Anatomy beyond the pandemic: A Q‐methodology study exploring student perceptions toward a hybrid curriculum

As a result of the COVID‐19 pandemic, anatomy education was forced to adopt online modes of delivery. Previous research on student views revealed areas of strong preference (asynchronous lectures) and strong dislike (virtual specimens) in online anatomy courses. The current study seeks to compare the views of a single cohort of students experiencing both online and in‐person undergraduate introductory anatomy and physiology courses. This comparison can highlight what students consider beneficial to their education and can inform future hybrid course offerings. Q‐methodology was used to assess the opinions of students. Students sorted 41 statements on anatomy education in a quasi‐normally distributed grid based on their degree of agreement with the statements. The rankings underwent a by‐person factor analysis which categorized students with shared perceptions into groups. Data were collected from 246 students in the primarily online fall semester and 191 students in the primarily in‐person winter semester. Analysis revealed three distinct factors (groups) in the cohort. Factor one (n = 113 (fall), n = 93 (winter)), was satisfied overall with the course materials and delivery. Factor two (n = 52 (fall), n = 18 (winter)) had a deep dislike of online learning, and factor three (n = 37 (fall), n = 49 (winter)) had a strong preference for online learning. While many students were comfortable in both online and in‐person learning environments, this was not the case for all learners. The strengths and weaknesses of each teaching modality suggest the opportunity to explore hybrid learning as an option for future course offerings and specifically highlight valuable aspects to incorporate from each environment.

grew substantially to include lecture videos, laboratory modules, and interactive online learning platforms as a means of providing alternative pathways to anatomy learning. 1With the easing of COVID-19 pandemic restrictions, educators are now faced with challenging decisions as to how anatomy courses should be delivered moving forward (i.e., in-person, online, or hybrid), and are considering how the learning experience will be perceived by students.
The surge of online anatomy content generation has prompted multiple studies on the effectiveness of this form of anatomy education from students' perspectives on their learning.These studies have yielded mixed results with regard to students' perceptions toward online education with some indicating favorable views based on the convenience of online learning, 2 accessibility of content, 3 and ideal conditions for self-directed learning 4 ; while others indicating negative views related to the lack of personable interactions in an online curriculum, 5 inability to work with specimens 6 and encounters with technical difficulties. 7One study used Q-methodology (a semi-quantitative qualitative approach) to explore undergraduate student perceptions toward an online curriculum of anatomy and physiology. 8,9The study revealed three distinct perspectives toward the virtual learning environment: students that were satisfied with the course, students that were unhappy with several course elements, and students that enjoyed interactive course components like tutorials.This study also found that some perspectives were shared amongst all students such as students' preference for physical specimens over virtual ones.A limitation in most of these studies however, was that the cohorts examined reflected on the student experience solely in a virtual environment.Student perceptions of in-person learning were primarily hypothetical or based on courses taken by students pre-pandemic.The added value of this study's method is the ability to compare two learning experiences (virtual and in-person) within a consistent cohort.
While realizing that certain aspects of online learning were indeed successful, alongside the desire to return to the classroom, postsecondary institutions are now considering a revitalized move toward a hybrid learning environment.Understanding, however, which course aspects are most appropriate for the hybrid model is unclear.Critically, a cohort study of the perceptions of students who experienced both online and in-person environments in succession is an unprecedented opportunity to explore what students feel is effective education through a temporally meaningful comparison.
As such, the primary goal of this longitudinal, cross-sectional study, is to explore the evolution of perceptions within a single cohort of students toward an anatomy and physiology course as it transitions from virtual to in-person delivery using a Q-methodology analysis.It is hypothesized that student perceptions of the course may be used to uncover areas of strengths and weaknesses of both virtual and in-person learning that may provide recommendations for potential hybrid course offerings.

