Andragogy in Graduate Health Programs During the COVID-19 Pandemic

Online learning in graduate health programs has been considered a method at least equally as effective as traditional learning (Cook et al., 2008; Lima et al., 2019; McCall et al., 2018; McCutcheon et al., 2015; Pei & Wu, 2019), offering benefits in cost reduction, accessibility, flexibility, and autonomy (Nguyen, 2015). While a portion of studies has demonstrated the effectiveness of online learning amidst the COVID-19 pandemic (Hong et al., 2020; Rad et al., 2021; Rosenthal et al., 2021; Rüllmann et al., 2020), many students are dissatisfied with the quality of the experience (Abbasi et al., 2020; Aziz et al., 2020; Garris & Fleck, 2020; Loda et al., 2020; Singal et al., 2020; Weber & Ahn, 2021; Wu & Zeshan, 2020).

Graduate health programs have a responsibility to craft online learning experiences that meet the unique needs of adult learners while also anticipating and circumventing potential pitfalls commonly encountered with a virtual learning environment. As introduced by Malcolm Knowles (1970), the assumptions of andragogy offer a conceptual framework for instructors designing learning experiences for adult learners. Additionally, concerted efforts to reduce the transactional distance (TD; (M. Moore, 1997) and promote a community of inquiry (CoI; Garrison et al., 2000) increase the likelihood for successful application of online learning. This study seeks to evaluate each andragogical assumption in the context of online learning during the COVID-19 pandemic, utilizing the available body of literature to assess ways in which each principle has been fulfilled or neglected by graduate health programs. Additionally, factors influencing the quality of the learning experience, such as TD and CoI, are evaluated.

The COVID-19 pandemic brought with it a surge of interest in student outcomes related to online learning. As professional programs moved to this delivery method en masse, student curriculums were migrated to learning platforms that quickly substituted for face-to-face educational interactions. Instructional delivery modes pivoted quickly, and the technological capacity of instructors who may have limited experience with applications that enhance student online learning was pushed to its limits. With this impromptu shift common in professional programs across the United States, research questions of interest to student learning outcomes took a new turn. Increasingly, the literature from the pandemic period reported adverse outcomes related to student engagement and educational quality delivered through the online experience (Abbasi et al., 2020; Aziz et al., 2020; Garris & Fleck, 2020; Loda et al., 2020; Singal et al., 2020; Weber & Ahn, 2021; Wu & Zeshan, 2020). The widespread perception of an inferior educational product has resulted in students filing lawsuits against their universities, seeking partial refunds for classes that were shifted from face-to-face to online instruction, claiming “the quality of [online] instruction is far below the classroom experience” (Binkley, 2020, p. 1).

There appear to be vast differences in research quality within this body of literature, making the transferability of findings difficult. Some authors report successful implementation of online learning yet offer no details of methods or experience. In a letter published in the Indian Journal of Pediatrics, the authors describe the successful implementation of online learning in medical education, occurring via a 12-day online teaching session utilizing the free version of Zoom (Agarwal & Kaushik, 2020). Data obtained from a survey of 77 respondents revealed that 97% of students felt the sessions met their learning needs for clinical practice, and 99% reported sessions were “interesting and enjoyable.” These positive outcomes are listed without details of session structure, student interaction, mechanism of assessment, length of sessions, disclosure of survey questions, or description of instructor background or training. Despite the lack of research transparency, the authors conclude that “online teaching is feasible, cheap and must be made a part of the postgraduate training in India beyond the prevailing lockdown” (Agarwal & Kaushik, 2020, p. 1). Affirming statements such as this promote further adoption and implementation of online learning, regardless of instructor aptitude or course design methodology.

