The most striking result to emerge from the data is the extent to which the COVID-19 pandemic affected various areas of the respondents’ work and how separate factors related to it seemed to intertwine among medical teachers’ diverse duties. The statements of the respondents demonstrate a process in which the first response to the emerging crisis was a rapid decline in their perception of their self-efficacy. This was followed by the subsequent rebuilding of task-specific self-efficacy and gradually maturing to a growing sense of general self-efficacy. The deterioration in self-efficacy in the first phase was aggravated by the specificity of the work of clinical teachers, resulting in a sense of fear and helplessness. Then, as time passed, the respondents built back their self-efficacy with a sense of responsibility for others, at first in minor tasks, aiming to maintain the continuity of the didactic process, and then, this process seemed to evolve and started to involve building a sense of self-efficacy not only for individual tasks but also their performed role. Among the many factors that affect self-efficacy at various stages of responding to the crisis, the ones that deserve special emphasis include the multifaceted nature of interpersonal relations and selected elements of organizational culture and institutional support—described in detail in dedicated sections below.
The decline of self-efficacy in the first phase of the crisis
The pandemic significantly affected the everyday functioning of both the sector of higher education and the functioning of healthcare facilities. The everyday functioning of clinical teachers in both environments simultaneously multiplied the potential factors, directly and indirectly, influencing their sense of self-efficacy in both roles performed, as shown in Fig. 1.
Factors indirectly (solid lines) and directly (dotted lines) affecting clinical teachers’ self-efficacy during the first phase of the health crisis
The factor that most often appeared in the respondents’ statements were unprecedented changes in the first phase of the crisis in response to a hitherto unknown threat and epidemiological precautions introduced both at hospitals and at the University that led to changes in their everyday functioning, structural and organizational redesigns of either of those environments. In the hospital setting, these involved the introduction of online consultations with patients, limited numbers of patient admissions, and the scope of performed procedures due to pandemic restrictions. At the same time, at the University, all classes with students were moved to distance learning forms, including the clinical and practical ones, since all wards and clinical hospitals were closed for students to prevent the spread of the virus.
The situation was additionally exacerbated by the frequency and unpredictability of pandemic restriction changes resulting in teachers’ sense of uncertainty and lack of stability. Teachers had limited opportunities to freely plan their classes as they saw fit, with a simultaneous constant need to monitor frequently changing recommendations and guidelines on the new virus, which at some point made it impossible to track them.
R2: “I will say this: planning classes before a pandemic, I mean, it may sound strange, but it was much, much, much, much simpler. I just had a flow chart of things that I do, and simply by going through my classes, I was ticking them off—I showed, I did, I passed, I questioned. During a pandemic, it is not that simple anymore because I have to adapt to whether I will or will not be able to do something, so it is often the case that although I have something planned, I move it to later because, for example, we do not have the possibility and I will have to do it later when I have such an opportunity because the restrictions will be reduced […] so my plans this year were actually changing from week to week.”
R24: “These frequent changes, such as the ones introduced by the University, related to the didactic process and work-related imposed by the Director [of the hospital] were sometimes difficult because there were frequent changes. For example, in one week, the ward was completely closed to scheduled patients’ admissions and there were only acute admissions, then the scheduled ones were restored […] it was changing very often.”
The changing recommendations and regulations were accompanied by an increased number of duties, a large part of which were completely new and significantly different from the specificity of the activities with which the respondents were familiarized so far. The number of patients needing help increased across various fields of medicine, exceeding the capacities of wards and healthcare personnel. Additionally, some respondents or their colleagues started to work at COVID-19 wards, which entailed further burden.
R4: “We also had a huge burden related to the enormity of patients who suddenly needed help, so there was the question of the willingness and the time possible to devote.”
R8: “We, too, as clinicians, collided with a different reality in the clinic, and that was also something we had to learn a bit differently because we had to redesign one department. The work system in the ward was different. Some of us went to the COVID hospital, so our normal activities were also turned upside down, we had teleconsultations with patients at the clinic, not physical visits.”
