Indian J Pediatr DOI 10.1007/s12098-014-1362-2
REVIEW ARTICLE
E-Learning in Newborn Health – A Paradigm Shift for Continuing Professional Development for Doctors and Nurses Aparna Chandrasekaran & Anu Thukral & Ashok K. Deorari
Received: 30 October 2013 / Accepted: 22 January 2014 # Dr. K C Chaudhuri Foundation 2014
Abstract Neonatal mortality can be largely prevented by wide-scale coverage of components of essential newborn care and management of sick neonates in district-level healthcare facilities. A vital step in this direction is imparting the requisite knowledge and skill among healthcare providers. Medical education programs with their static curricula seldom adapt to the changing needs of neonatal healthcare providers in patient-centered, collaborative and remote delivery contexts. E-learning is emerging as the cutting edge tool towards refinement of knowledge, attitude and practices of physicians. Module-based e-learning courses can be blended with a skill learning contact period in partnering institutions thus saving resources and rapidly covering a wide geographical region with uniform standardized education. In this review, the authors discuss their experience with e-learning aimed at introducing and refining the understanding of sick newborn care among pre-service and in-service doctors who manage neonates. Keywords E-learning . Newborn health . Education
Introduction Improving newborn survival and health is fundamental to achieve the Millennium Development Goal 4, which aims at reducing under-5 deaths by two-thirds by the year 2015 from A. Chandrasekaran : A. Thukral : A. K. Deorari Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
the 1990 baseline rates. A large proportion of neonatal mortality can be averted by essential newborn care practiced by healthcare providers [1]. Health care providers and systems are faced with the multifaceted challenge of catering to an increasingly proactive healthcare seeking population coupled with an explosive growth of knowledge and technology leading to widening health inequalities within and between countries [2]. Therefore, the need for keeping oneself updated with the latest, also referred to as “continuing professional development” (CPD) cannot be over-emphasized. Consequently, a paucity of competent teachers to train healthcare professionals has emerged. Medical education programs, with their static curricula, seldom adapt to the changing needs of physicians in patientcentered, collaborative and disparate delivery contexts. In addition, it may be difficult for health care providers to attend time-bound educational activities because of other time, money constraints for travel and professional commitments. Moreover, adults often find it difficult to take up passive learning through didactic lectures [3]. With a wide availability of information technology, the emphasis is now shifting from “expert-led teaching” to “user-led learning” through adaptable medical educational packages [4]. E-Learning is emerging as the cutting edge strategy to acquire knowledge and skills. It offers the added advantage of providing a platform to engage and collaborate with individuals in remote locations at flexible timings and at low training cost. Thus this modality encourages self paced learning with standard course delivery and monitoring [2].
Current Status of E-Learning in the Medical Arena A. K. Deorari (*) WHO Collaborating Centre for Training and Research in Newborn Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: [email protected]
E-learning has adapted itself to be disseminated through a multitude of gadgets starting from internet-connected computers to smart phones [5]. E-learning has been successfully
Indian J Pediatr
used in several specialties such as anatomy [6], oncology [7], dermatology [8], otorhinolaryngology [9] etc. However, data supporting the usefulness of e-learning has not been uniform due to varying methodology between studies and lack of standardized evaluation techniques [7]. Ricks et al., developed a web-based computerized tutorial using digital images, short video clips, and instructional text in three pediatric emergency procedures - laceration repair, splinting of fractures, and lumbar puncture and randomized a group of undergraduate doctors to web based learning or control [10]. The residents who received computer assisted learning had higher mean scores in a multiple choice examination at the end of the program compared to controls. In another study, a total of 28 students undertook a simulated pediatric resuscitation assessment before and after completing a structured e-learning module. There was a 57.7 % improvement (95 % CI 34.9–80.5 %) in basic life support competence after the module and a significant augmentation in the time to recognition of cardiac rhythm and time to first defibrillation [11]. A meta-analysis of 201 eligible studies found significantly higher scores in the internet based learning group for knowledge, skills, behavior and patient effects in comparison to no intervention. The topics covered in internet based training included ethics, anatomy, evidence-based medicine, interpretation of electrocardiograms and pulmonary function tests in addition to many others. Most interventions involved tutorials, some involved online discussion with peers, instructors, or both. Non-internet comparison interventions most often involved face-to-face courses, paper modules, satellite-mediated video conferences, and slide-tape self-study modules. Internet based learning however failed to demonstrate any difference from the non-internet based traditional learning [12]. Due to an enormous growth in technology, entertainment and design, there has been an upsurge in the power of this new collaborative learning medium. In addition there has been an explosion of interest and aggressive engagement from top global universities in the field of online learning. There is no limitation of time zones, income or any physical or political boundaries. The earlier barriers of bandwidth and the cost of Internet access are also falling. The scope of internet based learning presently covers all the possible fields of medical education [13, 14].
