Navigating COVID-19 through diverse student learning communities: importance and lessons learned

Abstract

Purpose

The purpose of this case study is to describe one Southern United States of America (US), historically Black medical school's approach to adapting medical education training through learning communities (LCs) during the COVID-19 pandemic.

Design/methodology/approach

The COVID-19 pandemic created a wide variety of problems for higher education. Classes moved quickly from in-person to virtual instruction with little time for training; faculty and students had to adapt to new learning platforms, learning styles, study techniques and technological challenges. Emotions ran high due to constant change, transitions and numerous unknowns. The LC structure embedded in the curriculum of this US medical school aided in the navigation of these challenges.

Findings

Of the 95 MD1–MD4 respondents combined who responded to the COVID-19 LC survey, 67% rated the LC sessions good/outstanding, 20% average, 7% poor/fair and 5% N/A. When asked if LCs had helped them during the pandemic, overall, 66% said “yes” and 34% said “no.” When asked how LCs have helped during the pandemic, themes emerged related to safety, adapting to feelings of isolation/mental health/emotional support, and academic progress.

Originality/value

The small LC group structure created a sense of security for receiving academic help, emotional support, a network of assistance resources and a place to process COVID-19 losses and insecurities. Receptivity to utilizing the LC structure for support may relate to the medical students' commitment to addressing health disparities, serving the underserved and embracing a medical school culture that values community.

Citation

Mitchell, A.K., Mork, A.L., Hall, J. and Bayer, C.R. (2022), "Navigating COVID-19 through diverse student learning communities: importance and lessons learned", Health Education, Vol. 122 No. 1, pp. 37-46. https://doi.org/10.1108/HE-01-2021-0012

Introduction

The COVID-19 pandemic's impact on higher education has been widespread and fast-moving. While e-learning has been used in some settings for a number of years (Rodrigues et al., 2019), many colleges and universities began transitioning to virtual learning in record time while still having to continue to meet their student populations' educational and emotional needs. Classes moved quickly from in-person to virtual instruction with little time for training; faculty and students had to adapt to new technological learning platforms, learning styles, study techniques and challenges while still mastering the content being taught and studied. Much has been written about learning structures (Bloom et al., 1956; Krathwohl, 2002) as well as theories about communities of practice and the learning environment across disciplines (Lave and Wenger, 1991; Roberts, 2006). Yet, during the pandemic, emotions ran high due to constant change, transitions and numerous unknowns, including factors impacting learning that are not as well studied.

This was uniquely true for medical schools, where tightly packed and in-person reliant curricula shifted to being taught through hybrid or online learning with stricter testing procedures and fewer chances for in-person clinical experience. Pandemic changes and stressors affected medical students' mental and physical well-being (Chandratre, 2020) in addition to the normal rigors of medical school. To address these realities, medical schools must respond to the needs of their students through the implementation of strategies to enhance student coping and mental preparedness (Kazerooni et al., 2020, p. 763).

One education structure to consider for working on enhancing student coping and mental preparedness is the learning community (LC). An LC can be described as a group of individuals sharing common goals, values and ideas that actively engage in learning with and from each other. LCs, an iteration of small group learning, provide opportunities for students to engage in mentoring and wellness activities with support from both their peers and faculty (Shochet et al., 2019). LCs intentionally focus on fostering student engagement and communication, not only with faculty and the curriculum but also with peers and through self-reflection (Ferguson et al., 2009). This is often accomplished through a perceived increase in social and community support.

The purpose of this case study is to describe one Southern United States of America (US), historically Black medical school's approach to adapting medical education training through LCs during the COVID-19 pandemic.

Approach

The medical doctorate (MD) student LCs focus on building knowledge, attitudes and skills related to the Accreditation Council for Graduate Medical Education (ACGME) six core competencies: professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills and systems-based practice (ACGME, 2020). The MD LC program was created to serve a secondary purpose of encouraging relationships and fostering a sense of community during a period of medical class expansion. Students are divided into LCs named after school-based values and culture. Prior to their first day in medical school, faculty assign student LC groups that are racially, ethnically and geographically diverse.