Apart from the clinical overload described above, their preparation for online classes also took significantly more time than before the pandemic. As a result, respondents experienced a sense of increasing pressure accompanied by a lack of time to deal with all emerging tasks. This seemed to negatively affect respondents’ sense of self-efficacy.
R4: “the amount of work put in its preparation, coordination, the preparation of the [educational] material was enormous. It really was incomparable to the preparation of traditional classes, also absolutely much more work […], not all assistants wanted to be involved in it on an equal level.”
This observation finds confirmation in the words of another respondent whose department, due to the shape of the class schedule, had more time to prepare for online classes, which gave them more comfort and a sense of relief.
R8: “We probably even had such comfort in quotation marks that we had such a gap in diabetology that there were many classes in early September, October, and November, so they took place as normal. When the lockdown came, we did not have diabetology right away—it was sometime around April, so we had a certain comfort of time to sit down and work it out, and there really was, I was sitting with my boss, there was a lot of brainstorming what to do.”
Similarly, once the materials for the classes were ready, they could be easily reused, which reduced the time necessary to prepare for subsequent editions of the classes for the following student groups.
R4: “On the other hand, once these materials were prepared, in these subsequent courses, of course, we modified them a bit depending on what we saw worked or not, but then it was easier, of course, these next courses. So, the first year was harder. Later in the next year, I will be honest, it went absolutely faster.”
Time management also constituted an important issue for respondents. Some of them noticed that they lacked the time and had to work extra hours to check and discuss students’ assignments.
R1: “It was also difficult, especially since at the beginning, all this situation surprised us, and the students were coming up with that, for example, he could connect at 20:30. The first group—I played along a bit, but then I realized, no way, I am only connecting with someone all day, that’s it. […] later we introduced some, uh, no-freedom to arrange, but only within these hours of classes or together we agreed on a convenient date as the rest wanted.”
Online learning might have also been perceived as more time-consuming by some teachers as it prevented them from multi-tasking and balancing their clinical and didactic duties.
R9: “it deeply disorganized the work in the ward if the physician who was on the ward had to conduct online classes because, as I said, sometimes, unfortunately, we had to do five things at the same time. With students [at the ward], it was doable because some things can be done with students, somehow even involve some of them for help. And when you are online, then at some point there were such pathological situations that most doctors in the ward were locked in their offices conducting online classes and only one was left for the entire ward, which is really not cool.”
R22: “A negative aspect of distance learning is the fact that I am tied to a computer while conducting online classes. I have no or very limited possibility of taking care of my patients. When the classes are at the ward, I take the students to patients, we examine them together, talk with them, consider potential options. […] The realization of it while being on the other side of the camera is practically impossible. I’ve been thinking about various science-fiction ideas—to put a GoPro camera on my forehead, for example, so that students could see what is happening, but this creates very big problems related to the protection of personal data. The patients would have to agree to it, it is impossible to realize.”
Finally, the work overload also affected the scientific activity of academic teachers.
R4: „In the context of the NCN [Narodowe Centrum Nauki – National Centre of Science – a Polish grant agency], I had to write for an extension of the substantive report because I was not able to write a single article during the pandemic, and you know there are deadlines and various problems may arise from it because it was simply working at night.”
Balancing these various roles and responsibilities came at the expense of respondents’ personal life.
R4: “It all comes at the expense of private time. I can see it very clearly, because the biggest, so to speak, sensor are children who, for example, see that mum—you have no time recently or you are on the computer all the time, because my children indeed saw me all the time on Teams, online, because I basically worked non-stop, not to mention scientific work, which in all of this was probably only at night.”
In addition, respondents were faced with uncertainty and fear as well as increasing concern and expectations on the part of both students and patients. This all led to a sense of frustration and crisis for some respondents. They wanted to help their patients better but felt that the situation was beyond their control. Patients’ and students’ frustration unrightfully directed against them enhanced this feeling of helplessness.
R6: “We are just as helpless in the sense that there are certain rules imposed from above, and I personally feel that the patients also direct anger, helplessness, and frustration at us, the visits have been canceled. […] new regulations come out, and we are all victims, in fact, in this situation. Still, frustration and anger are directed towards healthcare workers with enormous strength, and I really feel it on a daily basis, and it is also very difficult.”
