To create an engaging learning experience for learners, medical educators must learn to implement technologic advances, using media that are effective both interpersonally and academically (Darr et al., 2019; Hann et al., 2019; Garg et al., 2020). Despite the plethora of articles in the literature about converting educational activities and programs into online or virtual platforms, few have described conceptual frameworks that underpin their application and development (Gordon et al., 2020). Explicit frameworks are critical for conceptual transferability of programs offering useful models to other educators and scholars (Stake, 1995).

In response to the challenges posed by having more than 1,600 faculty dispersed throughout a major metroplex, we collaborated to deliver a virtual academic writing retreat to provide uniform accessibility. We describe the transformation of a traditional in-person workshop into a virtual platform using Community of Inquiry (CoI) (Garrison, Anderson and Archer, 2000; Garrison, Anderson and Archer, 2010)  as the theoretical framework. Our aim is to provide a conceptual model and practical recommendations that medical educators and faculty developers can use for designing their own CoI with effective virtual synchronous learning, using their respective curricula.

(Adapted with permission from D. Randy Garrison (Garrison, Anderson and Archer, 2000).

Social Presence is defined as “the ability of participants in the community of inquiry to project their personal characteristics into the community, . . . [thereby] facilitating the process of critical thinking carried on by the community of learners” (Garrison, Anderson and Archer, 2000). Positive social interaction is key to providing a successful learning experience, especially in a lengthy meeting such as our writing retreat. Interactive and respectful discourse offers learners a sense of belonging and importance, powerful and influential drives (Baumeister and Leary, 1995), even when restricted to two or three sentences. By keeping the sessions semi-casual, we established a relaxed yet professional environment.

Teaching via video conferencing platforms requires different levels of concentration to engage one another (Jiang, 2020; Daigle, 2020)  and places strains on one’s social presence that are more taxing than those presented in traditional social exchanges (Roberts, 2020). To establish a pleasant social climate and ‘ethical appeal’ (Kinneavy, 1969; Kinneavy, 1971, 1980), we began the retreat by introducing ourselves and briefly describing our backgrounds and areas of expertise.

To set boundaries that facilitate building healthy relationships and environments (Cloud and Townsend, 1992), we explained a few housekeeping rules of etiquette, such as to be mindful of background interference and other possible interruptions, and encouraged participants to refrain from muting their mics. Although using mics could be counterintuitive for some participants, it is the best practice to induce engagement according to the founding developer of one of the world’s most successful remote and distributed open-source software, WordPress (Mullenweg, 2020). 

During the presentation itself, we implemented numerous social engagements (e.g., time for participants to share ideas, reflect on the material presented, take notes, and interact with the workbook handouts) to complement the didactic component. The breakout room option allowed for formation of small groups to discuss the material that had been presented didactically, using different forms of prompts (e.g., reflection, case study, debate, think-pair-share).

The chat feature, monitored by one of the facilitators, allowed participants to comment, question, and request explanations without interrupting the didactic presentation or distracting other participants. In some cases, the facilitator responded directly; in others, the questions were integrated into the presentation so all the participants benefited from the input. It picked up momentum and further strengthened the sense of having a CoI, providing a sense of participation and individual importance.

One of the features that we decided not to use is the recording option, as we aimed to create a psychologically safe space in which participants could discuss freely without feeling conscious about being recorded.

Cognitive Presence is defined as the “extent to which the participants in a particular configuration of a community of inquiry are able to construct meaning through sustained communication” (Garrison, Anderson and Archer, 2000). To ‘set the stage’ for learning, we distributed a brochure with the titles of topics to be covered, e-mailed respondents in advance with a course outline, and solicited questions/ideas in advance. Given that we had already used Kolb’s experiential learning cycle (Kolb, Boyatzis and Mainemalis, 2001, 2010) to design the curriculum, we made only minor reconfigurations to create the cognitive presence through ‘triggering event,’ ‘exploration,’ and ‘integration of knowledge’ (Garrison, Anderson and Archer, 2001). 

We strategically interwove various experiential options with the didactic presentations, using case studies or shared experiences (triggering event) to activate prior knowledge. Participants explored new knowledge through individual or small group exercises prior to reconvening for integration of knowledge with the didactic presentation. For instance, in an asynchronous exercise on ethics of publication, we had participants list all potential authors for a given project on a provided worksheet. We then presented the Committee on Publication Ethics (COPE) requirements for authors, had the participants reflect on the lists they had made and place a check mark beside the names of individuals who met those criteria, and explained how to deal with the individuals who do not qualify. For a synchronous exercise, we used a case study (a real-life problematic experience with order of authors) to trigger discussions in small groups as they sought to determine, especially, first and senior authors; debated in a large group about appropriate order of authorship; and summarized lessons learned and recommendations.

The retreat was undergirded by a PowerPoint presentation and am accompanying workbook that includes the slides in thumbnails and provides supportive materials (e.g., full articles, website links) and templates. The latter serves as a take-home resource guide to reinforce the didactic presentation with materials that cannot be covered within the time constraints of the retreat.

Virtual workspace platforms (e.g., Google Doc, Google Slides, Microsoft Team) were used to enhance this cognitive presence wherein all team members could work on an activity simultaneously during the session.

Teaching Presence includes the selection, organization, and primary presentation of course content, as well as facilitation “to support and enhance social and cognitive presence for the purpose of realizing educational outcomes” (Garrison, Anderson and Archer, 2000). We initially did a thorough review of the original PowerPoint presentation to ascertain what portions were relevant to or conducive for instruction on the virtual platform. The workbook was adjusted for a virtual audience, and all teaching materials were made available to the learners via a readily accessible institutional ‘box.’ To ensure that all the material is covered in a logical and smooth context while allowing ample time for social engagement and collaboration, we created an exacting time schedule for each topic. Each facilitator had a copy of the schedule and followed it carefully.

Each author assumed various roles: presenter, facilitator, encourager, mentor. Pratt’s five teaching perspectives (Pratt, 2002)  were informative, as each of the facilitators comes from a different background with different teaching styles, priorities, and perspectives, and helped us provide a strong complementary presence. One of the authors has more expertise using the virtual platforms and agreed to oversee the entire retreat to eliminate overlap or confusion that might occur if the responsibility is passed around from one presenter to the next. By appreciating our differences, we were able to complement one another and model a strong social presence.

We evaluated the retreat using a brief survey on teaching effectiveness at the end of the session and a follow-up survey on application to practice approximately one month later. The results were analyzed using descriptive statistics (mean and standard deviation).

The study was approved by the institutional review board at Baylor College of Medicine, Houston, Texas.

The result was a virtual, interactive, four-hour writing retreat for medical educators, based on a composite theoretic approach illustrated in Figure 1. Forty multi-disciplinary faculty attended the writing retreat. Most attendees (90%) participated in the entire 4-hour session; four participants had to leave before the session ended due to work-related duties. In the post-session survey (50% response rate), participants rated the learning activities highly and stated that the retreat helped them achieve learning objectives. They also gave high ratings on the overall teaching effectiveness (Table 1), using a 5-point Likert scale questionnaire (1= Not at all, 5= A great deal) . 

We also received valuable narrative comments from the participants. We categorized these comments, along with the effectiveness ratings (rated on a 5-point Likert scale in which 1= Not at all and 5 = A great deal), into three functions (namely, supporting discourse, setting learning climate, and regulating teaching and learning) of the CoI as a joint display (Table 2).

Pertaining to the curricular content, participants appreciated the comprehensiveness of the content, references and available resources, and practical writing tips and tools. One participant shared sentiment about the virtual platform, “I think doing it virtually may be as good as being an in-person activity (maybe better with regards to making it more feasible for more people, barring travel, etc.).” Regarding technical aspects, most participants enjoyed the breakout rooms, but the think-pair-share option was not as well received. One participant reported the other party was not present during the breakout in pairs.

Thirteen of 36 participants completed the follow-up survey, two and eight participants have started and made progression on writing their manuscript, respectively. Five participants have finished or submitted a manuscript for publication within a month after the writing retreat.

Guided by Garrison’s CoI framework (Garrison, Anderson and Archer, 2000; Garrison, Anderson and Archer, 2010), we successfully reconfigured the curriculum and instructional processes of our long-standing writing workshop into a virtual experience in a relatively short timeline and delivered the session with great results. The CoI framework also was very useful as an analytical lens for interpreting the evaluation results of the session. Importantly, the conceptual model and practical recommendations we provide can be used as a guide for other educators and faculty developers seeking approaches to transforming their curricula to virtual learning.

The initial CoI framework has been adopted and adapted by hundreds of scholars. In 2010, the authors addressed noted issues, explaining specifically that the three presences (social, cognitive, and teaching) and their areas of overlap “emerged in the specific context of computer conferencing in higher education . . . rather than from a traditional distance education theoretical perspective [that] assumed that students worked independently from each other.” With regard to cognitive presence, they stated that the cognitive presence may have been elevated to a higher status within the framework than it should have been; that the social presence had been researched and reevaluated and should be “seen as a mediating variable between teaching and cognitive presence”; and that the teaching presence had gained growing evidence as being seen as a “significant determinant of student satisfaction, perceived learning, and sense of community” (Garrison, Anderson and Archer, 2010). We attempted to bring a healthy balance to the virtual retreat, and we are confident that the framework will work well for medical educators teaching diverse disciplines and topics.

Using the CoI to analyze feedback received from participants, we learned about areas for improvement in the ‘teaching presence.’ Despite our careful reconfiguration of the curricular content and the processes, we got mixed feedback about the balance of didactic and other activities. Several factors may have contributed, including what has been called ‘zoom fatigue’ (Daigle, 2020; Roberts, 2020) with accompanying stress. We speculate that most participants might enjoy the session better should we deconstruct the retreat into smaller portions. Using aforementioned virtual workspaces (e.g., Google docs), documents can be viewed and edited by numerous individuals and, thereby, used to promote teaching and cognitive presence during those breaks.

Although most participants enjoyed our attempt to foster ‘social presence,’ we observed a hesitancy to participate in the interactivity during the first half hour. We also noted that the effect of the lively discussion in the breakout rooms led to better interactivity when participants returned to the main room. For future virtual sessions, we plan to use some free online platforms (e.g., FlipGrid, VoiceThread) for easy video recording and upload individual introductions to be viewed by all prior to the teaching activity to create social presence from the start.

As noted, we found Pratt’s teaching perspectives (Pratt, 2002) informative for appreciating one another’s teaching styles, priorities, and perspectives, thereby helping to maintain the participants’ enthusiasm. The schedule was essential to balancing the social and academic priorities.

We recognize that learners who attended this relatively long virtual session did so voluntarily and at no financial cost, so our population may have provided somewhat skewed responses. Nonetheless, we are confident that their responses reflect the value of the workshop and plan to give more in the future. We will continue to assess the workbook so the additional information is relevant and current, if necessary. We also plan to become more savvy using some of the other features offered by Zoom and to incorporate Google docs as applicable. 

We describe here how we optimized virtual learning by creating a modified Community of Inquiry framework to guide the development of a virtual writing retreat. The three elements of Social Presence, Cognitive Presence, and Teaching Presence easily lend themselves to various topics of medical education and provide a model for creating modified frameworks to offer diverse, challenging, and exciting courses for health profession educators and learners.