COVID-19 and Virtual Medical Education: A Correlational Study of Attitudes Towards e- learning, Perceived Stress, and Ethics among Faculty Members of Medical Universities in the Southern Region of Iran

doi:10.21203/rs.3.rs-4993640/v1

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Research Article

COVID-19 and Virtual Medical Education: A Correlational Study of Attitudes Towards e- learning, Perceived Stress, and Ethics among Faculty Members of Medical Universities in the Southern Region of Iran

https://doi.org/10.21203/rs.3.rs-4993640/v1

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Background: The COVID-19 pandemic forced a rapid shift to virtual education in medical universities, creating challenges for faculty due to a lack of preparedness, ethical concerns, and increased stress. This study examines the relationship between faculty attitudes toward e-learning, perceived stress, and ethical considerations in virtual medical education at Bushehr University of Medical Sciences in Iran.

Methods: This cross-sectional descriptive-correlational design study with a census sampling was employed to recruit 120 faculty members from Bushehr University of Medical Sciences. The faculty members were selected based on pre-established inclusion criteria and recruited between November and March 2023. The participants were provided with a link to the Google Forms questionnaire via their mobile phones, which they used to complete sections on faculty attitudes towards e-learning, perceived stress according to the Cohen scale, and the application of ethics in virtual education. In all cases, a significance level of less than 0.05 was employed. The data were analyzed using the statistical software package SPSS, version 20.

Results: A positive correlation was identified between attitudes toward e-learning and the ethical application of virtual education among faculty members (β = 0.279, p < 0.05). Nevertheless, no statistically significant correlation was observed between attitudes toward e-learning and its domains and perceived stress among faculty members (p > 0.05).

Conclusion: This study found a positive association between faculty attitudes towards e-learning and their ethical application of virtual education, suggesting that positive views on virtual education may lead to better ethical practices. However, no correlation was found between attitudes toward e-learning and perceived stress levels, indicating that positive attitudes do not necessarily mitigate stress. Further research is needed to explore factors contributing to faculty stress in virtual settings and develop strategies to promote positive attitudes and competencies while addressing stress concerns.

Attitude

E-learning

Stress

Ethics

Education

faculty members

COVID-19 Pandemic

The rapid advancement of technology and the evolving landscape of education have propelled e-learning to the forefront as a novel and practical pedagogical approach, often replacing traditional methods. This underscores the importance of understanding instructors' attitudes and experiences with this form of education. E-learning, encompassing any form of learning conducted through digital media, has been defined in various ways. It includes activities using electronic tools such as audio-visual, computer-based, and other digital means. Essentially, the learning process facilitated by programs delivered through computer networks is termed e-learning (1). The American Society for Training and Development (ASTD) provides a comprehensive definition of e-learning, encompassing Many programs and processes, such as web-based learning, computer-based learning, virtual classrooms, and digital content (2). While e-learning, including virtual learning, was employed in the educational systems of numerous countries, its implementation was limited in some, including Iran. The emergence of the novel coronavirus (SARS-CoV-2) and the subsequent global pandemic (3), coupled with the imperative of prioritizing medical directives such as social distancing, highlighted the crucial role of virtual learning (4). Consequently, many countries worldwide were compelled to implement e-learning (5) on a large scale across all levels of education and academic disciplines. Instructors in health-related fields, including medicine, dentistry, public health, nursing, and other related disciplines, also broadly adopted e-learning (6). The transition from traditional in-person learning to e-learning in a virtual setting, particularly in communities with limited experience with this methodology, presented unique challenges for educators. The rapid transition to virtual medical training, and the difficulties it presented, required instructors to acquire proficiency in new technological platforms, this situation increased the perceived stress levels of educators in some communities (7, 8). "Perceived stress" refers to a condition or emotional state that arises when an individual feels the demands placed upon them surpass their resources and coping abilities (9). The emergency and rapid transition from in-person to e-learning, particularly in countries where e-learning was not a prevalent practice, left educators ill-prepared and with limited resources to navigate the novel circumstances. The lack of interest in virtual education before the pandemic, inadequate preparation of electronic content, difficulties with learning management systems (LMS), low computer proficiency, the absence of reliable assessment procedures, inadequate training in e-teaching, and insufficient motivation all contributed to the challenges encountered in adapting to the new situation and, made teaching a stressful endeavor (10). An individual's attitude towards a situation can significantly influence their motivation. An attitude may be defined as a voluntary orientation towards a concept that has the potential to influence an individual's capacity for adaptation to novel situations. There's a reciprocal relationship between this orientation and the stress experienced in these novel situations (11). Alanazy (2018) showed that people who are more anxious about computers tend to have fewer positive attitudes towards e-learning. Their theoretical model suggests a two-way relationship between computer anxiety and attitudes toward e-learning (11). Most studies on stress caused by e-learning and attitudes towards e-learning have concentrated on the learners themselves (9, 12, 13) and have demonstrated that these two factors can impact the efficacy of e-learning. Most studies examining instructors' attitudes toward e-learning (14–18) focus on the factors influencing these attitudes and the effectiveness of this teaching method.