Due to the specificity of the work performed, the sense of uncertainty was accompanied by a strong sense of responsibility for the people entrusted to their care.
R22: “And when it comes to non-COVID patients, there is growing frustration about the fact that we cannot help patients. Our patients should also be admitted to us for scheduled diagnostics, but we are forbidden to admit such patients, and they are waiting, we don’t know for how long. And the only way for them to get to the hospital is that their health has to worsen enough to endanger their lives, and only then can they get to us for the diagnostics they might have had three months earlier.”
R9: “These [student] groups are also big, so they cannot enter the ward, and I think it is probably the worst moment, maybe not for me, for me, as an academic teacher, it is not only the regime that I will show them fewer patients, it is not something that cannot be coped with, because I will simply use words, but for them, as students, it is very difficult, and they complain about it very much. […] such helplessness that everything is not as it should be, and it is not even clear who to blame for it. Because, on the other hand, as a doctor, I care more about the health of patients, so I prefer to tell students something than, for example, to expose patients that they will get infected, so I understand a bit. I mean, I feel for the students, but even more, I feel for the patients.”
Respondents reported that they found it more difficult to convey the practical or clinical aspects of the course. They emphasized that students cannot acquire practical skills without actually performing them or having contact with patients.
R24: “I think that in such a normal situation, they have a better chance to learn the contact with the patient from me—I don’t know—that when we are going in, we say hello, the way we ask questions, the way we talk to these patients.”
R21: “Even the best presentations, […] or uploading videos to YouTube cannot provide the comfort I had when conducting classes with patients, for example with pneumonia, when they [students] could themselves hear pneumonia. Because we normally were going to patients […]. Once you hear it, you will remember it for the rest of your life. And when we play YouTube videos, despite our best intentions, we are not able to show it to them in any way. Or such skills as percussion, throat examination where you have to be able to quickly put that stick in the mouth of such a little child to open the mouth. This is a problem in the sense that we felt unsatisfied here, as a team, not only me but the whole team. How were we supposed to teach physical examination to our students online? It didn’t make sense.”
In this context, teachers doubted whether students were able to gain intended learning outcomes, which for some of them, took the form of personal defeat.
R6: “The assumed goals were not achieved, that is, the learning outcomes, neither in the field of communication, nor the field of social competencies, nor the field of physical examination […] They did not acquire these competencies. They just didn’t do it. […] this subject did not really take place in the sense that I discussed the materials online with them, and that was all, and they, well, the subject was not realized, in my opinion, it simply should be repeated.”
They also questioned the reliability and credibility of their role as an assessor. Respondents pointed out that as teachers, by giving students credit, they confirm that they have certain qualifications. At that time, they emphasized the responsibility that rests on them, pointing to the relationship between making the wrong decision that a student passed an exam and the potential consequences of this decision for this student’s future patients.
R6: “I’m worried that somehow I had to allow them to pass this subject because it was not their fault […] I can see that they have very specific shortcomings, and in a few months, they will start working as midwives, and I’m sure that they are just not prepared.”
This situation was also very emotional for some respondents and constituted a source of distress and empathy toward students.
R1: “I mean, I feel sorry for them that their chances of working with the patient are limited, that we cannot perform any more of these procedures.”
R20: “Very strong emotions. Because everyone was afraid of the disease, infection, but most of all, when it comes to the role of the teacher, we were terrified of how we would teach these students, right? If we cannot show them, if they cannot perform these skills, then what will they be qualified to do later? And there was a lot of emotions here, a lot of discussions.”
But at the same time, the feeling of one’s duty and obligation to others seems to become crucial in adapting to these new circumstances and putting additional effort into learning new skills, finding alternative ways to work, and managing time effectively.
Building task-specific self-efficacy
Feeling overwhelmed by the multitude and variety of tasks entrusted to them, some of the respondents admitted to presenting resistance towards this change or a temptation to procrastinate.
