Joanne Callinan Milford Care Centre Limerick

AIIHPC Clinical Research Fellow 2014

Supervisor Dr Oliver McGarr University of Limerick

Healthcare professionalrsquos barriers and facilitators to

adopting E-Learning in palliative care education

Healthcare professionalrsquos barriers and facilitators to

adopting E-Learning in palliative care education

Abstract

Aim To examine barriers and facilitators to adopting e-learning in palliative care in Ireland

by nurses doctors and allied health care professionals

Objectives 1) To understand the barriers that exist for those accessing e-learning courses

in palliative care and to examine how we can facilitate the adoption of e-learning by those

undertaking e-learning courses 2) To understand the barriers that exist for palliative care

educators wishing to adopt e-learning and to examine how e-learning can be adopted by

palliative care educators on the Island of Ireland

Design amp methodology Cross-sectional surveys (web-based surveys and print surveys) were

developed piloted and disseminated to clinical staff in Irish hospice services Semi-structured

interviews were conducted with six palliative care educators on the Island of Ireland to

understand their perceived attitudes and experiences to adopting e-learning as well as how

these difficulties can be overcome

Results Sixty-seven per cent of learners indicated that having limited time would be a

challenge for using E-Learning and fifty-four per cent indicated that they preferred face to

face interaction Twenty-eight per cent of responses cited accessibility and flexibility of E-

Learning as a motivator to engage with online learning in terms of doing it from anywhere in

your own time and pace The most important motivators ranked in order of importance were

1) Dedicated time to participate in E-Learning activities 2) Quick technical and administrative

support 3) Dedicated computer training before completing an E-Learning course 4) Regular

contact with the educator in online course work Fifty per cent of respondents indicated face-

to face assistance as the type of support that they would like to receive with E-Learning

Palliative care educators had mixed views on e-learning but had a preference for utilising a

blended approach E-Learning increases access to palliative care education enables the

educator to incorporate different multimedia and adopt creative teaching strategies Itrsquos

adoption and utilisation is dependent on many factors including the organisationrsquos culture

structured policies adequate resources and supports for both the educator and the learner

Conclusion ndash By understanding healthcare professionalrsquos attitudes knowledge and

experiences of utilizing e-learning it will assist us in understanding the barriers that exist in

adopting e-learning amongst palliative care educators in Ireland and assist us in addressing

those needs

Background

The research project aims to understand what barriers and facilitators exist to adopting e-

learning in Ireland by doctors nurses healthcare assistants and allied health care

professionals in palliative care from the perspective of learners and education

providersldquoEducation is a core component of specialist palliative care The culture of

continuing professional education and development should be promoted among health care

professionals in all disciplines that are involved in the delivery of palliative care (DOHC

2001)rdquo It is recognised that the palliative care approach should be a core skill of very

clinician at hospital and community level as many patients will have their care needs met

without referral to specialist palliative care units or personnel (HSE 2009)

E-learning provides flexibility to learn regardless of location allowing self-paced learning to

occur at a time and place that suits the learner This may be particularly important for health

care professionals who are required to update their clinical skills From an organizational

perspective it may offer a method of recording training monitoring learnerrsquos progress and

assessing learning

E-Learning also called online learning includes any means of delivering learning materials

by the World Wide Web (Whittington 2000) E-Learning is appropriate to adult learning

because they have control over their own learning (self-directed) Digital media incorporating

audio graphics animation and text has the potential to appeal to individuals with different

learning styles such as those with preferences for visual aural readingwriting and

kinaesthetic (Fleming amp Baume 2006) and multiple intelligences (Gardner 1993)

Utilising digital media requires learner participation and interaction and is less teacher-

centred therefore creating more meaningful learning Educators utilising e-learning should

ensure that the learner is at the centre of the process and not the technology itself

Opportunities exist to combine different learning styles and varying delivery systems to

create the best learning experience possible (Hodges 2010) A virtual learning environment

using Moodle can also facilitate lifelong learning at a time when it is more difficult for staff to

be released to attend courses Although e-learning has increased in popularity in recent

years it has not been readily integrated into teaching practice in nurse education (Petit dit

Daniel Wharrad amp Windle 2013) Therefore it is necessary to understand what barriers

exist amongst health care practitioners in palliative care to adopting e-learning

According to Hart (2012) difficulties in adopting new technologies can be due to lack of

understanding of how to use the technology appropriately to enhance the studentrsquos learning

A number of barriers to adoption may exist at both the individual and organisational level At

the individual level these include attitudes towards e-learning perceived usefulness

perceived ease of use pressure to use e-learning and the availability of resources needed to

use e-learning (Ahmed 2008)

According to Becker (2009) there is a small yet increasing number of interactive websites

that offer palliative care education to health professionals and these are growing along with

technological developments They offer course participants the opportunity to study

regardless of geographical location and enable flexible learning outside their normal working

hours It has been argued that a blended approach to learning is appropriate to palliative

care as e-learning fits the scientific fact-based knowledge of palliative care whereas the

face-to-face element is suited to the human dynamics of caring (Becker 2009)

In September 2010 we introduced a virtual learning environment (VLE) to support

candidates doing a distance learning programme called the European Certificate in Essential

Palliative Care which is aimed at doctors and nurses Whilst forum participation occurred

between some candidates during the 8 week period there was less participation between

candidates and facilitators via the VLE in the pilot and post-pilot phases (Callinan amp

McLoughlin 2012) Similar to other studies using Moodle there was poor uptake of the

forums (Burgess 2008 ) particularly in the pilot phase However the introduction of case

studies on the forums in the post-pilot phase were rated quite highly by candidates and

some candidates did participate in the case study questions even though this was an

optional activity One facilitator in the pilot phase perceived that students may not engage

with Moodle due to fear of the technology although we did not find this to be the case

In a study conducted on the usage of virtual learning environments in Ireland a number of

key drivers and barriers to their uptake and usage were identified (Cosgrave 2011))

Among them were confidence and competency in IT The most important factor inhibiting

studentrsquos use of the virtual learning environments (eg Moodle Blackboard etc) was the

lecturerrsquos reluctance to use it A feeling of isolation in distance education learners has been

reported often in the literature (Carnwell 1998 Price 2000) Therefore understanding

difficulties to e-learning adoption and use amongst clinical staff in palliative care is important

to ensure that appropriate support mechanisms can be put in place to facilitate e-learning A

literature review (Surrey Ensminger amp Haab 2005) identified barriers to integrating e-

learning into higher education including the technology infrastructure required faculty effort

technology satisfaction IT competency policies training technical amp pedagogical support

Good quality e-learning initiatives take a long time to develop but the key to success is the

support offered to the students (Becker 2009) and there are cost and resource implications

to this An EAPC paper on core competencies in palliative care education (2013) supports

the use of shared learning opportunities across countries and indicates that there is

evidence that using digital learning tools enhances understanding of palliative care theory

and its application to practicerdquo

E-learning can increase educational opportunities for healthcare professionals in Ireland

regardless of where they live It is important to understand how we can facilitate e-learning

for educators and healthcare professionals to ensure that the palliative care approach is an

integral part of caring for patients at the end of life in all settings and that the spiritual

physical and psychosocial needs of patients and their families are met

By understanding healthcare professionalrsquos attitudes knowledge and experiences of utilizing

e-learning it will assist us in understanding the barriers that exist in adopting e-learning

amongst palliative care educators and learners in Ireland and assist us in addressing those

needs It will also highlight healthcare professionalrsquos attitudes towards e-learning as a mode

of learning for continuing professional development and understand the likely uptake to such

e-learning courses

Method

Data collection procedure

The study consisted of two phases

Phase 1

Data was collected from a convenience sample of doctors nurses allied healthcare

professionals and healthcare assistants using a questionnaire instrument Respondents

were employed in specialist palliative care in hospice day care and the community on the

