Instructors’ experience and acceptance of online mental health training: implementation considerations

ABSTRACT

Objective:

In 2020, with the onset of the COVID-19 pandemic and associated physical distancing restrictions, Mental Health First Aid® (MHFA™) face-to-face instruction was paused and existing courses were rapidly redeveloped for online delivery. The new MHFA Blended Online course comprises a self-paced eLearning component and 2 × 2.5-h synchronous video conferencing sessions led by an Instructor. This study uses a qualitative approach to explore Instructors’ experiences and perspectives on pivoting to online MHFA training and whether Instructors perceived whether their teaching style, skill instruction and capacity to engage students translated to an online mode.

Methods:

Online interviews with 20 Blended Online MHFA course Instructors explored their experiences of the course in six areas: (1) what worked well, (2) what did not work well, (3) feasibility, (4) acceptability, (5) ease of delivery and (6) perceived effectiveness.

Results and discussion:

Thematic analysis identified that Instructors had favourable experiences with online delivery. Experiences with technology, facilitation and engagement, beliefs about effectiveness, and perceptions of safety are explored, and key challenges discussed.

Conclusion:

This qualitative study identified that MHFA Blended Online courses are perceived by Instructors as acceptable and effective, though online delivery comes with specific challenges. Implications for future course implementation are discussed.

KEYWORDS:

• Online learning
• mental health first aid
• early intervention
• TAM
• UTAUT
• TPACK

1. Introduction

Online instruction and remote learning in health education were widespread even prior to the COVID-19 pandemic emergency response (Guppy et al., 2022). In the last decade, health training simulations and interactive online modules saw increased development (Andraous et al., 2022; Elsaesser & Bellas, 2020; Salarvand et al., 2023). Despite this, pedagogical approaches still commonly rely heavily on online lecture delivery, either streamed live or recorded (Barraclough & Pit, 2022; Walker & Koralesky, 2021). In early 2020, in adherence to pandemic-related restrictions and lockdowns in Australia, almost all instruction and learning moved online (Martin et al., 2022; McGill et al., 2021). The delivery of health education and training was transformed, revealing conceptual, pedagogical, educational and technological challenges (Salarvand et al., 2023; Zhu & Zhang, 2022). Of key concern was whether it was feasible to rely entirely on online tools to replace all components of health education and training, especially practical and clinical skill development. In this rapid transformation, instructors’ acceptance of and experience with online instruction played a crucial role in curriculum design and implementation (Martin et al., 2022; Zhu & Zhang, 2022).

Mental Health First Aid^® (MHFA^®) training teaches members of the public how to help a person developing a mental health problem or in a mental health crisis (Kitchener & Jorm, 2002). Prior to the pandemic, there were two modes of delivery offered for the Standard, Workplace and Tertiary MHFA courses (Bovopoulos et al., 2013; Kitchener et al., 2013, 2017). These included a 2-day course delivered face-to-face and led by a Licensed MHFA Instructor (henceforth Instructor), and a blended course, consisting of a self-paced eLearning component, followed by a 4-h face-to-face Instructor-led session. The eLearning component includes interactive activities, quizzes and films. Previous studies found that MHFA’s eLearning component and blended delivery mode improved aspects of mental health-related knowledge, increased confidence to support a person with a mental health problem, and reduced stigmatising attitudes in comparison to control conditions where MHFA training was not provided (Jorm et al., 2010; Reavley et al., 2018). These training effects were maintained in the longer term (Reavley et al., 2021).

With the onset of the pandemic and associated restrictions, the 4-h Instructor-led component of the blended course was redeveloped from a face-to-face mode of delivery to 2 × 2.5-h synchronous Zoom video sessions. The additional hour allowed for the provision of technical support and revision. The video conference sessions were designed for attendance of up to 12 learners, and included discussions, scenarios and practice conversations related to course content. The following literature sheds light on instructors’ and educators’ experience adapting to online delivery, and their beliefs about professional knowledge and practice.

1.1. Online instruction literature

Instructors’ prior experience with technology and their acceptance of online instruction and learning are key implementation factors in online health education (Elsaesser & Bellas, 2020; Martin et al., 2022). Those who have more online teaching experience perceive online delivery as more effective (Elsaesser & Bellas, 2020). More experienced and accepting Instructors saw the shift to online instruction as a positive opportunity for professional growth, to gain confidence and new understanding in teaching health concepts remotely, or as a chance to make innovative changes (Martin et al., 2022).

