Open Research Online Students’ experiences of synchronous online tuition in health and social care

This article considers the online tutorial experiences of 10 female undergraduate students studying a health and social care module at a large UK-based university that specialises in distance learning. The research uses the Community of Inquiry as a theoretical framework and takes an experience-centred narrative approach, using Voice-Centred Relational Method to analyse diaries and interviews. The analysis uncovers how tutorial experiences are embedded in the social and cultural contexts of students’ lives and are fitted around their caring roles. These stu- dents experience variation in tutorial design and in the tutors’ characteristics. They value friendly, empathetic tutors who enable students’ contributions and respond encouragingly. Students avoid using microphones in tutorials for multiple reasons but enjoy taking an active part via other tools. They appreciate hearing peers’ per- spectives and prefer small group sizes. A sense of community is missing, particularly for students with fewer supportive friends, colleagues, or family members. They long to see people’s faces and build relationships. An awareness of students’ contexts and preferences can help educators to enable positive tutorial experiences.


Introduction
For almost 20 years, synchronous online learning has played a key role within distance education in the United Kingdom (UK) and a developing role within other universities, often as part of a blended approach. With the arrival of the coronavirus 2019  pandemic in the UK in March 2020, how to teach effectively online became a pressing topic for educators as face-to-face teaching became unfeasible. Online learning is likely to continue to play a significant role, so it is essential to understand how students perceive their experiences of this medium. The significance of student voices has sometimes been overlooked in research in technology-enhanced learning (Levy 2015).
This research considers the online tutorial experiences of 10 female undergraduate students studying a health and social care module at a large UK-based university that specialises in distance learning. Two of the research questions addressed by the study will be considered in this article: (1) How do the narratives of students' experiences of synchronous online tutorials in a health and social care module vary and what factors account for this variation?
(2) What can we learn about the needs which drive the preferences students express around synchronous online tuition in health and social care?

Literature review
There are few recent studies that looked at health and social care students' perceptions of their experiences of synchronous online learning. An Australian study that used a course evaluation instrument and questionnaires to compare experiences of first year distance nursing students after the introduction of synchronous online tuition found an increase in student satisfaction (O'Flaherty and Laws 2014). Online tutorials helped them to feel part of a group, reducing isolation and providing opportunities for sharing and collaboration. The exam pass rate rose significantly.
A study of 43 American postgraduate nurse education students who evaluated the introduction of weekly synchronous sessions produced similarly positive results (Foronda and Lippincott 2014). Students enjoyed the sessions and liked their convenience and flexibility. They described high levels of interaction and thought their experience as good or better than face-to-face, although there were occasional technical problems.
In other disciplines, studies of students' perceptions of synchronous online tuition tend to focus on three related areas: social presence, a sense of community, and interaction. The way in which social presence is defined and understood has evolved considerably over time (Richardson et al. 2017). The most recent definition offered by Garrison (2009) reflects the common purpose and collaborative nature of groups and incorporates the significance of shared group identity: the ability of participants to identify with the community, communicate purposefully in a trusting environment and develop inter-personal relationships by way of projecting their individual personalities. (Garrison 2009, p. 352) A strong relationship has been identified between perceived social presence and both student satisfaction and perceived learning (Caskurlu et al. 2020). Factors affecting these relationships include course length, with stronger relationships in longer courses. In one study, postgraduate education students in the United States of America (USA) described how synchronous sessions combined with forum discussions strengthened social presence, some feeling that they became better acquainted than in face-to-face settings (Yamagata-Lynch 2014). Berry (2019, p. 164) defines community as 'feelings of membership and closeness within a social group'. Their study using video and interview data with doctoral education students shows that synchronous online community is crucial and plays an important role in retention (Berry 2017). Other studies using 3 (page number not for citation purpose) surveys and focus groups have evidenced how a strong sense of community can be generated in synchronous online sessions (Gauvreau et al. 2016;McDaniels, Pfund, and Barnicle 2016). They note the importance of extensive planning and the tutors' pivotal role.
Other studies examine perceptions of a third aspect of students' experience: interaction. Four types of interaction have been identified in online tutorials: 'learner to interface', 'learner to content', 'learner to teacher', and 'learner to learner' (Martin, Parker, and Deale 2012). Studies with postgraduate students have found that students value peer interaction and experiences of community (Bondi et al. 2016;Hokanson et al. 2019). A survey of 1056 adults with experience of online learning in multiple contexts in the USA found lack of interaction was the biggest barrier to learning online (Muilenburg and Berge 2005). This had a strong relationship with students' enjoyment of study and the effectiveness of learning, although these relationships are not necessarily causal. Similarly, a study of 206 UK students' perceptions of synchronous online tuition in maths and computing found that, whilst it was seen as being as effective as face-to-face for learning and convenient, it compared poorly for interaction (Lowe, Mestel, and Williams 2016).
There are also studies which focus on students' perceptions of online room tools. Education students at the University of Florida commented positively on the affordances of the online environment (McBrien, Cheng, and Jones 2009). Polling tools, for example, allowed shy students to express opinions confidently, without feeling judged. Questionnaires returned by psychology students at The Open University suggested a reluctance to use the microphone (Middleton and Smith 2013). Up to 170 students attended these sessions; these unusually high numbers are likely to have affected experiences. Many students preferred using the text chat, which some found distracting. The distracting nature of the text chat has been highlighted elsewhere, including how the tool makes it possible to ask questions when someone is talking, an impossibility when working face-to-face (McDaniels, Pfund, and Barnicle 2016).
Several studies specifically consider the impact of tutor webcam use on student perceptions. One found that tutor webcams had a positive impact on students' feelings of instructor co-presence (Han 2013), whilst Guichon and Cohen (2014) found that webcams made no difference in this regard, although the teacher spoke more when webcams were absent and there were more student silences, perhaps reflecting the lack of visual clues. Only one study reviewed specifically mentions student webcams (Gedera 2014). Students were positive about being able to see each other but reported anxiety about technology failure.
The literature reviewed highlights the importance of viewing synchronous online education as a social, interactive process and led to the choice of the Community of Inquiry framework as a framework for this study.

