Research Report
Connectedness, Sense of Community, and Academic Satisfaction in a Novel Community Campus Medical Education Model Rupal S. Vora, MD, and Marjorie N. Kinney, MEd
Abstract Purpose Developing a sense of community and establishing connectivity are important in enhancing learners’ success and preventing their sense of isolation. The A.T. Still University School of Osteopathic Medicine in Arizona (SOMA) has implemented a novel approach to medical education in which, beginning in the second year, students are geographically dispersed to 11 community campuses associated with community health centers around the United States, at both inner-city and rural locations. This study assessed students’ sense of community, academic satisfaction, and level of connectedness
T
echnology allows students to learn in novel environments; they are spending less time in classrooms and more time learning online.1 Although the effects of online learning on knowledge acquisition are still being studied (and may require novel methods of investigation),2 its negative effect on students’ sense of community is clear.3 Students prefer traditional classroom communities over online communities, although online learning does not impact learners’ satisfaction.4 Positive relationships exist between students’ sense of community and their perceived academic gains, engagement, and overall satisfaction, though these positive relationships are not required for academic success.5
Dr. Vora is associate professor of internal medicine, A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona. Ms. Kinney is curriculum assessment analyst, A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona. Correspondence should be addressed to Ms. Kinney, 5850 E. Still Circle, Mesa, AZ 85206; telephone: (480) 219-6149; e-mail: [email protected]. Acad Med. 2014;89:182–187. First published online November 25, 2013 doi: 10.1097/ACM.0000000000000072
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in their first through fourth years of medical school at SOMA. Method The Rovai Classroom Community Scale and open-ended questions were administered via an online survey instrument to 412 students enrolled at SOMA for the 2011–2012 academic year. Participation was voluntary, and all results were anonymous. Data were analyzed using one-way ANOVA to compare results between classes. Results Comparisons revealed an increasing degree of isolation and a decreasing sense of community and academic
A positive correlation has been established between learners’ satisfaction and their achievement,6–8 and sense of community has also been shown to help avoid isolation, enhance retention, and promote satisfaction.9 The literature points toward connectedness and community as keys to satisfaction in distance education. With the introduction of new medical school learning models and structures, assessing students’ levels of connectedness and academic satisfaction is vital in addressing their needs. Postgraduate institutions, including those in the health care field that use distance education, have thus been studied with regard to learners’ satisfaction and sense of community with students.10–12 With regard to medical education, the data are sparser. Though it has been shown that medical students’ attitudes about the importance of social issues and medical skills decline during the course of their education, such evidence addressing whether connectivity and academic satisfaction decline during medical school was not found.13 The goal of our investigation was to closely examine medical students’ perceptions of community and academic satisfaction,
satisfaction progressing from the first through fourth years of medical school. Students suggested possible solutions that may be applied to medical schools and other graduate schools to improve the level of connectedness for students who are learning at a distance. Conclusions Connectivity, sense of community, and academic satisfaction may decrease for students in undergraduate medical education participating in a combination of distance learning and intermittent inperson activities. Interventions have the potential to improve these parameters. Long-term follow-up of students’ satisfaction is suggested.
specifically in an innovative medical school with second-year didactic presentations provided primarily via distance learning. The School of Osteopathic Medicine in Arizona (SOMA) is unique in its curricular model and structure. Students spend only their first year on the Mesa, Arizona, campus; they spend the next three years at community health centers throughout the nation, mostly in underserved communities. The curricular model is based on clinical presentations within the framework of a systems-based model.14,15 Students’ first year of instruction is provided in largegroup settings, small-group settings, and laboratory sessions. Additionally, large-group presentations are all recorded and available for students who prefer home study. Students are then sent to 1 of 11 community campuses throughout the nation where they are under the guidance and supervision of regional directors of medical education (RDMEs). In that second year, the curriculum includes in-person small-group sessions, independent-study podcasts developed in Mesa by basic science and clinical faculty, guided medical skills, osteopathic
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procedure practice, and clinical exposure. Students at all 11 sites are exposed to the same learning materials, taught asynchronously, but tested synchronously. Finally, the third and fourth years at SOMA are parallel to other medical schools throughout the country in that traditional clinical rotations are the basis of students’ learning, although the students at SOMA are primarily placed in underserved areas, at campus-affiliated community health centers. In light of SOMA’s unique approach of dispersing students early in their training, and also of the more generalized increasing use of technology resulting in less direct person-to-person interaction throughout the four years of medical school, we set out to determine our students’ perceived academic satisfaction, sense of community, and level of connectedness. We gathered baseline data for the first through fourth years of medical school using the Rovai Classroom Community Scale, which has been shown to be both valid and reliable.9 We added open-ended questions to the survey to allow for student feedback. The complete survey instrument can be found in Appendix 1. Method and Results
In January 2012, we invited all 412 students enrolled at SOMA for the 2011–2012 academic year to participate in a voluntary, anonymous electronic survey. The invitations, sent to the students’ school e-mail accounts (which they are required to check daily), included a link to the online survey. Citing the practice of conducting research in established or commonly accepted educational settings involving normal educational practices, and the lack of risk to the anonymous participants, the ATSU institutional review board exempted the study from review. The survey consisted of the Rovai Classroom Community Scale; demographic questions on gender, campus assignment, and academic year; and additional, connectivity-related questions. We analyzed the data regarding student connectivity and academic satisfaction using one-way ANOVA. The response rate was 70%, with 288 completed responses from 412 surveys distributed. Of the completed responses, 74 came from 109 first-year students (67.89%), 84 from 105 second-year
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Table 1 Student-Reported Levels of Connectedness and Learning Satisfaction at 1 Originating and 11 Additional Community-Health-Center-Associated Sites, A.T. Still University School of Osteopathic Medicine in Arizona, 2012*
Students’ academic year
Connectivity subscale
Learning Satisfaction subscale
M
SD
M
SD
First Second
25.05 24.39
7.38 7.98
27.31 26.58
4.23 5.20
Third
21.06
6.90
24.51
5.39
Fourth
19.10
7.80
22.93
5.36
*Average Rovai Classroom Community Scale Connectivity and Learning Satisfaction subscores (M) and standard deviations (SD) for each student cohort.
