Skip to main content

Providing an interactive undergraduate elective on safety culture online – concept and evaluation



The COVID-19 pandemic has made it more difficult to maintain high quality in medical education. As online formats are often considered unsuitable, interactive workshops and seminars have particularly often been postponed or cancelled. To meet the challenge, we converted an existing interactive undergraduate elective on safety culture into an online event. In this article, we describe the conceptualization and evaluation of the elective.


The learning objectives of the safety culture elective remained unchanged, but the teaching methods were thoroughly revised and adapted to suit an online setting. The online elective was offered as a synchronous two-day course in winter semester 2020/21 during the “second wave” of the COVID-19 pandemic in Germany. At the end of each day, participating students evaluated the elective by completing an online survey. Items were rated on a six-point Likert scale. We used SPSS for data analysis.


Twenty medical undergraduates completed the elective and rated it extremely positively (1.1 ± 0.2). Students regard safety culture as very important and felt the learning objectives had been achieved. Moreover, they were very satisfied with the design and content of the elective, and especially with interactive elements like role-play. Around 55% of participants would recommend continuing to offer the online elective after the pandemic.


It makes sense to offer undergraduate medical students online elective courses on safety culture, especially during a pandemic. The elective described here can serve as a best practice example of how to teach safety culture to undergraduates, especially when physical presence is unfeasible. Electives requiring a high degree of interaction can also function well online.

Peer Review reports


During the COVID-19 pandemic, medical education had to be adapted to the new situation. Worldwide, assessments and placements had to be cancelled, postponed or offered in a different format [1]. A review of the immediate consequences of the pandemic for the education of medical students and residents revealed that the most common change was to switch to an online format [2]. Among online courses, presentations, virtual case reviews and tutorials were commonly used [2]. The authors of the review also stated that reports of a switch to online courses for medical students understate the true situation [2]. The transition to an online implementation was found throughout the entire preclinical setting [3]. However, online courses rarely employ multimedia design principles in undergraduate medical education [4].

Medical electives have proved themselves to be beneficial to the individual development of future physicians [5] and help medical students acquire useful skills outside the traditional curriculum [6]. Electives on safety culture are a valuable means of imparting knowledge on the subject, especially in view of World Health Organization (WHO) recommendations that the profile of patient safety in medical education should be raised [7].

In response to the WHO recommendation, several universities in Germany are now offering courses on safety culture [8], mostly as part of the advanced medical curriculum. We explicitly chose to offer the elective to undergraduates and thus to follow recommendations to teach the subject at an early stage of medical studies [7].

Medical students require intensive coaching in soft skills, such as communication skills [9], and in dealing with medical errors and safety culture in general [7]. Role-play and simulations are suitable techniques to train these skills [10]. Despite COVID-19-related contact restrictions, we wanted to avoid leaving out these interactive elements, as confining teaching to theoretical aspects would negatively impact the skill-sets of future physicians [11, 12].

It was necessary to develop a robust online concept, as opposed to simply using flipped classrooms and recording lectures [13]. This is especially true for sensitive topics such as safety culture. We therefore developed an online elective on safety culture for undergraduate medical students that was based on a previously described and evaluated in-person elective [8]. We retained elements that successfully involved a high degree of interaction such as role-play, and modified them according to multimedia design principles from the Association of American Medical Colleges Institute on the Effective Use of Educational Technology in Medical Education [14], as these have been shown to improve knowledge retention in medical education [15]. This article describes the development and evaluation of a two-day synchronous online elective for undergraduate medical students.



The safety culture elective was originally conceptualized by an interprofessional team of authors (physicians, health scientists, a psychologist and a bioscientist) and developed by the following lecturers, AM, OAS, MP, TB, KS and BSM. The learning objectives were based on the National Competence-Based Learning Goal Catalogue for Medical Studies (NKLM) [16]. The principal learning objectives were concerned with safety culture and patient safety, as well as communication when an error has occurred. All learning objectives are displayed in Table 1.

