E-learning in a new era

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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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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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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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