Island of Ireland

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Healthcare professionalrsquos barriers and facilitators to

adopting E-Learning in palliative care education

Abstract

Aim To examine barriers and facilitators to adopting e-learning in palliative care in Ireland

by nurses doctors and allied health care professionals

Objectives 1) To understand the barriers that exist for those accessing e-learning courses

in palliative care and to examine how we can facilitate the adoption of e-learning by those

undertaking e-learning courses 2) To understand the barriers that exist for palliative care

educators wishing to adopt e-learning and to examine how e-learning can be adopted by

palliative care educators on the Island of Ireland

Design amp methodology Cross-sectional surveys (web-based surveys and print surveys) were

developed piloted and disseminated to clinical staff in Irish hospice services Semi-structured

interviews were conducted with six palliative care educators on the Island of Ireland to

understand their perceived attitudes and experiences to adopting e-learning as well as how

these difficulties can be overcome

Results Sixty-seven per cent of learners indicated that having limited time would be a

challenge for using E-Learning and fifty-four per cent indicated that they preferred face to

face interaction Twenty-eight per cent of responses cited accessibility and flexibility of E-

Learning as a motivator to engage with online learning in terms of doing it from anywhere in

your own time and pace The most important motivators ranked in order of importance were

1) Dedicated time to participate in E-Learning activities 2) Quick technical and administrative

support 3) Dedicated computer training before completing an E-Learning course 4) Regular

contact with the educator in online course work Fifty per cent of respondents indicated face-

to face assistance as the type of support that they would like to receive with E-Learning

Palliative care educators had mixed views on e-learning but had a preference for utilising a

blended approach E-Learning increases access to palliative care education enables the

educator to incorporate different multimedia and adopt creative teaching strategies Itrsquos

adoption and utilisation is dependent on many factors including the organisationrsquos culture

structured policies adequate resources and supports for both the educator and the learner

Conclusion ndash By understanding healthcare professionalrsquos attitudes knowledge and

experiences of utilizing e-learning it will assist us in understanding the barriers that exist in

adopting e-learning amongst palliative care educators in Ireland and assist us in addressing

those needs

Background

The research project aims to understand what barriers and facilitators exist to adopting e-

learning in Ireland by doctors nurses healthcare assistants and allied health care

professionals in palliative care from the perspective of learners and education

providersldquoEducation is a core component of specialist palliative care The culture of

continuing professional education and development should be promoted among health care

professionals in all disciplines that are involved in the delivery of palliative care (DOHC

2001)rdquo It is recognised that the palliative care approach should be a core skill of very

clinician at hospital and community level as many patients will have their care needs met

without referral to specialist palliative care units or personnel (HSE 2009)

E-learning provides flexibility to learn regardless of location allowing self-paced learning to

occur at a time and place that suits the learner This may be particularly important for health

care professionals who are required to update their clinical skills From an organizational

perspective it may offer a method of recording training monitoring learnerrsquos progress and

assessing learning

E-Learning also called online learning includes any means of delivering learning materials

by the World Wide Web (Whittington 2000) E-Learning is appropriate to adult learning

because they have control over their own learning (self-directed) Digital media incorporating

audio graphics animation and text has the potential to appeal to individuals with different

learning styles such as those with preferences for visual aural readingwriting and

kinaesthetic (Fleming amp Baume 2006) and multiple intelligences (Gardner 1993)

Utilising digital media requires learner participation and interaction and is less teacher-

centred therefore creating more meaningful learning Educators utilising e-learning should

ensure that the learner is at the centre of the process and not the technology itself

Opportunities exist to combine different learning styles and varying delivery systems to

create the best learning experience possible (Hodges 2010) A virtual learning environment

using Moodle can also facilitate lifelong learning at a time when it is more difficult for staff to

be released to attend courses Although e-learning has increased in popularity in recent

years it has not been readily integrated into teaching practice in nurse education (Petit dit

Daniel Wharrad amp Windle 2013) Therefore it is necessary to understand what barriers

exist amongst health care practitioners in palliative care to adopting e-learning

According to Hart (2012) difficulties in adopting new technologies can be due to lack of

understanding of how to use the technology appropriately to enhance the studentrsquos learning

A number of barriers to adoption may exist at both the individual and organisational level At

the individual level these include attitudes towards e-learning perceived usefulness

perceived ease of use pressure to use e-learning and the availability of resources needed to

use e-learning (Ahmed 2008)

According to Becker (2009) there is a small yet increasing number of interactive websites

that offer palliative care education to health professionals and these are growing along with

technological developments They offer course participants the opportunity to study

regardless of geographical location and enable flexible learning outside their normal working

hours It has been argued that a blended approach to learning is appropriate to palliative

care as e-learning fits the scientific fact-based knowledge of palliative care whereas the

face-to-face element is suited to the human dynamics of caring (Becker 2009)

In September 2010 we introduced a virtual learning environment (VLE) to support

candidates doing a distance learning programme called the European Certificate in Essential

Palliative Care which is aimed at doctors and nurses Whilst forum participation occurred

between some candidates during the 8 week period there was less participation between

candidates and facilitators via the VLE in the pilot and post-pilot phases (Callinan amp

McLoughlin 2012) Similar to other studies using Moodle there was poor uptake of the

forums (Burgess 2008 ) particularly in the pilot phase However the introduction of case

studies on the forums in the post-pilot phase were rated quite highly by candidates and

some candidates did participate in the case study questions even though this was an

optional activity One facilitator in the pilot phase perceived that students may not engage

with Moodle due to fear of the technology although we did not find this to be the case

In a study conducted on the usage of virtual learning environments in Ireland a number of

key drivers and barriers to their uptake and usage were identified (Cosgrave 2011))

Among them were confidence and competency in IT The most important factor inhibiting

studentrsquos use of the virtual learning environments (eg Moodle Blackboard etc) was the

lecturerrsquos reluctance to use it A feeling of isolation in distance education learners has been

reported often in the literature (Carnwell 1998 Price 2000) Therefore understanding

difficulties to e-learning adoption and use amongst clinical staff in palliative care is important

to ensure that appropriate support mechanisms can be put in place to facilitate e-learning A

literature review (Surrey Ensminger amp Haab 2005) identified barriers to integrating e-

learning into higher education including the technology infrastructure required faculty effort

technology satisfaction IT competency policies training technical amp pedagogical support

Good quality e-learning initiatives take a long time to develop but the key to success is the

support offered to the students (Becker 2009) and there are cost and resource implications

to this An EAPC paper on core competencies in palliative care education (2013) supports

the use of shared learning opportunities across countries and indicates that there is

evidence that using digital learning tools enhances understanding of palliative care theory

and its application to practicerdquo

E-learning can increase educational opportunities for healthcare professionals in Ireland

regardless of where they live It is important to understand how we can facilitate e-learning

for educators and healthcare professionals to ensure that the palliative care approach is an

integral part of caring for patients at the end of life in all settings and that the spiritual

physical and psychosocial needs of patients and their families are met

By understanding healthcare professionalrsquos attitudes knowledge and experiences of utilizing

e-learning it will assist us in understanding the barriers that exist in adopting e-learning

amongst palliative care educators and learners in Ireland and assist us in addressing those

needs It will also highlight healthcare professionalrsquos attitudes towards e-learning as a mode

of learning for continuing professional development and understand the likely uptake to such

e-learning courses

Method

Data collection procedure

The study consisted of two phases

Phase 1

Data was collected from a convenience sample of doctors nurses allied healthcare

professionals and healthcare assistants using a questionnaire instrument Respondents

were employed in specialist palliative care in hospice day care and the community on the

Island of Ireland

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Background

The research project aims to understand what barriers and facilitators exist to adopting e-

learning in Ireland by doctors nurses healthcare assistants and allied health care

professionals in palliative care from the perspective of learners and education

providersldquoEducation is a core component of specialist palliative care The culture of

continuing professional education and development should be promoted among health care

professionals in all disciplines that are involved in the delivery of palliative care (DOHC

2001)rdquo It is recognised that the palliative care approach should be a core skill of very

clinician at hospital and community level as many patients will have their care needs met

without referral to specialist palliative care units or personnel (HSE 2009)