Several theoretical frameworks aim to explain these links between instructors’ acceptance of technology and their use of technology in teaching. Zhu and Zhang’s (2022) recent work on Davis’ (1989) Technology Acceptance Model reinforced that instructors’ perceptions about the usefulness and ease of use of technology impacts their acceptance and influences the degree to which they believe technology could enhance job performance. Indicators such as subjective norms, job relevance, output quality and result demonstrability were present in instructors’ perceptions when they were required to rapidly shift courses to online modes (Zhu & Zhang, 2022). The Unified Theory of Acceptance and Use of Technology is another model that highlights the importance of instructors’ subjective beliefs in transitioning to online learning (Kassianos et al., 2023). This model outlines four barriers to user adoption: (1) performance expectancy, (2) effort expectancy, (3) social influence and (4) facilitating conditions, showing complex associations between intentions to use, and subsequent use of, technological innovations (Venkatesh et al., 2003).

In the context of health education, research has found that instructors commonly perceived online teaching to be mostly useful, easy and effective (Elsaesser & Bellas, 2020; Zhu & Zhang, 2022). Best-practice in online instruction include user experience features, such as flexible and accessible self-paced options (Barraclough & Pit, 2022); and organisational provisions, such as provision of technological support and resourcing (Martin et al., 2022). Of high importance is that online learning nurtures critical thinking, reflection and real-world application (Barraclough & Pit, 2022). Instructors believe online learning has positive benefits, including increased knowledge retention, greater flexibility, greater accessibility and more efficient task completion (McGill et al., 2021; Singh et al., 2022).

1.1.1. Beliefs about teaching practical skills online

Health educators commonly believe that key practical skills cannot be taught appropriately online or through simulation-only, and that a complete substitute for face-to-face practicums is not feasible (Andraous et al., 2022; Martin et al., 2022). In some institutions, only a few health educators were shown to use simulations, adaptive learning and data analytics systems (Guppy et al., 2022). In an international study on health educators, Martin et al. (2022) found that instructors were unsure whether teaching clinical skills online could be safe and effective, or if it could prepare job-ready graduates for real-world health practices. Best-practice models within health education and training thus centre on the belief that traditional face-to-face course components, such as practical classes and integrated workplace practicums, are irreplaceable (Martin et al., 2022; Zhu & Zhang, 2022).

1.1.2. Beliefs about teaching interpersonal skills

Instructors and health educators perceive a range of challenges in online environments, including engaging learners, fostering vibrant interactions, limited opportunities to develop learners’ interpersonal communication skills and relationships, inadequate feedback opportunities and reduced communication, student social presence, social learning and collaboration (Elsaesser & Bellas, 2020; Salarvand et al., 2023; Zhu & Zhang, 2022). To address these limitations, health education programmes needed to reimagine the use of online teaching and learning (Martin et al., 2022). Shifting from time-oriented learning and teaching towards competency-based education (Singh et al., 2022), allowed instructors to utilise technology to develop collaborative activities (e.g. purposeful use of breakout rooms) and facilitate learners’ interactions (Zhu & Zhang, 2022). Careful engineering of activities to foster authentic and collaborative online engagement was a feature of successful implementation (Zhu & Zhang, 2022).

1.1.3. Technological pedagogical content knowledge

Technological Pedagogical Content Knowledge (TPACK) (Koehler & Mishra, 2009; Mishra & Koehler, 2006) explains how instructors deliberate the use of educational technologies. The framework is comprised of Pedagogical Content Knowledge (PCK) (Gudmundsdottir & Shulman, 1987) and Technological Content Knowledge (TCK) (Koehler & Mishra, 2009; Mishra & Koehler, 2006). PCK includes content knowledge and expertise in effective teaching methods and TCK is understanding how technology can help achieve desired learning outcomes. Instructors’ and educators’ professional identity closely relates to self-confidence in their ability to perform their role and their professional knowledge. Unfamiliar online teaching methods, technologies and questions about how to role-model professional practice or how to instruct complex or difficult topics via an online forum were noted concerns (Salarvand et al., 2023).

Even prior to the pandemic, health educators were known to require more training in how to incorporate technology into the instruction process (Ait Ali et al., 2023). Being forced to transition all instruction completely online highlighted gaps in technological knowledge and information literacy (Zhu & Zhang, 2022). In the early phases of transitioning to strictly online instruction, the different levels of technological knowledge and usage among health educators were a key obstacle (Singh et al., 2022). Complex technologies were not equally accessible and sometimes prevented the use of virtual simulation or telehealth experiences (Martin et al., 2022). A prominent constraint was delivering learning outcomes in unfamiliar online environments, while catering to learners’ diverse digital abilities and access which required reconceptualising components of traditional curriculum (McGill et al., 2021). Addressing some of these barriers required the collaboration of two previously separate areas of expertise; expertise in technology, traditionally held by Instructional Designers, and the pedagogical and content knowledge of health educators (Singh et al., 2022).

This article reports on the results of a qualitative study that aimed to explore whether the online delivery of MHFA training is feasible and acceptable by capturing Instructors’ perceptions, beliefs and experiences of the Blended Online courses. This includes Instructors’ initial experiences adapting to online delivery, the impact of the transition on Instructor technological pedagogical content knowledge, and how aspects of professional knowledge and practice could be better supported in future delivery and Instructor training initiatives. Considerations for the implementation of sustained and purposeful development of online delivery are proposed.