Theoretical framework
The Community of Inquiry framework conceptualises the relationship between the elements necessary for a worthwhile learning experience: social presence, teaching presence and cognitive presence. A Community of Inquiry is defined as 'a group of individuals who collaboratively engage in purposeful critical discourse and reflection to construct personal meaning and confirm mutual understanding'. (Garrison, Archer, and Anderson 2011, p. 2) The framework's focus on learning processes, including critical thinking and the significance of identifying with the group, and its recognition of interconnectedness between different elements make it valuable for examining experiences of learning.
This framework has often been used for gathering quantitative data using the Community of Inquiry Survey Instrument (Athabasca University no date), but here it is used in the context of a qualitative study, using descriptions of what these presences might look like within online health and social care tutorials developed from the survey instrument ( Figure 1).

Methodology
Viewing the students as experts on their experience or the 'privileged knowers' (Hesse-Biber and Leavy 2011, p. 42), this study took an experience-centred narrative approach,

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which gives external expression to individual, internal representations of phenomena, including thoughts and feelings. It is well-suited for accessing in-depth understandings of learners' perceptions and experiences (Baughan 2017;Cousin 2009).
Researchers using narrative methods within higher education are encouraged to explore at least five narratives and 10 if time permits (Cousin 2009). Every narrative generates extensive, rich data, so gaining an in-depth understanding is always prioritised over increasing the sample size.
Ten students studying an undergraduate health and social care module about children's and young people's well-being took part in the study. Approval for the study was granted by the Human Research Ethics Committee. Inclusion in the study was based on freely given, explicit consent, which required participants to opt in. All participants were female and identified as either white or Asian but in other ways they were a diverse group (Table 1). All the students had studied at least two 60-credit modules previously. Participants chose their own pseudonyms.
The students completed diaries and were interviewed about their experiences of one of more tutorials attended via Adobe Connect™ between October 2020 and May 2021. Whilst face-to-face interviews would have been advantageous because they enable non-verbal communication and more emotional feedback, they were not a practicable choice for these participants, who were located throughout the UK. Most were interviewed by telephone, a way of communicating which the participants perceived as more convenient and less intrusive than a video call. One was interviewed by email because hearing loss made telephone conversations difficult for her. Students also completed a table about their personal learning networks prior to interview to show which individuals and groups they usually discuss their studies with and how often.
The diaries and interview transcripts were analysed using voice-centred relational method (VCRM), an approach to narrative analysis that reflects a relational ontology (Brown and Gilligan 1991;Mauthner and Doucet 1998) and recognises that relationships are often central to people's experiences. Researchers using VCRM carry out multiple 'listenings' to the data, a term that acknowledges participation of both the teller and the listener (Gilligan et al. 2003). None of the listenings stand alone; only together can they represent someone's experience.
The steps in the analysis were: (1) listening for the broad story, including the context and the drama, paying attention to repetitions, metaphors and emotional resonances, revisions and absences, changes of narrative position and also considering the researcher's response and the responses of other tutors to the narrative.
(2) listening for the 'self' speaking in the story through the construction of 'I' poems and reflecting on participants' expressions of identity as a student.
(3) listening for the contrapuntal voices of the personal, the communal and the institutional context, as represented by 'I', 'we' and 'they' to gain insight into the extent to which students perceive themselves to be part of a community and how they perceive their relationships with peers, tutors and others.