Course information
The current study explores student perceptions toward virtual and in-person learning in an undergraduate anatomy and physiology course at McMaster University during the 2021-2022 academic year as students transitioned from online to in-person learning.This lower-level course was interdisciplinary in nature, enrolling students across several programs (health sciences, integrated biomedical engineering and health sciences, engineering, and midwifery).
The purpose of the course is to introduce students to major concepts in anatomy and physiology concerning structure and function.
The course was delivered in two parts across two semesters with a final grade given at the end of each semester.Part one of the course (offered in the fall 2021 semester) focused on communication and locomotion and topics covered included: the nervous system, musculoskeletal system, and endocrine system.Part two of the course (offered in the winter 2022 semester) focused on homeostasis and topics covered included: the cardiovascular system, immune system, gastrointestinal system, respiratory system, urogenital system, and reproductive biology.Details regarding student enrollment are found in Table 1.
The course was comprised of three mandatory components: lecture, laboratory, and tutorial.Lectures were scheduled for 2 h a week and emphasized the integration of anatomy (structure) and physiology (function) through a systems approach.Laboratory sessions provided students with the opportunity to ask questions to clarify their understanding of course material and explore cadaveric specimens.Tutorial sessions were program-specific.They were used to reinforce content from laboratory sessions and lectures and bellringer practice and included peer teach presentations where students shared their knowledge of anatomical structures and built upon their discipline-specific knowledge.The delivery of material was primarily virtual in fall 2021 and primarily in-person in winter 2022 (details in Table 2).
Final grades were determined using the following assessments: term tests (45%), a laboratory-based bellringer (OSPE-objective structured practical exam) exam (35%), laboratory modules (6%), laboratory worksheets (4%), and "peer teaches" (student presentations, 10%).Term tests consisted of multiple-choice questions, bellringerstyle questions, and short-answer questions set at regular intervals throughout the semester.The final bellringer exam assessed students' ability to identify structures and answer follow-up questions.The virtual bellringer used images from a digital specimen library, students were presented with one station at a time and were not allowed to go back to previous questions.The in-person bellringer was conducted like a regular exam, with students given all specimen photos and corresponding questions that they completed within the allotted time.All virtual assessments utilized Respondus: Lock Down Browser an online proctoring software.

Q-Methodology
Student perceptions toward virtual and in-person learning were explored using Q-methodology, which is a combination of qualitative and quantitative approaches that identifies salient viewpoints of a group toward a given topic. 10As is typical of Q-methodology, the study went through four phases: instrument development, data collection, factor analysis, and data interpretation.Details on the Q-methodology process can be found in the following papers: Akhtar-Danesh et al., 10 Brewer-Deluce et al., 11 Brown, 12 and Valenta and Wigger. 13e first step to a Q-methodology study is the development of Next, an online module was created in which participants could sort the statements into a Q-sort table (Figure 1).The table  factoring is an appropriate approach for exploring the underlying factors for theoretical purposes. 14,15The extracted factors were rotated using the varimax approach as the most common rotation technique. 16This analysis revealed groups (factors) of students that held similar perceptions, that is, they ranked statements similarly.
After factor groupings were finalized, the factor scores were calculated for all statements related to each factor.

RE SULTS
A total of 246 Q-sorts were collected in the fall semester and 191 in the winter semester.Of which 226 and 182 Q-sorts were used in the final analysis in the respective semesters (incomplete Q-Sorts and duplicates were excluded from the final analysis).Although some students participated in the study both in the fall and winter semesters, they were not matched for the analysis.The timeline of data collection and the number of study participants per factor (i.e., viewpoint or perception) are illustrated in Figure 2. The distinguishing and consensus statements identified in fall 2021 and winter 2022 are illustrated in Tables 3 and 4, respectively.

Fall semester: Student perceptions toward virtual learning
Three factors were identified upon completion of the fall 2021 semester of the anatomy and physiology course.Based on the distinguishing statements, consensus statements, and qualitative feedback (Table 3), the authors characterized these groups as the happy campers (n = 113), unplugged learners (n = 52), and tech testers (n = 27).Abbreviations: lab, laboratory; MCQ, multiple choice question; TA, teaching assistant.