students (80.00%), 69 from 101 thirdyear students (68.31%), and 61 from 97 fourth-year students (62.89%). The response rate was significantly higher for second-year students compared with first- and fourth-year students (P < .01) and third-year students (P < .10). There were no other statistically significant differences in response rates. The survey tool included two subscales: Connectedness and Learning Satisfaction. Table 1 shows the average score and standard deviation on the two subscales for each year in the SOMA program. ANOVA analysis showed significant variance between years in both Connectedness and Learning Satisfaction (P < .01): Rovai Connectedness subscale: F = 9.54, P < .01 Rovai Learning Satisfaction subscale: F = 10.59, P < .01 ANOVA analysis completed on each individual Classroom Community Scale question showed on which items SOMA student scores varied the most dramatically from year to year. Results are shown in Table 2. We categorized 97 responses to the open-ended survey item “Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success?” into themes using text analysis. Table 3 shows those suggestions received from more than one student; 19 responses were judged to be unique from each other and the categories in the table.
Discussion
As medical schools introduce new learning models and structure, assessing students’ level of connectedness and academic satisfaction is vital in addressing their needs. It is believed that developing a sense of community and establishing connectivity are important in enhancing learners’ success and preventing a sense of isolation during their educational years. SOMA’s geographic and temporal distribution of our second-, third-, and fourth-year medical students is unique. We have been considering the possibility of students’ potential isolation, sense of disconnect, and other adverse effects on academic satisfaction as a result of this geographic dispersion, the placement of certain students in rural environments, and the implementation of distance education. The results of our study confirm that there is a statistically significant drop-off from the first through the fourth years with regard to connectedness and academic satisfaction and an increase in perceived isolation. The significantly higher response rate of the second-year students may be influenced in part by SOMA’s unique program structure. As they transition from the Mesa campus to geographically disparate sites and smaller communities, students may be motivated by their early isolation to take more interest in connectivity and community. Part of the rationale for embedding students in community health centers is the increased likelihood that they will later choose to practice medicine in rural and other needed locations.16 Given the shortages of physicians in these areas, that longterm benefit is thought to outweigh the
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Table 2 Connectedness and Learning Satisfaction Scale Item ANOVA Results at 1 Originating and 11 Additional Community-Health-Center-Associated Sites, A.T. Still University School of Osteopathic Medicine in Arizona (SOMA), 2012 Average Rovai Classroom Connectivity score Item
First year
Second year
Third year
Fourth year
F statistic
P value
2.84 2.93
3.10 2.99
2.83 2.77
2.74 2.39
2.40 6.49
.068 .000
I feel that students in SOMA care about each other I feel that I am encouraged to ask questions* I feel connected to others in SOMA*
2.72
2.30
1.74
1.51
18.00
.000
I feel that it is hard to get help when I have a question*
3.00
2.75
2.06
2.03
16.65
.000
I do not feel a spirit of community*
2.46
2.33
1.77
1.56
10.84
.000
I feel that I receive timely feedback*
2.73
2.75
2.41
2.18
6.52
.000
I feel that SOMA is like a family*
2.35
2.35
1.81
1.33
14.66
.000
I feel uneasy exposing gaps in my understanding
2.20
2.27
1.97
2.08
1.19
.315
I feel isolated in SOMA*
2.69
2.26
1.90
1.46
13.19
.000
I feel reluctant to speak openly
2.57
2.45
2.46
2.13
1.91
.129
I trust others in SOMA
2.71
2.64
2.56
2.34
1.88
.133
I feel that SOMA results in only modest learning
2.61
2.50
2.47
2.33
0.78
.507
I feel that I can rely on others in SOMA*
2.66
2.64
2.26
2.15
4.89
.002
I feel that other students do not help me learn
2.66
2.83
2.68
2.57
0.94
.423
I feel that members of SOMA depend on me
1.96
1.94
1.83
1.64
1.49
.217
I feel that I am given ample opportunities to learn
2.85
2.77
2.66
2.52
1.88
.132
I feel uncertain about others in SOMA
2.00
2.24
2.16
2.02
1.37
.253
I feel that my educational needs are not being met*
2.76
2.40
2.30
2.10
4.23
.006
I feel confident that others will support me*
2.70
2.64
2.28
2.36
3.27
.022
I feel that SOMA does not promote a desire to learn
3.04
2.93
2.80
2.62
2.59
.053
*Statistically significant difference between student cohorts (P < .05).
