writing assignment provided a closer look at impact on the trainee after they were given the opportunity to self-reflect on what they learned through independent study of the modules and performance of teaching activities. It was surprising to learn that participants already had learned about health literacy in medical school, but that they still found value in real-life opportunities to practice providing education to patients.  Their depth of understanding of the challenges to effective teaching and insight on tools to mitigate this challenge was also noteworthy.  Finally, the participants saw the value of self-reflection and how this promotes a growth mindset as they develop as clinician-educators.  These themes complement the quantitative data set in supporting the overall positive impact of this curriculum on teaching performance and self-efficacy.

Strengths of this study include the convergent mixed methods design to investigate curriculum impact from multiple angles.  Qualitative methodology was particularly rigorous through applying principles of grounded theory and having two investigators independently code the data set.  The curriculum design also differed from more traditional classroom-based approaches, in that it was online and asynchronous, but with opportunities to practice the skill set in real-life scenarios.  The main limitation was the small number of participants, certainly impacted by limited rural rotations during the COVID-19 pandemic.  The participants were also all pediatric residents, raising the question of generalizability to other specialties.  With the small number of participants, we were unable to demonstrate significance of impact in the quantitative portion of the study or reach saturation in the qualitative portion.

This study suggests that trainees can gain valuable teaching skills in an online format with minimal instructor contact.  This approach may be of use for program directors who would like to provide advanced training on education-skills, but lack the time for synchronous activities.  The program takes advantage of concurrent clinical activities as opportunities to practice teaching, rather than the time-intensive creation of standardized teaching encounters.  Asynchronous online curricula could be advantageous for trainees who are interested in professional development, but are on rotations away from the academic hub.  It is also a timely approach given the limited in-person experiences due to the COVID-19 pandemic.

This study will be ongoing to increase the number and diversity of participants.  We plan to include participants from other specialties, health professional students, and fellow trainees rather than only residents.  With more participants, we hope to reach saturation in the qualitative data set.  It would also be interesting to assess durability of impact, through assessment of participants at later time points after completion of the curriculum. Overall, an online asynchronous trainee-as-teacher program is a novel way to equip medical trainees with important teaching skills.  Providing resources for self-study, opportunities for real-life practice, and prompts for self-reflection led to trainees who felt confident in their teaching abilities and learners who were positively impacted by the trainees’ teaching performance. Ongoing implementation of this pilot study will allow for more thorough evaluation of the impact of this unique approach.


Appendix A:  Trainee Feedback Form – Patient Teaching

Appendix B: Trainee Feedback Form – Educational Session to Clinical Team

Appendix C: Reflective Writing Assignment

Appendix D: Trainee-as-Teacher Self-Efficacy Assessment


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XR Educational Classrooms for Health Sciences


Immersive technologies such as Virtual Reality (VR), Augmented Reality (AR), and Mixed Reality (MR) – known together as Extended Reality (XR) – are moving from a source of entertainment into a new technology for education. The University of Utah is a leader in this effort with 16 departments across campus conducting cutting-edge research in fostering new ways of teaching and learning using XR technologies. For example, the School of Dentistry uses VR to simulate implant dentistry that allows for continuous tracking of hand movements with sub-millimeter accuracy during practical learning. The Trauma Code Resuscitation VR Platform brings trainees into one of two real-life scenarios where decisions they make have direct impact on patient care. The College of Health has a VR Lab that effectively manipulates mobility-related anxiety while maintaining participant safety in the real world. Since the creation of an XR learning community began in 2018 and with the COVID-19 pandemic creating a heightened use of virtual scenarios for teaching, there has been an increased demand by instructors for modules that help students learn. This is especially true for health sciences education, where hands-on, experiential learning is essential to their professional training. However, in the larger education community, there are relatively few examples of deploying XR modules into the physical classroom space. A unique opportunity exists to design a dedicated XR classroom that will allow for easy deployment of XR education modules in health sciences courses. This report will review the literature and interview managers of existing XR classrooms to examine best practices and ways of addressing potential challenges in designing a classroom hosting this technology.


Literature review

The librarian conducted a literature search in IEEE Xplore (ieeexplore.org, 1988-2021), Scopus (scopus.com, 1970-present), and Academic Search Ultimate (Ebscohost, 1965-present). Inclusion criteria included a designated physical classroom with head-mounted display (HMD) technology, such as VR, AR, and MR. Two reviewers screened title/abstract and then a team screened the full text articles and extracted data into Microsoft Excel Online. Extracted data included citation, institution, location, XR classroom dimensions, XR equipment, other equipment, furniture, room set-up, instructors, students, educational content, study design, outcomes, recommendations, reservation system, security, staff maintenance, funding model, cleaning/sanitizing, media, and URLs.

Interviews with existing XR spaces

            A list of existing XR spaces was created by way of interviewing Roger Altizer and crowdsourcing names from the University of Utah’s VRplus listserv members. After securing a list of universities and institutions with designated XR spaces, the authors invited leaders to participate in a virtual interview on Zoom. The interview questions posed to the XR space leaders are listed in Table A.

Table A: Questions asked of XR space leaders that responded to an invitation.

Table A: Questions asked of XR space leaders that responded to an invitation.


Literature review

Our search returned 113 unique results after the duplicates were removed in EndNote (Clarivate). Following title and abstract screening, we reviewed 28 full-text articles for relevancy. Four studies met our criteria; 2 articles and 2 conference proceedings. See Appendix A for full data extraction, including location, classroom dimensions, XR equipment, furniture, room set-up, and funding model.

Interviews with existing XR spaces

            Nine XR space leaders responded to the invitation to discuss their XR space. Many of the spaces are multifunctional, serving as research labs and production studios, with a few using HMD technology to instruct students. Appendix B includes short descriptions and websites about each space.


Leveraging collected data from 13 XR spaces, including nine XR space leader interviews and four articles, best practices and challenges to XR classrooms were identified. The first section lists the best practices, which focus on space and support. The latter section identifies the four major challenges for educational XR classrooms with possible solutions and considerations.

Best practices when designing an XR classroom

            From the data collected, the authors determined best practices (and things to avoid) when designing effective XR classrooms. A summary of those best practices is listed below:

Provide an area for discovery and priming before engaging in classroom activity. Since XR is a newer educational technology, it may be the first time a student is using and experiencing this technology. They need an opportunity to discover the applicability of it before introducing the educational experience. Posters and video tutorials introducing people to the space would be helpful, as well as a headset to practice fit and comfort adjusting. Weekly open hours for people to come and visit the space also helps prime individuals interested in this technology.

The space should be multifunctional and modular. Having flexibility in how the room is structured is best. Many XR experiences happen in a collaborative and social space, which may occur after a discussion in a standard lecture-format classroom. Many of the spaces researched have multiple areas (small conference rooms to medium-sized development rooms with computers). Having one large open space is difficult as equipment tracking will often get in the way of multiple students and different size play spaces are better for different applications.

There should be ample room for moving around and safety should be emphasized. Using XR technologies is a physical endeavor and space accommodations should be met. The standard space per individual is 6 by 6 square feet, but it is better to provide more space to reduce injury or interference among students. VR games designed for interactions tend to be action-packed and require students to move around and produce rapid, sudden movements.

In designing the space, it’s important to balance need and demand. The space is not going to be everything to everybody. Instructors and students will dictate how the space is used and which equipment is needed. Some may find it easier to have their own equipment and run their own XR space. It is good to focus on how to best meet the largest demand. Having a reserve fund available can continue to address needs and keep up with technology advancement throughout the initial few years of use.

A technology-based classroom requires ease of use and available support to be successful. It should be simple for a student to obtain the hardware needed (headset and controllers) and access content. On-site support is preferred, especially during a person’s first visit or during open visiting times. It’s important to take a consistent approach in supporting students using the space while also balancing staff availability and tutorial content. Most XR spaces also provided a check-out service for equipment.

Challenges when designing an XR classroom

There are four major challenge areas when designing and implementing an XR classroom. This section presents the challenges with their associated questions and then the recommendations based off gathered data.

Assessing XR modules in the marketplace. When a new XR idea is proposed, what is currently available for free or what is for cost? Is there a current database that captures this information? If not, how might a database be created for available XR Modules that describe the educational content and purpose of the module?

            There is no database currently used to package and assess educational XR modules. In order to locate existing XR experiences, one must employ a variety of discovery methods, including:

Instructors and students should explore a variety of existing XR content to identify what best meets their learning objectives or needs. A commercially available XR module may be preferred because it will have more built-in support and ease, compared to a custom-developed module created for a class or research project, which is costly and takes a lengthy period of time to develop. A person will need to reach out to those XR module creators and ask if they will share the code for implementation at their institution.

When searching for existing and relevant XR modules, the searcher should consider the different audiences: gamers, educators, and discipline-specific groups. For example, an article about an educational virtual reality game for autistic children could be published in a gaming, education, or medical journal. Considering these multiple audiences means multiple searches, time, and patience. Those inquiring about search strategies should reach out to a librarian for assistance.

If an institution wants to create a database of XR modules, there are two existing digital collections at the University of Utah worth looking into. Previous work and findings from these can be used to craft and consider viability of an XR module collection. The two digital collections which contain some VR/AR materials are the EAE Archive (2010-present) and The GApp Lab (2014-2018). These two collections contain wrap kits of games, containing packages of materials like code, artwork and production materials of varying level of detail, since the author determines what is presented (e.g. description vs. code). In 2018-2019, Anne Morrow and Tallie Casucci received a grant from the Institute of Museum and Library Services to research and provide practical recommendations for complex, born-digital scholarly works, such as games. Their final report is available at https://collections.lib.utah.edu/ark:/87278/s61z92q4. The findings of this report can be applied to VR module database/collection.

