Art & science | e-learning
Implications of online learning for nurse managers Jillian McCarthy looks at the benefits and possible pitfalls in using e-learning programmes Correspondence [email protected] Jillian McCarthy is a senior lecturer at Manchester Business School, University of Manchester Date of submission August 8 2014 Date of acceptance August 29 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nm-author-guidelines
Abstract Online learning for nurses is growing in popularity, with programmes ranging from mandatory update training to part-time master’s degrees. E-learning, as it is known, offers flexibility in access to learning, study time and learning styles. In busy clinical areas, where guidance is provided on minimum nurse staffing levels, e-learning provides solutions for managers who wish to encourage professional development while maintaining adequate nursing cover. Caution must be taken, however, when choosing e-learning programmes, as quality and efficacy differ across the range. This article highlights the properties of good e-learning pedagogy to prepare nurse managers for successful assessment of these programmes. Keywords Online learning, e-learning, mandatory updates, continuing professional development, pedagogy, andragogy, communication technologies
Introduction ONLINE TRAINING and programmes of study for nurses are growing in popularity globally. E-learning, as it is known, offers flexibility of study, to the extent that it has been dubbed ‘Martini learning’: any time, any place, anywhere. It has the advantage of not requiring time away from the workplace for attendance and, in a climate of nurse shortages and minimum staffing ratios, this provides a neat answer for nurse managers who wish to encourage professional development while maintaining optimum staff numbers in clinical areas. Other advantages to online learning include the ability to study and revise materials to embed learning. The advent of mobile technologies has NURSING MANAGEMENT
increased the convenience factor, with nurses now accessing learning on tablets and smartphones as well as laptops and personal computers. However, the question of convenience versus efficacy lingers over e-learning. This paper addresses the growing trend for this type of learning among nurses, while considering how effective such a method of delivery is and how it affects nurse leaders and managers. E-learning is an all-encompassing term to describe learning supported by the use of information and communication technologies. It is suited to distance learning, but it can also be used with face-to-face approaches, when it can be referred to as blended learning. It is common for e-learning to be presented via a virtual learning environment (VLE), often with a managed information system, in order to create a private, managed learning environment. This can support all aspects of a programme through a standard user interface; examples include Blackboard and Moodle. Distance learning, flexible learning and open learning are all broader terms that often incorporate e-learning, but they include all instructional situations where educators and students are physically separated. The literature on the use of e-learning in nurse education is extensive, with support for and warnings against its efficacy. McKenzie and Murray (2010), for example, describe how technology can be harnessed to maximise learning opportunities for nurses and shape their professional identities. Conversely, McCarthy (2011) warns of the consequences of e-learning programmes designed hastily by inexperienced healthcare educationalists. The Department of Health (DH) has published several documents in support of e-learning, claiming unprecedented opportunities for flexible ways of working, savings in time and finances, and better patient care (DH 2011, 2012). Likewise, the Royal November 2014 | Volume 21 | Number 7 23
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Art & science | e-learning College of Nursing (RCN) offers a suite of online training resources, demonstrating a commitment to this style of delivery.
