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Fostering Symbiosis Between E-tutors and Lecturers of an English Studies Module at an Open Distance Learning University in South Africa


Thembeka Shange

University of South Africa, ZA
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E-tutors are viewed as major role players in supporting virtual collaborative learning. This is the view espoused by Kopp et al. (2012). Consequently, they are expected to bridge the gap between academics and students in an Open Distance Learning (ODL) environment. However, it has become apparent that the interaction between e-tutors and lecturers is somewhat problematic. This paper discusses the perceptions and expectations that e-tutors and lecturers of a module in the Department of English Studies, Academic Language and Literacy in English (ENG1503) at the University of South Africa (Unisa), an ODL institution, have about their interaction with one another. Data was obtained through responses to a survey completed by e-tutors and lecturers. Content analysis was conducted to find themes and patterns emerging from the e-tutors’ and lecturers’ comments. Preliminary findings indicate that the interaction between e-tutors and lecturers is concerning. Further research should explore ways of foregrounding the interaction between e-tutors and lecturers for the same module.

How to Cite: Shange, T. (2021). Fostering Symbiosis Between E-tutors and Lecturers of an English Studies Module at an Open Distance Learning University in South Africa. Open Praxis, 13(3), 253–263. DOI:
  Published on 31 Dec 2021
 Accepted on 29 Aug 2021            Submitted on 10 Oct 2020


E-tutoring is regarded as one of the ways of facilitating interaction between students and the teaching staff with the aim of providing student support in an Open Distance Learning (ODL) environment. When Unisa, where this study was conducted, introduced an integrated model of student support in 2013, I was appointed as an e-tutor for one of the modules in the Department of English Studies. At the time I observed that there was minimal interaction between the e-tutors and the lecturers of this module. Previous studies have reported that students as well as e-tutors in an ODL environment often feel disconnected, isolated and demotivated (Mashile & Matoane, 2012, as cited in Joubert & Snyman, 2018).

When I joined the University as a full-time lecturer at the end of 2018, I became interested in investigating the interaction between e-tutors and lecturers involved in the Academic Language and Literacy in English module (ENG1503) as I believed that this would impact positively on the students’ success and also contribute to minimising the distance between the teaching staff and the students. Available studies focus on the interaction between e-tutors and students, but none so far have paid attention to the interaction between e-tutors and lecturers.

To unpack the interaction between e-tutors and lecturers the following research questions were explored in the research:

  • RQ1: What are the perceptions of the e-tutors and the lecturers on their interaction in the e-tutoring space?
  • RQ2: What are the expectations of the e-tutors and the lecturers regarding e-tutoring in this module?

Literature review and the Community of Inquiry (CoI) framework

All research needs to be underpinned by theory. In fact, Silverman (2000) says the following: “Without theory, research is impossibly narrow, without research, theory is mere armchair contemplation”. In order to address the research questions of this study the Community of Inquiry was the lens through which the interaction between e-tutors and lecturers was viewed. This framework was considered suitable for the study because it emphasises the social constructivist theory which views learning as an active and constructive process in which a learner actively constructs their own reality through interaction with objects, events, and people in the environment (Bhattacharjee 2015, as cited in Caga & Skhephe, 2019, p. 139).

Recently many researchers in ODL highlighted the importance of a Community of Inquiry in online learning spaces. Anderson & Garrison (1997), and Moore (1989), as cited in Garrison & Cleveland- Innes (2005), state that a CoI must include various combinations of interaction among content, teachers, and students. In the view of Garrison and Akyol (2013) the CoI theoretical framework represents a process of creating a deep and meaningful (collaborative-constructivist) learning experience through the development of three interdependent elements – social presence, cognitive presence and teaching presence. Social presence has to do with the affective or emotional wellbeing of an individual. Lowenthal and Lowenthal (2010) explain this as the ability of people to present themselves as “real people” through a communication medium. Cognitive presence is the ability to construct and confirm meaning through sustained reflection (Anderson et al. 2001, as cited in Fiock 2020, p. 19). The third pillar, teaching presence, is concerned with the design, facilitation and direction of cognitive and social presences to support learning (Garrison & Arbough, 2007, as cited in Fiock 2020, p. 19). These are crucial pillars for providing support in an online environment as it puts the learners at the centre while also affording them the opportunity to construct meaning with their peers, their lecturers and the e-tutors in the case of the Unisa situation. In the view of Saadatmand et al. (2017, as cited in Mare & Mutezo, 2021, p. 166) the CoI framework considers learning in an online environment which requires learners to be actively engaged with the instructor, other learners and content to achieve meaningful and deep learning. E-tutors therefore play a role in providing learners with a platform to construct meaning through interaction with them about the content; they also play a social learning role by creating a student-friendly social environment conducive to interactive learning and helping students to overcome feelings of isolation and lack of motivation (Mare & Mutezo, 2021).