modules delivered over a 1-year period, within a “Virtual Learning Environment” [15]. The program served a highend group of pediatricians at tertiary care facilities. Although participation was high initially (100 %), the authors reported that it gradually declined to 46 % in the final module, mainly due to inadequate time. Nearly 85 % trainees were contactable at the programme end of which, majority (92 %) reported that participation had “added value” to their training, attributable to the high-quality curriculum, the educational resources, the process of collaborative networking and the sharing of best practices. A module on essential newborn care (ENC) for nurses encompassing core newborn care elements (care of the baby at birth, feeding and thermal protection of newborn, resusCitation, prevention of infection etc.) was developed at the All India Institute of Medical Sciences (AIIMS). Subsequently the first ENC online course (including the above modules, webinars and videos on essential newborn care, discussion forums, case studies and chat sessions) was piloted and then run simultaneously at seven centres in India and Maldives. Among 98 participants enroled in the study, 79 % completed the posttest assessment. There was significant increase in knowledge and skills scores [multiple choice question (MCQ) test: mean difference: 6.4 (95 % CI: 5.6–7.17), objective structure clinical examination (OSCE): mean difference: 15.4 (95 % CI: 12.7– 18.1)]. All the participants expressed satisfaction with content and delivery of the learning module. The detailed feedback and results of this course have been previously published [3, 16].
Need of a Structured Content for E-Platform With the explosive growth of material on medical education on the internet and the increasing access to these resources by one and all, one tends to get overwhelmed by the quantum of this information. Much of this information is either general or too detailed [17]. A structured platform focusing on vital concepts make the entire effort more interesting and useful for students. The ONTOP-IN (Online Neonatal Training Orientation Program- in India) an online web based teaching learning program was conceptualized by senior faculty members of the Division of Neonatology, AIIMS, New Delhi. This program incorporates all the key criteria required for designing a successful module [7].
E-Learning in Newborn Health In the field of neonatology, the neonatal online training and education (NOTE) program was the first attempt in neonatal postgraduate and specialist training launched by the University of Southampton, United Kingdom. The program provided online education to ninety trainees from 14 countries, primarily in Europe, using six educational
E-Learning Platform ONTOP This e-learning platform hosts two main ongoing courses and is based on Moodle platform. Essential newborn care course has been designed for the nursing professionals and sick newborn care course has been designed for the first and
Indian J Pediatr
second year pediatrics residents and in-service doctors. The contents of essential newborn nursing course for small hospitals has been digitized, supplemented with additional resource materials and provided online to the nurses for a period of 6 wk followed by skill-learning in partnering institutions. The systematic evaluation of this course has been previously published [14]. The first sick newborn course enroling 226 participants spanned 3 mo from June 2012 to August 2012 followed by the second course with 260 participants. Each group had 2–3 tutors chosen from the cohort identified and in addition a more senior tutor (who was generally a specialist on the core content). The tutors had a previous experience in online learning or had participated in a previous online learning program [16]. Likewise, the second course catered participants from 11 centers (9 from India and one each from Pakistan and Nepal) between August and October 2012 and the course early in the year 2013 had over 250 participants. The 4th sick newborn course which was launched on 5th September is currently underway with 212 participants.