Consensus statements
Certain perceptions are shared amongst all students.Statements that receive a similar ranking from students of all three factors are called consensus statements.A selection of the strongest consensus statements is discussed below.
Contextual feedback revealed that while practice questions made by TA's were beneficial in preparation for examinations, they would prefer faculty-made bellringer practice that would help them gauge the difficulty and style of questions that would appear on a test.
Students also agree (HC: +3, UL: +4, TT: +4) that they would like transcripts for lectures.Contextual feedback revealed that taking notes from lectures often took more time than anticipated as students wanted to take down every word.They believe that having transcripts will decrease the amount of time spent blindly transcribing lectures and will provide them with time to absorb lecture content.Students found learning from human prosections to be a Factor one: "Happy campers" These students were once again generally content with the course components and delivery.They strongly agreed (+5) that TA office hours were helpful.They were in moderate agreement (+3) that professors improved their understanding of course material.One student stated, "I love how enthusiastic [the professors] are and the simple language they use to explain things."Finally, this group of students strongly disagreed (−4) that evaluations were unfair and did not adequately represent material covered in lecture indicating, again, that this factor felt they were evaluated fairly.Student statements such as "I think A&P is one of the courses that is actually well worth the tuition that I am paying" and "value that [the anatomy department] brings to us is absolutely unique and valuable" further emphasize the general positive regard toward the course students belonging to this factor have.
The composition of the happy campers factor did not undergo any major changes between semesters and learning modalities indicating these sentiments are likely not based on the learning environment or at least much more strongly influenced by other course aspects that are independent of the modality.
Factor two: "Disgruntled learners" The "disgruntled learners" are similar to the unplugged learners of the fall semester in their preference for in-person learning.Students belonging to this factor were in high disagreement (−5) that they would prefer online course offerings in comparison to the in-person format.This is echoed in qualitative feedback with statements such as "In-person lectures are far more engaging to me than asynchronous online lectures and I enjoy being in an environment with other students." By contrast, however, "disgruntled learners" were primarily dissatisfied with course and test content.These students were in high agreement (+5) that they were tested on insignificant details, and that the MCQs involved far more integration and application than taught (+4) indicating that these students were unsatisfied with the difficulty and content of tests.A few students expressed their dissatisfaction with tests, one stated that "I didn't feel like they tested how well I understood the concepts or overall processes but rather my ability to remember random details." Students strongly disagreed (−4) that the lectures covered an appropriate amount of content and some qualitative feedback suggested that some students found lectures to be far too detailed and claimed that "it is hard for [

them] to see how most of this information would be useful in [their] career[s]."
This is in line with this group of students disagreeing (−4) that course content would be useful in their future careers.
Despite the semester being in-person, the disgruntled learners preferred mode of learning, they were unsatisfied with the course.
The difficulty of evaluations and the time needed to go through detailed lectures did not feel worthwhile for these students, especially as they thought this course would not help them in future endeavors.
Factor three: "Tech testers" Similar to the "tech testers" in the fall semester, these students also had a preference for the online learning environment.They are in high agreement (+4) with the statement "I prefer online learning compared to the in-person format".One student stated that "In-person classes are too crowded and not having the option rewind makes in-person material being covered relatively difficult to understand."Students belonging to this factor strongly disagree (−5) that they would perform better on an in-person exam.Students stated that they "find it easier to get distracted while writing an exam in person and the environment is very stressful."Students belonging to this cohort preferred the online course delivery and testing even after experiencing in-person lectures, tests, and laboratory sessions.Based on contextual feedback, the student's preference for online was primarily focused on their liking of online testing, hence the name "tech testers".

Qualitative feedback
Qualitative feedback (Table 5) provided by participants on strongly ranked (+5 or -5) statements was considered to contextualize student perspectives.

Comparison of virtual versus in-person learning between semesters
A Pearson Chi-square test indicated that the distribution of students changed significantly (p < 0.001) between the fall and winter semesters (Appendix C).Factor preferences for virtual or in-person learning were drawn using rankings of statements 3,8, 32, 34, 40, and 41 in each factor.Based on these rankings' students belonging to the factor one (happy campers) had no preference, students belonging to factor two (unplugged learners or disgruntled learners) preferred in-person learning, and students belonging to factor three (tech testers) preferred online learning.By the end of the fall semester, the majority of students had no preference for online or inperson learning (Figure 3).Following the shift to in-person learning in the winter semester, a larger percentage of students indicated a preference for online learning.