(4) listening for evidence of the different types of presence from the Community of Inquiry framework using descriptions of what these presences might look like within online health and social care tutorials developed from the Community of Inquiry Survey Instrument (Athabasca University no date).
(5) composing an analysis of what was learnt via separate listenings in relation to the research questions, bringing the separate voices back into relationship with each other and reflecting on the learning process.
In narrative research, there are five levels of representation or points at which meaning can shift: attending, telling, transcribing, analysing and reading (Riessman 1993). As such, participants' narratives, researchers' interpretations, and readers' understandings are all unique. Five processes were applied to enhance credibility (Twining et al. 2017): involving others (tutor colleagues and supervisors) in the data analysis, gathering data from different participants who attended different combinations of different tutorials, triangulation of method through using both diaries and interviews, considering a range of theoretical perspectives and participant checking of transcripts.

Findings
The analysis identified two ways in which students' experiences vary. These relate to the two different environments within which students are situated during tutorials: the physical, off-screen, social and material environment of their home or wherever the student happens to be, and the virtual online environment of the tutorial itself.

Variation in students' social and material environments
The narratives show how tutorial experiences are embedded in the social and cultural contexts of distance learning and students' lives, with students fitting study around their work and caring responsibilities. Family members are sometimes physically present during tutorials but invisible to the tutors and other students. For one student, Tilly, her diary shows that she usually joins tutorials from her kitchen diner, her family cooking and eating around her, and once she joined via a mobile whilst collecting her daughter from a club. For another student, Deborah, her baby is asleep next to her and her 6-year-old watching Netflix nearby for the first tutorial, as her 7 (page number not for citation purpose) diary describes. Being a single parent, Vicky 'hopes and prays' that her childcare arrangements can fit around her own tutor's sessions. Amie has no one to look after her children: Having small children does make it hard. I do have to tell them to just sit down and watch TV for some time, but, you know, it's not guaranteed that they will just sit down, not for an hour and a half, and one of my children has learning disabilities. He doesn't take instructions very well. (Amie, interview) Another student, Karen, describes the stress of her husband's recent severe illness. Her husband is in her mind, despite him being in a different room during the tutorial. Her studies are 'a bit of normality' and 'something to focus on for herself', although she worries that this sounds selfish.
So, during online tutorials, there is plenty of competition for students' attention. Being online can mean that there are virtual distractions too. Joanne shares, Also, when I'm on the laptop, I'll be thinking, 'Oh, I wonder what happened with that in the news today'. I know towards the end that definitely happened. My mind wandered off a little bit. (Joanne, interview) This means that cognitive presence, the 'extent to which learners are able to construct meaning through sustained communication' (Garrison, Anderson, and Archer 1999, p. 89), is affected not only by what is happening within the tutorial itself but what else is happening for the students and their families in their home environments and in their online environments.
There are other people who feature in students' narratives who are not present during tutorials but who can be described as vicariously present in terms of how tutorial information is subsequently shared. Sophia describes sharing what she has learnt with many family members: I like to share what I'm learning as well, especially about the health and the learning and relationships… We learn really well when we teach. (Sophia, interview) In these ways, the tutorials are influenced by the presence of other people but also have an influence on others far beyond those visibly present in the tutorial.