Nevertheless, the interrelationship between these attitudes and other pivotal factors, such as perceived stress and the application of ethics in virtual education, remains largely unexamined. One of the most crucial elements of any educational system is the adherence to ethical standards. The efficacy of any teaching or learning process, whether virtual, in-person, or blended, is contingent upon the conduct of professionals and organizations (19). However, the normative and ethical framework governing virtual spaces is a crucial aspect that is often neglected (20). Ethical conduct in virtual education requires respect for the rights of all parties involved, including the individual, their colleagues, and the more comprehensive educational organization. This is achieved by implementing behavioral and communication standards that guide individuals in fulfilling their ethical duties and responsibilities within the organization (14, 19).

The absence of ethical application in virtual education has resulted in a range of adverse outcomes, including managerial misconduct, student depression, a lack of enjoyment in professional life, burnout among instructors and trainers, harm to individuals' lives, the creation of social classes, the prioritization of individual interests over social benefits, and the violation of student's rights in the academic environment (21).

In light of the distinctive ethical characteristics inherent to e-learning, it is imperative to address this concept and its associated factors in a manner sensitive to the nuances of different cultural contexts. The shortage of requisite facilities and resources for e-learning in underprivileged areas, such as the community under investigation in this research, may give rise to challenges such as skepticism about the efficacy of this approach, technical difficulties, and the necessity for alterations in pedagogical methods and interactions with students, which can result in heightened stress for instructors. On the other hand, it's important to look closely at the ethics of virtual education, as it's a new and important topic. It would be useful to look at the relationship between attitudes toward e-learning, stress, and ethics among faculty members at Bushehr University of Medical Sciences. This could help us to design and implement effective and efficient virtual educational programs.

Therefore, this study aimed to determine the relationship between attitudes toward e-learning, perceived stress, and ethical application in virtual education among faculty members of medical universities in the southern region of Iran during the COVID-19 pandemic.

Study Design

This study employs a cross-sectional correlational research design. This design allows for the examination of potential changes in attitudes, stress, and the application of ethics over time. The correlational design enables researchers to examine multiple variables concurrently and ascertain the extent of their correlation. Accordingly, a cross-sectional correlational design represents an optimal and economical approach to ex the relationship between attitudes, stress, and the application of ethics among faculty members at Bushehr University of Medical Sciences.

Participants and Data Collection

The research units comprised all faculty members of basic and clinical sciences in the schools of Medicine, Nursing and Midwifery, Paramedical Sciences, Dentistry, and Health and Nutrition at Bushehr University of Medical Sciences, one of the universities in the south of Iran. To be included in the study, participants were required to meet the following criteria: to have taught at least one virtual course, to have a minimum of six months of work experience, to be willing to participate in the study, and to own a smartphone. Those who did not complete at least one questionnaire were excluded from the study.

Sample Size

The sample size was determined using the formula for regression analysis, which involves taking 10 to 30 samples per predictor variable. The sample size for this study was calculated to be 220 participants, with 20 samples per variable. Given that the number of active faculty members at the university was 227, all faculty members who met the inclusion criteria and consented to participate in the study were included, and a census sampling method was employed.

Data Collection Tools

The data collection tools employed in this research included a demographic information form, the faculty attitudes towards the E-learning questionnaire (Seyed Naghavi, 2007), the Perceived Stress Scale (PSS; Cohen, 1983), and the application of ethics in Virtual Education Questionnaire (Narimani et al., 2014). The validity and reliability of all these questionnaires have been established through appropriate methodology.

Demographic Information Form

The demographic information form included a series of questions about the respondent's gender, age, marital status, educational background, academic department, employment status, years of service, teaching experience, income level, academic rank, history of attending workshops on the use of software or virtual education systems, the number of virtual courses taught, and the software used in virtual education.

