Factors influencing the utilisation of e-learning in post-registration nursing students

Introduction 

Recent trends and current policies guiding the direction of higher education indicate that effectively embedding an e-learning culture within its structure is an essential element to future educational development. Aims to establish e-learning within a flexible framework that is student focused and which ensures development of life long learning (Department of Education and Skills, 2003, Higher Education Funding Council for England, 2005) are echoed by the Department of Health (DoH, 2001). A central role was identified for e-learning including proposals to equip all nursing staff with the skills and resources to access learning opportunities and share knowledge electronically at a time and place that fits their lifestyle (DoH, 2001). Computer literacy and the ability to utilise information technology is fundamental for all nursing students however evidence suggests we may still be a long way from this ideal. The now defunct NHSu (2005) noted that an estimated 230,000 NHS staff lacked functional computer literacy and numeracy skills. The challenge for nurse educators is to appropriately incorporate technology within programmes both to equip students with the necessary skills and facilitate student learning (Wharrad et al., 2004).

This paper discusses the findings from a study investigating the factors that influence the utilisation of e-learning by nursing, midwifery and health visiting students undertaking post-registration studies. It explores student perceptions of e-learning and considers the challenges facing nurse educators in facilitating effective and equitable utilisation of e-learning in post-registration programmes.

Literature review 

The expansion of e-learning in higher education poses a significant challenge for nurse education. The importance of students’ experience and opinion and the impact these may have on its utilisation are clearly important.

Exploration of the literature highlighted common perspectives influencing e-learning:

Method 

Survey questionnaire 

The fundamental aim of the research sought to identify causative factors that might influence the utilisation of e-learning in nurse related education. Critical reflection on previous research and information collated from preliminary interviews identified the range of variables for further exploration.

The questionnaire consisted of 12 questions including a range of dichotomous, multiple choice and attitude statement questions. A range of demographic data was collected including age and gender. Students were asked about computer ownership, acquisition of computing skill, and previous experiences of e-learning. The questions selected aimed to explore inter-relationships and possible correlation between factors (e.g. age, gender and skill level) relevant to the population of interest. To explore the significance of student perceptions of e-learning both quantitative and descriptive enquiry was utilised. Respondents were asked to clarify their previous experience of professionally related e-learning by identifying the positive and negative factors of their experiences. Likert style scales were utilised to elicit the opinions of respondents to the highlighted themes. To ensure reliability of Likert scales consistency in scoring was maintained and no assumption was made in analysis that there was equality of differential between the rating scores (Cohen et al., 2003). In addition open-ended responses were used to enhance authenticity and depth of responses.

Data analysis 

Results of the research included nominal, ordinal, interval and qualitative data. For the purpose of statistical analysis data was coded and values applied. The computer generated SPSS package was utilised for data analysis. Descriptive statistics were compiled for each data set within the questionnaire with results displayed as frequency of response and percentage. Non response has been excluded for the purpose of analysis and valid percentages have been utilised for data presentation. Non parametric analysis was undertaken, Chi-squared was utilised for nominal data and Kruskal–Wallis for ordinal data. Levels of 95% probability that results represented a real difference against 5% that they occurred by chance were accepted a minimum 5% (p<0.05) level for statistical significance was used throughout.

Responses to all open-ended questions were subjected to content analysis and were coded initially by informative descriptive data then recurrent themes and words highlighting relevant factors and subsequent interpretation and reflection on meaning (Richards, 2005). Researcher subjectivity in interpretation of data analysis was minimised by use of an independent researcher to check for consistency.

Findings 

Overall response rates were high 70 (79.5%) of the 88 questionnaires were returned. The sample was predominantly female 62 (88.6%) and eight (11.4%) male. It was acknowledged that the small numbers of male response sets may have impacted on the validity of gender related data. The age of respondents showed a fairly even distribution 35.7% (n=25) age 21–30, 28.6% (n=20) age 31–40 and 31.4% (n=22) age 41–50 with the exception of those over 50 years at 4.3% (n=3).