Each LC contains approximately 12–14 students and is facilitated by two to three faculty mentors: at least one teaching in the basic sciences and one from a clinical field. LCs are longitudinal, with students continuing in the same LCs for all four years of medical school. LCs are a required component of a longitudinal interdisciplinary course that blends human values, human behavior, epidemiology and biostatistics, clinical preceptorship, introductory patient diagnosis, wellness, interprofessional education (IPE) and professionalism topics as a series of lectures and activities. Due to the structure of the curriculum and the need for additional clinical experiences in years 3 and 4, the number of LC sessions per academic year descends as students move through medical school: 15 in MD Year 1, 8 in MD Year 2, 4 in MD Year 3 and 1 in MD Year 4.

A typical prepandemic 90-min LC session begins with a faculty-developed discussion guide that is provided to the student leaders at least one week prior to the scheduled session. The student leaders, having signed up to lead the session at the beginning of the year, use the provided discussion guide as a template. From there, they create their session specifics by providing necessary background or instructional materials followed by open-ended questions and student-facilitated discussion. All students in the LC are expected to engage in the discussions. Faculty mentors are present at all sessions to provide clarification or additional information on a topic if needed but avoid taking a leadership role in the session. Each session can begin with an optional 15-min student check-in. This check-in is designed to allow students to speak freely about their current experiences, thoughts and emotions.

In March 2020, all LC sessions were changed from in-person to virtual sessions. In acknowledgment of unique pandemic stressors, LC mentors purposefully encouraged more connection with and among students, focusing less on the scheduled topics. This can be seen in the adjusted schedule. The LC schedule was altered to allow for sessions fully focused on students checking in as well as for other sessions to be particularly catered to pandemic scenarios. Table 1 displays both the prepandemic and current schedule of topics for LCs. To coincide with the schedule, the discussion guides were altered to keep in mind the new foci and the virtual format of the sessions. For example, the introduction to LCs session included discussion on online etiquette, proper quarantine/isolation communication protocols and school-related pandemic resources. In-person interactive activities were also revised or replaced with virtual conferencing activities. Additional group reflections on individual wellness were added to each discussion guide. Several content-specific portions were removed and placed within the course's suggested readings and resources for self-directed learning.

Each year, students complete electronic mid and end of year LC evaluations. The electronic evaluations assess student perceptions of the learning environment, peer-to-peer and student-to-faculty interactions, benefits of LCs and concerns about learning communities. This evaluation includes both Likert-scale questions and open-ended response questions. For academic year 2020–2021, students also completed a short mid-year assessment with a focus on LCs during the COVID-19 pandemic. In this mid-year survey, students self-reported their overall experience so far, how LCs have helped them during the pandemic and how LCs can help in the pandemic and in general in the future. The survey included both multiple-choice and open-ended questions. Students completed the evaluation online using Survey Monkey, a web-based survey software service. Students received links to the survey via their school email.

For both mid and end of year evaluations, open-ended student questions were analyzed using content analysis to identify trends in phrases used by students to describe LC strengths and areas of improvement. Quantitative questions were calculated using the Survey Monkey Analysis feature.

Findings

Ninety-five (95) MD students from across years (MD1, MD2, MD3, MD4) completed a brief survey on LCs and COVID-19 in fall 2020. Of the 95 respondents combined, 67% rated the LC sessions as good/outstanding, 20% rated them as average, 7% as poor/fair and 5% as N/A (Table 2). When asked if LCs had helped them during the pandemic, overall, 66% said “yes,” and 34% said “no.” (Table 3) When asked how LCs have helped during the pandemic, themes emerged related to safety, adapting to feelings of isolation/mental health/emotional support, and academic progress. In the open-ended responses, phrases related to the theme of safety included “COVID-19 precaution reminders (wear a mask, 6 feet of social distancing, wash your hands for 20 s with soap and water),” “safe space for discussion” and “a place to vent.” For the theme of feelings of isolation/mental health/emotional support, sentiments expressed included “adaptation to isolation,” “connection,” “community,” “support,” “encouragement,” “kept me sane” and “forming bonds and friendships with fellow classmates.” In academic progress, the theme emerged from responses related to asking for help “staying on track” and “providing resources both academic and non-academic.”