E-Learning Attitude Questionnaire

The E-Learning Attitude Questionnaire was adapted from the faculty section of Seyed Naghavi (2007). The E-Learning Attitude Questionnaire comprises two sections. a) The first section assesses familiarity with the Internet and computers. This section consists of, six items, which are rated on a 7-point Likert scale that ranges from "No Experience" to "Excellent Experience." b) Attitude towards e-learning: This section comprises 19 items and six subscales, which are rated on a seven-point Likert scale, ranging from "strongly disagree" to "strongly agree." In the present study, the second part of the questionnaire was utilized to assess, faculty attitudes toward e-learning. The six subscales included in this section are as follows: Self-Efficacy (3 items), Interest (3 items), Usefulness (3 items), Intention to Implement E-Learning (3 items), Satisfaction (3 items), and Multimedia Training (4 items). The scoring method employed for this questionnaire is based on a 7-point Likert scale. A rating of 7 indicates strong agreement, 6 indicates agreement, 5 indicates somewhat agreement, 4 indicates neutrality, 3 indicates somewhat disagreement, 2 indicates disagreement, and 1 indicates strong disagreement. The questionnaire does not include any reverse-scored items. The minimum and maximum scores for each participant were 19 and 133, respectively, with higher scores indicating a more positive attitude. In Seyed Naghavi's study, the Cronbach's alpha coefficient was reported to be 0.95 (15). Moreover, the questionnaire underwent a confirmatory factor analysis in the study by Akbarilakeh et al. (2019), which confirmed its validity and reliability, with a Cronbach's alpha of 0.91 (16).

Cohen et al.'s Perceived Stress Questionnaire (1983)

The Perceived Stress Questionnaire, developed by Cohen et al., consists of 14 questions. Each question is answered on a 5-point Likert scale, ranging from "never" to "very often."

The scoring method is based on the 5-point Likert scale, whereby responses are assigned the following values: never = 0, rarely = 1, sometimes = 2, fairly often = 3, and very often = 4. Items 4 to 7 and 9, 10, and 13 are reverse scored, with "never" assigned a value of 4 and "very often" assigned a value of 0. The minimum score is zero, and the maximum score is 56. A higher score is indicative of a more excellent perception of stress (22). In the study by Sepahvand et al. (2008), the questionnaire was valid and reliable, with a Cronbach's alpha coefficient of 0.80 (23).

Narimani et al.'s (2014) Questionnaire on the Application of Ethics in Virtual Education

The Questionnaire on the Application of Ethics in Virtual Education, as developed by Narimani et al., comprises 60 items and four subscales, including the questionnaire four subscales, namely, Design and Development of Virtual Education Courses (15 items), Teaching and Implementation of Virtual Education Courses (15 items), Evaluation of Virtual Education Courses (15 items), and Use of Technologies in Virtual Education (15 items).

The scoring method for the questionnaire is based on a 5-point Likert scale. The rating scale is as follows: 5 = Very High, 4 = High, 3 = Moderate, 2 = Low, and 1 = Very Low. The minimum and maximum score for each participant is 60 and 300, respectively. A higher score indicates a higher level of ethical application. In the study by Narimani et al., the questionnaire was valid and reliable, with a Cronbach's alpha coefficient of 0.94 (24).

All questionnaires and demographic information checklists were uploaded to Google Forms, which was used to create the relevant link for distribution to instructors and completion of the questionnaires.

Implementation Method

To conduct the research, the researcher, following the approval of the proposal and the acquisition of the requisite ethics code, visited the office of the Vice Chancellor for Research at Bushehr University of Medical Sciences to obtain a cooperation letter to conduct the research in the university's faculties. Subsequently, the researcher obtained the list of faculty members and their respective class schedules from the educational departments of the research environment, having received the requisite permission. Subsequently, the researcher proceeded to the classes mentioned above, under the provided schedules, and liaised with the pertinent educational unit to elucidate the research objectives to the instructors, enhancing their awareness and satisfaction with participating in the study. Subsequently, the researcher obtained the instructors' phone numbers under the established criteria and transmitted the Google Forms link, which pertained to the demographic information checklist and the questionnaires on attitudes toward e-learning, perceived stress, and the application of ethics in virtual education, to the instructors as mentioned above via external social messaging applications, such as WhatsApp, or internal social messaging applications, like Eitaa, Bale, and so forth. To guarantee the voluntary participation of the subjects and their subsequent response to the questionnaire items, the study’s objective was explicitly stated in the invitation message sent to the eligible individuals. The message explained that if participants consented to participate in the research and were willing to answer the questionnaire, they should click on the provided link and complete the survey questions.

