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Is there a place for e-learning in infection prevention?
Australian Critical Care 26 (2013) 167–172
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Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Review Paper
Is there a place for e-learning in infection prevention? Sonia O. Labeau RN, MA, MNSc, PhD ∗ Faculty of Education, Health and Social Work, University College Ghent, Ghent, Belgium
article information Article history: Received 2 December 2012 Received in revised form 3 October 2013 Accepted 4 October 2013 Keywords: E-learning Infection prevention Infection control Adult education
a b s t r a c t Background: In the last few decades, e-learning, a method which integrates information technology and the learning process by using materials delivered through the internet, has become widely used in educational initiatives for healthcare professionals. Purpose: To evaluate whether there is a place for e-learning in the field of infection prevention. Methods: Non-comprehensive review of the literature. Findings: E-learning courses in the field of infection prevention and control are still scarce, often restricted to local initiatives and not specifically directed toward critical care providers. Although methodological flaws and potential biases hamper the generalizability of results from some currently available studies, findings related to both learners’ satisfaction and effectiveness suggest that e-learning might prove an effective educational tool for the (continuing) education of healthcare providers. Further investigations, including research pertaining to the cost-effectiveness of e-learning, are required to provide a better insight in these issues. Conclusion: Further research is required to determine the (cost)effectiveness of e-learning in general, and in the field of infection prevention and control in particular. Current insights suggest that e-learning should be based Web 2.0 technologies to address a wide range of learning styles and to optimize interactivity. As a gap in the literature was detected with respect to e-learning modules on infection prevention and control which are specifically oriented toward critical care providers, it can be recommended to promote the development and subsequent assessment of such tools that meet high-quality standards. © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Access to the right knowledge at the right time is a key factor for an effective and efficient healthcare system. Education of all members of the multidisciplinary team is therefore considered a first and crucial requirement when targeting implementation of interventions for infection prevention and control.1 For critical care nurses, keeping up to date with the latest insights is vital in order to provide optimal patient care. Simultaneously, it is a great challenge, as critical care environments are among the most quickly evolving settings in acute care hospitals. In the mid-nineties of the previous century the emphasis in education has shifted from providing instruction to producing learning.2 Traditional instructor-centered teaching was substituted by a learner-centered approach, in which students are held responsible for their own learning processes and outcomes. Critical thinking, independent and evidence-based learning, and feedback
∗ Correspondence to: Faculty of Education, Health and Social Work, University College Ghent, Keramiekstraat 80, B-9000 Ghent, Belgium. Tel.: +32 9 321 21 38. E-mail address: [email protected]
are since being regarded as indispensable features of this new learning paradigm.3 In the field of providing educational activities for healthcare professionals, the last few decades have witnessed an increase in demands on academic faculty.4 Changes in health care delivery, advances in medicine and technology,4 shortages in staffing, and cost constraints5 have created important challenges for nurse and medical educators. Quite simultaneously, a rise in the use of information technologies in education took a start. E-learning, a method which integrates information technology and the learning process by using materials delivered through the Internet,6 soon was adopted and widely used in educational initiatives for healthcare professionals.7 There were high expectations that online learning might successfully integrate the features of the new learning paradigm into a novel approach to adult education, that tackles the challenges mentioned above. To provide an answer to the question whether there is a place for e-learning in infection prevention, a non-comprehensive review of the literature was conducted. Relevant publications were searched for by entering combinations of the keywords “e-learning”, “Web-based learning”, “online learning”, “distance learning”, “Internet education”, “Internet-based learning”, “healthcare workers”, “healthcare professionals”, “healthcare
1036-7314/$ – see front matter © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.aucc.2013.10.002
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providers”, “critical care”, “intensive care”, “infection prevention”, and “infection control” in the electronic databases PubMed, CINAHL, and Web of Science. Articles in English, French, German or Dutch were eligible for inclusion. As e-learning is a relatively new concept, no restrictions in publication dates were taken into account. The concept of e-learning In its broadest sense, e-learning is the use of the Internet for education. The simultaneous use of various terminologies makes it however difficult to develop a generic definition.8 Besides elearning, terminology includes online learning, Internet education, distance education, IT-learning, Web-based education, Web-based instruction and advanced distributed learning.9 In so-called synchronous learning, the educational content of Internet-based learning is provided at the same time as it is delivered from an instructor; in asynchronous learning, on the contrary, it is disconnected from the actual time of instruction and provided by tools such as recorded and saved audio, video, or text presentations.4 The separation of teacher and student in time and space clearly classifies web-learning as distance learning.10 Reime et al. describe e-learning as a method which integrates information technology and the learning process by using material delivered through the internet to create, foster, deliver and facilitate learning, anytime and anywhere.6 A brief history of e-learning The seeds for distance learning have been sown as far back as the 1700s with the development of the first correspondence course. In England, in 1840, shorthand classes were being offered by correspondence courses through the mail. This method of distance learning gained considerable popularity in the early part of the last century.10 In the centuries to follow, new technologies made distance learning easier. Radio, television, video recorders all made significant contributions. As an example, in 1953 the University of Houston offered the first televised college credit classes. Most courses aired at night so that students who worked during the day could watch them. The genesis of e-learning as we know it today can be traced to the development of network communication in the late 1960s.11 The invention of the World Wide Web by Tim Berners-Lee in 1989 has significantly impacted on distance learning.12 This internet-based hypermedia initiative for global information sharing introduced an unprecedented opportunity for people to communicate and collaborate despite differences in time and place. Early Web-based courses were often criticized for poor standards and lack of quality control methods, as they relied almost exclusively on the learner’s ability to read information and to use that information to answer questions.10,13 They have been gradually evolving over time and gaining in quality, following the evolution of the Internet through two phases, Web 1.0 and Web 2.0. Web 1.0 is often described as the “read-only Web”, as it provides the user with a relatively passive experience. Its technology allows users to search and read texts, to watch and listen to multi-media files, and to interact with pre-programed games and simulators. The introduction of the Worldwide Web initiated Web 1.0 technology, which is generally considered to have been replaced by Web 2.0 in the year 2003. Web 2.0 defines the more interactive and dynamic phase of the www. and is commonly referred to as the “read-write Web” for its concept of offering users a participatory platform. Hereby, users
are able to generate Web site content, and to communicate interactively through wikis, blogs, podcasts, video-sharing, and social networking sites. Both Web 1.0 and 2.0 incorporate various technologies that are commonly used in e-learning environments today.14
Advantages and disadvantages of e-learning Advantages More than anything else, its multifaceted flexibility appears to make e-learning attractive to learners.15 Different learning styles can be addressed and learning can be facilitated through mixed activities. Learners may also have the option to select study materials that meet their specific level of knowledge and interest. Moreover, self-paced learning modules allow learners to study at their own pace, not having to work faster to keep up with more advanced students or holding their pace to wait for struggling learners. Course materials can be reviewed as frequently as desired to enhance learners’ own understanding.16 Thus, e-learning encourages students to take responsibility for their learning process. Students are not required to travel to attend classes. The justin-time nature of e-learning allows them to learn from the comfort of their own home or from any place where technical accommodations are available. E-learning thus reduces travel-related costs and time.16 Healthcare professionals are expected to be computer and information literate at registration. As an additional asset, e-learning promotes the learners’ development of computer and Internet skills, and of skills in time management.6,13,17,18 Finally, e-learning contributes to methodological diversity and to changing the focus away from teaching to learning.19 From the point of view of the organization, e-learning overcomes issues such as class room or instructor availability, staffs’ combination of vacation schedules, current classes, or differing employee shifts. Training is accomplished more rapidly, while ensuring content consistency and standardization,16 and allowing organizations to provide educational materials tailored to their employees’ specific needs. Another benefit pertaining to the organization is that, if desired, learners’ activity is traceable. E-learning permits to log participants’ actual course attendance, study time, test scores and study progress. These features can be an important asset for healthcare settings where clinicians’ activities for continuing education are (partially) funded, and therefore controlled, by the organization. A recent study assessed the economic sustainability of elearning within a large scale via personnel work hour saving, and yielded positive results.20 Upfront costs associated with the development of e-modules will predominantly depend on the software used and the investment in personnel cost. In environments or economic climates with restricted resources for educational purposes, the use of open source software could prove to be highly advantageous.