There is danger in generalizing online learning as unequivocally “good.” Just as face-to-face learning resides across a wide range of effectiveness, so does online learning. Effective implementation of any instruction requires intentional and thorough planning. In gauging the amount of time required by a single instructor to adequately transition a face-to-face class to online, Gutruf et al. (2020) estimated that 80 hours of work was required. The unplanned shift to online learning in response to COVID-19 likely did not allow adequate time for course revisions, instructor training, learning system development, resource allocation, or the establishment of proper information technology support. Many changes likely occurred out of necessity, with decisions driven by practicality, expediency, and health concerns rather than the educational needs of each student.

As faculty and departments have developed technological proficiency to meet the demands of online coursework during the COVID-19 pandemic, the future role of online learning in higher education is starting to become apparent. Online learning is here to stay. Based on evidence accumulated before the COVID-19 pandemic (Cook et al., 2008; Lima et al., 2019; McCall et al., 2018; McCutcheon et al., 2015; Pei & Wu, 2019), there is strong justification for instituting greater levels of online learning across all health profession disciplines. This evidence, however, is primarily based on programs and faculty that have made concerted and deliberate efforts to ensure that the quality of the online experience is equal, if not superior, to traditional learning.

Familiarity with traditional teaching does not guarantee success with a novel online medium. Online teaching is different. Reacting to an unexpected pandemic, instructors and programs made commendable advancements to achieve at least the minimum proficiency required for shifting content online. These advancements allowed education to continue. Nevertheless, there is danger in contentment with the current quality of the online experience. As the work involved in transitioning a face-to-face class to an online format is generally frontloaded, instructors may be tempted to proceed with the same methods established during the COVID-19 pandemic, irrespective of effectiveness. Instructors should not shy away from online delivery; however, care must be taken to ensure a quality online experience moving forward. If not, the literature is likely to remain cloudy concerning online learning. A course correction for online learning can occur by reflecting on the assumptions of andragogy and designing educational experiences that account for potential constraints of the online learning environment.

The andragogical model (Knowles et al., 2014) is based on six assumptions of adult learners. Simply described, adults:

1. need to know why they need to learn something (need to know).

2. should be given opportunities for selfdirection (self-directedness).

3. tend to connect new learning to prior experience (experience).

4. need to be in a state of readiness to learn (readiness to learn).

5. learn best when real-life application is possible (problem-based).

6. respond best to internal motivation (motivation).

Effective instructional strategies can be achieved in both the traditional setting (Merriam & Bierema, 2014) and online (Decelle, 2016; Muirhead, 2007) when the educator is attentive to the needs and priorities of adult learners. By illuminating the importance of the subject matter, providing opportunities for engagement, creating a scaffold to synthesize the new information with prior knowledge, and challenging students to utilize new information to solve practical problems, students are internally motivated, and learning occurs (Knowles et al., 2014). While the principles of andragogy apply equally to traditional and online learning, the mechanisms by which they are achieved are different due to underlying differences between the classroom and the distance platform (Garrison et al., 2000; M. Moore, 1997). For this reason, attention must be given to a variety of factors innate to online education likely to impact student perception and academic outcomes.

Transactional distance has received additional attention (Bozkurt et al., 2020; Chen et al., 2020; Karakaya, 2021) since the onset of COVID-19, as instructors seek reasons for disengaged students or poor student outcomes. Transactional distance theory (TDT), as conceived by Michael G. Moore (1997), describes the psychological space between instructor and student, impacted by three factors: dialogue, structure, and autonomy. The theory defines constructs that help educators better understand the engagement implications of their instructional design decisions and offers a mechanism for gauging the psychological gap between students and instructors.

While not exclusive to online learning, TD is most commonly encountered in virtual learning environments, lacking face-to-face communication. Instructors seeking to reduce TD must promote dialogue with students. Successful interaction stems from the quality of dialogue rather than quantity (M. Moore, 1997). Structure, in Moore’s definition, refers to the rigidity of the course design. A course high in structure may offer less opportunity for instructors to individualize course direction to meet the needs of students. As the rigidity of structure increases, student interaction decreases, and TD increases (Moore & Kearsley, 2004). On the other end of the spectrum, course design lacking structure may lead to student dissatisfaction and confusion (Falloon, 2011). Finally, autonomy overlaps with Knowle’s andragogical assumptions, recognizing that self-direction leads to positive learning experiences. The right amount of autonomy must be prescribed, however. Too little autonomy can lead to student frustration, while too much autonomy increases the perception of TD (M. Moore, 1997).

