‘Virtual café’ sessions: supporting medical sonography students learning anatomy online

ABSTRACT Medical sonography students require a deep understanding of three-dimensional (3D) structural anatomy. In addition, they are required to identify anatomical structures from medical images. To enhance and support online anatomy learning of first year medical sonography students ‘virtual café’ sessions were designed and offered as weekly activities. They were facilitated by higher year level student peers, who provided contextualisation of anatomy learning, guided discussions about the sonography programme and generated social discussions to allow students to get to know one another. This study investigated the impact of virtual cafe sessions on the student’s experience, student learning, student satisfaction with their programme of study and future career. The results indicated scheduled peer facilitated informal student discussions afforded the opportunity for students to catch up, meet each other, talk, and learn in a non-intimidating and social manner, whilst nurturing support was offered. A culture of positive contextualised, and authentic learning was developed which improved student engagement and enthusiasm for their programme of study. Most importantly, virtual café sessions facilitated students building social connections and trust with each other, so they subsequently felt less isolated and overwhelmed, but rather gained a sense of belonging, which motivated their learning.


Introduction
Anatomy education forms one of the most crucial components of foundational learning in nursing, medical and health clinician university programs (McLachlan & Patten, 2006).The level and focus of anatomical knowledge, and detail required to be understood by students, is profession dependent, and hence, anatomy education must be tailored to meet the specific needs of the discipline (Terrell, 2006).As anatomy is often taught in early years of the curriculum of the course, it is important that anatomy knowledge gained is meaningful and contextualised, and Social online interactions can be effective in assisting online students to learn.Students can discuss their observations, organise their thoughts, reflect on their understanding, and find gaps in their reasonings and self-other monitoring (Okita et al., 2013).Without direct social learning in a lab environment, online students are encouraged to work collaboratively to enhance their understanding.However, creating conditions to facilitate interactive peer discussions, social interactions for collaborative learning, and reciprocal teaching in the online learning environment can be challenging (Okita et al., 2013).
Studying online can be an extremely lonely experience for students, particularly first year students who do not know their peers and can be intimidated by making online connections.Students can be intimidated by approaching other students and their teachers.Online only learning not only limits student-student communication pathways but can also provide more opportunities for distractions from study.This is reported particularly by school leavers, who are learning to become more autonomous with their time management due to the less structured environment, as they are used to interacting with teachers and fellow students on a regular basis in a face-to-face environment (Laslo-Roth et al., 2022).Online students can experience loneliness and a disconnectedness with other students, their program of study, university, and learning community, which can impact not only their learning experience but possibly also their enthusiasm for continued learning, which can result in attrition (Gibbons et al., 2019).
Belonging is considered a fundamental psychological need (Leary & Baumeister, 1995).When students feel a sense of belonging, and social connections with staff and peers within their program of study, it can contribute to improved self-esteem, perseverance, academic motivation and engagement, enjoyment in learning tasks and academic success (Pedler et al., 2022).Managing student anxiety, expectations, and student connections and engagement, and ultimately their wellbeing whilst studying anatomy online, is important but developing the most appropriate medium for students to communicate can be difficult (Gibbons et al., 2019).Creating a nurturing learning environment is important, but many academics struggle with ways to facilitate this for online students.As such, this study aimed to investigate the incorporation of a weekly catch up for first year medical sonography students studying anatomy via 'virtual café' sessions, facilitated by 4 th year students, to explore the impact on: (a) student anatomy learning, and contextualisation of learning (b) student experience learning anatomy online (c) student satisfaction with their program of study (d) student understanding of their future career (e) student facilitators and their mentoring experience.

Materials and methods
In 2021, the curriculum design of a first-year online unit: 'Relational anatomy and image recognition', was adapted to provide a student facilitated 'virtual café' into weekly learning activities.Fourth year students were selected to oversee these sessions to encourage discussions in a non-intimidating manner, provide guidance to students about their program of study and contextualise their first-year learning.

Context
The 'Relational anatomy and image recognition' unit is a mandatory foundational unit of an articulated undergraduate and post graduate medical sonography (four year) program offered at Central Queensland University (CQU), Australia.In 2021, this program was offered at five campuses widely geographically distributed around Australia: Mackay, Brisbane, Sydney, Melbourne, and Perth.Students complete their first year of studies online.The unit is 12 weeks in duration and delivered to sonography students only.In Semester 2, 2021, there were 198 students enrolled in the unit.
The unit provides blended learning via a combination of synchronous and asynchronous learning.Pre-recorded asynchronous lectures were provided each week to unpack the anatomy content, which students watch in their own time.They were supported by weekly, three-hour, scheduled online tutorials (held Tuesdays) and study group (held Thursdays) facilitated by the unit coordinator.The synchronous tutorials and study groups allowed for regular communication between students and tutor and peer-peer discussions to enhances the learning environment and keep students engaged.The interactive learning during tutorials and study groups was personalised to make students all feel included and bring everyone together to develop a sense of a learning community.The sessions were recorded for those that could not attend and also allow students to watch again if needed for revision (Heilporn et al., 2021).

