An essential component of the delivery of the National Health Service (NHS) Plan is a well-developed, educated and competent workforce. ‘Working Together—Learning Together’,1 the national learning strategy, admits that this is a challenging and complex task. There is intense pressure to maintain the service, ensuring that training is relevant for the purpose, and flexible enough to take account of different learning styles. Both the national learning strategy and the now-superseded NHS University (NHSU) identified e-learning as a central strategic delivery mechanism.1,2 The role of strategic advice and direction for learning in the NHS has now been taken over by the NHS Institute for Innovation and Improvement (http://www.institute.nhs.uk/).
Most UK universities are also investing in e-learning for all different student categories, including health. In recent years, e-learning has become a high profile approach for pre-registration health students and for continuing professional development (CPD) needs of NHS staff. Despite e-learning's high profile, e-learning is not straightforward and very often raises many issues. Research suggests a number of key issues and questions that need to be considered. E-learning may be more effective as a combination (or blending) with traditional class-room based learning. The level of personal support required, e.g. through e-tutors, has been frequently underestimated. How will the role of current and future trainers change? What information communication and technology (ICT) infrastructure is required to support e-learning? What organizational policies and processes are needed? Do the barriers differ, depending on the individual's profession or roles in the NHS? There is a pressing need to understand these issues and establish how they can be addressed.
E-learning strategies covering the different educational sectors have recently been published. The Department for Education and Skills (DfES) strategy, ‘Harnessing Technology: Transforming Learning and Children's Services’3 provides a joined up approach across schools, colleges, universities and adult and community learning organizations. Its four objectives comprise:
‘Transform teaching, learning and help to improve outcomes for children and young people, through shared ideas, more exciting lessons and online help for professionals,
‘Engage “hard to reach” learners, with special needs support, more motivating ways of learning, and more choice about how and where to learn,
‘Build an open accessible system, with more information and services online for parents and carers, children, young people, adult learners and employers; and more cross-organization collaboration to improve personalized support and choice,
‘Achieve greater efficiency and effectiveness, with online research, access to shared ideas and lesson plans, improved systems and processes in children's services, shared procurement and easier administration.’
The Higher Education Funding Council for England (HEFCE) has also recently published its 10-year e-learning strategy for universities and colleges.4 This strategy was developed in parallel with the DfES strategy. HEFCE's strategy aims:
‘to support the HE sector as it moves towards embedding e-learning appropriately, using technology to transform higher education into a more student-focused and flexible system, as part of lifelong learning for all who can benefit.’
Its objectives are:
‘To enable institutions to meet the needs of learners and their own aspirations for development,
‘To support institutions in the strategic planning, change management and process development that are necessary to underpin their development and embedding of e-learning,
‘To promote learning research, innovation and development that begin with a focus on student learning rather than on developments in technology per se, enabling students to learn through and be supported by technology,
‘To support lifelong learning by joining up our strategy with those of other sectors of education, enabling connections between academic learning and experiential learning in the workplace and other aspects of life.’
The NHSU, as well as promoting the development of 5- year local e-learning strategies in NHS organizations (e.g. Delivering E-Learning in the NHS. Getting the Blend Right. A Strategic Approach for the North-West5), also worked towards developing a national e-learning strategy for the NHS. A discussion paper6 and on-line consultation on this paper7 have been produced. The NHSU's website (at the time of writing this article) stated:
‘The national vision for e-learning in the NHS is to enable staff to access learning opportunities at times and places that best fit in with their lifestyle. This means 24-h access to knowledge and learning resources, 365 days per year, from places that are most convenient for individuals and groups, with the technical support structures to ensure this happens … NHSU is working with the SHAs [Strategic Health Authorities] to develop a shared strategy for e-learning across the whole of the NHS. The strategy will embrace e-learning, knowledge management and network technology, and provide local guidance to help bring coherence to the many initiatives already underway across the NHS. The strategy will create a clear and practical framework for the development and delivery of e-learning which can be adapted to meet regional and local needs. It will also provide a context for NHSU partners and stakeholders including the Department of Health, NHS Trusts, national agencies, suppliers and professional bodies to develop their own strategies.’