DISCUSS ION
We aimed to explore student perceptions toward the hybrid delivery of an undergraduate anatomy course in fall 2021 (virtual) and winter 2022 (in-person).The analysis of the factors identified by the Q-methodology assessment highlighted multiple themes across the fall and winter semesters such as preference for online testing, appreciation for human prosections, positive learning environments, and benefits of asynchronous lectures and transcripts.

Preference for online testing
With the shift to online learning, an important element of education also moved online, course examinations.One of the most significant differences between the three groups in both cohorts was their at-

Lectures
Strong Agreement I like that the asynchronous lectures allow me to stop, rewind, and listen to lectures multiple times "I would pause to be able to write complete notes and make sure I am understanding, and if something wasn't clear to me, I was able to rewind and listen to that part again.""This is probably the most useful aspect of learning for me because it often takes me multiple runs through a lecture to fully understand the material." Strong Agreement I think there should be transcripts for lectures "It was difficult to get all the information down during the lecture and it would be much easier to go through the lectures if there was a script or transcript that I could use to quickly write down terms I did not know or understand properly."

Testing
Strong Disagreement I think I would perform better on an in-person exam than an online exam "I believe that the lack of stressors present in my bedroom during an online exam would make me, on average, more successful in online exams.""Having an immunocompromised family member, I would be worried and distracted while writing an exam in-person with so many people that I might bring something home to my family."

Human prosections
Strong Agreement I feel that learning from human prosections is a privilege "Donations from our communities that help our learning is a great privilege.It helps my learning a lot when I can see and touch something tangible.""Human prosections are definitely a privilege because these are donations from real people who wish to help us students with our learning.These prosections are not something that we can just get anywhere and I feel privileged to be able to study them."

Course structure and environment
Strong disagreement I find the laboratory sessions to be a toxic environment because some students will try to show off "Laboratory sessions are a very safe environment for learning.""I always find I am helped by my peers." Strong agreement I think TA office hours are very helpful "These are probably the most helpful part of the course.It gives the opportunity to test your knowledge, ask any outstanding questions, and just really cement your understanding.Definitely an amazing study tool.""The TAs are very helpful when it comes to letting me know whether certain pieces of content should or should not be focused on, they often present information using metaphors or using different language that helps me better grasp concepts covered in the main lecture, and their practice questions provide ample opportunity for active recall." As previously described, happy campers are students that were generally content with their learning in the course regardless of the environment.This extends to their testing preferences as students in this factor felt confident in their ability to perform similarly in both testing environments.Both unplugged learners and their counterparts, the disgruntled learners, were in favor of the in-person learning environment.However, during the virtual fall semester, these students believed that they performed better on online tests.This opinion changed and became more neutral following the return to in-person examinations.By contrast, the tech testers in both cohorts strongly believed that they would perform better on an online test.Interestingly following the implementation of in-person testing in winter 2022, the proportion of students that fall under this factor greatly increased.While the specific reason for this shift is not concrete, student feedback indicated that this observation was possibly linked to the lack of environmental stressors present when taking an exam in the comfort of one's own home (Table 5).Students cited poor organization, disruption to distribute exam answer cards, whispering peers, waiting to enter an exam hall with many anxious students, and nervousness about filling in the answer card correctly as a cause of stress and distraction.It is important to note that for many of these students, this was the first in-person evaluation they had experienced in the post-secondary environment.Many of the worries that they have presented may dissipate after gaining some familiarity with in-person evaluations.
Some students also expressed concern over the ongoing COVID-19 pandemic despite the easing of restrictions (Table 5).A study done by Ewell et al. 17 states that text anxiety can be influenced by situational factors (i.e., how prepared a student feels for the test) as well as competing priorities (i.e., the COVID-19 pandemic).The unfamiliarity with paper tests and COVID-19 concerns could have impacted students' experience taking in-person tests, thereby contributing to their anxiety and dislike toward them.
Test averages for online examinations, in which the use of a lockdown browser and proctoring software was in full effect, were higher in comparison to previous years.Despite students' better performance in the online setting however, students felt that they needed more time with this platform (TT; W: +4, F: +1) While not stated this preference may be due to students wanting to utilize additional time to seek out more resources when testing online.
Students are motivated by their performance in a course, and as such their increased preference for the online environment may be attributed to their desire for better grades.