When one looks at the situation of e-tutors at Unisa, it is clear that they are crucial role players within the Community of Inquiry framework as they are expected to provide the three presences as articulated in Figure 1.

Community of Inquiry framework (Garrison et al., 2000)
Figure 1 

Community of Inquiry framework (Garrison et al., 2000).

The key aspect of the CoI framework is to put the learners at the centre by providing them with an educational experience in a collaborative environment with lecturers, e-tutors and other peers. It remains a concern that interaction between e-tutors and lecturers seems to be lacking as this may affect the students’ educational experience in a negative way.

E-tutoring in an English Studies module at Unisa

Currently academics in the English Studies modules are not directly involved in the e-tutor appointments. The University sets out the recruitment criteria and the appointments are handled by the Tutorial Services, Discussion Classes and Work Integrated Learning (TSDL) Directorate. The primary lecturer for the module receives CVs from TSDL seeking approval. According to advertisements for 2020/2021 e-tutors, the minimum requirement is an honours bachelor’s degree in the subject concerned. Kiran et al. (2012, as cited in Mare & Mutezo, 2021, p. 169) emphasise the importance of appointing an e-tutor who is also a practitioner or specialist in a specific subject area. In some disciplines a bachelor’s degree is acceptable. In terms of e-tutor duties and responsibilities the following have been set out by the University of South Africa as per advertisement by the College of Human Sciences (2019):

  1. Facilitate online delivery of tutorial material
  2. Manage students’ learning experiences online
  3. Facilitate students’ interactions with their peers online
  4. Provide students with academic and technical support online

The duties and responsibilities outlined above capture the three pillars, that is, social, cognitive and teaching presence as highlighted by the Community of Inquiry framework. Once the e-tutors are appointed, the academic co-ordinator arranges their generic training which is provided for all e-tutors from various disciplines. The primary lecturer for the module is the main leader providing guidance to the e-tutors on academic matters. The academics involved devise an e-tutoring plan for the module which the academic co-ordinator then shares with the e-tutors. For the ENG1503 module an e-tutor site was created on myUnisas with the aim of fostering interaction between e-tutors and lecturers. Additionally, some e-tutor activities have been included in Tutorial Letter 501 which is the study guide that student are using at the moment. This is another way of enhancing interaction between e-tutors and students. Currently there are 26 e-tutor sites activated for the Semester 2 ENG1503 students. The total number of students is approximately 28000. The supervision of e-tutors lies with lecturers. Each lecturer manages about two e-tutors, depending on the number of active e-tutor sites. At the end of each semester, reports on the e-tutors’ performance are compiled by the academics so as to assist with the e-tutor activation in the following semester.

The role of e-tutors

Kopp et al. (2012) contend that e-tutors play a critical role in fostering productive interactions in collaborative settings. In the view of Kirschner et al. (2006), collaborative learning per se is not successful without adequate support. It would appear as though collaborative learning also has its challenges. For instance, O’Connaill et al. (1993, as cited in Kopp et al., 2012, p. 12) opine that virtual collaborative learning is even more demanding for learners as the virtual context involves new ways of communication and collaboration. For example, since this context lacks non-verbal cues, learners often do not know how to collaborate adequately (Kopp & Mandl, 2011, in Kopp et al., 2012, p. 12), and therefore it becomes necessary to provide support in collaborative learning situations. This is the role that e-tutors are expected to play in a collaborative learning environment. Different online environments give various names for the phenomenon of providing support to e-learners. Rautenstrauch (2011, as cited in Kopp et al., 2012, p. 12) provides the following names: tele-tutor, online coach, e-moderator, tele-teacher, online facilitator and e-trainer.