R8: “Initially there was this feeling of resistance that it was impossible, it was pointless, but when we started to show that we cannot otherwise because we will not reschedule these classes, nor are we able to, I don’t know, to cancel them. Well, they have to take place. Because in March, at the beginning of the pandemic, there were voices that it would be 2–3 months and we would go back to what was before, so there was a temptation to postpone some of the classes to June, maybe part of July, so there was a moment, a bit of an escape from it […].”
R24: “I remember that at the beginning, the attitude towards these online classes was full of reservations. And at the beginning, we were looking for some ideas on how to go around the didactics. […] it was not known how much we should prepare for these online classes, how long will it take, whether we should put a lot of energy into it.”
However, when it turned out that the crisis would last for a longer period of time, clinical teachers began to gradually shift their focus on the specific tasks they faced and look for solutions that would enable their effective implementation in the new reality. One of the key elements at this stage turned out to be institutional support visible through securing and providing tools allowing maintaining the continuity of the teaching process. Those respondents who saw support from the University provided some examples, which mostly revolved around the availability of didactic resources, courses, technical issues, and reduced teaching hours in justified cases.
R13: “I think the University tried to react very quickly and adapt as quickly as it could. […] Practically overnight, these tools were made available for work, and as we know earlier, it was not like that that the entire University worked on a huge messenger application [Teams].”
R11: “It must be admitted that it was known how to act and what to do. […] Personal protective equipment, masks, gloves, and disinfectants were also provided.”
R25: “There were certainly prepared aids about Teams—how to use this platform […] if something did not work, the IT team would surely help us, and we knew we could count on it.”
As a result of difficulties in conducting clinical classes, teachers were forced to look for substitute solutions to facilitate students’ learning of practical skills. An important solution provided by PUMS decision-makers was access to the Medical Simulation Center, which had an important impact on enhancing their self-efficacy in terms of teaching practical skills but also motivating students to pay bigger attention during online classes.
R2: “And due to the fact that I have the possibility, in addition to conducting e-learning seminars, I prefer to transfer it all later into a simulation center—it leads to their bigger interest in what I say because they know they will be able to see it. They know that when I say something, I will verify it in the practical part.”
Despite these interventions, one of the commonly mentioned factors that could have reduced teachers’ self-efficacy was the occurrence of technical and Internet connection issues, insufficient equipment amounts, or inappropriate conditions to conduct classes.
R5: “I have observed it even at my clinic—I have my own room that I work in, I have my computer, I can close [the door], hang a piece of paper – ‘I have classes, please do not disturb.’ But what can an assistant do sitting in a room with three other assistants? […] through the prism of my friend – ‘listen, what should I do? I don’t have conditions, there is no library’, there is no room to find there so that she could do as I do. So, my friend had to go home to have classes with students so that it would take place in comfortable conditions. And then she had to return to work – to her other duties.”
R23: “We are not prepared for the number of online classes in hospitals. I mean, we use our equipment, we use our personal computers, webcams, we don’t have rooms where we could hide for these classes and conduct them during work, right? Because we are in the hospital at that time and we have to hide somewhere. Two people who lead Teams [classes] next to each other, well, you can’t conduct classes like that. So, this is also an organizational problem for sure. […] Some doctors had a problem that they didn’t have the equipment in order to run these classes, or the Internet – not everywhere is the Internet good enough to conduct these classes.”
Another important factor that affects teachers’ self-efficacy in the context of clinical education was their clinical experience. While more experienced clinicians, having the freedom to use the rich base of resources accumulated so far, could concentrate on reorganizing their use in the course of classes, at the same time, the young clinicians had to search for or even create the necessary resources from scratch.
R4: “It often happened when we talked about depression because in this theoretical part, I, for example, simulated a depressive patient. […] And we role-played such scenes, what if during the whole interview, the patient, for example, cries, what if he screams, what if, I don’t know, he insults, and we formulated these questions depending on the situation. It required a lot of my commitment as an assistant and a lot of clinical experience. Because, let’s not hide, after 18 years of work and thousands of patients, I can play every patient at the click of a finger. […] It was certainly more difficult for assistants who, for example, were only starting their teaching work because they had fewer resources they could draw from in the context of experience.”