            Another potential avenue for database creation would be to develop a national effort through a group or organization. Potentially, the National Library of Medicine, IEEE-VR, or AAMC’s MedEdPORTAL could be potential partners. Oculus, Valve, or other emerging XR companies may also be interested in partnering to create an education-specific database. Existing online education platforms like Khan Academy, Coursera, or EdX may also express interest.

Demonstration collection and repository

Should XR educational modules be collected? If yes, what are the details of collecting, managing, and providing access to these modules? How is this collection shared among multiple students simultaneously?  

Questions around a shared demo collection or repository have been the hardest to answer through the data collected. XR spaces seem to be divided in whether or not they provide a collection of XR games and applications for students. There is a current lag in content sharing ability for the major commercial players in the XR arena, which forces classroom space managers to decide if it’s better to have students manage their own content or take on the responsibility themselves. This is especially true for commercial content, where the major player, Facebook’s Oculus, requires individual logins per headset. If a student signs into Oculus with their personal Facebook account, they are requested to logout and reset the device before leaving the space. Concerns for requiring students to login to a device using their personal Facebook account included student privacy issues and the inability to have a shared library. Facebook’s attempted solution to this is an Oculus Business license, which space leaders reported as being underwhelming – it’s expensive ($180 per device per year) and requires a Facebook Workplace (which still captures data and is hard to access). The interviewed managers said Facebook Workspace does not meet the demands of an educational setting. Instead, some spaces decided to create “distribution” Facebook accounts where a single login belonging to the space can be shared across multiple devices. This has been a temporary measure until Facebook and other companies develop and release a long-term solution available to educators.

Sharing content among multiple students from commercial stores does help with engagement in the space. The Marriott Library has 10 STEAM accounts that manage applications and games for devices. Common applications or games first purchased include discovery games (First Steps, Beat Saber and Google Earth), anatomy education (ShareCare and Organon 3D), art-related applications (Tiltbrush and MasterpieceVR), and storytelling experiences (Google Spotlight Stories and 360-degree video stories like Traveling While Black). Custom-developed XR modules are also shared among XR spaces with each having their own management system. GitHub is the most popular way to store developed educational and research games and applications after they’re built in the Unity or Unreal Game Engines. Some choose to invest in headsets which don’t require login information, like the Pico Neo 2, but these devices lack the same marketplace for popular games and applications faculty and students want to use. To get a sense of what XR devices require logins, the Creativity and Innovation Services team at the Marriott Library at the University of Utah developed an XR Headset Summary Cheat Sheet

The best way to meet both a demand for commercially-made content and the ability to share custom-developed modules may be to invest in a combination of devices and in a device management system. To manage devices, while having the ability to build a library of applications and push content to headsets, some spaces invested in a management software. Software companies like ArborXR, SpringBoardVR, or GroveXR, are considerably cheaper than an Oculus Business license (around $40 per device) and seem much more robust in their transferability to an educational setting. Regardless of the combination of devices and content, it’s important to be forward thinking in ways of managing devices and what they’ll need to support relevant content.

Education and training

How can faculty be taught to use XR technology as part of their teaching? How can campus education support and training groups be involved? How about including faculty who teach the instructional design curriculum?   

            Hands-on workshops and lectures are necessary to expose professors and instructors to VR for their teaching. Within the literature there are several case reports of successful workshops for teachers and professors, such as Young and Manson’s (2018) pre-conference workshop for K-12 teachers. Seed funding that helps faculty projects get off the ground like those coming from the University of Michigan’s XR Initiative and events and speaker-series like those happening at University of Rochester’s StudioX are prime examples of engaging educators. Locally, it is worth continuing the VR Symposium that the University of Utah libraries hosted in 2019 and become more involved with national conversations and organizations, such as the Frameless Symposium at the Rochester Institute of Technology.

Many interviewees discussed the role that discoverability and play have to expose faculty to XR technology for use in the classroom. They suggested weekly open classroom hours to invite those interested to come and discover the space and technology for themselves. Dr. Grace Ahn from University of Georgia commented that most VR devices that are bought are plug and play, and don’t require any technological prowess. On-boarding programs built in the app store are plentiful and help students take their first steps in VR and teach them about how to use the controllers, move around in the space, etc.

At health sciences schools and colleges, there are many potential partners for increasing educational XR usage and implementation on campus. In addition to the library’s XR-related offerings, other partners to consider include a health sciences-focused educators symposium, a faculty center, learning with technologies center, and instructional design or teaching with technology programs. Many interviewees emphasized the importance of presenting to teaching conferences and symposiums within the institution to expose faculty to XR technology.

            When commercial options are not available, there are several options for creating local content. It might be worth reaching out to a video game development or computer science program on campus. At the University of Utah, The GApp Lab is the ideal lab for creating health-related VR games, since it brings together game development students, content experts, and Electronic Arts and Entertainment (EAE) faculty. EAE or computer science students can be hired directly as well, but it is highly recommended to involve EAE faculty member(s) for project guidance and field expertise.

Support model for XR classrooms

What should customer service look like for an XR Classroom to make sure equipment is charged and in working order for the next class? What cleaning and sanitizing needs to be done? Who should be on call when classes are in session and technology breaks down?

            The support model for an XR classroom is most vital to ensure success of the space. The interviewed managers all emphasized the importance of having staff on hand for technical assistance and ensuring classroom readiness. Different staffing models existed amongst the XR spaces, but most have a dedicated manager who keeps an inventory of hardware, updates software, and repairs technology. Technology malfunctioning doesn’t happen often and part-time student workers help prevent or troubleshoot possible errors. An instructor and their students should be able to get help quickly and most managers have an office in or near the classroom spaces. Some institutions used endowment funds to support student or faculty fellows doing projects in the space and holding informational workshops that utilize XR technology. Specified areas for equipment storage with charging stations should be available. For example, the Marriott Library has 3D printed controller stations, that keeps everything charged and organized (Sams & Leither 2021). Another example is a hidden wall of cabinets and movable walls with charging stations in the Digital Innovation Lab at the Rehabilitation Hospital at the University of Utah. Wireless networking infrastructure is also essential so that wi-fi access points that connect to wireless headsets can be controlled by staff.

            Safety and security should also be of utmost importance in developing the XR classroom. Safety protocols should be developed and posted visibly in the room. It is preferred that the space equal 10 by 10 square feet per individual, and at minimum 6 by 6 feet should be met. Cords and equipment should be off the ground and its helpful to have padded floors for stability. Seated VR is another common way to experience games and applications, especially for those with lower-limb injuries, and swivel chairs should be made available in the space. StudioX at the University of Rochester and GAVEL at University of Georgia provide small and medium conference rooms to provide spaces for private sessions. The Digital Innovation Lab at the University of Utah has frosted glass panes that can be turned on and off for privacy. Sanitizing dispensers and wipes should be on hand to promote good sanitation with ultraviolet light cleaning boxes for headset and controller cleanliness. There are also add-ons to headsets to substitute cloth fabrics with soft plastic that can be easily wiped clean. If someone is not physically in the space and equipment is not secured, the space should be locked. Card access for equipment or room reservations also helps secure equipment. The Marriott Library’s VR classrooms provide a permanent reservable space with the equipment provided.


XR has the potential to transform education. Personal observation suggests that students and educators are asking for XR technologies to explore. Instead of a portable option, Picker (2020) found that students want “a dedicated VR room in every [K-12] school… for learning.” Of course, this can be applied to the higher education setting as well. There are plenty of opportunities for future growth, including:

  • developing an open access software repository for educational content,
  • investing in a device management system to help collect and push content,
  • partnering to create training workshops for teaching and content creation,
  • hosting consistent open houses to orient new users, and
  • supporting research and educational outcomes using XR hardware and supported software.

Challenges still present themselves, and include:

  • lack of clear hardware leaders,
  • lack of support from the industry to develop for educational purposes,
  • challenge in creating XR content from scratch, and
  • access to paid applications in stores and how to share them with multiple students simultaneously.

It’s important to be realistic in balancing future growth opportunities while addressing the challenges. Early adoption means that changes may happen frequently, so it is important to stay nimble about the process and remain flexible in creating and maintaining an XR Classroom. The Eccles Health Sciences Library has begun creating a temporary XR Classroom in the Eccles Health Sciences Education Building to begin experimenting with room setup and support. Using this report as a backbone, one can identify and meet with instructors that would utilize an XR classroom space for their teaching and start developing solutions for their institution. Staying current on the newest XR technology, while maintaining a space that can be depended upon by educators, will take a fine balance. There is crucial need for those managing the XR classroom to stay abreast to the latest happenings in the field through professional conferences and organizations, continuous professional development, and industry product demonstrations and trainings. Intentional industry partnerships could supply spaces with the newest technologies, similar to film schools’ partnership with camera companies. There is a lot of growth potential and areas for exploration.


The authors would like to thank fellow XR task force members for their assistance in the creation of the original white paper on XR classrooms. The authors also thank the VRplus interest group and the XR classroom managers for their time and expertise on these topics.


Pirker, J., Holly, M., & Gütl, C. (2020, 21-25 June 2020). Room Scale Virtual Reality Physics Education: Use Cases for the Classroom. Paper presented at the 2020 6th International Conference of the Immersive Learning Research Network (iLRN).