Ethical Considerations

This study was approved by the Research Council of Bushehr University of Medical Sciences (project number 1521, dated August 20, 2022) and subsequently registered by the Ethics Committee of the Vice Chancellor for Research at Bushehr University of Medical Sciences (ethics code IR.BPUMS.REC.1401.084). The research process and objectives were delineated for the research units. The participants were at liberty to complete the questionnaire at their discretion. The participants were informed that their data was strictly confidential and that the findings would be disseminated solely in an aggregated format for research purposes.

Data Analysis

The data were analyzed using the statistical software package SPSS, version 20. Descriptive statistics, such as mean, median, standard deviation, and frequency tables, were used to summarize the data. The researchers used three statistical methods to analyze the relationships between variables: Pearson correlation, univariate linear regression, and hierarchical multiple regression.

All tests were conducted with a significance level of p < 0.05.

The mean age of the participating professors was 43.94 ± 8.62 years. Of the participants, 55% were female, and the remaining 45% were male. Furthermore, 54.2% of the participants held a doctoral degree, and 74.2% were married. Among the participants, 54.2% were assistant professors, and 68.3% had attended workshops on utilizing virtual education software. Table 1 presents the demographic characteristics of the research units the relationship between these variables and the dependent variable of ethical application in virtual education. As evidenced in Table 1, there is a statistically significant correlation between educational degree, academic group, and the number of courses taught virtually with the total score of ethical application in virtual education. These variables were deemed suitable for inclusion in the multiple regression analysis (Table 1).

Table 1

The Relationship Between Demographic Variables and the Application of Ethics in Virtual Education Among Participating Faculty Members in the Study, 2023
Variable		Frequency (%) Mean(SD)*	Total Ethical Application
Variable		Frequency (%) Mean(SD)*	Standardized Regression Coefficient	P-value
Age (year)		43.94(8.62) *	0.052	0.575
Male gender (reference: female)		54 (45%)	-0.119	0.196
Single status (reference: married)		31 (25.8%)	-0.093	0.315
Educational Qualification (Professional Doctorate Reference)	Doctor of Philosophy (PhD)	65 (54.2%)	0.390	< 0.001
	Master's Degree	17 (14.2%)	0.318	0.001
Department (Dental Reference)	Clinical Sciences	29 (24.2%)	0.111	0.391
	Basic Sciences	22 (18.3%)	0.378	0.003
	Nursing and Midwifery	21 (17.5%)	0.417	0.001
	Health and Nutrition	15 (12.5%)	0.245	0.025
	Paramedical Sciences and Librarianship	19 (15.8%)	0.440	0.001
Teaching Service Record (Reference: Less than 5 Years)	5 to 10 years	36 (30%)	-0.056	0.635
	11 to 15 years	19 (15.8%)	0.106	0.340
	16 to 20 years	12 (10%)	0.058	0.583
	More than 20 years	27 (22.5%)	0.115	0.319
Type of Employment (Contractual Reference)	Permanent	50 (41.7%)	0.807	0.421
Type of Employment (Contractual Reference)	Other (Commitment Plan, Military Service, and temporary)	28 (23.3%)	-1.620	0.108
Income (reference: less than the cost of living)	Equal to the cost of living	60 (50%)	-0.060	0.549
Income (reference: less than the cost of living)	More than the cost of living	15 (12.5%)	-0.099	0.321
Academic Rank (Reference: Professor)	Associate Professor	23 (19.2%)	0.103	0.510
	Assistant Professor	65 (54.2%)	0.015	0.931
	Instructor	23 (19.2%)	0.119	0.449
Participation in a Software Workshop		82 (68.3%)	0.174	0.057
The number of virtual teaching units exceeds four units (reference: less than four units)		100 (83.4%)	0.265	0.003
Software used for virtual teaching (reference: Adobe Connect)	Skype	17 (14.2%)	-0.123	0.264
	sky room	21 (17.5%)	0.043	0.703
	big blue button	46 (38.3%)	0.167	0.171
	Other	13 (10.8%)	-0.135	0.203

The mean total attitude score towards e-learning was 102.11 ± 18.52, the mean perceived stress score of the professors was 20.53 ± 5.68, and the mean total score for the ethical application in virtual education was 235.14 ± 28.85. The mean and standard deviation of the primary research variables and their respective domains are presented in Table 2.