E-learning provides flexibility to learn regardless of location allowing self-paced learning to

occur at a time and place that suits the learner This may be particularly important for health

care professionals who are required to update their clinical skills From an organizational

perspective it may offer a method of recording training monitoring learnerrsquos progress and

assessing learning

E-Learning also called online learning includes any means of delivering learning materials

by the World Wide Web (Whittington 2000) E-Learning is appropriate to adult learning

because they have control over their own learning (self-directed) Digital media incorporating

audio graphics animation and text has the potential to appeal to individuals with different

learning styles such as those with preferences for visual aural readingwriting and

kinaesthetic (Fleming amp Baume 2006) and multiple intelligences (Gardner 1993)

Utilising digital media requires learner participation and interaction and is less teacher-

centred therefore creating more meaningful learning Educators utilising e-learning should

ensure that the learner is at the centre of the process and not the technology itself

Opportunities exist to combine different learning styles and varying delivery systems to

create the best learning experience possible (Hodges 2010) A virtual learning environment

using Moodle can also facilitate lifelong learning at a time when it is more difficult for staff to

be released to attend courses Although e-learning has increased in popularity in recent

years it has not been readily integrated into teaching practice in nurse education (Petit dit

Daniel Wharrad amp Windle 2013) Therefore it is necessary to understand what barriers

exist amongst health care practitioners in palliative care to adopting e-learning

According to Hart (2012) difficulties in adopting new technologies can be due to lack of

understanding of how to use the technology appropriately to enhance the studentrsquos learning

A number of barriers to adoption may exist at both the individual and organisational level At

the individual level these include attitudes towards e-learning perceived usefulness

perceived ease of use pressure to use e-learning and the availability of resources needed to

use e-learning (Ahmed 2008)

According to Becker (2009) there is a small yet increasing number of interactive websites

that offer palliative care education to health professionals and these are growing along with

technological developments They offer course participants the opportunity to study

regardless of geographical location and enable flexible learning outside their normal working

hours It has been argued that a blended approach to learning is appropriate to palliative

care as e-learning fits the scientific fact-based knowledge of palliative care whereas the

face-to-face element is suited to the human dynamics of caring (Becker 2009)

In September 2010 we introduced a virtual learning environment (VLE) to support

candidates doing a distance learning programme called the European Certificate in Essential

Palliative Care which is aimed at doctors and nurses Whilst forum participation occurred

between some candidates during the 8 week period there was less participation between

candidates and facilitators via the VLE in the pilot and post-pilot phases (Callinan amp

McLoughlin 2012) Similar to other studies using Moodle there was poor uptake of the

forums (Burgess 2008 ) particularly in the pilot phase However the introduction of case

studies on the forums in the post-pilot phase were rated quite highly by candidates and

some candidates did participate in the case study questions even though this was an

optional activity One facilitator in the pilot phase perceived that students may not engage

with Moodle due to fear of the technology although we did not find this to be the case

In a study conducted on the usage of virtual learning environments in Ireland a number of

key drivers and barriers to their uptake and usage were identified (Cosgrave 2011))

Among them were confidence and competency in IT The most important factor inhibiting

studentrsquos use of the virtual learning environments (eg Moodle Blackboard etc) was the

lecturerrsquos reluctance to use it A feeling of isolation in distance education learners has been

reported often in the literature (Carnwell 1998 Price 2000) Therefore understanding

difficulties to e-learning adoption and use amongst clinical staff in palliative care is important

to ensure that appropriate support mechanisms can be put in place to facilitate e-learning A

literature review (Surrey Ensminger amp Haab 2005) identified barriers to integrating e-

learning into higher education including the technology infrastructure required faculty effort

technology satisfaction IT competency policies training technical amp pedagogical support

Good quality e-learning initiatives take a long time to develop but the key to success is the

support offered to the students (Becker 2009) and there are cost and resource implications

to this An EAPC paper on core competencies in palliative care education (2013) supports

the use of shared learning opportunities across countries and indicates that there is

evidence that using digital learning tools enhances understanding of palliative care theory

and its application to practicerdquo

E-learning can increase educational opportunities for healthcare professionals in Ireland

regardless of where they live It is important to understand how we can facilitate e-learning

for educators and healthcare professionals to ensure that the palliative care approach is an

integral part of caring for patients at the end of life in all settings and that the spiritual

physical and psychosocial needs of patients and their families are met

By understanding healthcare professionalrsquos attitudes knowledge and experiences of utilizing

e-learning it will assist us in understanding the barriers that exist in adopting e-learning

amongst palliative care educators and learners in Ireland and assist us in addressing those

needs It will also highlight healthcare professionalrsquos attitudes towards e-learning as a mode

of learning for continuing professional development and understand the likely uptake to such

e-learning courses

Method

Data collection procedure

The study consisted of two phases

Phase 1

Data was collected from a convenience sample of doctors nurses allied healthcare

professionals and healthcare assistants using a questionnaire instrument Respondents

were employed in specialist palliative care in hospice day care and the community on the

Island of Ireland

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

According to Hart (2012) difficulties in adopting new technologies can be due to lack of

understanding of how to use the technology appropriately to enhance the studentrsquos learning

A number of barriers to adoption may exist at both the individual and organisational level At

the individual level these include attitudes towards e-learning perceived usefulness

perceived ease of use pressure to use e-learning and the availability of resources needed to

use e-learning (Ahmed 2008)

According to Becker (2009) there is a small yet increasing number of interactive websites

that offer palliative care education to health professionals and these are growing along with

technological developments They offer course participants the opportunity to study

regardless of geographical location and enable flexible learning outside their normal working

hours It has been argued that a blended approach to learning is appropriate to palliative

care as e-learning fits the scientific fact-based knowledge of palliative care whereas the

face-to-face element is suited to the human dynamics of caring (Becker 2009)

In September 2010 we introduced a virtual learning environment (VLE) to support

candidates doing a distance learning programme called the European Certificate in Essential

Palliative Care which is aimed at doctors and nurses Whilst forum participation occurred

between some candidates during the 8 week period there was less participation between

candidates and facilitators via the VLE in the pilot and post-pilot phases (Callinan amp

McLoughlin 2012) Similar to other studies using Moodle there was poor uptake of the

forums (Burgess 2008 ) particularly in the pilot phase However the introduction of case

studies on the forums in the post-pilot phase were rated quite highly by candidates and

some candidates did participate in the case study questions even though this was an

optional activity One facilitator in the pilot phase perceived that students may not engage

with Moodle due to fear of the technology although we did not find this to be the case

In a study conducted on the usage of virtual learning environments in Ireland a number of

key drivers and barriers to their uptake and usage were identified (Cosgrave 2011))

Among them were confidence and competency in IT The most important factor inhibiting

studentrsquos use of the virtual learning environments (eg Moodle Blackboard etc) was the

lecturerrsquos reluctance to use it A feeling of isolation in distance education learners has been

reported often in the literature (Carnwell 1998 Price 2000) Therefore understanding

difficulties to e-learning adoption and use amongst clinical staff in palliative care is important

to ensure that appropriate support mechanisms can be put in place to facilitate e-learning A

literature review (Surrey Ensminger amp Haab 2005) identified barriers to integrating e-

learning into higher education including the technology infrastructure required faculty effort

technology satisfaction IT competency policies training technical amp pedagogical support

Good quality e-learning initiatives take a long time to develop but the key to success is the

support offered to the students (Becker 2009) and there are cost and resource implications

to this An EAPC paper on core competencies in palliative care education (2013) supports

the use of shared learning opportunities across countries and indicates that there is

evidence that using digital learning tools enhances understanding of palliative care theory

and its application to practicerdquo

E-learning can increase educational opportunities for healthcare professionals in Ireland

regardless of where they live It is important to understand how we can facilitate e-learning

for educators and healthcare professionals to ensure that the palliative care approach is an

integral part of caring for patients at the end of life in all settings and that the spiritual

physical and psychosocial needs of patients and their families are met

By understanding healthcare professionalrsquos attitudes knowledge and experiences of utilizing

e-learning it will assist us in understanding the barriers that exist in adopting e-learning

amongst palliative care educators and learners in Ireland and assist us in addressing those

needs It will also highlight healthcare professionalrsquos attitudes towards e-learning as a mode

of learning for continuing professional development and understand the likely uptake to such

e-learning courses

Method

Data collection procedure

The study consisted of two phases

Phase 1

Data was collected from a convenience sample of doctors nurses allied healthcare

professionals and healthcare assistants using a questionnaire instrument Respondents

were employed in specialist palliative care in hospice day care and the community on the

