Within the health care professions, there is an ongoing requirement to continually update knowledge and skills through continuing professional development (CPD). In the health care sector, CPD has been defined as a “process by which health professionals engage in activities to maintain and extend their knowledge, skills, and performance, as well as develop the personal and professional qualities required to be safe and effective clinicians, educators, and researchers.”1(p1104) CPD encompasses a range of formal and informal activities, including reflecting on professional experiences, conducting research, participating in self-directed learning activities, and engaging with formal education events, such as seminars, workshops, and conferences.2

Over the past number of years, online education has become widely used for teaching and mentoring in the health care professions.3–5 Online formats have been recognized as a key lever for capacity building, particularly for rural communities6 and in low- and middle-income countries.7,8 However, educational conferences and professional meetings, which served as focal points for professional societies,9 typically took place in person, on-site, and involved several days away from the normal work environment to network, socialize, and share new research and practices.10 During the COVID-19 pandemic, there was an urgent and necessary move to deliver all CPD events online.11,12 The impact on access to such events after the pandemic is expected to be far reaching and permanent for some health care professionals.13 Having experienced the convenience associated with online meetings and conferences, many may favor this format going forward, whereas others may be yearning to return to in-person sessions. As the worst ravages of the pandemic recede, there is a need to understand health care professionals' views on CPD modalities. Such information is of benefit to CPD providers and event organizers to ensure that they meet the needs of health care professionals into the future.

Globally, CPD is increasingly being seen as a key element of the health care education continuum, and as such, it is continually evolving.14 The pandemic, however, has given considerable impetus to changes in CPD modalities. The requirement to rapidly disseminate the latest information about the COVID-19 virus led to the harnessing of communities of practice and the use of social media and online discussion forums to keep pace with the evolving COVID-19 information.13 In addition, the widespread restrictions imposed as a result of the pandemic created a mass transfer from in-person to online conferences, professional meetings, and workshops.

A Best Evidence Medical Education scoping review set out to map the extent, range, and nature of medical education development in response to the COVID-19 pandemic.15 Particularly, it reported 22 studies that were focused on continuing medical education, mainly run by academic hospitals with some collaborations and national organizations. The most represented speciality was surgery. Graduate medical education separately reported 14 studies, with a large proportion focused on delivering simulation to support clinical staff to treat patients with COVID-19.

Evaluations highlight that online delivery was acceptable for knowledge acquisition. However, it was challenging with regard to learning clinical skills and procedures.16,17 Advantages to online delivery included ease of access, no travel time, and convenience. Some studies also reported higher attendance.18 Other benefits included better access to international experts.19 Disadvantages included less access to networking and discussions and distractions within the home environment.11,20 Online delivery was also hampered by internet connection problems, and respondents reported fatigue from being online.21,22 Content types varied, from regular lectures and blended learning to novel events such as the live streaming of ward rounds to enable attendees to participate in live Q&A sessions.

In light of the significant changes brought about during the pandemic, it is timely to explore the views of health professionals regarding how they would like to access and engage with CPD as the most severe restrictions of the pandemic recede in many parts of the world.

METHODS

This study involved a mixed-methods design,23 which included an international survey to access the range of views of health care professionals and a purposive interview study to gain a deeper understanding of factors that inform views on future access to CPD. The use of a mixed-methods approach in this way facilitated the capture of a rich data set24 that could provide a big picture view of health care professionals' preferences and more nuanced perspectives on the drivers of those preferences.

The research question was as follows:

What are the views of health care professionals regarding access to CPD after the easing of COVID-19 lockdowns?

Stemming from this question were the following subquestions:

1. What conditions inform preferences for in-person and online CPD? 2. What is the optimum length and type of online and in-person CPD events, including industry-sponsored CPD?

The study proposal was submitted to the university research ethics committee, and the approval was granted.