decreased connectivity with peers and the Mesa campus. Our data come with several important limitations. The results describe the connectedness and satisfaction of a particular group at a specific time; they may not be representative of graduate or medical students as a whole. We did not compare our students against themselves over time but, rather, against other students in other academic years. Because the Classroom Community Scale has not been normed, the results should be used to compare the levels of connectedness and satisfaction from students in various years of the program rather than comparing those levels against students in other programs. Additionally, the Classroom Community Scale is for use with students in an online learning environment. Because the SOMA students receive both online instruction and varying degrees of inperson instruction during the second, third, and fourth years, the reported levels of connectedness and academic satisfaction may be higher than if they
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were completing their education in a solely online environment. Finally, the Classroom Community Scale assesses academic satisfaction, not academic success. Although studies have shown a correlation between the two factors,6–8 a future study might examine the relationship between the two factors at SOMA because the ultimate desired outcome is academic success. In addition to having students complete the Classroom Community Scale, we asked them, “Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success?” On the basis of the students’ recommendations, there is clearly room to improve students’ experiences through intervention. Other institutions using distance education may wish to consider implementing these recommendations. Having obtained these Rovai Classroom Community Scale baseline results, the goal is now to implement interventions to improve connectivity, sense of
community, and academic satisfaction at SOMA. The primary intervention we are considering is learning communities.17 Beginning with the class of 2017, each student will be assigned to a learning community consisting of approximately 10 students on the basis of the community campus to which they are assigned, with two Mesa campus advisors (one basic scientist and one clinician) and at least one RDME clinician advisor. These learning communities, which will continue throughout the student’s medical school years, will help provide social support, academic support (peer tutoring, study groups, academic advising, career mentoring, faculty–student mentorship), community service opportunities, leadership opportunities, and interprofessional education. Additionally, students of the classes of 2013 through 2016 will be provided with access to support from their original first-year Mesa academic advisor, to supplement the advising support by their local RDMEs. The Classroom Community Scale survey will continue to be given annually to assess
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Table 3 Osteopathic Medical Students’ Suggestions for Establishing Connectivity and Enhancing Academic Success, A.T. Still University School of Osteopathic Medicine in Arizona, 2012* No. of responses
Suggestion Establish annual retreats and/or trips to the Mesa campus for the students Offer more opportunities for and fund classwide or community campus-wide nonacademic activities
12 10
Improve overall quality of school environment (includes suggestions such as listening to student feedback, celebrating Match Day, and admitting nontraditional students)
10
Increase quantity of communication through additional newsletters, updates, or cards
8
Increase amount and quality of didactic material for third- and fourth-year students
6
Reduce required class time and content
5
Provide more centralized guidance in regards to career, residency, and rotations
5
Provide opportunities to exchange rotations between campuses, or provide opportunities to travel to other campuses
4
Increase visits to the community campuses by Mesa faculty
4
Increase interaction between first-, second-, third-, and fourth-year students
4
Improve telecommunications and learning management system technology
4
Maintain contact with first-year academic advisor
3
Increase interactivity during class sessions
3
*Only categories with multiple student responses are included.
students’ sense of community, level of connectedness, and academic satisfaction. Although starting these interventions as soon as possible will limit our ability to determine whether any observed changes are due to the intervention or due to cohort differences, we decided that the potential benefits of intervening outweigh the potential comparison opportunities of a longitudinal study. Of note, some interventions have already been implemented since the completion of the survey analysis. For example, grand rounds at the community health centers involving second-, third-, and fourth-year students working together have been started. Students from the Arizona community health center sites in Phoenix, Flagstaff, and Tucson have also visited with first-year students at the Mesa campus to help ease the transition from first to second year. First-year advisors in Mesa have been encouraged to maintain communication with their advisees during all four years of medical school instead of just the first year. “Medical disorder of the day,” an online discussion on Google+, was started to engage medical students at all of the community health campuses,
Academic Medicine, Vol. 89, No. 1 / January 2014
establish communication between faculty and students, and assist with board examination review. The use of social media sites has been shown to be effective, so implementing social media may improve our students’ satisfaction with their medical education.9 Future areas of study to consider include exploring whether community composition and location affect students’ sense of isolation and disconnect. In particular, distinguishing between students’ levels of satisfaction at rural and urban community health center sites is warranted. Another consideration includes norming the Rovai Classroom Community Scale to determine whether SOMA students’ levels of connectivity and academic satisfaction are typical of medical students as a whole or solely representative of their unique situation. Finally, we recommend measuring students’ levels of connectedness and academic satisfaction as they relate to their assigned community campus, rather than to SOMA as a whole. The open-ended responses of many students indicated that they felt more connected to their community health centers and RDMEs than to SOMA as a whole, and
so a future study examining connectivity to and satisfaction with community campuses is justified. Another appropriate future study would determine whether students’ connectedness to their community health centers influences their selection of training in needed specialties or increases their likelihood of serving the underserved in rural or inner-city settings. Students expressed a desire to feel more connected with the Mesa campus, as seen by their interest in establishing annual retreats and trips to the Mesa campus. Other indications of students’ desire to increase connectivity include their suggestions for more communication, more centralized guidance regarding career, residency, and rotation planning, maintaining contact with their first-year advisors, improving telecommunications and learning management system technology, and increased visits to the community campuses by Mesa faculty (at present time, there are approximately biennial visits). Future study may focus on assessing whether immersion and connectivity of students in their individual communities or increased local connectedness combined with a strong sense of community with the larger cohort better enhance students’ academic and professional development. Moving forward, our hypothesis is that, with the implementation of continuity with first-year advisors and the establishment of learning communities, as well as with certain additional interventions as stated above, there will be an improvement in the overall level of connectedness, academic satisfaction, and sense of community in our medical students. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was found to be exempt by the A.T. Still University institutional review board, January 5, 2012, reference no. 2012-01.
