Online anatomy and physiology: piloting the use of an anatomy and physiology e-book–VLE hybrid in pre-registration and post-qualifying nursing programmes at the University of Salford


Michael Raynor, ISD, Allerton Building, University of Salford, Salford, Greater Manchester, M5 4WT, UK. E-mail:


Background : Anatomy and physiology (A&P) teaching and learning in nursing curricula poses problems for educators because of the often varying levels of students’ background knowledge. This study reports on a pilot project that attempted to normalize these differentials by delivering A&P teaching using an online interactive e-book–virtual learning environment (VLE) hybrid.

Objectives : Evaluate the effectiveness of using an online interactive resource to deliver A&P teaching.

Methods : Data were collected from pre-registration and post-qualifying students by questionnaire and observation, and from lecturers by structured interviews. Scale-up issues were identified and documented as part of support for the ongoing pilot.

Results : The pre-registration group encountered problems accessing the resource and yielded evidence to suggest that inexperienced learners require a high level of direction to use the resource effectively. The post-qualifying group benefited from the resource's interactive elements and 24/7 availability. There was clear evidence that the group were able to relate knowledge gained from the resource to practice.

Conclusions : This hybrid has great potential to add value to A&P learning on nursing programmes at post-qualifying level. The resource could replace its printed equivalent; however, negotiations need to take place between institutions and publishers in order to resolve scale-up issues.


Literature search

The following sources were searched on the topics of e-book development and e-book usage in health and social care disciplines: cinahl, medline, Business Source Premier, Intute and Library and Information Science Abstracts. cinahl and eric were searched for literature covering biological sciences in the nursing curriculum and the use of computers in nurse education.

Anatomy and physiology teaching in nursing

In the nursing literature over the last decade, the scope and level of anatomy and physiology (A&P) in the curriculum has been clearly identified as problematic in both pre and post-registration diploma and degree courses.1–5 One of the largest problems identified is the differing levels of background knowledge that A&P students have at the beginning of their courses. These differences can promote high levels of fear and anxiety among students and a perception that the subject is very difficult.6 It is likely that biological science will continue to prove difficult for students who have a poor biological background unless appropriate strategies are put in place within the course. Two studies7,8 report some measure of success using online resources or computer-assisted learning packages developed in-house. Although successful, the materials used in these studies address discrete portions of a teaching and learning experience, which is often limited to a module or a specific point in time. These do not always have an accompanying textbook that students can use alongside their e-learning throughout a 3-year programme.

The development of the ‘e-book’

A seemingly universal trend in e-book literature is the debate about the future of the e-book; functionality, pricing models and end-user uptake concern suppliers, educators and information professionals alike.9–12 The most widely available form of e-book entity on the market offers primarily functional enhancements to enrich an end-user's experience of reading. These enhancements typically include access to an online dictionary and the ability to carry out a keyword search across an e-book collection or within the full text of a title. One of the largest e-book providers, Netlibrary,13 also offers an online note-making facility, allowing the user to bookmark and annotate text that can be stored and retrieved for future reference. In addition, this service also offers the user the option of developing and storing collections of their favourite titles. The relatively recently launched Books@Ovid14 takes advantage of publishing speeds in the electronic medium by updating chapters as information becomes available from publishers. Exclusive e-content, including multimedia interactions, is also available, signposted from the table of contents. Although these systems all have the potential to enhance an end-user's engagement with the text, the e-book still remains a passive learning resource rather than an active teaching aid.

E-books have the potential to greatly benefit students in the health and social care disciplines; firstly, the emphasis on practice-based learning sees many users spending a large proportion of their time (up to 50% in the case of pre-registration nurses) on clinical placement remote from print collections. Secondly, learning and teaching styles such as problem-based learning and a drive towards evidence-based practice require students to read widely about a subject, often under time-pressured conditions. Although many librarians feel uptake of e-books is not as great as expected,15 even a cursory glance at the Netlibrary usage statistics for the University of Salford collection indicates a proportionally high usage by Health and Social Care students. Seventy-six per cent of the most accessed titles fall within the medicine, health and social care categories. A cohort study by Appleton16 of student midwife usage of e-books supports the supposition that health and social care students recognize the benefits of e-books. Ease of cross searching of titles, as well as remote access, were cited as useful additions to the printed text. The same students also recognized the e-book's potential to deliver interactive learning experiences. When asked about features they would like to see that were not currently available to them, several members of the cohort were keen to see ‘more pictures and diagrams’, ‘interactive 3-D anatomy pictures’ and ‘video clips of clinical procedures’.