Virtual specimens and appreciation for human prosections
A drawback of virtual anatomy education is the omission of what is known as the "hidden curriculum," which refers to the teamwork, ethical reasoning, empathy, and respect that is brought upon through interaction with body donors. 18,19A previous study conducted by our group on a completely virtual Anatomy course revealed students' indifference regarding the privilege of learning from virtual human prosections 8 which directly contrasts with the current study's findings.In fact, all students were in strong agreement that it was a privilege to learn from human prosections, and a slight increase in agreement was noted following the winter semester and more in-person laboratory experiences, as exemplified by student feedback expressing gratitude toward donors for enhancing their learning (Table 5).
While students were also in agreement that learning from virtual human prosections was a privilege, the extent of this agreement was lesser than that of the physical prosections (Table 4).In-person laboratory sessions and interaction with physical specimens have emphasized the importance of respect for body donors.This respect has not been translated over to virtual specimens.While the lack of a F I G U R E 3 Student learning preferences across fall and winter terms presented in percentage of Q-sorts.Factor one: no preference for virtual or in-person learning, factor two: prefer in-person learning, factor three: prefer virtual learning (as determined by responses to statements 3,8,32,34,40,41).
physical specimen may make it easier to dismiss the effort that goes into creating virtual specimens, it is only possible to make these valuable resources because of generous donors, and others who have taken time to carefully digitize specimens.Perhaps by broadening the pedagogical base of anatomy and integrating aspects of teamwork, respect, and empathy into the formal curriculum students may come out of the course with not only anatomical knowledge but with compassion and professionalism minimizing the loss of "the hidden curriculum" in a virtual environment. 20

Positive learning environment
One of the most significant changes observed following the return to in-person laboratory sessions was the change in classroom culture.Students, pre-pandemic, had anecdotally reported a toxic environment in the laboratory sessions that hindered their learning.
For example, some students would flaunt their anatomical knowledge, calling out and belittling other students who were attempting to study using laboratory specimens.At present all groups strongly disagreed with the statement "I find the laboratory sessions to be a toxic environment because some students will try to show off." Students found laboratory sessions to be a safe environment where they could get help from peers (Table 5).This is encouraging and may suggest that pandemic learning has provided the opportunity to cultivate a more positive learning environment where students can learn from their peers.Instructors could create spaces for students to share resources and engage in group study to further promote a collaborative learning space. 21 addition, students belonging to the "happy campers" strongly agreed (F: +4, W: +5) that TA office hours were helpful.Students found TA office hours provided them the opportunity to test their knowledge and ask any outstanding questions making them a great study tool (Table 5).While almost half of the cohort responded well to the TA's help, the rest of the students remained neutral in their opinion of TAs.Perhaps students belonging to other factors did not find office hours to be a tool that worked for them.As former students of the course, teaching assistants could have a better understanding of difficulties in learning the subject and might be better equipped to help students overcome those challenges.In considering how we might better support the role of TAs in future courses, some research suggests that providing TAs with additional training in pedagogy and anatomy can improve their skills as an educator. 22is training may help TAs be better equipped to help students that did not find TAs to be a valuable resource.