2. Methods

MHFA Australia delivered their first suite of Blended Online courses in May 2020. Instructors could upskill to deliver any of the three Blended Online courses: Community, Workplace and Tertiary, each comprising a self-paced eLearning component and 2 sessions of 2.5 h video conferencing. For the present qualitative study, MHFA Instructors of the Blended Online courses were invited to participate in one-on-one semi-structured interviews. Recruitment avenues included advertisements in MHFA Australia’s newsletters, website and social media channels, as well as through MHFA mailing lists of Instructors who had completed the relevant upskill training. Instructors were eligible to participate if they were aged 18 years or older, lived and worked in Australia, and had delivered at least one Blended Online MHFA course. Participation was voluntary and withdrawing consent and data at any time was permitted. Consent was sought and study participants were informed that their responses would be deidentified. This study was approved by the Human Research Ethics Committee at the University of Melbourne (ID: 1852098.1).

Twenty-one study participants (MHFA Licensed Instructors) consented and participated in the study. Demographic data was collected through a Registration of Interest form on Survey Monkey (see Supplementary File 1). Due to a technical fault, one recorded interview was inaudible and excluded from the dataset. Of the remaining 20 Instructors, 17 were female and 3 were male. Two Instructors were under 35 years of age, 11 were aged between 35–54 years and 7 were aged 55 years of age or over. 17 lived in metropolitan or urban areas and 3 were in regional, rural or remote areas.

One-hour semi-structured interviews were conducted on the synchronous video conferencing platform Zoom between August 2020 and October 2021. The interviews were led by two members of the research team (AR and KJC) using a semi-structured interview schedule (see Supplementary File 2). Questions related to Instructors’ perceptions in six areas: (1) aspects of the Blended Online course that worked well, (2) aspects of the course that did not work well, (3) feasibility of the course, (4) acceptability of the course, (5) ease of delivery and (6) perceived effectiveness. Recordings were transcribed and de-identified for analysis.

Data were analysed using thematic analysis (Braun & Clarke, 2006) to interpret broader meanings embedded in the responses and understand Instructors’ experiences in more depth. Two researchers conducted the two-staged analysis contributing to interrater reliability. In the first stage, interview transcripts were read several times so the researchers (AW and KJC) became immersed in the data. Analysis was driven by the data in an inductive or ‘bottom-up’ method (Braun & Clarke, 2006). Coding that emerged were two initial broad codes, ‘works well’ and ‘needs improving’. Excerpts were further analysed to identify sub-codes, emerging patterns and recurring themes. Themes were categorised in parent/child relationships; and were then checked and revised against the coded data by the two investigators.

3. Results and discussion

The key findings, reported in detail below, are organised into four broad categories: (1) experiences with technology; (2) beliefs about facilitation and engagement; (3) beliefs about effectiveness; and, (4) perceptions of safety. Overall, the online mode of delivering MHFA’s Blended Online courses was found to be acceptable and effective by Instructors, especially as Instructors and course participants (known as participants henceforth) became more familiar with the technology and communicating over Zoom. Instructors reported largely favourable experiences pivoting to online delivery and highlighted perceived benefits of the solely online course, including positive participant feedback, enjoyable and good quality content and its strengths in terms of accessibility, reach and flexibility. Despite these overall positive experiences, some implementation challenges were noted.

3.1. Experiences with technology

A small number of teething problems were noted by Instructors. These included managing technical malfunctions, as well as increasing user technological capability, e.g. knowing how to sort participants into groups, inviting them back into the ‘main room’, using chat in breakout rooms, using polls and sharing screens.

Learning the technical delivery as well as the new material combined - was a little bit stressful to learn at the same time, but now of course it's - you don't even think about it you do it without a second thought. [Instructor 21]

This reflects the experiences of other educators’ during the early phases of transitioning to solely online delivery where different levels of knowledge and experience with technology were a key obstacle to implementation (Singh et al., 2022). Instructors reported that collegial support from their peers was central to the transition: co-hosting training sessions and a collegial help desk on social media were noted as integral forms of technological support.

I am on that Facebook group for the Instructors. So that's really, really good resources and I sometimes contribute as well, but it's just a wealth of knowledge on there was just amazing. And people really willing to help each other out. … that was really helpful. [Instructor 8]

These experiences echo other health education studies (McGill et al., 2021; Venkatesh et al., 2003), where social influence and developing professional learning networks have been described as impacting the likelihood that Instructors will adopt technology to deliver training courses. At times, potentially due to unavailability of other formal support, Instructors in the present study were left to manage participants’ technical challenges, which proved to be time-consuming.