The survey was based on the Course format and learning environment section of a larger previous survey into the preferences of Irish general practitioners regarding CPD.25,26 Some minor adaptations were made to make the survey more international in focus and relevant to health professionals more generally. The adaptations are highlighted in Supplemental Digital Content 1 (see Appendix 1, https://links.lww.com/JCEHP/A216). This section of the survey invited respondents to respond to 16 statements relating to their CPD habits and preferences along a 7-point scale, ranging from 1, strongly disagree, to 7, strongly agree. The questionnaire was supplemented by demographic questions and items related to factors that may influence CPD (see Appendix 2, Supplemental Digital Content 2, https://links.lww.com/JCEHP/A216, for a list of the additional questions). The survey was hosted on the online platform SurveyMonkey and emailed to university alumni, which includes doctors, surgeons, nurses, physiotherapists, and pharmacists, as well as fellows and members of a health care–focused professional organization with which the university is affiliated. It was also circulated to colleagues in other universities to distribute and made available through social media channels. The exact numbers who received the survey are difficult to estimate because the emails are several years old and not easily updated, and many people emailed will not have opened the request to take part in the survey. Nonetheless, a broad range of health professions was approached internationally.

The survey ended with an invitation to respondents to provide their email address if they were willing to take part in a short online interview, highlighting that a small purposive sample would be approached, and they may not necessary be invited. In total, 22 respondents provided contact details. Maximum variation was used to purposively invite respondents to take part in the interview (variation in profession, country, or gender). The interviewees consisted of five surgeons, four consultant physicians, two nurse educators, two psychologists, a theater nurse manager, a prosthodontist dentist, and a hematology registrar. They were located in Ireland, the United Kingdom, the United States, Qatar, Bahrain, and Australia. Interviews were to continue until theoretic sufficiency was reached, that is, no new themes were identified.27,28 The interviews, which were conducted by D.C., J.I., and G.E., were semistructured and lasted between 20 and 40 minutes. The question guide can be seen in Supplemental Digital Content 3 (see Appendix 3, https://links.lww.com/JCEHP/A216).

The survey data were analyzed using descriptive statistics to identify frequencies and compare patterns in responses. For clarity, the 7-point scale was collapsed into the categories of disagree, neutral, or agree at the reporting stage. The original results along the 7-point scale can be seen in Supplemental Digital Content 4, 5, and 6 (see Appendices 4, 5, and 6, https://links.lww.com/JCEHP/A216). The interviews were transcribed verbatim and pseudonymized before being analyzed using reflexive thematic analysis29 following the stages of familiarization, coding, developing themes, and writing. One researcher (D.C.) generated initial codes through a process of open coding, a process of careful line-by-line reading of the transcripts aimed at identifying concepts and categories that capture the data.30 Phrases and sentence fragments were then organized by their codes, and the fragments were reread to gain insights into overlaps and identify broader themes. Finally, the data were summarized according to the identified themes.

RESULTS

The survey generated 340 responses, although the number of respondents who answered the majority of the questions was significantly lower (239). It had a global reach, with over 21 countries represented. As can be seen in Table 1, most respondents who gave their country of employment were from Europe. Of those who provided demographic details on gender, 54% were women and 46% men. Of those who provided their profession, the majority were physicians (40%), surgeons (18%), or nurses (16%), but there was also representation from other health care professions. In terms of seniority, the majority (70%) of respondents were 10 or more years post gaining their licensure qualification, and most worked in a publicly funded health organization (45%) or were self-employed (25%).

TABLE 1. - Demographic Details Items Demographic Details n % Geographical region Europe 149 78 n = 192 North America 17 9 Middle East 11 6 Others 15 8 Gender Man 88 46 n = 193 Woman 105 54 Occupation Physician 76 40 n = 192 Surgeon 34 18 Nurse 31 16 Others 19 10 Pharmacist 12 6 Physiotherapist 10 5 Psychiatrist 6 3 Scientist 2 1 Psychologist 2 1 Career stage In prelicensure (undergraduate) training 4 2 n = 194 Less than 23 mo post qualification (postlicensure) 8 4 2–5 y postlicensure qualification 15 8 6–10 y postlicensure qualification 20 10 10+ years postlicensure qualification 135 70 Others (please specify) 12 6 Employment status Employed by a publicly funded institution 88 45 n = 194 Self-employed 49 25 Employed by a privately funded institution 39 20 Others (please specify) 18 9

