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272 British Journal of Community Nursing June 2020 Vol 25, No 6
E-learning in a new era:
enablers and barriers to its
implementation in nursing
Kate Uprichard
Digital Project Nurse, Stockport NHS Foundation Trust, Manchester
[email protected]
E-learning can be defined as delivering training using technology, such as virtual learning environments (VLEs), the internet, social media or mobile
applications (Ruggeri et al, 2013). E-learning can also be
split into two distinctive categories in terms of how it is
delivered and the role of the student and/or facilitator.
Synchronous learning is facilitated by a teacher, is usually
scheduled and takes place in real time. The technology
used serves as an additional resource to the teacher, as
opposed to replacing the facilitator, and learners can
interact with one another (Shahabadi and Uplance, 2015).
An example of this would be using teleconferencing to
conduct a lesson, which is commonplace in the ongoing
lockdown due to the COVID-19 pandemic. On the other
hand, asynchronous learning is more flexible, as it can be
completed at any time or place convenient to the student.
It also relies on the student being adequately motivated
to self-study (Hratinski, 2008). An example of this would
be a mandatory online course about adult safeguarding.
However, when conducting a systematic review around
e-learning for health professionals, Vaona et al (2018) found
that there is no standardised definition for e-learning at
present. Since e-learning is often used to describe a range
of methods using technology to educate people (Regmi
and Jones, 2020), Sangrà et al (2012) suggested that no one
definition can truly capture what e-learning is, since it is
a term used in so many different professions and contexts.
Within healthcare, e-learning is used regularly to
provide both mandatory and service-specific training. The
mandatory training required is determined by the UK
Core Skills Training Framework (CSTF), such as Equality,
Diversity and Human Rights (Skills for Health, 2019).
CSTF courses can be found via E-Learning for Healthcare,
a website created in 2008 in partnership with Health
Education England (HEE), which provides the NHS with a
variety of e-learning programmes for a range of professions
(HEE, 2020a). These courses can also be accessed via the
electronic staff record (ESR). ESRs can also be used to
complete service-specific courses, such as the safe use of
insulin in the community. These courses will be created
and updated by the foundation trust, in line with the trust’s
standard operating procedures and policies.
Enablers in the implantation and
use of e-learning
One of the clear benefits of using e-learning to deliver
training is the flexibility of the location and time it needs to
be completed. The health service runs 24 hours a day, 7 days
a week, but most face-to-face training takes place during
the day, often running from 9 am to 5 pm. In contrast,
e-learning can be completed at any time and, therefore,
suits the needs of this group of professionals (Fletcher et
al, 2017). For example, the author chose to run e-learning
around the use of EMIS Mobile in the community for
district nurses as a drop-in session at the trust’s main site.
The reasoning behind this was that community nurses
manage their own time efficiently on a day-to-day basis,
as patients may need to be seen based on geographical
location, need, vulnerability or if it is an emergency.
Therefore, it seemed sensible to allow community nurses
to use their time management skills when it came to meet
the training needs of the service. The decision to remain
on the trust’s main site was due to the potential disruption
that may occur if the nurses completed the training at their
own base.
ABSTRACT
During these uncertain and unprecedented times, the use of technology has
become paramount to staying connected to friends, family, work and society.
Social distancing has forced a huge digital transformation to take place, and
this will inevitably change the way we work, particularly within healthcare.
One dramatic change is the reliance upon e-learning, which is now the
preferred method of teaching and training. This article will explore both the
benefits and barriers to e-learning, drawing upon the author’s experience as
a digital project nurse who aided with the implementation of e-learning for
community nurses.
KEY WORDS
w E-learning w Nursing w Digital literacy w Virtual learning environment
w Interprofessional learning w Social distancing
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British Journal of Community Nursing June 2020 Vol 25, No 6 273
However, the ability for e-learning to be moved to a different
location became paramount when the threat posed by the
COVID-19 pandemic became more real. The decision was
made to move the training from the trust’s main site to a local
district nursing base to reduce footfall to the hospital grounds.
This allowed space for social distancing measures while still
having access to computers to complete the e-learning. The
issue that the learners may be distracted by their colleagues was
still present, but minimised by the presence of the author, who
was facilitating the sessions. The team leaders were involved in
the initial decision-making process and reduced the number
of colleagues working in close proximity.
The ability for e-learning to be flexible in terms of
location also means that it is more accessible to people
in general than traditional face-to-face training. Anyone
with an internet connection can take part in e-learning,
and the Office for National Statistics (ONS) found that
93% of households now have access to the internet,
compared to 70% in 2009 (ONS, 2019). This accessibility
is particularly important during the ongoing lockdown,
especially within the health and social care workforce.