The higher education Joint Information Systems Committee (JISC) is currently funding an e-learning development programme (http://www.jisc.ac.uk/index.cfm?name=programme_elearning) focusing on: e-learning and pedagogy; e-learning frameworks and tools; e-learning and innovation; distributed e-learning. A range of individual projects have been funded to explore these issues.
The project used a range of qualitative approaches to data collection, comprising a systematic literature review, semi-structured phone interviews and a questionnaire survey. The use of this range of methods allowed for triangulation of the data. The prime focus was the exploration of barriers, and their possible solutions, to e-learning for NHS staff and healthcare students. The findings from the systematic literature review will be widely applicable. The interviews and questionnaires produced qualitative data, which are not generalizable. However, the NHS and higher education setting in the North-East is broadly similar to the rest of the UK, and there would seem to be no reason why these findings could not provide pointers to others.
The systematic literature review was conducted using methods promulgated by the Centre for Reviews and Dissemination8 but adapted to the particular demands of this project. The databases searched comprised: amed (allied and alternative medicine); assia (applied social sciences); Cinahl (nursing and allied health); ERIC (education); HMIC (health management); LISA (library and information science); PUBMED (Medline); Web of Science (Social Science Citation Index). The search strategy used the search phrases ‘e-learning’ or ‘computer assisted instruction’, limited by the terms ‘health’ and ‘barriers’. The bibliographies of selected articles were also assessed for relevant items. Overall restrictions were that articles should be written in English and be published no earlier than 1997. In summary a total of 142 references were obtained through these various search strategies. A further 19 references (mainly grey literature) were added from a separate search of the report literature and relevant websites, making a total reference pool of 161 references. Fifty-seven of the references were deemed suitable to be included in the final analysis templates. The subject content was the main criterion for selection, i.e. articles that discussed barriers to and solutions/critical success factors for e-learning in the health field. Study type was not an absolute criterion. Articles describing research on barriers/solutions were included: all types of research design were considered applicable. However, if an article was a ‘substantial’ discussion of the issue from an expert viewpoint or from a review of the literature than this was also included. The bibliographic references were managed using EndNote.
The selected references were analysed in two stages. First, appropriate content was extracted from the individual articles using a standard template with the following categories:
- • EndNote code
- • Publication year
- • Document type
- • Methodology/analysis details
- • Geographical location
- • Professional grouping
- • Provider
- • Project time span
- • E-learning subject
- • Type of activity
- • Barriers/Challenges/Issues
- • Solutions/Critical success factors
- • Memorable quote
Second, information on barriers and solutions were further summarized in the form of grids as follows:
- • By staff category
- • Then by issue
- • Then by context
A number of quality control procedures were inbuilt into the systematic literature review: double checking by two team members of article references considered to be suitable for inclusion; a sample of initial analysis templates cross-checked against the article by another team member to ensure consistency and reproducibility; secondary analysis grids cross-checked by two team members against the original article. It is harder to conduct a full, rigorous systematic literature review when the topic under study is difficult to define by specific, distinctive search terms and covers qualitative research and non-research publications. We have inbuilt as many of the objective processes of this methodology as is feasible, and therefore feel justified in describing our work as a systematic literature review.
The aim of the interviews and questionnaires was to ensure that the barriers and solutions identified from the systematic literature review were grounded in reality. The phone interviews aimed to obtain the views of managers and trainers. Thirteen interviews were undertaken. The questionnaire survey aimed to obtain the views of users/non-users of e-learning. One hundred and forty-nine questionnaires were returned.
The questions in the interviews and questionnaire were based on the findings from the systematic literature review. The interview schedule, in summary, comprised the following questions:
- 1Briefly, what is your work role?
- 2What involvement do you have with e-learning?
- 3How would you define e-learning?
- 4Have the necessary changes occurred to implement e-learning?
- 5Is e-learning effective?
- 6Is e-learning time-effective?
- 7Does e-learning support the variety of students’ learning styles?
- 8Are e-learning packages appropriate and well-designed?
- 9Do all the players have the necessary skills?
- 10Is the technology appropriate, available, reliable?
- 11Is e-learning cost-effective?
- 12Are there any more barriers from your viewpoint?
- 13The following solutions have been suggested—what do you think of them?
- 14Any there any more solutions from your viewpoint.
- 15Any other comments?