Sams, A., & Leither, L. (2021). Toward new creative services: a case study in building a virtual reality classroom in an academic library. College & Undergraduate Libraries, 1-13. doi:10.1080/10691316.2021.1898511

Young, A., & Manson, R. (2018). Pre-Conference Workshop – Creating XR Experiences for the Classroom. 2018 IEEE International Conference on Teaching, Assessment, and Learning for Engineering (TALE), 2018, pp. 1217-1218, doi: 10.1109/TALE.2018.8615379.

Public Health Clinicals During the COVID-19 Pandemic: Lessons Learned


Public health nursing clinical courses serve an essential role in the education of prelicensure baccalaureate students. When clinical sites closed due to the COVID-19 pandemic, it provided new opportunities for integrating virtual platforms into nursing clinicals. The new structure for the clinical courses included assignments using virtual software, synchronous online classes, and blended learning activities. Students developed care plans, role-played case scenarios, and participated in nurse-led and student-led presentations. The adaptation to an online environment demonstrated the value of several educational elements. These included opportunities for direct messaging, student role-play, and flexibility for nurse-led and student-led presentations. The alternative clinical experience provided a platform to facilitate difficult conversations, flexibility for presentations, and opportunities to strengthen students’ professional identities, all while providing an enriching learning experience. The positive experiences using a virtual environment for delivering public health clinicals encourage its inclusion with traditional clinical experiences moving forward .

An essential element of baccalaureate nursing education is to provide clinical experiences for students. Clinical experiences enable students to develop psychomotor and communication skills and develop their professional identity (American Association of Colleges of Nurses, 2008). Regardless of the semester, location, or population group, debriefing after clinical experiences plays a crucial role in helping students develop critical thinking and judgment skills and bridge the gap between theory and practice (Akram et al., 2018; Bradley et al., 2020). By exposing students to public health clinical courses, they are better prepared to intervene and promote health within populations and throughout patients’ lifespans (American Association of Colleges of Nurses, 2008). The students in this course examine international public health nursing standards for protecting, promotion and preserving the health of populations; and examine the role of the public health nurse locally, nationally, and globally. When placed at clinic sites in person the clinical placements include, school nursing, nursing in correctional facilities, home health nursing, free community clinics, nursing at a health department, and geriatric care. This is a required course for the baccalaureate nursing program.

The COVID-19 pandemic resulted in the sudden closure of clinical sites to nursing students, including those supporting public health clinical courses, in the spring of 2020. This forced faculty to quickly adapt how they would provide enriching learning experiences despite the limitations imposed by not interacting with a live clinical environment.  The development of the new curricula required creativity and innovation, but also provided new technology-supported opportunities that had not previously been explored. This paper describes the methods used by faculty at one college of nursing prelicensure baccalaureate program’s public health clinical course to create enriching public health clinical experiences for their students .

Description of Interventions

When it became evident that clinical sites would be unavailable to students due to the COVID-19 pandemic, faculty began brainstorming methods to achieve the most optimal student experience considering these new circumstances. Faculty intentionally focused on designing a holistic learning environment by providing active and engaged learning. The final class format consisted of weekly pre-class assignments using virtual software, weekly technology-supported synchronous class sessions, and blended learning activities with formative assessments. During online synchronous class, the students met as a large group and then divided into smaller sections during their six-week clinical. This format led to a total of 142 second- and third-semester undergraduate students completing their public health clinicals over a 12-week semester.

Virtual Software

The weekly clinical experiences were framed by the virtual software Sentinel City® (SentinelU, 2016), which is specifically designed for a public health experience. The software presented the learners with a virtual city that included built-in assignments from which faculty could choose and adapt to meet course objectives. The faculty identified five different assignments, which addressed each of the following areas: 1) education, 2) health and social services, 3) family support and home safety, 4) global health, and 5) public service. Within the virtual city, the students individually identified a unique population (such as children, homeless, veterans, etc.), explored the city for available resources, and developed care plans based on their assessments.  The course structure was organized so that students engaged with the virtual community each week.  Each assignment included a weekly clinical update in which students answered questions directly related to the virtual learning environment. The clinical update also provided space for informal student-focused mental wellness check-ins. The virtual software and associated assignments provided a safe environment that empowered the student to take the lead role as if they were a nurse assessing and exploring the needs of a community.

Synchronous Class Sessions

 During weekly online synchronous clinicals, approximately 36 students met together for 45 minutes. The majority of these meetings were comprised of presentations and question and answer sessions with local public health nurses with whom students would have completed their clinical experiences had the COVID-19 pandemic not occurred. These nurses included a school nurse, a home health and hospice nurse and business founder, a nurse from the juvenile justice system, and nurses working in public health clinics serving vulnerable populations. Students asked questions and commented during the question and answer sessions vocally and by utilizing a direct messaging function.

After the nurses shared and illustrated different public nursing roles, the group of 36 students broke into small groups of 8-10 for approximately one hour. The debrief was guided by the weekly focus from the virtual software assignments and standards from the Public Health American Association of Nurses Scope and Standards of Practice (2013). The faculty created role-play case scenarios for the students to further engage the students in the virtual software clinical experience. The students alternated between acting as the patient and the public health nurse in breakout rooms. Each scenario lasted approximately ten minutes. If the students finished the scenario before the designated time to return to the small group session, they were encouraged to debrief with each other.

Over the course of the semester, each student also presented a current event focused on a public, community, or global health topic. In their presentation, the students related how their chosen topic has been affected by the COVID-19 pandemic and assessed their peers’ understanding of the presentation.


The Value of Direct Messaging

One positive outcome of working in a virtual environment included a new forum for faculty and students to communicate privately via direct messaging. This enhanced student-teacher relationships and helped facilitate difficult conversations as the student and teacher could communicate privately without disrupting the class or other students in real time. In one small group presentation, a student chose the topic of the ‘defund the police’ movement and the riots taking place in the United States after the death of George Floyd by a police officer. Another of the students in the group was a former police officer. Because of direct messaging, the faculty member privately reached out to this student to invite them to share their perspective. As this invitation was not delivered in front of their peers, the student did not feel pressured to share and was able to gather their thoughts without being put on the spot. Their perspective helped diffuse negative feelings toward the police and reminded the students to consider multiple points of view.

Value of Nurse-Led and Student-Led Presentations

The local public health nurses invited to weekly virtual sessions offered students the opportunity to understand the wide variety of nursing roles in community settings. The students shared that they enjoyed learning about professional nursing opportunities they had not previously considered. While many of the students voiced a desire to work in acute care settings after graduation, they also noted the importance of understanding available community resources.

A few of the students focused their small group presentations on information gleaned from the public health nurse’s presentations. For example, after hearing from a school nurse, one student decided to explore the topic of reopening schools during a global pandemic. The student presented the immediate and long-term risks and benefits of reopening schools. They engaged the group in a discussion filled with evidence supporting both sides; and the group exemplified respect by listening to one another and then sharing their thoughts. While not all group members agreed with this student’s perspective, each student used reflective language and closed-loop communication to demonstrate they understood what was being shared and that their message was also understood.  Comments from students revealed they found the small class presentations deeply engaging and that they enjoyed the opportunities for exploration and leadership.

The small group student presentations included the student presenter incorporating evaluation methods to assess student understanding of their topic. Students were given the freedom to determine the method that would best assess if their peers understood the presentation’s content. Some students chose multiple-choice questions, while others utilized group discussion. Some of the questions or discussions occurred at the end, while others were intertwined throughout the presentation. A few students used online quiz platforms as their evaluation tool. Students expressed difficulty developing effective evaluation methods, but described how it encouraged them to think differently and communicated appreciation to faculty in continually developing evaluation methods.

Value of Student Role Play in an Online Environment

Based on information collected from the informal mental wellness check-ins, student feedback from weekly assignments regarding the case scenarios in breakout rooms was positive. While some disliked the role-playing aspect of the coursework, all students gave positive feedback regarding their discussions with their peers. The students were provided a quiet and more personal environment by being in the breakout rooms, which encouraged participation and made the experience more realistic than if they were in a large and distracting classroom. In one scenario, the students met with a client (played by a classmate) who was involved with drugs, had difficulty managing his temper, and not interested in making lifestyle changes. The students found this scenario particularly helpful as it prompted them to explore how to interact with and educate someone who is “not the most cooperative.” By including this scenario and debriefing afterward, those role-playing the nurse received real-time peer feedback on what their client felt during the discussion, even though the client chose not to follow the nurse’s recommendation.


The authors found the alternate clinical experience provided many benefits, including providing a platform to facilitate difficult conversations, creating flexibility for presentations, and strengthening students’ professional identities.

While each state regulates the ratio of faculty to students in clinical experiences, to effectively monitor students and debrief them, student groups should be relatively small, consisting of approximately 8-10 students per instructor (Spector, 2012). With the transition to the online environment, by maintaining small groups, faculty created opportunities for discussion and to “think like a nurse.” In-person public health clinicals can also afford some of these opportunities, but they cannot replicate the benefits of direct messaging described previously. Students sometimes feel shy expressing their opinions before their peers, particularly during controversial conversations. Direct messaging affords opportunities for personalized student-teacher communication without drawing the attention of the entire group. Showing respect and concern for students as individuals strengthen student-teacher relationships and help facilitate a safe environment where students are more likely to express their thoughts (Parsh, 2010).