Disadvantages E-learning requires more responsibility and self-discipline for the learner to keep up with a more free and unconstrained learning process and schedule. Unmotivated students or those with poor study habits may fall behind or experience difficulties in getting used to the lack of familiar structure and routine of conventional classes.21 Also, students requiring help or additional instructions are not always able to obtain immediate support from instructors or help desks.
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The standardization of learning contents for groups of students might conflict with the need for adapting learning packages to the learning style of individual learners. From a technical point of view, learners may be intimidated or confused by the related technology.22 Technical barriers such as low performance computers, slow or unreliable Internet connections or computer viruses may cause frustration.14 Additional related hindrances are a lack of technical support (organizational) firewalls, or restricted available bandwidth.19 Learners feeling isolated or missing social interaction and faceto-face contact of traditional classroom training may lead to high drop-out rates from e-learning courses.19 Also, if studying from home, potential distractors are well known to be numerous and highly seductive. While the proliferation of notebook computers and mobile phones has recently enhanced the portability of e-learning, printed materials may still be considered more easy to transport and to access. Also, they do not suffer from the restriction to be used in areas where internet connections are restricted or unavailable. Contrary to the acquisition of theoretical knowledge, e-learning might be less appropriate for the acquisition of skills, especially those that involve complex physical/motor or emotional components. Implementing e-learning in an organization might nevertheless also be associated with some disadvantages. There may be high upfront costs, related to both personnel investment and technological requirements. Also, for e-learning tools to be interactive instruments that offer users a participatory platform and real-life simulation opportunities, the inclusion of video and sound, simulation, chat technology and online teacher–student communication tools are recommended. Although the related development costs for such interactive modules may turn out to be quite substantial, the return on investment has not yet clearly been demonstrated.22 When implementing e-learning at the workplace, organizations need to invest in sufficient hardware, software and accommodations, that enable staff to meet the educational requirements online. Moreover, organizations where e-learning is implemented might expect staff to study at home, i.e. after working hours, without any financial or working time-related compensation. Providing mobile devices such as tablets and i-phones to staff to enable e-learning at home may also result in conflicting or unrealistic expectations toward employees. The Internet offers the extraordinary possibility to easily provide and share information with users worldwide. Caution is nevertheless warranted as not all resources made available are of equally good quality. A thorough expert evaluation and quality-check should precede each implementation of any e-learning tool. Finally, being up-to-date is a common issue with Web-based learning. Users may assume that the information published online reflects the most recent insights, but publication dates are often lacking.14 Organizations may be required to invest a significant amount of efforts, time and money to keeping e-learning tools in line with the most current insights.14 E-learning and learning styles Kolb et al. define learning style as an individual’s inherited foundation, particular past life experience and the demands of the present environment that emphasize some learning abilities over others.23 As in traditional education, learning styles are also considered valid predictors of success in e-learning.24 Various types of learning styles have been identified.25 When developing e-learning tools, awareness of student learning styles may be helpful to increase learners’ performance. Designing e-learning and creating content that matches the various learning styles is nevertheless challenging.
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A frequently suggested approach is to provide a wide-ranging variety of formats in which learning contents are presented, such as texts, pictures, video, exercises with feedback, simulation, in order to meet as many learning styles as possible, and to meticulously monitor their suitability in terms of students’ learning outcomes.25 Future research into the relationship between e-learning and learning styles might enhance current insights and be helpful to increase the effectiveness of e-learning tools. The value of e-learning for healthcare professionals With the rising use of Internet-based learning, various studies have attempted to evaluate its benefit for healthcare workers compared to no education, or as part of a blended-learning model. A recent meta-analysis by Cook et al.26 assessed the effect of Internetbased instruction for healthcare professionals compared to either no intervention or to non-Internet instruction. The authors identified 2193 studies, of which 201 met their inclusion criteria. Learners were students, postgraduate trainees, or health professionals in human or veterinary medicine. Outcomes included learner satisfaction with the course, knowledge, clinical skills, and behaviors or effects on patients. This meta-analysis concluded that the educational strategies assessed in e-learning appeared to be more effective than no intervention – which is hardly surprising – and are likely similar in efficacy to traditional educational methods.26 Taking into account that this meta-analysis includes early e-learning initiatives with modules that were developed before the emergence of Web 2.0 technologies, it might underestimate the effectiveness of today’s more attractive and interactive e-courses. Simultaneously, the results should be interpreted with caution. First, no funnel plots assessing publication bias were used. Also, several reports included lacked key contextual or methodological descriptions and/or were non-randomized or observational trials. Moreover, a wide inter-study variety of interventions was found, resulting in a considerable overall heterogeneity (I2 ≥ 79%). The effect of Internet-based instruction versus no educational intervention was demonstrated to be inconsistent across studies, although pooled effect sizes were commonly small (≤0.12, except for the outcome ‘behaviors/effects on patients’) and not statistically significant for all outcomes but knowledge. The authors recommend further research to focus on the direct comparison of different Web-based interventions. Cook et al.27 also sought to answer how e-learning compares with non-computer instructional methods in time spent learning, and to identify the features associated with improved learning efficiency. Of all studies published between 1990 and November 2008 investigating the use of the Internet to teach healthcare professionals in training or practice compared with another educational intervention, 20 were eligible for inclusion in a meta-analysis. Study participants were students, postgraduate trainees, physicians, nurses, pharmacists, dentists, veterinarians, and physical therapists. Random effects meta-analysis of eight studies comparing Internet-based with non-Internet-based instruction revealed that, overall, e-learning and traditional educational interventions require similar study time.27 A pooled effect size (ES) for time −0.10 (p = 0.63) was found, with positive numbers indicating a longer study time when using e-learning. Providing feedback (ES 0.67, p = 0.003, two studies) and greater interactivity (ES 0.25, p = 0.089, five studies) were shown to be associated with longer study time. Audio narration, video clips, interactive models, and animations were found to increase learning time but simultaneously to facilitate higher knowledge and/or learners’ satisfaction. Across all studies included, time correlated positively with knowledge outcomes (r = 0.53, p = 0.021). Funnel plots did not detect publication bias.