Another strategy proposed to create an effective online educational experience, recognizing the social and interactive nature of learning, is CoI. CoI refers to the collaboration among learners in social presence, cognitive presence, and teaching presence to create effective online educational experiences (Garrison et al., 2000). Although initially developed as a method for analyzing asynchronous online interaction, the concepts of CoI seamlessly apply to synchronous online interaction (Garrison et al.). Social presence includes factors of student expression and group cohesion. Garrison encourages low-stress small group interaction that occurs slowly throughout the course. He cautions against large-group forced interaction on the first day. Cognitive presence pertains to intellectually stimulating content, which requires exploration and integration of key course concepts. Teaching presence refers to the design, facilitation, and physical instruction (Akyol & Garrison, 2008). Garrison et al. stress that the third factor is “teaching” presence rather than “teacher” presence. Teaching presence in an online environment refers to the skill by which a teacher can facilitate enriching discussion. Garrison et al. warn that too much guidance can lead to a shutting down of student discourse. When correctly done, facilitation encourages students to take ownership of their learning (Garrison et al.). Whether through synchronous or asynchronous technology, facilitating Col promotes time for absorbing basic course principles and reserves interaction to discussion of these elements. Garrison promotes collaboration over interaction.

Cited by more than 6,600 sources on Google Scholar, Garrison et al.’s original publication (2000) detailing Col makes it one of the most prominent online learning theories in higher education. Col accounts for the value of interaction and collaboration in online education, a concept missing from many studies since the arrival of the COVID-19 pandemic. Studies of Col also complement TDT analyses, which have been criticized for failing to address collaboration and community (Wicks & Sallee, 2011).

Triangulation of TDT, CoI, and the assumptions of andragogy offer a comprehensive assessment of current practice as described in literature published since the arrival of the COVID-19 pandemic. Educational techniques both satisfying and neglecting the individual assumptions of andragogy will be assessed through the lenses of TDT and CoI.

Adults learn best when they understand the why, what, and how of the subject matter (Knowles et al., 2014). For graduate students in health programs, this includes understanding the clinical application of new knowledge. Removed from clinical context, the material is more challenging to learn and abstract in understanding. A study by Rosenthal et al. (2021) illustrates educational changes in response to the COVID-19 pandemic, satisfying andragogical principles while accounting for TDT and CoI factors. To accommodate the disruption to face-to-face learning for medical students at the Icahn School of Medicine at Mount Sinai in New York City, fourth-year medical students created online learning sessions in emergency medicine under the supervision of a faculty mentor (Rosenthal et al.). Each session included prelecture assignments featuring various multimedia resources, a short didactic lecture, and a case-based discussion. The interaction was assured through cold-calling (involuntary participation by calling on students), solicited comments, chat function, polling software, and utilization of the “hand raise” feature of the video conference platform (Rosenthal et al.). Sessions were 60–90 minutes in length and occurred twice each week for 2 weeks. Pre- and postcourse assessment of learning objectives revealed statistically significant improvement in self-assessed learning across all objectives.

Additionally, student participants favored group interaction and volunteer responses while expressing discomfort with cold-calling, consistent with prior research on forced participation (Wlodkowski, 2008). Notably, more passive participation techniques, such as the “hand raise” function, were deemed less engaging and nonimpactful to learning (Rosenthal et al., 2021).

The Rosenthal et al. study (2021) utilized methods supported in andragogical theory, implementing learning experiences rich in context, relevance, and application. The students ranked clinical scenarios (32 responses) and real-life examples (28 responses) as the most valuable parts of the class. Components of the class not directly applicable to clinical application garnered less support and included: reviewing physiology (7 responses), completing prereading assignments (5 responses), and completing the homework assignments (0 responses).