Many researchers agree that in addition to discipline-specific expertise, it is necessary for e-tutors to possess pedagogical, communicational and technological competencies (Denis et al., 2004, McPherson & Nunes, 2004, as cited in Kopp et al., 2012, p. 12). Since e-tutoring can be defined as all activities that support learners in their learning process, it seems necessary for e-tutors themselves to be equipped with an appropriate set of skills and attributes in addition to subject matter expertise. In previous research, a number of different specific competencies have been suggested for fostering online learning. They are:

  1. content-specific knowledge to support cognitive activities;
  2. pedagogical knowledge to initiate and sustain adequate learning processes on a motivational and meta-cognitive level, and to adequately cope with learners’ struggles on a social level (social activities); and
  3. technical knowledge about the functioning of the Internet, technical skills and knowledge on net-based communication. This kind of knowledge reflects the “e” in the term “e-tutor” (Lepper et al., 1997; Salmon, 2000; Schmidt & Moust, 1995, as cited in Kopp et al., 2012, p. 13).

Furthermore, the e-tutor needs a wide range of tutoring skills in order to assume different roles, such as content facilitator, metacognition facilitator, process facilitator, advisor/counselor, assessor, technologist, resource provider, etc. (e.g., Denis et al., 2004; McPherson & Nunes, 2004, as cited in Kopp et al., 2012, p. 13). Because of this diverse range of competencies, skills and roles, e-tutors must adequately prepare for their work in facilitating online collaboration (Banks et al, 2004, as cited in Kopp et al., 2012, p. 13). In the case of Unisa, it would be interesting to know how far these skills are being taken into consideration when e-tutors are appointed.

Student support in ODL

Tait (2000) opines that many factors influence student support in open distance learning. He further cites factors like the characteristics of the students, the demands of academic programmes and courses, the geographical environment, the technological infrastructure, the scale of the programme, as well as the requirements of management. He concludes that there is therefore no universal blueprint for the design of student support services. A number of researchers agree that the success of ODL depends on the use of a variety of technologies. Ngubane-Mokiwa and Letseka (2015) contend that every student’s learning can be optimally supported by modern electronic technologies and other digital facilities. It is against this background that I believe in the optimal use of available technologies in the Unisa learning system.

In my interaction with undergraduate students I noticed from the nature of their queries that they needed a lot of support over and above queries relating to academic work. I also realised that at times they needed to feel the lecturer’s presence, more than anything. Researchers in ODL emphasise the importance of maintaining a social presence in an ODL learning space. Saxena and Panigrahi (2019) highlight the importance of motivating the learners and solving their problems in a speedy manner. Lack of student engagement in ODL remains an unresolved issue which needs attention. In the view of Rose (2017, p. 24) the prevalence of faceless contacts may contribute to an inability to engage emphatically with others. Additionally, students may struggle to deal with what Rose and Adams (2014, p. 14) refer to as “technology enabled bombardedness”.

I have observed that students prefer to engage on other social platforms where they might feel more at liberty to make mistakes without anyone judging them or even have the freedom to talk about their personal issues without the involvement of the lecturer. Platforms like Telegram, Whatsapp, etc., seem to enjoy more support from the students compared to the official myUnisa platform. This is an area which needs intensive research so that academics in ODL can successfully integrate these social network tools in their course design. Some researchers argue that social media encourages collaboration among students and teachers, while also encouraging them to share meaning (Adamson 2012, as cited in Wiid et al., 2015). It is this collaboration and sharing of ideas that encourages social presence in online learning. I contend that well-planned student support provides students with access to a community of inquiry.

Research processes

Data collection

This study used a qualitative approach regarding the research questions on the interaction between e-tutors and lecturers. This research approach was preferred as the relevant method to provide the “thick” description of participants’ feelings, opinions and experiences, while also interpreting the meanings of their actions (Denzin, 1989, as cited in Rahman, 2017, p. 102). The study was conducted from a social-constructivist perspective. Due to the Covid-19 pandemic, the qualitative survey for the e-tutors was posted on the e-tutor site in the Learner Management System (n = 7), while the same questions were distributed to the lecturers (n = 6) by e-mail.

Out of 26 e-tutors that were allocated to ENG1503, only 7 participated on the e-tutor site. This is because e-tutors get activated as the students’ registration process gets finalised. It is also a challenge that e-tutors only get activated for one semester at a time and that they are not able to access the site after the semester has ended. The profiles of e-tutors and lecturers appear as Appendices 1 and 2.