Design
The 'virtual café' sessions were designed to provide further opportunity for peer assisted learning, facilitate discussions regarding anatomical content in a sonographic learning context, in a non-intimidating environment, and address the potential isolation of online learning for 1st year medical sonography students.The virtual café sessions were offered on weekends to allow students in this unit to catch up online in a social setting.Students were based all over Australia at five different campuses (Brisbane, Sydney, Melbourne, Perth, and Mackay).As learning can occur through interactions with others, two higher level, 4th year sonography students, who were concurrently completing clinical placements as part of the medical sonography four-year university course, and close to graduating, were recruited to facilitate one-hour virtual cafe sessions via Zoom for each week of learning, over 10 weeks.The 4th year students encouraged discussions and provided support to 1st year students (Manual et al., 2015;Sanders & Welk, 2005;Wass et al., 2011).Discussions related to the use of anatomical knowledge gained within the anatomy unit as well as future years of the sonography course, including clinical placements and the sonography profession.The sessions also provided the opportunity for social discussions and to check in on student well-being and provide tips for balancing life and study whilst learning online.

Data collection
The virtual café sessions were designed to facilitate collaborative learning and assist and guide students on the path to independent learning via the 'gradual release of responsibility' (Pearson & Gallagher, 1983).During the sessions the final year students were encouraged to share stories of their journey through the sonography course, their experiences with theoretical learning online and clinical placements, and their perceptions of their future career.Storytelling was encouraged, to generate discussions from first year students.At the completion of the sessions, and after student grades were released, anonymous surveys for 1st year students and student facilitators were conducted via Qualtrics.The survey gained responses to questions with a 5-point Likert scale, and the provision for qualitative comments.Students were asked how the virtual café sessions assisted their learning and understanding of anatomy, their learning experience and understanding of the medical sonography course and profession.This study was approved by the CQU human research ethics committee (Project number: 0000023061).

Results
Data was collected from twenty-two 1st year students and two 4th year student facilitators.The number of students who attended the virtual café each week varied.From a 5-point Likert scale, 100% of students who attended the virtual café reported that it provided a supportive environment and was helpful in gaining an understanding about the relevance of anatomical knowledge they were learning and how it would be required within the remainder of the course.First year students qualitatively reported they enjoyed discussions and hearing other student experiences: It was helpful when students from 4 th year shared their experiences of learning and placement.
I felt like I belonged, being able to talk to other people and discuss materials and use medical terminology with people who are also learning the medical language.
In addition, 100% of students reported the café sessions provided them with greater insight about their medical sonography course, what was involved, what to expect in the future years, and job opportunities once graduated.Student responses revealed: I was provided the opportunity to ask questions about the future and see what others have gone through and are currently going through, in order that I can prepare as best I can, knowing that this is an intense course, and giving myself the best chance to succeed.
Another participant commented that hearing of the journey of higher-level students helped them stay motivated to study and persist with their studies: The sessions helped me stay positive about the course, and that, as a mature age student, it could be done.
Furthermore, 100% of student respondents reported that they gained a better understanding about the sonography profession and how anatomy knowledge was used by sonographers.100% also reported they gained a deeper appreciation of their potential future career, and the café sessions helped them feel more comfortable with their choice to study sonography via an articulated undergraduate and post graduate pathway (offered at CQU).Qualitative results indicated the support and encouragement were noted to be particularly helpful to motivate them for studying online: I can see the benefit for those who find they need external support to assist them to keep them motivated and on track with their studies.
Students unanimously (100%) indicated that the ability to connect with other sonography students via the virtual café enhanced their learning experience.They identified they really appreciated the social connections made with fellow students, that this helped them feel less lonely when learning online, and that they were not the only ones sometimes finding it difficult: It was wonderful to meet other students from other states who I won't be able to meet in person on campus.
I really enjoyed the sessions of virtual café.It gave me something to look forward to every week.I wanted to learn more about the course and what will be expected of me in future units.Talking to other students doing the same course gave me a sense of community that I have never really felt before while completing the course online.I didn't feel so alone.It gave me the opportunity to meet new people that were going through the same struggles as me and we encouraged each other to keep going and it felt really good.
It is a great idea to bring students together.
92.3% of students recommended that virtual student café sessions be offered in the future: As a mature age student with a family, I would love to have the opportunity to participate in something like this next time and also believe it would be very helpful for younger students.
It was fantastic and would highly recommend it to anyone.
It has been a delightful experience.
Several 1st year student qualitative responses reported that the scheduling of virtual café sessions on the weekend made attending difficult due to casual work commitments.Students did report that they appreciated issues with the scheduling as 4th year student facilitators were on clinical placements from Monday to Friday, so not available.The 4th year student facilitators reported that the experience allowed them to reflect on their learning journey, share stories of their experiences, and consolidate and clarify their anatomy knowledge.They also gained experienced as mentors and gained an understanding of struggles experienced by other students and their different cultural situations.