The questionnaire, in summary, comprised the following questions:
- 1Your organization details
- 2Your professional details
- 3Your study details
- 4Briefly, how would you define e-learning?
- 5Your views on e-learning *
- 6Your views on time and e-learning *
- 7Your preferred learning style *
- 8Your views on the design of e-learning material *
- 9Your views on the skills required for e-learning *
- 10Your views on the technology needed for e-learning *
- 11Your views on the costs of e-learning *
- 12Briefly, do you have any other comments about e-learning issues?
- 13The following things would improve my e-learning *
- 14Briefly, would anything else help improve your e-learning?
In the questions marked * the respondent was asked to tick one of the options ‘I strongly agree’, ‘I agree’, ‘I disagree’ or ‘I strongly disagree’, to every statement in a list of statements.
Systematic literature review results
The findings are organized under each of the issues covered in the data extraction template, i.e. organizational issues, economics, hardware, software, support, pedagogical issues, psychological issues, skills. For each issue, first the barriers are described, followed by the solutions.
Organizational issues—barriers and solutions
Organizational barriers are clearly of concern to managers. Integration across the national and local levels is lacking.9 Undertaking e-learning requires change and management of this change is poor, with organizational inertia and staff resistance.10,11 Barriers occur with programme development and implementation. Adopting and developing e-learning programmes is time consuming.12 Quality standards are lacking.13 Modules need to be carefully scheduled11 and marketing can be problematic as it can be difficult to convey the benefits to potential learners.14 Package development is also problematic with lack of competition between suppliers13 and technical and time demands on developers.15 There are internal staffing difficulties with trainers lacking the time or skills to develop e-learning material.14,16 Facilities also need to be appropriately organized.17 Concerns about negative effects on patient care have been raised, both in terms of managing additional tasks and of interference in the doctor–patient relationship.18 Trainers also have concerns about the process of change10,19 their lack of involvement in e-learning developments20 and poor communication with IT staff.10 Lack of time is of great concern. Time is needed to develop e-learning programmes and to evaluate material but no dedicated time for this purpose is made available.10,11,21–23 Trainers also have workload concerns.21 Learners also have concerns about time; the time consuming nature of e-learning, and how to manage their time appropriately.21,24–30 Module scheduling and opening hours of facilities were inappropriate.11,24,30 Practical issues were also of concern, e.g. child care, geographical location, transport, staff shortages, and inappropriate facilities.17,24,28 Learners needed advice on organizing e-learning tasks.31
At managerial level a wide range of solutions were identified. There should be a national approach and support, e.g. a national accreditation body9,32 and national and local standards and guidelines.9,18,33 A strong commitment is needed from the institution and the trainers34,35 with a culture shift36,37 strategies, planning and processes for implementation10,17,37,38 and appropriate resource management.37 E-learning needs to be integrated into all aspects of the institution and into the curriculum17,35,37 with co-operation between departments and between software providers and trainers.17 Skilled staff are needed17,32 with systematic procedures and incentives for obtaining trainers’ input.17,18,34 From a more altruistic viewpoint there is a need for open access packages39 and packages in foreign languages.40 At the trainer level there needs to be collaboration between content, pedagogy and technology.41 Incentives for trainers are needed.17 Trainers need time to master the technology, to convert materials and to prepare teaching sessions.19,42 A crucial issue is that information or content obtained from patients must be with informed consent.39 Learners need flexible e-learning that can suit their individual work-life balance; flexibility in programmes, study methods and access to trainers.24,43–46
Economics—barriers and solutions
For managers economic issues can be significant barriers. There is a need for cost effectiveness/cost benefit evidence.16–18 E-learning has a wide range of associated costs: hardware costs, e.g. start up costs, providing sufficient equipment, and then the ongoing costs of keeping this equipment up to date;12,13,17,18,34,37,47 software costs, particularly for licenses;12,13,17,20,34,47 programme development costs;14,20 costs of training and development of trainers;12,13,17,48 costs of buildings and materials;17,21,48 hardware and software support costs.37 Trainers were concerned that the costs of e-learning would increase class sizes.49 Their involvement in e-learning could be constrained by lack of grants for materials and expenses.21 Learners were concerned about the costs of courses24,26 and of associated requirements such as computers, internet access and printing.43,50,51 This could cause inequitable access for those who lacked the necessary money.24,25,43,50 If learners are required to pay these levels of costs then sufficient materials need to be provided to justify them.20