Due to the unprecedented pressures people across the
country (and globe) are under, the Nursing and Midwifery
Council (NMC) has created a temporary register allowing
those who have recently left the register, those who are
registered but not working at present and qualified overseas
registrants to help ease this pressure, and these numbers
have reached over 10 000 (NMC, 2020b). This is in addition
to the over 22 000 student nurses who have opted to take
part in extended clinical placements during the pandemic
(NMC, 2020a). As well as those being redeployed to new
specialties, and managing new pressures, it is clear that these
nurses need to be provided with accessible training, while
maintaining social distancing.
One way this is being achieved is through the HEE
programme E-Learning for Healthcare (2020b), which has
released a module about coronavirus that is freely available
to all healthcare workers, whether in the NHS, social care
or the independent sector. This module covers several
important areas: updated guidance from the World Health
Organization (WHO) and Public Health England (PHE),
infection prevention and control, end-of-life care for those
with COVID-19 and staff wellbeing and resilience. There
are also guides for specialties such as critical care, acute
care, paramedics and pharmacists as well as primary and
community care settings (HEE, 2020b). For those outside
of the UK, the WHO also has an online learning platform
with coronavirus training, and this is particularly useful
for those who do not speak English (WHO, 2020). The
author, who is a community-based nurse, completed the
E-Learning for Healthcare course but chose to concentrate
on end-of-life care, symptom management and advice
for those in community settings, areas she felt were most
beneficial to her role during the outbreak. The content was
useful and aimed to replicate an interprofessional approach
to problem solving. The use of case studies, mini-quizzes
and short answer questions was beneficial to gain a deeper
understanding of the situations that were presented. The
fact that this training can be accessed by any professional
who is caring for a person or people who require care
during this global pandemic, for free, at any time of the day,
is impressive. Although some may say that this learning has
its limitations due to the lack of face-to-face interaction,
Vaona et al (2018) conducted a study comparing e-learning
with more traditional teaching, using a large sample of
health professionals and found no difference in terms of
patient outcomes or the skills of that professional. Of
course, this e-learning is also not designed to replace the
complex face-to-face training required to work in health
and social care, but to supplement it.
Interprofessional learning is defined as two or more
professions learning and collaborating with one another
to improve health outcomes (WHO, 2010) and is key
for improving the delivery of healthcare across the globe
(Varghese et al, 2012). However, since health professionals
are found in so many different contexts, it can be hard to
get these different professions together for training, which
would benefit from an interprofessional approach, such as
care of the dying person. This barrier can be overcome with
the use of e-learning, and Fletcher et al (2017) found that
the use of e-learning was beneficial in allowing multiple
disciplines to engage across a large geographical context.
Furthermore, using e-learning to deliver interprofessional
education allows more participants to join, as there are no
physical limits on class numbers (McCutcheon, 2014). An
example of this is a 5-week course that the author recently
took part in on artificial intelligence (AI) in healthcare,
which was delivered via FutureLearn, a digital learning
platform (HEE et al, 2020). The course was created in
conjunction with the University of Manchester and HEE
and was free for any professional. This course allowed those
with little to no understanding of AI, like the author, to
gain a basic understanding of how it can be used within
healthcare while considering the moral and ethical
implications for patients and staff. It consisted of a wide
range of professionals, some of whom were experienced
members of digital transformation teams, whereas others
were less experienced professionals who were keen to learn
(HEE et al, 2020). This mix of experience and professions
lead to healthy, in-depth discussions throughout the
course and allowed everyone to learn from each other’s
experiences. This would not have been possible if the
training was more traditional and held face-to-face, due
to the fiscal implications and the number of people on
the course.
Challenges in the use of e-learning
One of the main barriers to the use of e-learning is
technical difficulties. Ali et al (2018) conducted a literature
review into barriers to e-learning and found that there
were many technology-related barriers, such as lack of
technical support, poor and outdated computer systems and
connectivity issues. Within the context of the NHS, these
barriers are ever present, with thousands of computers still
using Windows 7 or even Windows XP, both operating
systems that are no longer supported by Microsoft support
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274 British Journal of Community Nursing June 2020 Vol 25, No 6
teams (Carding, 2020). This lack of up-to-date technology
aided hackers during the 2017 ‘WannaCry’ ransom
attack, and a report by the National Audit Office (NAO)
concluded that the use of Windows XP made hacking the
system achievable (NAO, 2017).