References 1 Parry M. Colleges see 17 percent increase in online enrollment. Chron Higher Educ. January 26, 2010. http://chronicle.com/ blogs/wiredcampus/colleges-see-17-percentincrease-in-online-enrollment/20820. Accessed September 7, 2013. 2 Saba F. Research in distance education: A status report. Int Rev Res Open Distance Learn. 2000;1(1). 3 Rovai AP, Wighting MJ, Liu J. School climate: Sense of classroom and school communities in online and on-campus higher education
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courses. Q Rev Distance Educ. 2005;6: 361–374. Allen M, Bourhis J, Burrell N, Mabry E. Comparing student satisfaction with distance education to traditional classrooms in higher education: A meta-analysis. Am J Distance Educ. 2002;16:83–97. Liu X, Magjuka RJ, Bonk CJ, Lee S. Does sense of community matter? An examination of participants’ perspectives in online courses. In: Reeves T, Yamashita S, eds. Proceedings of World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education. Chesapeake, Va: AACE; 2006:2615–2621. Quinn PD, Duckworth AL. Happiness and achievement: Evidence for reciprocal causality. Poster session presented at: Annual Meeting of the Association for Psychological Science; Washington, DC; 2007. Ostroff C. The relationship between satisfaction, attitudes, and performance: An
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organizational level analysis. J Appl Psychol. 1992;77:963–974. Samdal O, Word B, Bronis M. Relationship between students’ perceptions of school environment, their satisfaction with school and perceived academic achievement: An international study. School Eff School Improv. 1999;10:296–320. Rovai AP. Building a sense of community at a distance. Internet Higher Educ. 2002;(5):197–211. Lia-Hoagberg B, Vellenga B, Miller M, Li TY. A partnership model of distance education: Students’ perceptions of connectedness and professionalization. J Prof Nurs. 1999;15:116–122. So H, Brush T. Student perceptions of collaborative learning, social presence and satisfaction in a blended learning environment: Relationships and critical factors. Comput Educ. 2008;51:318–336. Debourgh GA. Predictors of student satisfaction in distance-delivered graduate
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14
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nursing courses: What matters most? J Prof Nurs. 2003;19:149–163. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: A cohort study. Med Educ. 2004;38: 522–534. Mandin H, Harasym P, Woloschuk W. Clinical problem solving and the clinical presentation curriculum. Acad Med. 2000;75:1043–1045. Mandin H, Jones A, Woloschuk W, Harasym P. Helping students learn to think like experts when solving clinical problems. Acad Med. 1997;72:173–179. Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose rural careers? Rural Remote Health. 2009;9:1083. Ferguson KJ, Wolter EM, Yarbrough DB, Carline JD, Krupat E. Defining and describing medical learning communities: Results of a national survey. Acad Med. 2009;84:1549–1556.
Appendix 1 Survey Instrument The following survey is for a research study conducted by the School of Osteopathic Medicine in Arizona (SOMA) at A.T. Still University. The purpose of this study is to examine the current level of connectedness, sense of community, and academic satisfaction of medical students in years 1–4 in SOMA. Your participation is voluntary, anonymous, involves this one page (20 item) questionnaire and a few additional questions only, will have no bearing on academic status, and will take approximately 10 minutes to complete. Although the research results may be published, data will appear in the aggregate assuring that all individual information will remain confidential. Completion of this online survey will serve as voluntary consent to participate in this research study. Questions may be directed to Dr. Rupal S. Vora at [email protected] (480) 219-6151. Thank you in advance for your consideration and contribution to this project. The data obtained will hopefully help improve your educational experiences at SOMA. Below you will see a series of statements concerning your time and education at ATSU-SOMA. Read each statement carefully and select the statement that comes closest to indicate how you feel about the program. There are no correct or incorrect responses. If you neither agree nor disagree with a statement or are uncertain, select “Neutral.” Do not spend too much time on any one statement, but give the response that seems to describe how you feel. Please respond to all items.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel that students in SOMA care about each other.
◯
◯
◯
◯
◯
I feel that I am encouraged to ask questions.
◯
◯
◯
◯
◯
I feel connected to others in SOMA
◯
◯
◯
◯
◯
I feel that it is hard to get help when I have a question
◯
◯
◯
◯
◯
I do not feel a spirit of community
◯
◯
◯
◯
◯
I feel that I receive timely feedback
◯
◯
◯
◯
◯
I feel that SOMA is like a family
◯
◯
◯
◯
◯
I feel uneasy exposing gaps in my understanding
◯
◯
◯
◯
◯
I feel isolated in SOMA
◯
◯
◯
◯
◯
I feel reluctant to speak openly
◯
◯
◯
◯
◯
I trust others in SOMA
◯
◯
◯
◯
◯
I feel that SOMA results in only modest learning
◯
◯
◯
◯
◯
I feel that I can rely on others in SOMA
◯
◯
◯
◯
◯ (Appendix Continues)
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Appendix 1 (Continued) Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel that other students do not help me learn
◯
◯
◯
◯
◯
I feel that members of SOMA depend on me
◯
◯
◯
◯
◯
I feel that I am given ample opportunities to learn
◯
◯
◯
◯
◯
I feel uncertain about others in SOMA
◯
◯
◯
◯
◯
I feel that my educational needs are not being met
◯
◯
◯
◯
◯
I feel confident that others will support me
◯
◯
◯
◯
◯
I feel that SOMA does not promote a desire to learn
◯
◯
◯
◯
◯
I am currently a year ____ student.
○ Ohio
○ 1
○ Oregon
Do you maintain regular contact (at least 3 times/year) with your Year 1 Mesa faculty advisor?
○ 2
○ South Carolina
○ 3
○ Washington
○ 4
○ male
Are you already or would you be willing to be involved in a social media forum to build a national sense of community with your classmates?
○ female
○ Yes
If you do not maintain regular contact with your Year 1 Mesa faculty advisor, would you be interested in maintaining contact?
○ other (please specify) ___________
○ No
○ N/A (I maintain regular contact)
I am assigned to the ___________ Community Campus.
Please list any social media forums that you utilize (Ex. LinkedIn, Facebook, Skype, Google+, Twitter).
○ Yes
My gender is ___________
○ Alabama ○ AZ-Flagstaff
________________________
○ AZ-Phoenix
○ Hawaii
If you listed at least 1 social media forum in the previous question, please indicate how often and for how long you use social media forums (for example, “40 minutes each day” or “5 minutes each hour”).
○ New York
_________________________
○ AZ-Tucson ○ California
Academic Medicine, Vol. 89, No. 1 / January 2014
○ N/A (1st year student) ○ Yes ○ No
○ No ○ If not, why not? ______________________ Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success? Do you have any additional comments you would like to share?