Table 2

Mean Scores of Attitudes Toward E-Learning, Perceived Stress, and Ethical Application in Virtual Education Among Participating Faculty Members in the Study, 2023
Variable (Range of Possible Scores)	Domain	Mean	SD
Attitudes Toward E-Learning (19–133)	Self-Efficacy	4.75	1.31
	Interest	5.28	1.27
	Usefulness	5.74	1.12
	Intention to Implement E-Learning	5.28	1.37
	Sense of Satisfaction with the System	5.48	1.00
	Multimedia Training	5.62	0.96
	Total Attitude	102.11	18.52
Perceived Stress (0–56)	Perceived Stress	20.53	5.68
Ethical Application in Virtual Education (60–300)	Design and Development of Virtual Education Courses	59.15	7.61
	Teaching and Implementation of Virtual Education Courses	59.55	7.78
	Evaluation of Virtual Education Courses	58.96	7.69
	Use of Technologies in Virtual Education	57.48	8.92
	Total Application of Ethics in Virtual Education	235.14	28.85

The analysis revealed no statistically significant relationship between attitudes toward e-learning and its domains and perceived stress (p > 0.05). Except for the positive correlation between professors' attitudes towards e-learning and its domains with the ethical application and its domains (p < 0.05), no significant relationship was observed between the domains of satisfaction with the system and multimedia education (two domains of attitude) and the use of technologies in virtual education (one domain of ethical application) (p > 0.05) (Table 3).

Table 3

Correlation of Attitudes Toward E-Learning with Perceived Stress and Ethical Application in Virtual Education Among Participating Faculty Members in the Study, 2023
Faculty Members’ Attitudes Towards E-Learning	Correlation Coefficient & P-value	Perceived Stress	Ethical Application in Virtual Education
Faculty Members’ Attitudes Towards E-Learning	Correlation Coefficient & P-value	Perceived Stress	Design and Development of Virtual Education Courses	Teaching and Implementation of Virtual Education Courses	Evaluation of Virtual Education Courses	Use of Technologies in Virtual Education	Total Application of Ethics in Virtual Education
Self-Efficacy	Correlation Coefficient	-0.096	0.299	0.222	0.183	0.209	0.252
Self-Efficacy	P-value	0.298	0.001	0.015	0.045	0.022	0.005
Interest	Correlation Coefficient	0.007	0.281	0.246	0.225	0.261	0.281
Interest	P-value	0.940	0.002	0.007	0.013	0.004	0.002
Usefulness	Correlation Coefficient	-0.159	0.328	0.223	0.211	0.216	0.270
Usefulness	P-value	0.082	< 0.001	0.015	0.021	0.018	0.003
Intention to Implement E-Learning	Correlation Coefficient	-0.104	0.288	0.210	0.200	0.197	0.246
Intention to Implement E-Learning	P-value	0.258	0.001	0.021	0.029	0.031	0.007
Sense of Satisfaction with the System	Correlation Coefficient	-0.013	0.249	0.197	0.203	0.164	0.224
Sense of Satisfaction with the System	P-value	0.886	0.006	0.031	0.026	0.074	0.014
Multimedia Training	Correlation Coefficient	0.005	0.247	0.249	0.210	0.131	0.229
Multimedia Training	P-value	0.958	0.007	0.006	0.021	0.154	0.012
Total Attitude	Correlation Coefficient	-0.072	0.336	0.268	0.244	0.235	0.298
Total Attitude	P-value	0.435	< 0.001	0.003	0.007	0.010	0.001

The multivariate regression analysis revealed that the demographic variables, included in the first model explained 21.1% of the variation in how ethically virtual education is applied (Table 4).

Furthermore, the model was statistically significant. In the second model, in which attitudes toward e-learning were incorporated, an additional 7.2% of the variance in the dependent variable was explained, and this increase was statistically significant. In total, the second model explained 28.3% of the variance in ethical application in virtual education. In the second model, which included all variables, attitudes towards e-learning were identified as a positive predictor of ethical application in virtual education (β = 0.279, p < 0.05). Among the demographic and occupational variables, those belonging to the academic groups of basic sciences, nursing-midwifery, health and nutrition, and paramedical and library sciences were identified as positive predictors of ethical application in virtual education. It is worth noting, that to avoid multicollinearity, the total score for attitudes towards e-learning was used in the regression model instead of the individual domains. Furthermore, the two variables of educational degree and academic group exhibited multicollinearity. Consequently, the scholarly group was incorporated into the regression analysis.

