RUTH TOBIN,1 CATHY LLOYD,2 MARK DAVIES3
1 Queen s University Belfast, Belfast BT9 5BN, Ireland
2 The Open University, Walton Hall, Milton Keynes, MK7 6AA, UK
3 Belfast City Hospital, Belfast, BT9 7AE, Ireland
Address for correspondence: Ms Ruth Tobin
Trainee Clinical Psychologist, School of Psychology, Queen s University Belfast, David Keir Building, 18-30 Malone Road, Belfast, BT9 5BN, UK
E-mail: rtobin01@qub.ac.uk; ruthtpsych@gmail.com
Introduction: Since the coronavirus pandemic, the amount of healthcare education provided online has increased enormously. Research has generally focused on the effectiveness of online courses. Little attention has been given to the lived experiences of educators transitioning their courses to an online format. This paper explores the thoughts and feelings of a team of educators who recently experienced such a transition.
Methods: In this qualitative study, a team of healthcare educators participated in a focus group or individual interview to explore what they learned from transitioning a four-day residential course teaching counselling skills and empowerment philosophy to healthcare professionals to an online format. A reflexive thematic analysis was employed to identify the themes that emerged from the data.
Results: Six key themes emerged: 1) impact of COVID-19; 2) initial perspectives; 3) support; 4) disintegration to reintegration; 5) understanding the relationship between the old and the new; and 6) future planning.
Conclusions: Transitioning an educational course from an in-person to an online format can initially be difficult but, with appropriate support, it is achievable and worthwhile. The process of transitioning a much-cherished course online was both an intellectual and an emotional process.
Practice implications: It is hoped that this paper will help to guide those transitioning a course traditionally taught in-person to an online format.
Br J Diabetes 2025;25(2)61-66
https://doi.org/10.15277/bjd.2025.490
Key words: healthcare education, online teaching, reflexive thematic analysis
Although online education existed prior to 2020, the coronavirus pandemic triggered an exponential increase in the amount of education and training offered virtually, and professionals and educationalists across the world had to adapt to a new way of teaching.1-3 This surge in online education has resulted in an increase in published research in this area. Of the studies published within the medical sector, the vast majority support the effectiveness of online courses.4-6 Identified advantages include flexibility, accessibility, convenience, lack of travel and more affordable costs.2,7-9 As well as disseminating knowledge, studies have demonstrated that online courses can improve clinical skills amongst course attendees.3,8,10 Disadvantages include difficulties with technology and internet connectivity, and the challenges of communicating with facilitators and with peers in a virtual environment.2,7,8
Less research exists on how educators and facilitators feel about transitioning a healthcare education course that they are used to teaching in-person onto an online platform. It is important to explore how educators and facilitators feel about transitioning courses online as their lived experience of this transition will affect how they engage with and teach the course. Moreover, it is important to gain their insights on whether they feel, from their perspective of teaching both, that the course is as effective online as it is in person.1,11 Examining experiences of transition from the educators points of view offers an opportunity to gain insight into challenges, to identify best practices and to understand effects on teaching and student learning outcomes to guide those undertaking similar transitions in the future.1,11
One healthcare education course that moved online during the pandemic, and continues to run both in-person and virtually, is the Knuston Diabetes Counselling and Empowerment Skills Course. This course, which was first run in 1987,12 supports diabetes healthcare professionals to gain skills to work in health settings with individuals using a person-centred care perspective. It focuses on teaching counselling skills and on fostering a philosophy of patient empowerment. The course is facilitated by a team of experienced educators from a variety of professional backgrounds. Since its inception, the quality and impact of the course has not gone unnoticed, with some attendees describing it as transformative .13 By 2020, approximately 50 in-person, four-day residential courses had been delivered. Each course is designed to include 18 delegates and six educators. At the outset of the pandemic, the course was transitioned online to support the ongoing needs of this group of healthcare professionals. This paper will explore the experiences of the course facilitators in the process of transitioning online.
Study design
This qualitative study employed reflexive thematic analysis, which allows for the identification and interpretation of meaning within qualitative data whilst recognising the active role that a researcher has in interpreting the data.14 Participants took part in either a focus group or a one-to-one interview, guided by an interview schedule with semi-structured open-ended questions, where they were invited to share their experiences of transitioning the Knuston course online. The interview guide is included in the Appendix.