Online learning and nursing The advantages of e-learning are manifold for nurse leaders in staff undertaking mandatory updates and professional development. In a climate of accountability, where guidance is issued on safe nurse staffing levels (RCN 2010, National Institute for Health and Care Excellence (NICE) 2014), it is often untenable for nursing staff to leave clinical areas to undertake training or programmes of study. E-learning provides the flexibility for staff to undertake learning in their own time, encouraged not only by mandatory requirements, but also by the need to keep up with current practice and the added expertise this brings to portfolios. Despite the popularity of e-learning in pre- and post-registration training modules, this has yet to translate into a full range of programmes offered in higher education establishments, which are still relatively slow to embrace this style of learning (Petit dit Dariel et al 2012). Nonetheless, distance from the teaching establishment poses few problems and nurses can source and undertake relevant programmes from further afield. E-learning has other advantages for staff in terms of personal learning styles, as online programmes can be designed to incorporate a range of resources that enable participants to choose materials that are better suited to their needs. Videos demonstrating staff engaging with patients in a range of difficult clinical situations have proven to be an effective means of teaching nurses strategies for dealing with similar real-life scenarios (McConville and Lane 2006). The early concern among learners of an inability to use computers effectively is now almost extinct as technology has invaded most UK households in some form and become commonplace. In 2014, 38 million adults accessed the internet every day; 21 million more than in 2006 (Office for National Statistics 2014). The literature cites convenience and flexibility as the main contributing factors to nurses’ satisfaction with online learning (Gerkin et al 2009). E-learning is a great equaliser among participants, allowing quieter, less outgoing personalities an equal voice and the ability to discuss issues effectively through online discussion forums, wikis, blogs and chat rooms. McKenzie and Murray (2010) note that personalities can develop online, with normally quiet nurses gaining confidence in putting forward ideas in this safe environment and bringing their new-found social skills back to the workplace. Adult learning, 24 November 2014 | Volume 21 | Number 7
or andragogy, has other benefits too as the nature of e-learning encourages participants to be self-directed in managing their own learning time and styles. Other notable benefits in online learning are the networking opportunities available and the communities of practice that can develop, often among participants from a diverse range of backgrounds and experiences. This enables learning to be shared and effective strategies and applications to be taken back to clinical areas. The opportunity for the internationalisation of learning is easily harnessed through internet communications, which gives access to worldwide resources and can enable discussions with experts around the globe. The NHS Leadership Academy, for example, offers a range of development programmes, including the Nye Bevan programme for executive leaders and the Elizabeth Garrett Anderson programme for mid-level leaders. Both of these take advantage of online tuition from international experts including academics from Harvard University in the US, and Pretoria University in South Africa. The professional identity of nurses can be strengthened by e-learning, as it allows for ideas and practices to be explored in a safe environment away from clinical areas and patients (McCarthy 2009). With the current requirements for evidence-based practice and accountability, researching online can be practised and honed. Yet, despite the many reasons why nurse managers and leaders should be encouraging staff to engage with online programmes and modules, this advice comes with a warning within much of the literature (McCarthy 2009).
Cautions with online learning Learning has become a lifelong process and continual professional development for nurses is essential. As a lecturer-centred approach to education can prove costly, one of the challenges in the financially constrained education and health sectors is to deliver programmes for nurses that will reduce class contact time without reducing the quality of programmes (Glen 2005). While start-up costs mean that delivering online is not always a cheaper option initially due to designing the materials and purchasing the software on which to host the learning, there is a body of literature purporting that expenditure will decrease once programmes are up and running effectively (Berke and Wiseman 2004). Consider how one online programme can provide learning for thousands of users; in terms of resources, this is a different scenario from that of traditional teaching. The literature cautions, however, that good quality NURSING MANAGEMENT
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e-learning resources are not cheap methods of education, nor should they be regarded as such (Njenga and Fourie 2010). There are several issues to consider with e-learning in nurse education. Substantial training is required for nurse educators as they adapt to different working practices, moving from classroom-based lecturer to facilitator of e-learning. The literature commonly states that e-learning cannot replace educators (Washer 2001, Conole and Fill 2004, Salmon 2004), but it does appear that it can change their role considerably (McCarthy 2011). The materials with online learning for nurse education can vary from poor to excellent, so discretion is needed when purchasing these programmes. Many mandatory training packages are provided for NHS staff by privately owned training agencies and educational institutions. These often consist of online packages that are short in duration and require participants to work through information independently before undertaking multiple-choice tests. On successful completion of the training, certificates are produced as evidence of achievement. Attempts at the test are not limited in number; the correct answers can be memorised from previous failed attempts and it can be taken until a pass standard is achieved. This is cheap, quick and convenient and it ‘ticks a box’ for