Among the factors that respondents perceived as important for rebuilding their efficacy in the role of an academic teacher was their previous participation in faculty-development (FD) initiatives. Some respondents acknowledged that they facilitated the transfer of practical teaching into the online environment. The knowledge and awareness of available solutions gave them a sense of control over the changing situation and thus increased their self-efficacy.
R6: “[talking about the FD course] Well, our trainer showed different forms of education, but it was rather as a curiosity, also e-learning, but it was rather just as an additional area, that there are such opportunities, that some universities also conduct classes in this way if the students are from away, for example, that it makes it easier in a certain way and she just showed us various instructional videos and various tools, these quizzes, for example—how to motivate students for example. Thanks to this, I was not afraid to start doing it, although I was not really prepared for it.”
The issue of evaluating students’ qualifications remained an unresolved problem affecting the sense of self-efficacy of teachers. Online assessment in the form of, so far commonly used, test exams was considered unreliable (in regard to students’ cheating and their use of books, notes, or the Internet during test exams). Meanwhile, replacing them with theoretical oral exams was too time-consuming, and access to practical exams was severely limited due to the pandemic restrictions. Some respondents questioned the quality of the didactic process carried out using online methods, so, not wanting to harm students, they avoided verifying students’ higher-order cognitive skills during the assessment.
R23: “The reliability of assessment was certainly better before the pandemic. And it certainly was a more complete assessment because now I can ask them about a few things, and in fact, not having the feeling that I could teach them something well, it is hard to question them about something difficult or more advanced because I do not have the feeling that this teaching has any level, to be honest. And I would not like for them simply to get a worse grade as a punishment for the pandemic. So, I think that this reliability is worse because they do not have the knowledge, and I don’t have the conscience to question them on the lack of knowledge caused after all not by us, in fact, rather by the world.”
Development of general self-efficacy
In view of the pandemic-enforced limitations on students’ presence in hospitals in clinical classes, some teachers were forced to draw a clear line between their duties as a teacher and, separately, as a clinician and, as a consequence, to prioritize their duties. Respecting the complexity of the situation of clinical teachers and introducing solutions at the institutional level gave the respondents a sense of security and clearly influenced their self-efficacy.
R10: “[The support from the University] was, in my opinion, big. Firstly, the possibility that we didn’t have to come to classes at times when we had absolutely no way to come [due to clinical work]. Secondly, there was a reduced teaching load for people working in the COVID hospital […] there was a moment when I was afraid that they [clinical teachers] would not come to these exercises, and then what? And when the University announced these changes, many people were relieved it could be combined. We had no way to come back from the COVID hospital. We couldn’t drop everything and go teach. And we would be in a pickle if the University hadn’t made some moves here.”
Many of the respondents’ statements indicate that care for patients occupied a higher place in the hierarchy of tasks than the implementation of the didactic process (see section Task-specific self-efficacy quotes R8 and R24). The separation of these roles gave some teachers the freedom to conduct classes in comfortable conditions without the feeling of neglecting their tasks in the other role.
R19: “During clinical classes in clinical hospitals, there is very little space dedicated to students, classrooms where you can sit down quietly, discuss certain things, so the online classes, when I sat in front of the computer in the office, and I didn’t have to think about or look for a classroom for students, they were kind of a facilitation.”
Although seemingly the possibility of finding time dedicated only to students should be conducive to building a partner relationship between teacher and learner in the educational process, online learning during the pandemic restricted interpersonal contact in an unprecedented way. Respondents noticed that students became more passive and started to hide behind the cameras. They reported difficulties initiating contact with them, getting to know them, interpreting their behavior, getting feedback on their teaching, or even convincing them to turn on their cameras. This lack of interaction with students translated into teachers’ lower sense of effectiveness and satisfaction from conducting classes.
R6: “I can’t cope with the situation when students don’t want to turn on the camera—I tell them that it would be nice because it’s hard to talk to the black screen, but if someone doesn’t do it, ignores me—I don’t know what to do then. Theoretically, of course, I can say that they will not pass the classes, but this is putting it on edge.”