Perceived benefits of asynchronous lectures and transcripts
Course content was delivered through pre-recorded videos during the virtual fall semester.Students belonging to all factors agreed (F21; HC: +5, UL:2, TT: +5) that it was beneficial to stop, rewind and watch the lectures multiple times.Students stated that they appreciated being able to pause recordings to write notes and re-listen to sections they were not clear on (Table 5).Many students expressed their desire to continue to have access to asynchronous lectures regardless of pandemic status.
In the winter semester, in-person lectures resumed, however, recordings of these lectures were available to students.Most students were once again in agreement that asynchronous lectures were beneficial (W22; HC: +4, TT: +5).Many students expressed that it was difficult to understand the content presented in an in-person lecture and that having the ability to go back and watch recorded lectures helped them solidify their understanding of the content.This is in concordance with research done by Chen et al. who found that having access to lecture recordings was important to students, it gave them the opportunity to review before tests or catch up in case they missed a class. 23A few students had a contrasting opinion, Disgruntled learners were not appreciative (−4) of asynchronous lectures stating that they were often distracted when going through pre-recorded lectures and that attending lectures in person allowed them to understand content more efficiently.
Mirroring feedback previously received for this course; students wanted to be provided with lecture transcripts.Students expressed difficulties with getting down all the information during a lecture and that transcripts would make going through lectures easier (Table 5).Further research is necessary to determine why students prefer to have transcripts, and the impact that providing transcripts has on their learning experience, engagement with content, and performance in the course.While the effects of providing students with transcripts have not been well researched, the benefits of notetaking are well established, and it can be hypothesized that providing students with transcripts may reduce their motivation to take notes.Studies indicate that the process of notetaking is beneficial even prior to the revision of notes as it increases attention to the lecture and notetakers perform better academically. 24In a recent paper, Schmidt reiterates the importance of notetaking stating that the process of notetaking helps store information more firmly in long-term memory. 25As note-taking is such an important aspect of student learning suggestions to support note taking might include presenting information in a clear and organized manner, providing students with material ahead of lecture time, and providing brief pauses for students to look over and fill gaps in notes. 25Perhaps helping students become better note-takers and pushing them to utilize this well-established learning tool would prove more beneficial than providing students with lecture transcripts.

Limitations
Students in this study were provided with the survey following the completion of all three term tests (prior to the final exam) during the fall semester but only after the completion of only two term tests in the winter semester.This may have impacted student perceptions of in-person learning and testing as they were not given the same

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors declare no competing interests.15.I feel that the expectations for the peer teaches/presentations are unclear.

O RCI D
16.I think there should be a standard set of slides/specimens that all groups will cover in laboratories and tutorials.17.I find the laboratory sessions to be a toxic environment because some students will try to show off.

a
concourse.The authors developed a comprehensive set of statements related to the anatomy and physiology course sourced from open-ended student feedback, prior concourses, 8 and the relevant literature.These statements were reviewed and refined with minor edits by a panel of experts including course instructors, administrators, and a Q-methodology expert for clarity and relevancy across both semesters.Following two rounds of review, a total of 41 statements were found to be relevant and selected to form the Q-sample-the series of statements to be ranked by participants (see Appendix A).
was formed to have an equal number of spaces as there were within the Q-sample (n = 41) and arranged in a quasi-normal distribution where the columns represented a spectrum of values from least agreement to most agreement (−5 to +5).The participants were asked to sort the statements into the Q-sort table based on their agreement assigning each statement to an independent box.The students were then given the opportunity to provide contextual feedback for critically ranked (−5 or + 5) statements.They also completed a short demographic survey.Students were given the opportunity to participate in the study prior to the final exam in both the fall and winter semesters, the survey went out following the completion of three term tests in the fall semester and two term tests in the winter semester.All participants received a $10 gift card.The "qfactor" program in Stata (StataCorp.2023.Stata Statistical Software: Release 17. College Station, TX) was used to analyze completed Q-sorts via by-person factor analysis.The factors were extracted using a principal axis factoring technique.The principal axis

F I G U R E 1
Example of Q-sorting table and statement used in the course evaluation.analysis was conducted separately for the fall and winter semesters and the factors were compared based on the similarities of their distinguishing statements and changes between factors from the fall and winter semesters.The correlations between factor scores from fall 2021 and winter 2022 were assessed using the Pearson correlation coefficient.A Chi-square test was used to examine the changes in the distribution of factors from fall 2021 to winter 2022.The statistical program of Stata was used for analysis.