nurse managers and nursing staff in terms of achieving the mandatory update in question, but it is questionable whether this is a satisfactory outcome in the shadow of the report into care failings at Mid Staffordshire NHS Foundation Trust (Francis 2013) and other critical reviews. Although no direct correlation was made in the Francis report between unsatisfactory care and mandatory update training, when training in topics such as moving and handling patients, basic life support and data protection are provided by distance without social interaction with colleagues being built into learning packages, it is hard to envisage how compassion within these remits can be taught and discussed effectively. Successful e-learning takes place in a complex system involving students’ experiences of learning, educators’ strategies, educators’ planning and thinking, and the teaching and learning context (Glen and Cox 2006). Nursing knowledge and practice are growing at an exponential rate and, with this, comes a short shelf life for learning programmes in terms of efficacy, as new knowledge is generated (Gonzalez 2004). Programmes should never be rolled out without evaluation by internal and external educators, and by nurse participants and their managers. NURSING MANAGEMENT
Good e-learning pedagogy Successful e-learning for nurses is facilitated by experienced nurse tutors who maintain a strong online presence and organise communities of practice through discussion forums and chat rooms. Learning that is underpinned by theories of social constructivism (Vygotsky 1978) will ensure that participants work together, building on previous knowledge and experiences. Although nurse educators are limited to some degree by the need to provide curricula that accord with government policies (McCarthy and Holt 2007), they can offer content that is fully supported by evidence-based, effective methods of online tuition. It is in nurse managers’ interest to see reviews of the content of learning programmes before buying them. For mandatory training purposes, e-learning packages are often purchased by human resource management departments on behalf of their health service organisations, but they should still be evaluated internally for currency, efficacy and value for money. Knowledge of the difference between online learning and traditional methods is essential to make realistic and pertinent evaluations. Ya Ni (2013), building on the work of McConnell (2000), produced a review of the main differences between online and traditional learning (Table 1). In addition to an understanding of the differences between the two forms of learning, a knowledge of what constitutes good e-learning pedagogy is required to evaluate the efficacy of programmes. Learning aimed at professional development should adhere to principles of andragogy. Knowles (1992) states that andragogical assumptions in learning differ from those of pedagogical assumptions (Table 2, page 27).
The way forward If online learning is to be successful in nurse education, attention must be paid to the design of the learning programmes concerned. Managers need to ensure that staff are satisfied with the programme content and the methods employed, and that attrition rates from programmes are not increased through studying online (Salmon 2004). Programmes of a longer duration must feature online support including a strong online tutor presence, in addition to online library and administrative access. Individual tutorials should be encouraged throughout longer programmes of study and these can take place by telephone or webcam technology when face-to-face attendance is impossible. Group interactions are vital to build the foundations on which personal learning can take place, and also November 2014 | Volume 21 | Number 7 25
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Art & science | e-learning Table 1
Comparison of online and face-to-face learning
Mode
Online
Face-to-face
Discussions through text only. Can be structured. Dense, permanent, limited, stark where there are only pages of text.
Verbal discussions: a more common mode, but impermanent.
Sense of instructor Less sense of instructor control. control Easier for participants to ignore instructor.
More sense of leadership from instructor. More difficult to ignore instructor.
Discussion
Group contact continually maintained. Depth of analysis often increased. Discussion often stops for periods of time, then is picked up and restarted. Level of reflection is high. Able to reshape conversation on the basis of ongoing understandings and reflection.
Little group contact between meetings. Analysis varies, depending on the time available. Discussions occur within a set time frame.
Less sense of anxiety. More equal participation. Fewer hierarchies. Dynamics are ‘hidden’ but traceable. No breaks, constantly in the meeting. Can be active listening without participation. The technology has an impact on the learning as distances can give confidence. Different expectations about participation by the learners. Slower due to time delays in interactions or discussions.
Anxiety during meetings for less confident group members. Participation unequal. More chance of hierarchies. Dynamics evident but lost after the event. Breaks between meetings. Listening without participation may be frowned upon. The room may have less impact as it cannot be made visually appealing like the online setting. Certain expectations about participation.
Rejoining
High psychological and emotional stress of rejoining.
Stress of rejoining is lower.
Feedback
Feedback on individuals’ pieces of work is detailed and focused. Whole group can sometimes see and read each other’s feedback. Textual feedback only. No one can ‘hide’ and not give feedback. Permanent record of feedback obtained by all. Delayed reactions to feedback. Sometimes little discussion after feedback. Groups look at all participants’ work at same time.
Less likely to cover as much detail in a session as can be provided online; often more general discussion. Groups hear feedback.
Loose-bound nature encourages divergent talk and extracurricular learning. On discussion forums, the medium frees the message sender but may restrict the other participants (receivers) by increasing their uncertainty as to what is meant. Online discussion can be unclear and confusing, whereas in a classroom questions can be asked in real time.
More tightly bound, requiring adherence to accepted protocols.