Content of the Module Sick newborn care module which targets the first and second year pediatrics residents and in-service doctors working in the small hospitals, consists of a 13-wk program focused on core topics pertaining to newborn health, each topic being covered over a week’s time. The topics include breast feeding, feeding of healthy newborns and alternative methods of feeding, temperature maintenance and kangaroo mother care, neonatal hypoglycemia, seizures, hyperbilirubinemia, neonatal sepsis and infection prevention, respiratory distress, shock, retinopathy of prematurity and triage of sick newborn. Ongoing changes were done in the contents based on feedback from students and teachers. The more extensive topics such as neonatal sepsis were covered over 2 wk. The learning materials comprise of: & &
&
&
Online webinars by experts in neonatology from all over the country on common neonatal morbidities Audio visual podcasts along with job-aids on common neonatal equipment with corresponding explanatory texts covering indications, parts of the equipment with functions, mechanism of action and trouble-shooting Self-reading materials – a) Standard treatment protocols of common neonatal diseases approved by the World Health Organization (WHO) for use in SCNUs and b) Evidencebased, peer-reviewed management protocols of neonatal diseases practiced in the apex institute and c) Matching script for the equipment podcasts A poster illustrating the key messages of the week
&
Video films relevant to the week’s topic (e.g., expression of milk, kangaroo mother care)
Purpose and Creation of the Contents The self-reading lesson was available online for free downloading and reading. The text of the lesson was designed to complement the pre-service/in-service education materials and orientation of health professionals. It was reviewed by the experts in that field and then loaded for reading. The webinar on the week specific topic, presented in a lucid manner by an expert neonatologist of the country illustrated the important aspects of the topic and also summarized key practical messages. The power point presentation used in the webinar with a matching script was also provided every week to ensure a wholesome learning experience. In addition, a video illustrating the skill of a particular procedure (e.g., the method for recording a temperature in a newborn and a video on the actual practice of kangaroo mother care) were loaded. This approach helped the learners clarify their doubts and also enlightened them on the practical issues in the implementation of the skill or the routines. The evolution of the podcasts on neonatal equipment constituted a vital aspect of the module. It was realized that despite the availability of the-state-of-the-art equipment, health professionals at small hospitals get frustrated with the frequent breakdowns, minor malfunction and the delay in maintenance measures of the equipment; thus compromising the continuity and quality of care of patients. In view of this need, these audio-visual podcasts were specifically developed to address day-today issues in equipment-the principle behind their functioning, common errors encountered and common managerial and maintenance trouble-shooting. The podcasts incorporated visual images of the equipment and their parts with explanation on the mechanism by which they function. The text and the power point of each podcast were reviewed by three experts in that field. In addition, the inputs from the dealers of the equipment were taken to ensure that the common issues have been well addressed. Podcasts were created for the radiant warmer, dextrometer, oxygen concentrator, phototherapy, resuscitation bag, pulse oximeter and weighing scale. In addition to these podcasts, reading text material, job aids for easy handling of the equipment covering important points for handling and some frequently asked questions (FAQs) were also developed. After the creation of the entire package, the contents of each module were loaded week wise with pre-specified objectives to enable the learner to concentrate on the key issues in that specific topic.
Indian J Pediatr
Complementary Interactive Platform
Feedback
Weekly Lessons/Discussion Forums
The participants are motivated constantly by means of a) student-to-student as well as student-to-facilitator interaction provided in the online “discussion forum” of the course platform b) reinforcement and critical appraisal by the course facilitator and faculty of individual groups personally, through telephone calls, e-mails and short message services on mobile phones and c) positive feedback, prizes and appreciation to the winners of quizzes and toppers of MCQ tests. The ongoing interest of the participants is ensured through a regular feedback of their daily logs to their online tutor who provides them the feedback and regular appraisal through emails. The online tutor, in addition, has the responsibility of helping the participants with any local server related or course related issues. The students who logged in and answered all the MCQ’s and the quiz on the slotted time are complemented with more reading material. This is done with the aim to make them better clinical managers. The limitation faced in the first course was relative poor internet connectivity with some students and slow downloading of course content. This was overcome in the next two courses by providing the entire course material on a separate DVD which was given to all the participants at the outset. The participants who enroled in the third recently concluded course on sick newborn and successfully completed it were given a certificate with detailed marks (based on scores in MCQ, regular log-ins and participation in the discussion forum).
With each week, the lessons (including webinars, podcasts, and self-reading texts) for the week’s topic are posted on a website based on Moodle platform. Along with the week’s lessons, two case studies are provided describing a neonate’s clinical history, physical findings and laboratory investigations. This is followed by 4–5 questions which can be answered based on analytical reasoning gained from the knowledge of the week’s lessons. Participants are motivated to seek clarifications and to post comments and feedback through the “Discussion Forum” which functions via wiki board – where all participants can read and share views, answer queries and post fresh questions. The forum encouraged users to interact, share concepts presented by answering questions, challenge existing practices and post relevant citations and links to full text articles for those interested in deeper reading. Wherever pertinent, the case scenarios are accompanied by radiology- X rays and MRI images (e.g., MRI image of hypoglycemia induced brain damage), pathology – peripheral blood smears (e.g., hemolytic anemia) and clinical material – clinical photographs, videos (e.g., neurological signs in baby with kernicterus).
MCQ Examinations The participants are evaluated using multiple choice questions conducted synchronously for all cohorts at a stipulated timing. The questions have an assortment of true/false, multiple choice questions, calculations and one-word answers. The scores facilitate in tracking the progress made by users and also to identify the key areas which needed reinforcement. The test is repeated within the subsequent 24 h for those participants who could not take them up due to unavoidable reasons. A few selected questions pertinent to very vital aspects of management have negative marking. The score obtained and correct answers are provided instantaneously to encourage ongoing engagement. Immediate feedback with the correct solution is provided to reduce unwanted distraction and confusion allowing participants to focus on concepts presented.
