Hackathons are collaborative events that bring together diverse groups to solve predefined challenges. The COVID-19 pandemic caused by SARS-CoV-2 has emphasized the need for portable and reproducible genomics analysis pipelines to study the genetic susceptibility of the human host and investigate human-SARS-CoV-2 protein interactions. To build and strengthen institutional capacities in OMICS data analysis applied to host-pathogen interaction (HPI), the PHINDaccess project organized two hackathons in 2020 and 2021. These hackathons are aimed at developing bioinformatics pipelines related to the SARS-CoV-2 viral genome, its phylodynamic transmission, and the identification of human genome host variants, with a focus on addressing global health challenges, particularly in low- and middle-income countries (LMIC). This paper outlines the preparation, proceedings, and lessons learned from these hackathons, including the challenges faced by participants and our recommendations based on our experience for organizing hackathons in LMIC and beyond. In December 2019, the very first positive case to SARS-CoV-2 virus, the causative agent of the COVID-19, was identified in Wuhan Province in China. On March the 11th 2020, COVID-19 disease was declared by the World Health Organization (WHO) as a worldwide pandemic. At the writing time (May 2022), there have been more than 520 million confirmed infection cases and 6 million deaths globally. This devastating pandemic has brought together researchers and communities across the globe to tackle this scourge in an unprecedented manner. Indeed, to prevent the transmission of SARS-CoV-2, governments imposed lockdowns on the entire country or in several cities, instructed the public to follow social distancing, and recommended the wearing of masks as primary means of preventing COVID-19 spread . High-inAmong the most popular and reliable sources of solutions to challenges in healthcare that are able to generate enthusiasm for innovation are hackathons . HackathIn our context, the PHINDaccess (Pathogen-Host INteraction Data access) project is a twinning project, coordinated by the Institut Pasteur de Tunis (IPT), that intends to empower its capacities to efficiently exploit the extraordinary potential of omics data generated in the context of pathogen-host interaction (PHI) studies. PHINDaccess has established a genuine partnership with four world-class European institutions evolving at the forefront of infectious disease research and omics science: the Institut Pasteur (IP), the Center for Genomic Regulation (CRG), the Max-Planck-Institute for Molecular Genetics MPI-MG, and the Robert Koch Institute (RKI). PHINDaccess should in fine improve institutional capacities in OMICS data analysis applied to infectious diseases and host-pathogen interactions. In the frame of its main objective, it aims to train and mentor IPT early career researchers that are benefiting from a complete multicomponent training program including both hard and soft skills on PHI.In the phenomenal context of the COVID-19 pandemic, PHINDaccess project members decided to organize a hackathon on the “Study of genetic susceptibility to COVID-19 and SARS-CoV-2 human host-pathogen interaction” involving project participants. We aimed this hackathon to strengthen IPT OMICS data analysis institutional capacities in pathogen-host interaction and actively participate in international efforts on COVID-19-related data analysis.This paper discusses the proceedings of the PHINDaccess hackathons, which gathered IPT Tunisian scientists from different backgrounds and various areas of expertise to apply what they have learned in the frame of the PHINDaccess series of training in OMICS data analysis. They designed and developed bioinformatics pipelines and workflows related to SARS-CoV-2 and human public data, producing valuable resources that could be applied to other diseases. We report on our experience running hackathons, highlight key participants' learnings from the hackathon events, explore the various challenges of relevance, and come out with recommendations to run hackathons in an LMIC.PHINDaccess project is a H2020 twinning project aiming to foster and consolidate IPT members' capacities to analyze omics data generated in the context of pathogen-host interaction (PHI) studies. Sixteen participants that undertook the PHINDaccess bioinformatics course series joined the hackathon. Bioinformatics courses that were previously organized and followed by all participants included theoretical and practical sessions, namely, related to “Database development,” “Introduction to Linux,” “Introduction to Python,” “NGS-DNASeq for WGS, WES, and de novo genome sequencing,” “Introduction to R and R studio,” and “NGS-RNASeq for RNA sequencing and data analysis”. These courses were intended to build core staff at the different IPT labs to boost up bioinformatics and computational biology knowledge and skills. Hackathon participants that have previously followed these courses came from different backgrounds as shown in To better prepare for both events, good and early planning was mandatory to be able to achieve the hackathons expected outcomes and better tackle the challenges. Thus, three months before the first event, monthly meetings were scheduled and occurred through conference calls and face-to-face meetings in order to organize this hackathon. All participants attended these meetings showing their interests and enthusiasm to participate in the events and contribute to make them successful. These meetings allowed us to identify the topic, the time, the duration, the venue, and the format of the hackathon. It also helped to initiate the discussion between all the participants and to identify the specific objectives and potential outcomes. At this level, team members initiated collaborations with each other and started to identify data sources and types of data to be collected as well as the list of tools that were needed, which facilitated the work at the start of the first hackathon. Numerous collaborative tools for centralizing teams' communication and material sharing were employed including a Slack channel and a WhatsApp group. Google Meet was used to conduct meetings. Google Docs was utilized for sharing minutes of meetings and centralizing documents. Among the participants, few displayed strong skills in omics data analysis and were already familiar with bioinformatics tools, pipeline development, and Linux basic commands. Based on their willingness, background, and research areas, the hackathon's participants were grouped into five teams . Team 1 Bioinformatics tools are increasingly used in the field of modern biology in order to organize, analyze, visualize, and correctly interpret biological data. To better prepare the proceedings of the hackathons, a series of basic and advanced bioinformatics tools running on the Ubuntu 20.04 operating system were installed and configured by the system administrator using automated scripts before the hackathon venue. Furthermore, all participants have been previously initiated to the use of the Conda environment to create, export, list, remove, and update environments that have different versions of Python and/or packages installed in them. Participants could therefore activate, deactivate, and switch between environments when needed to use the appropriate tools useful for their analyses. The major advantage is that they were able to list all the created environments and easily switch between environments by activating and deactivating the laters. Users were also able to share the created environment with a team member using an environment.yml file to recreate the same environment with all needed tools ensuring the reproducibility of computational pipelines. Using such command lines, participants were able to apply in practice what they learned during previous courses organized in the frame of the PHINDaccess project. Participants showed confidence with the command-line tool to explore the operating file system, create files, and move between directories. They were able to use Conda to manage the computational environment and load appropriate bioinformatics tools used for these hackathons. Finally, they familiarized themselves with their personal GitHub repositories.The first hackathon was organized in IPT from 01 September to 09 September 2020, corresponding to seven working days.In developing pipelines, participants were expected to test, optimize and benchmark different bioinformatics tools. Often, these activities need to be performed on different computer hardware that is not necessarily compatible or on operating systems to which users do not possess full control or lack expertise that allows them to compile and install the required tools. For such a reason, participants were trained on how to use the Conda virtual environment with a special focus on the capabilities offered by the bioconda channel that allows access to more than 9000 bioinformatics packages that could be integrated into workflow management tools. Practical tutorials aiming to teach participants how to create virtual environments, how to install specific versions of software, and how to reproduce and share the environment's components using yaml files were therefore set up during this session.Bioinformatics projects may become complicated by different interfering tasks and nonlinear development as well as the diversity of data and the involvement of multiple contributors. Some of the problems that can arise from a complex project are the creation of conflicting versions by collaborators and the difficulty to spot bugs and fixing errors in workflows. For such reasons, participants undertook practical training on the git version control system. The session focused on topics regarding how to create repositories, how to initiate and monitor the tracking using git, and how to manage remote repositories and conflicting git commits. The hackathon program was based on a series of presentations and talks highlighting the objectives of the different projects. The first day of the hackathon was dedicated to a detailed presentation of the objectives, the format, and the composition of the teams followed by a discussion concerning the planning of the week. For the following days, teams split into their individual collaboration areas at IPT to plan their strategies, identify the data to be collected, and select the tools to be used. A report-back session was scheduled at the end of each day, during which each team leader presented the procedures followed, the advances made, and the challenges that have been faced. Because they were made by each team in front of the others, these wrap-up sessions helped each team to receive valuable comments from all team members and created a room for beneficial panel discussions. This helped teams to clarify views, consolidate efforts, rectify procedures, and fine-tune strategies. To efficiently organize each working day, a day-to-day detailed working plan was prepared at the end of the day before. The panel discussions also presented the progress made in the frame of the working plan, which helped refine each daily program and prevent delays. For the three last days of the hackathon, participants were obliged to switch from face-to-face meeting to online meetings due to the first COVID-19 wave and the sudden increase in the number of COVID-19 positive cases among IPT personnel. Although the five different teams achieved significant progress toward data collection, appropriate tool identification, installation, and testing during the hackathon, further work was required for all the projects. Thus, the team members