Discussion of results
The virtual café sessions provided an opportunity for social interaction between students of the same and different year levels of a program of study.The regular social interactions facilitated by 4th year students were successful at developing a culture of positive and authentic learning.Students embark on a higher education journey to not only learn, but to be extended and develop as a person, and prepared for future employment.Within their first year at university, students need to be inspired, supported, and gain a sense of belonging and connectedness to their discipline for engagement and retention, but also to set the basis for learning success in years to come (Kift, 2009).The student learning experience can be impacted by pedagogy, curriculum design, and learning and teaching practices in the physical and virtual classrooms (Kift et al., 2010).Transitioning students into a new discipline and program of study requires contextualisation of content, so students feel a connection to their teacher, fellow students, university, and future career.Educators using online learning need to consider a variety of activities to provide students with multiple opportunities to interact and participate and consider student thinking, feeling and belonging, with the opportunity for rewarding discussions (Hrastinski, 2008).As student cohorts become more diverse, student-centred models of delivery and support are required.
When teaching structural anatomy online to 1st year students, the contextualisation of anatomical learning needs to be added to the technological, pedagogical and content knowledge of the teacher (Mishra, 2019).Virtual café discussions, as used in this study, included contextualised learning of anatomical structures relevant to the medical sonography program of study and sonography profession and discipline, incorporating transition pedagogy into practice (Kift, 2009).Peer instruction, including discussing content, and how to solve problems with other students to create new knowledge can have great benefits to student learning (Tullis & Goldstone, 2020).Peer verbal discussions prompted students to coherently explain their thought processes around anatomy.This allowed students to detect and correct errors in their anatomical knowledge, as students could identify their knowledge gaps and construct new knowledge to fill those gaps.These verbal discussions allowed for student reflections and subsequent greater student understanding (Knight et al., 2013).
As teachers, we need to facilitate holistic learning, where we consider the learner as a person, not a robot who is programmed to learn content.Many clinicians turned teachers can be focussed on the content component of teaching (the curriculum) rather than the how and the why (pedagogy).The benefits gained from the virtual café sessions were greater than initially anticipated.They offered the opportunity for pastoral care provision to 1st year students by student peer mentors, facilitated socialisation and the development of a community of learners.As teachers, we encourage students to develop new ways of thinking, scaffolding them through a path of critical enquiry, providing guidance on why learning is important, what it will lead to, and encourage lifelong learning (Illeris, 2004).The provision of peer facilitated learning allowed student trust relationships to be fostered (Gibbons et al., 2019).It may be assumed that students who do not join in discussions in tutorials may be quiet or shy, and not as engaged in learning.They may however be taking notes and/or listening, reflecting, and considering what has been discussed.They may also be expressing their engagement in nonverbal methods such as responsive facial expressions and head nods (Nieuwoudt, 2020).
Students are no longer restricted to a physical learning space, and online learning environments can allow collaborative learning and peer instruction when used effectively (Okita et al., 2013).Shared discussions and stories related to the medical sonography discipline, outside of formal online classrooms, aided student enthusiasm for learning (Liao & Wang, 2020).The storytelling provided by 4th year students helped 1st year students understand why things happen and how decisions are made in a temporal order.This not only contextualised their learning but gave them an opportunity to start to experience and appreciate that patient care involves listening to patient stories, as part of their practice, to help gain answers to clinical questions (Brownlie, 2023).This is important for students entering a patient centred profession to appreciate.
Narrative medicine includes healthcare practices with narrative competence to recognise, absorb, interpret, and be moved by sharing and reflecting on human experiences including suffering and dilemmas (Charon, 2008;Fernandez et al., 2015).In this study, 1st year students enhanced their knowledge and understanding through thematic and opportunistic discussions (Knight et al., 2013).4th year students benefited by being able to consolidate their knowledge and clarify their own understanding, share their experiences with others and add meaning to their experiences (Sin et al., 2019).The virtual café fostered a culture of inclusion, collaboration, reflection, sharing of knowledge, and enhanced each student's learning experience.It also allowed the student network to be enlarged, and students who were geographically separated could make friendships and pathways for future collaborations.Additionally, the perceived barriers to approaching other students to make connections, initiate discussions and make friendships were overcome.