At a managerial level, the main solution is evidence for the true costs of e-learning and associated cost-effectiveness and cost benefits. In contrast, the solution for learners is cheap or free courses and materials24,39 although paying up front may make the learner become more involved in the outcome of the programme.52
Hardware—barriers and solutions
From a managerial viewpoint, the hardware is in the earlier stages and insufficient for the task.13,18,38 There is a lack of information about hardware17 and transportability and compatibility can be a problem.17,18 As mentioned above, costs of hardware are a significant barrier.12,13,17,18,34,37,47 There is a lack of computer hardware for trainers.20,33 The technology available can be inappropriate or not used to its full potential18,53 and there can be technical problems.29,52,54 A major concern for learners is lack of, or inadequate, technology at both work and home, e.g. computers, printers, applications, internet access, access speed.10,21,22,27,33,38,43,50,51,55,56 Technology can be poorly designed18 with transportability and compatibility problems.17,42 Learners also experience technical and practical problems with hardware.29,30,57
At a managerial level, a national approach would be beneficial, e.g. delivery channels and broadband strategy.9 Appropriate location of equipment is necessary.13 Equipment needs to be future proofed.15 Trainers need easy access to equipment25 and they need to be comfortable with it;27 suggestions on effective use of specific items of hardware should be available.46 Hardware needs to be reliable39 and technological problems need to be solved quickly.42 Similar solutions are relevant to learners: easy access to computers, including from home;25,58 being comfortable with the hardware;27 reliable equipment.39
Software—barriers and solutions
Similar problems are experienced with software as with hardware. From a managerial viewpoint, software is in the earlier stages and insufficient for the task13,34,40,57 there is a lack of availability of good software9,17,34 and a lack of information.17 Transportability and compatibility is a problem.17 Costs, particularly for software licenses, can be a significant barrier.12,13,17,20,34,47 Lack of trainers’ time for evaluating course software or developing materials is another barrier.10,12 Trainers find that software packages are of poor quality.18 They are also concerned that they are not involved in the selection, evaluation or development of materials.10,17,20,59 Learners lack access to required software and to the Internet at both work and home.10,17,21,24,27,43 Design of software can be problem40,60 as can its currency20 and transportability and compatibility.17,20 The Internet can be disappointing in terms of the difficulty of finding relevant material and the poor quality of the content.27 Once again for learners, the cost of software is a problem.17
Managers need to consider generalized solutions of developing content33 with a combination of in house program development and improved feedback between software providers and trainers.17 Evaluation research on software packages is needed.17 Use of an intranet rather than the Internet has several advantages.61 Trainers need to be comfortable with the software.27 They need to be able to preview and evaluate the software.17,40,41 It is also important that the learner is comfortable with the software.27 Software needs to be carefully designed from the user viewpoint and easy to use.36,60 User piloting and feedback are crucial.40,41
Support—barriers and solutions
From a managerial viewpoint there is a lack of technical support staff10,13,21,37 a lack of suitable support materials10 and hardware and software support can be costly.37 Trainers also lack support, both technical and administrative.10,17,21,49 There is a limited awareness of available support material, or recognition of its usefulness in the curriculum.38 Learners lack support from their managers for their personal development.24 They also need support from their trainer35,38,50 and could lack feedback.21 Technical support is also lacking.17,37
Managers need to ensure that there is support for trainers and learners18,35,52 with ongoing technical support27 and quick solutions to technological problems.42 Administrative support is required37 and access to technical expertise, e.g. graphics experts.15,46 Trainers need to provide support for learners, with deployment of different staff resources (facilitator, technician, instructor) as required.46 Trainers need to provide learners with information and guidance25,38 and feedback.39,53
Pedagogical issues—barriers and solutions