committed to contributing and investing time to finalize the development of their bioinformatics pipelines in the frame of the five projects.At the end of the first hackathon, milestones and task assignments were set by members of each team/project. These tasks consisted of steps needed to finalize the development and the running of the distinct pipelines. The progress of these tasks was supervised by constant meetings between the project members through platforms such as Slack, WhatsApp, and Google Drive. A series of meetings with mentors and organizers were convened to monitor and gauge the progress as well as the team productivity in solidifying and achieving the pipeline development between both hackathon events.A second hackathon was scheduled during these meetings to refine the developed pipelines and valorize the work done by the teams. The second hackathon took place on the 28th and 29th of October 2021, in which members of the five projects met again for two days to polish the developed pipelines and start to draft potential publications. A summary of the hackathons' timeline planning is provided in The first working group is aimed at validating and setting up a pipeline for SARS-CoV-2 variant study and SNP identification. For this, they downloaded a sample SARS-CoV-2 genome SRR12532546) from GenBank on 03 September 2020. This sample was isolated from the Philippines, and its data were generated using the paired-end library on the Illumina platform. In addition, the team used the sequence NC-045512.2 of the established severe acute respiratory syndrome coronavirus 2 reference sequence isolated from Wuhan-Hu-1. The main goal of the second team was to understand the early transmission dynamics of the SARS-CoV-2 in Africa. To reach their objective, whole genome FASTQ sequences related to 1800 SARS-CoV-2 isolates from Africa, and references from all over the world were downloaded from the GISAID database 6 from Ge. Team 4 Q-score >30) were firstly mapped into the human genome using the BWA tool. Only unmapped reads were assembled to contiguous sequences (contigs) using the SPAdes algorithm software [Team 1, which involved two participants, was able to develop a full pipeline, allowing the assembly of the SARS-CoV-2 viral genome, as well as the identification of all mutations within the genome by comparison to the NC-045512.2 reference sequence isolated from Wuhan-Hu-1. Briefly, the team initiated its work by trimming adaptor sequences and primers from the SRR12532546 sample using the Trimmomatic 0.33 tool. Quality control of data was performed using the FastQC software . The cutsoftware . The teaTeam 2, focusing on the study of the transmission dynamics of the SARS-CoV-2 and its introduction in Africa, collected complete genome sequences related to 1800 SARS-CoV-2 isolates from Africa and references from all over the world. Bayesian coalescent analyses were performed on major lineages of the Nextstrain build in which  sequences fell. The purpose of these analyses was to (i) confirm the estimated date of origin for SARS-CoV-2, (ii) infer the estimated date to the most recent common ancestor for major lineages, and (iii) infer the estimated dates of viral introductions into Africa. The full pipeline is available within the GitHub repository.The COVID-19 pandemic has accounted for millions of infections and hundreds of thousand deaths worldwide. Patients demonstrated a great diversity in clinical manifestations and disease severity. However, little is known about the host genetic contribution to the observed interindividual phenotypic variability mainly in African populations.Whole genome sequencing (WGS) and whole exome sequencing (WES) methods were used to detect these genomic variants. While WGS is more and more used in research and clinical diagnosis of hereditary diseases, WES is a more economic approach compared to WGS and is becoming a standard. The aim of team 3 was to develop a reproducible pipeline for the simultaneous analysis of multiple human whole exome sequences (WES) that could be used for host genetic studies and analysis. Until recently, most WES pipelines used for genetic variant discovery process one sample at a time. During this hackathon, team 3 endeavored to develop a reproducible pipeline for joint analysis of multiple human whole exome sequences (WES). To do so, the team employed many “for” loops all along the pipeline, in order to iterate the different analysis steps for multiple samples. The pipeline displayed in Using a combination of keywords including “SARS-CoV-2 human proteins interactome” on the PubMed database, team 4 obtained 126 results. The team proceeded with a first manual curation of abstracts to select articles that provided a list of SARS-CoV-2 human protein-protein interactions. The selected articles were then retrieved, and a second manual curation on the whole content of papers was performed by team members to retrieve all viral-host protein interactions. In total, 2989 interactions involving 33 SARS-CoV-2 proteins and 1483 human proteins were retrieved. Based on the collected data, an R script using R shiny, visNetwork, and shiny dashboard packages was built to retrieve data from generated csv files and display it on the web interface over the web. An in-house Perl script was developed to make protein interactions in appropriate format. All data and scripts are available on GitHub.In order to investigate differentially expressed genes in COVID patients using the RNAseq analysis approach, a set of data was chosen from the National Center for Biotechnology Information Search database (NCBI) by team 5. The aim was then resumed in a comparison of the expressed genes in COVID(+) vs. COVID(-) samples and the identification of the over- and underexpressed genes by the means of different tools. To be able to achieve their goals, members of the Team 5 designed a bioinformatics pipeline starting by the quality control where they compared outputs generated by two softwares FasTQC and RSeQC. The second step was the trimming of low-quality data and adapters using Trimmomatic and Skewer. The third step corresponds to the alignment of the retained reads against the reference genome with BWA, STAR, and SALMON –28. FinaOne of the major aims of this hackathon was to give to participants the opportunity to apply what they learned from the PHINDaccess course series and put into practice the acquired knowledge. While some teams succeeded to reach their initial goals, other teams were confronted with many issues to reach their aims. In the following, we report challenges raised by participants during the hackathons.Regarding the communication between team members, due to the COVID-19 pandemic and the series of successive confinement periods, it proved difficult to ensure regular meetings between team members. Besides these challenges, the team members faced some technical challenges, mainly related to the internet connection. In fact, IPT, as every structure in an LMIC, has a relatively poor quality internet connection, summed up in two points: a low internet bandwidth and an unstable internet connection leading to frequent loss of the connection. This low bandwidth can either be caused by the Mbps rate that the current broadband has, or the bandwidth could be slowed down because too many people are connected to the network at the same time. During the hackathon, slow internet connection has prevented some team members from downloading real OMICS raw data  from a public biorepository in order to be able to develop their analysis pipelines, leaving them with a feeling of frustration. Some teams decided finally to retrieve dummy data  to overcome this issue. Another encountered challenge consisted in the lack of intensive computation resources available at the time of the hackathons. It is well known that a comprehensive analysis of omics data requires vast computational resources for multistep analysis pipeline development. These computational resources can be summarized in the number of available CPUs and the amount of memory available on the machine. Again, some team members dealing with a large quantity of data faced these challenges. After the hackathon, the participants were requested to provide assessments on what they thought of the event, how they found the atmosphere and the process, what they learned during the first hackathon, what they learned after both hackathons, what was the outcome of the two hackathons on their works, and what are the challenges faced during both hackathons. The organizers came up with a survey consisting of a few simple questions and, in the following, the participants' feedback. All participants responded to the survey. Link to the survey is provided at the end of this manuscript. Regarding what they learned during the first hackathon, four answers out of 16 included team and collaborative work. In addition, participants mentioned that they learned about the utility of the Conda package management system and applied what they learned during the PHINDaccess course series. Throughout these hackathons, they were able to develop bash and R scripts calling appropriate bioinformatics tools for their respective projects and interact with the GitHub repository to make their scripts public. Participants appreciated the hackathon topic, the organization, the collaborative work, and the interactions between group members. Concerning what they learned after both hackathons, answers included the way to work remotely due to the COVID-19 pandemic and the ability to develop some pipelines using bioinformatics tools integrated within a Conda environment. Concerning what participants appreciated the most during the hackathon, nine participants highlighted the familial and friendly atmosphere, the teamwork and the diversity of team members and their expertise. Participants were also asked if they were able to run or organize such events on their own. Eight participants responded that they were able to organize such events on their own. 12 participants were able to apply what they learned in the frame of the series of omics training performed in the frame of the project including Linux commands, R language, Python, and the NGS data quality control and trimming. The latest answers highlighted the utility of the series of courses followed by the trainees before the organization of both hackathons. While the objectives of both hackathons consisted to strengthen the capacity of IPT users in OMICS data analysis, some teams seem to be more ready to publish their work than other teams who encountered some challenges including internet connection and a delay in public raw data download. Gathering these feedbacks was highly useful for the hackathon organizers to understand how the events were perceived by the participants and how to better plan for next similar events. Finally, Although both events were deemed successful, we identified some limitations that were noticed by the participants and/or the organizers that could raise several constraints and pose a set of hurdles affecting the scope and outcomes.For instance, the relatively smaller number of participants in this event compared to other ones organized in more developed locations could have significant drawbacks. The participation of a smaller number of persons with the necessary set of skills could affect the diversity of ideas and viewpoints brought to the hackathon, potentially limiting the solutions developed.Another aspect that can highly limit the outputs of these events is the technical issues related to internet traffic. Due to this and the fact that the needed data were very large, the participants' ability to download and