Island of Ireland

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

learning into higher education including the technology infrastructure required faculty effort

technology satisfaction IT competency policies training technical amp pedagogical support

Good quality e-learning initiatives take a long time to develop but the key to success is the

support offered to the students (Becker 2009) and there are cost and resource implications

to this An EAPC paper on core competencies in palliative care education (2013) supports

the use of shared learning opportunities across countries and indicates that there is

evidence that using digital learning tools enhances understanding of palliative care theory

and its application to practicerdquo

E-learning can increase educational opportunities for healthcare professionals in Ireland

regardless of where they live It is important to understand how we can facilitate e-learning

for educators and healthcare professionals to ensure that the palliative care approach is an

integral part of caring for patients at the end of life in all settings and that the spiritual

physical and psychosocial needs of patients and their families are met

By understanding healthcare professionalrsquos attitudes knowledge and experiences of utilizing

e-learning it will assist us in understanding the barriers that exist in adopting e-learning

amongst palliative care educators and learners in Ireland and assist us in addressing those

needs It will also highlight healthcare professionalrsquos attitudes towards e-learning as a mode

of learning for continuing professional development and understand the likely uptake to such

e-learning courses

Method

Data collection procedure

The study consisted of two phases

Phase 1

Data was collected from a convenience sample of doctors nurses allied healthcare

professionals and healthcare assistants using a questionnaire instrument Respondents

were employed in specialist palliative care in hospice day care and the community on the

Island of Ireland

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Phase 2

Data was collected from a purposeful sample of hospice educators on the Island of Ireland

using semi-structured interviews

Piloting

The instrument was pre-tested for content validity with six experts in the subject areas of

palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete it Subsequent revisions to the

instrument were carried out which were based on feedback received in the pilot phase and

were concerned with the length of the questionnaire and re-wording some of the statements

for clarity

Ethical approval for phases 1 amp 2

An email explaining the purpose of the research study was sent to the CEO and Director of

Nursing in the hospice services and permission was requested to access the sample in each

organisation Upon receiving permission to carry out the study at the site ethical approval

was then sought and obtained from Research Ethics Committees in the Republic of Ireland

and Northern Ireland for both phases of the study

Participants in both phases of the study received information on the purpose of the study

that their anonymity would be upheld in the reporting of the data and that it would be stored

securely to ensure confidentiality Participants in the semi-structured interviews received a

participant information sheet to enable them to make an informed consent It explained the

aims and objectives of the study the nature of their participation in the study any risks to the

participant the voluntary nature of their participation and explained how confidentiality and

anonymity would be maintained They also signed a participant consent form The

transcriber was also sign a confidentiality agreement

Sampling procedure Questionnaires

Print and online questionnaires were sent to hospice services on the Island of Ireland inviting

clinical staff from specialist palliative inpatient units homecare community and day care

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

services to participate in the study A reminder email was sent to organisations

approximately 3 weeks later Respondents had the option of entering a prize-draw which

was used as an incentive to complete the questionnaire The questionnaire included an

explanation of the purpose of the study and its voluntary nature

Inclusion criteria Questionnaires

Clinical staff including doctors nurses healthcare assistants allied health care professionals

including physiotherapists occupational therapists social workers dieticians pharmacists

chaplains artmusichorticulture or other therapists working in specialist palliative care

Sampling procedure Semi-structured Interviews

Purposeful sampling was used to identify participants for the semi-structured

interviews The target number of interviews was based on research showing a minimum of

six interviews is required to achieve over-arching themes (Guest G 2006) All participants

were recruited by email invitation which included a participant information sheet informing

them of the purpose of the study its voluntary nature and are made aware that they can

withdraw from the study at any point without repercussion A reminder email was sent

approximately two weeks later The interviews occurred at a location date and time that

suited the participants Recruitment continued until the target number of participants for this

study was obtained

Three of the interviews were carried out in the participantrsquos workplace and due to

logistical challenges three were telephone-based interviews The interviews were audio-

recorded by the researcher with consent from the participants The interviews were

transcribed and the data was thematically analysed Each transcript was read several times

to identify possible themes which were then coded and analysed (Guest MacQueen amp

Namey 2012)

Inclusion criteria Semi-structured Interviews

The inclusion criteria for participation is that participants must be employed in an education

facility within a hospice environment have clinical experience and be involved in the delivery

of palliative care education as their primary role

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Instruments

Questionnaire

A literature search was undertaken to ascertain if a valid and reliable instrument could be

utilised or adapted for this study We did not find a validated tool which could be adapted to

healthcare professionals in this setting We designed and developed an instrument based on

a comprehensive review of the literature Multiple scale items were primarily adapted from

Watson Leigh amp Triner 2004 and used to elicit self-efficacy in relation to computers skills

and engaging online perceived usefulness ease of use normative beliefs and their

motivation in an online environment

The instrument was pre-tested for content validity with six experts in the subject

areas of palliative care IT and education Based on their feedback this instrument was

subsequently revised and re-drafted The instrument was piloted with ten healthcare

professionals to clarify their understanding of the items used in the instrument ease of use

length of questionnaire and the time taken to complete Subsequent revisions to the

instrument were carried out based on feedback received in the pilot phase and mainly

concerned the length of the questionnaire and re-wording some of the statements for clarity

The four-page questionnaire is comprised of 25 questions covering 1) Demographics

2) Access to computers and the internet 3) Confidence using IT and E-learning 4) Prior

experience of E-learning 5) Attitudes towards E-Learning ndash Barriers Facilitators Suitability

in palliative care education

Interviews

Upon reviewing the existing literature of E-learning adoption by educators an interview

guide consisting of fourteen questions was developed Questions consisted of educatorrsquos

experience of using e-learning perceived usefulness of e-learning to them and their

students key indicators and challenges to using e-learning in palliative care education and

attitudes towards e-learning from the perspective of the palliative care educator

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Findings

Respondent profile

A total of 397 responses was obtained from a convenience sample sent to thirteen

specialist palliative care centres which had inpatient units located in the Republic of Ireland

and in Northern Ireland as well as all specialist palliative care homecare services located in

the Republic of Ireland

It was not possible to obtain a response rate across all sites The average response rate

obtained across six sites was approximately 35

Among the respondents 54 worked in an inpatient unit 7 worked in day care

29 worked in the community and 11 indicated that they worked elsewhere

Approximately 91 were female and 646 were nurses followed by 131 healthcare

assistants and 105 doctors Approximately 12 worked in the allied health care

professions in specialist palliative care Thirty-three per cent of respondents were 45-54

years old followed by 31 who were 35-44 years old Seventeen percent were 24-34 years

old and approx 17 were also 55 years or older Only 2 of respondents were 16-24 years

old

Nearly eighty-two per cent of respondents used a computer at least once a week or

more at work Approximately 115 used it less than once a week and only 7 reported

never using a computer at work Similarly 92 reported using computers outside of work at

least once a week and the remainder using it less than this A high percentage of

respondents had internet access in work (92) and outside of working hours (97) More

than half of respondents (53) reported their level of confidence using computers as good

or excellent Nearly 8 indicated that they had poor or very poor confidence with computers

Thirty-nine per cent of respondents rated themselves as average in terms of their confidence

using computers Despite the high percentage of internet access only 50 of

questionnaires were completed online

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

What is your age

16 to 24 yrs

25 to 34 yrs

35 to 44 yrs

45 to 54 yrs

55 + yrs

Are youNurse

Doctor

Occupational Therapist

Dietician

Social Worker

Physiotherapist

Chaplain

Pharmacist

Speech amp Language Therapist

Healthcare Assistant

Other

How often do you use a computer for work

Never

A few times a year

Once a month

A few times a month

Once a week

A few times a week

Every day

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Learner Computer self-efficacy

Respondentrsquos perceived confidence carrying out a number of computer tasks was

measured The study found that respondents confidence levels for basic skills such as

logging onto the computer searching the internet and sending file attachments by email was