Due to the variety of clinical locations in public health nursing clinicals, it is impossible for students to personally experience each one. Inviting local public health nurse presenters is one way to help bridge this gap. However, scheduling these presentations can be difficult due to travel and time constraints. By hosting these nurses through a virtual environment, the travel constraint was eliminated and the time constraint was greatly reduced. Even after returning to in-person public health clinicals, choosing to continue the virtual nurse presentations will help foster opportunities for students to consider different nursing specialties. The local public health nurses opened the students to new experiences, which, combined with the debriefing from faculty, strengthened their identity as nurses and encouraged them to embrace the flexibility nursing affords (Akram et al., 2018).

While role-playing is not a new educational technique in nursing, completing the scenarios in a virtual breakout room provided new opportunities for both students and faculty. The quiet, personal environment helped students feel that they were not on display to be judged by their peers or faculty. By mitigating that anxiety, students better participated in the scenario and learned from their experiences, strengthening their confidence in their professional identity (Wittman-Price et al., 2016). Even the students who did not enjoy role-playing found value in the discussions and debriefing with their peers. This provides additional support to the effectiveness of virtual case scenario role-playing and the importance of faculty creating a safe, engaging debriefing environment (Bradley et al., 2020). The breakout room also afforded students the ability to feel safe giving each other individualized feedback regarding what went well and what could be improved.

Challenges Encountered

Because of the sudden transition, faculty were still developing course assignments related to the virtual software when the semester began. Additionally, as the software was new to faculty, troubleshooting technical difficulties with students necessitated additional time. These disturbances decreased substantially over the semester as students and faculty became more familiar with the software.

While the nurse-led presentations piqued student interest in public health nursing, students expressed disappointment that they could not participate in the described clinical experiences in person. The virtually supported clinical course content provided many benefits, but it could not completely replace traditional public health clinical experiences where students interact with live patients to apply nursing skills.


The sudden transition to a virtual, online clinical experience required creativity, innovation, and flexibility from both faculty and students. All involved frequently expressed appreciation for the patience of others while navigating this unique period in history. Through the various interventions described in this paper, the authors found they were able to develop a safe environment to facilitate difficult conversations, provide flexibility for presentations, and strengthen students’ professional identity, all while providing meaningful learning experiences. As clinical sites gradually open up to nursing students, public health clinicals will continue to evolve. In particular, the positive experiences with using a virtual environment for local public health nurse presentations and clinical debriefing should encourage its use in conjunction with traditional clinicals moving forward. Further research directly comparing student experiences using virtual versus in-person platforms for public health clinical debriefing is warranted to better understand student experiences. These lessons will inform and improve public health clinicals in the future.


American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, D.C.: American Association of Colleges of Nursing. 

American Nurses Association. (2013). Public Health Scope and Standards of Practice 2nd ed.  American Nurses Association.  

Akram, A. S., Mohamad, A., & Akram, S. (2018). The role of the clinical instructor in bridging the gap between theory and practice in nursing education. International Journal of Caring Sciences, 11(2), 876-882. 

Bradley, C. S., Johnson, B. K., & Dreifuerst, K. T. (2020). Debriefing: A place for enthusiastic teaching and learning at a distance. Clinical Simulation in Nursing, 49, 16-18. 

Parsh, B. (2010). Characteristics of effective simulated clinical experience instructors: Interviews with undergraduate nursing students. Journal of Nursing Education, 49(10), 569-572. https://doi.org/10.3928/01484834-20100730-04

SentinelU. (2016). Sentinel City [Computer software].

Spector, N. (2012). Clinical education and regulation. In N. Ard & T. M. Valiga (Authors), Clinical nursing education: Current reflections (pp. 181-198). New York: National League for Nursing.  Wittmann-Price, R. A., Price, S. W., Graham, C., & Wilson, L. (2016). Using simulation to prepare nursing students for professional roles. Holistic Nursing Practice, 30(4), 211-215. https://doi.org/10.1097/HNP.0000000000000139

Social isolation and social media consumption among graduate students during COVID-19: An examination using Social Comparison Theory


The COVID-19 crisis transformed the way we communicate with each other. Pre-existing theoretical frameworks can build structure out of the chaos; social-interaction theory is one of these. During our social distancing and prior to the vaccine’s arrival, physical distancing was adopted as the primary strategy to ‘flatten the curve’ of the virus’s spread. The human desire to connect, however, led to increasing reliance on social-platform outlets. Yet meaningful communication in these forums is elusive and often results in unsatisfying interactions that lack the natural cadence of in-person communications. There is a need to reflect back on how and why our various styles of social-media consumption often paradoxically increase rather than ameliorate our feelings of social isolation. Following this overview, the authors will recommend ways to recognize and change such counterproductive patterns of online activity.

Social isolation in the time of COVID-19

Individuals who feel socially disconnected or lonely suffer from more negative health outcomes, both mental and physical (Cacioppo et al. 2006; Hawkley et al. 2006; Holt-Lunstad et al. 2010;  Holt-Lunstad et al. 2015; Reblin and Uchino 2008). With the public-health mandates of COVID-19, an unprecedented number of people are reaching out through social-media channels to fill their desire for camaraderie or social support. Interestingly, these virtual connections do not guarantee that our social needs will be met. Depending on an individual’s emotional state, level of self-confidence, and social-media consumption style, the virtual connections they build in a social network exacerbates feelings of social isolation, and may have a negative impact on health (Turkle 2012).

Prior to COVID-19, we enjoyed a panoply of options to converse and connect, both online and in person. In a post-COVID landscape, in-person group interactions have been suspended; social media and online interactions have taken center stage. This new social-interaction architecture is accompanied, however, by unexpected social comparison and self-scrutiny (Haferkamp and Krämer 2011). In these uncertain and stressful times, we know that individuals tend to lean heavily on their social networks to validate their experiences in an effort to support wellbeing and/or self-esteem (Gonzalez and Hancock 2011). To cope in these novel conditions, we seek reassurance that we are safe in our interactions and relationships. That quest is complicated by the fact that our insight and coping ability may change in any given week, day, or moment.

In this post-COVID social climate, we are forced to communicate through virtual appointments; many are finding it harder than ever to connect at organic, meaningful levels. This sets up a conflict: we want and need to encourage scenarios where people support each other, yet it is rare that our mental health or general attitudes allow us to synchronize and engender a shared empathy during stressful times. Instead, primal survival instinct kicks in, causing us to reconcile the most basic blocks in our support structure. Any cognitive dissonance experienced at an individual level unconsciously introduces social comparison to create meaning where we need itand can even cause a misattribution of value or make more global assumptions about our relationships as they relate to one encounter (Festinger 1962; Dutton and Brown 1997).

Framework: Social Comparison Theory

When the psychologist Leon Festinger introduced Social Comparison Theory in 1954, his intent was to recognize that people naturally compare themselves to others as a part of their self-evaluation (Festinger 1954). The theory essentially postulates that, in unclear times, individuals will engage in: (1) self-evaluation across social norms or opinions (i.e. a fill-the-gap approach); and, (2) personal performance comparisons with others in order to improve or compete (Festinger 1954). As a result of social changes due to COVID, we can see that the majority of Americans are forced into engagement with social media and telecommunication in order to stay connected with support systems and remain engaged.

Framed and harnessed in a productive way, social comparison offers benchmarks for an individual to gauge value or feedback, which may result in greater self-insight. Most often, people engage in a strategy that fits their emotional or informational needs, and choose to compare themselves to similar and relevant others (Festinger 1954; Goethals and Darley 1977). Ironically, in times of personal crisis or lower self-esteem, social comparison can have deleterious effects on wellbeing and can negatively impact self-esteem (Tesser and Collins 1988). The nuances of social comparison are often portrayed as a duality, sometimes called upward and downward comparison.

Upward and downward comparisons

Whether one engages in “upward comparison” (comparing the self to others deemed better) or “downward comparison” (comparing the self to those deemed worse), the major drivers for the value of the experience (i.e., for whether it is considered positive or negative) stem from an individual’s self-esteem and cognitive framing (Tesser and Collins 1988; Vogel et al. 2014; Wills 1981). Tesser and Collins (1988) identified distinct psychological forces that drive self-evaluation and its effects on self-esteem, highlighting the role that ‘relationship closeness’, as a concept, plays in how we assess ourselves. Social comparison tends to occur more frequently in our local network (for example, when evaluating one’s performance with that of a friend’s), rather than in broader social contexts (such as when comparing oneself to a national average). This is referred to as the “local dominance effect” (Zell and Alicke 2010). In a socially isolated COVID landscape, this feels particularly relevant. As an individual struggles to deal with a perceived condition of social isolation – or loneliness, it is natural for them to seek out close, like-minded friends for affirmation or validation of one’s experience (Young 1982).

However, we also know that social comparison impacts self-esteem and is associated with wellbeing (Tesser and Collins 1988), feelings of regret (White et al. 2006), increased competitive drive, the feeling of a missed opportunity, and even feelings of scorn and envy (Tesser and Collins 1988; White et al. 2006; Garcia et al. 2012; Bauer and Wrosch 2011; Fiske 2010; Johnson 2012; Salovey and Rodin 1984; Creemers et al. 2013). In times of crisis, self-esteem tends to decrease even more than usual, making individuals more prone to interpret any differences as deficits, rather than opportunities (Creemers et al. 2013). Keeping in mind that one’s proximity to a standard or goal increases a social-comparison effect and that distance decreases it, COVID-19 introduces a novel dichotomy of connectedness wherein our friends (the ones we need for support in crises) also become our primary comparison targets. Thus, depending on an individual’s dynamic goals and level of self-esteem at the time of an encounter (as in a Zoom call), surprising or even disturbing feelings may result from this self-evaluation, ones that may be so novel that the individual lacks the coping skills to understand them fully.