analyze these big multiomics datasets was greatly hampered. These limitations may have a significant impact on the quality of the hackathon outcomes.IPT is an academic institution based in a LMIC. In the present section, we will summarize important organizational and technical recommendations that we believe are essential for organizing a successful hackathon within LMIC settings. These recommendations are derived from valuable insights gained during the conducted hackathon and curated after a comprehensive analysis of the hackathon experience and the subsequent identification of critical gaps.In order to organize a successful hackathon, organizers should firstly decide the theme and define the goals of the scheduled hackathon as well as the target audience at least six months ahead of time. Organizers have to identify the skills and profiles of the participants needed to be able to achieve the goals of the hackathon. This will help define a solid general guideline for the event and ensure that the participants have the necessary skills and knowledge to run the hackathon successfully.Secondly, organizers have to decide the hackathon format , the timing (how many days?), the date, the venue, the sponsors, if any, and need to set up rules or a code of conduct during and after the hackathon. Organizers should avoid public holidays, weekends, and religious days when choosing the date of the hackathon. Despite the fact that this may prove to be somewhat restrictive for the organizers and participants in terms of their personal schedules, it will guarantee that the majority of participants can attend and be present throughout the process.Thirdly, organizers need to set up the program of the hackathon, the list of speakers that will be involved, and the moderators of each session. If speakers are involved, they should be contacted to have their approval for participation. These steps need to be dealt with around two to three months before the hackathon. One month before the event, organizers should contact and sign on food caterers and miscellaneous vendors such as T-shirt suppliers. During the hackathon, organizers should ensure the good progress of the registration, the respect of the time dedicated to each session within the program, and the well-being of participants during the whole period of the hackathon. These recommendations are of the utmost importance in ensuring the smooth progress of the different steps involved during the hackathon. However, this absolutely requires a high level of communication between the organizing team. They also need to communicate on the event by generating videos and photos of the event for marketing purposes, as media coverage could provide important visibility for the event and ensure future collaborations.It is also recommended to establish a contingency plan when organizing an “in-person hackathon”. For instance, in our scenario when confronted with the COVID-19 pandemic, the organizers swiftly transitioned from an “in-person hackathon” to a virtual/hybrid format by having a well-thought-out alternative plan in place, thereby maintaining the integrity of the event and minimizing disruptions to participant engagement, ensuring safety, and maintaining collaboration. This proactive approach, if unforeseen circumstances arise, safeguards the hackathon's objectives and outcomes while demonstrating an adaptive and resilient organizational strategy. It is very important to share surveys and forms with participants to get their feedback regarding the event proceeding, the experience gained, and what has been learned. In that sense, a pre- and posthackathon survey would allow organizers to gauge improvements from the hackathon. Finally, a follow-up should be performed by the organizers after the event to ensure that all fixed objectives are fulfilled.One of the major issues in LMIC institutions is the internet connection where the bandwidth is low, the internet is not stable, and the costs tend to be the highest. Hackathon organizers should ensure an acceptable internet connection to allow participants to retrieve data from public databases, to consult the literature and web sites, to communicate with each other, to exchange documents, scripts, and pipelines, and to work in a collaborative way. During our first hackathon, we faced some internet issues, and one group working on expression data analysis spent a lot of time downloading RNASeq data from the SRA repository as many users have been using the network at the same time. Thus, for huge volumes of data, we recommend organizers to prepare and download the dataset for participants in advance before the event and make it available for participants at the starting of the event to avoid spending time downloading data during the event. Furthermore, to be able to analyze OMICS data, organizers should ensure the availability of computational resources and memory as bioinformatics pipelines require minimum resources. Finally, in case of having a stable internet connection but a lack of appropriate computational resources for hackathon purposes, cloud computing can serve as a viable alternative as the latter allows a faster deployment to get the resources required at low cost with all softwares integrated without any additional efforts to integrate applications.In conclusion, the present paper reports on the PHINDAccess consortium experience to organize and run omics data analysis hackathons related to COVID-19 host-pathogen interaction prediction. It highlights all the organizational steps undertaken, details the hackathon proceedings, reports key participants' learnings from the events, explores the various challenges of relevance, and comes out with recommendations to run hackathons in LMICs.


The exploration of entrepreneurship has become a priority for scientific research in recent years. Understanding this phenomenon is particularly important for the transformation of entrepreneurship into action, which is a key factor in early-stage entrepreneurial activity. This gains particular relevance in the university environment, where, in addition to the conventional teaching and research functions, the entrepreneurial university operation based on open innovation, as well as the enhancement of entrepreneurial attitudes of researchers and students, are receiving increased attention. This study is based on a survey conducted among students attending a Hungarian university of applied science in Western Transdanubia Region who have demonstrated their existing entrepreneurial commitment by joining a national startup training and incubation programme. The main research question of the study is to what extent student entrepreneurship intention is influenced by the environment of the entrepreneurial university ecosystem and the support services available at the university. A further question is whether these factors are able to mitigate the negative effects of internal cognitive and external barriers by enhancing entrepreneurial attitudes and perceived behavioural control. The relatively large number of students involved in the programme allows the data to be analysed using SEM modelling. The results indicate a strong covariance between the perceived university support and environment among students. Another observation is the distinct effect of these institutional factors on perceived behavioural control of students. Recognizing the role of entrepreneurship in exploring new opportunities is not a new scientific discovery. This was first introduced into economic sciences by the advocates of the Austrian school of economics . The pheEntrepreneurial drive and commitment are certainly not isolated and context-free phenomena. Similar to other factors, they are strongly influenced and shaped by environmental conditions. It is no coincidence that an ecosystem approach to the analysis of entrepreneurship and innovation systems , 7 is gaFor the analysis of this topic, many different and very diverse models have been developed combining the contextual elements into a single system. Of these, the conceptual framework for the present study is based on the Theory of Planned Behaviour (TPB), developed  and lateThe research presented in the article focuses on university students with relatively strong entrepreneurial intentions and examines the effects of the perceived university environment and the support services of the university on entrepreneurial intentions and entrepreneurial attitudes, considering other contextual elements. Previous research results –26 have The aim of the paper is twofold. First, is to provide insights about the influencing mechanisms of higher education on student entrepreneurial intention in a specific socio-economic and geographic context  Second, is to gain a better understanding of student’s perceptions on campus environment which is highly influenced with the effects of entrepreneurial model shift process nowadays in Hungary. In our view, the survey results in an emerging innovator country  could alThis study is structured as follows: First, it identifies what factors influence entrepreneurial drive and discusses the relevant literature on entrepreneurial intention and formulates the main hypotheses to be tested. The next section presents the research method i.e., the applied SEM method, the variables and their structuring. In the last section, the results are presented along with an introduction to testing the hypotheses. Due to the subject-matter of the research, the final sections present a range of possible limitations, as the results may not be applied to the entire population of university students.Entrepreneurial intention is an area that has been analysed and has been debated on many aspects for decades in entrepreneurship literature. This is a rapidly evolving and expanding research topic based on the findings of related systematic literature reviews , 12, 30.Intention is a factor that affects the realization of entrepreneurial action in the model. The progress from intention to behaviour requires entrepreneurs to disentangle many inconveniences linked to implementation. Individuals may delay behaviour or do not act due to some factors. Therefore, the importance of understanding the influence of entrepreneurial intention on behaviour is crucial. Several additions to the model have been published in the literature in recent years. While searching for greater explanation several variables have been introduced, such as anticipated ambivalence , social Research on the impact of the university as a specific entrepreneurial ecosystem  also appThe key element of Ajzen’s Theory of Planned Behaviour (TPB)  is that H1: The entrepreneurial intentions (EI) of the surveyed students are (very) strongly influenced by their existing attitude toward behaviour (ATB).Within the framework of the Ajzen model, particular attention is paid to perceived social/subjective norms denoting a set of family, kinship and friend opinions related to the launch of a business and serving as a reference. In this context, there have been rather controversial research findings. Kolvereid and Isaksen identified a weak correlation between entrepreneurial attitude and perceived social standards . Franke H2: Social norms perceived by the surveyed students (PSN) positively influence their attitude toward behaviour (ATB) and perceived behavioural control (PBC).The impact of the perceived behavioural control (PBC) on the business startup intention has already been demonstrated in relation to the original Ajzen model, but this correlation is supported also by several research , 49–53fiH3: Perceived behavioural control (PBC) positively affects both entrepreneurial intention (EI) and