R23: “I am worn out. Because, in general, I can see that it does not fall on a [fertile] ground, in the sense that nobody wants to—they don’t want to, I don’t really want to because I know that it doesn’t bring anything. I’m trying, right? Well, because everyone is trying […] I’m generally tired, I’m tired because this is just talking, there is no such interaction, they have no questions […] after these classes, I am generally tired and depleted of strength.”
This lack of direct contact with students was especially difficult for some teachers, who get emotionally attached to students.
R2: “Well, there was sometimes anger that I can’t do that, that I can’t get in, that I have to do e-learning classes, that I can’t show, meet these students. I am more focused on contact with students when I see them, see their reactions, emotions, I am with them rather than the cameras turned off and talking to the laptop.”
One respondent also expressed a wish for more feedback on her teaching, given the new and extraordinary character of the situation, as well as reduced feedback from other sources, e.g., students. It accounts for the lack of confidence in non-contact classes.
R6: “I have a lot of doubts about the quality of my classes conducted online when this subject requires contact with the patient and quality and effectiveness. I cannot even judge at all if this is it—these are the classes where I give lectures and seminars. Because for me, such personal contact with another person is very important because then some relationship is established to feel the specific energy of this group of students, I am completely unable to find myself when these classes are only in the online form. I don’t know how they perceive it at all. […] I need someone to tell me if I’m doing it right and if I’m not doing it right, then how to do it better […] I asked for auditing of these classes […] I don’t know if I designed it, planned it well, or if the tasks I gave are OK.”
Similarly important for teachers’ self-efficacy was the presence or lack of support from their co-workers. The uplifting importance of a sense of community was emphasized at many different stages of realizing the professional tasks. This support could take the forms of both contact groups for members of the faculty and individual interactions between the teachers.
R4: “I say a support group, that is, as we did groups, individual subgroups for students, I also created so-called assistant groups […]. It was also cool because it was a place where you could get help quickly, and we also saw what other assistants were doing so that it was at the same level for all students. […] Someone, for example, attached some material – ‘I have a proposal, maybe we could include it? It could be done so and so’—and everyone accepted it, and then very quickly on the same day, it was possible to add or modify something for the students.”
R5: “Very good, we supported, we talked, it wasn’t like that that I thought of a way on an ongoing basis, but then we talked with my friend – ‘I did it so and so, and how do you do it?’—and we collected what could be done better to make it more creative. Well, he said – ‘I will also be showing some endoscopic pictures’ – we all were drawing one from another. I think these relations were very good. We were all supporting each other.”
R21: “I think that such group therapy and group support played a large role here, in the sense that we discussed various topics, we tried to find common solutions, and all these discussions about our internal fears somewhere, that we were on the contagious ward, there was a higher probability that we would get infected in the hospital and transfer it to our relatives and so on. So, I think we’ve been a lot of support for each other in these difficult times, and somehow as a team, I think we passed the exam, and we did it.”
Despite the online learning limitations described above, the COVID-19 pandemic has contributed to the dynamic development of educational technologies, giving teachers unprecedented opportunities to support the educational process. Some respondents emphasized that the widespread access to these tools allows them to better moderate the learning process.
R8: “Contrary to appearances, I discovered that on Teams, I was able to involve each individual student more—I discovered that. It was incredible for me because when each of them had their homework, each of them had to confront me, share their thoughts […] So this is the thing that seemed to be better at Teams. I discovered it because I tried to involve everyone during my clinical classes, but I never felt that I was able to engage everyone in 100%. And here they had no choice—everyone had a task, everyone had to solve it.”
On the other hand, for some respondents, the pandemic also brought positively perceived changes in the specifics of their scope of practice or performed tasks. For example, pharmacists observed legal recognition of the long-awaited expansion of their competencies, while physicians were provided with self-development opportunities by caring for patients outside of their specialty.
R17: “I think it changed a lot in the context of my responsibilities and what is really going on in the pharmacy because even vaccinations or changes to the Act on the Pharmacist’s Profession—all of this really happened due to the pandemic, thanks to the pandemic.”
R23: “I learned a lot of new things. We became a COVID ward, and I had to learn everything really—from diabetes to leukemia, so I think it had developmental effects on us. It mainly increased our development and the profile of those [patient] cases that we had.”