Table 1 Learning objectives

We based the development of this online elective on our own preparatory work on the topic of safety culture, as well as our teaching experience, including our medical-didactic knowledge of online formats [17,18,19]. The formal requirement for the undergraduate elective was the approval of the curriculum by the study commission. This was obtained previously due to importance of the topic. The organizational framework set forth by the Department of Medicine was two hours a week for one semester (16 h). We divided the 16 h into two block seminars of 8 h in length, conducted as synchronous video conference using the software Zoom on two consecutive days in the winter semester of 2020/21. Final grades were based on active participation during the elective and the assessment of a Critical Incident Reporting System (CIRS) report.

The online elective on safety culture was developed on the basis of the in-person elective we offered in 2020 [8]. Established multimedia design principles [14] were used when showing presentations. Since the elective was mainly carried out synchronously, we focused on in-person didactical principles in the interactive parts.


It was possible for a total of 20 medical students in their third undergraduate semester to voluntarily enrol in the online elective.

The online elective on safety culture

The structure of the online elective is presented in Table 2.

Table 2 The online elective on safety culture


Role-play was used in break-out sessions, whereby four students were assigned to one lecturer and each group was provided with one scenario. The available roles were those of doctors, their supervisors and colleagues that were involved in a conflict that had to be resolved. The scenarios resulted from a situation in which an error had been made that compromised patient safety. The scenarios included several hierarchical levels and professional groups, so that the role of the (interdisciplinary) leadership in building a strengthened safety culture could be reflected from different perspectives. One student in each group acted as an observer and was responsible for providing feedback to the other students. The lecturers also gave constructive feedback.


We used a standardized online questionnaire to evaluate the elective. The questionnaire was based on the existing evaluation templates of the Institute of General Practice and the Department of Medicine [20]. It consisted of 17 items to be completed on the first day and 18 items to be completed on the second. The original German version as well as the English translation are available in the supplement. An online link was used to access the questionnaire and participants filled it out anonymously.

Most items were rated on a six-point Likert scale, with the points equivalent to German school grades (1 = very good, 6 = insufficient). The participants also had the opportunity to comment on strengths and limitations, as well as any need for improvement, in the online elective in free-form text. We expressly asked the students to comment on strengths and any need for improvement.

Statistical analysis

We used descriptive statistics to analyze the results. Arithmetic means and standard deviations of the values are presented below. IBM SPSS Statistics 25 software was used for data analysis.


The 20 available places in the online elective were all taken up. Of the 20–30 year old participants, 80% were female and 20% male, while 20% had previous experience in the field of medicine, e.g. as practical trainees, research assistants or paramedics. The evaluation results are presented in Table 3.

Table 3 Evaluation results

The response rate was 100% (20/20). The lecturers were rated by the students as highly motivated (mean 1.1, standard deviation (SD) 0.0) and good at teaching (mean 1.3; SD 0.4). The students also rated the lecturers’ ability to actively involve them in the course positively (mean 1.1; SD 0.2).

All students gave additional feedback voluntarily. They considered the structure and teaching atmosphere of the elective to be reassuring. Furthermore, the high levels of interactivity within the group were remarked upon. Students explicitly mentioned that working on group tasks in break-out sessions and participating in role-play helped them achieve their learning objectives. They did not consider the virtual design to have impaired their assessment of safety culture topics. The following summaries are examples of answers to the question what students particularly liked about the elective:

"The learning atmosphere was very pleasant throughout the group, right from the beginning, and that helped keep any inhibitions to participating actively to a minimum. Furthermore, the variety, with short presentations, discussions in small groups and in the whole group as well, was very good because it stopped things becoming boring and monotonous"

"The content of the seminar was very important and interesting. Theoretical aspects were communicated interactively and in a good way, so you never felt bored. I also thought the break-out sessions were particularly practical because swapping more personal information is probably easier in a smaller group. Overall, a great success!"

"The interaction; lots of different impressions; the best possible implementation of the course despite limited possibilities (Corona zoom); the feedback session that followed the role-play on help through self-reflection."