Chat Session Every fortnight, chat sessions are conducted on this platform, among clusters of 6–7 cohorts steered by local tutors and the expert neonatologists, where participants share around 90 min of meaningful discussion on the topics covered in the previous 2 wk.
Discussion In this paper, the authors have discussed their experience with e-learning to introduce and refine the understanding of sick newborn care for the first and second year pediatrics residents and in-service doctors. The strengths of the online platform were a wide target population spread all over the country and abroad; being a comprehensive, peer-reviewed and evidence based educational material; incorporation of practical case management simulations within the conceptual framework; direct interaction with expert neonatologists on discussion and chat sessions; a user-friendly interface with regular assessment and feedback; and the participation of motivated tutors from various regions. The largest hurdles faced included poor internet connectivity in certain regions, dwindling motivation of students and tutors, ongoing service commitments and time constraints. The authors distributed a DVD/USB drive containing the materials to counteract the problem of poor internet connectivity and maintained online logs of all participants, which were periodically circulated to motivate those who defaulted.
Indian J Pediatr
In general, E-learning programs are faced with the disadvantages of lacking face-to-face interaction, high dropout rates, poor internet connectivity, non-user friendly interfaces, digital illiteracy, lack of accountability of learners and tutors and lack of hands-on activities [2]. This can be circumvented by blended course with skill-learning in the end and evaluation by OSCE. The key elements for the success of e-learning are- managerial and information technology (IT) support, committed instructors, motivated users and a flexible, userfriendly interface. Challenges to overcome before e-learning disseminates further in the field of medical education will need to be addressed. A great barrier to our understanding of the benefits of e-learning is the inadequacy of structured evaluation methods. A critical appraisal of the impact of this mode of teaching-learning on the level of understanding of concepts and skills is fundamental. Second, it is important to ensure that the skills acquired via e-learning are implemented on day-today basis, failing which attrition of acquired knowledge would be inevitable. Finally, if e-health programs were to expand, development of guidelines for accreditation of health facility shall also be crucial [2]. Research priorities in e-learning include studies to evaluate the correct place of computer-based learning in the medical curriculum, evaluation of applications disseminated via other gadgets, such as android phones, evaluation of the ideal “repetition interval” for e-learning and the advantage of implementation of associated practical sessions and their effect on psychomotor skills [11].
Conclusions E-learning for newborn health is still at nascent stage and the present experience is among the first of its kind from India. Use of hand-held devices (tablets and smart phones) are likely to emerge as the most cost effective medium for continuing education of health care providers. The learning can be blended with a component of contact period for skill learning in partnering institutions thus saving resources and covering a wide geographical area with uniform standardized education. The course content can be easily updated; tailored to the needs of medical professionals; and successful implementation of the E-learning programme in developing countries can turn out to be game changer.
Contributions AC: Helped in preparing the draft document and writing of the manuscript. She helped in developing contents of the course; AT: Helped in creation of contents of course, running the web based platform, conceptualised evaluation of course and helped in development of the draft and supervised the writing of the manuscript; AKD: Conceptualised the based teaching, co-ordinated the effort with other faculty and provided
inputs in manuscript writing as well and did overall supervision of the contents and would be the final guarantor of the manuscript. Conflict of Interest None. Role of Funding Source None.
References 1. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, costeffective interventions: How many newborn babies can we save? Lancet. 2005;365:977–88. 2. Ruggeri K, Farrington C, Brayne C. A global model for effective use and evaluation of e-learning in health. Telemed J E Health. 2013;19:312–21. 3. Deorari A, Thukral A, Aruna V. Online learning in newborn health: A distance learning model. Natl Med J India. 2012;25:31–2. 4. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of e-learning in medical education. Acad Med. 2006;81:207–12. 5. León SA, Fontelo P, Green L, Ackerman M, Liu F. Evidence-based medicine among internal medicine residents in a community hospital program using smart phones. BMC Med Inform Decis Mak. 2007;7:5. 6. Nicholson DT, Chalk C, Funnell WRJ, Daniel SJ. Can virtual reality improve anatomy education? A randomised controlled study of a computer-generated three-dimensional anatomical ear model. Med Educ. 2006;40:1081–7. 