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Although 17 out of 20 studies included were randomized, it should be taken into account that most time outcomes were self-reported by the learners, and that heterogeneity and inconsistencies among studies were considerable. Additionally, key data on interventions or outcomes were lacking from various reports included. These limitations may reduce the generalizability of the authors’ findings. E-learning for critical care providers Wolbrink and Burns14 conducted a MEDLINE/Pubmed systematic review from January 2000 to July 2011 to investigate the suitability of e-learning for critical care providers. Their merely descriptive report includes six publications that assessed the use of e-learning specifically for healthcare professionals working in intensive care environments. These included the assessment of an online burn care module for medical students and interns in surgery and emergency medicine,28 an online course to teach medical students how to properly fill out a death certificate,29 a Web-based intervention on recommended clinical guidelines for patients with acute respiratory distress syndrome,30 an e-course on sterile technique for central venous catheter placement,31 a difficult airway management course in anesthesia for internal medicine trainees,32 and an avatar-based training to teach principles of crisis resource management to medical students and first-year residents in emergency medicine.33 Some of these publications suffer from methodological flaws (such as no control group28,29 ; no pre-test or post-test comparison28 ; underpowered28,30 ; very low response rate30 ), suggesting that further work is necessary to develop a robust learning platform incorporating a variety of learning modalities for critical care providers.14 Web-based learning nevertheless appears to be advantageous for critical care providers if features such as interactivity, feedback and exercises are included. A concise review by Kleinpell et al.34 aimed to identify, catalogue, and critically evaluate non-industry sponsored Web-based resources for critical care education. As a result, an impressive list of over 135 tools specifically developed for ICU clinicians was generated, identifying a number of noteworthy educational websites and e-learning materials. All were meticulously reviewed to fulfil a set of stern requirements of quality and credibility. The authors concluded that e-learning today is being actively integrated into critical care medical and nursing training programs and for competency training purposes. Although not objectively measured to date, it is suggested that awareness of available Web-based educational resources may enhance critical care practitioners’ on-going learning and clinical competence.34 E-learning in the field of infection prevention and control The impressive above-mentioned list of Web-based resources for critical care providers34 was found to include four tools only related to the field of infectious diseases. These nevertheless do not focus on infection prevention or control, but cover specialized topics, mainly for advanced learners. Of all resources listed, only the Society for Critical Care Medicine’s Infection Knowledge Line35 appears to include a broad range of items, and addresses both beginners and advanced learners. Publications reporting on the use of e-learning specifically pertaining to the prevention and control of infections are rather scarce, and appear not to be explicitly conceived for critical care providers. Knowledge of infection prevention is nevertheless known to be inadequate among critical care nurses. Surveys using validated multiple choice questionnaires (MCQ) related to the prevention of ventilator-associated pneumonia, central line-associated infection and surgical site infection in a sample of 3405 European critical
care nurses yielded overall test scores below the conventional 50% threshold to pass a test.36–38 Hence, an innovative approach such as e-learning directed specifically toward the educational needs of this target group could prove highly beneficial. Reime et al.6 account on a Norwegian college of nursing that aimed to combine the development of a new curriculum with the enhancement of students’ competences in cross-infection control. In collaboration with the Centre of Nosocomial Infection Control at the local hospital, they evaluated different approaches to acquiring and applying knowledge. Thereto, students were allocated to two groups that were randomly assigned to receiving traditional lecturing (n = 73) or e-learning (n = 68), and that were comparable in terms of gender and age. Learning effects in both groups were measured by means of a 40-item MCQ, that had been pilot-tested by 24 college teachers and evaluated by infection control nurses (n and methods of evaluation not reported). Subsequently, students’ experiences with the teaching methods, learning goals, and the MCQ were assessed in focus groups that consisted of 21 of 33 randomly invited students (64%). Among other results, the sum score on the MCQ was higher in the traditional lecture group than in the e-learning group (p = 0.01), with no significant difference between groups in study time (p = 0.67). Focus groups interviews revealed that the students were satisfied with both teaching approaches. The authors conclude that e-learning and traditional lecturers both have to be regarded as equivalent educational resources.6 Recently, Pellowe et al.39 reported on the evaluation of an e-learning infection prevention module embedded in the preregistration nursing program in the United Kingdom. The course included various topics such as healthcare-associated infections; risk to patients; how to protect patients and one’s self; hand hygiene; personal protective equipment; waste and sharps; and environmental cleanliness. The module was evaluated using a Likert-scale questionnaire pertaining to the ease of access; the use of the materials; and the relevance of the contents to the students’ stage of training. It was completed by 282 of the 495 students who had taken the course (57%). Besides a substantial overall satisfaction with the use of the e-learning course, the relevance of the program for their current education was acknowledged by 94%. Confidence in understanding the infection prevention topics studied was enhanced in 97% of students and 96% reported applying the knowledge gained to clinical practice.39 Although not acknowledged by the authors, caution is warranted when interpreting these results. The questionnaire may predominantly have been completed by students who enjoyed the use of e-learning (selection bias). Moreover, self-reporting of attitudes is well-known to be prone to social desirability bias. Finally, no ‘harder’ outcomes, such as actual increase in knowledge or in application of the knowledge gained in clinical practice, have been measured. Another initiative to provide e-learning about infection control also emerged in the United Kingdom, where Desai and colleagues developed an Infection Control Training and Policies multimedia software package consisting of an introductory infection control training course and a hypertext version of a published book on infection control practices.40 The module included information on hospital-wide policies; policies for medical and surgical wards; special organisms; hospital support services; and staff and student health. It was implemented at the local hospital and at three campuses of medical schools. Learning effects obtained by studying the course were evaluated by 52 third-year medical students attending an infection control lecture. These students were submitted to a pre-training 30-item MCQ, then randomly assigned to study the e-course (n = 23) or to attend a traditional lecture with the same contents (n = 29). Afterwards both groups completed a 30item MCQ post-test. While no significant differences in the groups’
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pre-training scores were found, both methods of learning significantly increased students’ knowledge levels. The increase in knowledge in both groups increased significantly (p < 0.0001 in both groups), but their overall post-test scores did not differ significantly. The course’s usability was assessed by means of a questionnaire survey among the 23 e-learning students; additionally, questionnaires returned by the first 25 ward-based nursing staff who voluntarily used the training, and by three hospital infection control staff were analyzed. All nursing and infection control staff, and 87% of the medical students found the program easy and enjoyable to use. Nevertheless, questionnaires returned by the first 25 hospital staff who voluntarily studied the course may reflect the views and experiences of a subsample of early adapters, highly enthusiastic about a new learning method; or of healthcare workers particularly interested in e-technologies or e-learning. Therefore, it is warranted to take potential selection bias into account.40 In Canada, Atack and Luke developed an online self-study course for workplace training on infection control to facilitate the delivery of standardized training to large numbers of healthcare providers.41,42 The course consisted of three modules: hand hygiene, routine practices, and the chain of transmission. Besides text, photographs, video and graphics, pre- and post-module knowledge tests and various exercises were integrated. The impact of studying the course on nurses’ and allied healthcare professionals’ competency in infection prevention and control was assessed among a convenience sample (n = 76) by means of Likert-scale preand post-intervention questionnaires. Eighty-eight percent (n = 67) of the participants completed both the pre- and post-intervention competency questionnaires. The pre-course mean score was 64% and the post-course mean was 77.3% (p < 0.001). The majority of participants reported to be highly satisfied with the course. They found it extremely useful (100%), and the learning activities were found to helpful (100%) and creative (95%). As acknowledged by the authors, the generalizability of these results is nevertheless limited by the use of convenience sampling. Also, the impact on learners’ clinical practice remains unclear by lack of follow-up observation. The results of this study led the authors to conclude that e-learning can be considered an effective way to enhance knowledge and skills related to infection control and prevention.41,42 Bryce et al.43,44 developed an e-learning module to deliver standardized infection control training to all healthcare professionals across a Canadian health authority. The course was developed by a multi-disciplinary team from a variety of healthcare settings, and included features such as drop and drag technology, animation and video. The entire module, i.e. pre-test, lessons, and post-test, was completed by 280 study participants. Of these, 65.3% were recruited by their supervisors or took the module as part of their hospital orientation (65.3%); the remaining 36.5% were voluntary learners. Pre- and post-tests demonstrated a significant increase in postcourse improvement in infection control knowledge (p < 0.01). There was no significant difference in test scores between the mandated and voluntary participants. Observations of 117 participants’ practice during clinical orientation sessions in a realistic setting yielded a 35% overall improvement for all scenarios in healthcare workers with less than one year’s experience.43 A user satisfaction survey completed by 82 learners indicated that the course was experienced as relevant and simple to navigate (score 4.22 out of a possible 5.0; SD = 0.15).44 The characteristics of the healthcare workers who returned this survey are nevertheless not mentioned by the authors. Therefore, potential selection bias needs to be taken into account.