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Connectedness, Sense of Community, and Academic Satisfaction in a Novel Community Campus Medical Education Model Rupal S. Vora, MD, and Marjorie N. Kinney, MEd
Abstract Purpose Developing a sense of community and establishing connectivity are important in enhancing learners’ success and preventing their sense of isolation. The A.T. Still University School of Osteopathic Medicine in Arizona (SOMA) has implemented a novel approach to medical education in which, beginning in the second year, students are geographically dispersed to 11 community campuses associated with community health centers around the United States, at both inner-city and rural locations. This study assessed students’ sense of community, academic satisfaction, and level of connectedness
T
echnology allows students to learn in novel environments; they are spending less time in classrooms and more time learning online.1 Although the effects of online learning on knowledge acquisition are still being studied (and may require novel methods of investigation),2 its negative effect on students’ sense of community is clear.3 Students prefer traditional classroom communities over online communities, although online learning does not impact learners’ satisfaction.4 Positive relationships exist between students’ sense of community and their perceived academic gains, engagement, and overall satisfaction, though these positive relationships are not required for academic success.5
Dr. Vora is associate professor of internal medicine, A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona. Ms. Kinney is curriculum assessment analyst, A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona. Correspondence should be addressed to Ms. Kinney, 5850 E. Still Circle, Mesa, AZ 85206; telephone: (480) 219-6149; e-mail: [email protected]. Acad Med. 2014;89:182–187. First published online November 25, 2013 doi: 10.1097/ACM.0000000000000072
182
in their first through fourth years of medical school at SOMA. Method The Rovai Classroom Community Scale and open-ended questions were administered via an online survey instrument to 412 students enrolled at SOMA for the 2011–2012 academic year. Participation was voluntary, and all results were anonymous. Data were analyzed using one-way ANOVA to compare results between classes. Results Comparisons revealed an increasing degree of isolation and a decreasing sense of community and academic
A positive correlation has been established between learners’ satisfaction and their achievement,6–8 and sense of community has also been shown to help avoid isolation, enhance retention, and promote satisfaction.9 The literature points toward connectedness and community as keys to satisfaction in distance education. With the introduction of new medical school learning models and structures, assessing students’ levels of connectedness and academic satisfaction is vital in addressing their needs. Postgraduate institutions, including those in the health care field that use distance education, have thus been studied with regard to learners’ satisfaction and sense of community with students.10–12 With regard to medical education, the data are sparser. Though it has been shown that medical students’ attitudes about the importance of social issues and medical skills decline during the course of their education, such evidence addressing whether connectivity and academic satisfaction decline during medical school was not found.13 The goal of our investigation was to closely examine medical students’ perceptions of community and academic satisfaction,
satisfaction progressing from the first through fourth years of medical school. Students suggested possible solutions that may be applied to medical schools and other graduate schools to improve the level of connectedness for students who are learning at a distance. Conclusions Connectivity, sense of community, and academic satisfaction may decrease for students in undergraduate medical education participating in a combination of distance learning and intermittent inperson activities. Interventions have the potential to improve these parameters. Long-term follow-up of students’ satisfaction is suggested.
specifically in an innovative medical school with second-year didactic presentations provided primarily via distance learning. The School of Osteopathic Medicine in Arizona (SOMA) is unique in its curricular model and structure. Students spend only their first year on the Mesa, Arizona, campus; they spend the next three years at community health centers throughout the nation, mostly in underserved communities. The curricular model is based on clinical presentations within the framework of a systems-based model.14,15 Students’ first year of instruction is provided in largegroup settings, small-group settings, and laboratory sessions. Additionally, large-group presentations are all recorded and available for students who prefer home study. Students are then sent to 1 of 11 community campuses throughout the nation where they are under the guidance and supervision of regional directors of medical education (RDMEs). In that second year, the curriculum includes in-person small-group sessions, independent-study podcasts developed in Mesa by basic science and clinical faculty, guided medical skills, osteopathic
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procedure practice, and clinical exposure. Students at all 11 sites are exposed to the same learning materials, taught asynchronously, but tested synchronously. Finally, the third and fourth years at SOMA are parallel to other medical schools throughout the country in that traditional clinical rotations are the basis of students’ learning, although the students at SOMA are primarily placed in underserved areas, at campus-affiliated community health centers. In light of SOMA’s unique approach of dispersing students early in their training, and also of the more generalized increasing use of technology resulting in less direct person-to-person interaction throughout the four years of medical school, we set out to determine our students’ perceived academic satisfaction, sense of community, and level of connectedness. We gathered baseline data for the first through fourth years of medical school using the Rovai Classroom Community Scale, which has been shown to be both valid and reliable.9 We added open-ended questions to the survey to allow for student feedback. The complete survey instrument can be found in Appendix 1. Method and Results
In January 2012, we invited all 412 students enrolled at SOMA for the 2011–2012 academic year to participate in a voluntary, anonymous electronic survey. The invitations, sent to the students’ school e-mail accounts (which they are required to check daily), included a link to the online survey. Citing the practice of conducting research in established or commonly accepted educational settings involving normal educational practices, and the lack of risk to the anonymous participants, the ATSU institutional review board exempted the study from review. The survey consisted of the Rovai Classroom Community Scale; demographic questions on gender, campus assignment, and academic year; and additional, connectivity-related questions. We analyzed the data regarding student connectivity and academic satisfaction using one-way ANOVA. The response rate was 70%, with 288 completed responses from 412 surveys distributed. Of the completed responses, 74 came from 109 first-year students (67.89%), 84 from 105 second-year
Academic Medicine, Vol. 89, No. 1 / January 2014
Table 1 Student-Reported Levels of Connectedness and Learning Satisfaction at 1 Originating and 11 Additional Community-Health-Center-Associated Sites, A.T. Still University School of Osteopathic Medicine in Arizona, 2012*
Students’ academic year
Connectivity subscale
Learning Satisfaction subscale
M
SD
M
SD
First Second
25.05 24.39
7.38 7.98
27.31 26.58
4.23 5.20
Third
21.06
6.90
24.51
5.39
Fourth
19.10
7.80
22.93
5.36
*Average Rovai Classroom Community Scale Connectivity and Learning Satisfaction subscores (M) and standard deviations (SD) for each student cohort.