attitude toward behaviour (ATB).Trivedi points out  that theH4/A: Internal (cognitive) barriers (COG_BARR) have a negative impact on attitude toward behaviour (ATB) and perceived behavioural controls (PBC).H4/B: External barriers (EXT_BARR) strengthen and positively influence internal barriers (COG_BARR).The role of the university environment and the entrepreneurial-university ecosystem are shaping entrepreneurial attitudes and commitment constitutes a particularly well-researched area. There are several theoretical models related to the role of higher education institutions in the ecosystem , 57, whiThe campus environment includes curricular and extra-curricular training activities of universities to enhance entrepreneurial skills, as well as events and programmes related to entrepreneurial activities, and, furthermore, the attitude, culture and atmosphere of the higher education institution towards entrepreneurship and entrepreneurial lifestyle –61. The University support goes substantially beyond the campus atmosphere and educational activities, as it includes specific forms of support provided by the university to businesses  . In thisH5/A: A supportive university environment (UNI_ENV) has a positive impact on students’ attitude towards becoming entrepreneurs (ATB).H5/B: The university’s business support services (UNI_SUPP) have a positive impact on students’ perceived behavioural control (PBC).As explained above, the theoretical framework of the present research is a slightly modified EICM model. This provides a suitable tool for the purposes of the research, i.e. for examining the effects of the university environment and support. However, it should be noted that the applied model has several weaknesses, which appear as a limiting factor in the interpretation of the results. One of the most important weaknesses of the model is that it does not include variables related to creativity, anticipated ambivalence and social valuation among the factors that affect entrepreneurial intention. Another weakness is that it does not analyse the relationship between entrepreneurial action and intention, which is also influenced by many factors.The hypotheses identified by the research are shown in :The survey underlying this research took place in November and December 2021. The population consisted of students studying at Széchenyi István University of Győr, Hungary who had enrolled in the aforementioned HSUP programme. Széchenyi István University is the largest higher education institution in North Transdanubia. This region has the most developed agricultural and food industry in the country, but it is clearly the industrial sector that plays a leading role and has fostered dynamic growth and development since the second half of the 1990s. The northern part of the region, mainly Győr-Moson-Sopron county and to a small extent Vas county, is geographically well integrated into the European and world market, and its comparative advantage still lies in its industry (mainly machinery and automotive). The latest important step in the transformation of the entrepreneurial university is the process known as the higher education model change, which aims to create an efficient and modern higher education system in Hungary. In the process, the founding and maintenance rights of the model-changing institutions were transferred from direct state ownership to trust foundations, which created new opportunities for technology-focused universities such as Széchenyi István University.In the academic year 2021–2022, 480 students from Széchenyi István University applied for the HSUP programme. This group of students was sent an anonymous questionnaire with full respect of the data protection rules in force by means of GoogleForms. A total of 145 respondents (N = 145) returned the questionnaire within the 30 days given to complete the survey, which is a fairly good response rate compared to the baseline population. Based on the relevant methodological literature, the sample size should be greater than 10 times the maximum number of inner- and outer model links pointing at any latent variable in the model , 77. At The conducted research can basically be divided into 4 major sections. The demographic characteristics of the respondents (Section 1). This section contains the control variables of the questionnaire. The research basically operated with 3 control variables . Age and specialization did not significantly influence the results and the model, but it can be observed that the entrepreneurial intention of female university students is slightly lower compared to male students. Observing and analysing gender-based differences were not the focus of current research, however the results confirm the insights of previous articles and systematic literature reviews on this topic , 30, 78 The set of questions selected for the independent variables is mainly based on questions used and applied in previous surveys with similar objectives , as wellIn order to evaluate the responses from the completed questionnaires, following the data transformation procedures required to run the IBM-SPSS analysis, we first applied factor analysis with varimax rotation and Kaiser normalisation to extract the specific variables.To check for adequate reliability, the item-to-total correlation should be at least 0.35 for questions related to a single variable, and the Cronbach’s Alpha value should exceed 0.70, as recommended in the related literature , 81. It In terms of validity, both convergent and discriminant validity were checked on the basis of literature recommendations . For comCertainly, the literature also provides guidance on discriminant validity requirements . These cThe root of the expressed average variance of a given factor exceeds the correlation coefficient between the respective factor and all other factors.The maximum split variance (MSV) value shall be less than the average variance expressed (AVE) by the factors. That is: MSV < AVE.The value of the average shared variance (ASV) shall be less than that of the variance expressed by the factors (AVE). That is: ASV < AVE.The indices of discriminant validity are summarised in Overall, it can be concluded that the reliability and validity analyses confirm the hypotheses that the questions used and the variables derived are suitable for the assessment of correlations. Following the goodness-of-fit analysis, the results and the model outlined using the SEM method are discussed below.The primary objective of the research is to examine the relation between entrepreneurial intention (as a dependent variable) and the predictors defined in the EICM model on a sample in which the entrepreneurial commitment of the population can be considered high. In order to be able to test the model on the basis of the variables presented in the previous section, it is first necessary to make sure that the goodness-of-fit is guaranteed. Based on the literature recommendations, the fit itself can basically be examined in three aspects –85:Absolute fit, where the focus of attention should be placed on the GFI (goodness-of-fit) index, the RMSR  and the RMSEA (root mean square error of approximation).Incremental fit, where the TLI (Tucker-Lewis index), IFI  and CFI (comparative fit index) indicators are examined.Parsimonial fit, where the PGFI (parsimony-adjusted goodness-of-fit index), the PCFI (parsimony-adjusted comparative fit index) and the PNFI (parsimony-adjusted normed fit index) figures are to be matched to specified thresholds.The results of the goodness-of-fit analysis carried out by means of the SPSS-AMOS 28 software and the relevant thresholds defined in the referenced literature are summarised in In summary, the fit of the model is very good , with a CMIN/DF value of 1.541 (threshold <2). The P-value (Probability level) of 0.044 can also be considered good, taking into account the threshold of < 0.05. The derived variables are suitable for further analysis and drawing conclusions. As mentioned earlier, the original Ajzen model’s  extendedThe analysis leads to the following conclusions:2 = 0.68 value with respect to EI provides clear evidence of this. Entrepreneurial intention is most strongly influenced by attitude toward behaviour , which explicitly confirms the statement defined in hypothesis H1 of the present study.Entrepreneurial intention (EI), as the basic dependent variable of the research, is highly influenced by independent and partially independent variables. The resulting Rp<0.001). Contrary to the results of the previous research testing the EICM model [p>0.05) based on the present research results. Thus, the statements proposed in hypothesis H2 were only partially confirmed.The social norms perceived by students (PSN) definitely influence entrepreneurial attitudes (ATB), and the effect is positive  and attitude toward behaviour (ATB) . The former relation was also described in the original EICM model, the latter is a novelty based on the results of this research, which fully confirm the statements outlined in hypothesis H3.Perceived behavioural control had a clearly positive effect on both entrepreneurial intention (EI)  both on entrepreneurial attitudes (ATB) and on perceived behavioural control (PBC) . This mechanism was also explored in the original model and confirms the statements outlined in hypothesis H4/A. The external barriers broken down into two factors (EXT_BARR) do not have a significant effect on attitude (ATB) or perceived behavioural control (PBC). However, based on the present research, they strengthen the internal (cognitive) barriers (COG_BARR) , which are negative predictors of entrepreneurial attitude toward behaviour (ATB) and perceived behavioural control (PBC). By the indicated relation, the hypothesis H4/B of the present research is confirmed.It can be explicitly demonstrated that the cognitive  barriers (COG_BARR) have negative impact  on attitude (ATB), while perceived university support (UNI_SUPP) positively influences perceived behavioural control (PBC) . The latter is also interesting because the strength of this effect is comparable to the negative effects of internal (cognitive) barriers (COG_BARR), and as a result, the role of university support services seems to have a noticeable countervailing effect. Based on the above-mentioned fact, we can establish that the assumptions of hypothesis H5/A were not confirmed, whereas hypothesis H5/B was proven.The university environment (UNI_ENV) has no significant effect  and university support (UNI_SUPP). This particularly strong relationship see  suggestsp<0.001) was found between the university environment (UNI_ENV) and the perceived social norm (PSN). Nevertheless, the resulting R2 = 0.07 does not allow us to consider this as significant, yet the relationship still exists.The potential impact of the university environment on perceived social norms has not been in the focus of research so far. When reviewing the relevant literature, we did not find any research of this type; therefore, no corresponding hypothesis was proposed. However, in the analyses required to develop the model , it was remarkable that, without any exception, a positive and significant relationship  to explain the entrepreneurial intention among university students. The research validates the essence of the original Ajzen model [The slightly modified EICM model, which was tested in the framework of this research, has proved to be suitable  barriers among the factors that shape entrepreneurial intentions and provides a useful method for measuring them. Among the internal (cognitive) factors, risk tolerance/risk-taking willingness  and the The location, role and support