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Due to the extensive positive response, use of the module has been extended since to various health facilities in the region.43 E-leaning on infection prevention for critical care providers Based on the current and previous searches of the literature, and to the best of our knowledge, no interactive Web-based e-learning course for critical care providers was available until recently. Following the disappointing results of an analysis of the educational needs of critical care nurses regarding the prevention of healthcare-associated infection,36–38,45,46 we developed the EVIDENCE Crash Course, that bundles all essentials of evidence-based infection prevention in a comprehensible way, and that is directed specifically toward healthcare providers working in a critical care environment.47 The course has proven content validity and usability, and is available in English, Spanish, Portuguese, Turkish and Dutch languages (www.evidenceproject.org) (data not yet published). Discussion In the past two decades, education for healthcare workers has witnessed a shift from one devoid of significant computer-based resources to that where such tools are regularly incorporated. The need for continual learning to enable professionals to maintain and develop their knowledge and skills to function effectively has greatly contributed to the ever-growing importance of e-learning, and many nursing and medical students have reported e-learning to have been helpful toward their educational advancement. Although the studies included in this review are generally positive about the effects of e-learning, some critical reflection is warranted. First, the large heterogeneity of tools developed and methods used to assess their effectiveness make it difficult, if not impossible, to draw general conclusions. Contextual frameworks are often lacking, and methodological issues open the door to (reported or unreported) potential biases. Reports on user satisfaction outcomes only may provide information about how a tool is perceived by a limited sample of learners, but leaves the reader without any evidence about the tool’s potential to increase knowledge or enhance clinical practice. Finally, the assessments reported are often conducted with self-developed MCQs and scales, which have not been validated nor tested on reliability. The above considerations are warranted to be taken into account when drawing a realistic image of the effects of e-learning for infection prevention and control. Another aspect of e-learning which has not yet been fully investigated pertains to its cost-effectiveness. Although open source software is available, the development, implementation and maintenance of e-learning courses may be associated with considerable investments in efforts, time and money. Further research that focuses on return on investment, thereby taking into account wide ranges of potential costs and benefits, is needed to gain a better insight in these issues. Future research focussing on the association between e-learning content, learning styles and learning outcomes is also highly recommended. In the field of infection prevention and control, e-learning courses are, however, still scarce, and often restricted to local initiatives. This non-exhaustive overview of initiatives to develop, assess and implement e-learning modules for infection prevention and control suggests that there is a place for e-learning in infection prevention. In spite of documented deficiencies in knowledge of infection prevention among critical care nurses, the current literature provides no evidence for the existence of such tools specifically developed for these healthcare professionals.
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Lastly, it should be acknowledged that, if e-learning would prove to be an effective tool to transfer and increase knowledge, the association between better knowledge and improved adherence to evidence-based or clinical guidelines for infection prevention and control has not yet been established. While knowledge undeniably is a primary condition, it does not open the door directly to adherence. Changing clinicians’ behavior is a multifaceted challenge that, besides time, requires insight in facilitators and barriers, and in various psychological mechanisms, and that is well-known to be a considerable challenge. Conclusion Today, the literature on e-learning for infection prevention and control and the evidence on the effectiveness of e-learning in general still is limited and suffers from various limitations. The overall positive findings related to both learners’ satisfaction and individual tool’s effectiveness are nevertheless suggestive for recommending its promotion. The development of novel e-learning should be based on Web 2.0 technologies in order to maximize interactivity. Finally, the development of high-quality modules on the prevention and control of infections, specifically oriented toward critical care providers, and the promotion of their use on a large scale, can be highly recommended. References 1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu HT, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–32. 2. Barr RB, Tagg J. From teaching to learning: a new paradigm for undergraduate education. Change 1995;November/December:13–25. 3. Alur P, Fatima K, Joseph R. Medical teaching websites: do they reflect the learning paradigm. Med Teach 2002;24:422–4. 4. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81:207–12. 5. Benson EP. Online learning: a means to enhance professional development. Crit Care Nurse 2004;24:60–3. 6. Reime MH, Harris A, Aksnes J, Mikkelsen J. The most successful method in teaching nursing students infection control - E-learning or lecture. Nurse Educ Today 2008;28:798–806. 7. Choules AP. The use of elearning in medical education: a review of the current situation. Postgrad Med J 2007;83:212–6. 8. Anderson T. The theory and practice of online learning. 2nd ed. Edmonton: AU Press, Athabasca University; 2008. 9. Kahn B. A framework for web based learning. Engelcliffs, NJ: Educational Technology Publications; 2001. 10. Dunet D, Reyes M. Stakeholder-focused evaluation of an online course for health care providers. J Contin Educ Health Prof 2006;26:257–67. 11. Harasim L. A history of e-learning: shift happened. In: Weiss J, Nolan J, Hunsinger J, Trifonas P, editors. The international handbook of virtual learning environments. Dordrecht: Springer; 2006. 12. Masters K, Ellaway R. e-Learning in medical education Guide 32 Part 2: technology, management and design. Med Teach 2008;30:474–89. 13. Forman D, Nyatanga L, Rich T. E-learning and educational diversity. Nurse Educ Today 2002;22:76–82. 14. Wolbrink TA, Burns JP. Internet-based learning and applications for critical care medicine. J Intensive Care Med 2011;27(5):322–32. 15. Schoech D. Teaching over the internet: results of one doctoral course. Res Soc Work Pract 2000;10:467–86. 16. Berke WJ, Wiseman TL. The e-learning answer. Secure this education solution by setting a vision for its usage and building a sound business plan for its purchase. Crit Care Nurse 2004;24:80–4. 17. Atack L. Becoming a web-based learner: registered nurses’ experiences. J Adv Nurs 2003;44:289–97. 18. Haigh J. Information technology in health professional education: why IT matters. Nurse Educ Today 2004;24:547–52. 19. Ellaway R, Masters K. AMEE guide 32: e-learning in medical education Part 1: learning, teaching and assessment. Med Teach 2008;30:455–73.
20. Mazzoleni MC, Rognoni C, Pagani M, Imbriani M. Online education in a large scale rehabilitation institution. Stud Health Technol Inform 2012;174:67–71. 21. Bouhnik D, Marcus T. Interaction in distance-learning courses. J Am Soc Inf Sci Technol 2006;57:299–305. 22. Cantoni V, Cellario M, Porta M. Perspectives and challenges in e-learning: towards natural interaction paradigms. J Vis Lang Comput 2004;15:333–45. 23. Kolb DA, Rubin IM, McIntyre JM. Learning and problem solving: on the management and the learning process. In: Simon HA, editor. Organizational psychology: a book of readings. Englewood Cliffs, NJ: Prentice-Hall; 1974. p. 27–42. 24. Ford N, Chen S. Individual differences, hypermedia navigation and learning: an empirical study. J Educ Multimed Hypermedia 2000;9:281–312. 25. Markovic´ S, Jovanovic´ N. Learning style as a factor which affects the quality of e-learning. Artif Intell Rev 2012;38:303–12. 26. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: a meta-analysis. JAMA 2008;300:1181–96. 27. Cook DA, Levinson AJ, Garside S. Time and learning efficiency in Internet-based learning: a systematic review and meta-analysis. Adv Health Sci Educ Theory Pract 2010;15:755–70. 28. Cochran A, Edelman LS, Morris SE, Saffle JR. Learner satisfaction with Web-based learning as an adjunct to clinical experience in burn surgery. J Burn Care Res 2008;29:222–6. 29. Degani AT, Patel RM, Smith BE, Grimsley E. The effect of student training on accuracy of completion of death certificates. Med Educ Online 2009;14:17. 30. Belda TE, Gajic O, Rabatin JT, Harrison BA. Practice variability in management of acute respiratory distress syndrome: bringing evidence and clinician education to the bedside using a web-based teaching tool. Respir Care 2004;49:1015–21. 31. Xiao Y, Seagull FJ, Bochicchio GV, Guzzo JL, Dutton RP, Sisley A, et al. Video-based training increases sterile-technique compliance during central venous catheter insertion. Crit Care Med 2007;35:1302–6. 32. Bello G, Pennisi MA, Maviglia R, Maggiore SM, Bocci MG, Montini L, et al. Online vs live methods for teaching difficult airway management to anesthesiology residents. Intensive Care Med 2005;31:547–52. 33. LeRoy Heinrichs W, Youngblood P, Harter PM, Dev P. Simulation for team training and assessment: case studies of online training with virtual worlds. World J Surg 2008;32:161–70. 34. Kleinpell R, Ely EW, Williams G, Liolios A, Ward N, Tisherman SA. Concise review: web-based resources for critical care education. Crit Care Med 2011;39:541–53. 35. SCCM’s Infection Knowledge Line. Available from: http://www.learnicu.org. 36. Labeau S, Vandijck D, Rello J, Adam S, Rosa A, Wenisch C, et al. Evidencebased guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses. J Hosp Infect 2008;70:180–5. 37. Labeau S, Witdouck S, Vandijck D, Claes B, Rello J, Vandewoude K, et al. Nurses’ knowledge of evidence-based guidelines for the prevention of surgical site infection. Worldviews Evid Based Nurs 2010;7:16–24. 38. Labeau SO, Vandijck DM, Rello J, Adam S, Rosa A, Wenisch C, et al. Centers for disease control and prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses. Crit Care Med 2009;37:320–3. 