When asked how LCs could help them with COVID-19 and medical school in the future, students indicated the following suggestions:

1. A call for all LCs to have check-ins at the beginning of each session,

2. More support for managing isolation,

3. Requests for additional LC sessions with the individual LC group as well as across other LC groups to make more connections,

4. Advice on Zoom/virtual learning burnout,

5. Advice on navigating academic testing as well as virtual residency interviewing, and

6. Guidance on how to stay connected.

Lessons learned

During the pandemic, the LCs, held virtually through web conferencing, helped streamline information, empower student leadership, identify support systems and foster relationships between faculty and students as well as peer to peer. There were several lessons learned during this experience. First, there could be some differences in LC experiences by medical school year. The response rate (22%) was too small to do expansive comparisons across the MD1, MD2, MD3 and MD4 responses, yet we included two sets of data categorized by class to get a sense of possible early trends (Tables 2 and 3). MD1 and MD2 students had more scheduled LC sessions during the time period evaluated than MD3 and MD4, which skews the perspectives presented more toward the preclinical years. MD1 students were the first MD class at this institution to start medical school in a fully virtual environment, hence their perspectives may differ from the MD2, MD3 and MD4 students who have had a much greater level of in-person interaction and education in prior years. In total, 77% of the MD1 class respondents to the survey rated their experience as “Outstanding/Good,” higher than any other class response, which suggests an elevated level of support from LCs in the midst of the isolation of the pandemic. It also suggests that the support role of LCs may have been less necessary for those students who had previously experienced in-person learning and had the opportunity to build additional supportive relationships outside of the LC structure.

Similarly, the MD3 class particularly enjoyed the virtual LCs. In previous years, the MD3 students, who were scattered across the metroplex in different clinical sites, noted difficulties with attending in-person sessions due to scheduling and traffic. The change to virtual sessions alleviated some of those student stressors. MD4 students did not have a scheduled session during the time period evaluated but were included as they may have gathered independently of the formal curriculum during the time period as a means of support or connection; this may explain the N/A and low percentage of perception of formal LC curriculum support.

Second, regularly reminding faculty and students to stay flexible, adaptable and open to change in the face of numerous unknowns is helpful in decreasing anxiety for situations outside of their control. LCs served as a vehicle to deliver information to students with immediate student feedback to said information. Third, altering curricular content to make space for check-ins and processing world events is helpful for enhancing feelings of safety as well as a sense of community. Mentors and student leaders were given the flexibility to deviate from the assigned content to use all or a portion of the 90-min session as a student check-in. LC sessions often began with “Roses and Thorns,” an assessment of student experiences, successes and challenges since the last session. This portion of the session enabled students to voice their concerns in a safe space, giving peers the opportunity to support each other in agreement.

Fourth, the virtual learning environment and the in-person physical learning environment function differently. A 90-min, large group in-person session does not necessarily transfer minute for minute in the virtual learning environment. Verbal and nonverbal communication strategies look and feel different in the virtual environment compared to in-person learning; numerous online distractions lead to decreased focus and increased fatigue. During the 90-min LC sessions held via Zoom, students were required to engage by having their cameras on (i.e. Join with Video). This was essential in order to both give and receive verbal/nonverbal feedback from others and simulate “in person” as much as possible to support a sense of belonging. Students being completely aware that LCs are a safe space and that “what is said in LC, stays in LC” began to express specific concerns, such as not being in a quiet space at their fully “occupied” homes, some with multigenerational families; others were in dwellings alone and were deafened by the “silence;” while others were embarrassed of their surroundings, which now were clearly visible on Zoom calls. Nonetheless, amidst these hardships, a sense of camaraderie emerged when “survival skills,” new learning techniques and self-care tips were shared via peer feedback. Yet the one thing that surfaced at the top of the gnawing list of concerns was sustaining their academic grades. In a medical school environment, which already tended to be a highly competitive academic arena, the pandemic only heightened academic anxieties.