of the university environment has long been a central theme in research on the factors influencing entrepreneurial intentions. The available resources and the knowledge and the services that can be accessed and directly exploited strengthen self-efficacy  and inteAlthough the validity and the goodness-of-fit analyses notably show favourable values, the results of the research exhibit several limitations. The limitations are highlighted in the summaries of all the research on this topic, and it is apparent that they constitute a significant part of the explanatory power differences across the models constructed. These include the characteristics of the target groups selected for the research, national or regional specificities, temporality, and  the relevant characteristics of the university/universities concerned. In view of the above considerations, the results of the present research can be interpreted along the following limitation criteria:The research was carried out between November and December 2021. During this period, the COVID-19 epidemic still caused significant difficulties in the region . In 2020 and 2021, effects of the epidemic particularly affected the higher education sector, where in-person education and events became impossible to hold. However, university courses were held in person format in the Hungarian higher education system in Fall Semester 2021, including our research period. All these circumstances may have reduced the perceived negative effects of COVID in education, but it is necessary to note that events were not allowed during this period either. These conditions may have influenced the results of our research.The survey was conducted on a sample of students of a Hungarian, and in particular a regional university. National and regional characteristics strongly influence entrepreneurial ecosystems  and the The sample selected for data collection was taken from a technology-focused university. Therefore, the results obtained can only be valid for this group, while the specific characteristics of science universities in the classical sense and universities of arts are likely to have an impact on the support and university atmosphere perceived by students, thus separate research may be required for these types of institutions. A similarly influential factor is the so-called higher education model change process currently in progress in Hungary, which aims to transform the vast majority of the Hungarian higher education system into an entrepreneurial university enhancing the third mission .actual control, and which include objective factors . The impact of these on the action is not addressed in the research, yet it is necessary to indicate that among the variables that belong to the actual control category (and influence action) there are several ones that overlap with the elements that influence entrepreneurial intention . The influence of these variables on specific actions was analysed on a Hungarian sample by Gubik et al. [The model applied for the analysis has a certain number of weaknesses that limit the interpretation of the results. As discussed above, a main weakness of the model is that the factors influencing entrepreneurial intention do not incorporate variables related to creativity, expected ambivalence and social evaluation. A further weakness is that it does not analyse the relationship between entrepreneurial action and intention, which is also influenced by a number of factors that are referred to in the literature as “actual control” . The essk et al.  and it wThe limitations of the research provide an interpretative framework for the results, which should be seen in this context. Their utilisation for policy purposes should also be based on this. The model change process of the Hungarian higher education  gained momentum in 2019 and was completed in administrative/normative terms in 2020 with the reorganisation of some universities into foundation operating forms and with the inclusion and declared assumption of the third mission and entrepreneurial university functions in the rules of operation. The literature shows that the first entrepreneurial universities date back centuries in the USA  and seveentrepreneurial education functions, as they cover a much narrower field and thus the results obtained there will not be comparable to the present results.) Perhaps one of the most surprising results is that contrary to preliminary expectations (based on the literature), no significant correlation between entrepreneurial attitudes, entrepreneurial intentions and the university environment has been found. At the same time, there is a fairly strong positive relation between the variables of perceived behavioural control and university support. In addition, a covariance between the perceived university environment and the perceived university entrepreneurial support can also be detected. The above results can be explained in several possible ways. Among these explanations, the one with a theoretical background in organisational development seems to be the most convincing, considering all contextual circumstances, and this provides implications regarding future challenges for higher education policy makers.Several studies have confirmed that the university environment has a significant impact on entrepreneurial intention and entrepreneurial attitudes of students. This is supported by dozens of studies related to entrepreneurial education at universities, but other contextual elements have also been proven to influence these variables . Even thhard" and the factors influencing the university environment variable as "soft". The soft elements are the shared values of the given institution, the set of skills and competences, the leadership and management style, and the motivations and attitudes of the staff. The hard elements include the institutional strategy, the organisational structure and the systems that influence day-to-day procedures and workflows. Perceived university environment factors  are more likely to be influenced by the soft institutional elements. Based on experience, achieving the changes envisaged in these plans is only feasible in the longer term [The institutional characteristics influencing the factors that constitute the variables associated with each university ecosystem can be relatively easily aligned with the McKinsey 7S model , a frameger term . On the Based on the logic of the framework presented above, a possible explanation is outlined for the lack of a significant correlation between perceived university environment and entrepreneurial attitudes and entrepreneurial intention. Since the survey lacks a longitudinal dimension, the data collection can be considered a snapshot regarding the students. This snapshot is taken at a higher education institution that has undergone a model change process and is in transition. For this reason, it is likely that, on the one hand, reforms on the hard elements that can be implemented in the shorter term are already perceived as having an impact among students . On the other hand, it is also likely that changes in the soft elements that can have an impact in the longer term have not yet reached the critical point where they can have a meaningful impact on the student community, which may explain the current lack of correlation between the university environment and student entrepreneurial attitudes and entrepreneurial intentions.Since there is also covariance between the perceived university environment and the perceived university support based on the research results, the presented possible explanation also carries policy implications, which, accepting the above interpretation, can be summarised as follows:The transformation into an entrepreneurial university should be seen as a long-term process with regard to achieving the desired effects.Among the desired effects, those based on direct university support  will be the earliest to be perceived, which will primarily enhance entrepreneurial intentions by influencing students’ behavioural control.The development of a supportive university environment  is a time-consuming process and its results can only be measured in the long term.The level of development of the national and regional innovation system is also a key factor that needs to be taken into account in designing the elements and measures of the innovation ecosystem. In an emerging innovation country, different measures and entrepreneurships programs are needed than in a moderate or strong innovator country.At the initial stage in the process of transformation into an entrepreneurial university, the university support environment will not yet directly support students’ entrepreneurial intentions, but international experience and research show that at some point in this transformation this will become perceivable and measurable.In the process of transformation into an entrepreneurial university, a key element of university governance is performance assessment, which is central to the competitive market environment of higher education. In terms of performance assessment, the present research suggests that it is worth considering a gradual introduction of the enhancement of student entrepreneurial attitude (as a performance indicator), since the conditions that promote this are developed gradually in the system.Due to the covariance between perceived university support and perceived university environment, we can identify interacting yet separate elements regarding students. It is evident that there is a greater scope and perspective for improvement in those factors which currently do little or nothing to foster student entrepreneurial intentions, although international experience shows that they are capable of doing so. At the same time, when university management perceives shortcomings in the university environment related to the entrepreneurial mindset, it will not be able to compensate with hard elements . Conversely: the lack of capital and supporting market expertise cannot be compensated for by a supportive university environment, atmosphere, and entrepreneurial courses."Hard is soft. Soft is hard" [The essence of the 7S strategy developed by Tom Peters is summarised in six words by the author himself in the foreword to his book: is hard" . The resS1 File(XLSX)Click here for additional data file.


