Etiquette of Virtual Learning; Tips to Ensure Eﬀective Learning for Medical Students

COVID-19 pandemic is putting immense pressure on medical education delivery, due to sudden complete transition to virtual learning. Medical schools do acknowledge that this is the most challenging experience that they had faced in their educational journeys, given the unprepared community that includes medical educators and students. Being delivered via the Internet, virtual classes have their own ethical challenges. Ethical codes regulating the functionality of institutions, as well as the performance of educators, staﬀ, and students during the online era need to be carefully developed. Virtual manners that are up to the standard provide a healthy environment for successful online teaching sessions. In this article, we are suggesting tips to help educators create and support etiquette online norms.


Introduction
Etiquette when broadly defined comprises the rules or customs governing behavior considered as correct or acceptable in official or social life (Collins, 2009), it is considered the framework of courtesy.The rules for good behavior and interaction online are known as network etiquette or "netiquette" guidelines (WebWise Team, 2012).
Virtual Learning refers to computer-based systems delivering instruction and learning materials via the Internet, allowing students to manage their time and create their own comfort zone.
COVID-19 pandemic created massive changes for the world health care institutions disrupting the traditional way of learning process.Since they were invented, computers have been increasingly used in medical education.Computer technology has converted physical sources to electronic format that has added a valuable and reusable tool to the educator's toolkit and was convenient to the learner as it has effaced geographical boundaries and transcended time zones.In medical education e-Learning has been used alongside, and not a substitution to non-electronic methods, as physical skills that should be acquired by the medical student, are best learned by doing (Choules, 2007).
During the current unprecedented time since the outbreak of COVID-19, the obligatory isolation dictated complete virtual delivery of materials that is likely to continue at least for the near future.This is also applied to physical skills that can be taught virtually to prime medical students until they can attend the actual teaching session.As educators, we are always committed to delivering high quality experience to learners through effective online learning sessions.A crucial step to achieve successful online sessions is setting appropriate rules of etiquette for online behavior.
Etiquette online is necessary; it is not just nice to acquire.Lack of etiquette can destroy online communities by causing discomfort, embarrassment, confusion, annoyance, and even fear (Preece, 2004).Ethical issues arise, when conflict of interests occur between individuals, which necessitates following higher level of principles that suit all subjects concerned (Schultz, 2005).Therefore, rules of etiquette are needed to preserve or enforce comfort and empathy in the community while supporting reasonable behavior (Preece, 2004).

Tips 1. Prepare yourself before class
To ensure effective learning, students as well as educators should prepare themselves and surrounding environment before launching their online class.To start with; dressing appropriately helps putting students in the 'learning mode'.In an online class, every day may feel relaxed as a casual Friday, yet, a certain degree of formality is expected as regards the way of communication with instructors as well as student's attire.This is also important for the medical student to get used to dressing formally, as wearing formal physician attire is often preferred by the patients.Clearing the room of pets or siblings comes next.Also, turning off cell phones, TV and other distracting devices is essential to ensure that student's attention does not distracted from learning.Lastly, before showing up to the session on time, students must exit any applications on their devices, open any necessary documents, download any necessary software, connect and test microphones and video cameras (Petrilli et al., 2018).

Secure classroom privacy
Doctors are expected to respect their patients' privacy.The fulfillment of patient privacy ensures protection of human dignity as well as confident communication between patients and their health teams (Tehrani et al., 2018).Securing the classroom privacy is part of the training of future doctors to get used to respect privacy with all the meanings that this word holds.Training on respecting privacy can be practiced in virtual classes.All platforms for video and audio conferencing can be set to ensure order and security.They come with many security features in order to prevent class disruption and to control online classrooms.Examples or those netiquette rules are; require registration or password-protect the classroom, disable join before host, locking the virtual classroom right after the start time to prevent late students from joining, enabling the waiting room in some platforms so as to keep out people who are not supposed to attend the session, control sharing of the screen to prevent students sharing random content, lockdown the chat to prevent students privately messaging each other, remove some participants if need be.An important recommendation for educators is to be committed to protecting their students' privacy by refraining from posting virtual classroom photos anywhere online, particularly on social media (Toprak et al., 2010).