As a simple example, individuals who are goal-driven in an interaction may unconsciously adopt an upward-comparison approach when they learn of a friend’s success in homeschooling during COVID, and respond to it as a worthy challenge. An individual taking such an approach seeks a goal of mastery, which protects them from viewing it as a negative competition (Poortvliet et al. 2007). The individual believes they can change. By contrast, an individual with a fixed mindset (i.e., a belief that he/she cannot change or grow) will approach upward comparison with envy, diminishing their overall wellbeing (Dweck 2007). Those individuals who view their position as malleable, utilizing a growth mindset, tend to frame an upward comparison as an inspiring rise to challenge, an opportunity to improve themselves (Dweck 2007). The catch is that the same person can employ both of these strategies in different times or situations; we are not bound to just one approach. Depending on our self-esteem and goals, we tend to employ the strategy needed to make sense of the situation. By identifying the better approach for a given situation, we can take steps to enhance or ameliorate the impact of social comparison.

Social media consumption style

To understand how online interactions and social comparison work together, it is critical to identify the user’s style and what factors may be beneficial or detrimental to mental health. For example, Forest and Wood (2012) found that individuals with low self-esteem who regularly use social media to express their thoughts (in a presumably safe environment) often fall victim to a cycle of social comparison that exacerbates their low self-esteem. There is a similar disenchantment with, or disappointment in people who overly curate their online persona, resulting in a sense that “real life” can never live up to their expectations (Chou and Edge 2012).

Researchers continue to attempt to identify specific mechanisms that result in positive online interactions; preliminary results appear to suggest that purposeful and intentional engagement yields positive results (Burke et al. 2010). Examples of purposeful engagement include: searching for a like-minded community, specific information, or support from a specific community. Reciprocal exchanges help form relationships and a sense of community; self-disclosure and interaction facilitate a sense of integration with others (Lee et al. 2013). A strong sense of online social support is facilitated by authentic connections that enhance self-efficacy and resilience (Young 1982; Oh et al. 2014). Interestingly if individuals use go online to talk to friends, less depression was experienced. If a person talked with stranger, the opposite was found; they reported increases in depression (Kraut and Burke 2015).

Passive use of social media exemplifies an observational approach with minimal engagement with other users (Escobar-Viera et al. 2018). While some passive use can be helpful in determining group norms, regular passive social-media use has been shown to reduce wellbeing (Krasnova et al. 2015; Tromholt 2016; Verduyn et al. 2015). However, the effects of use on well-being are dependent on how individual use sites (Kraut and Burke 2015).

Aligning Use with Self-Assessment

Wherever individuals find themselves on the social-comparison continuum, we can use social media to bolster our connections. Most people wish to foster more natural and rewarding interactions with our communities, but how does this happen in a new world of virtual interactions? Borrowing from well-described positive psychology interventions and social-psychology theory, we discuss below a range of interventions to address and realign our responses to this COVID-19 social landscape as it relates to our dynamic social-media consumption.

Upward comparison and its interventions

An example of upward comparison could be a situation where a parent of a young child, weary from quarantine and generating homeschool activities, witnesses another parent posting about their creative family projects and excitement about family time on social media. Sensing a difference in attitude or effort, this parent may experience their social comparison as either a positive response of hope and inspiration or as a negative response of dissatisfaction or envy. Depending on the response, a range of interventions can alleviate the negative effects of social isolation or self-esteem. In the case of the parent who is inspired by the comparison, a successful strategy has been to start with small changes toward the goal. Shifting the frame of our success to smaller steps engenders the momentum needed to achieve the goal.

An example of a negative effect of downward comparison would be to respond with envy, or disappointment in one’s performance or situation. Using the converse of the example above, this parent would view the excellent homeschooling by the other parent with regret that their family might never be able to achieve something of such quality. Employing a fixed mindset, the parent finds little likelihood that they can meet a similar standard. Two practical interventions that can help pivot an individual away from feelings of isolation or dissatisfaction with their current situation are (1) the practice of self-compassion (Neff 2020), and (2) increasing the sample size of the comparison (Garcia and Tor 2009).

Self-compassion is a common exercise in mindfulness in which an individual experiences the difficulty of a moment (e.g. feeling isolated), acknowledging the pain; yet they embrace their feelings with kindness and care toward the self (Neff 2020). In the context of physical distance and resultant difficult interpersonal communication that characterizes our current COVID-19 crisis, it is particularly salient to remember that we all share this very human, very humbling experience. Neff (2020) goes on to suggest that when a person can connect with this shared sense, it may enable the power needed to go through a painful encounter and make way for personal growth and transformation. An in-depth exploration of self-compassion and its related exercises may be found at https://self-compassion.org/tips-for-practice/.

In addition to building self-compassion, other therapeutic approaches such as Acceptance and Commitment Therapy (ACT) or integrating the Buddhist principles of equanimity and acceptance may increase an individual’s level-headedness, so as to better address imperfect environments, such as COVID-19 (Fung 2015). If these skills feel too amorphic or far-reaching in the moment, the quickest remedy toward feeling isolated or negative in social comparison is to widen your sample size in your social-media browsing targets. In other words, the more people to whom you compare yourself, the more social comparison’s negative effects tend to decrease (Fung 2015).

Downward comparison and its interventions

In downward comparison, a positive outcome could be an expression of gratitude for one’s current situation. As another example, when an individual is scanning the social-media feed, they may recognize how lucky or grateful they are to have all their social needs met during COVID-19. To enhance this positive effect, a simple intervention might be to start a pandemic diary, into which the individual could jot down these moments of gratitude or appreciation as they occur. During stressful times or times in which social isolation feels too heavy, the individual can then reread the entries in order to ground any current less adaptive feelings, reminding the individual of positive cues in life (Keltner et al. 2003).

When an individual responds to downward comparison with a negative response, their perspective may result in scorn. A scornful response would be to see another person’s efforts to cover basic social needs as evidence that they must have done something wrong along the way and that their predicament is a result of that choice. It is a fixed-mindset way to resolve the uncomfortable feeling that “bad things may happen to me, too.” By assigning the blame to the other person, the individual making the comparison feels more distant from others, and from the undesirable or scary situation at hand. The assignment of blame is essentially a defense mechanism employed in order to make sense of the uncertainty.

Downward comparisons resulting in scorn are the most difficult to change because the power dynamic of feeling superior tends to increase self-centeredness in the assessor. A greater sense of empathy is required to bridge the gap (Fiske 2010). Such an approach will vary with individual encounters, and this contributes to the complexity of intervention.

Empathy plays a pivotal role in confronting scornful feelings, an awareness that scorn diminishes consideration for how others think and feel (Fiske 2010).  In our example above, a more productive approach to addressing feelings of scorn may be the use of cognitive reframing to challenge thoughts of superiority and/or blame-laying. Purposeful and mindful assessment of the realities of another’s struggles helps us to move back into a place of empathy. Upon disengagement from scorn, it becomes easier to consider how this kind of stereotyping and laying blame on others not only alienates us from them, but can also be harmful to our own mental health and wellbeing. By recognizing unhealthy thought patterns, paired with empathy for one’s self through self-acceptance and self-forgiveness, feelings of scorn can be transcended.

Table 1: Upward and downward comparison effects and brief intervention examples
Table 1: Upward and downward comparison effects and brief intervention examples


Social interactions during the COVID-19 pandemic have forced everyone into a new virtual landscape with significant increased social-media use. A basic drive of human beings is to connect, to affirm our humanity and confirm our place in the world. Unfortunately, not all social-media interactions result in a sense of connection, and for some, this failure has reinforced disconnection and a sense of isolation — or worse, contributed to negative self-perception. Of course, this novel communication environment caused by COVID has ignited imaginations, driven ingenuity with positive collaborations and shared strategies. There is also a community of people for whom this increased social-media interaction has resulted in a reduced sense of community and wellbeing, whose lowered self-esteem has only been further reduced, resulting in a greater sense of isolation and comparisons that leave them less hopeful. Social Comparison Theory provides a helpful structure to understand this bidirectional outcome. If an individual is able to gain insight on their style of social-media consumption and their strategy of social comparison within an interaction, there is an opportunity to redefine the experience, which will protect them from damage to their value placement and self-esteem.


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  • Funding Sources: This study was funded in part, by the National Institute of Nursing Research of the National Institutes of Health under award number T32NR013456 and F31NR01898. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
  • Conflicts of Interest: The authors declare that they have no conflict of interest.
  • Contributions: SS, SW, JKM, RP, and LC drafted the manuscript; and all authors contributed substantially to its revision.
  • Keywords: COVID-19, social isolation, social media, social comparison, coping mechanisms

Evaluating Teaching Methods about Obstetrical Emergencies among Comadronas in Urban Guatemala


Background: Indigenous traditional midwives attend 60% of all births in Guatemala where maternal deaths are the highest in Central America at 95 deaths per 100,000 births, and 90% of births in rural areas where maternal deaths are as high as 290 deaths per 100,000 births. Understanding how low-literacy traditional midwives, called “comadronas” in Spanish, learn and retain knowledge is critical to addressing the country’s maternal deaths. A paucity of data exists on comadrona knowledge of obstetrical emergencies in urban Guatemala.

Methods: A pretest posttest design was used to evaluate the effect of a culturally sensitive teaching on knowledge of obstetrical emergencies among urban comadronas. A Checklist from the American College of Nurse Midwives (ACNM) was used to assess and compare knowledge about obstetrical emergencies before and after the teaching. Participants also interpreted drawings of obstetrical emergencies used for knowledge retention.