Group dynamics
Divergence and choice level
26 November 2014 | Volume 21 | Number 7
Often little time for reflection during meetings. Conversations are less likely to be shaped during meetings.
Quicker, more immediate interactions or discussions.
Verbal and visual feedback. Possible to ‘free-ride’ and avoid giving feedback. No permanent record of feedback. Immediate reactions to feedback possible. Usually some discussion after feedback, looking at wider issues. Groups look at one participant’s work at a time.
Uncertainty less likely due to common understandings about how to take part in discussions.
NURSING MANAGEMENT
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Table 2
Andragogical assumptions
Subject
Pedagogical
Andragogical
Concept of the learner
Dependent personality
Increasingly self-directed
Role of learner’s experience
To be built on more than used as a resource
A rich resource for learning by self and others
Readiness to learn
Uniform by age level and curriculum
Develops from life tasks and problems
Orientation to learning
Subject centred
Task or problem centred
Motivation
By external rewards and punishment
By internal incentives such as gaining additional qualifications, promotion and salary rises
for nurses to build on previous knowledge and experiences. Weller (2002) discusses the problems with group work online, which may be due to a lack of the visual clues that aid face-to-face communications. The use of webcam technology can aid group work, by providing faces to names and allowing more personal interactions. Issues of synchronous and asynchronous learning are raised here, however, and it may be that timetables need
to be devised so that discussions and group work are given set times. If this is impossible, participants should be given guidelines regarding ‘netiquette’, the importance of which must be stressed. The use of ‘emoticons’ to accompany online discussions should be encouraged to clarify meaning (McCarthy 2009).
Conclusion If e-learning programmes are granted sufficient time for development by experienced and knowledgeable nurse educators, with additional technical and administrative support, these can be successful in educating and training nurses. Well designed online programmes acknowledge prior learning and allow this to be built on by groups of participants sharing and pooling knowledge and experiences that can be brought back to the workplace. Not only can online programmes assist with the problem of nurse shortages by providing flexibility in learning, they can also support differences in learning styles and study time. When designed appropriately, and evaluated and updated regularly, e-learning is not a cheap training option, but it can prove to be cost effective, not least because staff cover is not required for attendance. Wherever possible, however, study days should be allocated to staff undertaking online learning to demonstrate support and a clear commitment to the workforce. An educated and updated nursing team is essential in today’s economic climate, and well designed and managed e-learning programmes can successfully provide for this.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Berke WJ, Wiseman TL (2004) The e-learning answer: secure this education solution by setting a vision for its usage and building a sound business plan for its purchase. Critical Care Nurse. 24, 2, 80-84. Conole G, Fill K (2004) A learning design toolkit to create pedagogically effective learning activities. Journal of Interactive Media in Education. Portable Learning, Special Issue. Department of Health (2011) A Framework for Technology Enhanced Learning. www.gov. uk/government/publications/a-framework-fortechnology-enhanced-learning (Last accessed: September 25 2014.) Department of Health (2012) The Mandate. www.gov.uk/government/publications/ nhs-mandate-2014-to-2015 (Last accessed: September 25 2014.) Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. www.midstaffspublicinquiry.com/report (Last accessed: September 25 2014.) Gerkin KL, Taylor TH, Weatherby FM (2009) The perception of learning and satisfaction of nurses in the online environment. Journal for Nurses in Staff Development. 25, 1, 8-13.
NURSING MANAGEMENT
Glen S (2005) E-learning in nursing education: lessons learnt. Nurse Education Today. 25, 6, 415-417.
McConnell D (2000) Implementing Computer Supported Cooperative Learning. Kogan Page, London.
Glen S, Cox H (2006) E-learning in nursing: the context. In Glen S, Moule P (Eds) E-learning in Nursing. Palgrave Macmillan, Basingstoke, Hampshire.
McConville S, Lane A (2006) Using on-line video clips to enhance self-efficacy toward dealing with difficult situations among nursing students. Nurse Education Today. 26, 3, 200-208.