Building upon this andragogical perspective, the study can be assessed through TDT and CoI lenses. From a TDT perspective, dialogue between instructors and students was achieved using a variety of techniques. Scheduled synchronous sessions promoted minimal autonomy; however, course structure allowed for participant feedback and participation. Presumably, these tactics promoted a reduction in perception of transactional distance. From a CoI perspective, social presence was achieved with group interaction. Not all interaction was deemed beneficial, as negative perceptions occurred with cold-calling techniques. Cognitive presence was promoted with the use of case-based discussions on clinical topics. The authors’ attention to teaching presence is noted, with instructors serving as discussion facilitators, soliciting student comments. Overall, a CoI was established through the achievement of social, cognitive, and teaching presence.

The principle of self-directed learning (SDL) relates to andragogy and includes the central tenet that adults learn best in an autonomous environment (Conaway & Zorn, 2015). This is not to say that adults always learn best independently, but, instead, the ability to choose different learning strategies is what is most important (Knowles et al., 2014). As the desired self-direction varies between learners and by subject matter, course instructors need to structure courses to accommodate all degrees of self-direction. As explained in The Adult Learner:

This variability explains why a reduction in teacher direction and an increase in learner expectation do not automatically translate to improved outcomes via the principles of SDL. Self-direction in online learning should be fluid, allowing instructors to modify activities to assess higher order processing and synthesis rather than simply divulging the content and asking students to regurgitate the facts (Mahlaba, 2020). When done correctly, instructors motivate their students to take ownership of the material, self-assess their learning, and make goals for improvement.

Instructors ( n = 125) within medical and dental programs throughout Pakistan were surveyed as part of a study (Aziz et al., 2020) investigating the impact of COVID-19 on medical education, following a shift to online learning. The majority of instructors (52.8%) rated online teaching ineffective. Online instruction consisted of “short didactic lectures with no interaction” (Aziz et al., p. 183). Sessions lacked common aspects of a face-to-face class, such as student interaction, psychomotor skills, or simulation. Instructors complained of robotic delivery of content, lacking physical interaction and eye contact. There was uncertainty regarding student comprehension, with instructors reporting ambiguity in determining whether learning objectives had been met. The authors offered these findings alongside contrasting evidence in the literature, citing a prior study that found online learning useful in promoting student self-direction, depth of discussion, and quality of outcomes (Akbar et al., 2020). Notably, the referenced study (Akbar et al.) described the use of online learning as a complement to face-to-face learning, allowing for remedial work or enrichment, utilized to improve communication between student and instructor. The authors of the cited study (Akbar et al.) noted the benefit of promoting student self-directedness, as students are not constrained by the limitations of individual teacher attention (Akbar et al.). These studies offer contrasting methods of online learning methodology: the first method involves haphazard shifting of content online, absent any interaction or experience, the second method uses online learning to promote student self-directedness, utilizing the online medium to enhance the learning experience.

From TDT and CoI perspectives, removal of peer interaction and reduction in instructor-student dialog negatively impacted learning. Comprehension of learning outcomes was challenging to assess secondary to lack of student-instructor feedback. While online learning afforded increased student flexibility or convenience, the rigidity of structure, making no attempt for modification of coursework to meet student needs, resulted in the widening of TD. Moreover, the lack of social, cognitive, or teaching presence prevented any sense of community of inquiry from developing, as students independently completed coursework.

Existing as a major difference between educating children and adults, adults possess a deep and diverse history of experiences (Knowles et al., 2014). This experience can be harnessed, shared, and used in collaboration to promote learning. Two recent studies offered superb examples of how andragogical assumptions of experience can be applied. These methods stand in stark contrast to previously described methods which haphazardly shifted content online, removing any sense of collaboration or reflection.