In total, 231 respondents chose to answer questions about their main source of CPD, with 51% selecting their professional bodies. Respondents mainly chose to attend meetings in their own specialism (77%), but a large minority was interested in doing CPD outside their specialism (46%), and more were interested in doing interdisciplinary courses (64%). Only 32% identified international meetings as the main source of their CPD, and 21% saw industry-sponsored meetings as important for their CPD. Respondents were mainly interested in courses that improved knowledge and skills, even when there was no associated postgraduate qualification (76%). However, a large proportion reported accessing CPD to gain a professional qualification (59%). The breakdown can be seen in Figure 1. More granular data are available in Supplemental Digital Content 4 (see Appendix 4, https://links.lww.com/JCEHP/A216). Figure 2 shows the responses related to CPD formats. Most respondents reported that they possessed the technical skills to participate in online courses, and 74% reported that they frequently accessed medical resources online, but only 32% preferred total online delivery. Most preferred a blended learning format, with only 31% favoring solely in-person delivery. In-person workshops were more preferred for practical courses, however. When it came to the factors that influenced the decision to attend in-person CPD, the cost to themselves, the opportunities it afforded to the network in person, and their caring commitments were the key drivers (Figure 3).

FIGURE 1.:

Main source of CPD.

FIGURE 2.:

Modality preferences.

FIGURE 3.:

Influencing factors for attending in-person CPD.

There was a strong appetite for long, in-person events (duration of five hours or more) when these were hosted by a professional body. However, long online events were not seen as desirable, particularly if they were hosted by industry. However, online events of short duration, up to 90 minutes, were the preferred format for industry-sponsored events. For in-person industry-sponsored events, events between 3 and 5 hours were acceptable. The details can be seen in Supplemental Digital Content 7 (see Appendix 7, https://links.lww.com/JCEHP/A216).

In total, 198 respondents answered questions relating to the channels through which they received information about CPD. The preferred formats to receive information about future CPD events were through email, their professional body, or from a peer. Less common was the use of social media. In fact, as Figure 4 shows, a large minority of respondents reported that they did not use social media. However, for those who did, Twitter was the most popular channel, followed by LinkedIn, Facebook, and Instagram.

FIGURE 4.:

Social media platforms used.

The aim of the interview phase was to explore health professionals' views on CPD in greater depth, with a particular focus on how their perspectives on CPD formats may have changed after their increased exposure to online formats during the pandemic. As described above, in total, 16 interviews were conducted online, the transcripts were analyzed, and the data were summarized under the five themes discussed below.

CPD Activity Before and During COVID

The interviewees engaged in a wide range of CPD activities that spanned clinical audit; professional meetings, conferences, and workshops; industry showcases; and peer group discussions, among others. Their motivation to engage came from both intrinsic—including personal interest—and extrinsic factors, such as the requirements of their professional regulatory bodies. Before the advent of the pandemic, the interviewees reported that the vast bulk of this activity was conducted in person. They viewed these activities as important for networking, learning, and establishing and directing their careers.

It's the collegiality, it's the follow up. It's the ability to, you  know a lot of the work is done over a cup of coffee rather than  actually listening to the lecture. It's the developing of rela tionships with people especially overseas. [Surgeon 1: Ireland]

During the pandemic, conferences and meetings moved online and videos, webinars, and podcasts came to play a more central role in CPD.

So how I did before COVID came? I hardly did any online  lectures they just were not the done thing. I think I might have  done 2 but uhm and I and I don't listen to podcasts and I had  never listened to an online lecture of somebody else. So I was I  was not familiar with the format. [Surgeon: UK]

Networking and Social Aspects

In-person meetings and conferences facilitated levels of sociability and informality that interviewees identified as important in building collegiality and laying the groundwork for research collaborations and other career-enhancing opportunities. Conferences and seminars were valued as much for the informal gatherings and serendipitous encounters as for the formal content of the events themselves. Interviewees who were not part of a team in their daily work commented that they valued the opportunities to engage with other professionals and experience collegiality. Such encounters were perceived as energizing and a source of enjoyment for most of the interviewees, and they valued the opportunity to leave their regular surroundings and have space and time dedicated to participation.