First year students were provided a safe place to ask higher level students not only about anatomical content, but also about the sonography course they were enrolled in and the profession they were becoming qualified for-the questions they may not want to ask university academics.Discussions regarding why certain competencies are required were helpful, as 1 st year students could appreciate why clinical training at clinical placements was required, and how it would help their own eventual clinical practice once qualified.As there were two higher level 4 th year students present, they could conduct discussions about challenging situations they had experienced on clinical placements sharing their stories of how they navigated the challenges of study.This was achieved with minimal additional financial and workload costs.The social environment created online was accessible, and students could experience different points of view from those in the classroom (Sin et al., 2019).
Consideration is required regarding how to ensure the resilience of students when learning structural anatomy online.Resilience can be defined as the capacity to resist adversity without developing physical, psychological, or social disabilities, and resilient students have a better quality of life and better perception of their educational environment (Tempski et al., 2015).This in turn makes them mentally and emotionally available and present to learn (Lischer et al., 2021).As individuals, we are motivated to form and maintain close and meaningful relationships with others (Baumeister & Leary, 1995).Student isolation can have negative consequences for personal health and wellbeing as well as student success in learning.It can be overlooked by educators as an important factor for student motivation for learning and student success at university.The provision of peer-to-peer interaction between senior and junior level health profession university students has been identified as an effective educational intention that aids learning for both parties but also benefits their social and emotional connectedness and wellbeing (Sin et al., 2019).These findings were supported by the results of this study.
An additional and unexpected benefit of learning by teaching was gained by the 4th year students acting as teachers (Tempski et al., 2015).They could learn when they took on the role of teacher (Palinscar & Brown, 1984) and realised the benefits of sharing their stories and experiences from a personal level.The 1 st year students responded by opening up more and allowing themselves to feel more connected.The 4 th year students appreciated the need for nurturing and encouraging those they mentored (Claramita et al., 2019).They have subsequently reflected, since the completion of this study, that they are more emotionally available for student sonographers they mentor in their roles as qualified and professional sonographers, and that this nurturing does not need to occur in a face-to-face environment and can be applied in virtual support for mentees.
At the completion of this study, the 4 th year student mentors felt better equipped to teach sonography students under their guidance in the future.They gained an appreciation for the need for connectedness with their future mentees.They came to value their stories and the impact that sharing their stories and learning journeys can have on those they mentor.Another benefit to the 4 th year student mentors was a deeper understanding of cultural awareness.Cultural awareness is the knowledge and appreciation of backgrounds, beliefs and needs of others (Leininger & McFarland, 2006), which is essential for the cultural competency of healthcare workers (Haas, 2018;Kumlien et al., 2020).This is important as, in Australia in 2017, 29% of the estimated resident population were born overseas, and is also reflected in the CQU student cohort (Australian Demographic Statistics, 2017).The 4th year students appreciated the opportunity to practise mentoring others from diverse cultural backgrounds and identified it would aid them to provide support to patients from different cultures and co-workers in the workplace once qualified.
The virtual café provided a pathway for student participation in a learning community, collaboration between students of different year levels, and facilitated leadership opportunities for the peer mentors.It was particularly useful for 1st year students transitioning into a new course as it allowed them to quickly develop an affiliation with their discipline and gain an identity as a medical sonography student (Kift et al., 2010).This low cost, highly effective tool provided many additional and unexpected benefits including motivation of student learning, improvement of student wellbeing, and fostering a collaborative culture and connectedness amongst the student body in the discipline (Tan, 2021).The study results indicate that social interactions and peer mentoring can subsequently reduce student attrition, as students feel a sense of belonging and feel encouraged and motivated to keep going on their learning journey by other peers (De Leon-Pineda, 2022).

Limitations, future research, and implications for practice
On reflection, it is important for us, as teachers, to facilitate the social connectedness of our students to allow student collaborations.This can assist in providing a nurturing learning environment, where students feel safe and ready to learn.A limitation of the study was the small sample size which limits interpretations and generalisations made from the results.Further studies could be conducted with larger samples of students.As this study only examined students from one discipline, sonography, and 1st year students, further studies could be conducted to investigate whether virtual café sessions may enhance learning and connection in higher year levels and across disciplines.This type of activity, the virtual café, is something other practitioners could investigate to improve student course satisfaction, reduce attrition, and offer opportunities to enhance student wellbeing.