Publishers have begun to recognize this potential and a new generation of products with a higher order of interactivity has begun to emerge. Products like Knovel and Evolve from Elsevier17 and WileyPLUS from John Wiley & Sons, Inc. (Wiley) have developed the e-book into a website–book hybrid that also functions as an online course. While continuing to provide the traditional text and additional functional enhancements, they have also begun to exploit some of the interactive potentialities of a networked environment. The engineering e-books package Knovel18 was amongst the first to offer this compound approach with interactive equations, graphs and tables intrinsically linked to the text of a book.

The WileyPLUS system

WileyPlus19 takes the character of Knovel and extends the genre to provide the lecturer and student with an interactive book that includes many of the features of a virtual learning environment (VLE). In addition to the standard textbook content and e-book functions, the package allows the teacher to integrate their own content via PowerPoint slides, images and text. The enhancements include multimedia interactions, quizzes and case studies, which are tightly structured around textbook content (see Fig. 1). The tutor is able to add formative assignments by choosing from a list of preset questions or by setting their own. All assessments can be marked and grades stored in the package's online Gradebook.

Figure I.

Example of a preset interactive animated quiz in WileyPLUS. Reproduced from Tortora and Derrickson, Principles of Anatomy and Physiology, 11th edition (2006) with permission from John Wiley & Sons, Inc.

Aims and objectives

The overall aim of this pilot was to evaluate the effectiveness of using an online resource to supplement face-to-face A&P teaching and learning. The evaluation was carried out from both a pedagogical and a library and information technology (IT) services perspective. Effectiveness was evaluated against five objectives.

  • 1The potential of an interactive electronic textbook to supplement lecture, seminar and practice placement activity that develops knowledge of A&P.
  • 2The technical practicalities of using interactive online A&P resources at university, home and in work-based learning environments.
  • 3Costs and benefits of this type of provision from university, student and health care trust perspectives.
  • 4The ease of scale-up with respect to technical infrastructure and end-user training.
  • 5The efficacy of the system to replace the printed version of the text.


The project was planned to evaluate over 2 years, beginning in September 2005. In year 1, the University bought 168 licences to Tortora and Derrickson, Principles of Anatomy and Physiology, 11th edition through the WileyPLUS system ( These were valid for 1 year, allowing the students a free 12-month trial. In year 2 (2006/2007), if the students wanted to continue using the resource, they would need to pay for renewal of the licence themselves; this was optional.

Three groups were given access to WileyPLUS in year 1 and their responses elicited by questionnaire and interview. These groups were:

  • Group A: 135 pre-registration BSc students for whom independent learning in A&P was expected from semester 1 onwards to supplement classroom lectures and ward experience. Group A completed a questionnaire simultaneously with their module evaluations at the end of semester 1. A second questionnaire was completed at the end of semester 2.
  • Group B: 25 post-registration MSc students, who were experienced and highly independent practitioners whose needs in relation to in-depth knowledge of A&P differed with their speciality. Group B completed a questionnaire at 6 weeks. Qualitative data was collected by observation, during conversation and by e-mail.
  • Group C: eight volunteer lecturers and their base groups, who were interested in exploring the resource for potential future use. Group C were given a questionnaire to complete but only two (n = 8) were returned. Three lecturers preferred to be interviewed. These interviews were conducted using an interview guide.


Pedagogy results

Group A  From the cohort of 135 students, 74 questionnaires were returned. Of the respondents, 76% said they would like the opportunity to continue using the resource; 24% did not respond to the question. There was little evidence at this early stage of their programme to suggest students were able to relate independently their A&P to practice. The main reasons given for not using WileyPLUS were access problems related to confusion over URLs, passwords, user names or e-mail addresses, while 11 students specifically mentioned that they disliked computer-based learning (CBL) and two students felt that not having broadband at home curtailed their use. However, the pre-registration undergraduate students that used the programme were enthusiastic. They voted their ‘top three’ valued-added features of the resource to be self-test questions, animations and the opportunity offered for online note making.

Group B  The members of this group were universally positive and their usage was highly independent. A few preferred to use the hardback book, but would also access the animations concurrently. Most used the resource with some direction to revise material before a lecture and extend knowledge after a lecture. All liked the self-test, animations, case studies and used the online texts for note taking. There was clear evidence that the members of this group were more able to apply the knowledge gained from the resource to practice; for example, greater understanding of vaccinations and antibodies, cardiac interventions and the behaviour of cells.

Group C.  Questionnaire return rate was very poor and not worth a descriptive statistical analysis. However, from the three lecturers formally interviewed, and from discussion with other lecturers, there is strong support and recognition that this is an excellent and flexible resource. The interactive elements were perceived as pedagogically sound, and the online delivery of the material seen as a value-added element because of its 24/7 availability. WileyPLUS was perceived as a tool that could be integrated into a problem-based learning curriculum and would enable students to develop effective strategies in using fixed resources to develop their knowledge base for clinical reasoning. The latter was illustrated by a lecturer leading an MSc level group who noted a marked difference in pre-lecture knowledge and subsequent classroom interaction, as a result of setting pre-lecture quizzes on the resource.