Students identified where they had acquired their computer skills (respondents could select more than one option) (Fig. 1). A high proportion 65.7% (n=46) felt they were self-taught, 31.4% (n=22) indicated school acquired skills, 28.6% (n=20) FE College, 24.3% (n=17) university acquired and 15.7% (n=11) the workplace. Only one respondent indicated that they had no IT skills. Analysis highlighted students aged 21–30 were more likely to have acquired computer skills in a formal environment of school or university and correspondingly those aged 41–50 were less likely to have formally acquired computer skills (Kruskal–Wallis p=.008 school acquired, p=.027 university acquired) (Table 1, Table 2). Moreover the majority of those with formally acquired skills indicated a positive perception in relation to their IT skills.

View Large Image Download to PowerPoint

Figure 1. Respondents identification of where computer skills acquired.

Table 1. Respondent age group/acquisition of IT skills school

		IT skills school		Total
		Yes	No
	Respondents age group
	21–30yrs	14	11	25
	31–40yrs	5	15	20
	41–50yrs	3	19	22
	Over 50yrs	0	3	3
	Total	22	48	70

Table 2. Respondent age group/acquisition of IT skills University

		IT skills university		Total
		Yes	No
	Count
	Respondents age group
	21–30yrs	10	15	25
	31–40yrs	6	14	20
	41–50yrs	1	21	22
	Over 50yrs	0	3	3
	Total	17	53	70

Only 43.5% (n=30) of respondents had experience of e-learning as part of their professional nurse training (pre- or post-registration programmes). The range of experience was highly variable the largest numbers were CD-ROM 50% (n=15) and Blackboard virtual learning environment 43.3% (n=13) very few had utilised complex interactive methods of e-learning (Table 3).

Table 3. Previous e-learning experience

		Type e-learning Blackboard	Type e-learning CD-ROM	Type e-learning Discussion Board	Type e-learning video conferencing	Type e-learning other
		Count	Count	Count	Count	Count
	Yes	13	15	5	0	11
	No	17	15	25	30

46.4% (n=13) of students with e-learning experience indicated they had no training to be an e-learner and 36.7% (n=11) felt they did not have the necessary skills. Age and gender differences did not appear to be predicting factors in relation to previous e-learning training or necessary skills.

Correspondingly the descriptive evidence supported these results with a high number (13) of comments indicating the negative impact levels of computer literacy and skill has on e-learning capability.

‘My lack of training in computer use caused barriers in accessing’.

The results indicate that although basic e-learning methods are being employed and integrated into nursing curricula its prevalence may not be as high as expected. Moreover higher level more complex methods of e-learning such as interactive learning technology and student inter-communication appear to be even less well established. Whilst student perceived ability for independent learning was high 21 (70%), perceived skills 15 (50%) and relevant training 19 (63.3%) were lower indicating that e-learning educational requirements remain high.

The results highlighted the impact computer technology has had on home environments indicating high personal ownership and availability. Home computer availability was 95.7% (n=67) and workplace 92.9% (n=65) which corresponded with Internet availability, 91.4% (n=64) home and workplace although the data did not identify the type/ speed (e.g. broadband) of Internet availability. These results were less encouraging when examined in relation to accessibility with clear differences between home and workplace. Whilst the majority of students were positive about ease of accessibility to a computer 88.1% (n=52) in the home, workplace accessibility was much lower at 55.9% (n=33). This gap widened when explored in relation to opinions of whether workplace accessibility could be utilised to support e-learning with only 24.1% (n=14) in agreement (Table 4).