388 423 and 403 respectively on a scale of 1 to 5 where 1= Not confident and 5= Very

Confident Sixty-two per cent of respondents felt that they would feel confident using E-

Learning as a learner even if they had never used it before

Learner E-Learning experience

Only 37 of clinical staff in palliative care had previous experience of completing a course

using E-Learning alone with forty-three per cent having completed a blended course which

had an e-learning component As part of continuing professional activities nearly fifty-two

per cent of all clinical staff reporting listening to podcasts or watched videos and fifty per cent

reported that they completed quizzes online Forty-six per cent of respondents had uploaded

assignments to a website for assessment and thirty-nine percent reported using learning

management systems such as Moodle Blackboard or Sulis Thirty-two percent had reported

using HSEland (The Irish Health Service Executive online resource for Learning and

Development) and 15 had previously used the Irish Hospice Foundation e-learning

resources as part of their continuing professional development Participation by clinical staff

was lowest for live webinars (17) blogs (18) and video conferences (26)

0

20

40

60

80

100

120

140

160

Very Poor Poor Average Good Excellent

Confidence using computersNumber of Respondents

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Learner Attitudes towards e-learning

Eighty-six per cent of respondents either ldquoagreedrdquo or ldquostrongly agreedrdquo that E-Learning would

be useful for their continuing professional development and 63 believed that E-Learning is

easy to use Sixty-two per cent of respondents believed that there are limitations with E-

Learning about palliative care Fifty-seven per cent reported that positive aspects

outweighed negative aspects of using E-Learning in palliative care and fifty-five per cent

reported that their colleagues used E-Learning Eighty per cent of respondents reported that

if a course or study module they were interested in became available which had an E-

Learning component they would avail of it

43

57

Have you ever completed a course which involved both ELearning and face-to-face interaction with the tutor in class

Yes No

000 2000 4000 6000

a) Used HSELand

b) Irish Hospice Foundation e-learning resources

c) Participated in a video conference

d) Used Blackboard Moodle Sulis or other E-Learning Platform

e) Accessed course lecture notes from the internet eg Moodlehellip

f) Completed course quizzes online

g) Uploaded assignments to a website for assessment

h) Participated in a course forum or discussion via the internet

i) Attended a live webinar (presentation seminar or workshophellip

j) Listened or watched a podcast which may contain audio or video

k) Participated in a blog

l) Other E-Learning activity

Engagement in different E-Learning Activities

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

0 20 40 60 80 100 120

a) I would feel confident using E-Learning as a learner even if Ihad never used it before

b) I believe E-Learning is useful for my continuing professionaldevelopment

c) I believe E-Learning is easy to use

d) I believe there are limitations with E-Learning for learningabout palliative care

e) Positive aspects outweigh negative aspects of using E-Learning in palliative care

f) My colleagues use E-Learning

g) I think that I would be able to complete an E-Learningcourse even if there were distractions (Online television etc)

Attitudes towards E-Learning

Strongly Disagree Disagree Not sure Agree Strongly Agree

0

50

100

150

200

250

Highly Unlikely Unlikely Not Sure Likely Highly Likely

Likelihood of availing of a course or study module which had an E-Learning component

Number ofRespondents

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Learner Barriers to E-Learning

Sixty-seven per cent indicated that having limited time would be a challenge for using

E-Learning and fifty-four per cent indicated that they preferred face to face interaction

Nearly one third indicated that remaining motivated would be a challenge in E-Learning

Interestingly only thirty-four per cent reported that lacking computer skills would be a barrier

to using E-Learning

There were thirty-nine responses to the open-ended question about other challenges

to e-learning An analysis of qualitative data from open-ended question on other challenges

found that approximately one third of those responses highlighted the importance of face to

face interaction The following include some of the responses

ldquolack of opportunity for impromptu engagementgroup dialoguerdquo

ldquoI think Palliative care education is enhanced by personal and group interactionrdquo

ldquounable to ask questions as you gordquo

Twenty-three per cent of them reported that access to good IT facilities is

particularly important in the workplace especially a designated space without interruptions

Eighteen per cent of responses indicated that a challenge would be having designated time

to carry out E-Learning with one respondent stating that there is a ldquoRisk of limited study

leave support from work organisation as the time spent on E-Learning is hiddenrdquo

Other challenges when participating in e-learning are dependent on the course design such

as having deadlines to keep you motivated blended learning well designed courses with

embedded links which are functional Course outline should indicate appropriate target

audience and course content Lack of confidence and computer skills were also identified by

10 of the responses to this question eg ldquo I think this is an age thing as most of the

younger nurses were brought up with modern technology and itrsquos more natural for themrdquo

Respondents were asked what would prevent them from participating in a course with an

e-learning component in future There were 244 responses to this open ended question

(615 response rate) All of the responses were analysed and coded and ten main factors

were identified The biggest factor was the need for protected time as 42 of responses

highlighted time constraints during already busy working schedules as a big inhibitor of

studying online

- ldquoWould depend on the time required to complete it versus how busy my clinical post was

at that time That being said E-learning courses would take up much less time than

classroom based course - travelling to amp from etc and could be done to own schedulerdquo

- ldquoNot having enough time in work to do itrdquo

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

- ldquoEnsuring designated learning time computer access in quiet areardquo

Approximately 27 indicated lack of computer skills lack of confidence and a requirement

for technical or other support using E-Learning as factors preventing them doing E-Learning

- ldquoIf there was no support structure in place if struggling with course from a computer

literacy perspective or from a course content perspectiverdquo

- ldquoNot knowing enough about computersrdquo

Relating to course design ldquoE-learning is not a filing cabinet for information - needs to be a

very interactive component amp a sharing of ideas with ones in your personal fieldrdquo

Ten per cent of responses stated ldquoNothingrdquo would prevent them from doing E-Learning

Other factors identified in participant open-ended responses included a preference for face

to face learning (8) cost finance (6) motivation self-discipline (5) relevancy (3)

accessibility to computer resources including software or computers good quality internet

connection (6)

- ldquoI prefer face-to-face interaction learning amp discussion I dislike reading documents on a

screenrdquo

- ldquoI have trouble using computers at home as there are constant interuptionsrdquo

- ldquoEasier to concentrate on material written on paper difficulty on maintaining

concentration on a computer screen for prolonged periodsrdquo

- ldquoDont know much about it to be comfortable in doing it but I would give it a gordquo

Five per cent also reported other course issues which included preference for blended

learning too much course content poor quality of course suitability of topic lack of

discussion as other factors which would prevent them from doing a course with an E-

Learning component

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Learner Motivators to use E-Learning

What would motivate you to use E-Learning in future

There was a 655 response rate (260397) to this open-ended question When the

data was coded approximately twenty-eight per cent of responses cited accessibility and

flexibility of E-Learning as a motivator to engage with online learning in terms of doing it from

anywhere in your own time and pace

- ldquoConvenient flexible can do in work or at homerdquo

- ldquoDifficulty getting time to go out for study days can do it if and when you have timerdquo

- ldquoEase of use the chance to repeat if necessary my time amp my pacerdquo

- ldquoI can log on at home or at work Easy access is vitalrdquo

- ldquoIt is the future Most onsite training is on the East coast I live in the West Coast-this

usually involves up to 6 hour round trip in a day rdquo

Approximately one in five stated that keeping up to date for their personal and

professional development would be a motivator to do an E-Learning course in palliative care