students (80.00%), 69 from 101 thirdyear students (68.31%), and 61 from 97 fourth-year students (62.89%). The response rate was significantly higher for second-year students compared with first- and fourth-year students (P < .01) and third-year students (P < .10). There were no other statistically significant differences in response rates. The survey tool included two subscales: Connectedness and Learning Satisfaction. Table 1 shows the average score and standard deviation on the two subscales for each year in the SOMA program. ANOVA analysis showed significant variance between years in both Connectedness and Learning Satisfaction (P < .01): Rovai Connectedness subscale: F = 9.54, P < .01 Rovai Learning Satisfaction subscale: F = 10.59, P < .01 ANOVA analysis completed on each individual Classroom Community Scale question showed on which items SOMA student scores varied the most dramatically from year to year. Results are shown in Table 2. We categorized 97 responses to the open-ended survey item “Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success?” into themes using text analysis. Table 3 shows those suggestions received from more than one student; 19 responses were judged to be unique from each other and the categories in the table.
Discussion
As medical schools introduce new learning models and structure, assessing students’ level of connectedness and academic satisfaction is vital in addressing their needs. It is believed that developing a sense of community and establishing connectivity are important in enhancing learners’ success and preventing a sense of isolation during their educational years. SOMA’s geographic and temporal distribution of our second-, third-, and fourth-year medical students is unique. We have been considering the possibility of students’ potential isolation, sense of disconnect, and other adverse effects on academic satisfaction as a result of this geographic dispersion, the placement of certain students in rural environments, and the implementation of distance education. The results of our study confirm that there is a statistically significant drop-off from the first through the fourth years with regard to connectedness and academic satisfaction and an increase in perceived isolation. The significantly higher response rate of the second-year students may be influenced in part by SOMA’s unique program structure. As they transition from the Mesa campus to geographically disparate sites and smaller communities, students may be motivated by their early isolation to take more interest in connectivity and community. Part of the rationale for embedding students in community health centers is the increased likelihood that they will later choose to practice medicine in rural and other needed locations.16 Given the shortages of physicians in these areas, that longterm benefit is thought to outweigh the
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Table 2 Connectedness and Learning Satisfaction Scale Item ANOVA Results at 1 Originating and 11 Additional Community-Health-Center-Associated Sites, A.T. Still University School of Osteopathic Medicine in Arizona (SOMA), 2012 Average Rovai Classroom Connectivity score Item
First year
Second year
Third year
Fourth year
F statistic
P value
2.84 2.93
3.10 2.99
2.83 2.77
2.74 2.39
2.40 6.49
.068 .000
I feel that students in SOMA care about each other I feel that I am encouraged to ask questions* I feel connected to others in SOMA*
2.72
2.30
1.74
1.51
18.00
.000
I feel that it is hard to get help when I have a question*
3.00
2.75
2.06
2.03
16.65
.000
I do not feel a spirit of community*
2.46
2.33
1.77
1.56
10.84
.000
I feel that I receive timely feedback*
2.73
2.75
2.41
2.18
6.52
.000
I feel that SOMA is like a family*
2.35
2.35
1.81
1.33
14.66
.000
I feel uneasy exposing gaps in my understanding
2.20
2.27
1.97
2.08
1.19
.315
I feel isolated in SOMA*
2.69
2.26
1.90
1.46
13.19
.000
I feel reluctant to speak openly
2.57
2.45
2.46
2.13
1.91
.129
I trust others in SOMA
2.71
2.64
2.56
2.34
1.88
.133
I feel that SOMA results in only modest learning
2.61
2.50
2.47
2.33
0.78
.507
I feel that I can rely on others in SOMA*
2.66
2.64
2.26
2.15
4.89
.002
I feel that other students do not help me learn
2.66
2.83
2.68
2.57
0.94
.423
I feel that members of SOMA depend on me
1.96
1.94
1.83
1.64
1.49
.217
I feel that I am given ample opportunities to learn
2.85
2.77
2.66
2.52
1.88
.132
I feel uncertain about others in SOMA
2.00
2.24
2.16
2.02
1.37
.253
I feel that my educational needs are not being met*
2.76
2.40
2.30
2.10
4.23
.006
I feel confident that others will support me*
2.70
2.64
2.28
2.36
3.27
.022
I feel that SOMA does not promote a desire to learn
3.04
2.93
2.80
2.62
2.59
.053
*Statistically significant difference between student cohorts (P < .05).