"Looking for possible solutions yourself; using role-play to creatively apply what you have learned, and a very good atmosphere within the group."

Suggestions for improvement included more short and scheduled breaks of three to five minutes. With respect to content, students would have preferred more psychological background information. One student suggested employing role-play at the beginning and the end of the elective to assess the effectiveness of the training.


The adoption of an online format for undergraduate courses on safety culture would appear to be a sensible reaction to the COVID-19 pandemic. Students were very satisfied with the design and content of the elective, and particularly with the opportunity for intense interaction provided by role-play.

Safety culture and patient safety face enhanced challenges in times of COVID-19 [21, 22]. As a result of the pandemic, both dealing with errors professionally and communicating effectively are becoming increasingly important and may help protect patients in the future. It is essential to maintain high quality in medical education with respect to safety culture and communication and to raise students’ awareness of the importance of good interdisciplinary teamwork across hierarchical levels.


After finding no differences in learning outcomes, one review has suggested that online education is as effective as traditional teaching, [23]. We successfully used online teaching techniques such as defining tasks and discussing them online [24]. A U.S. study has described an online elective for undergraduates [25] that involved virtual students interacting with patients. Since the communication strategies were the same as for real students, the online elective also succeeded in training communication skills.

Limitations and strengths

As the number of participants was limited to 20 persons, the size of our sample was small. Since students enrolled in the elective voluntarily and probably had a previous interest in the topic, a self-selection bias cannot be ruled out, and they may have been more likely to be satisfied with the content. However, this effect was unlikely to have had a significant influence on perceptions of the online format. It is also worthy of note that one participant considered the use of diverse techniques to have enhanced the elective. However, as no other course in the preceding 10 months of the pandemic had yet used them, it was impossible to compare our use of new techniques with those of others. Furthermore, social distancing (no classes with colleagues for months) may have increased the readiness of the participants to be content with the elective, simply because they welcomed the chance to solve tasks and learn in groups again. The circumstances and conditions may therefore have had a greater effect on their assessments than learning outcomes [4]. Moreover, undergraduate students are more likely to rate online classes positively than students in clinical semesters [26]. As we have not conducted a formal examination, we cannot assess whether participants have achieved the learning objectives. This would be a valuable addition to a future elective.

Furthermore, the study was based on a single elective at a single academic institution. The authors would therefore recommend that lecturers consider employing both asynchronous and synchronous online teaching opportunities [27] in order to balance the pros and cons for specific users [28]. A limitation of our synchronous format is that it leaves the audience little time to reflect on the topic. We attempted to implement asynchronous elements by reflecting on the homework each student had to do between day 1 and day 2. As students also had the opportunity to give feedback at any time, we were also able to change the pace of instruction in line with their individual wishes.

One strength of our synchronous concept is that after some preparation, online interactions could promote group discussion, encourage social interaction and enable participants to plan tasks that required real-time feedback [27]. All these elements were included in our online elective.


The use of an online elective to educate undergraduate medical students in patient safety is a feasible alternative to classroom instruction. In medical education, interactive elements can be implemented in various ways, and include training for doctor-patient consultations. Insights from our study can therefore be transferred to various settings in which medical education is maintained despite the pandemic. Electives with interactive elements, even those of high intensity, can be successfully designed using an online format. This elective can serve as a best practice example of how to use a multimedia design to teach patient safety. Although the application of the science of learning to medical education is widely recommended [15, 29], we would like to point out that online courses require elaborate preparation that is adapted to suit the needs of an online format [27, 28].

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files]. Any further information can be provided by the corresponding author upon request.



Critical incident reporting system


National Competence-Based Learning Goal Catalogue for Medical Studies


Standard deviation


World Health Organization


  1. Choi B, Jegatheeswaran L, Minocha A, Alhilani M, Nakhoul M, Mutengesa E. The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: a national survey. BMC Med Educ. 2020;20:206.