I've had one or two other times I've had to jump on Zoom calls with people beforehand … [I was] able to troubleshoot them through it and that's been good … it takes up instructor time to have to do that stuff. [Instructor 21]

A specific challenge was to ensure participants had their video cameras switched on and that each participant has access to their own monitor. For Instructors, these expectations reflected participant readiness and their ability to interact meaningfully within the training, as well as allowing appropriate monitoring of both participant learning and psychological safety.

In every single course someone will have their camera off … sometimes people just don't want to be on camera and so they pretend that they have internet issues, and they still participate, but they don't want to be visible for whatever reason … . So that does make it really hard to monitor someone’s safety when I can't see them the same way and I can't see if they're visibly distressed or upset. [Instructor 20]

Instructors noted that for certain audiences, these technological aspects were more challenging and, for some, anxiety-provoking.

[For] some people in the community courses, just navigating the technology was a little bit tricky and I do feel for those people potentially delivering in a video conferencing format detracts a little bit for them, just because actually they've had to spend a little bit of time navigating the technology. [Instructor 21]

Despite technology challenges related to course implementation, overall, Instructors reported high levels of confidence in using technology and found this format rewarding and enjoyable.

… I really enjoy facilitating it. It's funny because some people do say … maybe it's not for everybody … it's not face-to-face, but you still get a pretty good feeling for the participants and for how they're engaging, how they're taking it on. [Instructor 5]

Consistent with models of technology acceptance (Venkatesh et al., 2003; Zhu & Zhang, 2022), Instructors’ perceptions of the usefulness and ease of use of the new platform appeared to have impacted their acceptance of online delivery and the degree to which technology could enhance their facilitation of the training. Acceptance of technology is significant (Zhu & Zhang, 2022), because it allowed Instructors to address social elements of the training session that were missing in an online setting and thus prioritise collaborative activities and learner interactions. Making decisions about which technological tools are appropriate to use for specific learning outcomes was a professional concern that Instructors deliberated:

So many people have never had break rooms or polls before, so when they get to do it, I find that it really replicates as close as you can do a face-to-face classroom. [Instructor 11]

I think one of the great things about Mental Health First Aid is they do give you plenty of options so, you know, you can ask these questions or you can do this as a poll. [Instructor 17]

Evidence of Instructors’ technological and pedagogical knowledge included the reconceptualising of how online technologies could best facilitate content and skill instruction (McGill et al., 2021).

Practice with Zoom was key to increasing proficiency and gaining confidence in managing silences and breaks. Strategies Instructors used to improve their online teaching included creating technology guidelines, identifying backup plans, using technology support services, using a greater array of tools for different pedagogical purposes, and taking planned breaks to manage exhaustion.

[I gained] confidence with the material; confidence with Zoom, yeah all of those things. Just repetition and feeling comfortable and you’ve got much more of a routine going on … I tend to use the chat a lot now – I never used to at the start, I use that more. [Instructor 14]

Instructors perceived the ‘breakout room’ feature of Zoom to be easy and enjoyable to use for themselves and participants, as well as effective for encouraging participants’ social connections and conversations. This is notable given that decreased social learning and collaboration were common concerns in health education at the start of the pandemic and associated transitions to online learning (Elsaesser & Bellas, 2020; Salarvand et al., 2023; Zhu & Zhang, 2022). Providing a forum in which learners could have conversations with each other was seen as key for facilitating a sense of connection, collaboration and problem-solving among participants.

Quite a few of [the participants] have come back and said that they loved working with the students in the breakout sessions … I’ve tried to incorporate some of the questions that you’re meant to ask in the main group and I’ve actually made it into breakout sessions purely because it just breaks the monotony, … because there have been all the social isolation things, it’s something that is important for them and they really enjoyed that. [Instructor 12]

The feedback I'm getting from participants is that they like that more, because it gives them a chance to chat to each other and have more meaningful conversations than they can in a big group. [Instructor 14]

… Particularly when we do the big role play [and] practise scenarios, I give plenty of time to that so I can go in and have a conversation with each of the breakout rooms. [Instructor 7]

The findings of this study are consistent with those of Zhu and Zhang (2022) where Instructors encountered challenges when using technology at the initial stage of transitioning to online delivery but were able to adapt by drawing on available resources, practicing and collaborative learning.

3.2. Experiences of facilitation and engagement

Instructors found it was feasible to facilitate MHFA courses over Zoom in an engaging manner:

I still feel like I have really good rapport with people, I still am extremely focused on everyone in the session. [Instructor 21]

The video conferencing does still allow them to have the same opportunities that they would if they were in a room with me to participate and I think that’s true for most people. [Instructor 20]

Notwithstanding, challenges in facilitating online and maintaining participant engagement were notable. Instructors found online facilitation tiring and more intense than face-to-face delivery, noting that they needed to exercise a higher level of concentration than during face-to-face instruction. Some Instructors expressed that, at times, they felt the need to compensate for the lack of in-person energetic interaction. Instructors described that there was more to manage simultaneously in online facilitation, making one 2.5 h session feel like a full day of work.