Lecturing has always been one of the traditional instructional methods in medical education. It is cost-effective, especially when it comes to conveying a large amount of information to many students at once. However, disadvantages are plenteous, one of which is its passive way of knowledge delivery and learning. Active learning, on the contrary, has better students' engagement and longer retention, and it results in better students' achievement. The emergency medicine residency training program at KAMC-Jeddah has modified the educational activity to become more aligned with the end-of-year assessment in the form of active learning. This study aimed to explore the experience of the residents regarding the implementation of the new educational approach. An exploratory-qualitative study utilizing constructive grounded theory was conducted, collecting our data through an in-depth 1:1 interview using semi-structured open-ended questions. Purposeful sampling was used, and saturation was reached after interviewing 24 residents. The general perception of residents toward the new teaching modes slightly varied, highlighting the positivity of the new educational environment, the desired impact on their learning, the challenges they encountered, and finally their high satisfaction level and support for this new experience. It was asserted that such experience could be permanently implemented to increase the efficacy of teaching and learning. Lecturing has always been one of the traditional instructional methods in medical education . It is dHowever, disadvantages are plenteous, especially if learners have different levels, backgrounds, and thought paces. Furthermore, it becomes increasingly difficult to maintain attention when students passively learn, seldom interact with teachers, and need feedback on their questions or thoughts .On the other hand, engaging the students in the learning process is considered active learning . In a syOne of the active learning strategies widely used is collaborative learning. Collaborative learning requires learners to engage in groups rather than work individually, whether solving a problem, completing a task, or creating a product . Over thIn particular, small group discussion (SGD) is an example of collaborative learning. Several studies have shown its positive effect on learning –11. As Oflipped classrooms as “a pedagogical method in which students learn new knowledge through short videos, podcasts, e-books as well as internet outside class and consolidate what they acquired through classroom activities with the help of classmates and teachers.” On the other hand, case-based learning (CBL) is widely used in undergraduate and postgraduate medical training residency programs  has been used in education since the times of Socrates (468-399 B.C.), Plato (427-347 B.C.), and Aristotle (384-322 B.C.). According to Barrow , IBL helSince its establishment, the Emergency Medicine Residency Training Program in the western region of Saudi Arabia has been conducting its full-day educational activity once per week using traditional lecture-based learning to deliver the theoretical component of the curriculum. As the program started to grow, the disadvantages of this teaching strategy became evident, and residents' engagement could have been much better. Such difficulties included a lack of motivation to attend, less interaction with the presenter, less engagement in the topic, and, therefore, less learning. At King Abdulaziz Medical City-Jeddah (KAMC-J), the Emergency Medicine Residency Training Program Committee has incorporated active learning into the weekly educational day to overcome such learning obstacles.As part of ensuring the quality of the emergency medicine residency program at KAMC-Jeddah, this study aimed to explore the residents' experiences regarding implementing the new teaching and learning approach.Objectives:To explore the experience of residents about the implementation of the new active teaching strategies in terms of:° Engagement° Positive and negative impact° ObstaclesThe study took the form of an exploratory qualitative design. Data were collected using semi-structured, in-depth interviews with the emergency medicine residents at King Abdulaziz Medical City-Jeddah. The resident's experience with the modified teaching was studied using a constructive grounded theory approach.The study was conducted at King Abdulaziz Medical City in Jeddah. Currently, the institute has 33 residency and 23 fellowship training programs. The total number of trainees is 567. The Emergency Medicine Residency program was established in 2002 as the first emergency medicine program in the western region. In the following years, multiple programs were established and joined the mother program, constituting the joint emergency medicine program in the western region. The emergency medicine program at KAMC-J became a separate program in 2020. Complete programs earn accreditation based on specific criteria proposed and followed by the SCFHS in Saudi Arabia. The Emergency Medicine program at KAMC-J can accept 10 new residents per year. The educational activity was separated from the regional program activity in October 2022. At the time of conducting this study, the program had 36 residents. Twenty-six residents had experienced lecture-based teaching, whereas ten were new to the program.The modified learning approach was implemented for a whole academic year (October 2021 to June 2022). The educational activity schedule introduced the theoretical part in the morning. The residents were divided into eight small groups, with a minimum of three residents and a maximum of six in each group. Each group had a ratio of one senior to two junior residents. Members were attached to their assigned groups for the whole academic year. The didactic lecture was then dissected into chunks, giving the residents enough time to discuss each chunk, followed by questions and answering techniques. Questions were designed following the objectives of the Saudi Commission for Health Specialties (SCFHS) emergency medicine curriculum. Residents were allowed to search for information and introduce updated knowledge to the topic. Based on previous years' residents' recommendations, the afternoon periods also included practical sessions. Those practical sessions included simulation, structured oral exam (SOE), and multiple-choice questions (MCQs) revision sessions. Three hands-on workshops were conducted to familiarize the residents with high-acuity emergency medicine procedures and to train them on the skills they need to maintain. The aim of introducing the above methods was to enhance the residents' clinical experience and to align the teaching methods with the final-year assessment strategy, which included both MCQs and SOE.The study targeted all residents of the Emergency Residency Training Program at KAMC-Jeddah in the academic year 2021–2022. The sampling technique used to select the participants was purposeful sampling. In-depth interviews took place between 12 October 2022 and 4 November 2022 once the Institutional Review Board (IRB) approved the research proposal at the King Abdullah International Medical Research Centre (KAIMRC).Both IRB approval and consent forms were presented to the residents in advance. Interviews were conducted using the Zoom Video Program. The residents consented to the video recording of the interview, which was later used for thematic analysis.In total, 12 male and 12 female residents were interviewed, of whom 13 were seniors (in their third and fourth years) and 11 were juniors (in their first or second year). The selection of residents was prioritized based on their own free time. In all, six residents were newcomers. Subject characteristics are explained in Data were collected using semi-structured, open-ended interview questions refined and adjusted after meeting with the Educational Activity Committee members based on the aims and objectives of this study. The meeting aimed to pilot the questions and brainstorm for any additional ones to probe the residents' experience.The interview guide contained five domains: demographic data, satisfaction experience, advantages and disadvantages of the modified teaching approach, challenges experienced, and recommendations for improvement. All interviews were conducted in English and videotaped. Recordings were transcribed verbatim manually and then imported into the data analysis program.NVIVO  version 20.7.0 was used for data analysis. The thematic analysis was performed according to the six phases proposed by Braun and Clarke . Data weThe participants were divided into senior and junior levels. In total, 12 male and 12 female residents were interviewed, of whom 13 residents were seniors (in their third and fourth year) and 11 were juniors (in their first or second year). Saturation was reached by the 24th resident. The average length of the interview was between 40 and 70 min.Five main themes were identified and explored and are believed to thoroughly explain the residents' experience with the new educational approach. The main themes generated from our data were the general perception of residents toward the new teaching modes, the learning environment, the impact of the new educational approach, the challenges they encountered, and their general satisfaction level with the new experience. The thematic analysis map is displayed in There are three different teaching modes the residents were exposed to:They experienced the theoretical knowledge delivery mode, which consisted of small group discussions and monthly MCQ sessions.They went through a practical mode that consisted of monthly simulation sessions, biweekly SOE sessions, and hands-on workshops.They took part in both physical and online teaching modes.The residents felt more engaged in the educational cycle; they were constructing new knowledge, solidifying the existing knowledge, and having their misconceptions corrected. They believed the formerly mentioned benefits had improved knowledge retention and reiteration much better than traditional lectures. Moreover, small group discussions made them more enthusiastic about learning, resulting in a more meaningful learning experience.Small group discussion made me interested to learn the topics that I have to know about. It made the learning experience more interesting and thus made the learning more meaningful. (J3)The majority felt that the new approach also helped them know each other better, share their knowledge freely, irrespective of their level, develop rapport toward each other, and respect each other's opinions. Such skills are essential when it comes to group discussion.I had the opportunity to share my knowledge with the group which built my enthusiasm to share knowledge again. (J3)One of the advantages is establishing rapport with colleagues. (S4)Moreover, seniors believed they had an opportunity to develop mentoring and coaching skills for the juniors, whereas juniors believed that senior contribution to the educational cycle was a significant advantage.Small Group Discussion helps mentoring and guiding the junior in the group. (S4)It increased the level of understanding as a junior, and I was discussing at my level, and I had additional feedback from the R3 and R4. (J10)Another advantage of small group discussions over traditional lectures is the better preparation for the final exam and the effect on home study. They believed the question-and-answer technique in the small group discussion helped point out the preliminary information. This technique improved their home study because they had to pre-read the topics to contribute to the discussion. They also better understood the topic when they studied it again after the activity. However, they described the small group discussion as useless when group members did not read beforehand and, accordingly, had less collaboration. Another disadvantage was the cognitive overload they felt toward the end of the activity and the amount of mental exhaustion. They argued that they had to stay attentive all the time compared to the traditional lectures, where they could blank out when needed as their continuous participation was not necessary. Although this was discussed as a disadvantage, it explains why this activity helped improve learning as it caught their attention all the time.I need to be all the time attentive which sometimes made me cognitively overloaded. (S5)Other disadvantages included the need for more training in professional presentation skills for juniors. Some seniors believed that the new method did not cultivate the proper presentation skills juniors needed for future professional talks at conferences, and that was a drawback seen by seniors.No practice of solo presentation skills so they can't develop presentation skills to huge audience. (S2)[SIC]Regarding the disadvantages related to the groups themselves, issues such as being assigned to one group the whole year, the random assignment of the members