Gonzalez C (2004) The role of blended learning in the world of technology. Benchmarks Online. www.unt.edu/benchmarks/archives/2004/ september04/eis.htm (Last accessed: September 25 2014.) Knowles MS (1992) Applying principles of adult learning in conference presentations. Adult Learning. 4, 1, 12. McCarthy J (2009) The Effects of E-learning on Nurse Identity Construction. Thesis. Manchester Metropolitan University. McCarthy J (2011) E-learning. In McIntosh A, Gidman J, Mason-Whitehead E (Eds) Key Concepts in Healthcare Education. Sage Publications, London. McCarthy J, Holt M (2007) Complexities of a policy-driven pre-registration nursing curricula. Nursing Standard. 22, 10, 35-38.
Petit dit Dariel O, Wharrad H, Windle R (2012) Exploring the underlying factors influencing e-learning adoption in nurse education. Journal of Advanced Nursing. 69, 6, 1289-1300. Royal College of Nursing (2010) Guidance on Safe Nurse Staffing Levels in the UK. RCN Publishing, London.
McKenzie K, Murray A (2010) E-learning benefits nurse education and helps shape students’ professional identity. Nursing Times. 106, 5, 17-19. National Institute for Health and Care Excellence (2014) Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals. NICE, London. Njenga J, Fourie L (2010) The myths about e-learning in higher education. British Journal of Education Technology. 41, 2, 199-212. Office for National Statistics (2014) Internet Access: Household and Individuals 2014. www.ons.gov.uk/ons/rel/rdit2/internetaccess---households-and-individuals/2014/ stb-ia-2014.html (Last accessed: September 25 2014.)
Salmon G (2004) E-moderating: The Key to Teaching and Learning. Routledge Falmer, London. Vygotsky L (1978) Mind in Society: The Development of Higher Psychological Processes. Harvard University Press, Cambridge MA. Washer P (2001) Barriers to the use of web-based learning in nurse education. Nurse Education Today. 21, 6, 455-460. Weller M (2002) Delivering Learning on the Net. Kogan Page, London. Ya Ni A (2013) Comparing the effectiveness of classroom and online learning: teaching research methods. Journal of Public Affairs Education. 19, 2, 199-215.
November 2014 | Volume 21 | Number 7 27
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Implications of online learning for nurse managers Jillian McCarthy looks at the benefits and possible pitfalls in using e-learning programmes Correspondence [email protected] Jillian McCarthy is a senior lecturer at Manchester Business School, University of Manchester Date of submission August 8 2014 Date of acceptance August 29 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nm-author-guidelines
Abstract Online learning for nurses is growing in popularity, with programmes ranging from mandatory update training to part-time master’s degrees. E-learning, as it is known, offers flexibility in access to learning, study time and learning styles. In busy clinical areas, where guidance is provided on minimum nurse staffing levels, e-learning provides solutions for managers who wish to encourage professional development while maintaining adequate nursing cover. Caution must be taken, however, when choosing e-learning programmes, as quality and efficacy differ across the range. This article highlights the properties of good e-learning pedagogy to prepare nurse managers for successful assessment of these programmes. Keywords Online learning, e-learning, mandatory updates, continuing professional development, pedagogy, andragogy, communication technologies
Introduction ONLINE TRAINING and programmes of study for nurses are growing in popularity globally. E-learning, as it is known, offers flexibility of study, to the extent that it has been dubbed ‘Martini learning’: any time, any place, anywhere. It has the advantage of not requiring time away from the workplace for attendance and, in a climate of nurse shortages and minimum staffing ratios, this provides a neat answer for nurse managers who wish to encourage professional development while maintaining optimum staff numbers in clinical areas. Other advantages to online learning include the ability to study and revise materials to embed learning. The advent of mobile technologies has NURSING MANAGEMENT
increased the convenience factor, with nurses now accessing learning on tablets and smartphones as well as laptops and personal computers. However, the question of convenience versus efficacy lingers over e-learning. This paper addresses the growing trend for this type of learning among nurses, while considering how effective such a method of delivery is and how it affects nurse leaders and managers. E-learning is an all-encompassing term to describe learning supported by the use of information and communication technologies. It is suited to distance learning, but it can also be used with face-to-face approaches, when it can be referred to as blended learning. It is common for e-learning to be presented via a virtual learning environment (VLE), often with a managed information system, in order to create a private, managed learning environment. This can support all aspects of a programme through a standard user interface; examples include Blackboard and Moodle. Distance learning, flexible learning and open learning are all broader terms that often incorporate e-learning, but they include all instructional situations where educators and students are physically separated. The literature on the use of e-learning in nurse education is extensive, with support for and warnings against its efficacy. McKenzie and Murray (2010), for example, describe how technology can be harnessed to maximise learning opportunities for nurses and shape their professional identities. Conversely, McCarthy (2011) warns of the consequences of e-learning programmes designed hastily by inexperienced healthcare educationalists. The Department of Health (DH) has published several documents in support of e-learning, claiming unprecedented opportunities for flexible ways of working, savings in time and finances, and better patient care (DH 2011, 2012). Likewise, the Royal November 2014 | Volume 21 | Number 7 23
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Art & science | e-learning College of Nursing (RCN) offers a suite of online training resources, demonstrating a commitment to this style of delivery.