From a managerial viewpoint, e-learning packages are of poor quality and inappropriate or insufficient for the task.12,14,34,48 Obtaining trainer involvement in and acceptance of e-learning can be a problem.14,17,38,43 Trainers need information and guidance.10,38 Trainers can be reluctant to adopt new systems that disrupt established practices, and can be sceptical of their benefits.18 There is resistance to the need for change in teaching methods, with unclear messages from management and a lack of guidance or good practice.19,23,32,38,50,51,55,56,59,61 Trainers find that packages are of poor quality, inappropriate or insufficient for the task with a lack of standards and they lack information about packages and the time to evaluate them.10,14,17,18,33,38,48,59 There are a number of myths about e-learning which act as barriers to its adoption and affect the way it is used in practice. According to one author62 these myths include: it is a passing fad; it is only for knowledge acquisition; it is ineffective and inefficient; ‘the lonely learner’; ‘the redundant teacher’; ‘technology is king’; ‘an unrealistic dream’. Another author36 covers the psychological myths of e-learning: it is just another method of delivery; it is less effective than traditional methods; it takes the same time as traditional methods; it cannot cope with different types of learner; it is demotivating; it is not engaging; it provides too fragmented a learning experience; it lacks realism; it lacks retentive qualities. Trainers do see lack of interactivity and lack of personal contact as barriers21,29,33 as well as marketing and curriculum issues.17,49 They also identified detailed problems which are specific to the modules they are running.52,54,56,61,63 Intellectual property rights, copyright and plagiarism are problems.49,51,56 Learners need appropriate content, wide choice and guidance on selection.25,49,59 They can lack motivation to undertake study.24 Learners need to change their learning styles19,21,24,25,32,35,47,63 and may see lack of interactivity as a problem and prefer personal contact.21,26,29,33,35,64 E-learning can be time consuming27,35,53 with a significant risk of information overload.51 Copyright and plagiarism are issues for learners.51 There are language barriers for foreign students.40 Learners also identified detailed issues which are specific to the modules they are undertaking.30,52,54,57,60,61 There is a risk of creating a two tier system of education with the bottom tier being those learners who do not have access to the Internet or whose trainers do not choose to use e-learning methods.55 Concerns about negative effects on patient care have been raised, both in terms of managing additional tasks and of interference in the doctor–patient relationship18 and little focus is given to how to apply IT to practice.51
From a managerial viewpoint, solutions include a national approach with standards, quality assurance and integrated services.9,39 Evaluation of e-learning packages is needed.34 Collaboration is required between content, pedagogy and technology.15,41 E-learning needs to be integrated into the curriculum.18,32,35,38 Flexibility for learners needs to be built into the programme45 and trainers must be flexible to adapt to the needs of learners.42 E-learning packages need to be tailored to local needs, regularly modified and kept up to date.12 Accreditation and outcomes should be equivalent to traditional methods.32 From the trainer and learner perspective there are many factors that result in effective e-learning programmes, courses and materials. Collaboration is needed in the design process between content, pedagogy and technology.41 Courses and packages should be piloted, and then evaluated regularly.12,13,15,39–41,45 Trainers and learners should share responsibility for the quality of the learning process.32 E-learning should be based on principles of evidence, standards of care, academic freedom and respect for copyright rules.39 Blended teaching, incorporating both traditional and e-learning methods, seems the preferred approach.25,35,60 Content needs to be relevant, e.g. more NHS orientated15,25,36 and be logically organized.36,45 Content can be divided into small learning ‘chunks’ which are flexible, recyclable and deliverable in a variety of formats.13,53 There should be flexibility and variety in the use of methods10,28,41,46,63 and imagery as well as video and multimedia are of benefit.10,18,36,46,53,64,65 The design should allow for self-pacing (within a module and between modules)18,30,36,45,47,60 and provide interactivity.21,36,41,46,53 The package should be easy to use13,39,65 with good navigational tools.60 Support should be provided on use of the package and the content, e.g. being clear about assignments and timelines19,35 providing ‘wrap around guides’23 and support materials.35,61,65 Learners should be given feedback on their progress.13,18,39,53 User testing and assessment should be provided,13,35,45,46,53,60 but it is important that assessment results are consistent with traditional methods.46 If the language is tailored appropriately the package will be accessible to international users.41 There is a need to identify and disseminate examples of good practice.38
Psychological issues—barriers and solutions
From a managerial viewpoint, barriers comprise resistance to change13,34 and how to motivate trainers to undertake e-learning.17 For trainers barriers comprise: resistance to change;10,19 motivation and motivators;17,20 technophobia, computer anxiety and lack of IT confidence;18,51,56 dissatisfaction at losing the benefits and enjoyment of personal contact with learners and other trainers.32,49,54,56 Learners had similar barriers: resistance to change13 with women possibly more resistant to the introduction of computer-based innovations;50 motivation26 and negative views of the value of e-learning;16 technophobia, computer anxiety and lack of IT confidence;13,16,18,19,24,33,51 lack of interactivity and preference for personal contact;49,52,53,56,57,64 lack of control;21 specific issues with particular types of technology such as newsgroups27 and live video sessions.52