Results: Seventeen urban comadronas participated in a one-day educational session in San Raymundo, near Guatemala City. The mean pretest score was 3.06 with a SD of 1.436 compared to the mean posttest score of 5.13 with a SD of 1.147. Change in knowledge was a statistically significant with a p value of 0.01. Participants understood simple, color drawings from Guatemala better than complex, black and white drawings from the U.S.

Discussion: Future teachings about obstetrical emergencies should present information orally in the native language of low-literacy urban participants. Future teachings also should use simple, color drawings of obstetrical emergencies from Guatemala for knowledge retention.

Key Words: Guatemala, traditional midwives, obstetrical emergencies, education


Guatemala is a small, developing country with disparate populations. Nearly 17 million Guatemalans live in a 42,042-square-mile area slightly smaller than Tennessee (Central Intelligence Agency [CIA], 2020). About half of the population are descendants of indigenous Mayans who have lived Guatemala since 12,000 BC, speaking 21 different dialects. The other half of the population are predominately Spanish-speaking Ladinos descended from Spanish conquistadores who invaded Guatemala in 1523 (Summer et al, 2019). Teaching Guatemalan comadronas about obstetrical emergencies may warrant different approaches, one for urban Ladinos and one for rural indigenous Mayans.

Indigenous Mayans are considered a marginalized group due to facing higher poverty rates (Nieves Nelazques et al, 2018), being more likely to live in rural areas with less access to resources (Chary et al, 2013) and facing worse health outcomes than Ladinos. Indigenous women endure a higher Maternal Mortality Rate (MMR) than Ladinos, accounting for 70% of maternal deaths annually (Martinez et al, 2017; Stollack et al, 2016). Indigenous Mayans also suffered disproportionately during the Guatemala’s civil war from 1960 to 1996 (Public Broadcasting System, 2011). Indigenous Mayans comprised 83% of two million injury victims (Hernandez, 2017) and 73% of 200,000 mortalities during the longest civil war in Latin America (McFarland, 2012). The country’s most recent MMR is predictable in the aftermath of Guatemala’s 36-year civil war. The MMR was 72nd highest in the world at 95 deaths per 100,000 births in 2017 (CIA, 2020).

In addition to disparate urban and rural populations, Guatemala lacks a consistent maternity care system. Obstetricians attend births in hospitals but the country’s institutional capacity for to medical services can only accommodate 20% of births (Goldman et al, 2001). Further, doctors charge more than twice the average monthly household consumption while comadronas ask for half what doctors charge and will accept payment in kind from patients without money (Goldman et al, 2001). Instead of going to the hospital, most Guatemalan women prefer to birth at home with comadronas (Juarez, 2020), who are well-respected community leaders often spiritually called to their vocation (Goldman et al, 2001). Guatemala doesn’t offer university training for midwives. The most highly educated midwives are called parteras. They receive training at birth centers often from foreigners. Comadronas, who are apprentice-trained and have low literacy, attend the majority of births (Fahey, 2013; Hernandez et al, 2017; Kestler et al, 2013, Walker 2015). Comadronas attend 90% of births in rural areas (Summer et al, 2019) and 60-70% of all births (Zeltzer, 2018) In 2018, 23,320 comadronas were registered with the Guatemalan Ministry of Health (Zeltzer, 2018).

The government has offered since 1955 training programs for comadronas that have been modified several times (Goldman et al, 2001). Currently, the government program is 15 hours a day for eight days and is taught by a nurse with at least one year of education (Goldman et al, 2001). Topics include basic hygiene and how to identify “signs of danger” so complicated cases can be transferred to hospitals (Zeltzer, 2018) Practicing midwifery is illegal without the government training (Goldman et al, 2001). Licensing for midwives was introduced in 1935 (Goldman et al, 2001). In exchange for attending government trainings programs, comadronas are supposed to get a stamp to sign birth certificates, a duffle bag with birth supplies, and a Birth Log with simple color pictures of “signs of danger” to remind comadronas when to transfer patients to the hospital, however, government programs are not consistently offered (Thompson, 2014). Nearly 70% of Guatemala’s comadronas have attended the trainings (Goldman et al, 2001). Unfortunately, the trainings have not changed comadrona knowledge (Summer et al, 2017)

Criticism of the government programs are that they are culturally insensitive because they are presented in Spanish with written material and condemn comadrona practices (Maupin, 2008; Walsh, 2006) Understanding how to best educate low-literacy indigenous Mayans, such as comadronas, is essential to curtailing the country’s MMR, as comadronas are crucial health care providers that are uniquely poised to 1) detect obstetrical emergencies that occur in homes births, 2) intervene if their training permits, and 3) refer patients to hospitals in they cannot intervene themselves. Methods from a new government training in 2014 and three non-governmental teachings for comadronas will be reviewed.

Previous literature has demonstrated a significant change in knowledge among rural comadronas after attending non-governmental programs when they were intensively trained (Thompson, 2014) or when the trainings were culturally sensitive because they were presented orally in the native language of participants (Garcia et al, 2012; Garcia & Dowling, 2018) A paucity of data exists regarding change of knowledge among comadronas in urban Guatemala.

Further, limited data is available about knowledge retention among comadronas in urban and rural Guatemala. A follow up study in 2017 with comadronas in Sarstun, one of the most remote areas of Guatemala, on the Belize border with some of the worst health outcomes in the country, revealed comadronas did not retain knowledge eight years after a non-governmental culturally sensitive teaching. A small sample of Sarstun comadronas in 2009 initially showed a change in knowledge when tested immediately after the non-governmental teaching (Garcia, et al, 2012). When retested on the same material in 2017, Sarstun comadronas did not retain knowledge about addressing postpartum hemorrhage (PPH), which is the leading cause of maternal death in Guatemala (Pan American Health Organization, 2017). More data is needed at a closer interval to further explore this finding.

In addition, none of 13 comadronas from Sarstun who participated in the original non-governmental training in 2009 still had laminated Take Action Cards in 2017 to remind them of steps for addressing PPH. The cards display complex, black and white drawings of obstetrical emergencies to encourage knowledge retention after the 2009 training. The cards were part of the ACNM’s Home-Based Life Saving Skills (HBLSS) Curriculum. Granted, revisiting Sarstun comadronas ideally should have occurred in a closer interval than eight years, as literature shows knowledge retention decreases after six months (Garcia et al, 2010; Weiss-Laxer, et al, 2009; Mosby, et al, 2015) However, Sarstun comadronas may not have kept their Take Action Cards, regardless of the interval between trainings, because Sarstun comadronas may not have understood drawings on the cards. One elderly comadrona held her Take Action Card upside down during the 2009 non-governmental teaching, casting doubt of whether the cards were culturally competent and aided in initial understanding and later knowledge retention.

Comadronas might better understand simple, color drawings from a slightly new government training program introduced in 2014. The government trained nearly 3,000 comadronas to identify obstetrical emergencies, called “signs of danger” in Guatemala (Lopez et al, 2014). Comadronas who attended the 2014 government trainings were given Birth Logs with simple, color drawings to remind them of the “signs of danger” (Garcia & Dowling, 2018). Comadronas who participated in the 2017 non-governmental trainings appeared to understand the simple, color drawings from Guatemala better than complex, black and white drawings from the U.S. (Garcia & Dowling, 2018). However, this interpretation was based solely on observation, not on data. A paucity of data exists about reinforcing knowledge retention with drawings among indigenous low-literacy indigenous Mayanas, such as Guatemalan comadronas.

This study has two aims. One is to evaluate which drawings best reinforce teaching about obstetrical emergencies among urban comadronas. The other aim is to evaluate the affect of a culturally sensitive teaching on knowledge about obstetrical emergencies among urban comadronas.

Theoretical Framework

Dr. Madeline Leininger’s Theory of Culture Care Diversity and Universality provided the framework for this mixed-methods observational study. Leininger’s theory holds that combining

generic (or emic) cultural care beliefs, values, patterns and expressions with professional (or etic) care practices is essential for culturally congruent care (McFarland & Wehbe-Alamah, 2019). In other words, generic beliefs from inside the culture and professional health factors from outside the culture in diverse environmental contexts greatly influence health and illness outcomes (McFarland & Wehbe-Alamah, 2019). For this reason, this study began with focus groups to understand the generic care practices of comadronas in urban Guatemala before presenting professional teaching methods from the ACNM. Previous focus groups with comadronas from rural Guatemala informed this culturally sensitive teaching. Data from this focus group will guide future culturally sensitive teachings, following an action research format.

Materials & Methods

Participants & Setting

Several weeks before the study Refugee International volunteers advised nurses at the local Ministry of Health (MOH) about the study. MOH nurses then recruited both Ladino and indigenous comadronas for the study when comadronas came to the MOH for monthly government trainings. No differences in recruitment strategies were practiced for Ladino or indigenous comadronas. Refuge International, is a non-government organization that has maintained three clinics in Guatemala for more than two decades. The founder started Refuge International after attending a medical mission in San Raymundo as a Family Nurse Practitioner student in 2000. Refuge International has a locally run board so the non-profit enjoys a strong relationship with the community.

Seventeen comadronas from San Raymundo participated in the one-day non-governmental teaching at the Refuge International health clinic. San Raymundo is a suburban community comprised of at least 47,000 Ladino and indigenous Mayans who live in a city, town and 10 outlying villages nearly 30 kilometers north of the capital city of Guatemala (National Institute of Guatemalan Statistics [NIGS], 2018). Nearly 31,605 people live in the municipality of San Raymundo, and 15,447 people live in the town of San Raymundo (NIGS, 2018).