There was also with an emphasis on courses which were accredited to enable to

practitioners to ldquoUpdate palliative skills and knowledgerdquo and in ldquoMeeting the criteria for

professional CPDrdquo

- ldquoRelevant to my education needs Accreditation with a recognised bodyrdquo

Twenty per cent also stated courses or topics that were relevant and interesting

would motivate them to participate in E-Learning

- ldquoIf the content of the course was exciting motivating amp interestingrdquo

- ldquoIf I was really interested in the course- came highly recommended I have seen colleges

struggle with e-learning When it goes down no fall backrdquo

Nearly fourteen per cent stated that ldquoDedicated time to participate in e learning within

working hoursrdquo would also motivate them to use E-Learning in future

- ldquoShort modules that could contribute to CPD hoursrdquo

- ldquoWell designed simple to use courses that did not involve a lot of hours at any one given

timerdquo

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

- ldquoGiven time within my working day to access a computer in a quiet room with no

distractionrdquo

In open-ended responses asking participants what would motivate them to use E-

Learning four per cent cited better access to computers faster internet at home Seven per

cent cited various supports included education and training and practical instruction using

computers and how to access E-Learning

- ldquoSomeone showing me how to do it or go about itrdquo

Eight per cent cited ease of use followed by improving their computer skills having

prior experience of doing E-Learning and if was recommended by other colleagues

0

50

100

150

200

250

300

350

400

Regular contactwith the tutor isimportant to my

success in onlinecourse work

Quick technical andadministrative

support you couldcall on

Dedicated time toparticipate in E-

Learning activities

Dedicatedcomputer training

before undertakingan E-Learning

course

As a learner which of the following are likely to motivate you to use E-Learning in future

Not Important

Slightly Important

Average Importance

Quite Important

Very Important

Number of Respondents

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

EDUCATORrsquoS PERSPECTIVE

Different Learning Styles

All of the educators had experience of using e-learning as students themselves and

acknowledged the advantages and challenges it faced Their level of experience of using e-

learning for teaching varied between educators depending on their organisation

The educators identified challenges and advantages of using of using E-Learning

themselves as students

E-Learning can suit some individuals learning styles better than others

- ldquoI enjoyed it because I am quite happy learning on my own I find it suits me for the type

of learner I am for my own learning style but I donrsquot think it would suit everybodyhelliprdquo

- ldquoInitially the first six months I guess were very dauntingrdquo

Shared Learning

The educators spoke of the positive effects of E-Learning for them as students

ldquoIt was good for bringing us together when we were outside of class ldquo

- ldquoI wouldnrsquot have had the time to attend all face-to-face content whereas this allowed me

to It opens up opportunities that I would not have had without having the E-Learning

componentrdquo

From another educatorrsquos perspective some students might respond well to browsing through

an online programme and participate in it However online learners have to be disciplines

and motivated (REF)

E-Learning also provides learners the opportunity to share experiences and learn from

individuals from different disciplines and countries

- ldquolearning from such as small group of people from very diverse backgrounds with

experience and knowledge you gain from thatrdquo

- ldquoThat made it interesting and yoursquod never capture that perspective otherwise so the time

difference didnrsquot make any differencerdquo

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

- ldquoI would have to say and people find this hard to believe I did develop rapport with the

group even though I didnrsquot see anybody never met them face to face but I feel that

there was a bond thererdquo

Challenges as a learner

They also identified a number of challenges they found as E-Learners such as unreliable

internet connection the need for specific equipment such as headphones or lack of access

to YouTube in the workplace

ldquoYou miss being able to ask questionsrdquo

Some of the challenges with online discussions were dependent on how they were

structured

ldquoIt was frustrating because not everyone participated within the group but we got no grades

for it so you put all that work in and it wasnrsquot acknowledgedrdquo

Synchronous discussions ldquoI found it difficult because I wasnrsquot that fast at typing and to try

to keep up with whorsquos saying what was difficultrdquo

Non-synchronous discussion ldquoYoursquod have time to think about it reflect on it and send your

comments back That was more worthwhile It was more structured ldquo

The importance of having a strong leader to facilitate the discussion and give feedback was

also identified They identified the amount of effort and time the E-Learner has to put in to

construct a response for the online discussion which has to be of academic standard

- ldquoYoursquore getting something out of it yourself but if you were in a classroom yoursquod

probably have the discussion in a quarter of the timerdquo

Opportunities E-Learning created for them

Advantage of a blended approach as opposed to totally online

ldquoWe would have put together a study day got people into groups got feedback and

you donrsquot get that when you are onlinerdquo

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Educators feedback from students ldquoThis E-Learning wersquore expected to do this in our

own time but wersquore not getting the day out to do it and itrsquos very time-consumingrdquo

All of the interviewees had used different E-Learning activities as part of their teaching

strategy

Educators highlighted the benefits of complementing the classroom sessions with

multimedia such as video and following it up with a discussion or critical analysis

Educatorrsquos Perspective Reasons for using it

International perspective Using E-Learning enables the educator to include the international

perspective into their teaching through the inclusion of speakers from other countries ldquoThere

is so much out there on guru speakers in palliative carerdquohellipYoursquore missing that if you donrsquot

use itrdquo

Flexibility and cost-saving E-Learning offers a flexibility There are no travel expenses and it

overcomes the difficulty obtaining time to be released from work to attend full days

Accessibility E-Learning provides an opportunity to reach different audiences so that more

people can deliver the palliative care approach It can provide an opportunity to educate

general health care staff as well as educate the public so that they are more aware of it It

also enhance multidisciplinary learning

Improve academic writing and IT skills It enables learners to improve their academic

writing critical appraisal skills and provides an opportunity for them to improve their IT

skills

It allows the use of multimedia- creative teaching strategies and gets information out to large

groups of people It enables the educator to use different teaching strategies such as case

studies quizzes YouTube and can be used to assess their knowledge before a class room

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

session E-Learning can provide the opportunity for ldquoassessing knowledge and their level of

analysis and comprehensionrdquo

- ldquoYou can be creative online ndash itrsquos all there for them It fits nicely into their schedulesrdquo

ldquoI like been creative as part of my teachingrdquo

- ldquoThere could be a place doing some pre-reading and pre-learning I am passionate that

time is so precious that lot of them are coming and they are expecting the basics to be

covered againhelliprdquo

Assessment There is an opportunity to use it to ldquotest their knowledge at appropriate

intervals along the wayrdquo and also to supplement it with class room teaching

- ldquoActually itrsquos quite challenging for one day courses using e-learning but if have a 3 or 4

day course itrsquos wonderful to have some kind of discussion forumrdquo

- ldquoIt would be good as way of communicating hellipand networking and getting them to

come together and learn from experiencerdquo

Quality of the program ldquoI think there has been this slating of E-Learning in saying itrsquos not the

same and that you really need to have them in the classroom but you could be standing

there delivering the lecture they could be sitting there silentwhatrsquos the difference between

that and putting it up on Moodleor whoever is facilitating it if theyrsquore not engaging theyrsquore

just giving informationrdquo

Context ldquoThere is a plenty of E-Learning out there from other countries but we are lagging

behind in palliative care in Ireland so to contextualise it is very importantrdquo

Inevitable There is an inevitability that E-Learning is part of education and teaching

- ldquoI think it is the way of the future I think people are becoming more competent in

technology I feel that if we donrsquot use E-Learning in palliative care we will be left

behindrdquordquo

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Educatorrsquos Perspective Reasons for not using it

Topics which are emotional such as spirituality loss and bereavement If someone is upset

in the classroom there is support for them therehelliprdquobut thatrsquos not going to happen if you are

online because yoursquore not going to write about how you feel onlinerdquo It is difficult to ldquotease

out their understanding of the topicrdquo in an online environment

- ldquoIt needs group discussion because of the nature of palliative care Itrsquos quite emotive It

does require that face to face interactionrdquo

Preference for face to face interaction ldquoI like the buzz of a study day I like the interaction

with people I like the face to face element and I like the socialisation aspect of itrdquo

E-Learning if often considered dehumanising For some educators this is a more profound

reason for not using E-learning than for others In the classroom there is group dynamics

whereby you get initial feedback and can see their reactions This interaction guides the

educator to reassess their teaching method or teaching plan dependent on their learner

needs ldquoIn some situations you wouldnrsquot use it (E-learning) because of the richer context of

the classroom environmentrdquo

Time-consuming ldquoI wouldnrsquot not use it If I was not using it I think it would be down to the

time to develop itrdquo

Consider the audience and their background ndash eg age and experience of using a computer

Consider the topic ldquowhat is the best way to deliver this

- ldquoIt depends on the goal aims of the programme if you want the type of learning

where there is critical review therersquos reflection there is opportunity for feedback I think

itrsquos more difficult to achieve thatrdquo

- ldquoYou might say something in the class rooms and sombody might say- what do you

mean And you might be able to clarify it and they wouldnrsquot get the wrong ideardquo