F I G U R E 2 Factor 1 " 4 0 − 2 Factor 2 "− 5 Factor 3 "
Factor one: Happy campers "Happy campers" (HC) were students that had a generally positive experience with the course.They did not have any strong dislike toward either course components or delivery.The students in this group strongly agreed (+4) that TA office hours were useful, helping improve their understanding of course material.One student stated, "I went to pretty much every TA office hour I could because they were so awesome."They were also in moderate agreement (+3) that the different components of the course (laboratory, lecture, etc.) worked well together in a way that aided their learning.Finally, this group of students strongly disagreed (−4) that evaluations were unfair and did not adequately represent material covered in lecture.Many students expressed that they "thought the anatomy department's evaluations were more than fair" and that "the questions are fairly representative of the topics and concepts covered in class."Themoniker "happy campers" reflects the fact that the students belonging to this group are comfortable and content with their experience in the course.They were content or possibly indifferent toward the mode of delivery (online in the fall semester) and felt positive about course components and evaluation.Factor two: Unplugged learners "Unplugged learners" (UL) are students who were deeply unsatisfied with aspects of the course.Students belonging to this group felt unsupported and unable to keep up with content in the online learning environment.They very highly agreed (+5) with the statement that this course was like "paying tuition to watch YouTube videos."Qualitative feedback indicates these students felt quite isolated when taking the course, they had no additional support from instructors or peers.One student stated, "if you did not understand [lecture content], you had to literally just refer to YouTube videos and find a way to teach yourself."Unplugged learners found it difficult to keep up with course content (+5), and this added to their dissatisfaction with the course.One student shared that "With the lectures being asynchronous and just getting caught up with other coursework, it was very hard to keep up with this class and I often found myself binging the lectures before a test… I think I would do better in in-person learning…" Students of this factor are in high agreement (−5) that they prefer the in-person environment to the virtual one.Model of data collection timeline and study participants.The name "unplugged learners" refers to the student's preference for the in-person environment, as well as their disconnect with the course material and instructors likely owing to dissatisfaction with their online anatomy and physiology education.The whole experience was isolating for them, they found it difficult to keep up with course content and felt like they were teaching themselves.The online environment is not one in which these students thrive.Factor three: "Tech testers" "Tech testers" (TT) are students with a strong preference for the online learning environment.They are in high agreement (+4) with the statement "I prefer online learning compared to the in-person format".One student stated that "Online learning allows me to learn at my own pace" and another that "the online learning environment made learning anatomy more fun and less stressful."Students belonging to this factor strongly disagree (−5) that they would perform better on an in-person exam.Many students expressed finding an in-person testing environment stressful and "prefer[ing] to do tests from the comfort of [their] home."Students in this group also agreed (+4) that they need more time to complete tests.Further, these students were in high disagreement (−4) with in-person laboratory sessions being critical to their understanding of anatomy.Students belonging to this factor prefer both the online learning environment as well as the online testing environment as indicated by their distinguishing statements.Given that the fall semester was primarily online they had a positive course experience.TA B L E 3 Selection of distinguishing and consensus statements from fall 2021.Happy campers" (HC, n = 113) 24 I think TA office hours are very helpful 4 0 18 I feel that the different components of the course (lecture, lab, and tutorial) complement each other well in a way that is effective to my learning way in which we are evaluated does not fairly represent what the material covered −Unplugged learners" (UL, n = 52) 41 I feel like I am teaching myself.It is like paying tuition to watch YouTube videos difficult to keep up throughout the semester-it was super easy to fall behind 0 5 27 I found the textbook was useful and supported what I learned in lecture online learning compared to the in-person format −1 Tech testers" (TT, n = 27) 32 I prefer online learning compared to the in-person format −1 −5 29 I need more time to complete my test/exam −1 0 6In-person lab sessions were critical to my understanding of anatomy 1 school removes the opportunity to learn from and communicate with would perform better on an in-person exam than an online exam from more faculty-made bellringer and short-answer practice 4 3 38 I think there should be transcripts for lectures 3 4 7 I feel that learning from human prosections is a privilege 5 4 17 I find the lab sessions to be a toxic environment because some students will try to show off −5 −4 −4 Note: Distinguishing statements by factor are in bold (indicate significantly different value from other factors, p ≤ 0.05); Consensus statements (no significant differences between factors).
titude toward online testing.The statement "I think I would perform better on an in-person exam than an online exam" was ranked neutrally by the happy campers (F: −1, W: 0) and disgruntled learners (W: 0), in mild disagreement by the unplugged learners (F: −3), and in strong disagreement by the tech testers (F: −5, W: −4).TA B L E 5 Selection of distinguishing statements and qualitative feedback.
amount of time to acclimate to it.In addition, most students in this cohort had not experienced in person university-level education until winter 2022, this may have impacted their responses as they were adjusting to a new environment.In addition, the first 4 weeks and first term test of winter 2022 were conducted online due to a resurgence of COVID-19 cases at the time limiting student's time in the in-person environment.CON CLUS IONThis study used Q-methodology to evaluate student perceptions of an introductory anatomy and physiology course as it transitioned from online to in-person.Q-methodology identified that there were students who preferred the online learning environment, those who preferred in-person learning, and students who thrived in either environment regardless of the course delivery modality.A closer examination of student perceptions revealed a collective preference for asynchronous lectures and a respect for human prosections.Contrasting opinions centered on preference for online testing and preference of learning environment.A major strength of the online environment was the comfort of learning at one's own pace made possible through the use of resources like asynchronous lectures.The strengths of the in-person environment centered around opportunities for collaboration and educational support from peers, Tas, and instructors.By utilizing resources such as asynchronous lectures in conjunction with in-personal laboratory sessions instructors can create a hybrid learning environment that addresses the needs of students in the post-pandemic world.FU N D I N G I N FO R M ATI O N This project was supported by an Education Scholarship Fund from the McMaster Education Research, Innovation & Theory (MERIT).