Participants
All nine Knuston course facilitators were invited to participate in the study. Two were unavailable due to unforeseen circumstances, five took part in a focus group and two facilitators met with the lead researcher (RT) for individual interviews.
Procedure
Focus group interviews were chosen as the primary method of data collection as the interactions amongst participants in a focus group can often lead to a more expansive and deeper exploration of topics.15 All interviews were conducted using the Zoom virtual platform and were recorded and transcribed verbatim. Each participant was anonymised and was indicated in the results by Interviewee followed by a number between 1 and 7.
Interview recordings were listened to in their entirety by the lead researcher (RT) and were then transcribed using the transcription feature on Microsoft Office 365. Following initial transcription, RT listened to the interviews again whilst reading each transcription thoroughly to ensure that interviews had been transcribed verbatim and to add appropriate punctuation and utterances. Listening to the interviews whilst reading the transcripts repeatedly allowed the lead researcher to immerse herself in the data prior to analysis.
Data analysis
All interviews were analysed following the 6-stage approach to reflexive thematic analysis detailed by Braun and Clarke.16 An inductive, data-driven approach was adopted insofar that themes emerged from the data without consideration of any prior existing theories or frameworks; both semantic and latent codes were recorded in the data to gain understanding of the participants experiences.14
Once the lead researcher was familiar with the data, initial codes were created based on the data itself and the lead researcher s interpretation of it. Codes consisted of direct words, quotes and summaries. After initial coding, the transcripts were re-examined until it was felt the codes best represented the data.
Concurrently, two co-researchers (CL and MD) examined the transcripts and created codes which they felt to be significant. All three researchers then compared and contrasted codes, and agreement was reached as to the codes which best represented the data.
Following the development of codes, themes and sub-themes were identified and discussed by the research team to best capture the story told during the interviews. Once the research team were content with the analysis, an initial draft of the paper was shared with the participants to ensure validity of the analysis. This methodology ensured the reliability and validity of the results, whilst also considering the reflexive position of each researcher.
Researcher positioning
It is important that the positioning of the researchers involved in this project is described since their positions may have influenced their interpretation of the data. Whilst undertaking this study, RT was on a 11-month clinical placement in a diabetes psychology service as part of a Doctorate in Clinical Psychology. MD is a Consultant Clinical Psychologist who works clinically with clients who have diabetes and has extensive research experience leading or supporting an array of research projects. He facilitates a 45-minute component of the virtual Knuston course and facilitates the Irish version of the in-person course. He was not involved in the process of transitioning the in-person into an online course. CL is a professor at The Open University with an extensive background in research and the delivery of online education. She supported facilitators of the Knuston course to transition the course online with her experience of virtual teaching.
RT observed both the in-person and the online courses prior to conducting interviews and undertaking data analysis. She also met with some of the key facilitators of the course and had ideas about how they felt about the transition to a virtual format. She did, however, still approach the data with curiosity and with an open mind and recognised that the story that interviewees told during interviews should be translated as objectively as possible to the write-up of the research.
Ethical considerations
This study was completed as part of RT s Doctorate in clinical psychology course requirements. The research team at the School of Psychology, Queen s University Belfast approved the project as a service evaluation project that did not require formal ethical approval. All participants provided informed consent to partake in the research, they had capacity to do so and the study posed no risk to the participants nor did it cause any distress. All recorded interviews were destroyed after transcription.
Thematic analysis revealed six key themes (along with sub-themes) which are detailed below: 1) impact of COVID-19; 2) initial perspectives; 3) support; 4) disintegration to reintegration; 5) understanding the relationship between the old and the new; and 6) future planning.
The impact of COVID-19
Before the COVID-19 pandemic some thought had been given to transitioning the course online, but the idea had not been acted upon. The pandemic lockdowns triggered a do or die moment and provided the impetus to act.