Maintain academic and personal integrity
In order to cultivate a culture of trust, institutions must establish a culture of academic integrity, clearly defining appropriate and inappropriate usage of electronic material.Rules and regulations of academic integrity also apply to online discussion forums.The World Association of Medical Editors (WAME) defines plagiarism as the use of others' published and unpublished ideas or words (or other intellectual property) without attribution or permission, and presenting them as new and original rather than derived from an existing source."Therefore, whenever an idea is shared, the source of information must be acknowledged to the audience (Khadilkar, 2018).Even sharing materials in private messages, as chat boxes, without acknowledgement of the source is inappropriate, true privacy does not exist online.Clear policies instructed early in the course is an effective way to avoid breaching the rules of academic integrity (Javaeed et al., 2019).Moreover, personal integrity is a requirement for future physicians, and personal behaviors are included in professionalism that medical students learn by either direct teaching or experiential learning (Jahan et al., 2016).This can be practiced while using the chat boxes.Knowing the virtual classroom etiquette may turn the chat boxes from a major distraction to a helpful resource.Students should use the chat box to exchange information that is relevant to the topic and not go off-topic and distract their peers.

Use a professional style of writing
In an online environment, communication occurs to a great extent via written texts.Therefore, it is crucial to acquire some common good online etiquette rules, as immediate feedback as well as body language cues are missed.This ensures that the intended message is conveyed with the correct meaning.Think of the virtual classroom as any professional environment, where educators as well as learners are expected to check the grammar, the spelling and the style while they are writing.All participants should use a proper writing style as if you are drafting a scientific paper, while making sure not losing own voice.participants has to remember that they can be judged by others.Often messages with good intent are misunderstood and misinterpreted as rude.To avoid these unfortunate situations, useful tips are to keep the message formal, short and clear, read the message out loud before sending it, avoid strong language, exclamation marks and all capital letters, the latter might be interpreted as shouting.It is important to take notice that, as opposed to a spoken comment that can be forgotten, written information in the digital world is permanently recorded and can be housed forever on the internet.Moreover, private conversations can go public, therefore, care must be taken in virtual environment.It is wise to think of writing messages in a virtual meeting as writing an email.Medical education has a distinctive nature, students' inappropriate writing etiquette could adversely affect how they are perceived.Educating medical students written correspondence etiquette contributes to the improvement of student-faculty relationships, as faculty are bothered by low degree of formality encountered in student's writing (Kim et al., 2016).In addition to unpleasant feelings, serious consequences may occur due to unprofessional writing such as underestimating student competency as well as unwillingness of the faculty members to collaborate with or help the student (Stephens et al., 2009).

Show respect to others with a professional attitude
Students must abide to behavioral regulations that should be instructed by the educational institution before starting the online course, as the virtual interaction might feel less personal.Similar to face-to-face interactions, strict regulations should be provided to ensure respectful interactions in an online class.Among the fundamental regulations; students should use their real names, raise their virtual hands and wait to be recognized, say "please" and "thank you" when soliciting help from others, show tolerance even when disagreeing and acknowledge the valid points of your peers' arguments, and very cautiously use humor and sarcasms .It is also important not to badmouth anyone, students can disagree with ideas, however, mocking people is unacceptable (Bolkan and Holmgren, 2012).
If doctors want to become great doctors, they must strengthen their communicative skills and humanistic dimensions alongside their medical skills.
We should be our best selves in the digital world, the manners we have been taught by our parents apply online too.An online classroom is still a classroom.People should stay nice and considerate when they are in an online forum.
Sometimes not being face to face leads to rude behavior when they disagree with each other.Participants could still slip into a mocking or mean tone and poorly treat one another because of the distance between screens.Future doctors should choose to be kind and respectful in their comments even if they disagree with someone.
Good netiquette is all about conducting yourself with the same respect, politeness and professionalism in an online class similar to that showed in a real-life classroom.
Higher-order language is expected in the academic environment.Although a central part of academia, criticism must be constructive, well-articulated and well-meaning.Students should be advised to avoid profanity and keep interactions classy.
Participants are encouraged to interpret virtual classroom messages with the assumption that everybody have good intentions.Calmly discussing misunderstandings helps developing good online communication skills (Sadati et al., 2016).

Encourage group work
Sharing professional knowledge during online sessions demonstrates successful interprofessional collaboration.In an online interprofessional module in a faculty in the United Kingdom, many health and social care students were first apprehensive about the use of technology.Supportive interaction was observed between students, they maintained motivation to complete work on time.On the other hand, students were uncomfortable with critiquing each other's work through peer review, also, sensitivity may have inhibited the level of critical debate.Nevertheless, one of the advantages of this online module is that it brought students from different professions and sites together (Miers et al., 2007).Encouraging online group work will help medical students get used to collaborating with each other for the benefit of the patient, in healthcare, Interprofessional collaboration (IPC) is when various health and social care professional groups work together to produce a positive impact on patient care.IPC includes continuous interaction and negotiation between professionals, valuing the contributions and expertise brought by different healthcare professionals to patient care (Reeves et al., 2017).
All participants in a session should commit to group activities to ensure effective group collaboration, also the presence in an environment that makes all group members feel comfortable will foster their participation.Lack of face-to-face contact makes collaboration of distance group difficult.Virtual worlds should provide engaging platforms that support multiple users and collaboration among them.Make one requirement for passing the course is providing insightful contribution in the online discussions, also class points can be offered to those who participate in the conversation (Miers et al., 2009).
One of the benefits of online interactive education is that students can act as facilitators, and educators should allow themselves to learn from their students especially when it comes to technology where nobody is an expert.Encourage students who are experienced in using online discussion forums to be additional educators.This will give them a boost of confidence and will help engage other students.Furthermore, the students who receive help will be more willing to help others in the future.

Appreciate cultural Diversity
Doctors are responsible of providing highest care and excellent services to people from different cultural backgrounds (Roh and Nirta, 2018).Cultural diversity should be taught to medical students, as they are supposed to be future health advocates people from all cultures and ethnicities (Nirta and Roh, 2019).With the sudden shift from traditional to virtual classrooms due to the COVID-19 crisis, there should be even more emphasis on cultural diversity respect during the class time.Virtual classroom should be a safe space for people of all races, ages, sexes, sexual orientations, religions, socioeconomic statuses and disabilities.It is essential to maintain the online conversation in a direction to enhance understanding and supporting students from different cultures and accept that others are at liberty to have their own prospective in the issue.This will help improvement of online course facilitation in addition to having an impact on the overall classroom experience.Hyland (2013) pointed out that feedback given to English language learners may have broader implications.These students tend to look for hidden messages and often interpret the feedback differently from the original intent.It should be noted that culture can impact the exchanges dynamics as well.Common beliefs and expectations of a society may impact the timing and way students respond to questions, including how they perceive their roles within a forum.For example, in some cultures, students view the educator as a facilitator, in other cultures the role of the educator is more authoritative in nature.Acknowledging that culture influences learning should be followed by eliciting culturally relevant examples during discussions as well as identifying cultural cues in discussion.This will set the tone for a safe space in the virtual classroom where students become more open to sharing their experiences and viewpoints (Milheim, 2014).Offensive language and demeaning comments are unacceptable and immediate action should be taken by educators to protect the comfort of students.Cultural diversity should be celebrated in the classroom (Milheim, 2017).

Pay attention to others' discussions
On campus or online, discussion etiquette is similar, though the absence of visual and auditory clues may create some unique situations in online discussions.The environment should be safe to foster thoughtful comments and open discussions without hostile or inappropriate comments.As online discussions tend to go out of control quicker than face to face debates, therefore, it is crucial for online educators to ensure that participants engage in proper internet etiquette to keep discussions focused, organized and productive.General awareness among students assists in enhancing the learning experience.
An important tip to ensure a rich learning experience, is to show the other participants that you have been paying attention before sharing your thoughts and expertise.This might be achieved by building upon others' thoughts before crafting a reply or adding something new.
Discussions are best to be centered around a collaborative constructivist approach; inviting students' responses after introducing a new concept and adding new thoughts (Coker, 2018).On the other hand, overly outspoken students need to be asked by the educators to wait for other participants contributions (Berge, 2008).
Online educators need to show enthusiasm, listen carefully, pay attention to students' needs and answer their questions.Meanwhile, they need to provide direction, and encourage the students to participate in the discussion (Abdous, 2011).Each student needs to be supported by valuing their participation (Coker, 2018).

Use web cameras properly
Sometimes students might not want to enable their web camera and prefer to engage only through the chat function.Similarly, some educators prefer disabling student's video, in order to block inappropriate gestures or distracting content.On the contrary, Wang (2004) supported video conferencing usage in distance learning to provide oral and visual interaction (Wang, 2004, (Martin et al., 2012).Using the web camera confers visual presence to all participants, keeps them focused, engaged, and makes them feel they are present at the 'same' meeting.It also helps personalizing the conversation, create intimacy as participants can see each other's body language and facial expressions.Leaving webcams and microphones on best simulates in-person conversations.Etiquette rules can be set to ensure formality, such as refraining from chewing gum, eating or drinking in front of the camera.
Nonverbal communications that can appear in virtual classes are facial expressions, eye contact, body language, they all make verbal conversation more expressive and meaningful.Evidence shows that physician's nonverbal behavior leads to higher patient satisfaction (Khan et al., 2014).Medical students should learn and practice this attitude during virtual classes (Mast, 2007).

Design formal honor codes for online assessment
Rigor and grade-level expectations are amongst the most concerning ethical issues that face the credibility of online education.In general fraud is an important issue with distance education.Some online courses consist of preprogrammed software that let the student watch a lecture or read a content and then take a quiz or a test, and finally the software scores the assessments.If these courses are not carefully managed, what will keep the students from having someone else taking the exam for them?someone who can get better scores.This is difficult to ascertain.
On the other hand, it is unfortunate to avoid online testing for fear of cheating or any form of academic dishonesty as it has many benefits, as being easier to administer and less expensive.Additionally, they cause less anxiety and are more satisfying to students (Dorrian and Wache, 2009;Stowell and Bennett, 2010).Many methods have been tried to reduce cheating, as students are very tempted to be academically dishonest when taking an online test.Using webcam proctoring (Mirza and Staples, 2010), examination centers and honor codes to decrease the cases of plagiarim.To combat academic dishonesty, honor codes are highly recommended.Signing an honor pledge holds students accountable for their actions.However, honor codes are only effective when they accurately identify what is ethical and unethical behavior, otherwise they may be misunderstood.Some honor codes emphasize on ethical principles, others emphasize on consequences (Khare and Lam, 2008).Some studies show no difference between the students' attitude towards cheating before and after the implementation of honor codes (Roig and Marks, 2006), others show significant decrease of cheating at schools with honor codes (McCabe, 2001).
It has also been found that the perceived certainty of being reported and the consequent risk of penalty is inversely related to academic dishonesty (McCabe et al., 2002).Thus, using an honor code that is formal, and has consequences would minimize academic dishonesty.This will also solve other academic integrity issues encountered in virtual environment such as steeling work from other students as a result of sharing passwords and usernames, as well as the cases of unlicensed teachers using their posts as a place to share religious or political views.
Taking unethical shortcuts, such as hiring someone else to sit your exam or to write your essay may get you a shortterm gain, however, there has to be long term costs (Gurung et al., 2012).

Implement institutional bylaws tightly
Institutions must outline what is expected from medical educators and students.The combination of different experiences can lead to some constructive decisions; therefore, different professionals can collaborate to ease solving the ethical issues.This can lead each institution to develop their own guidelines for virtual classrooms users.A policy should be established and announced by the institution that include a section on following netiquette rules during the online course.Warnings and penalties for those who violate those rules should be implemented in case of failing to follow the rules for multiple times (Haughey, 2007).

Conclusion
Virtual learning is more demanding and requires more care as regards technology ethics issues.Online discussions tend to spiral out of control quicker than in-person ones.This kind of environment is harmful to the learning experience.Including a set of ground rules in the course syllabus is indispensable to assist educators enhancing learning experience, and raising awareness among students on collegiate ethics and academic honesty.Medical educators are using their own skills and endeavors to make the good doctors we want and need.It is a big responsibility.Following netiquette rules involves displaying courtesy when posting own views as well as respecting other users' views in online interactions.It simply requires embodying the life rules that are learned and perfected