I think it's just Zoom full stop, it's quite exhausting, it's – and there is research around that isn’t there, that you expend much more emotional energy, which is so true. [Instructor 1]

You feel like you almost have to bring more energy than what you normally would because you have to be quite animated. [Instructor 20]

I'm exhausted by the end of it because you have to concentrate so hard on making sure everyone engaged and okay and that you’re sort of meeting everyone needs, so it is a much more intense sort of form of concentration. [Instructor 21]

Instructors believed there was a greater need to manage both their energy levels and their participants’ energy levels, as well as well as implementing specific strategies for retaining engagement, for example taking appropriate breaks. In line with these findings, Singh, et al. (2022) recommends reducing prolonged video conferencing with proper breaks and intervals.

Consideration of Instructors’ effort expectancy is important when implementing standards for best practice online learning and instruction (Venkatesh et al., 2003). Instructors also felt they did more talking when facilitating online, especially when trying to encourage discussion and interaction between participants, and also when managing group dynamics.

When you're face to face, you are getting more participation because you can read body language a lot better. … You can read body language if they're triggered by something that you're talking about, and it's, you can quite quickly nip that in the bud … you give a task to someone else, and then, you know, go and talk to the person. With this, I found it really hard. I didn't want to be the one that was talking all the time. [Instructor 13]

The increase in talking compared to face-to-face delivery was ascribed to more rigid turn-taking online, possible lag time or participants talking over each other. Concerns about how to manage dominating or silent participants on Zoom were also raised.

Although some Instructors felt they needed to adapt their communication style for online delivery, others felt more comfortable instructing via an online platform, commenting that doing so aligned with their face-to-face pedagogical style. As noted in previous health education research (Salarvand et al., 2023), this capacity to adapt often aligns with Instructors’ confidence in their professional knowledge and ability to perform their role.

I kind of delivered that how I would face-to-face. Obviously, with using technology instead, but you know, the same sort of things, you know, asking open questions, encouraging people, making sure I encourage even the quiet people to participate, the way we used humour, you know all those. Just how I would normally facilitate, except that it's online, a few tweaks in that respect. [Instructor 16]

Overall, Instructors found the length of the online sessions acceptable for covering course content and keeping participants engaged. Instructors perceived that participants adequately discussed key content knowledge and were motivated, interested and engaged in this type of learning. Given the known challenges in engaging learners in online collaborative interactions (Zhu & Zhang, 2022), this perception of participant engagement is positive, and suggests that online instructor-led components of MHFA courses are satisfying and engaging, similar to those delivered face-to-face (Bond et al., 2021; Reavley et al., 2018).

Instructors did cite challenges with online delivery, for example, some Instructors reported it being hard to tell if participants needed additional instructions for small group tasks in breakout rooms. Concerns about inadequate feedback opportunities when delivering health education online are known in the literature (Elsaesser & Bellas, 2020; Salarvand et al., 2023; Zhu & Zhang, 2022).

Views of whether a Zoom session is comparable to a face-to-face session varied. Some Instructors enjoyed the unique energy of an online environment, believing it offered the same or more participation opportunities:

I definitely find online better in terms of energy levels … You just have a fun time, everyone’s eating, everyone snacking, there's kids around. I find it better. There's like puppies that are in the background. Something that's difficult to define. [Instructor 11]

Other Instructors perceived that monitoring participation and engagement levels was difficult online, due to varied individual distractions or tech disturbances:

[It is] trickier in the online space, I feel there are so many more variables. People, when they're at home, they’ve got their cat in the background, or someone’s making a cup of tea and … other distractions; really, how engaged people are? [Instructor 16]

You have to be on the ball with people texting you, I've had to re-invite people to the Zoom meeting, that's tricky because then you have to pause everyone else while you're doing that … people dropping out and then sending you a message via text or email. [Instructor 14]

Difficulties with participant engagement, including that due to uncontrollable individual distractions, has previously been identified as a key challenge of online learning (Zhu & Zhang, 2022). Instructor-identified strategies to address this included use of a breakout room protocol, co-facilitation so one Instructor could monitor participants while the other delivered content, and using mute or camera-off purposefully.