Variation within the tutorials
There was considerable variation in the tutorials that participants experienced. The characteristics of the tutor(s) were highlighted as key to a positive experience. Students valued friendly tutors who showed understanding of the challenges of distance learning, enabled students to contribute and responded to each one encouragingly. Where sessions were co-tutored, students noted the importance of tutors working 'as a team'. For the five co-tutored tutorials that Tilly recounts, she always comments on how each pair of tutors work together and how this affected her experiences. Mostly, this influence was positive. She felt as though the whole group was 'working together'. About her only negative experience she writes, The main tutor talked over the co-tutor and dismissed her tip about writing introductions. (Tilly, email interview) Analysis of the extent to which the different types of presence from the Community of Inquiry framework were apparent within the narratives found considerable variation in the number of instances of teaching presence, which is concerned with the tutor or tutors designing tutorial activities that enable dialogue and help students learn (Garrison, Anderson, and Archer 1999). Within Lisa's narrative, for example, the first tutorial she described involved the tutors 'talking to us', whereas the second involved the group watching clips together and then completing activities based on the clips.
Having activities and being engaged…, that was where I enjoyed the second one a bit more, whereas the first one was a lot of sort of talking to us if you know what I mean? (Lisa, interview) The tutors' more frequent use of the whiteboard within this tutorial led to a stronger sense of social presence, where students were comfortable interacting with each other, and felt that their point of view was recognised. Lisa, who enjoys contributing her ideas but does not use the chat box because she is dyslexic and worries about her spelling, felt able to participate if the whiteboard was used.
…we were able to add anonymously into the slide, to the table, and really get involved and to see how other people…their perspective of it which I found really helpful. (Lisa, interview) A stronger sense of social presence was also apparent in one of the tutorials that Deborah attended where tutors enabled students to learn about report writing from each other, sharing a sense of identity, not only as students but also as practitioners.
There was a lot of discussion done in the chatbox to the point where it got to full capacity... I'd actually taken notes on the tutorial, so I was actively listening to it. (Deborah, interview) So, there is evidence of a relationship between teaching presence and social presence. This seems to play a key role in generating cognitive presence for students too.

Preferences around synchronous online tuition
There were five areas in which students expressed clear preferences around synchronous online tuition: communication in the online room, being active and hearing the perspectives of others, face-to-face contact, building relationships and community, and numbers of students.
A theme coming out of almost all the narratives is avoiding using the microphone. A variety of reasons are given, including not being able to see who is talking because webcams are not used, the slight delay, having English as a second language, worrying about making mistakes and the influence of family members in the background. Another preference was the avoidance of multiple simultaneous conversations, where 9 (page number not for citation purpose) one tutor communicates via the microphone, whilst students and the other tutor type in the chat box.
It can be quite tricky to follow what is going on in the tutorial when one tutor is talking and the other is writing because I'm focusing on the text box waiting for an answer. (Vicky, interview) The most positive tutorial experiences were those in which students described themselves as being active, not passive. Even those who characterized themselves as 'shy', 'not very articulate' or even, in one case, as 'a silent student', liked to be involved in the session and hear the perspectives of other students. Amie said, This tutorial was better because instead of just talking themselves, the tutors encouraged the students who were attending the tutorial to participate, to present their ideas briefly. In that way, students were getting to say what they wanted to say, and a lot of ideas were being written on that whiteboard. (Amie, interview) For some students, the opportunity to build a relationship with their own tutor is an important aspect of tutorials. For others, this is less important. What is more often missing, however, are opportunities to connect with other students. This was particularly important for those students who have fewer friends, family members or work colleagues with whom to discuss their studies. For them a sense of community and connection is sometimes absent.
Despite the focus of the research being online tutorials, a priority was conveying a strong preference for face-to-face tuition. Even those who lived too far away to attend the optional face-to-face sessions longed to be able to see faces, even if this was only via webcam, something that they had not experienced.
[Using webcams] would make more of a difference and you could actually see people's faces and see their reactions. Recently, I have had a session with webcams because I'm currently retaking my English GCSE […] and that session was actually really good. I suppose that was different because I already know all of the other students, cos we see each other every Tuesday. It felt a bit more natural. (Melissa, interview) Three students suggested that keeping student numbers in a tutorial reasonably low is important to facilitate a positive experience. For Tilly's least positive tutorial experience, where the session felt rushed and the students seemed 'quite restrained', there were 32 attendees. She suggests that 15 is ideal: I think the tutorials work better with a smaller number of students -maybe around 15 would be ideal, otherwise you are all vying for attention, asking so many questions and responding to questions asked that the tutor doesn't get time to answer them all. Also with lots of students you can be lazy and not have to participate as much as you do when there are less students -you can wait for someone else to ask/answer the questions! (Tilly, email interview) These findings will now be discussed in relation to the literature.