The invitation to complete the survey included an informed consent procedure. Both groups of participants answered the same questions in what was marked Appendices 3 and 4. The participants’ demographic information included gender, age range, and the number of years teaching the module. The survey was used to collect data on: (a) the type of training received by the e-tutors from lecturers; (b) communication between e-tutors and lecturers; (c) communication among the tutors; and (d) the expectations that both groups had of each other.

Data analysis

Qualitative data was analysed through content analysis. Patton (2002) understands content analysis as any data reduction, and sense-making effort that takes a volume of qualitative material and attempts to identify core consistencies and meanings. Themes, patterns, and categories that emerged from the e-tutor and lecturer survey data were interpreted to answer the research questions on the interaction between e-tutors and lecturers of the ENG1503 module at Unisa.


In this section, the data obtained using a qualitative method is presented. The findings from the survey responses of e-tutors (n = 7), and the lecturers (n = 6) are also presented. In each case an analysis of the data will be followed by a brief interpretation of the findings. As mentioned above, the data analysis was done by examining the e-tutor and lecturer responses to a survey that they completed. The views and expectations of lecturers and e-tutors were used to further explore the interaction between these two groups.

The intention of the survey was to elicit the perceptions and opinions of the e-tutors and lecturers of the ENG1503 module about the interaction between them. These were identified through an analysis of the themes, patterns and categories that emerged from the data obtained through the responses of the two entities based on the survey questions. Looking at the e-tutor and lecturer profiles in Appendices 1 and 2, the average experience in e-tutoring and lecturing for both e-tutors and lecturers ranged from about two to twelve years. This number was confirmed by both e-tutors and lecturers. As mentioned earlier, Unisa introduced e-tutoring in 2013, and only one e-tutor had been serving since then. The age range of the participants was 32 to above 36. In terms of experience in teaching or e-tutoring in the module, the range was between 1 and 20 years.

Type of training received or conducted for the module

There was consensus among both groups that lecturers of this module had provided no training. Comments like the following were made by both e-tutors and the lecturers:

The college has a coordinator for e-tutors. English Studies is lucky to have a dedicated person for e-tutors. She has always handled e-tutor training. As lecturers, we only provide e-tutor guidelines” (Lm1).

From this comment one gets a sense that the lecturers did not give a lot of attention to the discipline-specific training of the e-tutors. What also transpired was that the only training the e-tutors seemed to have received, was the generic training provided by the University after they had been appointed. It appeared as though the lecturers depended mainly on the e-tutor academic coordinator to provide non-discipline-specific training. Both groups agreed that training by lecturers was crucial for the e-tutors. One e-tutor captured the scenario well by saying:

No training from the lecturers themselves. We had to complete a portfolio which served as an assessment for being appointed or not. We had a workshop by the Programme co-ordinator. It was informative in so far as what the do’s and don’t’s are of tutoring” (ETf1).

Other training for enhancing e-tutoring skills in this module

In terms of the training needs of the e-tutors what seemed to be common between the two groups, i.e., e-tutors and lecturers, was e-tutors’ need for training in using online tools and how to integrate online technologies to enhance their facilitation skills. What seemed to have been crucial for most of the e-tutors was training in how to keep the students engaged. One e-tutor commented:

I think I would like more training on how to engage the students more. What appeals to them, what makes them engage on the site” (ETf2).

Communication between e-tutors and lecturers

In terms of communication between e-tutors and lecturers, both entities agreed that there was little to no communication at all. One of the six lecturers who completed the survey expressed frustration about the issue, saying:

I communicated with them throughout the year but I have stopped this year because of the lack of support.” She added, “I was in constant contact with them until I was told I should not contact them and then I have stopped. E-tutors really found the interaction refreshing” (Lf2).

It is unclear if this lecturer interacted with e-tutors about module-related issues.

Communication among e-tutors of the module ENG1503

Regarding communication among e-tutors themselves, there seemed to be evidence of some communication but there was no clear indication of how this communication should have taken place. In other words, it appeared as though it was a voluntary activity, as one e-tutor put it:

With the exception of those whom I know, I don’t really communicate much with any of them” (ETf4).

On the side of the lecturers, it appeared as though they had little or no communication with e-tutors. (Lm3) commented that he only communicated with e-tutors “once in a while due to other demanding module commitments”. This comment may indicate that this lecturer did not regard communication with e-tutors as a priority. This contradicts the idea that e-tutors are key to the lecturers’ teaching as alluded to by (Lm2).