Roll-out results

The sheer novelty of delivering a hybrid resource to a large group of users meant that unforeseen problems had to be dealt with as and when they arose. However, invaluable lessons were learnt, particularly with respect to scale-up.

The tutor-specific approach to registration was inefficient and potentially counterproductive in terms of student uptake. The resultant impact of this on staff time was significant, with over 50 library and IT staff hours spent dealing with problems directly related to the registration process. This approach would clearly be unworkable if scaled up to an entire intake of students.

Administration of the sound and multimedia components across a network posed some problems in open-access personal computer (PC) rooms.

The conclusions which were drawn against the objectives are shown in Table 1.

Table 1.  Conclusions against objectives
1 Potential of using an interactive electronic textbook to supplement lecture, seminar and practice placement activity that develops knowledge of A&PWe determined that this hybrid type of resource has great potential to add value to A&P teaching on existing nursing programmes
The technical practicalities of using interactive online A&P resources at university, home and in work-based learning environmentsInitial quantitative evaluations of the BSc group usage indicated that nearly 50% of respondents encountered accessibility issues at some point and cited these as a reason for not using the resource
3 Costs and benefits of this type of provision from university, student and health care trust perspectivesIt was not possible to collect data from WileyPLUS on user activity, therefore it was not possible to quantify the time that students were spending using the resource, or at what point in their studies
4 Ease of scale-up with respect to technical infrastructure and end-user trainingThe labour-intensive, tutor-specific approach to registration posed serious barriers to scale-up and was abandoned for the year 2 intake in favour of John Wiley & Sons, Inc. pre-enrolling students
5 Cost-effectiveness and efficacy of the system to replace the printed version of the textInitial take up of WileyPLUS by the year 2, 2006 intake is encouraging: of 114 BSc students, 107 have purchased the licence and book and seven have purchased the licence only. No students have purchased the book alone


Evaluations carried out as part of this study highlighted the variety of ways in which this hybrid can be used: lecturers can use the full range of facilities and content to create a highly structured and closely monitored learning environment; or students can work independently, using it as a personal learning environment to support their ad-hoc learning experiences in different care settings. The resource can also be used by both beginners and advanced learners at different stages of their academic life.

The main barriers to access related to passwords, user names, URLs and issues with sound and animations. All the MSc students were able to access WileyPLUS from their hospital trusts and had no difficulty with running animations or audio. However, the BSc students had difficulty at ward level, because of limited access to PCs. Nevertheless, the majority of students were able to access the resource using PCs in the Trust libraries, or more commonly from PCs in their own homes. Students were also able to access the resource from a university open-access PC area provided they had brought their own earphones.

The interactive elements of Tortora in WileyPlus deliver sound and animations via Macromedia Shockwave Player and Macromedia Flash Player. Although subsequent data collection revealed a high proportion of users accessed WileyPlus from home PCs, facilities had to be provided to enable fully functional on-campus access. Each player was installed manually on 21 machines in an open-access PC drop-in. Subsequent testing identified issues with sound switching off between logins. The number of users of these PCs combined with the diverse range of software used was such that it was not possible to identify the cause of this issue.

Although an evaluation of cost-effectiveness was not possible the pricing model raises issues of cost-effectiveness. The one-licence, one-user mode of access does pass the cost on to the student and, although the licence alone does not exceed the cost of the textbook, this model negates institutional libraries from offering access to those that choose not to purchase.

In terms of scale-up, difficulties were encountered using a ‘tutor-specific URL’ approach to registration. Pre-enrolment of users by Wiley was more user-friendly as students were then able to register by visiting a single URL and entering an access code purchased from the University's campus bookshop. Registration was further enhanced through facilitation by an experienced tutor and the session was embedded in the teaching of the first module. Wiley also agreed to take on any subsequent WileyPLUS-related issues directly, promoting this support service to students via e-mail and via the WileyPLUS help pages. Wiley were also happy for university staff to pass on to them queries received directly from users. As of December 2006, with phase 2 of the project 4 months old, library and IT staff have received no queries about technical issues with the WileyPLUS system.

Sound on networked machines switching on and off poses issues for scalability. Although the problem was intermittent, it could be potentially amplified with scale-up and have huge workload implications for library and IT services, who manage over 270 PCs on the Health and Social Care campus alone. A more practicable solution would be for Wiley to package instructions for switching sound on and off within WileyPLUS's online help pages. Further, one can imagine similar issues with other Higher Education Institutes (HEI) open-access machines. It may therefore be prudent for Wiley to seek a technical solution to this issue, analogous to the browser tests now routinely incorporated into VLEs such as Blackboard.