There is a preference for the blended approach

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Greatest challenge as an Educator

Time Educators identified a number of challenges The greatest challenge for educators

was the amount of time it took to initially prepare material for E-Learning as well as the

challenge of updating new evidence into an existing E-Learning course There is also the

time require to prepare scripts and convene online discussion boards I think itrsquos time-

consuming to get everything rightrdquo

Other challenges for the educator is the time required to develop expertise

One interviewee commented on the importance of enjoying the creative aspect of e-learning

and the ability to think ldquooutside the boxrdquo with regard to creating e-learning courses but you

also need time to do this

Technical writing skills Another educator provided an example of creating an online quiz and

the difficulty ensuring that it is easy to comprehend

- ldquoIf you are doing quizzes the wording of things has to be so preciserdquo

Perception Another aspect of e-learning is that the work involved is often ldquohiddenrdquo because

people donrsquot see students in the classroom and the time involved in its development and

delivery is not obvious

- ldquoA lot of hidden work for the educators that goes on and I sense that organisations are

benefitting from thatrdquo

Hardware software support Access to hardware software and technological support to

deliver E-learning are crucial Access to the technical support in the classroom is also

important if you are using multimedia in your class

Getting ldquobuy-inrdquo One of the concerns identified by a few educators was ldquogetting buy in from

the learnersrdquo

- ldquoSome people when they hear E-Learning they just switch offrdquo As an educator thatrsquos a

challenge they must overcome and ldquoby showing them (learners) that itrsquos not all

Powerpoint after Powerpoint after Powerpointrdquo

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Some learners in healthcare organisations are resistant to E-Learning

- ldquotheyrsquore just point blank refuse to engage with it without really knowing enough about itrdquo

One of the educators did have some reservation on E-Learning despite been supportive of it

It can be a challenge for educators to balance the needs of the participants with the needs of

their organisation especially where there is a greater shift away from the classroom

environment

- ldquoWe have to be supportive to the staff as well and support their views because they miss

having face to face interaction and study sessionsrdquo

Quality E-Learning The quality of the course and its delivery is crucial in all formats and

especially in the online environment E-learning courses need to be user-friendlyengaging

and easy to navigate Otherwise the learner will get easily frustrated and opt out of doing it

- ldquoWe have to make it engaging in order to get people to look at itand there is a barrier to

those who are used to traditional more didactic forms of teaching with a face-to-face

approach and theyrsquore quite resistant to itrdquo

- ldquoEnsuring that you are using evidenced-based accredited resources which are

appropriate to the audience and that you have permission to use themrdquo

- ldquoEngaging E-Learning isnrsquot just about putting up a few articles Itrsquos about seeing how

they take that and really bring it back to their practice and that does take time to

producerdquo

One comment highlighted the difficulty with employees who donrsquot regularly check their

emails In some E-Learning courses learners must access their emails regularly and need to

be aware that this is imperative for participation with discussion forums and continuous

assessments

Applicability The challenge is bringing it back to practice

- ldquoThey may well be able to answer 20 knowledge questions but have they got the right

attitude have they got the right approachrdquo

- ldquoAgain you donrsquot see them and you have difficulty in trying to assess that level of

knowledge and also the understanding the deeper understandingrdquo

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

- ldquoThey can give the stories They can give their views They can back it up by evidence

but how do you check their attitude That would to me be the biggest challengerdquo

Support There is a lack of ongoing education to support those teaching online as well as the

requirement to update their skills regularly

ldquoVery little support for educators to teach onlinerdquo Educators also require the skills and the

understanding of how to create online educational resources

There is the expectation that support in the online environment is available 247 so quick

response time is required

o ldquoYou really need to give ongoing support so that is technically one of the

biggest challengesrdquo

IT Internet connection for students access to work PCs specifically for E-Learning and

computer skills can be a challenge

Other Supports

- ldquothe libraries here do provide free courses on computer skillsrdquo

- Some people get help from their children ldquowho know more about computers than they do

so they will help out but it is an age thingrdquo

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Educatorrsquos Perspective Factors for adoption

Organisation

Communication and providing staff with the relevant information about E-learning when they

start in the organisation is key to ensuring successful E-Learning adoption Itrsquos important to

keep people well-informed and ensure that there is additional support mechanisms in place

such as computer skills training Itrsquos crucial to ldquoget people on board firstrdquo and provide

information about E-Learning whatrsquos available and how to access it

Once E-Learning is in place it is important to have a contact person who can deal with

technical issues from the learner

- ldquoSo giving the information about what itrsquos about how they can get information from their

living rooms with their tablets etc itrsquos that type of mental preparation I think is a great

preparationrdquo

- An E-learning ldquoexpertrdquo in different departments to be a point of contact on the ground

would enhance implementation across the organisation

Organisations need to have a structured plan or policy in place ndashtargeted goals aims and

objectives and a plan of how itrsquos going to be resourced Management have a role in this shift

towards an ldquoE-learning friendly organisationrdquo

- ldquoFor an organisation having a structured plan in place that if we are going to do it what

do we need and how are we going to resource it how are we going to get the support

that we need It takes a whole team effort itrsquos not just yourdquo

There is a need for organisations to appreciate the amount of time required to participate in

e-Learning activities and to support employees in the same way they would for a face to face

courses

Technical and E-Learning support is important to resolve technical difficulties and to support

both the educator and the learner

Educator

Knowledge and understanding of what can be done devoting the time thinking creatively

and promoting the value of e-learning are important Educators must consider their learners

background and educational needs and to consider if E-Learning is the best method to adopt

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

or should it be a blended approach Educators need to consider if it suits the different

learning styles and to keep the content itself engaging and interactive and evaluate if this is

the best way of delivering the course Having the time experience expertise and access to

supports are important if e-learning is to be incorporated into palliative care education

A number of the interviewees emphasized a desire for a support mechanism for educators

themselves to enable them to share similar resources with each other and to link with other

institutions or organisations

- ldquoI think if there was a support mechanism between hospice educators and we had our

own forum around E-Learning I think that would be really really goodrdquo

The quality of the content delivered online is important and having a facilitator with expertise

in palliative care to convene it Core competencies in palliative care relate to the specific

knowledge attitudes and skills required by healthcare professionals Whilst knowledge can

be effectively measured online the attitude required by healthcare professionals such as

good communication skills empathy and sensitivity may not be as evident in an online

environment A blended approach with a face to face component would enable the educator

to assess the learnersrsquo attitudes Complementing the classroom with E-Learning is a way of

overcoming this Using webinars videos well-structured online discussions guided by a

good facilitator and creating group activities are some of the ways identified by the

interviewees to create interesting content

Time needs to be invested by educators in upskilling themselves and in understanding what

can be done to improve the quality of learning online One of the educators felt that there

was a requirement to document and record the hours spent on E-Learning activities and to

evaluate its impact ldquoI think we need to take responsibility for protecting our timerdquo and many

identified a need for training and upskilling for educators on delivering online courses

- ldquoItrsquos our responsibility recording documenting evidencing what we are doing and

evidencing the outcomerdquo

- ldquoWhat is the impact and I know that this is the biggest question whether its classroom or

E-Learningrdquo

One of the comments was the need to examine how to assess the learnerrsquos knowledge over

time and how to measure it relative to patient outcomes

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Educators need to be transparent when advertising an E-Learning courses and give a

realistic estimate of the amount of time required to complete it Whilst content such as the e-

learning packages and podcasts are available to the learner the challenge for the educator

is to bring it back to practice

Learner

It is also necessary to have a dedicated learning space for learners such as a library facility

with computers where people can access the online material

Should computer skills be a core competency for all healthcare staff One of the educators

identified ldquofear of technologyrdquo and the importance of resolving issues such as how to log in

and providing guidance online as well as a contact person if they have difficulties