Expectations of each entity

On this question there were slightly differing views between the e-tutors and the lecturers. For the first group the key issue was to have direct interaction with the lecturers whether face to face or by means of online technologies. A comment like:

… if they were to organize face to face training whereby e-tutors and lecturers will sit together and discuss the most important aspects of our module and how to successfully present lessons to our students” (ETm2)

suggests that e-tutors regard themselves as important role players in teaching the ENG1503 students. This notion was corroborated by (Lm1) who said this about the e-tutors:

They are our surest means to teach our students.”


In this section I discuss the findings presented and analysed in the previous section with regard to the themes that have emerged. I will do this in relation to the literature reviewed on e-tutoring and the CoI framework. The following themes are the principal ones that have been extrapolated from the data emanating from the e-tutor and lecturer survey. The themes from the findings are: lack of training, poor communication between e-tutors and lecturers, and non-aligned expectations.

Theme 1: Lack of training

When both groups were asked about the training of e-tutors, there was agreement that no training had been provided by the lecturers. One lecturer (Lf5) who had taught the module for eight years commented, “I have not exposed the e-tutors to any training”. This comment by one of the e-tutors (ETm1), “None from the lecturers, only e-tutor general training,” confirms that lecturers had not provided any content-based training for the e-tutors. What seemed to be clear is that lecturers depended on the generic training that the University provided for all the e-tutors once they got appointed. Kopp et al. (2012, as cited in Mare & Mutezo, 2021, p. 7) opine that e-tutors need to be equipped with appropriate pedagogical, communicational and technological competencies. Both groups also seemed to agree on the need for e-tutors to be trained in the use of online technologies. One lecturer spoke about:

how to integrate online technologies to enhance their facilitation” (Lm3).

This corroborates research which supports the view that e-tutors need to be equipped with technological competencies for them to successfully facilitate online learning.

E-tutors were quite explicit about the type of training they felt they needed. A comment like: “Training on how to engage with the students more, what appeals, what makes them engage on the site” (ETf2) indicates the e-tutor’s frustration with the lack of student engagement on the site. On the side of the lecturers, there seemed to be an expectation that e-tutors should be the ones fostering student engagement. This was echoed by this comment from one of the lecturers:

Help us find a way to attract more student participation” (Lm3).

Bomia et al. (1997, as cited in Saeed & Zyngier, 2012, p. 253) explain engagement as students’ willingness, need, desire and compulsion to participate in, and be successful in the learning process promoting higher level thinking for enduring understanding. From the views of both groups, it would appear as though the issue of student engagement in online learning remains unresolved. It was puzzling that lecturers seemed to expect e-tutors to assist them with promoting student engagement online when one would have expected lecturers to be the ones providing the e-tutors with the skills to facilitate fruitful student engagement. According to Bowers & Kumar (2015; Rose, 2017, as cited in Burke & Larmar 2021, p. 603), the ‘facelessness’ and lack of ‘personhood’ in online learning environments have been identified as isolating and challenging for many students.

Theme 2: Poor communication between e-tutors and lecturers

There was a general belief from both e-tutors and lecturers that communication between the two groups was not sufficient. This was confirmed by e-tutors’ comments like: “Very seldom…they are not easy to get hold of since they are in high demand” (ETf2) and “Seldom if ever” (ETf3). A similar sentiment was expressed by lecturers as one of them said the following: “Do not communicate with the tutors, only monitor and rate tutors” (Lm3). An e-tutor who seemed to be dissatisfied with the interaction with lecturers, said:

I have emailed lecturers in the past when I needed to upload external resources. We were told to obtain permission from them before uploading resources. I feel awful to say that I did not get a response to my email” (ETm1).

This may point to a lack of clarity about the Institution’s policy on e-tutoring. Also, the use of “them” may imply that there is a feeling of “us” and “them” and that the e-tutors do not see themselves as part of the team. This seems to corroborate the view that it may be a challenge to form meaningful relationships with ‘faceless others” (Rose, 2017). The importance of interaction in ODL is well documented. Moore (1989, as cited in Dzakiria & Idrus, 2005, p. 70) identified three types of interactions: student-content; student-teacher; and student-student. Also, in terms of the CoI, e-tutors play a similar role in facilitating a social, cognitive and teaching presence on the online platform. The lack of interaction between e-tutors and lecturers may lead one to conclude that the three presences are inadequately provided. According to Rovai (2000, as cited in Fiock, 2020, p. 286) lack of interaction may lead to a lack of commitment and dissatisfaction with group efforts.