39. Pellowe C, Adams J, Elliott S, Murrell K, Cox D. The use of an e-learning infection prevention programme in the pre-registration nursing curriculum. J Infect Prev 2010;11:55–7. 40. Desai N, Philpott-Howard J, Wade J, Casewell M. Infection control training: evaluation of a computer-assisted learning package. J Hosp Infect 2000;44: 193–9. 41. Atack L, Luke R. Impact of an online course on infection control and prevention competencies. J Adv Nurs 2008;63:175–80. 42. Atack L, Luke R. Improving infection control competency through an online learning course. Nurs Times 2009;105:30–2. 43. Bryce E, Yassi A, Maultsaid D, Gamage B, Landstrom M, LoChang J, et al. E-learning of infection control: it’s contagious. Can J Infect Control 2008;23:228, 30, 32 passim. 44. Bryce E, Choi P, Landstrom MJL. Using online delivery for workplace training in healthcare. J Distance Educ 2008;22:149–56. Available from: http://www.jofde.ca/index.php/jde/article/view/338/589 [accessed 16.12.12]. 45. Blot SI, Labeau S, Vandijck D, Van Aken P, Claes B, Executive Board of the Flemish Society for Critical Care N. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among intensive care nurses. Intensive Care Med 2007;33:1463–7. 46. Llaurado M, Labeau S, Vandijck D, Rello J, Rosa A, Riera A, et al. Southern European intensive care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. Med Intens/SEMICYUC 2011;35:6–12. 47. Labeau SO, Vandijck DM, Brusselaers N, Vandewoude K, Vogelaers DP, Blot SI. Web-based resources for critical care education. The EVIDENCE Crash Course: a Web-based interactive e-course on infection prevention for critical care clinicians. Crit Care Med 2011;39:2202–3.
Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Review Paper
Is there a place for e-learning in infection prevention? Sonia O. Labeau RN, MA, MNSc, PhD ∗ Faculty of Education, Health and Social Work, University College Ghent, Ghent, Belgium
article information Article history: Received 2 December 2012 Received in revised form 3 October 2013 Accepted 4 October 2013 Keywords: E-learning Infection prevention Infection control Adult education
a b s t r a c t Background: In the last few decades, e-learning, a method which integrates information technology and the learning process by using materials delivered through the internet, has become widely used in educational initiatives for healthcare professionals. Purpose: To evaluate whether there is a place for e-learning in the field of infection prevention. Methods: Non-comprehensive review of the literature. Findings: E-learning courses in the field of infection prevention and control are still scarce, often restricted to local initiatives and not specifically directed toward critical care providers. Although methodological flaws and potential biases hamper the generalizability of results from some currently available studies, findings related to both learners’ satisfaction and effectiveness suggest that e-learning might prove an effective educational tool for the (continuing) education of healthcare providers. Further investigations, including research pertaining to the cost-effectiveness of e-learning, are required to provide a better insight in these issues. Conclusion: Further research is required to determine the (cost)effectiveness of e-learning in general, and in the field of infection prevention and control in particular. Current insights suggest that e-learning should be based Web 2.0 technologies to address a wide range of learning styles and to optimize interactivity. As a gap in the literature was detected with respect to e-learning modules on infection prevention and control which are specifically oriented toward critical care providers, it can be recommended to promote the development and subsequent assessment of such tools that meet high-quality standards. © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Access to the right knowledge at the right time is a key factor for an effective and efficient healthcare system. Education of all members of the multidisciplinary team is therefore considered a first and crucial requirement when targeting implementation of interventions for infection prevention and control.1 For critical care nurses, keeping up to date with the latest insights is vital in order to provide optimal patient care. Simultaneously, it is a great challenge, as critical care environments are among the most quickly evolving settings in acute care hospitals. In the mid-nineties of the previous century the emphasis in education has shifted from providing instruction to producing learning.2 Traditional instructor-centered teaching was substituted by a learner-centered approach, in which students are held responsible for their own learning processes and outcomes. Critical thinking, independent and evidence-based learning, and feedback
∗ Correspondence to: Faculty of Education, Health and Social Work, University College Ghent, Keramiekstraat 80, B-9000 Ghent, Belgium. Tel.: +32 9 321 21 38. E-mail address: [email protected]
are since being regarded as indispensable features of this new learning paradigm.3 In the field of providing educational activities for healthcare professionals, the last few decades have witnessed an increase in demands on academic faculty.4 Changes in health care delivery, advances in medicine and technology,4 shortages in staffing, and cost constraints5 have created important challenges for nurse and medical educators. Quite simultaneously, a rise in the use of information technologies in education took a start. E-learning, a method which integrates information technology and the learning process by using materials delivered through the Internet,6 soon was adopted and widely used in educational initiatives for healthcare professionals.7 There were high expectations that online learning might successfully integrate the features of the new learning paradigm into a novel approach to adult education, that tackles the challenges mentioned above. To provide an answer to the question whether there is a place for e-learning in infection prevention, a non-comprehensive review of the literature was conducted. Relevant publications were searched for by entering combinations of the keywords “e-learning”, “Web-based learning”, “online learning”, “distance learning”, “Internet education”, “Internet-based learning”, “healthcare workers”, “healthcare professionals”, “healthcare
1036-7314/$ – see front matter © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.aucc.2013.10.002
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providers”, “critical care”, “intensive care”, “infection prevention”, and “infection control” in the electronic databases PubMed, CINAHL, and Web of Science. Articles in English, French, German or Dutch were eligible for inclusion. As e-learning is a relatively new concept, no restrictions in publication dates were taken into account. The concept of e-learning In its broadest sense, e-learning is the use of the Internet for education. The simultaneous use of various terminologies makes it however difficult to develop a generic definition.8 Besides elearning, terminology includes online learning, Internet education, distance education, IT-learning, Web-based education, Web-based instruction and advanced distributed learning.9 In so-called synchronous learning, the educational content of Internet-based learning is provided at the same time as it is delivered from an instructor; in asynchronous learning, on the contrary, it is disconnected from the actual time of instruction and provided by tools such as recorded and saved audio, video, or text presentations.4 The separation of teacher and student in time and space clearly classifies web-learning as distance learning.10 Reime et al. describe e-learning as a method which integrates information technology and the learning process by using material delivered through the internet to create, foster, deliver and facilitate learning, anytime and anywhere.6 A brief history of e-learning The seeds for distance learning have been sown as far back as the 1700s with the development of the first correspondence course. In England, in 1840, shorthand classes were being offered by correspondence courses through the mail. This method of distance learning gained considerable popularity in the early part of the last century.10 In the centuries to follow, new technologies made distance learning easier. Radio, television, video recorders all made significant contributions. As an example, in 1953 the University of Houston offered the first televised college credit classes. Most courses aired at night so that students who worked during the day could watch them. The genesis of e-learning as we know it today can be traced to the development of network communication in the late 1960s.11 The invention of the World Wide Web by Tim Berners-Lee in 1989 has significantly impacted on distance learning.12 This internet-based hypermedia initiative for global information sharing introduced an unprecedented opportunity for people to communicate and collaborate despite differences in time and place. Early Web-based courses were often criticized for poor standards and lack of quality control methods, as they relied almost exclusively on the learner’s ability to read information and to use that information to answer questions.10,13 They have been gradually evolving over time and gaining in quality, following the evolution of the Internet through two phases, Web 1.0 and Web 2.0. Web 1.0 is often described as the “read-only Web”, as it provides the user with a relatively passive experience. Its technology allows users to search and read texts, to watch and listen to multi-media files, and to interact with pre-programed games and simulators. The introduction of the Worldwide Web initiated Web 1.0 technology, which is generally considered to have been replaced by Web 2.0 in the year 2003. Web 2.0 defines the more interactive and dynamic phase of the www. and is commonly referred to as the “read-write Web” for its concept of offering users a participatory platform. Hereby, users
are able to generate Web site content, and to communicate interactively through wikis, blogs, podcasts, video-sharing, and social networking sites. Both Web 1.0 and 2.0 incorporate various technologies that are commonly used in e-learning environments today.14