Online learning and nursing The advantages of e-learning are manifold for nurse leaders in staff undertaking mandatory updates and professional development. In a climate of accountability, where guidance is issued on safe nurse staffing levels (RCN 2010, National Institute for Health and Care Excellence (NICE) 2014), it is often untenable for nursing staff to leave clinical areas to undertake training or programmes of study. E-learning provides the flexibility for staff to undertake learning in their own time, encouraged not only by mandatory requirements, but also by the need to keep up with current practice and the added expertise this brings to portfolios. Despite the popularity of e-learning in pre- and post-registration training modules, this has yet to translate into a full range of programmes offered in higher education establishments, which are still relatively slow to embrace this style of learning (Petit dit Dariel et al 2012). Nonetheless, distance from the teaching establishment poses few problems and nurses can source and undertake relevant programmes from further afield. E-learning has other advantages for staff in terms of personal learning styles, as online programmes can be designed to incorporate a range of resources that enable participants to choose materials that are better suited to their needs. Videos demonstrating staff engaging with patients in a range of difficult clinical situations have proven to be an effective means of teaching nurses strategies for dealing with similar real-life scenarios (McConville and Lane 2006). The early concern among learners of an inability to use computers effectively is now almost extinct as technology has invaded most UK households in some form and become commonplace. In 2014, 38 million adults accessed the internet every day; 21 million more than in 2006 (Office for National Statistics 2014). The literature cites convenience and flexibility as the main contributing factors to nurses’ satisfaction with online learning (Gerkin et al 2009). E-learning is a great equaliser among participants, allowing quieter, less outgoing personalities an equal voice and the ability to discuss issues effectively through online discussion forums, wikis, blogs and chat rooms. McKenzie and Murray (2010) note that personalities can develop online, with normally quiet nurses gaining confidence in putting forward ideas in this safe environment and bringing their new-found social skills back to the workplace. Adult learning, 24 November 2014 | Volume 21 | Number 7
or andragogy, has other benefits too as the nature of e-learning encourages participants to be self-directed in managing their own learning time and styles. Other notable benefits in online learning are the networking opportunities available and the communities of practice that can develop, often among participants from a diverse range of backgrounds and experiences. This enables learning to be shared and effective strategies and applications to be taken back to clinical areas. The opportunity for the internationalisation of learning is easily harnessed through internet communications, which gives access to worldwide resources and can enable discussions with experts around the globe. The NHS Leadership Academy, for example, offers a range of development programmes, including the Nye Bevan programme for executive leaders and the Elizabeth Garrett Anderson programme for mid-level leaders. Both of these take advantage of online tuition from international experts including academics from Harvard University in the US, and Pretoria University in South Africa. The professional identity of nurses can be strengthened by e-learning, as it allows for ideas and practices to be explored in a safe environment away from clinical areas and patients (McCarthy 2009). With the current requirements for evidence-based practice and accountability, researching online can be practised and honed. Yet, despite the many reasons why nurse managers and leaders should be encouraging staff to engage with online programmes and modules, this advice comes with a warning within much of the literature (McCarthy 2009).