Rüllman et al. (2020) described a virtual auscultation course for medical students in Germany. The COVID-19 pandemic necessitated a transition of face-to-face content to an online format. The authors utilized prerecorded auscultation sounds delivered during asynchronous video chat. Notably, this format was selected as “it most closely resembles the interactive character of face-to-face teaching” (Rüllmann et al., p. 1). Survey of student perception (n = 63) revealed positive self-report of student satisfaction (MV = 1.2) and comprehension (MV = 1.7), assessed via a six-level Likert scale (best score = 1). The structure of the 2-hour online sessions included 6–7 student participants, exploration of clinical cases, virtual auscultation of corresponding heart sounds, synchronous discussion of sound characteristics and diagnosis, analysis of sound, and synchronous discussion of diagnosis and therapeutic intervention (Rüllmann et al.). Students relied on prior experience and knowledge of diagnoses to build a conceptual understanding of auscultation and subsequently collaborate to determine proper therapeutic management. Participants “recommended that the course be established in the regular curriculum” (Rüllmann et al., p. 3).

At the Hamdan Bin Mohammed College of Dental Medicine in Dubai (Rad et al., 2021), a successful transition to online learning occurred following mandated instructor training in distance learning and the inclusion of additional online synchronous case-based discussion sessions. The case study sessions engaged the graduate learners “in specific clinical skills including diagnosis, decision making, and treatment planning, by encouraging critical thinking and providing constructive multistream dialogue between the learners and instructors” (Rad et al., p. 4). Student collaboration and sharing of clinical perspectives served as the primary driving forces to promote learning. A survey of student (n = 53) and faculty ( n = 18) perception of the sudden transition to distance learning revealed satisfaction among both student and faculty groups. Responding to the statement “Overall, I was satisfied with the distance learning,” student mean Likert score (4 = agree, 5 = strongly agree) was 4.02 while faculty Likert score was 4.50 (Rad et al.). Many lectures were shortened to combat the common complaint of shorter student attention spans during online learning, and activities were introduced to encourage group interaction (Rad et al.). Notably, instructor training in distance learning occurred before the implementation of the online teaching method.

From an andragogical perspective, these articles emphasize a commitment to collaboration, with students analyzing clinical cases, sharing perspectives, and relating the findings to clinical application. From TDT perspective, the use of small-group discussion promoted dialogue between students and instructors. Rad et al. also described flexible course design, with instructors shortening sessions in response to the dwindling student attention span with online learning. High dialogue and flexible structure increased the likelihood of a reduction in transactional distance. Regarding CoI, social presence was achieved with positive group interaction promoting “multistream dialogue between learners and instructors” (Rad et al., p. 4). Clinical scenarios reinforced cognitive presence while teaching presence served to facilitate discussion of appropriate therapeutic interventions.

Consistent with Maslow’s hierarchy of needs (Maslow, 1967), online learners must meet foundational needs before learning can be achieved. These needs include appropriate access to technology, internet access, and emotional and physical readiness for learning. The COVID-19 pandemic has undoubtedly worsened student access to educational resources.

In a recent systematic review, Rasheed et al. (2020) highlighted the challenges of the online component of blended learning. Technological illiteracy serves as the greatest threat to effective instruction for teachers. Instructors must be “technologically competent, to effectively use and manage technology for teaching, and also to create and upload learning materials to students (e.g. creating quality online videos)” (Rasheed et al., p. 2). Students, on the other hand, are most impacted by issues of selfregulation. The autonomy and flexibility afforded by online learning increase the likelihood of maladaptive behavior such as procrastination, poor time management, and underutilization of peer learning (Rasheed et al.). If technological illiteracy and issues with self-regulation are present, students are less likely to excel in an online medium.