18 .
I feel that the different components of the course (lecture, laboratory, and tutorial) complement each other well in a way that is effective to my learning.19.I learned about the systems that work together in a holistic approach, rather than about individual, specific anatomy.20.I think the content is definitely useful and applicable to my future career.21.I found it difficult to keep up throughout the semester-it was super easy to fall behind.22.The professors are helpful for my understanding of course content.23.I believe having multiple professors from different areas of specialty is a strength of this course.24.I think TA office hours are very helpful.25.I would benefit from more faculty-made bellringer and shortanswer practice.26.I think the Anatomy Department needs to create a more supportive and encouraging learning environment.27.I found the textbook was useful and supported what I learned in lecture.28.I think the way in which we are evaluated does not fairly represent what the material covered.29.I need more time to complete my test/exam.30.I think we were tested too much on small insignificant names and details instead of bigger ideas.31.I feel that the MCQ evaluations often require far more integration and application than we are taught in lecture, laboratory, and tutorial.32.I prefer online learning compared to the in-person format.33.I'm comfortable with the technology skills required for studying anatomy online.34.I think I would perform better on an in-person exam than an online exam.35.I think that virtual specimens do not replace the physical presence of specimens.36.I have difficulty understanding and practicing for the bellringer using the virtual specimens.37. I get confused because course information is on more than one platform.38.I think there should be transcripts for lectures.39.Watching in-person lecturers use their body to emphasize concepts really helps cement them in my brain.40.I believe online school removes the opportunity to learn from and communicate with other students.41.I feel like I am teaching myself.It is like paying tuition to watch YouTube videos.
Student demographics based on program of study.
TA B L E 1

The TA B L E 2
Components of the virtual and in-person course formats.
are called consensus statements.These statements reflect perceptions that all groups shared.Special attention was given to statements ranked strongly (+5 or −5).Distinguishing and consensus statements are interpreted collectively and alongside qualitative participant statements to help describe the perceptions identified in the participant cohort.a Mandatory Attendance (#) indicates the number of laboratory sessions, tutorials, or term tests in a given term, respectively.Where fractions are used, denominators indicate the total number of laboratory sessions, tutorials, or term tests.