7. Morgulis Y, Kumar RK, Lindeman R, Velan GM. Impact on learning of an e-learning module on leukaemia: A randomised controlled trial. BMC Med Educ. 2012;12:36. 8. Curran VR, Hoekman T, Gulliver W, Landells I, Hatcher L. Webbased continuing medical education (I): Field test of a hybrid computer-mediated instructional delivery system. J Contin Educ Health Prof. 2000;20:97–105. 9. Kandasamy T, Fung K. Interactive Internet-based cases for undergraduate otolaryngology education. Otolaryngol Head Neck Surg. 2009;140:398–402. 10. Ricks C, Ratnapalan S, Jain S, Tait G. Evaluating computer-assisted learning for common pediatric emergency procedures. Pediatr Emerg Care. 2008;24:284–6. 11. O’Leary FM, Janson P. Can e-learning improve medical students’ knowledge and competence in paediatric cardiopulmonary resuscitation? A prospective before and after study. Emerg Med Australas. 2010;22:324–9. 12. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: A metaanalysis. JAMA. 2008;300:1181–96. 13. Ma JD, Lee KC, Kuo GM. A massive open online course on pharmacogenomics: Not just disruptive innovation but a possible solution. Pharmacogenomics. 2013;14:1125–7. 14. Murphy K, Munk PL. Continuing medical education: MOOCs (Massive Open Online Courses) and their implications for radiology learning. Can Assoc Radiol J. 2013;64:165. 15. Hall MA, Cuttini M, Flemmer AW, Greisen G, Marlow N, Schulze A, et al. European online postgraduate educational programme in neonatology-the way forward? Eur J Pediatr. 2009;168:449–56. 16. Thukral A, Sasi A, Chawla D, Datta P, Wahid S, Rao S, et al. Online Neonatal Training and Orientation Programme in India (ONTOPIN)–the way forward for distance education in developing countries. J Trop Pediatr. 2012;58:486–90. 17. Kalet AL, Song HS, Sarpel U, Schwartz R, Brenner J, Ark TK, et al. Just enough, but not too much interactivity leads to better clinical skills performance after a computer assisted learning module. Med Teach. 2012;34:833–9.
REVIEW ARTICLE
E-Learning in Newborn Health – A Paradigm Shift for Continuing Professional Development for Doctors and Nurses Aparna Chandrasekaran & Anu Thukral & Ashok K. Deorari
Received: 30 October 2013 / Accepted: 22 January 2014 # Dr. K C Chaudhuri Foundation 2014
Abstract Neonatal mortality can be largely prevented by wide-scale coverage of components of essential newborn care and management of sick neonates in district-level healthcare facilities. A vital step in this direction is imparting the requisite knowledge and skill among healthcare providers. Medical education programs with their static curricula seldom adapt to the changing needs of neonatal healthcare providers in patient-centered, collaborative and remote delivery contexts. E-learning is emerging as the cutting edge tool towards refinement of knowledge, attitude and practices of physicians. Module-based e-learning courses can be blended with a skill learning contact period in partnering institutions thus saving resources and rapidly covering a wide geographical region with uniform standardized education. In this review, the authors discuss their experience with e-learning aimed at introducing and refining the understanding of sick newborn care among pre-service and in-service doctors who manage neonates. Keywords E-learning . Newborn health . Education
Introduction Improving newborn survival and health is fundamental to achieve the Millennium Development Goal 4, which aims at reducing under-5 deaths by two-thirds by the year 2015 from A. Chandrasekaran : A. Thukral : A. K. Deorari Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
the 1990 baseline rates. A large proportion of neonatal mortality can be averted by essential newborn care practiced by healthcare providers [1]. Health care providers and systems are faced with the multifaceted challenge of catering to an increasingly proactive healthcare seeking population coupled with an explosive growth of knowledge and technology leading to widening health inequalities within and between countries [2]. Therefore, the need for keeping oneself updated with the latest, also referred to as “continuing professional development” (CPD) cannot be over-emphasized. Consequently, a paucity of competent teachers to train healthcare professionals has emerged. Medical education programs, with their static curricula, seldom adapt to the changing needs of physicians in patientcentered, collaborative and disparate delivery contexts. In addition, it may be difficult for health care providers to attend time-bound educational activities because of other time, money constraints for travel and professional commitments. Moreover, adults often find it difficult to take up passive learning through didactic lectures [3]. With a wide availability of information technology, the emphasis is now shifting from “expert-led teaching” to “user-led learning” through adaptable medical educational packages [4]. E-Learning is emerging as the cutting edge strategy to acquire knowledge and skills. It offers the added advantage of providing a platform to engage and collaborate with individuals in remote locations at flexible timings and at low training cost. Thus this modality encourages self paced learning with standard course delivery and monitoring [2].