The resource's potential to replace print is promising. A comparison of number of issues of the print copies of Tortora from September to December 2005 with issues from the same period in 2006, revealed a reduction of 31%. However, this trend requires monitoring longitudinally to see if there is an inverse correlation between the number of library issues and the number of licences purchased. It is also interesting to note that students who purchased felt that they needed the book as well as the licence; suggesting confidence with this hybrid medium is in its embryonic stages.


The results of this pilot strongly suggest this resource is an effective online supplement to face-to-face A&P teaching amongst experienced, self-starting learners. The resource, however, requires tighter facilitation with less-experienced students, which would be difficult to manage and administer across large mixed-ability intakes. It is therefore envisaged that this type of e-book–VLE hybrid would be recommended as a learning resource supplementary to ‘traditional’ A&P teaching. The extent to which the VLE elements of the resource would be used would then be left up to individual tutors.

Tighter facilitation could be more effectively administered if the resources could be integrated and synchronized with institutional VLEs. This would also offer a better end-user experience by reducing the number of systems new students are required to master and consequently the number of end-user training sessions required of increasingly stretched trainers and teachers. Further, integration within a VLE would go some way to removing the access barriers highlighted by the pre-registration group who took part in this study, as well as allowing cost-benefits to be more accurately assessed.

The quantitative data gathered as part of this study indicates this resource is a potential replacement for print. However, until some kind of site-licence model can be can be offered, library and IT services at the University of Salford will not be investing book funds to pay for this resource and concerns remain that the single pricing model acts to exclude those who cannot purchase.

Implications for practice

During this project, tentative steps were made with Wiley to trial a ‘cartridge’ version of Tortora that delivered identical content directly into a university VLE. The cartridge approach allows the VLE functionalities of WileyPLUS to synchronize with their equivalents in a university VLE. Although the content would appear to the student user to be housed in an institutional VLE, it would still be delivered and updated on Wiley's servers. However, because of technical issues between Wiley's and other commercial VLEs, the University was not able to progress with this cartridge. Nevertheless, a solution may well be found, as publishers of these interactive hybrids recognize the commercial value of this method of delivery and tentative investigations indicated a promising solution to scale-up.

This approach would also slot neatly into a university's existing enrolment processes, short circuiting any enrolment issues, whilst retaining access control within the institution. If these hybrids are widely adopted by HEIs, delivery through institutionally adopted VLEs will remain an issue. The School of Nursing at the University of Salford is beginning to explore other hybrid products in the wake of the WileyPLUS pilot, and compatibility with existing VLEs will be high on the agenda before any large-scale trial could be undertaken.

The University of Salford is committed to providing equality of access to teaching and learning resources. Many of these resource entities have a one-licence, one-user access model which conflicts with this philosophy. The University would be keen to work with the vendors of these resources to investigate a site licence model of delivery to enable equality of access. With respect to equality of access, it is pertinent to point out that no member of the cohorts included in this study reported access problems related to personal disability such as visual impairment or dyslexia. However, under advice from university web technologists, a preliminary accessibility review20 of this resource has been undertaken using the Mozilla Firefox Web Developer Toolbar (; the results were mixed. Although the page selected for testing appeared to comply with proper use of Cascading Style Sheets (CSS), Java script and tags to deal with acronyms and abbreviations, there were issues around improper use of tags to convey structure and a lack of Alt attributes for some images. The site also employs frames and multiple pop-up windows which, along with the issues outlined above, could cause problems for users with screen readers or text browsers.

When questioned about whether the site conformed to W3C web-content accessibility guidelines, Wiley somewhat side-stepped the question and pointed out that they do provide an E-file that they describe as ‘a substitute for the traditional print version of the book’.21

These initial accessibility investigations need to be supplemented with detailed testing of the resource by users with disabilities, and the University would be keen to explore this issue further with the developers of resources such as WileyPLUS.

The BSc group clearly highlighted how limited access to PCs at ward level raised a barrier to this resource. Clearly, investigations need to be made into the compatibility of hybrids such as WileyPLUS with portable devices such as mobile phones, PDAs and MP4 players. A study of this type is required as part of a strategic investigation into delivering increasingly digital learning and teaching resources to geographically disparate students.

Key Messages

Implications for Policy

  • • Interactive e-books add value to A&P teaching.
  • • HEIs and publishers of interactive e-book–VLE systems need to work co-operatively to address issues of integration with existing institutional VLEs.
  • • Publishers need to establish flexible pricing models that ensure equality of access.

Implications for Practice

  • • The impact of these systems on learning is greater for experienced learners compared with new students.
  • • Interactive e-book–VLE hybrids are difficult to deploy as active teaching aids across large cohorts of inexperienced learners. For students to become independent in using these resources, they require several months of highly structured and supported input from lecturers.