to the group, and the effect of the absence of the group members on the quality of the discussion were raised. They also described the new technique as time-consuming compared to the traditional lectures in terms of preparation and conduct. However, they described the lectures as an ineffective tool to add to their learning as they lack discussion, do not grasp their attention long enough, and eventually do not result in information retention.You can't guarantee learning is happening. (J5)The information retaining is nearly zero. (S5)Boredom, lack of interaction, and lack of interest in studying were also mentioned as disadvantages of traditional lectures. However, only two residents mentioned that lectures provided them with more comprehensive review material that helped their reading. One resident mentioned she used to have better comprehension and retention of the topic when she prepared for lectures, as she was covering more information than just the objectives.When asked about their perception of the monthly MCQ sessions, the majority regarded the sessions as a challenging and effective tool to keep them studying, putting them in the hot zone of sitting for the exams and providing feedback that helped them know their level.The MCQ revision at the end of the month have given me a lot of advantage to know your exact level and to keep you in the mood of exam all the time. Gave me more confidence. (S6)[SIC]Additional modes of teaching were practical teaching sessions, including simulation, SOE preparation sessions, and hands-on workshops. The majority found the simulation beneficial and impacted their practice in learning and maintaining their leadership skills in managing sick patients, such as delegating, prioritizing actions, sharing information, decision-making, coordinating, coaching team members if needed, and closed-loop communication skills.Simulation experience give a quality time teaching. (J3)[SIC]However, one of the senior residents had difficulty appreciating its effectiveness since she was already mentally exhausted after a long day. Another senior resident felt cases were constantly challenging, which caused some frustration when he failed to act as needed.Simulation did not add to me at any point. I felt tired all the times by the time simulation is over I had no energy and I just wanted to go home. (S7)[SIC]On the other hand, the biweekly SOE preparation sessions gained the approval of all juniors and seniors as an effective tool to review and get oriented for the final SOE.Oral cases prepared us to the SOE well with good advantages, common cases, and challenging cases. The providers were well-oriented to the new way of conducting SOE. (J3)[SIC]Regarding the hands-on workshops, all residents believed that workshops were good tools for maintaining practical skills, especially for procedures not frequently encountered in actual practice.The residents had to experience both modes, physical attendance and online, in the years 2021–2022 due to the institutional social restrictions of COVID-19 that were applied for a few months. We assimilated the physical group distribution with the breakout room option in online mode using the Zoom program. Toward the end of the academic year and the resolution of the restrictions, the EAC decided to incorporate both modes into one hybrid mode, where the residents attended physically for the first 2 weeks of the month and then online for the remaining 2 weeks.Most residents preferred the physical attendance (onsite in the residents' quotes) to the online mode, arguing that it helped their engagement and interaction. Moreover, they highly regarded the social aspect of the experience, where they could meet and greet their friends and spend quality time. Some residents also mentioned better group management when attending physically, better focus, better collaboration, and more senior-to-junior observation.Onsite is better, more focused, and more attendance because you can't guarantee the presence of the students if camera is off. (S3)Onsite: Face to face, I can see all, I can manage my group better. Better group interaction although the commute takes long hours. (J9)While most residents voted for physical attendance, some of them favored the online mode that allowed them to save the commute time to and from the hospital. Moreover, they considered the online time as break time, which they attended comfortably from their place of stay. However, many disregarded the online mode as it was easy to disengage mentally, and some had technical difficulties.Online was more comfortable but not beneficial. (S3)Online: technical difficulty. The engagement is limited. More comfortable. We can do simple topics online. (J9)All residents favored the hybrid mode as a middle ground between the former and the later modes. The benefits of physical attendance are mostly recovered while reserving the online mode for more light topics, departmental mortality and morbidity discussion, and MCQs/SOE practice sessions.Hybrid: This is the best way; you have the benefit of having 1 day to have more time to study and you have the benefit to socialize with people and approach seniors directly. (J11)Modes of teaching delivered to the residents are illustrated as a sub-thematic analysis of Theme 1 in Residents were asked about their perceptions of the learning environment, and all of them found it friendly and family-like. The freedom to ask questions and share information without intimidation was highly spoken of by both juniors and seniors. Juniors precisely emphasized their willingness to commit mistakes in small group discussions.Big difference especially junior residents will not be afraid to make mistakes as opposed to making mistakes in front of the whole group. (J1)Residents also highlighted the positive attitude of the supervising consultants whom they had the chance to meet and share opinions with.The learning environment has zero blame and there's friendly consultant attitude. (S5)On the other hand, two senior residents noticed that anxiety about answering the presenter's questions was higher when the small group discussion was over, and the groups were called out to answer.In the small group, it was very safe. When we took it out, I felt the group uncomfortable to be called out randomly. Better for them to go on turns. [sic]The residents' point of view regarding the new learning environment is illustrated in The impact of the modified educational approach on residents was explored in multiple aspects to measure its benefits. Residents highlighted the positive effect of the small group discussion on their level of topic understanding and knowledge retention. Moreover, they discussed its favorable impact on their home study schedule, their daily practice, exam preparation, and their confidence level before examinations.The new approach helped them understand the topic and retain it longer through peer teaching and knowledge sharing compared to traditional lectures. The residents constantly spoke highly of the group's heterogeneity, where multiple residency levels contributed to the discussion, which made it more enriching. Moreover, juniors considered seniors in the group as a source of information, whereas seniors considered teaching their junior colleagues as a tool to help achieve a deeper understanding of knowledge.It increased the level of understanding on a junior level. Because I'm having 2 seniors in the group. I remember the seniors showing me how to study the topics. It makes me oriented more to the material. (J11)The group has a bigger chance to deliver the point and explain difficult one. The knowledge delivery wasn't one way form the presenter only but from the group members as well. (J10)It did improve the level of understanding. When you are the senior you'll need to explain things more to the junior which improved the level of understanding. (S6)[sic]However, two residents considered the repetitive pausing to discuss only one question disruptive to the flow of information. They wished to discuss more questions per time given for better time management and information processing.Frequent interruption to discuss after each question. And more time should be given with more questions to do and less interruption to the group study. (S1)Moreover, they considered studying the topic at home, followed by active discussion, and then revision at home, an example of a spaced repetition modality that helped with their knowledge retention and recall. In comparison to traditional lectures, their retention was better and longer. Apart from the motivation to read, most of the residents had aligned their home study schedule with the educational activity schedule; hence, they got better time management and less frustration about the number of topics they needed to read before the activity.Interactions coded the visual, auditory, and kinesthetic information better which helped retention. (J6)If you don't align the study, you'll not get benefit. I used to align my home study with the academic activity to have the most benefit. After the academic the reading is considered as a revision. I felt a lot of benefit. (S6)[SIC]In the Lecture based style, I didn't feel excited to read anything before the activity. (S10)On the other hand, those who did not align their home study schedule with the educational activity schedule perceived the pre-activity readings as a burden and additional work. Failure to align was either because the resident had different objectives, had less awareness of the benefits of alignment, or had excellent time management to read both their schedule and the educational activity schedule.I regret that I didn't align my study with the academic activity because we are covering everything in an amazing way. (J11)Most residents felt that the modified educational activity had impacted their daily practice in many ways, mainly by helping them develop a better approach to patients and decision-making. Debates and sharing knowledge around points of controversy gave them the confidence to face ambiguous cases. Others found connecting theory to practice easier, as discussions at the educational activity were often reflected in the clinical work. Many residents highlighted that simulation had positively empowered their leadership and communication skills during clinical work. Seniors constantly reported easier and better communication with juniors during the clinical shifts because they already spoke the same language and had developed the appropriate level of trust. However, one resident felt the educational activity had not impacted her clinical practice.The clinical practice improved because we were debating and discussing so you figure out the best approach. (J10)I strengthened my relationship with my junior colleagues. We knew each other's level or approaches. Working with them was easier. I knew my juniors' weaknesses, so I took the opportunity in the shift to improve them. (S5)The most frequently mentioned impact of the modified educational approach on exam preparation was the alignment between the teaching and the assessment tools. Residents continuously perceived their extensive SOE preparation sessions as an effective tool to familiarize them with the end-of-year final SOE. Moreover, they could recall information mentioned in the educational activity through small group discussions and large group debates. As for the monthly MCQ sessions, many found them challenging and tricky, but up-to-date and educational. Some residents explained how the MCQ sessions motivated them to read and refer to more MCQ banks to prepare for the final promotion exam. Others elaborated on the positive effect of