A pneumonia of unknown cause was detected in Wuhan, China, and reported to the WHO
Country Office in China on 31 December 2019. Labelled initially as a coronavirus,
then latterly Covid-19, the outbreak was declared by the World Health Organisation
(WHO) as a Public Health Emergency of International Concern on 30 January 2020 and
a pandemic on 11th March 2020. As Covid-19 swept around the globe, Health Professions’
educators (HPEs) have had to adapt their campus-based and clinical educational provision
in a context of rapidly changing circumstances and ongoing uncertainty.
Different countries varied in the speed and nature of their responses to the spread
of Covid-19. Our context of Singapore has well-developed protocols for outbreak preparation
(MOH 2019) and on 7th February 2020 the Ministry of Health (MOH) risk assessed COVID-19
as “DORSON Orange” (Disease Outbreak Response System Condition) (MOH 2020). This introduced
precautionary measures to minimise the risk of transmission of the virus in the country
(e.g., daily health checks, stringent contact tracing and quarantining, enhanced focus
on hygiene and protection, and segregating groups to contain disease spread). The
specific implications of these measures for medical education and teaching were that:
students in Singapore’s three medical schools were taken out of clinical environments;
students could not be taught on a whole or even half class basis; there was reduced
availability of clinicians to participate in educational activities, and clinicians
who were available could not always attend campus in person because of infection control
measures.
Our particular responses to these constraints were multiple. These included: shifting
our pedagogy from face-to-face Team-Based Learning (TBL: Rajalingam et al. 2018) to
e-TBL delivered online; reducing face-to-face class sizes and running classes repeatedly;
and introducing some novel simulations to prepare final year students for postgraduate
training. While undoubtedly the pedagogic, technical and operational aspects of what
we did will be of interest, particularly to those with a digital learning interest,
the focus of this editorial is not to tell you of our adaptations, or ask others to
consider how they responded in these uncertain and volatile times. Instead, we position
our response to unanticipated disruption as problem-posing rather than problem-solving
(Biesta et al. 2019), and a potentially positive driver within the educational research
space—if considered appropriately.
In keeping with the theoretical focus of Advances in Health Sciences Education, to
achieve this requires developing our understanding of Covid-19 and resulting education
responses in a way which both helps us understand what is happening and produces transferable
knowledge. To do so, we draw on a sociomaterial framework, one which specifically
assumes that all things are what they are in relation to other things (Law 2009; Gad
and Bruun 2010), and the human and non-human are equal in terms of agency (e.g., Fenwick
and Edwards 2010; Law 2009).
First, we believe that Covid-19 infection control measures can be framed as a sociomaterial
practice. Drawing on the risk assessment literature, DORSCON Orange (and its equivalents
in other countries) is founded on the assumption that “evaluating risk is a technical
matter to be resolved through objective and rational means to minimize uncertainty”
(Wherton et al. 2019, p. 329). Covid-19 risk assessments and precautions were driven
by governments, and so sit within wider political and social structures, but their
implementation depended on human actions, interactions, and relationships as well
as the material properties, affordances and symbolic meanings of precautions. For
example, a face mask is a material object, but face masks also have potent sociocultural
symbolism (e.g., Siu 2016). These symbolic implications influence how people perceive
facemasks, how people perceive those who use them, and suggest that the precise nature
of Covid-19 guidance may shift the symbolic significant of facemasks and hence influence
people’s adoption of facemasks as a precaution against infection. Similarly, focusing
on documents as a material component of Covid-19 management, we might consider how
official updates on Covid-19, circulated via different mediums, including Whatsapp,
text messaging, and more complex documentation, are intermediaries between the macro-actor
of government(s) and are all dependent on internet technology and reach. How do different
sources of knowledge (e.g., government advice, popular media) impact on people, and
act to construct or prevent certain behaviours? What is, and what is not, acceptable
behaviour during these strange times is entangled with the material (e.g., communications)
and the local (e.g., how people and groups respond to advice).
Moving our focus from societal to educational responses to Covid-19, we had to develop
our practices to fit within the boundaries of what was, and was not, allowed or possible
(e.g., with limited clinician availability). The medical school leadership had to
mobilise individuals (e.g., academic, administrative and IT staff, and students) and
existing technologies (e.g., the digital learning platform [LMS]), as well as integrate
more technologies into teaching processes (e.g., Whatsapp, Zoom), and these people
then collaboratively problem-solved how to address Covid-19 challenges within the
constraints of time and the boundaries of available technology. Different systems
came together more explicitly than was the case during “business as usual”. For example,
IT and digital learning colleagues became core rather than invisible (MacLeod et al.
2017), and the systems of teaching and teaching delivery were more obviously tied
together, with people and systems relating to one another in new and particular ways
(Landri 2012). There was also a very obvious interdependency of users and tools in
the network (Cecez-Kecmanovic et al. 2014): for example, we could not deliver teaching
or communicate with students without the use of laptops, cameras, Zoom, Whatsapp,
etc. IT had a dual materiality, enabling mobilization of teaching across space but
it also had design-driven constraints that required the IT and digital learning team
to engage in real-time “articulation work” (Kling and Lamb 1999) to make the IT work
in the way we needed.
Similarly, our initial observations were that using a combination of Zoom and Whatsapp
to deliver teaching offered affordances, opening up new channels of communication
and permitting new kinds of interactions. Yet at the same time, it changed some aspects
of the encounter; for example, students were more likely to pose questions via the
chat functionality than verbally. This suggests that the technology was shaping what
teachers and students did and hence mediating patterns of teaching and learning. This
generates questions relating to, for example: the “choreography” between the human
(clinicians, facilitators, content experts, students) and the material (the LMS, Zoom,
Whatsapp); how the role and significance of technology in our institution may have
shaped our response; and the hardware and videoconferencing may have shaped the interaction
between teachers and students, and potentially influenced the process and impact of
observation and feedback (Fenwick 2014).
Our examples are just that, but they are apt in the sense that they focus on some
of the central sociomaterial notions: affordances; of associations, or entanglements,
between elements; how practices might act to construct a particular reality; “knot-working”
(collaborative problem-solving; Engestrom et al. 1999) and articulation. We have not
provided a comprehensive overview of the many different sociomaterial approaches,
key concepts and terms (see Micheal 2017 for a general introduction). Nor have we
given a full or even satisfactory description of the situated, complex and messy situation
facing many medical educators around the world. These were not our aims in this short
commentary. Rather, we make the suggestion that sociomaterial approaches may provide
the language and methods to unveil and understand the nature of educational responses
to Covid-19.
Rather than merely describing was done during Covid-19, considering how practices,
people and things came together to enable educational practices to emerge is a way
to “forth particular realities in practice and learning, while highlighting opportunities
and entry points for change” (Fenwick 2014, p. 51).