Current Status of E-Learning in the Medical Arena A. K. Deorari (*) WHO Collaborating Centre for Training and Research in Newborn Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: [email protected]
E-learning has adapted itself to be disseminated through a multitude of gadgets starting from internet-connected computers to smart phones [5]. E-learning has been successfully
Indian J Pediatr
used in several specialties such as anatomy [6], oncology [7], dermatology [8], otorhinolaryngology [9] etc. However, data supporting the usefulness of e-learning has not been uniform due to varying methodology between studies and lack of standardized evaluation techniques [7]. Ricks et al., developed a web-based computerized tutorial using digital images, short video clips, and instructional text in three pediatric emergency procedures - laceration repair, splinting of fractures, and lumbar puncture and randomized a group of undergraduate doctors to web based learning or control [10]. The residents who received computer assisted learning had higher mean scores in a multiple choice examination at the end of the program compared to controls. In another study, a total of 28 students undertook a simulated pediatric resuscitation assessment before and after completing a structured e-learning module. There was a 57.7 % improvement (95 % CI 34.9–80.5 %) in basic life support competence after the module and a significant augmentation in the time to recognition of cardiac rhythm and time to first defibrillation [11]. A meta-analysis of 201 eligible studies found significantly higher scores in the internet based learning group for knowledge, skills, behavior and patient effects in comparison to no intervention. The topics covered in internet based training included ethics, anatomy, evidence-based medicine, interpretation of electrocardiograms and pulmonary function tests in addition to many others. Most interventions involved tutorials, some involved online discussion with peers, instructors, or both. Non-internet comparison interventions most often involved face-to-face courses, paper modules, satellite-mediated video conferences, and slide-tape self-study modules. Internet based learning however failed to demonstrate any difference from the non-internet based traditional learning [12]. Due to an enormous growth in technology, entertainment and design, there has been an upsurge in the power of this new collaborative learning medium. In addition there has been an explosion of interest and aggressive engagement from top global universities in the field of online learning. There is no limitation of time zones, income or any physical or political boundaries. The earlier barriers of bandwidth and the cost of Internet access are also falling. The scope of internet based learning presently covers all the possible fields of medical education [13, 14].
modules delivered over a 1-year period, within a “Virtual Learning Environment” [15]. The program served a highend group of pediatricians at tertiary care facilities. Although participation was high initially (100 %), the authors reported that it gradually declined to 46 % in the final module, mainly due to inadequate time. Nearly 85 % trainees were contactable at the programme end of which, majority (92 %) reported that participation had “added value” to their training, attributable to the high-quality curriculum, the educational resources, the process of collaborative networking and the sharing of best practices. A module on essential newborn care (ENC) for nurses encompassing core newborn care elements (care of the baby at birth, feeding and thermal protection of newborn, resusCitation, prevention of infection etc.) was developed at the All India Institute of Medical Sciences (AIIMS). Subsequently the first ENC online course (including the above modules, webinars and videos on essential newborn care, discussion forums, case studies and chat sessions) was piloted and then run simultaneously at seven centres in India and Maldives. Among 98 participants enroled in the study, 79 % completed the posttest assessment. There was significant increase in knowledge and skills scores [multiple choice question (MCQ) test: mean difference: 6.4 (95 % CI: 5.6–7.17), objective structure clinical examination (OSCE): mean difference: 15.4 (95 % CI: 12.7– 18.1)]. All the participants expressed satisfaction with content and delivery of the learning module. The detailed feedback and results of this course have been previously published [3, 16].
Need of a Structured Content for E-Platform With the explosive growth of material on medical education on the internet and the increasing access to these resources by one and all, one tends to get overwhelmed by the quantum of this information. Much of this information is either general or too detailed [17]. A structured platform focusing on vital concepts make the entire effort more interesting and useful for students. The ONTOP-IN (Online Neonatal Training Orientation Program- in India) an online web based teaching learning program was conceptualized by senior faculty members of the Division of Neonatology, AIIMS, New Delhi. This program incorporates all the key criteria required for designing a successful module [7].
E-Learning in Newborn Health In the field of neonatology, the neonatal online training and education (NOTE) program was the first attempt in neonatal postgraduate and specialist training launched by the University of Southampton, United Kingdom. The program provided online education to ninety trainees from 14 countries, primarily in Europe, using six educational
E-Learning Platform ONTOP This e-learning platform hosts two main ongoing courses and is based on Moodle platform. Essential newborn care course has been designed for the nursing professionals and sick newborn care course has been designed for the first and
Indian J Pediatr
second year pediatrics residents and in-service doctors. The contents of essential newborn nursing course for small hospitals has been digitized, supplemented with additional resource materials and provided online to the nurses for a period of 6 wk followed by skill-learning in partnering institutions. The systematic evaluation of this course has been previously published [14]. The first sick newborn course enroling 226 participants spanned 3 mo from June 2012 to August 2012 followed by the second course with 260 participants. Each group had 2–3 tutors chosen from the cohort identified and in addition a more senior tutor (who was generally a specialist on the core content). The tutors had a previous experience in online learning or had participated in a previous online learning program [16]. Likewise, the second course catered participants from 11 centers (9 from India and one each from Pakistan and Nepal) between August and October 2012 and the course early in the year 2013 had over 250 participants. The 4th sick newborn course which was launched on 5th September is currently underway with 212 participants.