3.3. Beliefs about effectiveness

Instructors perceived the online delivery mode to be an effective method for MHFA training. By the end of the Zoom sessions, Instructors observed that participants possessed the knowledge and confidence to participate in mental health conversations, which is a key learning outcome. Their perception is based on feedback they received from participants at the end of the second Zoom session, and post-course:

I did keep reviewing my feedback to make sure that well - am I still able to effectively teach this … we want participants to be able to walk out of these courses and go and have mental health first aid conversations go and use their crisis first aid - so is that coming across, so that was the first good thing about it. [Instructor 20]

People giving me feedback saying “I didn't think I would be able to have a suicide conversation, but after doing your course I feel like I can now”; and I've had that [feedback] three times with the online learning now as well. So it's the fact that I'm getting those in both means that it's working. It's doing what it's meant to, which is good. [Instructor 11]

I always find the same shift by the end of the course … which I love, and that happened on Zoom, they all said the same thing … “I feel so much more confident now in supporting my daughter”, or whatever the scenario is … so that was really nice to see, that personal shift happening even through Zoom. [Instructor 1]

Instructors believed that the online delivery of MHFA training was effective at meeting the learning outcomes of the course. According to Zhu and Zhang (2022), such perceived usefulness is a strong predictor of technological acceptance.

Instructors viewed the combination of a self-paced eLearning component with the instructor-led Zoom sessions as a key contributor to the course’s effectiveness. They ascribed this to the shared baseline participant knowledge created in the eLearning which they believe produced a higher quality of discussion, greater collaboration and improved engagement in the Zoom session. As seen in other studies (Elsaesser & Bellas, 2020; Singh et al., 2022), working through scenarios critically and collaboratively online was believed to be effective in meet learning outcomes:

What I found advantageous is that the students have actually covered that, and so when they actually come to you and they're all on an even footing to some extent with their knowledge. [Instructor 12]

One of the strengths I find about the course is actually people doing the theory side of things … first, because it means that … most of my time, we're talking about application and questions and working through the nuances of that as opposed to … taking them, you know, through the basics, and I think that enhances the quality of the conversations, of the interaction you can get with participants. [Instructor 17]

… We're grateful that they [MHFA Australia] took the time to do the eLearning part so that it makes it nice and short for the participants to stay attentive during the live [sessions]. [Instructor 11]

Participants love the practice sessions. So yeah, I think they're the highlights. They're actually getting people to, you know, to actually apply and speak to and talk through with each other. [Instructor 17]

Despite strong beliefs that the course was effective overall, Instructors did question whether sufficient opportunity is provided in an online forum for practical skill application:

I guess I don't know, I guess I'm not sure - are they coming out as skilled? I'm not sure, but I think that we need to factor in another practice session … [Instructor 5]

I don't think in the fully online that they get enough practical scenario work in order to build their skills and confidence to the same level as they would in the other course … I think they still may walk away not having the full confidence that they would from a face to face course. [Instructor 18]

Some Instructors’ views appeared to align with common beliefs found in other studies, that there is no complete substitute for face-to-face practicums in health education and that practical skills cannot be taught fully and appropriately online (Andraous et al., 2022; Martin et al., 2022). All Instructors felt strongly that participants should be provided more opportunities to engage in skills development as it is viewed as key to meeting learning outcomes. Suggestions on how this could be achieved included removing statistics-driven content in favour of more discussion and practice time and using model videos and case studies to further scaffold skills taught as part of the course.

Everyone would like more practise sessions. So, my query is, do we need to do as much: “remember so and so and so”? [Instructor 5]

Instructors reflected on whether there may be intrinsic limitations to online delivery in terms of engagement and skill development compared to the face-to-face course. Differences included the challenges of teaching interpersonal communication skills and practising nonverbal body language and communication, which is a well-known concern (see Elsaesser & Bellas, 2020 for review).

I think that the thing that is lacking [online] is the non-verbal skill building, and just that kind of communication. [Instructor 18]

And the hands-on practise is obviously easier face-to-face, it just flows a bit more smoothly. [Instructor 6]

Perceptions of effectiveness were also related to the lack of control some Instructors felt they had over online breakout room activities. Due to limited visibility in breakout room activities in an online environment, some Instructors felt it was difficult to gauge whether participants were able to apply mental health first aid conversation skills online, and that there were greater opportunities to observe participants’ application of skills in a physical room. Similarly, other research has found that Instructors were unsure whether teaching clinical skills online could safely prepare graduates for real-world health practices (Barraclough & Pit, 2022; Martin et al., 2022).

[Where] I think this course misses a little bit is really checking that they’ve got the application of ALGEE [skills] … and we don’t know with this course whether they're really – you know they come back and feedback a little bit about what they talked about, but like I said you can’t be in every room at once anyway. [Instructor 18]

3.4. Perceptions of safety

Safety is a key consideration of MHFA courses due to the sensitive content covered, e.g. responding to someone experiencing mental health problems or in a crisis situation. Overall, Instructors found it was feasible and acceptable to manage safety before, during and after Zoom sessions, although not without challenges. Monitoring participants by observation was a key strategy used to gauge their state, mood and level of understanding. Compared to face-to-face delivery, some Instructors found it harder to ‘read the room’ and more challenging to see and read body language, particularly with an introverted group.