 I feel sort of so much more motivated to go with it happening physically in a place … and sort of walking around posters and walking around presentations. That feels like you get more of a feel for what's going on than if you're having to navigate a virtual thing. [Medical Registrar: UK]  I think there's gonna be a place for the in-person type events in terms of building relationships and things like that … you have a back and forth discussion. In a setting like dinner or something like that or in a networking session outside of the place that you give your talk, people will come up to you if they were too nervous to raise a question. [ER physician: US]

By contrast, there was a broad agreement that the social dimension was diminished in the online environment. Interviewees felt that interaction and engagement was often poor. Participants' reluctance to turn their cameras on meant that there were few opportunities to get a sense of who people were or gauge their reactions. Many interviewees who spoke at online conferences talked about the difficulty of reading their audience because of the absence of nonverbal cues. Some interviewees noted that the lack of physical presence made it much more difficult to establish credibility with peers. Some also felt that it was harder to absorb new information in virtual contexts, perhaps because of the reduced access to nonverbal behaviors that form a significant element of communication.

When I give a lecture, I keep an eye on both the back row and  the front row and I will often ask the back row a question to  keep them engaged. We can't do that it Zoom and I've no idea  if… they're actually interested in what you're talking about.  [Surgeon 3: UK]

Some interviewees, however, suggested that the use of breakout rooms within online sessions afforded good opportunities to forge connections between participants. It was also noted that once relationships are established in person, it becomes easier to interact and work effectively online, particularly in smaller groups.

You have the breakout room facility, which I think really  helps make them intimate and helps you kind of form more of  a connection with other participants. [Psychologist 2: Ireland]

Access Versus Engagement

The access to CPD afforded by online platforms was recognized as a huge benefit, and many participants observed that a whole array of otherwise inaccessible opportunities had opened for them. This was particularly true for those who lived away from urban centers, those with caring responsibilities, and those in sectors where free or low-cost CPD had been rare before the pandemic.

[Online] works from my lifestyle perspective …for me it was  brilliant that I didn't have to go all over the place for meetings  like I used to before. [Endocrinologist: Bahrain]

I suppose for my colleagues who work away from the urban  hub, you know it [online] has really allowed us to sort of get  with the game again. [Psychologist 1: Ireland]

Interviewees appreciated having access to a greater variety of events and the flexibility to pick and choose sessions of interest, rather than attending entire events. They also valued the opportunity to continue learning during the pandemic. For some, online events created new opportunities to work with fellow specialists overseas. Moreover, some interviewees found the invisibility offered by features such as chat messaging made it easier and less intimidating to engage with experts at large online events.

I feel like what COVID has done, it's actually greatly  improved the access to information that a lot of people  wouldn't be able to have access to otherwise. [ER physician: US]

The flip side of the increased accessibility was that the commitment to engagement associated with traveling to an event was not typically a feature of online events. Interviewees revealed that they tended not to set aside focused time for online events as they would with in-person ones. The accessibility of online meant that participants often attended from their work desk or kitchen table, with one eye on emails, ongoing projects, and any emergencies that happened to arise. This contributed to the generally poor levels of online engagement.

If I'm doing something online then I'm most probably at  home and then get distracted by the kids or got pulled to do  something else while the online is going ahead. [Surgeon 4: UK]

Moreover, the sheer number of events that became accessible had a negative impact on some. One interviewee spoke about feeling overwhelmed by all the possibilities, and some reported that after such an extended period of attending online events, they had had enough.

There was a strong belief among the interviewees that not everything lent itself to online formats. Events with a strong experiential focus were considered not to work well online, including hands-on procedures and equipment demonstrations. Although the interviewees revealed some creative solutions they had experienced or initiated that enabled practical workshops and even surgical training, to take place online, it was felt that the visceral experience of the real environment could not easily be replicated.

Maybe a masters in disaster medicine. The theory could be  done online, but standing on an airport, runway with a jet  that's just crashed into a bus, you can't do that online. At least  you probably can't do it effectively and you can't do it vis cerally. [ICU consultant: Australia]

Cost

The cost of attending CPD events was a very significant factor for the interviewees, with the majority reporting that they largely funded attendance themselves. For in-person conferences and events, this generally meant paying for tickets, accommodation, travel, and subsistence. For those in private practice, there was also income forgone. This placed a limit on the number of in-person events they were likely to attend each year. Many welcomed the emergence of online alternatives, which enabled them to avail of the content without the prohibitive costs and time commitment. They viewed online formats as more affordable, facilitating greater access for those from economically disadvantaged regions, individuals at earlier stages of their careers, and those without funding to cover the event and associated costs.

The cost of not having to travel is fantastic and hotel bills and  all that kind of stuff so it does make it a lot cheaper. [Surgeon 3:  UK]

You've got people like residents often in the United States,  can't afford to go attend these things because of all of the  other expenses. [ER physician: US]

Time and Timing

Online formats were generally perceived as more time efficient because they tended to be more focused and did away with the need to travel. For some interviewees, however, the chance to travel to nice locations and avail of the amenities was a factor in their decision to attend certain events. Others, however, were not particularly attracted by these opportunities, commenting that most events did not typically allow any time for recreation-focused activities.

When you travel as much as I do, you cannot take a holiday  on your travels, you just you get to meet the people, which is  different. So you get a flavour of cultural difference, but you  don't get to tour the nice places. [Surgeon 3: UK]

There was a general recognition that it was more difficult to hold attention online than in person, and therefore, short focused events that last 90 minutes or less were preferable to half or whole-day sessions. Moreover, online events scheduled during the work day or in the early evening appeared to suit many of the interviewees. There was a general consensus that weekends were not optimal because of family commitments and lifestyle preferences.

There was a much greater tolerance for extended in-person events. Their immersive nature and the fact that the time and space was preallocated allowed individuals to be “present” in a way that online events did not facilitate. Moreover, engagement in such events tended to include a mix of formal and informal interactions, which interviewees found more productive than their online equivalents.

We had spent about six hours doing pieces of work, it didn't  feel like I was there for six hours because you were there face  to face, you were doing stuff, you had your break - you could  get up, go get a cup of coffee or whatever you could come  back and continue the workshop. [Surgery educator: Ireland]

DISCUSSION

The survey and interviews described above reveal nuanced perspectives on the value of CPD and the respective merits and drawbacks of in-person and online CPD modalities. In addressing the research questions, we will focus first on the subquestions before discussing the main question.

Conditions Informing Preference

Survey respondents reported being confident in accessing online CPD opportunities and saw many benefits from doing so, including saving travel time and reduced cost. This was strongly reinforced in the interviews, and there was much positivity about the access the online medium afforded to a wealth of CPD opportunities that would otherwise have been inaccessible. This accords with previous findings regarding the affordances of online learning.18,19 Interviewees reported that enhanced access was particularly valuable for those outside of large urban centers who may not previously have the same opportunities to engage in CPD activities. Interviewees in this cohort felt that the increased access has provided them with opportunities to keep abreast of wider developments in their professional spaces and helped them to feel included in conversations that their more geographically advantaged peers might take for granted.

Nonetheless, respondents clearly identified benefits from attending in-person events for networking and developing collaborations. They recognized that online events did not always provide the same opportunities for interaction. CPD was conceived by the interviewees in its broadest sense as offering not just access to information but to supportive professional networks that provide professional and personal enrichment.2 Such opportunities depend on individuals getting to know each other, which have proved more challenging in the online environment. At many online events, participants' reluctance to speak or turn their cameras on creates an environment where people feel vulnerable when making themselves visible or speaking freely. Under such conditions, it is difficult to provide the psychological safety31 necessary for participants to share opinions honestly and lay the foundation for productive relationships. This accords with previous research, which found that in-person contact is seen as important for building professional relationships and networks.11,20

Optimum Length and Timing

It was clear from both the survey responses and the interviews that online events need to be much shorter and more focused than their in-person equivalents. Moreover, the survey findings suggest that industry-focused events should be shorter than those associated with professional bodies—less than 90 minutes for online events and less than 3 hours for in person. The importance of getting the length and time right was also underscored in the interviews. There was an indication that for the purpose of keeping up to date and information gathering, there was great value in the convenience of short focused online events held during the work day or in the early evening. For events that were more hands on or where there was a much greater emphasis on networking, in-person events were seen as optimal, although there was a recognition from interview data that hybrid events—ones that allowed for smaller in-person events to be simultaneously delivered virtually—could provide the access, flexibility, and resilience32 that was difficult to achieve with entirely in-person events.

