Our study is the first to explore UK physiotherapy students’ perceptions of the online learning delivery during COVID-19 pandemic. Our novel and key findings include that overall students’ surveyed (79%) felt that the online learning delivery had a negative impact on their understanding of the subject and were disadvantaged compared to face-to-face traditional provision (mean 4.14 ± SD 1.06). Online physiotherapy delivery produced low student satisfaction, leaving respondents feeling disadvantaged by the model with decreased levels of engagement and the ability to practice ‘hands-on’ skills, a cornerstone of the profession. Despite this, physiotherapy students did highlight some advantages to online learning and preferred a mixture of synchronous and asynchronous approaches to delivery, which should be considered when designing pedagogical strategies to create as many learning and engagement opportunities as possible.
Transition to online learning
Over half of the physiotherapy students who completed the survey were apprehensive about the transition to online learning. This was reinforced by qualitative comments reflecting that the pedological delivery change may impact students’ ability to practice clinical skills.
‘I have found the transition very stressful, and I’m worried it is going to affect my clinical skills and future employability.’
‘It’s been really difficult, and I feel I’m missing out on a LOT of hands-on experience that is vital to our course.’
Similar experiences have been cited in college students who also reported significant challenges in their learning and life conditions due to the necessity of rapid adjustment and the uncertainty brought by the COVID-19 pandemic . University business students have acknowledged these challenges also with a negative perception of online learning . The new digital pedagogy was deemed inferior to the traditional on campus delivery. The shift to an online teaching strategy requires faculty to strive to understand both the technologies associated with e-learning whilst understanding the need to fundamentally change and transform pedagogical approaches to meet the instructional needs of online students [35,36,37,38,39]. A further layer of nuance is created by the practical nature of the physiotherapy discipline, ensuring that educators need to reconceptualise their teaching methods to meet the demands of an online paradigm shift .
Perceived advantages and disadvantages of online learning
In addition, to a sense of disadvantage, respondents were ‘impartial’ (2.76 ± 1.13) when asked if they were satisfied with the online learning approach provided within their degree. Online instruction has previously been considered a less satisfying learning experience for students . A number of perceived disadvantages of online learning were suggested by respondents with decreased cohort identify, lack of peer feedback and the inability to develop close working relationships (Table 3) recognised as drawbacks of the approach. Conventional classroom socialisation has been identified as a missing component of an online delivery strategy,  with real time sharing of ideas, knowledge and information partially absent from the digital world . Ke and Xie  suggest online curriculums may only allow superficial communication between students and lecturers which can impact upon the way content is absorbed and understood. Many challenges with online learning have been highlighted in studies across the globe, including connectivity issues, availability of the required technology, digital competence, home distractions and reduced student motivation [17, 43, 44]. This was replicated through our study in both quantitative and qualitative responses with a lack of designated workspace (50%, 118, 44 to 56), connectivity issues (63%, 149, 57 to 69) and confidence in using technology (17%, 40, 13 to 22) all acknowledged as barriers to online learning.
‘I frequently lose internet connection during sessions resulting in me missing key information and discussions, which gets really frustrating.’
‘I simply can’t concentrate to the same extent as when I am on campus, due to family at home, it’s hard to focus.’
‘I find myself having a lack of daily routine, before we had a schedule and now, we have the freedom of pacing ourselves, which decreases my motivation.’
It is possible that the resulting dissatisfaction of UK physiotherapy students was in part due to previous traditional on campus delivery and comparisons made against this norm.
Survey studies completed during the COVID-19 pandemic in India,  Pakistan,  Libya,  Philippines,  and Poland  have reported that the majority of medical students had a negative perception or expressed dissatisfaction towards online learning. In the UK, conclusions from 2721 medical students across 39 medical schools, suggested students did not find online teaching to be engaging or enjoyable, with limited opportunities to ask questions, and did not find it as effective as face-to-face teaching . Dost et al.  reported that 82.17% of students felt that they could not learn practical clinical skills through online teaching with the authors acknowledging that clinical skills remain a pertinent barrier to online teaching. This concern was also expressed by physiotherapy students in our survey, with 94% of respondents feeling disadvantaged by the reduced opportunity to practice ‘hands-on skills,’ and 63% reporting that they were concerned this would affect their future employability. Although further exploration of this is beyond the reach of this study, it would be pertinent to investigate the longer-term impact of the shift to online delivery during the COVID-19 pandemic on the acquisition of clinical skills, student success in examinations and employment.
In the existing literature, students have reported experiencing a lack of motivation, difficulty concentrating, decreased faculty and peer interaction as further limitations of online learning . In continuity with the aforementioned studies, commonly perceived barriers to using online teaching platforms included family distraction (26.76%) and poor internet connection (21.53%). The accumulative effects of these negative perceptions to online learning using metrics such as student attendance and achievement were not investigated in this study. However, in nursing students, investigations have shown that that academic performance was inversely related to the students’ experience, with 43.6% considerably affected and 30.6% greatly affected by the transition to online learning . This outcome may imply that the overall dissatisfaction, anxiety towards online learning and perceived barriers that have been identified, may also have a contributing impact not only on the students experience but also on other critical variables including engagement, achievement and overall success during this period.
Despite respondents’ overall dissatisfaction with online learning within our study, perceived advantages were identified. This method of delivery can be extremely convenient allowing students to engage at times and in locations that are flexible . Just under half the student physiotherapists surveyed agreed that such flexibility is a benefit of an online delivery (49%, n =116, 95% CI 43 to 55). This was especially important during the COVID-19 pandemic where students experienced lockdown rules or periods of isolation. The improved use of technology and digital skills (58%, 137, 52 to 64), ability to learn at one’s own pace and the convenience of home learning (49%, 116, 43 to 55) were all suggested as advantages of online teaching. Some further examples of advantages highlighted by students were evidenced in their qualitative responses.