Cautions with online learning Learning has become a lifelong process and continual professional development for nurses is essential. As a lecturer-centred approach to education can prove costly, one of the challenges in the financially constrained education and health sectors is to deliver programmes for nurses that will reduce class contact time without reducing the quality of programmes (Glen 2005). While start-up costs mean that delivering online is not always a cheaper option initially due to designing the materials and purchasing the software on which to host the learning, there is a body of literature purporting that expenditure will decrease once programmes are up and running effectively (Berke and Wiseman 2004). Consider how one online programme can provide learning for thousands of users; in terms of resources, this is a different scenario from that of traditional teaching. The literature cautions, however, that good quality NURSING MANAGEMENT
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 29, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
e-learning resources are not cheap methods of education, nor should they be regarded as such (Njenga and Fourie 2010). There are several issues to consider with e-learning in nurse education. Substantial training is required for nurse educators as they adapt to different working practices, moving from classroom-based lecturer to facilitator of e-learning. The literature commonly states that e-learning cannot replace educators (Washer 2001, Conole and Fill 2004, Salmon 2004), but it does appear that it can change their role considerably (McCarthy 2011). The materials with online learning for nurse education can vary from poor to excellent, so discretion is needed when purchasing these programmes. Many mandatory training packages are provided for NHS staff by privately owned training agencies and educational institutions. These often consist of online packages that are short in duration and require participants to work through information independently before undertaking multiple-choice tests. On successful completion of the training, certificates are produced as evidence of achievement. Attempts at the test are not limited in number; the correct answers can be memorised from previous failed attempts and it can be taken until a pass standard is achieved. This is cheap, quick and convenient and it ‘ticks a box’ for nurse managers and nursing staff in terms of achieving the mandatory update in question, but it is questionable whether this is a satisfactory outcome in the shadow of the report into care failings at Mid Staffordshire NHS Foundation Trust (Francis 2013) and other critical reviews. Although no direct correlation was made in the Francis report between unsatisfactory care and mandatory update training, when training in topics such as moving and handling patients, basic life support and data protection are provided by distance without social interaction with colleagues being built into learning packages, it is hard to envisage how compassion within these remits can be taught and discussed effectively. Successful e-learning takes place in a complex system involving students’ experiences of learning, educators’ strategies, educators’ planning and thinking, and the teaching and learning context (Glen and Cox 2006). Nursing knowledge and practice are growing at an exponential rate and, with this, comes a short shelf life for learning programmes in terms of efficacy, as new knowledge is generated (Gonzalez 2004). Programmes should never be rolled out without evaluation by internal and external educators, and by nurse participants and their managers. NURSING MANAGEMENT
Good e-learning pedagogy Successful e-learning for nurses is facilitated by experienced nurse tutors who maintain a strong online presence and organise communities of practice through discussion forums and chat rooms. Learning that is underpinned by theories of social constructivism (Vygotsky 1978) will ensure that participants work together, building on previous knowledge and experiences. Although nurse educators are limited to some degree by the need to provide curricula that accord with government policies (McCarthy and Holt 2007), they can offer content that is fully supported by evidence-based, effective methods of online tuition. It is in nurse managers’ interest to see reviews of the content of learning programmes before buying them. For mandatory training purposes, e-learning packages are often purchased by human resource management departments on behalf of their health service organisations, but they should still be evaluated internally for currency, efficacy and value for money. Knowledge of the difference between online learning and traditional methods is essential to make realistic and pertinent evaluations. Ya Ni (2013), building on the work of McConnell (2000), produced a review of the main differences between online and traditional learning (Table 1). In addition to an understanding of the differences between the two forms of learning, a knowledge of what constitutes good e-learning pedagogy is required to evaluate the efficacy of programmes. Learning aimed at professional development should adhere to principles of andragogy. Knowles (1992) states that andragogical assumptions in learning differ from those of pedagogical assumptions (Table 2, page 27).
The way forward If online learning is to be successful in nurse education, attention must be paid to the design of the learning programmes concerned. Managers need to ensure that staff are satisfied with the programme content and the methods employed, and that attrition rates from programmes are not increased through studying online (Salmon 2004). Programmes of a longer duration must feature online support including a strong online tutor presence, in addition to online library and administrative access. Individual tutorials should be encouraged throughout longer programmes of study and these can take place by telephone or webcam technology when face-to-face attendance is impossible. Group interactions are vital to build the foundations on which personal learning can take place, and also November 2014 | Volume 21 | Number 7 25
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Art & science | e-learning Table 1
Comparison of online and face-to-face learning
Mode
Online
Face-to-face
Discussions through text only. Can be structured. Dense, permanent, limited, stark where there are only pages of text.