In other words, students must have technological literacy, adequate access to technology, and sufficient internet bandwidth to have a chance for success with online learning. Within Liaquat College of Medicine and Dentistry in Pakistan, where online learning was rarely utilized before the COVID-19 pandemic, student perceptions ( n = 384) of the online format were poor, with 77% of students (n = 296) reporting a negative overall experience (Abbasi et al., 2020). Additionally, 84% of students reported limited student-teacher interaction. Virtual classroom technology offers an opportunity to improve interaction in online learning, but only if access is adequate and equal among learners. With negative implications on transactional distance and community of inquiry, students lacking access to basic digital technologies are prone to limitations in student-instructor and student-student dialogue. Unless digital access and proficiency can be ensured, student engagement and comprehension issues are bound to occur (Falloon, 2011).

Adults learn best when new knowledge can be applied to real-world problems (Knowles et al., 2014). For graduate health students, clinical experience, typically occurring within or after didactic content, serves as the pinnacle experience to foster learning. Across graduate health education, the COVID-19 pandemic necessitated the cancellation of scheduled clinical experiences as uncertainty influenced decisions based on patient and student safety (Chiel et al., 2020). Cancellation and minimizing clinical experience because of COVID-19 posed challenges to effective adult learning as graduate health students lacked the practical reward for prior learning. Fortunately, some graduate departments generated creative solutions to promote experiential problem-based learning.

Following the cancellation of multiple students’ clinical experiences, the University of Minnesota Physical Therapy Department established a pro bono telehealth physical therapy clinic with dual purposes focused on the benefit of telehealth physical therapy in terms of student physical therapy education and patient outcomes (Hong et al., 2020). Patients were virtually assessed and treated by student physical therapists under the online supervision of an expert faculty member. Guidance from faculty serving as clinical instructors was available during sessions using a private video conferencing text chat feature that allowed student and faculty interaction during patient evaluations. Success with this pilot program resulted in an expansion to multiple students, with additional faculty members serving as clinical instructors (Hong et al., 2020).

Educational experiences offering tangible opportunities to solve problems satisfy multiple assumptions of andragogy. Adult learners thrive when the immediate application of content is apparent. For graduate health programs seeking to maximize clinical application, online learning offers access to patient populations and clinical perspectives that are more difficult to achieve in a traditional classroom. Hong et al. (2020) offered examples of learning experiences rich in andragogy and protective against the potential pitfalls of the online medium.

The online learning experience created by Hong et al. (2020) minimized transactional distance by promoting real-time dialogue between student and instructor. Learning goals were established by faculty but allowed for fluid session structure dictated by student physical therapists under the guidance of a faculty member. With attention to CoI, social and cognitive elements were satisfied as students collaborated with each other and with faculty members to develop treatment plans based on prior foundational knowledge. Teaching presence consisted of “active peripheral involvement through real-time private discussion, quizzing, and reflection” (Hong et al., p. 280) utilizing the chat feature.

Closely tied to the first andragogical assumption of “need to know,” the assumption of motivation describes the awareness of value or satisfaction that is added to the adult’s life by learning a new concept or skill (Ferreira & MacLean, 2017). If this value is not realized, other life demands will prioritize the learning experience, as the adult deems the experience unworthy of time or attention. Instructors must harness and enhance the internal motivation of learners (Wlodkowski, 2008). The difficulty of this task is inversely related to the degree of interaction between instructors and students (M. Moore, 1997).

Students transitioning from traditional to online learning may struggle to maintain motivation, mainly if new distractions are present and content delivery is without social interaction. First-year medical and dental students (n = 80) from All India Institute of Medical Sciences in Baddi, India, completed a questionnaire detailing their perception of online learning compared to face-to-face learning (Singal et al., 2020). Students in the study had participated in face-to-face anatomy classes for almost 7 months before transitioning to online classes. Sixty-nine percent of students reported a lack of self-motivation to engage in online learning, and 68% reported being distracted by the comforts or discomforts of home (Singal et al., 2020). While the authors offered few details to the structure and resources used for online learning, the new format was described as video recorded lectures using PowerPoint with assessments occurring over Google form and Google thread following each topic. This method occurred in stark contrast to the previous learning experience, which was described as “cadaveric lab, face to face lectures, discussion with their classmates and interaction with mentors” (Singal et al., p. 2).