decreased connectivity with peers and the Mesa campus. Our data come with several important limitations. The results describe the connectedness and satisfaction of a particular group at a specific time; they may not be representative of graduate or medical students as a whole. We did not compare our students against themselves over time but, rather, against other students in other academic years. Because the Classroom Community Scale has not been normed, the results should be used to compare the levels of connectedness and satisfaction from students in various years of the program rather than comparing those levels against students in other programs. Additionally, the Classroom Community Scale is for use with students in an online learning environment. Because the SOMA students receive both online instruction and varying degrees of inperson instruction during the second, third, and fourth years, the reported levels of connectedness and academic satisfaction may be higher than if they
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were completing their education in a solely online environment. Finally, the Classroom Community Scale assesses academic satisfaction, not academic success. Although studies have shown a correlation between the two factors,6–8 a future study might examine the relationship between the two factors at SOMA because the ultimate desired outcome is academic success. In addition to having students complete the Classroom Community Scale, we asked them, “Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success?” On the basis of the students’ recommendations, there is clearly room to improve students’ experiences through intervention. Other institutions using distance education may wish to consider implementing these recommendations. Having obtained these Rovai Classroom Community Scale baseline results, the goal is now to implement interventions to improve connectivity, sense of
community, and academic satisfaction at SOMA. The primary intervention we are considering is learning communities.17 Beginning with the class of 2017, each student will be assigned to a learning community consisting of approximately 10 students on the basis of the community campus to which they are assigned, with two Mesa campus advisors (one basic scientist and one clinician) and at least one RDME clinician advisor. These learning communities, which will continue throughout the student’s medical school years, will help provide social support, academic support (peer tutoring, study groups, academic advising, career mentoring, faculty–student mentorship), community service opportunities, leadership opportunities, and interprofessional education. Additionally, students of the classes of 2013 through 2016 will be provided with access to support from their original first-year Mesa academic advisor, to supplement the advising support by their local RDMEs. The Classroom Community Scale survey will continue to be given annually to assess
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Table 3 Osteopathic Medical Students’ Suggestions for Establishing Connectivity and Enhancing Academic Success, A.T. Still University School of Osteopathic Medicine in Arizona, 2012* No. of responses
Suggestion Establish annual retreats and/or trips to the Mesa campus for the students Offer more opportunities for and fund classwide or community campus-wide nonacademic activities
12 10
Improve overall quality of school environment (includes suggestions such as listening to student feedback, celebrating Match Day, and admitting nontraditional students)
10
Increase quantity of communication through additional newsletters, updates, or cards
8
Increase amount and quality of didactic material for third- and fourth-year students
6
Reduce required class time and content
5
Provide more centralized guidance in regards to career, residency, and rotations
5
Provide opportunities to exchange rotations between campuses, or provide opportunities to travel to other campuses
4
Increase visits to the community campuses by Mesa faculty
4
Increase interaction between first-, second-, third-, and fourth-year students
4
Improve telecommunications and learning management system technology
4
Maintain contact with first-year academic advisor
3
Increase interactivity during class sessions
3
*Only categories with multiple student responses are included.
students’ sense of community, level of connectedness, and academic satisfaction. Although starting these interventions as soon as possible will limit our ability to determine whether any observed changes are due to the intervention or due to cohort differences, we decided that the potential benefits of intervening outweigh the potential comparison opportunities of a longitudinal study. Of note, some interventions have already been implemented since the completion of the survey analysis. For example, grand rounds at the community health centers involving second-, third-, and fourth-year students working together have been started. Students from the Arizona community health center sites in Phoenix, Flagstaff, and Tucson have also visited with first-year students at the Mesa campus to help ease the transition from first to second year. First-year advisors in Mesa have been encouraged to maintain communication with their advisees during all four years of medical school instead of just the first year. “Medical disorder of the day,” an online discussion on Google+, was started to engage medical students at all of the community health campuses,
Academic Medicine, Vol. 89, No. 1 / January 2014
establish communication between faculty and students, and assist with board examination review. The use of social media sites has been shown to be effective, so implementing social media may improve our students’ satisfaction with their medical education.9 Future areas of study to consider include exploring whether community composition and location affect students’ sense of isolation and disconnect. In particular, distinguishing between students’ levels of satisfaction at rural and urban community health center sites is warranted. Another consideration includes norming the Rovai Classroom Community Scale to determine whether SOMA students’ levels of connectivity and academic satisfaction are typical of medical students as a whole or solely representative of their unique situation. Finally, we recommend measuring students’ levels of connectedness and academic satisfaction as they relate to their assigned community campus, rather than to SOMA as a whole. The open-ended responses of many students indicated that they felt more connected to their community health centers and RDMEs than to SOMA as a whole, and
so a future study examining connectivity to and satisfaction with community campuses is justified. Another appropriate future study would determine whether students’ connectedness to their community health centers influences their selection of training in needed specialties or increases their likelihood of serving the underserved in rural or inner-city settings. Students expressed a desire to feel more connected with the Mesa campus, as seen by their interest in establishing annual retreats and trips to the Mesa campus. Other indications of students’ desire to increase connectivity include their suggestions for more communication, more centralized guidance regarding career, residency, and rotation planning, maintaining contact with their first-year advisors, improving telecommunications and learning management system technology, and increased visits to the community campuses by Mesa faculty (at present time, there are approximately biennial visits). Future study may focus on assessing whether immersion and connectivity of students in their individual communities or increased local connectedness combined with a strong sense of community with the larger cohort better enhance students’ academic and professional development. Moving forward, our hypothesis is that, with the implementation of continuity with first-year advisors and the establishment of learning communities, as well as with certain additional interventions as stated above, there will be an improvement in the overall level of connectedness, academic satisfaction, and sense of community in our medical students. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was found to be exempt by the A.T. Still University institutional review board, January 5, 2012, reference no. 2012-01.