When changes happen rapidly, such as those seen during the COVID-19 pandemic, and education is forced to go virtual without adequate planning time, courses may lead to Zoom/virtual learning burnout for both the faculty and students. According to Gaur et al. (2020), similar pedagogical challenges have been experienced in medical education in the United Kingdom as well as around the world. This may be more acute in student preclinical years as their curriculum is more heavily basic science focused and may utilize more virtual instruction during the pandemic compared to later medical school years. Consequently, the opposite may be true for students in clinical years, who may not see each other, either in person or in the virtual space, as often. Virtual LCs may help those students in clinical settings connect with their classmates when other modes are not readily available.

Fifth, committed and continuous faculty for LCs remains one of its strengths. LC mentors are dedicated to their LC not only by attending the LC 90-min group sessions but also holding one-on-one evaluation sessions with each student twice a year at mid academic year and end of the academic year. Through the individual and group interactions, as well as the fact that faculty mentors matriculate with the LC cohort from year to year; mentors become very familiar with their students' typical behaviors and personalities. As it was described by one LC mentor, “we are all in the same storm, but we are not in the same boat.” As such, LC mentors reported that they were able to pick up on nuances when the students displayed signs of struggling and/or voiced mental and emotional hardships. LC mentors were proactive in following up with the students via email or direct messaging in apps such as GroupMe and Facebook. When appropriate, they would encourage the student to seek assistance from Counseling Services or Student Learning Support Services and then follow up with the student at a later date. Additionally, based on faculty feedback, Counseling Services conducted an in-service for LC mentors on how to interact with students about whom they were concerned.

Sixth, LCs must continue to be relevant and timely or they risk being seen as an “add-on.” With a tightly packed curriculum, LCs can potentially become just another time commitment. Some students may find the loosely structured, conversation-focused LC sessions less critical in comparison to other coursework. It is important for faculty, student leaders and student participants to commit to the sessions. This engagement includes equal and active participation from all members of the LC. The relevance of the session should also be included in the discussion guide and explained during the conversation. A focus on the importance of self-reflection, peer mentoring, active listening and student engagement can enhance positive student perceptions of LCs.

These six LC lessons:

1. Noting the unique needs of different years in medical school,

2. Teaching and practicing adaptability and flexibility,

3. Encouraging student check-ins,

4. Acknowledging the differences, strengths and weaknesses of in-person versus online sessions,

5. Recruiting and maintaining committed faculty, and

6. Continuously assessing discussion topic relevance and student engagement, highlighting the complex nature of rapidly changing medical educational programs.

This time in medical education history calls for systematic innovation and ingenuity to continue training future physicians (Sahi et al., 2020). The call for innovation is particularly important in light of COVID-19's and numerous other health disparities' disproportionate impact on Black, Indigenous and People of Color (CDC, 2020). Our student body is comprised of more than 80% racial and/or ethnic minority students with a majority of students choosing primary care specialties in residency training. Medical school LCs should continue to evolve and change based on faculty and student feedback to address the needs of an increasingly diverse student body. This allows for streamlined and effective programming in service to future medical students and in future challenging times. As the USA approaches a “quasi normal” postpandemic, the impact that virtual learning had on current students' experiences needs to be monitored over the entirety of their time in medical school. Assessment of the cohorts affected by the COVID-19 pandemic will be essential to identify if unusual struggles or needs for resources arise.