Advantages and disadvantages of e-learning Advantages More than anything else, its multifaceted flexibility appears to make e-learning attractive to learners.15 Different learning styles can be addressed and learning can be facilitated through mixed activities. Learners may also have the option to select study materials that meet their specific level of knowledge and interest. Moreover, self-paced learning modules allow learners to study at their own pace, not having to work faster to keep up with more advanced students or holding their pace to wait for struggling learners. Course materials can be reviewed as frequently as desired to enhance learners’ own understanding.16 Thus, e-learning encourages students to take responsibility for their learning process. Students are not required to travel to attend classes. The justin-time nature of e-learning allows them to learn from the comfort of their own home or from any place where technical accommodations are available. E-learning thus reduces travel-related costs and time.16 Healthcare professionals are expected to be computer and information literate at registration. As an additional asset, e-learning promotes the learners’ development of computer and Internet skills, and of skills in time management.6,13,17,18 Finally, e-learning contributes to methodological diversity and to changing the focus away from teaching to learning.19 From the point of view of the organization, e-learning overcomes issues such as class room or instructor availability, staffs’ combination of vacation schedules, current classes, or differing employee shifts. Training is accomplished more rapidly, while ensuring content consistency and standardization,16 and allowing organizations to provide educational materials tailored to their employees’ specific needs. Another benefit pertaining to the organization is that, if desired, learners’ activity is traceable. E-learning permits to log participants’ actual course attendance, study time, test scores and study progress. These features can be an important asset for healthcare settings where clinicians’ activities for continuing education are (partially) funded, and therefore controlled, by the organization. A recent study assessed the economic sustainability of elearning within a large scale via personnel work hour saving, and yielded positive results.20 Upfront costs associated with the development of e-modules will predominantly depend on the software used and the investment in personnel cost. In environments or economic climates with restricted resources for educational purposes, the use of open source software could prove to be highly advantageous.
Disadvantages E-learning requires more responsibility and self-discipline for the learner to keep up with a more free and unconstrained learning process and schedule. Unmotivated students or those with poor study habits may fall behind or experience difficulties in getting used to the lack of familiar structure and routine of conventional classes.21 Also, students requiring help or additional instructions are not always able to obtain immediate support from instructors or help desks.
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The standardization of learning contents for groups of students might conflict with the need for adapting learning packages to the learning style of individual learners. From a technical point of view, learners may be intimidated or confused by the related technology.22 Technical barriers such as low performance computers, slow or unreliable Internet connections or computer viruses may cause frustration.14 Additional related hindrances are a lack of technical support (organizational) firewalls, or restricted available bandwidth.19 Learners feeling isolated or missing social interaction and faceto-face contact of traditional classroom training may lead to high drop-out rates from e-learning courses.19 Also, if studying from home, potential distractors are well known to be numerous and highly seductive. While the proliferation of notebook computers and mobile phones has recently enhanced the portability of e-learning, printed materials may still be considered more easy to transport and to access. Also, they do not suffer from the restriction to be used in areas where internet connections are restricted or unavailable. Contrary to the acquisition of theoretical knowledge, e-learning might be less appropriate for the acquisition of skills, especially those that involve complex physical/motor or emotional components. Implementing e-learning in an organization might nevertheless also be associated with some disadvantages. There may be high upfront costs, related to both personnel investment and technological requirements. Also, for e-learning tools to be interactive instruments that offer users a participatory platform and real-life simulation opportunities, the inclusion of video and sound, simulation, chat technology and online teacher–student communication tools are recommended. Although the related development costs for such interactive modules may turn out to be quite substantial, the return on investment has not yet clearly been demonstrated.22 When implementing e-learning at the workplace, organizations need to invest in sufficient hardware, software and accommodations, that enable staff to meet the educational requirements online. Moreover, organizations where e-learning is implemented might expect staff to study at home, i.e. after working hours, without any financial or working time-related compensation. Providing mobile devices such as tablets and i-phones to staff to enable e-learning at home may also result in conflicting or unrealistic expectations toward employees. The Internet offers the extraordinary possibility to easily provide and share information with users worldwide. Caution is nevertheless warranted as not all resources made available are of equally good quality. A thorough expert evaluation and quality-check should precede each implementation of any e-learning tool. Finally, being up-to-date is a common issue with Web-based learning. Users may assume that the information published online reflects the most recent insights, but publication dates are often lacking.14 Organizations may be required to invest a significant amount of efforts, time and money to keeping e-learning tools in line with the most current insights.14 E-learning and learning styles Kolb et al. define learning style as an individual’s inherited foundation, particular past life experience and the demands of the present environment that emphasize some learning abilities over others.23 As in traditional education, learning styles are also considered valid predictors of success in e-learning.24 Various types of learning styles have been identified.25 When developing e-learning tools, awareness of student learning styles may be helpful to increase learners’ performance. Designing e-learning and creating content that matches the various learning styles is nevertheless challenging.
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A frequently suggested approach is to provide a wide-ranging variety of formats in which learning contents are presented, such as texts, pictures, video, exercises with feedback, simulation, in order to meet as many learning styles as possible, and to meticulously monitor their suitability in terms of students’ learning outcomes.25 Future research into the relationship between e-learning and learning styles might enhance current insights and be helpful to increase the effectiveness of e-learning tools. The value of e-learning for healthcare professionals With the rising use of Internet-based learning, various studies have attempted to evaluate its benefit for healthcare workers compared to no education, or as part of a blended-learning model. A recent meta-analysis by Cook et al.26 assessed the effect of Internetbased instruction for healthcare professionals compared to either no intervention or to non-Internet instruction. The authors identified 2193 studies, of which 201 met their inclusion criteria. Learners were students, postgraduate trainees, or health professionals in human or veterinary medicine. Outcomes included learner satisfaction with the course, knowledge, clinical skills, and behaviors or effects on patients. This meta-analysis concluded that the educational strategies assessed in e-learning appeared to be more effective than no intervention – which is hardly surprising – and are likely similar in efficacy to traditional educational methods.26 Taking into account that this meta-analysis includes early e-learning initiatives with modules that were developed before the emergence of Web 2.0 technologies, it might underestimate the effectiveness of today’s more attractive and interactive e-courses. Simultaneously, the results should be interpreted with caution. First, no funnel plots assessing publication bias were used. Also, several reports included lacked key contextual or methodological descriptions and/or were non-randomized or observational trials. Moreover, a wide inter-study variety of interventions was found, resulting in a considerable overall heterogeneity (I2 ≥ 79%). The effect of Internet-based instruction versus no educational intervention was demonstrated to be inconsistent across studies, although pooled effect sizes were commonly small (≤0.12, except for the outcome ‘behaviors/effects on patients’) and not statistically significant for all outcomes but knowledge. The authors recommend further research to focus on the direct comparison of different Web-based interventions. Cook et al.27 also sought to answer how e-learning compares with non-computer instructional methods in time spent learning, and to identify the features associated with improved learning efficiency. Of all studies published between 1990 and November 2008 investigating the use of the Internet to teach healthcare professionals in training or practice compared with another educational intervention, 20 were eligible for inclusion in a meta-analysis. Study participants were students, postgraduate trainees, physicians, nurses, pharmacists, dentists, veterinarians, and physical therapists. Random effects meta-analysis of eight studies comparing Internet-based with non-Internet-based instruction revealed that, overall, e-learning and traditional educational interventions require similar study time.27 A pooled effect size (ES) for time −0.10 (p = 0.63) was found, with positive numbers indicating a longer study time when using e-learning. Providing feedback (ES 0.67, p = 0.003, two studies) and greater interactivity (ES 0.25, p = 0.089, five studies) were shown to be associated with longer study time. Audio narration, video clips, interactive models, and animations were found to increase learning time but simultaneously to facilitate higher knowledge and/or learners’ satisfaction. Across all studies included, time correlated positively with knowledge outcomes (r = 0.53, p = 0.021). Funnel plots did not detect publication bias.