Views Regarding Access to CPD After COVID

In relation to the main research question, almost all the interviewees stated that they were looking forward to returning to in-person events, but many also wished to continue to have the type of access and the range and choice of CPD opportunities that became available to them during the pandemic. Beyond the horizon of COVID restrictions, it would appear that the future of CPD is likely to feature a greater mix of in-person and online opportunities. As has been identified, both formats have affordances and drawbacks, and it is thus sensible to seek to build on the former and mitigate against the latter through the adoption of hybrid approaches, where possible. The pandemic has provided an opportunity to experiment with formats that open the door to greater inclusivity and diversity. It would be a lost opportunity if the advances made in enabling access to a broader cohort of participants were removed as we enter a postpandemic period.

Organizers of events need to reflect on the aims and purposes of those events and design them accordingly, considering a mix of online and in-person opportunities. In this way, they may be enabled to deliver the networking and social opportunities that are so highly valued by participants, while also developing avenues for online participation to extend the reach of the events and support a broader community. Central to the effectiveness to such events are strategies that will encourage participants to dedicate the time to fully engage to make them a better experience for all.

As populations are becoming more accustomed to interacting in the online space, it is important that more appropriate strategies are adopted to enhance online participation and engagement. Organizers can optimize events by developing a better sense of what works online in terms of formats and length and engagement strategies. Suggestions include the use of breakout rooms, the incorporation of virtual reality elements, and the use of short interactive group exercises, among others.33 There is a need for innovative thinking to create new online formats rather than merely replicating those of in-person conferences and meetings. For example, formats such as escape rooms34 have shown promise for their ability to promote engagement and interaction. Looking toward the future, the mainstreaming of Metaverse technologies may enable the creation of more immersive experiences.35 It is important to consider whether and how these capabilities might be harnessed to design events that will invite participants in and encourage productive interaction.

LIMITATIONS

The following limitations apply to this research:

There were large nonresponse rates for many of the survey questions, and it was not possible to tell whether there were significant demographic differences between responders and nonresponders. It is therefore not possible to be certain that the findings are representative of the populations identified.

Although the qualitative interviews revealed large differences between participants' attendance of online events before and during COVID, the survey questions, which were administered as the period of lockdowns was beginning to recede, did not distinguish between pandemic and prepandemic behaviors and attitudes. Consequently, there are no quantitative data pointing to the pandemic leading to a shift in perspectives.

CONCLUSION

It would appear that the changes brought about by the pandemic have accelerated the adoption of online CPD modalities for health professionals. The awareness generated of the capacity of online formats to deliver affordable, accessible learning opportunities means that there is likely to be a significant demand for these into the future. Moreover, the environmental cost associated with travel for CPD might be mitigated by online formats.

The challenge then is to achieve a balance between the flexibility and convenience of online and the need for personal interaction and engagement that is a strength of in-person engagement. Clearly, there is no one-size-fits-all solution. The onus is on providers and organizers of CPD events to consider in each instance the main goals and purpose of the engagement and whether they are best served by virtual or in-person opportunities or a mixture of both and to be open to reconceptualize the entire experience through innovative, engaging approaches.Lessons for Practice ■ Do not assume in-person CPD events as the default format—consider the purpose of the event and whether a hybrid event would be optimal for expanding access while facilitating networking. ■ Take a participant-centered view. What will work for your participants in terms of length and timing of events; consider how you might encourage them (and perhaps their employers) to ring fence time to engage fully in online events. ■ When designing hybrid and online events, seek to leverage the affordances of virtual environments by experimenting with innovative technologies that seek to foster engagement and participation.

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