Even among medical residents, issues are surfacing regarding the perception of engagement and concentration during online learning. Medical residents (n = 81) at the University of Chicago participated in a survey (Weber & Ahn, 2021) assessing the perception of participation in online conferences compared to face-to-face conferences. Eighty percent of respondents reported more significant engagement with presenters during face-to-face lectures than synchronous online lectures. Additionally, higher levels of peer interaction were reported with face-to-face lectures (85%) than online lectures. Participants expressed difficulty concentrating (65%) during online lectures with a tendency to be distracted by non-conference related activities such as the use of the internet, checking email, or daily tasks at a rate of 4.6 activities per hour during online participation, compared to 2.4 activities per hour with face-to-face participation (Weber & Ahn).

Adults are generally internally motivated to achieve their learning goals (Knowles et al., 2014); however, when faced with long lectures lacking interaction or occurring in a place with distractions, learning effectiveness worsens. Instructors must respect the more limited attention span of learners when learning online. From a transactional distance theory, synchronous sessions would presumably increase dialogue and promote the reduced perception of transactional distance. If the interaction was of poor quality, however, the regularly scheduled sessions could be perceived as contributing to rigidity of structure, thereby increasing transactional distance and decreasing autonomy (Falloon, 2011). Consistent with CoI principles, online experiences rich in social interaction, reflection, and discourse, and led by a trained facilitator, may increase the likelihood of maintaining student motivation and, thereby, increasing the effectiveness of adult learning.

A review of the current literature should also account for the likelihood of selection bias. There is an innate selection bias in educational research (Dawson & Dawson, 2018), which means that the reality of the online experience may be worse than what is being discussed in peer-reviewed journals. Authors seek publication for successful educational teaching strategies while hiding failures (Dawson & Dawson) or may be rejected by journals for reporting unfavorable results. Additionally, most of the online learning research has been developed by instructors who care enough about the quality of education to conduct empirical studies on the teaching process. An accurate reflection of teaching effectiveness would encompass a true cross-section of those providing instruction.

Since the onset of COVID-19, students have been forced to take greater ownership of their learning, which has afforded a degree of flexibility in schedule and participation methods; however, greater autonomy has not always translated to improved self-direction. Lack of basic technological equipment and access to adequate internet bandwidth (Abbasi et al., 2020; Singal et al., 2020; Zayapragassarazan, 2020) have impacted the sense of engagement and communication between instructors and students. This expansion of TD has been compounded by course designs that have failed to promote student interaction (Aziz et al., 2020; Singal et al., 2020). A successful online learning environment creates a “community of learners,” an intentional practice that takes “dedication and skill” (Sekulich, 2020, p. 22). Interaction among students and between instructors and students needs to be more deliberate during online learning. Simply having students watch the lecture synchronously is not enough.

Effective online learning in graduate health programs is achieved through adherence to the assumptions of andragogy. Before engaging in online learning, the technological literacy of instructors and students and access to the internet and technological devices necessary for reliable use must be assured. Lesson plans and lectures deemed successful in a traditional classroom cannot simply be shifted online. Consistent with face-to-face lectures, passive online lectures remain susceptible to adverse learning outcomes or poor student perception. Failure to recognize the greater propensity for TD in the online medium increases the likelihood of student dissatisfaction or disengagement.

Additionally, learning experiences in a traditional or online setting that fail to integrate social, cognitive, and teaching presence make learning dull, shallow, or ineffective. While not all interaction is equal, interaction is crucial to foster an online learning atmosphere that engages students in enriching learning experiences. Instructors and programs should strive to craft online learning experiences that cater to the unique learning needs of adults while acknowledging the intricacies of the online medium.