    Article  Google Scholar 

  2. Chasset F, Barral M, Steichen O, Legrand A. Immediate consequences and solutions used to maintain medical education during the COVID-19 pandemic for residents and medical students: a restricted review, Postgrad Med J (2021) postgradmedj-2021–139755.

  3. Rose S. Medical student education in the time of COVID-19. JAMA. 2020;323:2131–2.

    Article  Google Scholar 

  4. Tang B, Coret A, Qureshi A, Barron H, Ayala AP, Law M. Online lectures in undergraduate medical education: scoping review. JMIR Med Educ. 2018;4:e11.

    Article  Google Scholar 

  5. Mahajan R, Singh T. Electives in undergraduate health professions training: opportunities and utility. Med J Armed Forces India. 2021;77:S12–5.

    Article  Google Scholar 

  6. Agarwal A, Wong S, Sarfaty S, Devaiah A, Hirsch AE. Elective courses for medical students during the preclinical curriculum: a systematic review and evaluation. Med Educ Online. 2015;20:26615.

    Article  Google Scholar 

  7. Safety, W. P., & World Health Organization. Patient safety curriculum guide: multi-professional edition. Geneva: World Health Organization; 2011.

  8. Sawicki OA, Müller A, Pommée M, Blazejewski T, Schneider K, Kreuzmair L, Schwarz M, Tesky VA, Gerlach FM, Müller BS. Konzeption und Evaluation eines vorklinischen medizinischen Wahlpflichtfaches „Sicherheitskultur in der Medizin: Jeder Fehler zählt!“. Z Evid Fortbild Qual Gesundhwes. 2021;161:57–62.

    Article  Google Scholar 

  9. Choudhary A, Gupta V. Teaching communications skills to medical students: introducing the fine art of medical practice. Int J Appl Basic Med Res. 2015;5:S41–4.

    Article  Google Scholar 

  10. Nestel D, Tierney T. Role-play for medical students learning about communication: guidelines for maximising benefits. BMC Med Educ. 2007;7:3.

    Article  Google Scholar 

  11. Ahmed H, Allaf M, Elghazaly H. COVID-19 and medical education. Lancet Infect Dis. 2020;20:777–8.

    Article  Google Scholar 

  12. Patil NG, Chan Y, Yan H. SARS and its effect on medical education in Hong Kong. Med Educ. 2003;37:1127–8.

    Article  Google Scholar 

  13. Tang B, Coret A, Barron H, Qureshi A, Law M. Online lectures in undergraduate medical education: how can we do better? Can Med Ed J. 2019;10:e137–9.

    Article  Google Scholar 

  14. AAMC Institute for Improving Medical Education, Effective use of educational technology in medical education: Colloquium on Educational Technology: Recommendations and Guidelines for Medical Educators, 2007.

  15. Issa N, Schuller M, Santacaterina S, Shapiro M, Wang E, Mayer RE, DaRosa DA. Applying multimedia design principles enhances learning in medical education. Med Educ. 2011;45:818–26.

    Article  Google Scholar 

  16. NKLM, Lernzielkatalog. (Accessed 8 Apr 2021).

  17. Müller BS, Beyer M, Blazejewski T, Gruber D, Müller H, Gerlach FM. Improving critical incident reporting in primary care through education and involvement. BMJ Open Qual. 2019;8:e000556.

    Article  Google Scholar 

  18. Weißbarth B, Blazejewski T, Gruber D, Güthlin C, Lüttel D, Pommée M, Müller H, Rubin K, Heuzeroth R, Beyer M, Schadewitz R, Thomeczek C, Gerlach FM, Müller BS. Online-Workshop Fehlermanagement für Praxisteams: Konzeption Implementierung und Evaluation: online workshop on error management for practice teams: design, implementation and evaluation. Z Allg Med. 2019;95:387–93.

    Google Scholar 

  19. Ullmann-Moskovits J, Farquharson M, Schwär M, Sennekamp M. Learning how to conduct medical interviews online for the first time - this is what we learned in Frankfurt am Main. GMS J Med Educ. 2021;38:Doc19.