That you're remotely concerned about in terms of how they're travelling, and you're trying to read is it their wellbeing or is it their learning or is it something else. That can be tricky to monitor. [Instructor 16]

In a physical room, Instructors reported they could build a sense of trust and emotional support, monitor participants’ reactions to the content more closely and provide appropriate and timely support. In one big physical space, some Instructors felt more able to monitor participants simultaneously, even when they were working in groups.

But it certainly is harder to read people, even though I'd try and make as many opportunities as possible to do that? So the face-to-face is easier to read body language. It's easier to read engagement, it's easier to make sure that people are sort of physically okay as well. [Instructor 13]

Challenges regarding safety monitoring in the online breakout rooms were noted, especially when participants collaborated in role-play activities.

I can't see everyone, I don't know that they're all okay … so my preference is face-to-face for monitoring safety, because I feel like I can do that easier than I can via the video conferencing. [Instructor 20]

This was deemed to be especially important when covering crisis situations, or with high-risk cohorts. Setting up a safe space and approaching sensitive content with care was reported to be useful. In the online environment, observation depended heavily on participants’ camera use and a strong internet connection. Setting up several monitors with high resolution to view all participants simultaneously was noted as necessary.

Online, it's a bit harder. I always … start my session and say you're allowed to turn your camera off, but please for no more than 10 minutes. If it's off for more than 10 minutes, I will assume that something is not okay and I will follow up. [Instructor 11]

I mean fundamentally face-to-face is superior for this type of workshop and I think safer, even though you can put all the protocols in place, but it just takes a click of a button for someone to just go I'll disappear and whatever. [Instructor 15]

Instructors’ comfort in managing participants’ psychological safety was also dependent on the number of participants in a session, with a preference shown for low caps on numbers.

Despite the above challenges, Instructors reported no or minimal reports of distress. The small number of occurrences was said to be no greater than what Instructors recall occurring in face-to-face sessions, and they were effectively managed.

In terms of safety for them, I haven't actually had any problems. I do make sure that they know that they can text, they can chat with me privately. [Instructor 2]

… and you know … we haven't had any dramas with the distress protocol, but we have had people who have had probably more potential to have problems I guess you know with their experiences, their lived experience, but they will be fine and they'll say “you handled it well.” You know, that the structure was good and, you know, “the way you facilitated that was really helpful to help make it feel safe.” [Instructor 4]

Furthermore, Instructors reported that participants felt safe sharing lived experiences of mental health, which they perceived to be important for social connection and solidifying course content.

I think that's a really big strength of every single course. People knowing that they're OKAY to talk about their experience because that's how the content really solidifies it all. [Instructor 11]

Aligned with this finding, Elsaesser and Bellas (2020) assert that Instructors of an online mental health training course observed similar levels of personal disclosure of experiences online to face-to-face interactions. These authors reported that small group discussions facilitated meaningful social connections and contributed to an environment comfortable enough for self-disclosure. In the present study, Instructors described strategies they used for creating a shared psychologically safe space for discussing lived experiences. Some of these included setting up and reaffirming clear ground rules around participation and extending the first session to allow more time for social connection.

I tend to sort of say ‘look in the interest of time, this is a great conversation, but need to sort of pull it back there’. And look, most people are okay with it. And you’ve just got to try and stay calm and keep reiterating some of the ground rules that hopefully you spoke about earlier at the start … [this] is the key to it. [Instructor 14]

I had a student who … her brother died by suicide earlier this year … she actually disclosed to the group that this had happened … she said to me she's like thanks for you know, just working through that the way that you did that was really good. I felt really comfortable. [Instructor 4]

Instructors noted that social connection was particularly important for participants in the wider context of the pandemic. This finding aligns with literature that outlines the critical role of human connection in learning experiences and the need to build a sense of belonging and community (McGill et al., 2021).

Without the immediate contact and incidental conversations of the face-to-face environment, some Instructors found that extra effort was required to exercise their duty of care and provide the same level of support to course participants. Strategies used by Instructors included initiating contact with participants during breaks or after the session, sharing and collecting contact information, referring participants to helpline services and additional resources, finishing each session with self-care content, and extending the session or staying back for those who may be feeling more vulnerable.

Without fail every single session someone will stay back to talk to me, which is what you want as an Instructor, because it means they trust you and they know that you're going to be able to support them, which is great. So I've never found an issue with someone not being okay and not feeling like they could talk to me about it. [Instructor 11]

Increased online contact and greater caring responsibilities can hinder the capacity of health educators to provide effective support (McGill et al., 2021) and should be considered in best practice models of online learning.

4. Conclusion

This qualitative study explored the perceptions, beliefs and experiences of Instructors teaching MHFA’s Blended Online courses. Overall, Instructors perceive delivering MHFA training solely online as both acceptable and effective, but not without challenges.