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Although 17 out of 20 studies included were randomized, it should be taken into account that most time outcomes were self-reported by the learners, and that heterogeneity and inconsistencies among studies were considerable. Additionally, key data on interventions or outcomes were lacking from various reports included. These limitations may reduce the generalizability of the authors’ findings. E-learning for critical care providers Wolbrink and Burns14 conducted a MEDLINE/Pubmed systematic review from January 2000 to July 2011 to investigate the suitability of e-learning for critical care providers. Their merely descriptive report includes six publications that assessed the use of e-learning specifically for healthcare professionals working in intensive care environments. These included the assessment of an online burn care module for medical students and interns in surgery and emergency medicine,28 an online course to teach medical students how to properly fill out a death certificate,29 a Web-based intervention on recommended clinical guidelines for patients with acute respiratory distress syndrome,30 an e-course on sterile technique for central venous catheter placement,31 a difficult airway management course in anesthesia for internal medicine trainees,32 and an avatar-based training to teach principles of crisis resource management to medical students and first-year residents in emergency medicine.33 Some of these publications suffer from methodological flaws (such as no control group28,29 ; no pre-test or post-test comparison28 ; underpowered28,30 ; very low response rate30 ), suggesting that further work is necessary to develop a robust learning platform incorporating a variety of learning modalities for critical care providers.14 Web-based learning nevertheless appears to be advantageous for critical care providers if features such as interactivity, feedback and exercises are included. A concise review by Kleinpell et al.34 aimed to identify, catalogue, and critically evaluate non-industry sponsored Web-based resources for critical care education. As a result, an impressive list of over 135 tools specifically developed for ICU clinicians was generated, identifying a number of noteworthy educational websites and e-learning materials. All were meticulously reviewed to fulfil a set of stern requirements of quality and credibility. The authors concluded that e-learning today is being actively integrated into critical care medical and nursing training programs and for competency training purposes. Although not objectively measured to date, it is suggested that awareness of available Web-based educational resources may enhance critical care practitioners’ on-going learning and clinical competence.34 E-learning in the field of infection prevention and control The impressive above-mentioned list of Web-based resources for critical care providers34 was found to include four tools only related to the field of infectious diseases. These nevertheless do not focus on infection prevention or control, but cover specialized topics, mainly for advanced learners. Of all resources listed, only the Society for Critical Care Medicine’s Infection Knowledge Line35 appears to include a broad range of items, and addresses both beginners and advanced learners. Publications reporting on the use of e-learning specifically pertaining to the prevention and control of infections are rather scarce, and appear not to be explicitly conceived for critical care providers. Knowledge of infection prevention is nevertheless known to be inadequate among critical care nurses. Surveys using validated multiple choice questionnaires (MCQ) related to the prevention of ventilator-associated pneumonia, central line-associated infection and surgical site infection in a sample of 3405 European critical
care nurses yielded overall test scores below the conventional 50% threshold to pass a test.36–38 Hence, an innovative approach such as e-learning directed specifically toward the educational needs of this target group could prove highly beneficial. Reime et al.6 account on a Norwegian college of nursing that aimed to combine the development of a new curriculum with the enhancement of students’ competences in cross-infection control. In collaboration with the Centre of Nosocomial Infection Control at the local hospital, they evaluated different approaches to acquiring and applying knowledge. Thereto, students were allocated to two groups that were randomly assigned to receiving traditional lecturing (n = 73) or e-learning (n = 68), and that were comparable in terms of gender and age. Learning effects in both groups were measured by means of a 40-item MCQ, that had been pilot-tested by 24 college teachers and evaluated by infection control nurses (n and methods of evaluation not reported). Subsequently, students’ experiences with the teaching methods, learning goals, and the MCQ were assessed in focus groups that consisted of 21 of 33 randomly invited students (64%). Among other results, the sum score on the MCQ was higher in the traditional lecture group than in the e-learning group (p = 0.01), with no significant difference between groups in study time (p = 0.67). Focus groups interviews revealed that the students were satisfied with both teaching approaches. The authors conclude that e-learning and traditional lecturers both have to be regarded as equivalent educational resources.6 Recently, Pellowe et al.39 reported on the evaluation of an e-learning infection prevention module embedded in the preregistration nursing program in the United Kingdom. The course included various topics such as healthcare-associated infections; risk to patients; how to protect patients and one’s self; hand hygiene; personal protective equipment; waste and sharps; and environmental cleanliness. The module was evaluated using a Likert-scale questionnaire pertaining to the ease of access; the use of the materials; and the relevance of the contents to the students’ stage of training. It was completed by 282 of the 495 students who had taken the course (57%). Besides a substantial overall satisfaction with the use of the e-learning course, the relevance of the program for their current education was acknowledged by 94%. Confidence in understanding the infection prevention topics studied was enhanced in 97% of students and 96% reported applying the knowledge gained to clinical practice.39 Although not acknowledged by the authors, caution is warranted when interpreting these results. The questionnaire may predominantly have been completed by students who enjoyed the use of e-learning (selection bias). Moreover, self-reporting of attitudes is well-known to be prone to social desirability bias. Finally, no ‘harder’ outcomes, such as actual increase in knowledge or in application of the knowledge gained in clinical practice, have been measured. Another initiative to provide e-learning about infection control also emerged in the United Kingdom, where Desai and colleagues developed an Infection Control Training and Policies multimedia software package consisting of an introductory infection control training course and a hypertext version of a published book on infection control practices.40 The module included information on hospital-wide policies; policies for medical and surgical wards; special organisms; hospital support services; and staff and student health. It was implemented at the local hospital and at three campuses of medical schools. Learning effects obtained by studying the course were evaluated by 52 third-year medical students attending an infection control lecture. These students were submitted to a pre-training 30-item MCQ, then randomly assigned to study the e-course (n = 23) or to attend a traditional lecture with the same contents (n = 29). Afterwards both groups completed a 30item MCQ post-test. While no significant differences in the groups’
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pre-training scores were found, both methods of learning significantly increased students’ knowledge levels. The increase in knowledge in both groups increased significantly (p < 0.0001 in both groups), but their overall post-test scores did not differ significantly. The course’s usability was assessed by means of a questionnaire survey among the 23 e-learning students; additionally, questionnaires returned by the first 25 ward-based nursing staff who voluntarily used the training, and by three hospital infection control staff were analyzed. All nursing and infection control staff, and 87% of the medical students found the program easy and enjoyable to use. Nevertheless, questionnaires returned by the first 25 hospital staff who voluntarily studied the course may reflect the views and experiences of a subsample of early adapters, highly enthusiastic about a new learning method; or of healthcare workers particularly interested in e-technologies or e-learning. Therefore, it is warranted to take potential selection bias into account.40 In Canada, Atack and Luke developed an online self-study course for workplace training on infection control to facilitate the delivery of standardized training to large numbers of healthcare providers.41,42 The course consisted of three modules: hand hygiene, routine practices, and the chain of transmission. Besides text, photographs, video and graphics, pre- and post-module knowledge tests and various exercises were integrated. The impact of studying the course on nurses’ and allied healthcare professionals’ competency in infection prevention and control was assessed among a convenience sample (n = 76) by means of Likert-scale preand post-intervention questionnaires. Eighty-eight percent (n = 67) of the participants completed both the pre- and post-intervention competency questionnaires. The pre-course mean score was 64% and the post-course mean was 77.3% (p < 0.001). The majority of participants reported to be highly satisfied with the course. They found it extremely useful (100%), and the learning activities were found to helpful (100%) and creative (95%). As acknowledged by the authors, the generalizability of these results is nevertheless limited by the use of convenience sampling. Also, the impact on learners’ clinical practice remains unclear by lack of follow-up observation. The results of this study led the authors to conclude that e-learning can be considered an effective way to enhance knowledge and skills related to infection control and prevention.41,42 Bryce et al.43,44 developed an e-learning module to deliver standardized infection control training to all healthcare professionals across a Canadian health authority. The course was developed by a multi-disciplinary team from a variety of healthcare settings, and included features such as drop and drag technology, animation and video. The entire module, i.e. pre-test, lessons, and post-test, was completed by 280 study participants. Of these, 65.3% were recruited by their supervisors or took the module as part of their hospital orientation (65.3%); the remaining 36.5% were voluntary learners. Pre- and post-tests demonstrated a significant increase in postcourse improvement in infection control knowledge (p < 0.01). There was no significant difference in test scores between the mandated and voluntary participants. Observations of 117 participants’ practice during clinical orientation sessions in a realistic setting yielded a 35% overall improvement for all scenarios in healthcare workers with less than one year’s experience.43 A user satisfaction survey completed by 82 learners indicated that the course was experienced as relevant and simple to navigate (score 4.22 out of a possible 5.0; SD = 0.15).44 The characteristics of the healthcare workers who returned this survey are nevertheless not mentioned by the authors. Therefore, potential selection bias needs to be taken into account.