assimilating the exam environment monthly on the final year exam.During the oral, the SOE sessions were very helpful. We were prepared and I was thankful. Other centers noticed that were are good are the oral exam preparation because of the monthly sessions. (J11)-MCQs were educational but tricky unlike the board exam. The more MCQs you do the better you are trained. (S7)When asked about their confidence level toward sitting for the final exam, all residents mentioned the boost in their confidence for the final OSCE exam compared to previous years, which helped lessen the anxiety that usually accompanies the final written promotion exam. Moreover, all residents obtained better marks by passing the final year promotion exam. Out of the 24 interviewed residents, 2 have not found a noticeable impact of the modified educational approach on exam preparation.One of the constantly mentioned positive impacts is their attempts to adapt to the new style where audience engagement is mandatory. Residents who were not used to engaging their audience had to develop skills in thinking of the right questions to ask in order to deliver their knowledge. Adhering to the rule of slide presentation made their slides better with fewer written words and more pictures; hence, it was more entertaining. Residents also mentioned that anxiety was lowered when presenting because they knew the responsibility of knowledge delivery was mutual between them and the audience. One of the critical skills the residents mentioned was time management while presenting. Staying focused between the several pauses for discussion and the need to finish on time was initially difficult but then it got easier with time and practice.I developed the skill of how to make the lecture for the discussion, how to manage the time, how to covert the lecture to discussion, at first it was a distaste later it was piece of cake. (J11)Some residents also mentioned increased confidence when presenting in front of a large group and developing group management skills.One of the significant perceptions noticed among the residents was the strong relationship they developed along the way with each other. Juniors looked up to their seniors with gratitude and respect, while seniors looked after their junior colleagues with much attention and care.I gained their trust (referring to the. juniors). They came for study advice I became a mentor for them. (S2)The impact of the modified educational approach on different learning and social aspects as mentioned by residents is illustrated in The perception of challenges that the residents experienced along the way was crucial to properly putting together and improving plans for the next academic year. Acceptance of change was one of the mentioned challenges. Most residents had difficulty accepting the new modification in their learning experience, despite dissatisfaction with how educational activities used to be. It took them a while to experience the benefits of the modified approach to submit to these changes.I had a challenge to accept the change. But when we agreed that now we know better we got convinced. (S1)Residents took 4–9 weeks to adapt to the modified way of teaching. Adaptation varied depending on their personality type and residency level. Juniors were faster to adapt than seniors, especially the new residents who did not have prior experience with the educational activity's older versions. Resistance to change and longer adaptation time were most noticed among residency levels 2 and 3. Level 4 residents were more ready to accommodate the changes and accept the responsibility.- Different characters of residents and how deal with everyone was a challenge because you have to know all of them because you will work with them. Dividing us to small groups made the adaptation to the large number easier. (J3)[SIC]R1 needed help adapting to the enormous amount of curriculum they must cover. Some residents had difficulty adapting to speaking up and sharing their knowledge and opinions, and others had to take some time to adapt to the different personalities in the group. Moreover, a few junior residents needed help adapting to the new way of presentation.-We had to speak and interact rather than listening against my introvert personality. Adaptation took some time approximately 4 weeks. (J6)[SIC]One of the challenges the residents encountered was pre-reading the topics before attending the educational activity in order to participate and collaborate in the discussion. Many residents, especially the R1s, complained about the knowledge they needed to cover. Others acted differently and read only the objectives. The less complaining residents were those who managed to align their home study schedule with the educational activity schedule.The topics were huge to us and big struggle because we didn't have previous exposure. But I was assured that I will know this knowledge by time. (J9)[SIC]I need to read all topics before I come because I'm the senior. The long time was exhausting. (S3)Another huge challenge for most residents was the amount of mental effort they needed to exert in 6 h compared to the traditional way of teaching. Many residents attributed the mental exhaustion to the continuous attention they needed to pay during the discussion and their active participation. Some residents highlighted that they could reach the end of the activity cognitively saturated with energy loss to continue the afternoon part and accordingly gain less benefit. Other challenges were the early timing of the activity and the length of the day, especially for the group assigned to the simulation that week.Mental effort exerted during the activity was a challenge. Because we have to be ready to answer all the time. (J8)The challenges toward the modified educational approach as perceived by residents are illustrated in The high satisfaction level was almost consistent among junior residents but decreased slightly among seniors. General satisfaction included their engagement during the group discussions, better comprehension of the materials and longer retention, enthusiastic debates, peer teaching, and increased confidence to share knowledge.Other elements were mainly about the friendly atmosphere, utilization of simulation, hands-on workshops, and SOE preparation sessions.On the other hand, dissatisfaction elements were different for juniors and seniors. Juniors spoke mainly about the colossal curriculum they needed to cover, how the year started with tough topics for their level, and the self-study topics they wished they could discuss.Seniors spoke about the basic level of discussion for specific topics, the lack of certain non-medical topics such as ethics and professionalism, the lack of consultants' lectures, and the more attention given to the junior level compared to the senior level.Both levels, juniors and seniors, complained about the heaviness and length of the educational day, the limited benefit they perceived when group members did not share responsibility and read the topics beforehand, and the fact that we had to switch to complete online mode toward the middle of the year. Areas of satisfaction and dissatisfaction toward the modified educational approach as mentioned by residents are shown in The aim of the study was to explore the residents' experiences regarding implementing the new teaching and learning approach. The teaching strategies used in the new educational activity were based on multiple learning theories, including constructivism  and sociInquiry-based learning, case-based learning, and small group learning are examples of collaborative learning strategies used to enrich educational activities' quality, increase resident satisfaction, increase knowledge retention, and enhance resident engagement. One of the principles of Adult Learning Theory is that adults are self-motivated and promote their learning process . Thus, tThe new modified teaching approach faced the challenges of limited human, physical, and financial resources. In terms of human resources, educational activity used to rely heavily on consultants' involvement in terms of knowledge delivery. With the program separation and limited consultants' availability, the new approach considered all final-year residents as a source of excellent knowledge and experience for the rest of the group. Accordingly, each group had heterogeneous resident levels, allowing for hierarchical knowledge sharing. On the other hand, the consultants' role was diverted to supervision and moderation of the discussion. Such empowerment for the residents gave them more room to own their learning and engage in scientific debates to answer their inquiries instead of the ancient perception of having the consultant as the only source of information.Although the general perception of residents toward the change was considered very good, a few points had to be explored for better satisfaction and a durable impact. Active learning is considered a powerful tool that integrates theory into practice . With suPeer teaching is any educational activity involving students engaging in the educational cycle as partners . There aSpaced repetition is a learning method that allows students to learn more in less time. Although discovered over a decade ago, the technique has an enhanced effect on meaningful retention  at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS). Resources included the lecture hall, technical support, audio-visual support, and simulation center support. As for the financial support, the activity was self-funded by the residents who sponsored the catering and the appreciation events. Replicating the process with limited physical resources would take a lot of work. Good planning and preparation can mitigate the situation by considering factors such as utility and practicality.This qualitative study only captured the self-perceived views of the participants regarding the new approach. Moreover, there might be a potential unintended influence by the interviewer on the interviewee's responses regarding their satisfaction since the interviewer is the program director. However, the influence was limited since both parties were keen to explore the experience for future improvement.This study highlights the benefits and challenges of incorporating active learning into the postgraduate emergency medicine residency training program. Moreover, it links the benefits directly to the residents' home study, work environment, clinical practice, and exam preparation. It also shows improved self-perceived satisfaction compared to passive learning. The study tested several modes of information delivery with a detailed explanation of each one's advantages and disadvantages and concluded that mixing both modes, online and physical attendance, is highly regarded by the residents.The authors strongly recommend changing the learning culture from passive to active teaching in all post-graduate residency training programs. Moreover, the authors recommend mandatory curriculum alignment of the educational tools in the weekly educational activity to the assessment tools at the end of the year for better residents' exam preparation, confidence level, and hopefully better exam performance.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. The patients/participants provided their written informed consent to participate in this study.KB: interviewing candidates, recording interviews, records transcription, transcripts thematic analysis, and writing manuscript. SA-N and AA: reviewing transcription, reviewing thematic analysis, and reviewing manuscript. All authors contributed to the article and approved the submitted version.