‘The increased use of virtual meetings and lecturer catch-ups have increased the accessibility of the teaching team.’
‘I like the safety of the home environment as it’s less intimidating compared to large lecture theatres and practical sessions.’
‘I am more productive at home with more time for study and research, due to not having to travel to campus.’
Similar benefits have been identified by UK medical students, with reduced travel time, increased flexibility, the ability to learn at an individual pace, increased comfort and reduced costs associated with online teaching approaches .
Synchronous and asynchronous delivery
A mixture of both synchronous and asynchronous delivery approaches was preferred by respondents. The ability to clarify learning with faculty (87%, 205, 82 to 91) and the structured nature of a synchronous delivery pattern (70%, 165, 64 to 75) was valued by the majority of physiotherapy students surveyed. Synchronous delivery has resulted in overall positive experiences reported by students across sectors including education and technology [50, 51]. Such synchronous delivery can facilitate a stronger feeling of connection to peers and faculty,  a perceived disadvantage of online learning identified by physiotherapists in our study. A community of practice is developed through the increased student engagement provided by real-time association between students and academic staff [11, 53]. The benefits of synchronous delivery included a stable platform for student communication, increased task focus, which infuses a greater sense of participation whilst increasing student outcomes [54, 55]. Qualitative themes emerged highlighting the importance of student interaction during synchronous sessions (Table 6). Active learning and engagement are imperative for student learning and the development of collaboration with peers is intrinsically linked to students’ perceptions of engagement [56, 57]. It is important that when the physiotherapy curriculum is delivered online, a range of pedagogical activities are undertaken to engage cohorts, in order to improve satisfaction which is linked to student success.
Asynchronous delivery was also perceived to provide benefits to the physiotherapy curriculum delivery. Respondents found the flexible learning strategy (76%, 179, 70 to 81), where recording of resources could be viewed multiple times (80%, 189, 75 to 85) allowed them to learn at their own pace (74%, 74, 68 to 79). This was highlighted by the qualitative theme ‘pre-reading materials’ (Table 7). The advantages of a flexible approach to learning with a self-paced approach to study has previously been acknowledged [10, 58]. Interaction can still be achieved, e.g., discussion boards, allowing students the opportunities to fully express themselves without the time pressures of live interaction and responding directly to questions in real-time . Two further themes were derived from students responses within our study (Academic input; Learning validation) with several additional suggestions made to enhance interaction both within and following asynchronous sessions (Table 7).
Respondents were ‘impartial’ (3.13 ± 1.18) when asked if they felt supported by the academic faculty during online learning sessions. Importantly, just under half of the respondents (45%) felt that the faculty had the necessary skills to deliver effective online content meeting the curriculum outcomes. A wide range of teaching strategies were experienced, similar to the variety a traditional on campus delivery would include, however respondents acknowledged inconsistency in academics technological proficiency or confidence to teach online.
‘Some lecturers need additional support to improve their technical literacy with new features and ensure they have the support necessary to engage with and deliver these online classes’.
‘Most staff are very technologically proficient or can figure out a solution to a problem quickly. However, one member of staff is so confused by technology it is cringeworthy and my peers and I dread any interaction with them online.’
At the start of the lockdown period within the UK, academics were asked to transition contemporary teaching online in what has been described as ‘emergency remote teaching’ [60, 61]. The lack of preparation and planning time to deliver a curriculum which was not intended for an online delivery method may explain why respondents felt some lecturers lacked the necessary skills to provide effective online education. Faculty members new to online learning take time to understand their different roles and responsibilities in the new modality of learning and teaching [35, 62]. It is the pedagogy and not technology which is critical to the success of online delivery [63,64,65]. Staff having the time to plan and organise effective learning strategies, embracing new skills to reach distance learners, will provide a more enriching student experience [35, 38]. Understanding lecturers’ perceptions of online learning within healthcare would be an important step to develop competence in the area.
A limitation of this study includes the possibility of responder/non-response bias . It is possible that students who responded to the questionnaire are not representative of the entire target population . Whilst the approach undertaken was applied to capture students’ overall perceptions of physiotherapy online learning in higher education, further research is required to understand the reasons for respondents’ answers. These should be measured against important student outcomes in terms of clinical proficiency, achievement and employability. Future research should also explore how the academic faculty perceived the shift from traditional face-to-face campus delivery to a hybrid or purely online delivery model. This would provide a more complete picture of key stakeholders in higher education. With the emergence of mainstream telehealth, a solution to many access barriers and a viable and effective alternative for those who cannot access mainstream physiotherapy,  it is imperative that physiotherapy students are digitally competent. As higher education institutions review on-going provision to ensure that students are prepared for the challenges of the healthcare system,  the adoption of online learning and the advantages of a hybrid delivery model, need to be implemented with consideration to the challenges described in this survey.
Furthermore, as students become familiar with this pedagogical approach, additional exploration would provide a clearer perspective of attitudes towards online learning. Future investigation of key constructs identified from this exploratory study would help to provide clarity of how the pedagogical landscape has evolved. ‘Student engagement’ (e.g. attitudes towards online learning), ‘cohort identity’ (e.g. peer interaction and support), ‘standards of delivery’ (e.g. digital platforms, staff IT competency) and ‘barriers to learning’ (e.g. connectivity, family responsibilities, digital literacy) were all identified as key constructs from this investigation. Evaluation of these constructs would help to establish how this pedagogical approach has developed in physiotherapy education and if adherence to online learning is valued by future cohorts as we emerge from the pandemic.