References 1 Parry M. Colleges see 17 percent increase in online enrollment. Chron Higher Educ. January 26, 2010. http://chronicle.com/ blogs/wiredcampus/colleges-see-17-percentincrease-in-online-enrollment/20820. Accessed September 7, 2013. 2 Saba F. Research in distance education: A status report. Int Rev Res Open Distance Learn. 2000;1(1). 3 Rovai AP, Wighting MJ, Liu J. School climate: Sense of classroom and school communities in online and on-campus higher education
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courses. Q Rev Distance Educ. 2005;6: 361–374. Allen M, Bourhis J, Burrell N, Mabry E. Comparing student satisfaction with distance education to traditional classrooms in higher education: A meta-analysis. Am J Distance Educ. 2002;16:83–97. Liu X, Magjuka RJ, Bonk CJ, Lee S. Does sense of community matter? An examination of participants’ perspectives in online courses. In: Reeves T, Yamashita S, eds. Proceedings of World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education. Chesapeake, Va: AACE; 2006:2615–2621. Quinn PD, Duckworth AL. Happiness and achievement: Evidence for reciprocal causality. Poster session presented at: Annual Meeting of the Association for Psychological Science; Washington, DC; 2007. Ostroff C. The relationship between satisfaction, attitudes, and performance: An
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organizational level analysis. J Appl Psychol. 1992;77:963–974. Samdal O, Word B, Bronis M. Relationship between students’ perceptions of school environment, their satisfaction with school and perceived academic achievement: An international study. School Eff School Improv. 1999;10:296–320. Rovai AP. Building a sense of community at a distance. Internet Higher Educ. 2002;(5):197–211. Lia-Hoagberg B, Vellenga B, Miller M, Li TY. A partnership model of distance education: Students’ perceptions of connectedness and professionalization. J Prof Nurs. 1999;15:116–122. So H, Brush T. Student perceptions of collaborative learning, social presence and satisfaction in a blended learning environment: Relationships and critical factors. Comput Educ. 2008;51:318–336. Debourgh GA. Predictors of student satisfaction in distance-delivered graduate
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nursing courses: What matters most? J Prof Nurs. 2003;19:149–163. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: A cohort study. Med Educ. 2004;38: 522–534. Mandin H, Harasym P, Woloschuk W. Clinical problem solving and the clinical presentation curriculum. Acad Med. 2000;75:1043–1045. Mandin H, Jones A, Woloschuk W, Harasym P. Helping students learn to think like experts when solving clinical problems. Acad Med. 1997;72:173–179. Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose rural careers? Rural Remote Health. 2009;9:1083. Ferguson KJ, Wolter EM, Yarbrough DB, Carline JD, Krupat E. Defining and describing medical learning communities: Results of a national survey. Acad Med. 2009;84:1549–1556.
Appendix 1 Survey Instrument The following survey is for a research study conducted by the School of Osteopathic Medicine in Arizona (SOMA) at A.T. Still University. The purpose of this study is to examine the current level of connectedness, sense of community, and academic satisfaction of medical students in years 1–4 in SOMA. Your participation is voluntary, anonymous, involves this one page (20 item) questionnaire and a few additional questions only, will have no bearing on academic status, and will take approximately 10 minutes to complete. Although the research results may be published, data will appear in the aggregate assuring that all individual information will remain confidential. Completion of this online survey will serve as voluntary consent to participate in this research study. Questions may be directed to Dr. Rupal S. Vora at [email protected] (480) 219-6151. Thank you in advance for your consideration and contribution to this project. The data obtained will hopefully help improve your educational experiences at SOMA. Below you will see a series of statements concerning your time and education at ATSU-SOMA. Read each statement carefully and select the statement that comes closest to indicate how you feel about the program. There are no correct or incorrect responses. If you neither agree nor disagree with a statement or are uncertain, select “Neutral.” Do not spend too much time on any one statement, but give the response that seems to describe how you feel. Please respond to all items.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel that students in SOMA care about each other.
◯
◯
◯
◯
◯
I feel that I am encouraged to ask questions.
◯
◯
◯
◯
◯
I feel connected to others in SOMA
◯
◯
◯
◯
◯
I feel that it is hard to get help when I have a question
◯
◯
◯
◯
◯
I do not feel a spirit of community
◯
◯
◯
◯
◯
I feel that I receive timely feedback
◯
◯
◯
◯
◯
I feel that SOMA is like a family
◯
◯
◯
◯
◯
I feel uneasy exposing gaps in my understanding
◯
◯
◯
◯
◯
I feel isolated in SOMA
◯
◯
◯
◯
◯
I feel reluctant to speak openly
◯
◯
◯
◯
◯
I trust others in SOMA
◯
◯
◯
◯
◯
I feel that SOMA results in only modest learning
◯
◯
◯
◯
◯
I feel that I can rely on others in SOMA
◯
◯
◯
◯
◯ (Appendix Continues)
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Appendix 1 (Continued) Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel that other students do not help me learn
◯
◯
◯
◯
◯
I feel that members of SOMA depend on me
◯
◯
◯
◯
◯
I feel that I am given ample opportunities to learn
◯
◯
◯
◯
◯
I feel uncertain about others in SOMA
◯
◯
◯
◯
◯
I feel that my educational needs are not being met
◯
◯
◯
◯
◯
I feel confident that others will support me
◯
◯
◯
◯
◯
I feel that SOMA does not promote a desire to learn
◯
◯
◯
◯
◯
I am currently a year ____ student.
○ Ohio
○ 1
○ Oregon
Do you maintain regular contact (at least 3 times/year) with your Year 1 Mesa faculty advisor?
○ 2
○ South Carolina
○ 3
○ Washington
○ 4
○ male
Are you already or would you be willing to be involved in a social media forum to build a national sense of community with your classmates?
○ female
○ Yes
If you do not maintain regular contact with your Year 1 Mesa faculty advisor, would you be interested in maintaining contact?
○ other (please specify) ___________
○ No
○ N/A (I maintain regular contact)
I am assigned to the ___________ Community Campus.
Please list any social media forums that you utilize (Ex. LinkedIn, Facebook, Skype, Google+, Twitter).
○ Yes
My gender is ___________
○ Alabama ○ AZ-Flagstaff
________________________
○ AZ-Phoenix
○ Hawaii
If you listed at least 1 social media forum in the previous question, please indicate how often and for how long you use social media forums (for example, “40 minutes each day” or “5 minutes each hour”).
○ New York
_________________________
○ AZ-Tucson ○ California
Academic Medicine, Vol. 89, No. 1 / January 2014
○ N/A (1st year student) ○ Yes ○ No
○ No ○ If not, why not? ______________________ Do you have any suggestions regarding establishing connectivity, a sense of community, and enhancing your academic success? Do you have any additional comments you would like to share?
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