Originality

Perspectives from historically Black colleges and universities (HBCUs), particularly those focused on community engagement and service, widen the conversation around medical school offerings and curricula. Underrepresented students often come into medical school with lower MCAT scores compared to their counterparts (Lucey and Saguil, 2020). Students that are underrepresented in medicine may also experience different external pressures, cultural norms and realities that could be affected by an event like a pandemic. However, as Gasman and Nguyen explain, HBCUs are experienced in the transformation of these students from applicants to high-achieving and prepared professionals (2015, p. 12). Producing a competent and diverse healthcare workforce is essential in the quest for health equity and combating health disparities (Marrast et al., 2014). To retain and support a diverse medical student body, there must be consideration for the social determinants of health that may affect the global and national student population differently. Students choose HBCUs in part due to their environment, which focuses on mentoring and relationship building (Gasman and Nguyen, 2015). Since HBCUs are known for strong relationships and in-person experiences, a communicable disease pandemic creates challenges in maintaining the strengths of campus life through virtual experiences. This paper describes using LCs as a vehicle to create and maintain relationships, receive real-time feedback from students and monitor student well-being in the absence of in-person experiences.

This institution's values and mission attract students who are interested in health equity, service to the community and the importance of diversity in providing culturally appropriate health care, particularly for people of color and underserved urban and rural populations. Leadership, faculty and staff work together to recruit students who align with this culture and mission. This process creates a medical student body with a diverse set of backgrounds, cultural and social representations and community affiliations. The student body represented in this case study is composed of more than 80% racial and/or ethnic minority students, with a majority choosing primary care specialties in residency training.

Medical student success has been attributed to three key elements: (1) milieu and mentoring, (2) structure and content of the curriculum and (3) monitoring (Elks et al., 2018). LCs, part of all three key elements, are ingrained in both the curriculum and the culture. LC structure is used as an organizational basis for group work within courses, large school events and student-initiated meetings. Recruitment strategies, student body diversity and LC permanence are all factors that may contribute to the student body's amenability to sharing and reflecting with both faculty and peers.

The abruptness of the COVID-19 pandemic ushered in panic and insecurities. By utilizing the already established LC structure intrinsically built into this medical school curriculum, the cohesive small groups easily connected and were able to address concerns as a team. Navigating uncharted territories together brought a sense of security and further bonded the small LCs. Mentors and students alike voiced their uncertainties of the future, all while being supportive of one another. The LC structure was a forum to process academic anxieties, emotional concerns, COVID-19 losses and insecurities.

When changes to curriculum are mentioned, the focus is often on content-specific courses and not on academic and student support services. However, by focusing on students' ability to cope with stressors and self-reflect, students become more equipped to perform in their other coursework as well. During the pandemic, students were fearful of losing their academic momentum. Utilizing the LC model, peers began receiving academic assistance from each other. The sharp edge of competitiveness was replaced with collaborative efforts to see each other not only survive but also succeed. The LC students began to lean on each other and share what academic techniques worked and did not work for them. Additionally, this medical school has institutional resources that offer Student Learning Support Services, of which LC mentors frequently and intentionally remind the students to utilize. The Student Learning Support Services reported that many students utilized tutoring services during the pandemic, and some participated in the workshops.

This LC structure was already robust and impactful but became helpful as both a mode of teaching and of support for students during the pandemic. Students were able to interact with each other in a safe space that fostered validation and a sense of security. The faculty mentor involvement and relationship with the students were strong and worth the effort and investment. The students received assistance from their LC mentors, but perhaps, most importantly, they learned to be resilient from one another in these times of uncertainty.