Unfortunately, these technical difficulties not only
impact patient care, but also the ability to deliver training
via e-learning. The author struggled with technical
difficulties while helping to co-ordinate EMIS Mobile
training. Initially, the users would use their mobile devices
to access EMIS Mobile (the trust’s chosen clinical record
system) in a training environment, allowing them to
become more familiar with the technology they would
soon be using without potentially disturbing actual clinical
records. However, there were ongoing issues with the
Wi-Fi connection, causing the class to become disrupted
on a regular basis. Furthermore, EMIS Mobile was at that
time experiencing issues with its system; a blank screen
would appear upon logging in and impair the ability of
the trainers to use the devices reliably. This forced the
author to work with the learning team to come up with
an alternative. The decision was made to record tasks being
completed on the tablet, using screen-capture technology,
to be accessed by users via Moodle, the trust’s chosen
virtual learning environment. This way, the users were still
engaging interactively with the EMIS Mobile system, while
mitigating the issues previously experienced. The drawback
to this solution is that it removed the ability for users to
become familiar with the technology before using it in
their workplace. However, the author found that this did
not have any more of a negative impact than the previous
training-some struggled to grasp this new way of working
regardless of the initial e-learning. Their confidence with
the technology improved through use and support from the
author and the community electronic patient record team.
The benefit to altering the delivery method was that users
could return to Moodle at any point and revisit modules
they felt they needed support with.
Another barrier to the use of e-learning is technological
illiteracy. Digital literacy is defined by HEE as ‘the
capabilities that fit someone for living, learning, working
participating and thriving in a digital society’ (HEE, 2018).
Despite the slow progress in the NHS to update systems
and adopt new ways of working with technology, everyone
who works in health and social care needs to be capable
in using technology (HEE and Royal College of Nursing
(RCN), 2017). Specifically, within district nursing, digital
illiteracy is a prominent issue. Kuek and Hakkennes (2019)
found that those under the age of 50 years were frequent
users of mobiles, tablets, the internet and social media, and
would, therefore, be more confident in using them regularly
for work. However, a report by the Queen’s Nursing
Institute (QNI) into district nursing, with 2858 members
of district nursing teams across the country taking part,
found that 60% of the respondents were aged 45 years or
over (QNI, 2019). With a workforce that is predominantly
over 50 years, digital literacy needs to be a priority for staff.
As previously stated, the author found that a lack of
confidence and skill when using mobile devices was
a barrier to assisting with, and running, the training to
use EMIS Mobile in the community. Although it was
predominantly nurses who were older who struggled, this
was not always the case. Some staff felt confident using
their personal devices outside of work but felt that, when
working with patient details, they were less confident
and, therefore, less empowered to use the devices. Several
measures were put in place to mitigate this. All sessions,
both when using mobile devices and Moodle e-learning,
were facilitated by someone. This was normally a person
from the community IT team but was taken over by the
author as the digital project nurse. This meant that staff
could ask questions throughout the training, which were
largely service-specific questions as opposed to technical
questions. Furthermore, the author regularly visited the
nurses’ bases to provide support and provided learning
materials to look back on if needed. The next step would
be to look at nominating people in each team to be digital
link nurses, so that staff can empower and support one
another to use mobile devices to record clinical outcomes.
Conclusion
In the ongoing lockdown due to the COVID-19 pandemic,
technology is essential in ensuring everyone can be social,
educated, work from home and be entertained. Through
necessity, much of the workforce is having to become more
digitally literate and reliant on technology. It is important
that this enthusiasm be maintained and any progress made
in terms of digital transformation during the lockdown be
reflected upon in the future. This will enable continuous
transformation in the way work is done.
Although there known barriers to the use of e-learning,
these can be overcome. The NHS, healthcare and society,
in general, are becoming more reliant on the use of
technology, and this, in turn, is improving the computer
systems needed. This should mitigate issues caused by
technical difficulties, although it will not eliminate it. The
KEY POINTS
ww The outbreak of coronavirus and social distancing measures have caused
a shift in how reliant healthcare is on technology
ww Flexibility in terms of location and method of delivery, and accessibility,
are enablers in the use and implementation of e-learning. This has been
highlighted more by the impact of COVID-19
ww Challenges in the implementation and use of e-learning include technical
difficulties and digital illiteracy
ww Digital literacy is key when implementing the use of technology within
the workplace
CPD REFLECTIVE QUESTIONS
ww What e-learning have you completed that you found invaluable?
ww How would you improve your workplace’s e-learning?
ww How do you think you could develop your digital literacy?
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issue around digital literacy can also be solved by improving
knowledge and skills, but that can only be achieved if this
is made a priority. BJCN
Accepted for publication: April 2020
Conflicts of interest: none
Acknowledgements: Thank you to everyone at Stockport NHS
Foundation Trust for their hard work.
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