There is also the need to ensure that learnerrsquos questions can be addressed adequately in

the online environment by a contact person or facilitator similar to the classroom

environment

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Conclusion

The most important motivators for learners ranked in order of importance were

1) Dedicated time to participate in E-Learning activities

2) Quick technical and administrative support

3) Dedicated computer training before completing an E-Learning course

4) Regular contact with the educator in online course work

Fifty per cent of respondents indicated face-to face assistance and an equal number

indicating hands on training sessions as the type of support that they would like to receive

with E-Learning This was followed by online assistance at 47 and telephone contact at

33 Twenty-eight per cent indicated that they would like booklets and almost quarter

indicated that video demonstrations would be a support theyrsquod like to receive with E-

Learning

Understanding attitudes knowledge and experiences of utilizing e-learning in palliative care

education will enhance understanding the barriers that exist in adopting e-learning amongst

palliative care educators and learners in Ireland and assist us in addressing those needs

This study highlights healthcare professionalrsquos attitudes towards e-learning as a mode of

learning for continuing professional development and indicates the likely uptake to such e-

learning courses

The key reasons for using E-Learning as component of palliative care education is that it has

obvious advantages to the learner in terms of accessibility and flexibility It enables the

educator to utilise creative teaching strategies incorporating multimedia as well as facilitate

expert speakers from other countries Shared learning with participants from different

disciplines and cultural backgrounds brings an international perspective to the classroom E-

Learning can increase the number of participants who can access palliative care education

thereby increasing the potential to adopt the palliative care approach in different settings

Educators considered a number of factors when considering utilising E-Learning as part of

their teaching strategy In palliative care education consideration for the topic and its

suitability to the e-learning virtual environment is crucial especially were some topics are by

their nature very emotional The background of their learners ie their age and experience of

using computers is an important consideration as well as the resources available to offer

support to learners who require it Educators highlighted that the time required to prepare e-

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

learning materials as well as the time required to develop expertise can also be a factor

preventing them utilising E-Learning Having access to hardware software and technical

support is also crucial for both the educator incorporating E-Learning into their practice and

also for the learners

Educators were aware of the importance of developing and delivering good quality e-

learning programs and that e-learning is simply not ldquopowerpoint after powerpointrdquo A

challenge identified by some educators was the importance of evaluating the impact of e-

learning Like all educational programmes does it have an impact The challenge is

ldquobringing it back to practicerdquo and itrsquos application of the actual learning to clinical practice

which is key

A huge barrier identified by educators is ldquogetting buy-inrdquo from learners who may not have

ever used e-learning before or who are resistant to engaging with it In this study

approximately 54 learners indicated a preference for face to face interaction and the main

barrier identified was having designated time to participate in e-learning activities or

programs which was also identified by palliative care educators

Educators identified a number of organisational factors required to adopt e-learning which

included structured policies and plans requiring targeted resources to ensure desired goals

and objectives could be achieved The approach also requires communication with all staff

to create awareness or ldquobuy-inrdquo from the beginning about the role of e-learning in the

organisation and information about access and a requirement for support mechanisms for

educators and learners (including administrative technological technical educational

learning technologist)

From the educatorrsquos perspective having the knowledge and understanding of what can be

done and the time to invest in upskilling and in creating delivering and facilitating engaging

e-learning activities is key to the quality of e-learning programs Educators themselves

indicated in interviews a desire to have a support mechanism in place where hospice

educators could discuss and share knowledge and resources relevant to e-learning in

palliative care There all identified that e-learning alone would impose challenges for

teaching particular topics especially bereavement grief and spirituality which demanded a

ldquodeeperrdquo learning and not just based on knowledge of the subject alone

E-Learning can be used on its own or can complement face to face classroom learning in

many ways Itrsquos important to use e-learning at the right time with the right audience and for

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

the right topics and to focus on delivering good quality e-learning programmes which will

ensure that the desired learning outcomes can be met The organisational role in supporting

an E-Learning friendly learning environment is crucial with adequate resources to sustain it

in the future

Overall the views on the future of E-Learning in palliative care education were mixed Some

educators were very passionate and excited about the using E-Learning in palliative care

education in their organisations Others felt it had a lesser role to play in their teaching and

had a higher preference themselves for face to face classroom sessions The educators felt

that E-Learning has many positive advantages All of educators were keen on adopting a

blended approach thereby incorporating e-learning as a component into their teaching

strategies They acknowledged the challenges but felt that e-learning has a positive role in

palliative care education

- ldquoKnowing the benefits and the limitations and embracing that with the blended but my

biggest biggest thing is not to loose sight of the patientrdquo

- ldquo Why are we doing it hellipto support staff professional development organisational

developmentrdquo which is ultimately for ldquo The patient and the family and without that focus

wersquore lostrdquo

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

References

Ahmed Gad A-W (2008) Modelling studentsrsquo intention to adopt e-learning a case from Egypt The Electronic Journal of Information Systems in Developing Countries 34(1) 1-13

Becker R (2009) ldquoOnline courses for nurses working in palliative carerdquo European Journal of Palliative Care vol 16 no2 pp 94-7

Burgess J (2008) Is a blended learning approach suitable for mature part-time finance students The Electronic Journal of E-Learning 6(2) 131-138 Available wwwejelorg [accessed 13 September 2011]

Callinan J McLoughlin K (2012) Evaluation of a virtual learning environment (VLE) to support the delivery of the European Certificate in Essential Palliative Care Milford Care Centre Limerick

Carnwell R (1998b) Community nurses experiences of distance learning implications for autonomy and dependence Nurse Education Today 18 610ndash615

Cosgrave R et al (2011) Usage and uptake of virtual learning environments in Ireland Finding from a multi institutional study All Ireland Journal of Teaching and Learning in Higher Education 3(1) Available httpwwwnairtliedocumentsNAIRTLPaperpdf [Accessed June 25th 2013]

Department of Health amp Children (2001) Report of the National Advisory Committee on Palliative Care Department of Health and Children Dublin

Fleming N amp Baume D (2006) Learning Styles Again VARKing up the right tree Educational Developments SEDA Available httpwwwvark-learncomdocumentsEducational20Developmentspdf [Accessed May 3rd 2012]

Gamondi C Larkin P and Payne S (2013) Core competencies in palliative care an EAPC White Paper on palliative care education ndash part 2 European Journal of Palliative Care 20(3) 140-145

Gardner H (1993) Multiple intelligences The theory in practice New York Basic Books a division of Harper Collins

Hart C (2012) Technology and Nursing Education Building an Online Toolkit Journal of Continuing Education in Nursing 43 (10) 441-2

Health Service Executive (2009) Palliative Care Services - Five YearMedium Term Development Framework HSE Dublin

Hodges A (2010) ldquoCorporate E-learning How three healthcare companies implement and measure the effectiveness of E-learningrdquo Dissertation Abstracts International Section A Humanities and Social Sciences vol 71 no 2-A pp 537

Petit dit Dariel O Wharrad H amp Windle R (2013) Exploring the underlying factors influencing e-learning adoption in nurse education Journal of Advanced Nursing 69(6) 1289-300

Price B (2000) Problem-based learning the distance learning way a bridge too far Nurse Education Today 29 98ndash105

Ryan K Connolly M Charnley K Ainscough A Crinion J Hayden C Keegan O Larkin P Lynch M McEvoy D McQuillan R OrsquoDonoghue L OrsquoHanlon M Reaper-Reynolds S Regan J Rowe D Wynne M Palliative Care Competence Framework Steering Group (2014) Palliative Care Competence Framework Dublin Health Service Executive Accessible httpwwwhseieengaboutWhoclinicalnatclinprogpalliativecareprogrammeResourcescompetencyframeworkpdf Accessed 23715

Surry DW Ensminger DC amp Haab M (2005) A model for integrating instructional technology into higher education British Journal of Educational Technology 36(2)327-329

Whittington D (2000) Evaluating three yearsrsquo use of virtual university Quality Assurance in Education 8(1) 48-52

Acknowledgements

I would like to thank the All-Ireland Institute of Hospice and Palliative Care for funding this

Clinical Research Fellowship in Palliative Care Thanks to Milford Care Centre for supporting

this research and to each of the organisations their management and staff for participating

in this study and for assisting with data collection Thanks to Ms Niamh Henderson and Ms

Mary Keneghan for transcribing the interviews