Content of the Module Sick newborn care module which targets the first and second year pediatrics residents and in-service doctors working in the small hospitals, consists of a 13-wk program focused on core topics pertaining to newborn health, each topic being covered over a week’s time. The topics include breast feeding, feeding of healthy newborns and alternative methods of feeding, temperature maintenance and kangaroo mother care, neonatal hypoglycemia, seizures, hyperbilirubinemia, neonatal sepsis and infection prevention, respiratory distress, shock, retinopathy of prematurity and triage of sick newborn. Ongoing changes were done in the contents based on feedback from students and teachers. The more extensive topics such as neonatal sepsis were covered over 2 wk. The learning materials comprise of: & &
&
&
Online webinars by experts in neonatology from all over the country on common neonatal morbidities Audio visual podcasts along with job-aids on common neonatal equipment with corresponding explanatory texts covering indications, parts of the equipment with functions, mechanism of action and trouble-shooting Self-reading materials – a) Standard treatment protocols of common neonatal diseases approved by the World Health Organization (WHO) for use in SCNUs and b) Evidencebased, peer-reviewed management protocols of neonatal diseases practiced in the apex institute and c) Matching script for the equipment podcasts A poster illustrating the key messages of the week
&
Video films relevant to the week’s topic (e.g., expression of milk, kangaroo mother care)
Purpose and Creation of the Contents The self-reading lesson was available online for free downloading and reading. The text of the lesson was designed to complement the pre-service/in-service education materials and orientation of health professionals. It was reviewed by the experts in that field and then loaded for reading. The webinar on the week specific topic, presented in a lucid manner by an expert neonatologist of the country illustrated the important aspects of the topic and also summarized key practical messages. The power point presentation used in the webinar with a matching script was also provided every week to ensure a wholesome learning experience. In addition, a video illustrating the skill of a particular procedure (e.g., the method for recording a temperature in a newborn and a video on the actual practice of kangaroo mother care) were loaded. This approach helped the learners clarify their doubts and also enlightened them on the practical issues in the implementation of the skill or the routines. The evolution of the podcasts on neonatal equipment constituted a vital aspect of the module. It was realized that despite the availability of the-state-of-the-art equipment, health professionals at small hospitals get frustrated with the frequent breakdowns, minor malfunction and the delay in maintenance measures of the equipment; thus compromising the continuity and quality of care of patients. In view of this need, these audio-visual podcasts were specifically developed to address day-today issues in equipment-the principle behind their functioning, common errors encountered and common managerial and maintenance trouble-shooting. The podcasts incorporated visual images of the equipment and their parts with explanation on the mechanism by which they function. The text and the power point of each podcast were reviewed by three experts in that field. In addition, the inputs from the dealers of the equipment were taken to ensure that the common issues have been well addressed. Podcasts were created for the radiant warmer, dextrometer, oxygen concentrator, phototherapy, resuscitation bag, pulse oximeter and weighing scale. In addition to these podcasts, reading text material, job aids for easy handling of the equipment covering important points for handling and some frequently asked questions (FAQs) were also developed. After the creation of the entire package, the contents of each module were loaded week wise with pre-specified objectives to enable the learner to concentrate on the key issues in that specific topic.
Indian J Pediatr
Complementary Interactive Platform
Feedback
Weekly Lessons/Discussion Forums
The participants are motivated constantly by means of a) student-to-student as well as student-to-facilitator interaction provided in the online “discussion forum” of the course platform b) reinforcement and critical appraisal by the course facilitator and faculty of individual groups personally, through telephone calls, e-mails and short message services on mobile phones and c) positive feedback, prizes and appreciation to the winners of quizzes and toppers of MCQ tests. The ongoing interest of the participants is ensured through a regular feedback of their daily logs to their online tutor who provides them the feedback and regular appraisal through emails. The online tutor, in addition, has the responsibility of helping the participants with any local server related or course related issues. The students who logged in and answered all the MCQ’s and the quiz on the slotted time are complemented with more reading material. This is done with the aim to make them better clinical managers. The limitation faced in the first course was relative poor internet connectivity with some students and slow downloading of course content. This was overcome in the next two courses by providing the entire course material on a separate DVD which was given to all the participants at the outset. The participants who enroled in the third recently concluded course on sick newborn and successfully completed it were given a certificate with detailed marks (based on scores in MCQ, regular log-ins and participation in the discussion forum).