Table 4. Respondents place of work/given work time for e-learning

		Given work time for e-learning				Total
		Strongly agree	Agree	Disagree	Strongly disagree
	Respondents place of work
	Acute Hospital	0	4	17	14	35
	Community Hospital	0	1	1	2	4
	Primary Care	0	6	6	2	14
	Other	1	2	1	1	5
	Total	1	13	25	19	58

Descriptive analysis corroborated the strength of negative opinion for workplace support of e-learning with comments highlighting a lack of protected time and competing work commitments as barriers. Only one student indicated they had had positive support in the workplace. Descriptive evidence also demonstrated that in spite of high home ownership accessibility was often compromised by competing elements, e.g. family commitments, phone line access and time constraints.

E-learning flexibility was highly rated 90.9% (n=50) agreed that e-learning meant they could learn where and when they wanted 93% (n=53) (Table 5). This was clarified by comments, which cited speed and efficient access to information, pace and self direction as major benefits.

‘Able to access information and learn when you want’.

‘e-learning means you can work at your own pace a huge bonus’.

Table 5. I can study when I want

		Frequency	Percent	Valid percent	Cumulative percent
	Valid
	Strongly agree	23	32.9	40.4	40.4
	Agree	30	42.9	52.6	93.0
	Disagree	3	4.3	5.3	98.2
	Strongly disagree	1	1.4	1.8	100.0
	Total	57	81.4	100.0
	Missing
	No Response	13	18.6
	Total	70	100.0

However a shift in opinion was evident in the perception of time required for e-learning 51.9% (n=27) felt it was time consuming (Table 6). Exploration revealed no significant correlation between age and gender. Analysis of comments (n=12) relating to e-learning as time consuming indicated that all cited issues of computing skill and confidence as a significant influence.

‘I find it time consuming, understanding and knowing how to use e-learning affects the time spent and value of study’.

Table 6. E-learning is time consuming

		Frequency	Percent	Valid percent	Cumulative percent
	Valid
	Strongly agree	6	8.5	11.5	11.5
	Agree	21	30.3	40.4	51.9
	Disagree	23	32.9	44.2	96.1
	Strongly disagree	2	2.9	3.9	100.0
	Total	52	74.3	100.0
	Missing
	No Response	18	25.7
	Total	70	100.0

Discussion of findings 

The findings from this study highlight the potential inequities that may exist in utilisation of e-learning for nurse education. The significant issues raised relate to student functional abilities and perceived ability based on subjective experience and expectations. The possibility that these may be exacerbated by the nature of nurse education particularly in post-registration programmes is of paramount importance for quality assurance and equitable educative practice.

Indications were that overall levels of computer literacy were encouragingly high, suggesting that nursing professionals’ abilities are in line with the changing technological environment. However exploration of the data gave a clearer picture of the level of computer literacy, how this was acquired and skills in relation to e-learning. Although the evidence supported acquisition of computing skills within a formal education environment for a significant proportion it would appear that the most likely method of skill acquisition was through informal self-directed methods.

This study did not generate any evidence to support indications from the literature that females were less likely to utilise computers (Adams, 2004, Barrett and Lally, 1999, Washer, 2001) or were less confident in their computing skills (Bond, 2004). However there were indications that age and acquisition of formal computing skills were linked. The significance of where skills are acquired has implications for the future, as time progresses the need to ensure students undertaking higher education have basic computing skills may diminish as this becomes the norm within basic education. However nurse educators should consider it might remain an issue in nurse education given the high proportion of mature students and those undertaking post-registration studies. The issue of IT skills is complicated by student perceptions. Although students generally felt positive about their ability to be independent learners this was not met by an equal confidence in perceived e-learning capability where only half felt positive towards their abilities. It can be difficult ascertaining whether student perceptions of skill matched with actual ability or whether it is simply a perceived lack of confidence (Cole and Kelsey, 2004). However there may be a real risk that lecturers make assumptions about student capability particularly in short post-registration modules with limited student contact time. It is important then that nurse educators do not become complacent about expectations of student knowledge but remain aware of student needs, age, levels of capability and are able to facilitate equitable skills to minimise marginalisation. Moreover they may need to acknowledge, as with other learning styles, that not every student will benefit from e-learning. Advanced preparation, pre-course assessment of IT skills along with continuous support and feedback as noted in the literature (Atack, 2003, Beasley and Smyth, 2004, Sit et al., 2005, Wharrad et al., 2004) may be essential in facilitating effective e-learning.