Table 4: The Relationship Between Attitudes Toward E-Learning and the Total Score of Ethical Application in Virtual Education, Considering the Effect of Demographic Variables Among Participating Faculty Members in the Study, 2023

Variable		First model		Second model
		Standardized Regression Coefficient	P-value	Standardized Regression Coefficient	P-value	Confidence Interval 95%
		Standardized Regression Coefficient	P-value	Standardized Regression Coefficient	P-value	Lower Bound	Upper Bound
Department (Dental Reference)	Clinical Sciences	0.139	0.280	0.181	0.144	-4.227	28.585
	Basic Sciences	0.336	0.007	0.343	0.004	8.222	42.781
	Nursing and Midwifery	0.412	0.001	0.453	<0.001	16.935	51.550
	Health and Nutrition	0.227	0.036	0.237	0.022	3.434	43.773
	Paramedical Sciences and Librarianship	0.415	0.001	0.453	<0.001	16.001	50.131
The number of virtual teaching units exceeds four units (reference: less than four units)		0.186	0.038	0.128	0.143	-3.365	23.032
Attitudes Toward E-Learning		-	-	0.279	0.001	0.178	0.692
R square		0.211		0.283
F (P value)		5.045 (<0.001)		6.329 (<0.001)
R square change		-		0.072
F change (P value)		-		11.279 (0.001)
Dependent Variable: Total Score of Ethical Application in Virtual Education In addition to the variables included in the model, educational qualification was also found to be related to the dependent variable in the univariate regression. However, the presence of multicollinearity between the two variables, namely educational qualification and department, the latter was incorporated into the regression model. The presence of multicollinearity, the total score for this variable was included in the regression analysis instead of the domains of attitudes toward e-learning.

The present study is a cross-sectional correlational study designed to ascertain the relationship between attitudes toward e-learning, perceived stress, and the ethical application of virtual education among professors at Bushehr University of Medical Sciences in 2023. The data were analyzed for 120 participating professors. The findings indicated that the mean attitude score towards e-learning was above average, the mean perceived stress score was below average, and the mean score for the ethical application in virtual education was above average and desirable. A positive correlation was identified between attitudes towards e-learning and the ethical application of virtual education among professors. Nevertheless, no statistically significant correlation was identified between attitudes toward e-learning and its constituent domains and perceived stress among the professors. The study by Maleki et al. (2015) revealed that most faculty members at Zanjan University of Medical Sciences demonstrated a positive attitude toward e-learning. Additionally, their computer access and skills were reported to be favorable. This indicates that the faculty is well-placed to implement e-learning programs successfully (17). The favorable attitude toward virtual education indicates its popularity among users, which can be attributed to several factors, including the ease and practicality of accessing educational resources, the independence of content from temporal and spatial constraints, and other advantages. The attractive environment created by virtual education, which features colorful and animated images, with the possibility of telecommuting and studying, encourages individuals to pursue virtual education and develop a positive attitude towards it (25). The findings from the data analysis indicated that the highest average score for attitudes toward e-learning among faculty members was related to the domain of perceived usefulness, which highlights the effectiveness of the e-learning environment for educational purposes. Nevertheless, comparing the present study with previous studies reveals inconsistencies (26–31). One of the factors contributing to the discrepancies between the findings of the present study and those of other studies can be attributed to the timing of data collection. In the studies conducted by Abbasi et al. (2020) in April 2020 and by Muflih et al. (2021) from early April to May 1, 2020, the participants exhibited negative attitudes towards e-learning. These studies were conducted during the early stages of the COVID-19 pandemic. The pandemic began with the outbreak of the novel coronavirus (2019-nCoV). At that time, there was inadequate infrastructure for the initiation of virtual education and a lack of appropriate training workshops (27, 30). It appears that attitudes towards e-learning are influenced by the timing of its adoption and the availability of supporting infrastructure. In studies conducted before the onset of the SARS-CoV-2 pandemic, as well as in the present study, which was conducted during the fifth wave of the pandemic—a period during which there was ample opportunity to establish the necessary infrastructure—users expressed positive attitudes towards this educational method. However, in studies conducted at the onset of the pandemic, such as the study by Muflih, the findings indicated a negative attitude towards the educational method. This may be a significant factor contributing to the positive attitudes of the current study's participants toward e-learning in a virtual environment. Another noteworthy finding is that the perceived stress levels among the faculty members in this study were below the average range. Per the findings of this study, Jakubowski et al. (2021) reported that the stress levels of Polish faculty members engaged in virtual education during the ongoing pandemic were relatively low (32). In a different study, Pressley et al. (2021) found that instructors of virtual education were the most stressed out. It is important to note that the participants in Pressley's study were elementary school teachers. Considering the inherent difficulties in managing and supervising elementary students through online platforms, it is unsurprising that elementary school teachers reported higher stress levels compared with university professors. Moreover, it is noteworthy that Pressley's study employed a virtual education stress questionnaire, which may have contributed to the elevated stress levels perceived by instructors in the present study. In other words, in the present study, other stress-reducing factors, such as being with family, may have interacted with the stress associated with virtual education, resulting in a net reduction in stress (7). Another noteworthy finding of the present study was the application of ethics in virtual education, which was observed to be above average among the instructors. Sobhaninejad et al. (2017) investigated the dimensions of personality traits, adherence to educational regulations, standard evaluation, mastery of content, proficiency in teaching methods, understanding of learners' diverse needs, and the organizational dimension among the faculty members of Imam Khomeini Maritime University in Nowshahr from the student's perspective. The findings indicated that the level of application of professional teaching ethics among the instructors was considerable (18). In a study by Narimani et al. (2014), while faculty members reported high levels of ethical application in virtual education, students rated this aspect of their education as below average. This discrepancy between the views of instructors and students may be attributed to the differing criteria students consider compared to instructors, as well as potential conflicts of interest among instructors when responding to professional ethics questions (24). As Rajaie (2019) observed, the potential for individual or group conflicts between personal and professional interests to result in deviations from professional ethics is a significant concern (33). This indicates that future studies should evaluate not only the perspectives of instructors but also those of students and other individuals associated with instructors to validate further the results of the present study regarding the adherence to professional ethics by instructors in education.