The culturally sensitive teaching occurred in a large indoor cafeteria with tables and chairs where comadronas could sit comfortably. An Internal Review Board at the University of Utah gave the study an exempt status. The study met all nine of the ACNM’s Global Health Competencies and Skills. These include the following competencies, global understanding, clinical practice, health equity and justice, professionalism/ethics, communication, leadership, organization & program management, teaching/learning, research/continuous quality improvement, and health system strengthening (ACNM, 2018).

Data Collection

When comadronas arrived at the non-governmental, culturally sensitive teaching, the purpose of the study was explained in Spanish, and comadronas were told that their participation would be seen as consent. All questions about the study were answered, and comadronas were told they could leave at any time. Comadronas then filled out demographic and background data sheets in Spanish. Demographic data included gender, age, years as a comadrona, languages spoken, years of formal education, attendance at government trainings, and ability to read, write and count. Ethnicity was determined based on language spoken. Background data included distance from hospitals, reasons for transferring patients to hospitals, and level of comfort referring patients to hospitals. Finally, participants were asked to identify obstetrical emergencies for the pretest. Answers were compared to a checklist based on the HBLSS curriculum.

A panel of three, doctorly prepared nurse researchers established content validity of demographic and background data sheets, and Fog Index of 0.35, which indicates participants needed three and a half years of education to understand questions on the data sheets. The local community has provided input into the study design and instruments during debriefings after past educational sessions with comadronas. Refugee International volunteers asked questions verbally to illiterate comadronas, and recorded the answers on paper. Volunteers also translated information into Kaqchiquel for indigenous comadronas.

After data collection, comadronas were given juice and cookies while an oral teaching based on the HBLSS curriculum was provided about recognizing obstetrical emergencies, such as antenatal, intrapartum and postpartum bleeding, breast, uterine, urinary or vaginal infections, preeclampsia, birth delay and grand multiparous patients. Role playing and laminated Take Action Cards with drawings of obstetrical emergencies were used to reinforce the teaching. Role playing including scenarios, such as comadronas performing the test for Costal Vertebral Tenderness on each other’s backs and asking, “Does this hurt?” to inspect for urinary tract infections. Another scenario was comadronas demonstrating what they would do if a patient was bleeding too much after birth. The Take Action Cards have complex, black and white drawings of the obstetrical emergencies to remind comadronas what they learned.

Examples of Take Action Cards:
Simple Color Drawings of Antepartum Signs of Danger from the Guatemalan Ministry of Health
Complex Black & White Drawings of PPH from the HBLSS

After the teaching, which was designed to be culturally sensitive by being presented orally in the native language of participants, comadronas were asked again to identify obstetrical emergencies for the posttest. Finally, comadronas were asked to determine the meaning of two sets of drawings of obstetrical emergencies, one in color from a government Birth Log, and one in black and white from the HBLSS.After the teaching, comadronas were thanked for their participation and given birthing kits with blue chux to put under patients, plastic exam gloves, tape measurers, iodine, umbilical cord tape and clamps, scissors and razor blades for cutting umbilical cords.

All participants stayed for the entire teaching. Comadronas requested more information about hypertension and neonatal resuscitation in future teachings. Comadronas were told the next non-governmental teaching would include information about hypertension, and participants would be given blood pressure cuffs if they brought data from their Birth Logs to the future non-governmental teachings.


Change in knowledge was measured by comparing participants’ answers to a 10-item checklist of obstetrical emergencies that included antenatal, intrapartum and postpartum bleeding, breast, uterine, urinary or vaginal infections, preeclampsia, birth delay and grand multiparous patients, defined as having had five previous children. A pretest and posttest were used to evaluate knowledge based on limitations of the Primary Investigator’s time in Guatemala. The pretest/posttest was designed, validated and field tested in various locations throughout the developing world with positive results by nurse researchers who created the HBLSS (Barger et al., 2015) Pretest and posttest scores were the total number of correct answers from the checklist. Scores ranged from 0 to 10. Understanding of drawings of obstetrical emergencies was measured by assigning a percentage of the number of drawings participants correctly identified.


Measures of central tendency and frequencies were calculated by hand, not with a statistical package, to evaluate background and demographic data. A paired t test was used to compare number of correct answers on pre and posttests to measure change in level of knowledge Percentage of correct interpretation of drawings was used to analyze if participants understood the intended meaning of the drawings.


Among the 17 participants, five spoke Katchiquel and 12 spoke Spanish. The mean age of participants was 52, varying from 80 to 40. The mean years of comadrona experience was 22, ranging from 45 to three years. While many participants had attended government trainings, their mean level of formal education was 5.5 years, varying from none to 12 years. Indigenous Mayan participants were less literate and lived somewhat farther away from hospitals than Ladino participants. Indigenous Mayan participants lived an average of 29 kilometers from hospitals while Ladino participants lived an average of 25 kilometers from hospitals. All Ladinos participants could read and write, and eight could count. Three Indigenous participants could not read and write, and four could not count.

Indigenous Mayan participants were less trusting of hospital transfers and less frequently sent patients to hospitals than Ladino participants. Nine Ladino participants felt “very comfortable” and three felt “comfortable” with hospital transfers. Further, 11 Ladino participants had sent patients to hospitals. In contrast, two Indigenous participants felt “very comfortable,” two felt “comfortable,” and one was “not comfortable” with hospital transfers. No Ladino or indigenous participants were “slightly uncomfortable” sending patients to hospitals. Finally, three of indigenous participants had transferred patients to hospitals.

Regarding identification of obstetrical emergencies, the mean pretest score was 3.06 with a SD of 1.436 compared to the mean posttest score of 5.13 with a SD of 1.147. The time interval between the pre and posttest was two hours. Change in knowledge was statistically significant with a p-value of 0.01. Participants also understood 90.4% of simple, color drawings of obstetrical emergencies from a government Birth Log and 78.7% of complex, black & white drawings from the HBLSS.


Educating comadronas about obstetrical emergencies in Guatemala may warrant two approaches, as half the population lives in rural settings and half resides in urban areas. Comadronas, who are mostly indigenous and have low literacy, attend the majority of births in their country where the MMR is the highest in Latin American at 95 deaths per 100,000 births (CIA, 2020). Previous studies have demonstrated that intensive training and culturally sensitive teaching provided orally in the native language of participants changed rural comadrona knowledge about obstetrical emergencies. This study showed that a culturally sensitive teaching presented orally in the native language of participants changed urban comadrona knowledge about obstetrical emergencies. In addition, urban comadronas understood simple color drawings of obstetrical emergencies from Guatemala better than complex, black and white drawings from the U.S.

Limitations of the study are that Kaqchiquel comadronas may have been less likely to participate, leading to potential selection bias. Kaqchiquel comadronas may have been less likely than Ladino comadronas to go to the MOH where nurses speak Spanish, and thus less likely to learn about the study. Further, Kaqchiquel comadronas may have been less likely to understand the teaching, which was provided in Spanish and translated into Kaqchiquel, which could lead to a potential measurement error on the pretest and posttest. In general, Kaqchiquel comadronas were less literate, lived further way from hospitals, were less trusting of hospital transfers and less likely to transfer patients to the hospital than Ladino comadronas. This finding is consistent with other literature reports.


Future teachings about obstetrical emergencies should continue to provide information orally in the native language of rural and urban participants. Future teachings should continue to consider what drawings of obstetrical emergencies rural comadronas best understand for knowledge retention, simple color drawings from Guatemala or complex, black and white drawings from the U.S. In both urban and rural settings, follow up testing for knowledge retention should occur at regular intervals, such as every six months, and comadronas should be encouraged to keep data in their Birth Logs to evaluate whether teachings about obstetrical emergencies are changing practice. Ultimately, a change in comadrona knowledge should lead to correct identification and timely referral of obstetrical emergencies in order to address the country’s MMR.


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Virtual Shadowing as an Effective Approach to Gaining Exposure to the Field of Emergency Medicine


Physician shadowing plays a critical role in the education and professional development of medical students during their pre-clinical years. Many medical education programs require undergraduate shadowing as criteria for admission1. The COVID-19 pandemic has severely restricted access to the hospital for medical and premedical students, thereby impeding their career exploration, education, and access to potential mentors. The purpose of this study was to evaluate our novel virtual shadowing program in the emergency department for interprofessional health sciences students.

Medical students, particularly during their pre-clinical training years, rely heavily on physician shadowing to become more familiar with the clinical environment. Shadowing is often used for career development in order to help students foster relationships with potential mentors, explore different fields of medicine, gain experience with patients, and improve their medical reasoning skills through observation2-4. Many medical education programs implement some variation of the Association of American Medical College’s (AAMC’s) Careers in Medicine curriculum to equip students with the information needed to make an educated decision about which field of medicine they will choose to practice in5. The need for a Careers in Medicine program within medical schools is well accepted, with increasingly more schools choosing to formally adopt such programs as part of their curriculum6-9.

Shadowing typically involves a student following a physician for part of a shift. This allows the student to gain understanding of the physician’s role in patients’ medical care and observe the physician performing interviews, physical exams, procedures, etc.10,11. Traditionally shadowing has been an in-person experience however, due to the COVID-19 pandemic these in-person shadowing experiences were severely limited or suspended for pre-clinical medical students. Our institution’s emergency department (ED) was particularly impacted due to it being the front line in managing the pandemic. Thus, student shadowing was deemed too dangerous given the high risk of viral exposure in the ED.