Flexibility of e-learning was the principal positively rated factor which supported evidence from much of the literature highlighting this as the most significant benefit. However positive comments made were qualified by the relationship with necessary skill needed to reap the benefit. The link with level of literacy, confidence and perceived skill was also evident. These issues which potentially reduced motivation and increased frustration were also noted within the literature (Adams, 2004, Booth et al., 2005). Descriptive comments supported the quantitative responses and issues expressing frustrations with speed and quality of Internet access, competing with other family members and difficulties when phone line and Internet access are shared were evidently problematic.

The positive perception that e-learning rated highly as a flexible option was limited somewhat by its perception as time consuming. The exploration of the reasons underpinning this has strong implications for its successful implementation. A significant element was related to levels of literacy and student confidence however of equal significance was the focus on work time relationships. Interestingly within a climate of technological advance driven by government policies that seek to underpin both health and education with a significant technological element and correspondingly high access to both the computer and Internet in the work place, the perception of support in practice for e-learning was perceived as poor. Qualification of possible causal factors was evident from descriptive comments; views expressed exclusively related to either availability (i.e. numbers of computers or numbers of people accessing the computer) and the pressures of clinical workload. This corroborates with the findings of Atack (2003) who noted that related issues of professional work intensity and time meant that workplace access was rarely a practical reality. The benefits of e-learning flexibility from an organisational and management perspective can be seen in issues such as the flexibility of granting study leave which may minimise problems associated with releasing staff from clinical areas (Hewitt-Taylor, 2003). However in spite of drives to encourage computer use in the NHS it would appear that in reality work access is not well supported by actual time given for education purposes. Many post-registration courses have an expectation that additional and supported study time is required. It is evident that time is a major factor and in the current climate of increasing financial pressure on the NHS there may be increased expectations on students to work in their own time. Clearly these issues in terms of access to education and facilitation of learning to support practice, competency and lifelong learning have implications for both educators and practice managers.

Study limitations 

This is a small-scale study and the sample was drawn from a specific module. The study may have been influenced by extraneous variables indicative of characteristics specific to this student group not immediately evident from the findings or accounted for. Subjective experiences specific to module content and delivery may have contributed to student perceptions relative to e-learning.

Conclusion 

Although there are strong drives within education and health to increase the utilisation of e-learning, it is evident from student opinion that e-learning cannot be viewed as a universal panacea in nurse education. E-learning is subject to individual preference and diversity of opinion and the inter-relationship between educational, professional and personal perspectives was clearly a complex and often finely balanced issue. The utilisation of e-learning in nurse education is likely to increase in the future particularly in a climate with increased inter-professional education initiatives, perennial shortage of qualified nursing staff, and increased budgetary constraints both in health and education. The findings from this study would support the rationale for educators to develop an increasing awareness and understanding of student perceptions, particularly potential limiting factors, to facilitate effective use of and incorporation of e-learning within the curriculum. The implications of issues raised such as lack of necessary skill, student confidence and poor support in clinical practice by management hierarchies are highly significant for the successful adoption of e-learning.

Indications from this study and those highlighted in the literature demonstrate that, to facilitate effective e-learning, educators need to exercise caution that they are not too hasty too implement and utilise it without the appropriate technology, knowledge and level of student awareness to support it. Its strength lies in the ability to enhance and support teaching (Kenny, 2000). Teaching is only cost effective if the desired learning outcome is achieved. Recommendations to adequately support students through advanced preparation, pre-course assessment of IT skills, continuous support and feedback must be addressed. E-learning cannot be driven by the technology alone its successful incorporation into nurse education needs to be underpinned by an understanding of both its value and limitations supported by sound knowledge of both user and executor.