Trainers need to prepare for role change, from one of dispensing knowledge to one of guidance and support.27 A blended approach, mixing person-to-person contact with IT methods, seems the most preferred.26 E-learning must be learner centric.36 E-learning is about learners managing their own learning.31 Trainers need to support learner participation and interaction, either face to face or via video;29,42,46,52 Web based environments can enable learners to contribute more to discussions.31 Learners need to be reassured as they confront technological challenges.19 Trainers need to provide a safe environment for failure.13 Learners can learn from mistakes in a nonjudgemental atmosphere.12
Skills—barriers and solutions
From a managerial viewpoint, a barrier is the need for training for trainers and administrators12,17,55 though there can be lack of trainer interest in new skills34 and a lack of training opportunities.10,17,38 Trainers lack appropriate skills and need training in, e.g. course design, development and delivery of e-learning, IT, information management.9,10,17,38,47,51,55,62 Learners can also lack the necessary skills for e-learning, e.g. training needs assessment, IT skills, study and organizational skills, e-learning methodology, critical evaluation, internet searching.12,17,18,19,21,26,27,35,43,50,56,63,64 They lack training and the time for training17,18,20,38,50,51 although some learners may avoid the training they need.51
One possible solution for managers is to establish a policy that learners either take a basic computer literacy course or demonstrate computer skills as a basic prerequisite for admission to e-learning courses.27 Trainers themselves need training, e.g. in IT skills, e-learning techniques and information literacy/management skills.17,21,27,38,51 Trainers need to be familiar with the packages and equipment.13,35 Learners need skills training; in use of computers and the Internet;21,26,27,51,56,64 in information literacy.27,51,56‘Wrap around guides’ help learners manage their learning and navigate through the package.23
Interview and Questionnaire Results
As shown in the methodology section, the questions for the interviews and questionnaires were based on the results of the systematic literature review. This approach was used to test whether the results from the review reflected people's actual experiences. However, the review covers e-learning issues in more breadth and depth and not every topic in the review could be explored in the interviews and questionnaires. Overall the results from the interviews (managers and trainers) and questionnaires (learners) do support the reality of the findings from the review. There were some differences, which may be a reflection that, by its nature, information from the literature is less current. E-learning has progressed and access to technology has improved since the published studies described here. The managers/trainers agreed on barriers caused by requirement for change, poorly designed packages, inadequate technology, lack of skills, costs, need for a component of face-to-face teaching, time intensive nature of e-learning (though they were less concerned about trainers time issues), and need for standardization (though this was not mentioned by many respondents). The learners gave some agreement to the barriers caused by time issues, poorly designed packages, lack of face-to-face teaching, lack of skills, lack of support and costs. There was not a lot of support for the barrier caused by lack of access to technology. The managers/trainers agreed on the following solutions: strongly about standardization, strategies, funding, integration, skills training, support; less strongly about reviewing software, faster feedback, commitment; no responses on communication and timetabling; negative responses on trainer incentives and admission criteria. The learners agreed strongly on the following solutions: blended teaching, user-friendly packages, skills training, free courses, access to technology. They noted one solution—their employer giving them work time for e-learning—which was not mentioned in the literature.
The topic of the effectiveness of e-learning was explored in the interviews and questionnaires. Information on this topic was not extracted from the literature though it was present in some of the articles. Views on the effectiveness of e-learning were very positive. The majority of managers/trainers considered e-learning to be effective. However, they added provisos that this was dependent on the way it is implemented and the attitude and skills of the learner. They were more pessimistic about whether the necessary changes had occurred to implement e-learning. The situation was very variable and dependent on the specific organization involved. Learners’ views were very positive. They thought that e-learning was effective and improved education and training.