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Due to the extensive positive response, use of the module has been extended since to various health facilities in the region.43 E-leaning on infection prevention for critical care providers Based on the current and previous searches of the literature, and to the best of our knowledge, no interactive Web-based e-learning course for critical care providers was available until recently. Following the disappointing results of an analysis of the educational needs of critical care nurses regarding the prevention of healthcare-associated infection,36–38,45,46 we developed the EVIDENCE Crash Course, that bundles all essentials of evidence-based infection prevention in a comprehensible way, and that is directed specifically toward healthcare providers working in a critical care environment.47 The course has proven content validity and usability, and is available in English, Spanish, Portuguese, Turkish and Dutch languages (www.evidenceproject.org) (data not yet published). Discussion In the past two decades, education for healthcare workers has witnessed a shift from one devoid of significant computer-based resources to that where such tools are regularly incorporated. The need for continual learning to enable professionals to maintain and develop their knowledge and skills to function effectively has greatly contributed to the ever-growing importance of e-learning, and many nursing and medical students have reported e-learning to have been helpful toward their educational advancement. Although the studies included in this review are generally positive about the effects of e-learning, some critical reflection is warranted. First, the large heterogeneity of tools developed and methods used to assess their effectiveness make it difficult, if not impossible, to draw general conclusions. Contextual frameworks are often lacking, and methodological issues open the door to (reported or unreported) potential biases. Reports on user satisfaction outcomes only may provide information about how a tool is perceived by a limited sample of learners, but leaves the reader without any evidence about the tool’s potential to increase knowledge or enhance clinical practice. Finally, the assessments reported are often conducted with self-developed MCQs and scales, which have not been validated nor tested on reliability. The above considerations are warranted to be taken into account when drawing a realistic image of the effects of e-learning for infection prevention and control. Another aspect of e-learning which has not yet been fully investigated pertains to its cost-effectiveness. Although open source software is available, the development, implementation and maintenance of e-learning courses may be associated with considerable investments in efforts, time and money. Further research that focuses on return on investment, thereby taking into account wide ranges of potential costs and benefits, is needed to gain a better insight in these issues. Future research focussing on the association between e-learning content, learning styles and learning outcomes is also highly recommended. In the field of infection prevention and control, e-learning courses are, however, still scarce, and often restricted to local initiatives. This non-exhaustive overview of initiatives to develop, assess and implement e-learning modules for infection prevention and control suggests that there is a place for e-learning in infection prevention. In spite of documented deficiencies in knowledge of infection prevention among critical care nurses, the current literature provides no evidence for the existence of such tools specifically developed for these healthcare professionals.
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Lastly, it should be acknowledged that, if e-learning would prove to be an effective tool to transfer and increase knowledge, the association between better knowledge and improved adherence to evidence-based or clinical guidelines for infection prevention and control has not yet been established. While knowledge undeniably is a primary condition, it does not open the door directly to adherence. Changing clinicians’ behavior is a multifaceted challenge that, besides time, requires insight in facilitators and barriers, and in various psychological mechanisms, and that is well-known to be a considerable challenge. Conclusion Today, the literature on e-learning for infection prevention and control and the evidence on the effectiveness of e-learning in general still is limited and suffers from various limitations. The overall positive findings related to both learners’ satisfaction and individual tool’s effectiveness are nevertheless suggestive for recommending its promotion. The development of novel e-learning should be based on Web 2.0 technologies in order to maximize interactivity. Finally, the development of high-quality modules on the prevention and control of infections, specifically oriented toward critical care providers, and the promotion of their use on a large scale, can be highly recommended. References 1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu HT, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–32. 2. Barr RB, Tagg J. From teaching to learning: a new paradigm for undergraduate education. Change 1995;November/December:13–25. 3. Alur P, Fatima K, Joseph R. Medical teaching websites: do they reflect the learning paradigm. Med Teach 2002;24:422–4. 4. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81:207–12. 5. Benson EP. Online learning: a means to enhance professional development. Crit Care Nurse 2004;24:60–3. 6. Reime MH, Harris A, Aksnes J, Mikkelsen J. The most successful method in teaching nursing students infection control - E-learning or lecture. Nurse Educ Today 2008;28:798–806. 7. Choules AP. The use of elearning in medical education: a review of the current situation. Postgrad Med J 2007;83:212–6. 8. Anderson T. The theory and practice of online learning. 2nd ed. Edmonton: AU Press, Athabasca University; 2008. 9. Kahn B. A framework for web based learning. Engelcliffs, NJ: Educational Technology Publications; 2001. 10. Dunet D, Reyes M. Stakeholder-focused evaluation of an online course for health care providers. J Contin Educ Health Prof 2006;26:257–67. 11. Harasim L. A history of e-learning: shift happened. In: Weiss J, Nolan J, Hunsinger J, Trifonas P, editors. The international handbook of virtual learning environments. Dordrecht: Springer; 2006. 12. Masters K, Ellaway R. e-Learning in medical education Guide 32 Part 2: technology, management and design. Med Teach 2008;30:474–89. 13. Forman D, Nyatanga L, Rich T. E-learning and educational diversity. Nurse Educ Today 2002;22:76–82. 14. Wolbrink TA, Burns JP. Internet-based learning and applications for critical care medicine. J Intensive Care Med 2011;27(5):322–32. 15. Schoech D. Teaching over the internet: results of one doctoral course. Res Soc Work Pract 2000;10:467–86. 16. Berke WJ, Wiseman TL. The e-learning answer. Secure this education solution by setting a vision for its usage and building a sound business plan for its purchase. Crit Care Nurse 2004;24:80–4. 17. Atack L. Becoming a web-based learner: registered nurses’ experiences. J Adv Nurs 2003;44:289–97. 18. Haigh J. Information technology in health professional education: why IT matters. Nurse Educ Today 2004;24:547–52. 19. Ellaway R, Masters K. AMEE guide 32: e-learning in medical education Part 1: learning, teaching and assessment. Med Teach 2008;30:455–73.
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