Theme 3: Non-aligned expectations

When both groups were asked about what expectations they had of each other, there were differing views. One e-tutor expressed her opinion in a poignant manner and had this to say:

I think it would be nice if lecturers could put together an electronic portfolio for e-tutors. Don’t just give us topics to discuss, rather give us the content broken down into lessons so that all students and tutors are on the same level” (ETf3).

She further commented,

I’d like the Department to perhaps give ideas on what has been successful with other tutors and what types of activities students are responding to so that we can be more creative” (ETf3).

This comment puts an emphasis on the need for collaboration between e-tutors and lecturers, as well as among e-tutors themselves, and this collaboration talks to the CoI framework.

From the side of the lecturers, one of them said the following:

Guide the students through the module, offer a constant, consistent social presence for the students. This support is not necessarily simply one of content support but it is support in the form of ‘presence’. They are there for the students and that is key for me” (Lf2).

This comment seems to contradict the fact that almost all the lecturers had indicated that they had not provided any training to the e-tutors, yet they expected them to maintain a social presence for the students. Mare and Mutezo (2021) emphasise that it is crucial for a module teacher and an e-tutor to work together to determine which activities each site is conducting to eliminate repetition and confusion. This would also reinforce the interaction between e-tutors and lecturers to enhance the students’ educational experience online.


In this study, the survey questions that were answered by e-tutors and lecturers of ENG1503 helped to obtain their perspectives on the interaction between these two groups. Even though e-tutoring is viewed as an essential component for maintaining the three presences of the CoI framework, what became evident is that the interaction between the e-tutors and the lecturers remains an unresolved challenge in this module. The fact that e-tutors and lecturers did not seem to have clear communication may also contribute to an inadequate presence online.


All studies have limitations. Sometimes these limitations may have a negative effect on the outcome of the research. However, for the trustworthiness of the study, it is essential to acknowledge its limitations, as they may reveal areas for further research. In order to ensure the credibility of this research I ensured that the data from the participants was recorded accurately. Shenton (2004) explains credibility as an attempt to demonstrate that a true picture of the phenomenon under scrutiny is provided. To further increase credibility I included member-checking of the findings by obtaining feedback from the participants on the data, interpretation and conclusions. In this study, my colleague who is a Senior Lecturer in English Studies, acted as a “peer debriefer”, as he used his experience in ODL to advise on the flaws in the approach, which were then identified and eliminated. In this study, one of the limitations was that Unisa uses team teaching. This means that the same lecturers will not continuously deal with the same e-tutors since lecturers rotate within the different modules in the Department of English Studies. It should also be noted that this study is based on a small sample drawn from e-tutors and lecturers of one module, so the results may not be generalisable in a different context; however, the findings discussed may further influence future research on the subject of interaction in online learning.

It was also a challenge to find another study within the South African context which has focussed on the interaction between e-tutors and lecturers. This study investigated the interaction between e-tutors and lecturers of an ENG1503 module in an ODL institution. The literature review and the findings of the research confirm the need for more interaction between these two groups. Even though the concept of interaction in ODL has been the focus of much research, there seems to be no consensual definition for interaction in the existing literature (Soo & Bonk, 1998; Dzakiria & Idrus, 2003; Dzakiria, 2004, as cited in Dzakiria & Idrus, 2005, p. 69).

Future research should focus on foregrounding the interaction between e-tutors and lecturers to avoid confusion for the students. I would recommend that the interaction between these two groups should be explicitly foregrounded as part of the module design process so that the e-tutors and lecturers can work together in an integrated manner. This may also have implications for the Unisa e-tutoring policy which may need to be revisited, as the technology also triggers changes in the curriculum (Wang et al., 2015). The Covid-19 pandemic has made it even more urgent for ODL institutions to re-think their modus operandi and this would certainly have implications for e-tutoring at Unisa.

Additional File

The additional File for this article can be found as follows:


Appendix 1–4. DOI:

Competing Interests

The author has no competing interests to declare.


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