"If COVID never happened, then this wouldn't have ever happened. Motivation for me when, when COVID happened was if we don t do this then we re looking down the barrel of a gun. We might as well pack up and go away; we had to do it." [Interviewee 5]
"During COVID when we couldn't have the [in-person] course, we just said how can we do it? We had a group meeting and everyone said yeah, go for it and then the real work started. It came from COVID." [Interviewee 1]
Initial perspectives
Facilitators of the course expressed a range of perspectives, from sceptical to enthusiastic, about moving their long established and much cherished face-to-face course online. Those who tended towards scepticism tended to be anxious about technology and the challenge of maintaining integrity and reproducibility.
"I was feeling quite negative about it and whether it was going to work or not. I mean I wanted it to work, but I didn't see how we could recreate the magic and I don t know what the real word for magic is but the, the, intensity of experience that people on the face-to-face course experience I was quite negative about it and whether it was going to work or not." [Interviewee 4]
Those who felt more optimistic pointed to their belief that the central components of the course could be reproduced virtually or that the perceived benefits would outweigh the challenges.
"I've been thinking to myself it was straightforward really. It was can we interact with ourselves, with ourselves the facilitators and the facilitators with the participants and the participants with the other participants? And I think the answer is yes. We do interact and also given that the person-centered approach with the three core conditions, you know of empathy etc. I think those can be demonstrated online. I knew they could be and I couldn't see why we wouldn't be able to do it." [Interviewee 5]
Support
The importance of support in the process of the transition was highlighted. The team received support, guidance and inspiration from an affiliate of the course, CL, who was an experienced online educator. CL s support was described as essential in understanding how to deliver online courses, in guiding the course design, and in instilling confidence amongst the facilitators. CL also acted as a vital conduit between the facilitators and an IT professional with experience of virtual teaching who could support the team throughout the delivery of the course.
"CL has been an absolute rock throughout. She was the person that put the thinking, you know, into how do we actually do this. It was CL behind us, encouraging us. It wouldn t have happened without her, no doubt in my feeling. CL the whole time said to us it will work, it will work, you know." [Interviewee 1]
The importance of trusted IT support to ensure successful running of an online course was also mentioned by all interviewees.
"I'm adamant that if I m anything to do with the course, I m not relying on us doing amateur IT cause it s fine if everything works and it, it s a nightmare if something goes wrong and the whole thing could fall apart. So, you have somebody who knows how to fix the problems and that in my view can t be somebody who is actually part of delivering the course because if they re supposed to be in a triad facilitating and somebody in another triad s got shut out, what happens?" [Interviewee 6]
Disintegration to reintegration
Facilitators experiences of transition involved a process of change in which existing curricula and teaching methods were adapted (disintegration) and then rebuilt into a cohesive, effective online version (reintegration).
Letting go
The transition to an online course involved an element of letting go . In developing the online curriculum, changes to the course had to be made for pragmatic reasons, such as the amount of time delegates could tolerate being online at any one time. Though all facilitators had an attachment to the course s original format, compromise was required as elements of the course needed to change to make it suitable for the online platform. The prospect of losing some elements of the in-person course was daunting for some of the facilitators.
"We had to make some major decisions because, as I've said, the days were shorter [online]. And so the major decisions were to drop IPR, the interpersonal process recall; and the other big thing which we do regret and keep looking at how we could change, is on the last day [of the in-person course] we have actors coming in and we can t do that." [Interviewee 6]
"Some of it translates very well in my opinion to being online and I think it has some advantages, but some of it doesn't translate; some of the things had to be dropped and it s, it s a different experience. So I think the outcomes and the benefits, the pros and cons are different for both." [Interviewee 2]
Pilot
A feeling of stepping into the unknown and just do it (Interviewee 5) was evident. It was recognised that the only way to test whether it would work would be to offer a pilot course (at no expense to delegates). The pilot course proved to be extremely useful both as a means of obtaining delegate feedback and as a test of facilitators optimism.
When reflecting on the pilot, Interviewee 6 noted:
"I mean the, the first thing was that it could be done. I mean, that was absolutely key. It could be done, because we weren t sure. And also the IT worked that, because you know, I m, I m, I m sure you can imagine if you re taking something from face-to- face and making it shorter and more ahhmm, and pre-recorded it, it s quite a big leap so that was a worry, it was a relief that it worked." [Interviewee 6]
"I ended up almost in tears. Ever since that experience [the pilot] I, I was at once won over. I knew it was going to work (laughs)." [Interviewee 3]
Continuous adaptation and improvement
Following the pilot, the course was amended based on participant and facilitator feedback.