Discussion
The narratives of these 10 female students show how tutorial experiences are embedded in the social and cultural contexts of distance learning and students' lives, students fitting study around caring responsibilities and what was happening in their household at the time. Family members, particularly children, were often physically present, although invisible to the tutor and the rest of the tutor group or very much in mind. Also invisible were the makeshift study areas from which students joined tutorials. This invisibility and the associated affordance of being able to care for family members whilst learning can be valuable for students, but it can also hide the challenging nature of reality: students trying to participate despite multiple distractions.
The influence of these social relationships is bi-directional, the students sharing their learning with family members, friends and colleagues and using it to inform their practice. Drawing on ideas around sociomateriality, which is concerned with how the social and material are 'constitutively entangled in everyday life' (Orlikowski 2007(Orlikowski , p. 1437, it can be argued that online learning has become inappropriately conceptualised as separated from students' everyday lives, existing in a closed and separate 'magical realm' and incorporeal, whilst, in reality, it is entangled or interconnected with people's bodies, their physical spaces and social sphere (Gourlay and Oliver 2018;Jones 2005). The overlaps between participants' roles as parents, family members and practitioners are apparent in terms of time and geography as they try to perform multiple roles simultaneously, but also in terms of the knowledge that they can take from one context to another. Rather than perceiving students as free-floating autonomous human subjects (Gourlay and Oliver 2018), educators need to see learning as embedded in students' contexts, relational and embodied.
The care and attention of the tutors was perceived as key to a positive experience. As illustrated by the students' narratives, however, teaching presence is not only about what the tutor does but can also be about the person that the tutor is, their persona and characteristics. This reflects an alternative definition of teaching presence: …the specific actions and behaviours taken by the [teacher] that projects him/ herself as a real person. (Thomas and Thorpe 2019, p. 66) The students valued tutors who were friendly, understanding of the challenges learners face, who enabled students to contribute and responded to each student with encouragement. Educators should not control student voices but rather create spaces where everyone, including the tutor, can create, experiment and learn from each other (Morris and Friend 2020). So, tutors need social skills and empathy, not just technical skills. These skills include being 'human' and openly acknowledging differences in power.
What made a difference in the positive experiences described was having not only teaching presence, but a focus on enabling social presence. In the most positive tutorial experiences that students narrated, students reported that they felt able to interact with others and that all students' ideas were acknowledged. Students learned from each other, not just from the tutors. It was this combination of both teaching presence and social presence that helped to generate positive tutorial experiences with evidence of cognitive presence, emphasising the importance of a community of inquiry being a community where everyone learns from each other (Edwards, Perry, and Janzen 2011).