Another finding of the present study was that instructors' attitudes toward e-learning were identified as a positive predictor of the application of ethics in virtual education. In a study by Naderi et al. (2020) on "The Role of Competence and Professional Ethics in Elementary Teachers' Attitudes Towards Personalized Learning," it was reported that there is a significant relationship between teachers' attitudes toward personalized learning and professional ethics. In the study by Naderi et al., while teachers’ attitude personalized learning were assessed instead. The personalized learning questionnaire addressed several key dimensions, including authentic learning, student ownership, flexible teaching methods, the role of technology, collaboration, data usage, and classroom culture. These aspects are analogous to those included in the e-learning questionnaire utilized in the present study. A comparison of the study by Naderi et al. with the present study reveals that teachers' attitudes toward personalized learning are shaped by professional ethics. Specifically, those teachers who demonstrate a higher degree of professional ethics are more likely to consider the individual differences of their students in terms of learning. This contrasts with the present study, which posits that a positive attitude towards e-learning among instructors is a precursor to the application of ethics in virtual education. This offers a dual perspective on the attitude toward learning while applying ethics. Given the cross-sectional nature of the present study, a reciprocal relationship may be inferred. However, longitudinal studies could prove beneficial in determining the causal relationships involved. Therefore, to further elucidate the bidirectional nature of this relationship, it is recommended that studies be conducted to examine the role of instructors' ethical competence in their attitudes towards e-learning. Another finding of the present study was that there was no statistically significant relationship between attitudes toward e-learning and its domains and perceived stress among instructors (34). In a study that differs from the present study, conducted by Ozyurek et al. (2015), the results demonstrated a significant negative correlation between attitudes toward computer technology and perceived stress. the study mentioned above, it is pertinent to highlight that in Ozyurek et al.'s study, attitudes toward computer technology were evaluated in a face-to-face educational context, in contrast, learners' attitudes towards computer technology in a virtual learning environment were not taken into account. Moreover, over three-quarters of the research population possessed personal computers and had been engaged in computer-based instruction for at least one semester. As posited by Ozyurek et al., students encountered academic and environmental stressors and employed computers and virtual communications as a means of mitigating these pressures. As a positive attitude is associated with increased use, this increased use resulted in a reduction in stress levels. Nevertheless, the positive and stress-reducing interactions observed during virtual learning may be diminished by academic stress, examinations, and other factors, resulting in a lack of significant correlation between attitudes towards e-learning and stress (35). It is also important to note that a general stress questionnaire was utilized in this study. It is recommended that future studies employ a virtual learning stress questionnaire to more accurately examine the relationship between attitudes toward e-learning in virtual education and stress. The results of the present study are different from those of the Kalo et al. (2023) study, which found that instructors with positive attitudes toward distance education had lower stress levels. The discrepancy in the relationship between attitudes and stress in these studies and the lack of such a relationship in the present study is likely attributable to the demographic characteristics of the participants. In the study conducted by Kalo et al., the participants were women with full-time employment, a factor that, in conjunction with their status as mothers, increased the necessity for distance education and, consequently, a positive attitude towards it, which was associated with reduced stress. However, in the present study, the necessity for instructors to implement educational programs was largely determined by educational regulations, with minimal influence from the interests and needs of the student community and instructors (36). The lack of a correlation between attitudes toward virtual education and perceived stress could be explained by factors that minimize the impact of education, including virtual education, on student stress levels. Factors such as being separated from one's family, age-related crises, and emotional issues may also be significant. The increase in stress due to attitudes towards virtual education may be offset by the reduction in stress from being with family and other factors, which may explain the lack of a significant relationship. Furthermore, the scarcity of studies in virtual education, coupled with the potential for negative results to remain unpublished, has constrained the researcher's ability to identify and include relevant studies in this analysis.