"We pared down the programme after the pilot, if I remember we altered it slightly and we took things out." [Interviewee 1]
Thereafter, each time the course was delivered, the facilitators became more familiar and comfortable with online teaching and with the overall curriculum. Facilitators learned to adapt their way of teaching and interacting to the online platform.
"After about two or three, I think one or two of us were worried that it wasn't going to work, but it was getting better and it did get better, every single one got better as we went on." [Interviewee 4]
"CL said you have to think of this as a different kind of course, this is not a replication of the face-to-face course, and I remember thinking at the time, but I want it to be a replication of the face-to-face, because I want to recreate the magic. The feedback wasn't great to start but something changed and it s just got better and better." [Interviewee 4]
As facilitators became more confident, unexpected benefits of an online format began to emerge.
"Maybe the face-to-face because it has been presented as face-to-face for so long, it s a little bit more, more rigid. I think the online because it is new, people started thinking how are we going to do it? What are we going to present? So in a way I think the online has opened the door for some new ideas for doing things differently which I think in a way is positive." [Interviewee 7]
Through practice, the skill of each facilitator in teaching the course online also improved.
"I think it is difficult to communicate the core conditions online, and I think the online course has progressed because we probably have gotten better at it." [Interviewee 4]
As the online course evolved, and facilitators gained confidence in themselves and in the utility of online teaching, the online course became more established.
"The core conditions and the philosophy and the way in which the course is, I think is intact, I don t think that s different at all. I think it is maintained, it s ahh, authentic and those core conditions are in place. I think the person-centred, empowerment philosophy is intact in both." [Interviewee 2]
Facilitators expressed excitement about the future development of the online course:
"One facilitator took on a lot of new stuff for, for, I mean old stuff, but did it herself in her way. She and another facilitator worked in a completely new format that we hadn t seen before. That was very, very, very exciting. It was new creative stuff. It was exciting. It was a new version of the course really." [Interviewee 1]
Understanding the relationship between the old and the new
As facilitators began to appreciate that delivery of the online version of the course was successful, thoughts turned to the strengths and weaknesses of both the online and in-person courses.
"I'm a great believer in this course in that it opens it up to people that otherwise wouldn't get the opportunity and it s a great experience for them and the feedback is great and it is a complete benefit. I completely believe that. And ahh even though it s a different experience, I think it is valuable." [Interviewee 2]
"I realised that you can t put a group together on screen and get chat going, it s difficult. It s not like putting them in a room together. And if you re leading a discussion when you re in a room and everybody s around, you can pick up from the body language who s got something to say, or who maybe is a bit reluctant but still has something to say. When people are gazing at you on screen, you don t get that same feedback." [Interviewee 6]
Facilitators all noted that the online course, which has some pre-recorded sections included in it, is less organic and they noted that it can sometimes feel more isolating.
"When you re doing it online, when there s a break, everybody goes to their own, to their own life and they go to make a cup of tea on their own and while in, in, when you re doing the Knuston course together, the social unplanned part of the course is essential, is quite an important part of the course, and I think the online misses that side. You miss the informal discussion with the facilitators, the informal discussion with your co course attendees." [Interviewee 7]
Limitations to online learning were noted, including language barriers, distractions at home/work, internet problems and participants sometimes having limited IT skills.
"A Russian nurse, she said she would definitely want to do the face-to-face course because of the language barrier that, that there s less of a language barrier, if you re face-to-face than if you re online, which I think might be true." [Interviewee 1]
Future planning
The final theme that emerged from the data was future planning. Some facilitators worried about the survival of the in-person course, given the increasing popularity of working on online platforms, their relative affordability and the increasing success of the online course.
"I was also worried that we wouldn't get people to the face-to-face course because of the difference in cost, people would stop coming face-to-face and I was worried about that because I was absolutely, 100% sure and still am, that face-to-face is a richer experience, so you don't want people to put ahhmm, to, to not attend face-to- face when they could, because they're they're just thinking, well, it's easier and cheaper to do it online. It isn't, it isn't as good." [Interviewee 6]
Moving forward, it was noted that continuous development of the online course would be important now that all facilitators are comfortable with the online offering.