Verbal discussions: a more common mode, but impermanent.
Sense of instructor Less sense of instructor control. control Easier for participants to ignore instructor.
More sense of leadership from instructor. More difficult to ignore instructor.
Discussion
Group contact continually maintained. Depth of analysis often increased. Discussion often stops for periods of time, then is picked up and restarted. Level of reflection is high. Able to reshape conversation on the basis of ongoing understandings and reflection.
Little group contact between meetings. Analysis varies, depending on the time available. Discussions occur within a set time frame.
Less sense of anxiety. More equal participation. Fewer hierarchies. Dynamics are ‘hidden’ but traceable. No breaks, constantly in the meeting. Can be active listening without participation. The technology has an impact on the learning as distances can give confidence. Different expectations about participation by the learners. Slower due to time delays in interactions or discussions.
Anxiety during meetings for less confident group members. Participation unequal. More chance of hierarchies. Dynamics evident but lost after the event. Breaks between meetings. Listening without participation may be frowned upon. The room may have less impact as it cannot be made visually appealing like the online setting. Certain expectations about participation.
Rejoining
High psychological and emotional stress of rejoining.
Stress of rejoining is lower.
Feedback
Feedback on individuals’ pieces of work is detailed and focused. Whole group can sometimes see and read each other’s feedback. Textual feedback only. No one can ‘hide’ and not give feedback. Permanent record of feedback obtained by all. Delayed reactions to feedback. Sometimes little discussion after feedback. Groups look at all participants’ work at same time.
Less likely to cover as much detail in a session as can be provided online; often more general discussion. Groups hear feedback.
Loose-bound nature encourages divergent talk and extracurricular learning. On discussion forums, the medium frees the message sender but may restrict the other participants (receivers) by increasing their uncertainty as to what is meant. Online discussion can be unclear and confusing, whereas in a classroom questions can be asked in real time.
More tightly bound, requiring adherence to accepted protocols.
Group dynamics
Divergence and choice level
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Often little time for reflection during meetings. Conversations are less likely to be shaped during meetings.
Quicker, more immediate interactions or discussions.
Verbal and visual feedback. Possible to ‘free-ride’ and avoid giving feedback. No permanent record of feedback. Immediate reactions to feedback possible. Usually some discussion after feedback, looking at wider issues. Groups look at one participant’s work at a time.
Uncertainty less likely due to common understandings about how to take part in discussions.
NURSING MANAGEMENT
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Table 2
Andragogical assumptions
Subject
Pedagogical
Andragogical
Concept of the learner
Dependent personality
Increasingly self-directed
Role of learner’s experience
To be built on more than used as a resource
A rich resource for learning by self and others
Readiness to learn
Uniform by age level and curriculum
Develops from life tasks and problems
Orientation to learning
Subject centred
Task or problem centred
Motivation
By external rewards and punishment
By internal incentives such as gaining additional qualifications, promotion and salary rises
for nurses to build on previous knowledge and experiences. Weller (2002) discusses the problems with group work online, which may be due to a lack of the visual clues that aid face-to-face communications. The use of webcam technology can aid group work, by providing faces to names and allowing more personal interactions. Issues of synchronous and asynchronous learning are raised here, however, and it may be that timetables need
to be devised so that discussions and group work are given set times. If this is impossible, participants should be given guidelines regarding ‘netiquette’, the importance of which must be stressed. The use of ‘emoticons’ to accompany online discussions should be encouraged to clarify meaning (McCarthy 2009).
Conclusion If e-learning programmes are granted sufficient time for development by experienced and knowledgeable nurse educators, with additional technical and administrative support, these can be successful in educating and training nurses. Well designed online programmes acknowledge prior learning and allow this to be built on by groups of participants sharing and pooling knowledge and experiences that can be brought back to the workplace. Not only can online programmes assist with the problem of nurse shortages by providing flexibility in learning, they can also support differences in learning styles and study time. When designed appropriately, and evaluated and updated regularly, e-learning is not a cheap training option, but it can prove to be cost effective, not least because staff cover is not required for attendance. Wherever possible, however, study days should be allocated to staff undertaking online learning to demonstrate support and a clear commitment to the workforce. An educated and updated nursing team is essential in today’s economic climate, and well designed and managed e-learning programmes can successfully provide for this.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
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