Conclusion

The COVID-19 pandemic has created both challenges and opportunities for medical education. It is clear from this case study that finding ways to continue to create a sense of safety and community during times of stress and unpredictability are key for faculty and students at this institution. The preexisting LC structure appears to be an advantageous curricular component for adapting medical education during a pandemic, as well as creating a sense of safety and community. As time goes by, and space is intentionally made for reflection, curricular change may need to occur to assess what modes of medical education can remain virtual as opposed to in-person, as well as increase or decrease learning sessions based on student need. O'Byrne et al. (2020) call for pandemic preparedness content to be added to medical education curricula. As medicine continues to evolve, pandemic preparedness education will need to include not only the biomedical and research aspects of COVID-19, but also the psychosocial components for managing the lived realities of future frontline healthcare providers.

Table 1

Prepandemic and current LC schedules

Prepandemic LC schedule		Current LC schedule*
All sessions are in person sessions		All sessions are online via zoom
Session year	Learning community topics	Session year	Learning community topics
MD-1	Medical school dilemmas	MD-1	Medical school dilemmas
MD-1	Introduction to LCs/Setting up ground rules	MD-1	Introduction to LCs/Setting up ground rules/Online etiquette
MD-1	Self-assessment	MD-1	LC check-in
MD-1	Communication	MD-1	Communication and conflict management
MD-1	Conflict management	MD-1	Student choice/Current events
MD-1	MD 1/MD 2 meet and greet	MD-1	MD 1/MD 2 meet and greet
MD-1	It's a marathon, not a sprint	MD-1	Professionalism
MD-1	Ethics	MD-1	It's a marathon, not a sprint
MD-1	Current events	MD-1	Ethics
MD-1	Leadership	MD-1	LC check-in
MD-1	Cross-cultural experiences	MD-1	Cross-cultural experiences
MD-1	Career panel	MD-1	Career panel
MD-1	Navigating the healthcare system	MD-1	Student Choice/LC check-in
MD-1	Optimizing personal assets	MD-1	Optimizing personal assets
MD-1	Healthcare reform	MD-1	Healthcare reform
MD-2	Summer reflections	MD-2	Student updates and summer reflections
MD-2	Strategies for success	MD-2	Student check-in
MD-2	MD 1/MD 2 meet and greet	MD-2	MD 1/MD 2 meet and greet
MD-2	Sustaining balance in 2nd year	MD-2	Email check-in
MD-2	Implicit bias and unearned privilege	MD-2	Implicit bias and unearned privilege
MD-2	Death and dying	MD-2	Death and dying
MD-2	Looking back, looking forward	MD-2	Looking back, looking forward
MD-2	Something uplifting	MD-2	Something uplifting
MD-3	Adjusting to 3rd year/Maltreatment	MD-3	Adjusting to 3rd year/Maltreatment
MD-3	Career selection and self-awareness	MD-3	Career selection and self-awareness
MD-3	Looking back/Looking forward	MD-3	Looking back/Looking forward
MD-3	Taking on year 4/Advice to rising 3rd years	MD-3	Taking on year 4/Advice to rising 3rd years
MD-4	Final farewell	MD-4	Final farewell

Note(s): *All sessions were modified for a virtual platform and optional check-ins were encouraged in the first 15 min of each session. Pandemic related questions and resources were also added to preexisting topics

Table 2

MD1-4 students: reflecting on your learning community experiences from Summer 2020 through Fall 2020, please rate your overall experience so far

Student year	Outstanding/Good	Average	Fair/Poor	N/A
MD1	77%	17%	5%	0%
MD2	59%	26%	11%	4%
MD3	67%	19%	6%	6%
MD4	0%	0%	0%	100%
*Combined total yr 1–4	67%	20%	7%	5%

Note(s): *Data across all years combined, no distinction made in student year

Table 3

MD1-4 students: have LCs helped you navigate your medical school semester during the pandemic?

Student year	Yes	No
MD1	86%	14%
MD2	41%	59%
MD3	71%	29%
MD4	0%	100%
*Combined total yr 1–4	66%	34%

Note(s): *Data across all years combined, no distinction made in student year