Study Limitations

As with other studies, the present research has both strengths and limitations. One notable strength is its pioneering approach to examining the application of ethics in virtual education. However, the self-reporting nature of instructors in expressing their ethical practices might have influenced the results. Therefore, future studies should consider incorporating students' perspectives and employing more objective methods. Furthermore, the utilization of a generic stress questionnaire in this study may have influenced the results about the relationship between attitudes towards e-learning and stress. It is therefore recommended that future research employ a virtual education-specific stress questionnaire. Moreover, it is essential to note that this study was conducted within the medical sciences community. Therefore, caution should be exercised when attempting to generalize the results to non-medical communities. In conclusion, it is essential to note that this research was a cross-sectional study, and therefore, the results should not be interpreted causally.

In light of the substantial correlation between instructors' attitudes toward e-learning and the application of ethics in virtual education, as well as the observation that a more favorable attitude toward e-learning among instructors is associated with greater adherence to the application of ethics principles in virtual education, it is advised that virtual education administrators prioritize the development of strategies to enhance instructors' attitudes toward e-learning. Furthermore, it is recommended that resources, equipment, and facilities for e-learning be improved, that instructors be made aware of virtual education and its challenges, and that a more positive attitude and more vital adherence to ethical standards be fostered. Given the absence of a notable correlation between instructors' attitudes toward e-learning and perceived stress in virtual education, it is recommended that future studies consider additional factors related to stress and the application of ethics. These may include the educational environment atmosphere, students' perspectives, and the use of objective methods.

Acknowledgments

We would like to express our sincerest gratitude to the Vice-Chancellor for Research and Technology at Bushehr University of Medical Sciences for their invaluable financial and moral support of this project. Furthermore, we express our sincerest gratitude to all the instructors who provided invaluable assistance in executing this study.

Author contributions

Mohammad Amin Shadman (MS): Designing, Writing - original draft, Data collection, Investigation & Visualization.

Farahnaz Kamali (FK): Validation, Reviewing, and Editing.

Razieh Bagherzadeh (RB): Validation, Reviewing & Editing, Analysis and Interpretation of data.

Shahnaz Pouladi (SP): Supervision, Validation, Conceptualization, Writing - Review & Editing, Project administration, Submitting

Funding

Research expenses by the vice president of research and the student research committee of Bushehr University of Medical Sciences, Iran, have been paid.

Data availability

The datasets used and, or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical approval and consent to participate

The research has an ethics code number of IR.BPUMS.REC.1401.084 from the Research Vice-Chancellor of Bushehr University of Medical Sciences. All study participants provided written informed consent.

Consent for publication

Based on the positive feedback received from participants and the organization, this article is deemed suitable for publication.

Competing interest

The authors declare no conflict of interest in this research.

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No competing interests reported.

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COVID-19 and Virtual Medical Education: A Correlational Study of Attitudes Towards e- learning, Perceived Stress, and Ethics among Faculty Members of Medical Universities in the Southern Region of Iran

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Abstract

Background

Materials and Methods

Study Design

Participants and Data Collection

Sample Size

Data Collection Tools

Demographic Information Form

E-Learning Attitude Questionnaire

Cohen et al.'s Perceived Stress Questionnaire (1983)

Narimani et al.'s (2014) Questionnaire on the Application of Ethics in Virtual Education

Implementation Method

Ethical Considerations

Data Analysis

Results

Discussion

Study Limitations

Conclusion

Declarations

References

Additional Declarations

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