Although the suspension of in-person shadowing was justified, it is also quite possible that restricted shadowing could result in long-term disruptions in student career development. Lack of exposure to fields that are often not required in the clinical years, such as Emergency Medicine (EM), may limit students’ ability to make an informed decision about fields they have not had any exposure to. As a result, it may be difficult for students to make educated decisions about choosing fields such as EM for their clinical experiences or career. Additionally, shadowing has traditionally been an avenue for students already interested in EM to identify career mentors. However, the limitations on shadowing could curtail their opportunities to expand their social network.

To help fill the void left by the suspension of in-person shadowing, our team of faculty and students at a major academic medical center developed a virtual shadowing experience for pre-clinical students in EM with the hypothesis that a structured virtual shadowing experience could supplement or replace the in-person shadowing experience. To test this hypothesis, our team first designed and implemented a virtual shadowing pilot program. We then assessed the efficacy of the pilot program through surveys given to the students who participated. The results of this program are informative and applicable to helping medical schools successfully use virtual shadowing as a supplement to in-person shadowing.


Design and pilot of virtual intervention

With the approval of the Institutional Review Board, the team first designed and implemented a virtual shadowing pilot program. After a literature review of shadowing best practices, the authors designed a virtual shadowing program with the aims to 1) introduce students to the ED clinical environment and EM as a specialty, 2) reinforce clinical skills through use of a documentation template, and 3) encourage mentoring relationships between students and faculty. Six ED physicians in academic and community settings volunteered to guide small groups of medical students through virtual shadowing experiences for 2-hour sessions offered during October and November of 2020. Once the schedule for the 2-hour blocks was determined, first- and second-year medical students at the team’s institution were invited to register for the sessions via solicitation emails and social media posts. Up to 10 students were allowed per session. Virtual shadowing was conducted using an official University HIPAA compliant “ZOOM” account on an ED issued telehealth monitor or iPad. Prior to each session the students were emailed a copy of Chapter 1 of the Emergency Medicine Residents Association (EMRA) and Council of Emergency Medicine Residency Directors (CORD) student advising guide to read as an overview of what to expect in the field of emergency medicine. Students were also supplied with a “T” sheet (documentation template) for them to fill out during each patient interaction. The “T” sheets were for student use only and were given to help students organize each patient’s history, develop differential diagnosis, and encourage questions. During each session, the physician would bring the telehealth monitor to the location of each patient interaction, obtain permission from the patient, and then proceed to provide care while the students observed through the camera of the monitor. When appropriate and as time permitted, students were able to ask questions using their microphones or the chat feature within the Zoom app.

Evaluation of intervention (instrument design, data collection, data analysis)

Next, to assess the efficacy of the pilot program, surveys were given to the students who participated. Within 24 hours of the shadowing session, each participant was sent a survey about the shadowing experience and was given 1 week to respond. The survey consisted of 15 questions. The first 4 questions were about demographics, while the next 9 questions were Likert scale questions designed to evaluate the student’s perception of the virtual shadowing experience. The final 2 of the 15 questions were free response questions. The survey was designed, collected, and analyzed using the free online access Google Forms resource. All survey responses were anonymous.


In total, 58 students participated in the experience. Survey responses of these students were collected between October 20, 2020, and November 20, 2020. The overall response rate was 96.6% (56/58 surveys completed). Of respondents (N=56), 13 (23.2%) were second-year medical students, 43 (76.8%) were first-year medical students, 35 self-identified as female (62.5%), and 21 (37.5%) self-identified as male. All participants had, prior to COVID-19, shadowed a physician in-person 3 times or more in the past. Of the respondents, 46 (82.1%) rated the virtual shadowing experience as “effective” or “very effective” at providing exposure to EM. Fifty-three participants (94.6%) said they would participate in virtual shadowing in the ED again, and 48 (85.7%) would do virtual shadowing in another specialty were it available. When compared to in-person shadowing, 34 (60.7%) were somewhat less satisfied and 15 (26.8%) were equally as satisfied. Forty-nine (87.5%) participants would “absolutely” or “probably” recommend virtual shadowing to other medical students.

For the last 3 questions, students were asked to rank the likelihood of each of the 3 following scenarios to occur because of the virtual shadowing experience when compared to in-person shadowing: (1) finding a mentor (2) strengthening rapport with a fellow student with similar career interests (3) connecting with a more senior student with whom I could ask questions about the field. Twenty-three (41.1%) students rated scenario 1 as less likely, 25 (44.6%) rated scenario 2 as less likely, and 24 (42.9%) rated scenario 3 as less likely. The entirety of the student responses and results are included in Table 1.


Themed student feedback is shown in Table 2.



This novel pilot study of a virtual shadowing program for pre-clinical medical students found that virtual shadowing can serve as a feasible, easy to implement, and positively viewed program for medical students. The program was utilized as an alternative to in-person shadowing during the COVID-19 pandemic but could also be utilized as a supplement to in-person shadowing in non-COVID times. The experience allowed for students to interface with EM physicians, residents, and classmates; all of whom the participants may not have interacted with otherwise. During many of the virtual shadowing experiences contact information was exchanged between the students and the physicians. We are hopeful that the students’ exchange with the physicians via Zoom will help them to feel comfortable contacting them in the future for the purposes of mentorship and research.

Based on the student responses, the use of virtually shadowing appears to be a viable supplement to the career development of 1st and 2nd year students. Appropriate incorporation into the career development curriculum has the possibility to enhance the student’s ability to make educated decisions regarding what type of medicine they want to practice5.  With most medical programs requiring career development7, there is potential space for required virtual shadowing to ensure students have a larger breath of exposure prior to rotations and residency selection. Though the mode of observation is different during virtual shadowing compared to traditional shadowing, the goals of shadowing (mentorship, clinical experience, and enhanced medical reasoning) as outlined by Burgess and Zink can still be achieved through the virtual setting.

As a result of this study, we recommend increasing student and physician participation in virtual shadowing. The pilot program proved to be an accessible and effective way to allow a considerable number of students to gain exposure in a small amount of time. One benefit of virtual shadowing is that up to 10 students were able to gain shadowing experience by being virtually present within the examination room without overfilling the space. Another benefit of virtual shadowing is that it is more time efficient than in-person shadowing. For example, in this study using the virtual shadowing approach for 30 days, nearly 60 students were able to shadow an emergency room physician. While student evaluation responses were overwhelmingly positive, to more adequately assess the effectiveness of the virtual shadowing program there needs to be long-term implementation with greater student and preceptor participation. The participation should preferably come from multiple academic centers to increase the cohort diversity. The pilot program for virtual shadowing was easy to set up and required relatively little commitment and demands for both the attending and the student. These characteristics of the program will allow for it to be easily implemented into the career development curriculum at other programs without significant investment of time or resources.

Another appropriate progression of this study is the application of virtual shadowing to other specialties.  Because this study only assesses the use of virtual shadowing within the ED, it would be advantageous to apply the virtual shadowing program to other specialties to assess its viability in other areas. The ease of access for students could attract more students to shadow different medical specialties and may be an attractive primer even in the post-pandemic setting. When implemented, students no longer have to go through the cumbersome task of identifying their own shadowing opportunities. Using a virtual shadowing shift calendar, as was implemented with this pilot, it is very easy for students to be able to gain access to shadowing experiences. One exciting application of the program is the use of virtual shadowing to increase the ease of access for students to gain exposure to rural and otherwise difficult to access areas of medicine. This has the potential to foster more interest/exposure and career development in areas of medicine that desperately need more physicians. 

Although there are numerous benefits of virtual shadowing, there are also some challenges. Certain aspects of the shadowing experience are poorly portrayed through a virtual setting. For example, a shadowing student most likely cannot fully comprehend the atmospheric setting of busy ED or a frustrated patient through a virtual setting. This lack of atmospheric comprehensiveness could lead the student to perceive the field of medicine which they are virtually shadowing to be less interesting than they would have perceived it if they were shadowing using the traditional, in-person approach. Additionally, the lack of personal connection could be negatively perceived by the patient. Although, there were no negative comments made by any of the patients who consented to have the students virtually observe the interaction, it is likely that some patients would dislike virtual observation.

Some students also commented on the lack of personal interaction they felt with the physician and patient during the virtual shadowing experience when compared to their previous in-person shadowing experiences. These findings suggest that virtual shadowing may be an effective supplement for in-person shadowing but should not be considered as a replacement.

The most common area of critique by students for the pilot program was regarding technical difficulties during the sessions, including audio and video quality. These barriers could be addressed by having the attending physician wear a portable microphone or equip the monitor with a higher quality microphone and ensuring that the camera is angled correctly. Although the patient interviews were often easily visible, the visualization of procedures was often more difficult. Using portable stands made this easier. However, if the angle of the camera changed during the procedure the student’s view could end up being disrupted for the entirety of the procedure because the attending or resident were unable to adjust the view until after the procedure was completed. One possible solution is to have an in-person shadowing student be in charge of controlling the camera angle and video quality during the session.


This study is limited by its small sample size and single center design. A greater number of student participation and the participation of additional academic centers would allow for greater analysis of the effectiveness of virtual shadowing. Additionally, students who participated were self-selected which may introduce bias in their survey responses in that these students may have already been interested in EM. Finally, the pilot program did not include an attending physician survey, which could be beneficial for receiving more feedback on how to improve the experience for both physician and student.


Virtual shadowing utilizing mobile telehealth monitors in the ED is an easy way to implement, positive experience for preclinical medical students. Virtual shadowing may be a viable supplement to help students gain exposure to the field of emergency medicine and other specialties.


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