With each week, the lessons (including webinars, podcasts, and self-reading texts) for the week’s topic are posted on a website based on Moodle platform. Along with the week’s lessons, two case studies are provided describing a neonate’s clinical history, physical findings and laboratory investigations. This is followed by 4–5 questions which can be answered based on analytical reasoning gained from the knowledge of the week’s lessons. Participants are motivated to seek clarifications and to post comments and feedback through the “Discussion Forum” which functions via wiki board – where all participants can read and share views, answer queries and post fresh questions. The forum encouraged users to interact, share concepts presented by answering questions, challenge existing practices and post relevant citations and links to full text articles for those interested in deeper reading. Wherever pertinent, the case scenarios are accompanied by radiology- X rays and MRI images (e.g., MRI image of hypoglycemia induced brain damage), pathology – peripheral blood smears (e.g., hemolytic anemia) and clinical material – clinical photographs, videos (e.g., neurological signs in baby with kernicterus).
MCQ Examinations The participants are evaluated using multiple choice questions conducted synchronously for all cohorts at a stipulated timing. The questions have an assortment of true/false, multiple choice questions, calculations and one-word answers. The scores facilitate in tracking the progress made by users and also to identify the key areas which needed reinforcement. The test is repeated within the subsequent 24 h for those participants who could not take them up due to unavoidable reasons. A few selected questions pertinent to very vital aspects of management have negative marking. The score obtained and correct answers are provided instantaneously to encourage ongoing engagement. Immediate feedback with the correct solution is provided to reduce unwanted distraction and confusion allowing participants to focus on concepts presented.
Chat Session Every fortnight, chat sessions are conducted on this platform, among clusters of 6–7 cohorts steered by local tutors and the expert neonatologists, where participants share around 90 min of meaningful discussion on the topics covered in the previous 2 wk.
Discussion In this paper, the authors have discussed their experience with e-learning to introduce and refine the understanding of sick newborn care for the first and second year pediatrics residents and in-service doctors. The strengths of the online platform were a wide target population spread all over the country and abroad; being a comprehensive, peer-reviewed and evidence based educational material; incorporation of practical case management simulations within the conceptual framework; direct interaction with expert neonatologists on discussion and chat sessions; a user-friendly interface with regular assessment and feedback; and the participation of motivated tutors from various regions. The largest hurdles faced included poor internet connectivity in certain regions, dwindling motivation of students and tutors, ongoing service commitments and time constraints. The authors distributed a DVD/USB drive containing the materials to counteract the problem of poor internet connectivity and maintained online logs of all participants, which were periodically circulated to motivate those who defaulted.
Indian J Pediatr
In general, E-learning programs are faced with the disadvantages of lacking face-to-face interaction, high dropout rates, poor internet connectivity, non-user friendly interfaces, digital illiteracy, lack of accountability of learners and tutors and lack of hands-on activities [2]. This can be circumvented by blended course with skill-learning in the end and evaluation by OSCE. The key elements for the success of e-learning are- managerial and information technology (IT) support, committed instructors, motivated users and a flexible, userfriendly interface. Challenges to overcome before e-learning disseminates further in the field of medical education will need to be addressed. A great barrier to our understanding of the benefits of e-learning is the inadequacy of structured evaluation methods. A critical appraisal of the impact of this mode of teaching-learning on the level of understanding of concepts and skills is fundamental. Second, it is important to ensure that the skills acquired via e-learning are implemented on day-today basis, failing which attrition of acquired knowledge would be inevitable. Finally, if e-health programs were to expand, development of guidelines for accreditation of health facility shall also be crucial [2]. Research priorities in e-learning include studies to evaluate the correct place of computer-based learning in the medical curriculum, evaluation of applications disseminated via other gadgets, such as android phones, evaluation of the ideal “repetition interval” for e-learning and the advantage of implementation of associated practical sessions and their effect on psychomotor skills [11].
Conclusions E-learning for newborn health is still at nascent stage and the present experience is among the first of its kind from India. Use of hand-held devices (tablets and smart phones) are likely to emerge as the most cost effective medium for continuing education of health care providers. The learning can be blended with a component of contact period for skill learning in partnering institutions thus saving resources and covering a wide geographical area with uniform standardized education. The course content can be easily updated; tailored to the needs of medical professionals; and successful implementation of the E-learning programme in developing countries can turn out to be game changer.
Contributions AC: Helped in preparing the draft document and writing of the manuscript. She helped in developing contents of the course; AT: Helped in creation of contents of course, running the web based platform, conceptualised evaluation of course and helped in development of the draft and supervised the writing of the manuscript; AKD: Conceptualised the based teaching, co-ordinated the effort with other faculty and provided
inputs in manuscript writing as well and did overall supervision of the contents and would be the final guarantor of the manuscript. Conflict of Interest None. Role of Funding Source None.
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