Instructors adapted to the technology and met challenges by drawing on available resources, practising and engaging in collaborative learning. They felt capable and confident in course facilitation and engagement of course participants, though some drawbacks to online delivery included distractions, fatigue and sub-optimal interpersonal and emotional connections. Instructors perceived the course to be effective in meeting learning outcomes; however, providing more opportunities to practice skills and apply course content was strongly suggested as a valuable and necessary addition. Overall, Instructors found the course acceptable in terms of safety, though they reflected on specific strategies to achieve this in an online environment.

Instructors grappled with how to best use online technology for skill instruction and to meet learning objectives, and whether their online instruction style aligned with their face-to-face pedagogical style. Exploring Instructors’ acceptance of and experience with online delivery highlighted key professional knowledge as well as how Instructors can be supported in the future delivery of MHFA courses, online and otherwise. One example of this is the common belief that additional effective practice opportunities must be provided to participants online and, as was the view of some, across all courses.

Some online delivery challenges described by Instructors might be attributed to teething problems within the transition phase, or learning environments impacted by pandemic restrictions. However, other challenges may indicate that the mode is not suitable across all audiences and contexts, for example in contexts where extra supports may be needed for psychological safety. Instructors themselves reported different levels of comfort with and suitability of the mode depending on their pedagogical style and use of technology.

Some Instructors felt that a face-to-face course could not be replaced by Blended Online as they perceived online delivery did not reach the same standards in terms of engagement and effectiveness. This was consistent with the views of Zhu and Zhang (2022) who posit that the strong motivation to teach online was associated with the limited ability to offer any training during the pandemic, creating a subjective norm related to online teaching and contributing to Instructors’ sense of fulfilment from online instruction. Zhu and Zhang recommend a blended model that combines the advantages of online learning with the strengths of face-to-face instruction, collaboration and hands on practice.

Although some Instructors preferred face-to-face delivery and had reservations about delivering the course solely online, a belief common to all Instructors was that online delivery should continue to be an option alongside face-to-face courses. Some Instructors reflected that they preferred Blended Online and believed the course would be their core delivery mode going forward. Perceived advantages to solely online delivery included its flexibility, efficiency and accessibility for both Instructors and participants, benefits echoed by other studies (Barraclough & Pit, 2022; McGill et al., 2021; Singh et al., 2022).

For the course to continue to be offered alongside face-to-face options, consideration should be given to what best practice in online mental health learning could look like in the future. This might necessitate moving beyond mere substitution of face-to-face group discussion with online group collaboration. To improve engagement and skill development in MHFA courses, developers could review key learnings from innovative immersion technologies (see Kourgiantakis et al., 2020 for review). Implementation would be most effective if Instructors show acceptance towards innovative technology and believe it can improve engagement (Kassianos et al., 2023) and provide optimal skill practice.

Most centrally, we join the call to re-imagine post-pandemic online training (Martin et al., 2022), and align with the understanding that successful implementation necessitates careful engineering of online activities to create authentic and collaborative online engagement (Zhu & Zhang, 2022). Understanding the needs of each participant audience is key, as Instructors noted that their pedagogical style and use of online tools differ depending on their participants’ technical capabilities and learning environment. Technology must be utilised to develop collaborative activities and facilitate learners’ interactions (Zhu & Zhang, 2022). Moving forward, as suggested by Singh et al. (2022), it is appropriate for mental health training to offer well-planned and differentiated online programmes that meet diverse learners’ needs and provide Instructors with pedagogical technological solutions.

4.1. Strengths and limitations

A strength of the qualitative approach used in this study was the opportunity it provided for a detailed understanding of Instructors’ experiences of moving to solely online delivery. This is one of the few studies on MHFA training that explores the experiences of Instructors (Bovopoulos et al., 2016; Crisanti et al., 2015; Terry, 2010). Participants provided open, enthusiastic and detailed feedback on their experiences of course delivery. The findings could be used by MHFA Australia, international licensees of MHFA and other online training organisations to improve current training offerings, and for future course innovation.

A limitation to this study is the use of a convenience sample of MHFA Instructors, which may have resulted in the participation of Instructors who had either highly positive or highly negative experiences or beliefs. Another limitation is the single stakeholder focus of the study. Future qualitative and quantitative research with all stakeholder groups should be undertaken to better understand the impact and effectiveness of the Blended Online course.

Author contributions

Conceptualisation, A.R, N.J.R, C.M.K; Data curation, A.R, K.J.C, J.N.L, A.V.S, S.E.B; Formal analysis, A.W, K.J.C; Investigation, A.W, K.J.C; Methodology, A.R, C.M.K, N.J.R and K.J.C; Project administration, A.R, A.W, K.J.C.; Supervision, N.J.R; Writing – original draft, K.J.C, A.W; Writing – review and editing, all. All authors have read and agreed to the published version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset analysed in the current study is not publicly available, or available on reasonable request from the corresponding author, because participants explicitly consented to only have their data shared with the immediate research team.