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Students' reluctance to use the microphone has similarities with the findings of earlier studies (Middleton and Smith 2013;Smith and Smith 2014). Online environments have been conceptualised as 'uncanny spaces' (Bayne 2008), where students experience uncertainty in terms of people seeming ghostly or disembodied. It is questionable whether microphone use is always necessary for learning. There is a danger that discourses around student engagement in online spaces can unhelpfully define what students 'should' be doing, with particular observable behaviours coming to be seen as proxies for learning itself (Gourlay and Oliver 2018). A focus on enabling communication in any way that enables students to test out their ideas with others might be more beneficial to learning than insisting on microphone use. It is also important that tutors who are working together adapt their communication to support students effectively and avoid too many simultaneous interactions. Tutors can be proactive (McBrien, Cheng, and Jones 2009), for example, by agreeing beforehand which ways of communicating will be used at which points in the session.
Some students in this study longed to connect with other students, to feel a sense of belonging. This was less of a concern for some of the participants in the study than others. This difference was not necessarily because these students were, as suggested elsewhere, self-sufficient 'lone wolves' (McDougall 2019) but because, as indicated by the learning network tables that they completed, they had more friends, family and colleagues with whom they could discuss their learning. For students who lack this support, attending sessions with a strong sense of social presence in which there are lots of opportunities for interaction can be particularly important.
Despite the focus of the study being online tutorials, a priority for students was conveying how much they would prefer face-to-face tuition, even where students had not actually had this experience. None of the students in this study experienced webcams being used during the tutorials they attended, and this is not unusual, particularly with the Adobe Connect™ platform, as there are issues around webcams using excessive bandwidth causing students to lose their connections to the online room. Some participants had used webcams in other contexts and talked about the difference that they might make. Some students (and tutors) may want to keep the family members and intimate spaces in their backgrounds hidden. Going forward, when it comes to universities' choice of platforms for online delivery and tutors' choices around setting up online rooms, options that allow students to individually control whether to switch incoming and outgoing webcams on or off might enhance students' experiences.
The narratives suggest that tutorial experiences could be improved by keeping the numbers of students attending each session low enough to allow time for tutors to interact with every student. Having small groups where students can discuss their ideas with each other is important for learning how to think critically and the need for smaller classes has been identified in other studies (Lowe, Mestel, and Williams 2016;McDaniels, Pfund, and Barnicle 2016). Stommel (2018) argues that whilst universities have financial incentives to make classes bigger, there are no pedagogical ones. When it is not feasible to limit numbers, strategies which allow everyone's contributions to be acknowledged are essential, such as using polls or quizzes. Breakout activities are a further option, but they were rarely experienced by the students in this study. Small group work can be effective, giving students an opportunity to interact in a lower pressure environment. Small group work requires detailed planning, taking account of where students are up to in their studies and promoting confidence in their ability to contribute. However, tutors can be hesitant about using breakout rooms (Chandler 2016;Breeze and Holford 2021), and they need opportunities to develop skill and confidence in their use of online technologies. Making use of opportunities to interact with just a few others can transform students' experiences of learning.

Conclusion
A case-centred analysis of these students' narratives of online tutorial experiences suggests that students and educators need an awareness of the extent to which tutorial experiences are embedded in the social and cultural contexts of distance learning and students' lives. It is helpful to have an appreciation of the extent to which students might be trying to fit tutorial sessions around their work and caring responsibilities. Students will gain the most from each session by actively participating as much as they can, sharing their ideas and experience with the rest of the group. Tutors can enable positive tutorial experiences by being friendly, encouraging, and helpful; understanding of the challenges distance learners face; and supportive of co-tutors. The narratives also suggest that there are many things tutors can do to enable a positive experience for students. These include using a webcam (briefly if broadband connections allow) or a tutor picture so that students feel that they can build a relationship with the tutor; designing activities that minimise anxiety, but which allow ideas to emerge and everyone to contribute comfortably; enabling interaction in any way that encourages students to test out their ideas, rather than focusing on microphone use; and responding encouragingly to everyone's ideas, so that they know that their contributions are valued. Universities can enable positive experiences through adjusting their policies to maximise opportunities for students to connect with others in small groups, providing tutors with ample opportunity for tutorial planning, and providing training to develop tutors' skills and confidence.