"I don t think the online course it s reached its full potential yet. I still think there is, there is room to be delivered even better. I think there s, there will be more to online presentation which I don t think we are tapping into just because, ahhmm, I don t think we maybe, we don t have the skills or maybe we are a little bit more conservative still, but I think that will come. I think the course has proven itself that it is, it is valuable. I think it s something which as a team we should be proud of." [Interviewee 7]
Offering an online and an in-person course to interested participants in the future may actually benefit the quality and content of the course as elements of the online course which are received well by attendees may be incorporated into the in-person course and vice versa:
"So I think in a way because online gives us the opportunity to do something different I think people felt well, this is so good that we could use it in the face-to-face as well. So it s, it has been like, it s two-way learning so that initially the online was, was inspired by the face-to-face, but now part of the face-to-face is being like adjusted based on the online as well." [Interviewee 7]
All education courses are different. Some focus on knowledge transfer, some on skills acquisition and some, as in this case, a little on both. It might be suggested that longer, more emotionally intense educational courses might be harder to transition online. This paper offers no insight into that question.
What many courses have in common is that course facilitators will often feel an attachment and emotional investment to the course they teach and the prospect of adapting or dismantling something that has developed and evolved often over many years is daunting. In this case, some of the facilitators had been delivering the in-person course for more than 30 years. Their motivation for doing so is not pecuniary, as they do not receive any payment. Rather, it is the joy and satisfaction they experience from delivering a course that has an appreciable and significant impact on the professional lives of delegates.13
Each of the facilitators who took part in this study cherished their face-to-face course and it took both bravery and leadership to take a leap and risk losing the essence or the magic of the course by moving it online. As well as being a technical and an intellectual task, the transition online was an emotional process. This might not apply to all educators and to all courses but it will no doubt chime with many.
As with all qualitative studies, the question of generalisability is not a primary concern, however rigorous the methodology. Reflexive thematic analysis is inherently subjective, as the researcher s personal experiences and assumptions influence the interpretation of the data.
A limit of this study may be that the lead researcher observed both the in-person and online courses prior to analysis. Her perceptions of both versions of the course may have then influenced her reading and interpretation of the data. As a result of this, the lead researcher engaged in continuous self-reflection throughout the research process, transparency in the methodology was demonstrated, and analysis was collaborative and included the study participants.
These findings demonstrate that transitioning an educational course from an in-person to an online format can initially be difficult but, with the right support, it is both achievable and worthwhile. It is hoped this study might support healthcare educators in the future to understand and manage such transitions.
© 2025. This work is openly licensed via CC BY 4.0.
This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format, so long as attribution is given to the creator. The license allows for commercial use. CC BY includes the following elements: BY – credit must be given to the creator.
Copyright ownership The author(s) retain copyright.
Conflict of interest The authors declare they have no conflict of interest.
Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Formal ethical approval was not needed for this paper as it was a service evaluation approved by Queen s University Belfast. All participants in the study gave informed content to participate and the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements The authors thank the facilitators of the Knuston Diabetes Counselling and Empowerment Skills Course for their willingness to facilitate and engage in the study.
Main questions
-Why did you decide to move the Knuston course from in-person to online? What was the context?
-What were your initial thoughts re transitioning a course from an in-person to online format?
-Who did you expect to sign up to the course? (e.g. IT-savvy professionals)
-What guided your adaptation of the in-person course to a virtual format?
-What were the key things that you learned from the pilot course? How did you identify what went well and what did not go so well?
-Do you think the course has improved over time? If so, in what ways?
-What advice would you give to someone considering moving a course online?
Sub questions
-Prior to doing the course online what were your hopes for it? Had you any anxieties?
-How successful did you expect the course to be? (rate on Likert scale)
-How did you decide what to keep in or leave out?
-Did you look anywhere for guidance or advice or is there anyone who helped you?
-Did you get participant feedback? If so, why did you want it and how did it help? Were there any unexpected lessons?
-Have there been any surprising lessons? Has your experience of delivering the course changed how you think of virtual education?
-Do you think this course translated to the online platform or was anything lost?