    Article  Google Scholar 

  20. Koné I, Paulitsch MA, Ravens-Taeuber G. Internship in family medicine: which experiences are important for students? Z Allgemeinmed. 2016:0357–62.

  21. Michalopoulos N, Petropoulou Z, Danias N, Kokoropoulos P, Vassiliu P, Arkadopoulos N. The “misfortune” of being a COVID-19 negative patient during the coronavirus pandemic. J BUON. 2021;26:303–5.

    Google Scholar 

  22. Adamou M, Kamposioras K. The COVID-19 survey pandemic: a critical approach. J BUON. 2021;26:654–5.

    Google Scholar 

  23. Jung I, Rha I. Effectiveness and cost-effectiveness of online education: a review of the literature. Educ Technol. 2000;40:57–60.

    Google Scholar 

  24. Roy SF, Cecchini MJ. Implementing a structured digital-based online pathology curriculum for trainees at the time of COVID-19. J Clin Pathol. 2020;73:444.

    Article  Google Scholar 

  25. Wendt S, Abdullah Z, Barrett S, Daruwalla C, Go JA, Le B, Li E, Livingston C, Miller M, Nakhleh L, Pecha J, Pothula S, Pradhan S, Sathappan V, Shah A, Sonuyi AM, Ugoh P, Wang Q, Weber N, Succar T, Blieden L, Mortensen P, Elkin Z, Sun G, Lee AG. A virtual COVID-19 ophthalmology rotation. Surv Ophthalmol. 2021;66:354–61.

    Article  Google Scholar 

  26. Khalil R, Mansour AE, Fadda WA, Almisnid K, Aldamegh M, Al-Nafeesah A, Alkhalifah A, Al-Wutayd O. The sudden transition to synchronized online learning during the COVID-19 pandemic in Saudi Arabia: a qualitative study exploring medical students’ perspectives. BMC Med Educ. 2020;20:285.

    Article  Google Scholar 

  27. Rhim HC, Han H. Teaching online: foundational concepts of online learning and practical guidelines, Korean. J Med Educ. 2020;32:175–83.

    Article  Google Scholar 

  28. Hrastinski S. Asynchronous and synchronous e-learning a study of asynchronous and synchronous e-learning methods discovered that each supports different purposes. 2008.

    Google Scholar 

  29. Mayer RE. Applying the science of learning to medical education. Med Educ. 2010;44:543–9.

    Article  Google Scholar 

Download references


We would like to thank Phillip Elliott for editing the manuscript.


Open Access funding enabled and organized by Projekt DEAL.

Author information

Authors and Affiliations



AM, OAS, MP, TB, KS and BSM designed the online elective. AM, OAS, MP, TB, KS and BSM were involved in the online elective as lecturers. TB was responsible for retrieving evaluation data. JUM and JJP made critical revisions. AM, OAS and BSM drafted the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Angelina Müller.

Ethics declarations

Ethics approval and consent to participate

All methods were carried out in accordance with the Declaration of Helsinki and other relevant guidelines and regulations. Participation in the evaluation was voluntary. To assure confidentiality, each student generated their four-digit pseudonym instead of stating their name or student number on the evaluation sheet. In this way, longitudinal tracking of students is possible, but not the identification of individuals. Consent for publication of these anonymous evaluation results was obtained verbally from all participants for reasons of practicability. The institutional ethics committee of the Medical Faculty of the Goethe University Frankfurt (Ethikkommission des Fachbereichs Medizin Universitätsklinikum der Goethe-Universität) acknowledged the processes including verbal consent and waived ethical approval. Thereby our approach for this study was approved by our institutional ethics committee. Descriptive statistics were performed according to SAMPL guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Müller, A., Sawicki, O.A., Pommee, M. et al. Providing an interactive undergraduate elective on safety culture online – concept and evaluation. BMC Med Educ 22, 508 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: