Factors affecting nursing and health technician students' satisfaction with distance learning during the COVID-19 pandemic in Morocco: a descriptive study

Purpose Distance learning describes any learning based on the use of new multimedia technologies and the internet to allow students to acquire new knowledge and skills at a distance. This study aimed to determine satisfaction levels with distance learning and associated factors among nursing and health technician students during the coronavirus disease 2019 pandemic in Morocco. Methods An descriptive study was conducted between April and June 2022 among nursing and health technician students using a self-administered instrument. The student satisfaction questionnaire consists of 24 questions categorized into 6 subscales: instructor, technology, course setup, interaction, outcomes, and overall satisfaction. It was based on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Univariate and multivariate logistic regression analyses were conducted to identify factors associated with student satisfaction during distance learning. Results A total of 330 students participated in this study, and 176 students (53.3%) were satisfied with the distance learning activities. A mean score higher than 2.8 out of 5 was obtained for all subscales. Multiple regression analysis showed that students’ year of study (adjusted odds ratio [aOR], 2.34; 95% confidence interval [CI], 1.28–4.27) and internet quality (aOR, 0.47; 95% CI, 0.29–0.77) were the significant factors associated with students’ satisfaction during distance learning. Conclusion This study highlights the satisfaction level of students and factors that influenced it during distance learning. A thorough understanding of student satisfaction with digital environments will contribute to the successful implementation of distance learning devices in nursing.


Introduction Background/rationale
The mass implementation of distance learning activities in nursing education institutions during the coronavirus disease Factors affecting nursing and health technician students' satisfaction with distance learning during the COVID-19 pandemic in Morocco: a descriptive study 2019 (COVID-19) pandemic requires specific intent. Indeed, student satisfaction with distance learning is a critical component of student engagement and success [1,2]. Previous research findings before the pandemic were divergent, and some studies showed that students were satisfied both with distance learning and in face-to-face courses [3,4]. Other investigations reported that students are more satisfied with a face-to-face course than with an online one [5,6]. A systematic review showed that health students gave positive opinions on online learning during COVID-19 regarding perspectives, acceptability, motivation, and involvement [7]. Others have reported that factors such as interactions in the online class, student motivation to participate in the online class, course structure, and instructor facilitation and knowledge were related to student satisfaction [8].

Objectives
The study aimed to examine students' satisfaction levels with distance learning and identify factors associated with students' satisfaction with distance learning during the COVID-19 pandemic in Morocco.

Ethics statement
This study was approved by the Higr Institute of Nursing Professions and Technical Health in Laayoune (25-Apr-22). Informed consent was obtained from all participants.

Study design
An descriptive, quantitative, single-center study was conducted using a self-administered questionnaire. The study was described according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement [9].

Setting
This study was conducted among students at the High Institute of Nursing Professions and Technical Health in Laayoune, Morocco. Data were collected from April 26, 2022, to May 30, 2022 (Dataset 1).

Participants
This research included all students attending distance learning courses at the High Institute of Nursing Professions and Technical Health in Laayoune, Morocco for the academic year 2021/2022. There was no exclusion criterion.

Variables
The 24 items of the questionnaire were classified into the following subscales: instructor, technology, course setup, interaction, outcomes, and overall satisfaction.

Data sources/measurement
The measurement instrument used is a self-administered questionnaire divided into 2 parts (Supplement 1). The first part contained items on participants' socio-demographic and learning experience data such as age, gender, nationality, discipline, specialty, year of study, the educational platform used, and internet quality. The second part contained items from the students' satisfaction questionnaire developed by Bolliger and Halupa [10]. It consisted of 24 items categorized into the following subscales: instructor, technology, course setup, interaction, outcomes, and overall satisfaction. The questionnaire used a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The student satisfaction questionnaire's reliability was high (Cronbach α=0.91), and the reliability of all subscales was acceptable: instructor (α =0.82), technology (α=0.76), course setup (α=0.60), interaction (α=0.60), outcomes (α=0.72), and overall satisfaction (α=0.85) [10].

Bias
No selection bias was identified. The study included all students who agreed to participate and satisfied the study's eligibility criteria.

Study size
Since all target participants were invited and all of them re-sponded, sample size estimation was not estimated.

Statistical methods
The qualitative variables were presented as frequency, percentages, and mean ± standard deviation or median (interquartile range, IQR) for quantitative variables. The chi-square test was performed to identify differences in proportions of categorical variables between 2 groups (satisfied, not satisfied). This classification was conducted using the dynamic clustering method after calculating the total satisfaction score for each participant. Moreover, univariate and multivariate logistic regression analyses were carried out to identify the factors associated with student satisfaction with distance learning. The multivariate logistic regression analysis considered all independent variables with a P-value less than 0.25 in the univariate analysis. P-values less than 0.05 were considered to indicate statistical significance. Data management and statistical analysis were conducted using SPSS ver. 13.0 (SPSS Inc., Chicago, IL, USA).

Participants
Of 330 participants in this study, 249 (75.5%) were female, with a mean age of 20.2 ± 1.3 years (

Main results
Of the 330 students, 176 (53.3%) were satisfied with the distance learning activities, of whom 128 (51.4%) were female. Generalist nursing students represented 57.3% of the sample, of which 58.7% were satisfied with distance learning. More than half (60.3%) reported using the WhatsApp application, with which 53.3% were satisfied. Furthermore, 33.6% of the participants combined several educational platforms, and 55% of them were satisfied with this method. Concerning internet quality, 115 out of 192 (59.9%) participants declared that the internet connection was good and expressed their satisfaction with distance learning. However, statistically significant differences were detected according to the student's year of study (P = 0.016) and the internet quality (p = 0.008) ( Table 1).  1.28-4.27) and internet quality (good: aOR, 0.47; 95% CI, 0.29-0.77) were the significant factors associated with the students' satisfaction during distance learning (Table 4). The coefficient determinant of logis-

Comparison with previous studies
The study conducted by Amir et al. reported, on the one hand, that students were more satisfied with traditional classroom teaching than with distance learning and that first-year students are more likely to prefer distance learning. These revelations are in contrast to our results. On the other hand, it also concluded that internet connection quality was among the factors that caused challenges in distance learning, which is consistent with the findings of our study [7]. Moreover, another study found that stu-dent-teacher interaction, teacher performance, course evaluation, design, and technique were factors influencing student satisfaction [11]. In our study, students showed satisfaction regarding the interactions, instructors, course design, and technology. Another investigation stated that internet access is related to student satisfaction [12]. Indeed, this finding is in accordance with our results, showing that internet quality is a factor associated with student satisfaction with online teaching activities.

Limitations
This study had some limitations. First, the distance courses were rapidly implemented in response to needs without prior preparation by instructors or students. Second, the study did not consider the designs of the courses taught at a distance (synchronous/asynchronous). Third, the study focused on distance learning of declarative, procedural, and conditional knowledge sets. These limitations may influence our results, which should be interpreted with caution.

Generalizability
Although this was a single-center study, the results may be able to be generalized to all Moroccan nursing and health technician students if they participate in distance learning.

Suggestions
Distance learning is a required educational method in health professionals' education. Further similar research is recommended to study satisfaction with synchronous and asynchronous distance learning. Furthermore, reflections on how to develop the technical skills of distance students are highly recommended.

Conclusion
Distance learning was the alternative to face-to-face teaching during the COVID-19 health crisis. Many students were experiencing this for the first time. The study found that nursing and health technician students were satisfied with distance learning during the COVID-19 pandemic in Morocco despite the conditions of its introduction. The year of study and the internet quality were the factors associated with their satisfaction.